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2012

You still need to make important decisions now about rising health insurance premiums.

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• Enroll in a qualified High-Deductible Health Plan and open a Health Savings Account. This provides significant premium savings that can help fund your HSA account. With individualonly coverage, you are eligible to contribute up to $3,100 to your account or $6,250 with family coverage, on a tax-deductible* basis (members age 55–64 are eligible to contribute another $1,000).

• Investigate RAF Sales Health plans offer incentives through discounts off their risk adjustment factors (RAFs) for you to change health

plans. Instead of your medical rates increasing this year, we might be able to help you offset some of that increase.

• Mercer Select HRKnowHow If you play a role in your medical group’s health care and benefit plan decisions, stay current on challenging issues. Access is included at no charge for all members who purchase group health insurance through Marsh.

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* Marsh and the Society do not provide tax, investment or legal advice.

Please consult with your professional advisors for guidance on these issues.

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SAN JOAQUIN PHYSICIAN

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VOLUME 60, NUMBER 1 • MARCH 2012

{FEATURES}

25 40 48 56 SPrINg 2012

NAVIGATE YOUR WAY

Through HIgh-Risk Lawsuit Issues

{DEPARTMENTS} 21 CMA FOUNDATION

Help Physicians Improve Diabetes Care

30 IN THE NEWS

New Faces and Announcements

INSIDE CMA’S

Center For Economic Services

SELLING YOUR PRACTICE To A Hospital-Based Intergrated Delivery System

FAQS: THE BAR

On The Corporate Practice Of Medicine

39 DOCBOOKMD Case Study

59 GIVING BACK

Trading In Your White Coat For Gardening Gloves

61 IN MEMORIAM 64 NEW MEMBERS 68 AT A GLANCE

SAN JOAQUIN PHYSICIAN 3

President George M. Khoury, MD President-Elect Raissa Hill, DO Past-President James Halderman, MD Secretary-Treasurer Thomas McKenzie, MD Board Members Lawrence R. Frank, MD, Moses Elam, MD, Peter Drummond, DO, Ramin, Manshadi, MD, Alan Kawaguchi, MD, James J. Scillian, MD, Karen Furst, MD, Kwabena Adubofour, MD, Kristin M. Bennett, MD

Medical Society Staff Executive Director Michael Steenburgh Deputy Director Nikki West Office Coordinator Debbie Pope Administrative Assistant Jessica Wilkerson

San joaquin physician magazine Editor Moris Senegor, MD Editorial Committee Moris Senegor, MD, Kwabena Adubofour, MD, Mike Steenburgh Managing Editor Michael Steenburgh Creative Director Sherry Roberts,

Committee Chairpersons MRAC F. Karl F. Karl Gregorius, MD Decision Medicine Kwabena Adubofour, MD

sherrylavonedesign.com Contributing Writers James Noonan, Elizabeth Zima, William West

Ethics & Patient Relations to be appointed Communications Moris Senegor, MD Legislative Jasbir Gill, MD

The San Joaquin Physician magazine is produced by the San Joaquin Medical Society

Community Relations Joseph Serra, MD Audit & Finance Marvin Primack, MD Member Benefits Jasbir Gill, MD Nominating Hosahalli Padmesh, MD Membership to be appointed

Suggestions, story ideas or completed stories written by current San Joaquin Medical Society members are welcome and will be reviewed by the Editorial Committee.

Public Health Karen Furst, MD Scholarship Loan Fund Eric Chapa, MD

Please direct all inquiries and submissions to:

NORCAP Council Thomas McKenzie, MD

San Joaquin Physician Magazine 3031 W. March Lane, Suite 222W

CMA House of Delegates Representatives Robin Wong, MD, Lawrence R. Frank, MD, James R. Halderman, MD, Patricia Hatton, MD,

Stockton, CA 95219 Phone: 209-952-5299 Fax: 209-952-5298 Email Address: nikki@sjcms.org

James J. Scillian, MD, Peter Oliver, MD, Roland Hart, MD Kwabena Adubofour, MD, Gabriel K. Tanson, MD, Ramin Manshadi, MD

Medical Society Office Hours: Monday through Friday 9:00 AM to 5:00 PM

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SAN JOAQUIN PHYSICIAN

spring 2012

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SAN JOAQUIN PHYSICIAN 5

letter from the executive director

staff report

SJMS is Growing!

I

t only seems appropriate to be announcing that we have expanded our staff as we approach the spring season which represents new growth and brighter days.

As many of you already know, Gena Welch, our Membership Coordinator for the past three years has chosen to follow her heart, and that of her boyfriends, to sunny Las Vegas. As much as we hated to see Gena go, we wished her the best and I’m happy to report that she is doing well and enjoying the sunny weather down there for now.

With Gena’s departure and my recent promotion to working more closely with CMA in Sacramento, the Board felt it would be prudent to recruit a Deputy Director tasked with the areas of membership development and community relations. This past month we welcomed Nikki West to our SJMS family and she is fitting right in. Many of you have already met Nikki as she visits various offices and serves as the host to our monthly Office Managers Forum which is now growing larger each month. Be sure to check out our website which has info on each months topic and presenter.

Mike Steenburgh

{

With the addition of this new staff, we are eagerly working on several membership programs which we hope to debut later in the spring.

Nikki is a local business professional who resides in Lodi with her lovely three children, Morgan (17), Madison (14) and Michael (12). It was actually her daughter Morgan that introduced her Nikki to us by participating in the Decision Medicine Program this past summer. Nikki is looking forward to leading the DM program this summer and is already beginning to promote it to our area high schools.

In addition to Nikki joining our staff, we have also recently hired a new Administrative Assistant to continue the growth in membership we have been experiencing for the past several years. Her name is Jessica Wilkerson and be sure to introduce yourself the next time you call the office and receive her warm welcome.

Nikki West

With the addition of this new staff, we are eagerly working on several membership programs which we hope to debut later in the spring. We are also heavily involved in several grant opportunities with Public Health, Kaiser Permanente, health Plan of San Joaquin and the California Medical Association Foundation all relating to Diabetes.

Each of these projects are exciting and it’s wonderful that the medical society has the opportunity to partner with such fine organizations and affect the patient population in San Joaquin County in a tangible way.

Please join me in welcoming Nikki and Jessica to our team the next time you see them.

All the Best!

Mike Steenburgh Executive Director

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SAN JOAQUIN PHYSICIAN

spring 2012

spring 2012

SAN JOAQUIN PHYSICIAN 7

a message from your president - George M. Khoury, MD

Together We Are stronger

The CMA stopped trial attorneys’ efforts to increase physicians’ malpractice insurance risk and rates. CMA filed briefs and argued two cases where it fought back the trial attorneys’ argument that the cap on non-economic damages in malpractice cases should be eliminated.

ABOUT THE AUTHOR Dr. George M. Khoury is President of the San Joaquin Medical Society and practices at Stockton Diagnostic Imaging as a Radiologist.

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SAN JOAQUIN PHYSICIAN

T

he weeks after I finished my residency and came to Stockton were exciting and scary at the same time. My residency training in Internal Medicine followed by Radiology had prepared me well, at least to take care of patients. However I was inadequately prepared to run a business in medicine. I had some experience working while in college running a business as a week-end manger but the world of business and the world of medicine are at odds. In medicine our goal is to help our patients.

In Business the goal is to make a decent living. Daily, we are faced with the difficulty in achieving both goals because of financial restraints, insurance coverage limitations, competition with others in our specialties as well as those outside our specialties encroaching on our “turf”.

In the late 1980s IPA’s were taking hold, promising physicians a way to confront the onslaught of payors threatening to control reimbursement. The Idea was to manage health care efficiently; maximize patient-benefits and at the same time reduce expenses. In retrospect, this was just the first step toward what was to come in the future.

We learned what went wrong, found ways to improve on them and those that didn’t went spiraling out of business or were taken over by bigger entities. Learning to traverse this ever confusing and complicated terrain was as important as keeping up with CMEs. Why because if you were not aware of the

changes coming down the pike you could get wiped out.

Had it not been for the Medical Society I would not have known about the resources the CMA provided me. Being an active member of the medical society opened up opportunities for me to observe, assess and alter my business plans around the changes that were happening or about to occur in our community as well as at the State and National levels. Becoming involved with the Medical Society is the best thing I did after starting work in Stockton.

Today, twenty years later, it remains so important to get help in dealing with the never ending changes, reimbursement issues, difficult economic times, and seemingly incessant regulations and guidelines being thrown at us, albeit with good intentions. Some of our fears and worries with managed care and IPAs were exaggerated. Unexpected challenges popped up. The same thing occurred in the late 1960s with implementation of Medicare. Physicians thought that would be the end of private medicine. Here we are again facing yet another paradigm shift in health management. The ACOs, huge medical groups, Hospitals employing physicians, and perhaps universal health care system as well as some yet unknown health management configurations are all being evaluated as possible solutions for the Run Away Health Care costs.

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SAN JOAQUIN PHYSICIAN 9

a message from your president - George M. Khoury, MD

Here are but a few projects that they have done for all physicians in the past two years alone.

The CMA stopped 22% Medicare payment cuts to California doctors during health care reform (2009-2010) and continues to aggressively advocate for the repeal of the SGR. The CMA stopped a 10% cut in Medi-Cal reimbursements to physicians by filing a lawsuit that enjoined the cuts since 2008 (saving California physicians approximately $175 million per year in cuts) The CMA stopped $137 million in MediCal physician payment cuts for services provided to children. CMA lobbied CMS to not approve the State’s proposed across the board 10% physician payment cuts. As a result, the cuts will not apply to services provided to children. CMA is filing a lawsuit to stop the new round of cuts, including the proposed cap on physician visits and mandatory co-payments.

We are all faced with these and other issues as a solo practitioner, or a member of a multispecialty group. Educational institutions such as medical schools and residency programs, as well as governmental medical institutions are not immune either.

In California all these different working scenarios have one thing in common.

They all rely on the physician who cannot be employed by hospitals or other nonphysician corporations. So why aren’t we a major discussant at the table? We are too fractionated. The most divisive is primary care versus specialty care groups. The specialty societies are just that. They work for the good of the few usually counterproductive to other specialty societies. There is only one entity that fights for all physicians - CMA. By being part of a strong CMA, doctors can insure a voice at the table. Physicians have tended to be either mavericks piloting their spacecraft, or passengers.

Whichever you are the CMA provides you with guidance, control and preservation

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The CMA stopped trial attorneys’ efforts to increase physicians’ malpractice insurance risk and rates. CMA filed briefs and argued two cases where it fought back the trial attorneys’ argument that the cap on non-economic damages in malpractice cases should be eliminated.

The CMA won from IOM recommendations that the Medicare fee schedule be further cost- and risk-adjusted to account for California’s higher practice costs and more diverse, low-income patient population which means more resources and higher Medicare payments for California doctors.

The CMA fought for a health care reform bill that reigned-in insurance companies by preventing them from rescinding coverage when patients get sick and making it illegal for them to deny coverage to those with pre-existing conditions. CMA language was adopted to require all insurers to spend at least 85% of their revenues on direct patient care.

of your practice. In order to achieve and maintain this ability we have to support the CMA. There are far too many physicians in California who are not members of the CMA or County Medical Societies but benefit from the CMA’s efforts. As members of SJMS/ CMA it is up to us to educate and convince our friends and colleagues to join SJMS and the CMA. It is imperative that we strengthen the CMA to become a powerful force to negotiate with the State and Federal health insurance programs, hospitals, pharmaceutical industries and the health insurance companies with a strong demanding voice.

At the county level your Medical Society is enriching our strengths as physicians by reaching out and working with our neighbors in the community to reestablish our significance where it counts most. The medical society’s new strategic plan is to centralize the various community health projects. We are working with Public Health and community programs that already exist

CMA is working with CMS and with large integrated medical groups to provide alternative delivery models for doctors through ACOs and other mechanisms.

The CMA is submitting multiple proposals to the CMS Innovation Center (which was given $12 billion) to fund alternative Medicare payment and delivery models for physician groups to survive in California.

In 2010, CMA’s Center for Economic Services successfully recovered over $2.7 million from payors on behalf of physician members and is on target to surpass that number in 2011. On average, our local members utilize this service 20+ times per month alone.

to improve the health and welfare of our four county populations. This is of primary importance when it comes to the chronic diseases which it seems we have an inordinate amount of: diabetes, obesity, Hypertension, heart disease, asthma, mental disease, etc... .

We want to create an environment where our physicians are aware of available programs to help their patients and for the Medical Society to be the Hub for resources. This is a very challenging goal but it is exactly what is needed to mobilize us as physicians to work together for the greater good. This will get us ready for the new world that is around the corner.

To achieve these lofty goals we need all physicians in the four counties to join the Medical Society and the CMA. There is no time to lose quibbling about past misdeeds and trust issues which some of you may have with organized medicine and or the CMA. It is time to join forces and secure our future.

spring 2012

SAVE THE DATE! April 17, 2012 CALIFORNIA MEDICAL ASSOCIATION 38th ANNUAL LEGISLATIVE LEADERSHIP CONFERENCE April 17, 2012 • Sacramento Convention Center • 9:30 am - 5:00 pm

Keynote Address by Attorney General Kamala Harris Meet with legislators and their staff at the Capitol

Visit CMA’s Health Fair on the North Steps of the Capitol run by UC Davis Medical Students.

Register today for your chance to win a new iPad at www.cmanet.org!

Please check with your county medical society before making travel arrangements or making appointments with legislators.

SAN JOAQUIN PHYSICIAN For more information, please contact Nikki West at 209.952.5299 or visit www.sjcms.org.

spring 2012

11

a message from the editor - Moris Senegor, MD

Controlled release

After the success of cardiac stents, and the more recent, riskier intra-aortic stents, this new development promises to obviate the need for open heart surgery to replace diseased valves.

ABOUT THE AUTHORMoris Senegor, MD serves as the Chairperson of the Publications Committee for the San Joaquin Medical Society and Editor of its flagship publication the San Joaquin Physician.

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A

recent Wall Street Journal article described the “painstaking” release of a revolutionary new device on to the medical market. Christened “Sapien”, the device, sold by Edwards Lifesciences Corp. is a percutaneously inserted heart valve. After the success of cardiac stents, and the more recent, riskier intra-aortic stents, this new development promises to obviate the need for open heart surgery to replace diseased valves. The article mentions that having spent $1 billion and 12 years to bring this product to market, Edwards Lifesciences is scrutinizing its clients very carefully and selling the device cautiously only to those most likely to employ Sapien safely.

The scrutiny, unusual for implantable device companies, includes evaluation of hospital facilities, their cardiac case volume and mix, their outcomes data, and eventually , personal inspection of the hospitals themselves. The company’s marketing plan involves keeping its client hospitals to a mere 150-250.

In the dog-eat-dog world of implants where quick recoupment of heavy investment calls for rapid release to as wide a client base as possible, why such

caution? Having spent a quarter century in another world, that of spine surgery, I know and appreciate the answer well.

The first “revolutionary” procedure in spine that I personally witnessed was chymopapain in the early 1980’s. In those days spine surgery was stagnant.

This was the pre-MRI era, and the nature of spine degeneration was not well understood. The repertoire of surgical procedures for the spine was scant and largely involved removal of herniated discs, a procedure which we nowadays perform less commonly. When chymopapain came along, it promised –or threatened, depending on one’s point of view- to do away with lumbar discectomies. Compared to devices like intra-aortic stents or the Sapien valve, chymopapain was amazingly simple. It was an enzyme that dissolved collagen based tissue, and the procedure merely involved injecting it into a disc, something anyone could be taught in one afternoon.

The concept behind chymopapain was also very simple. The enzyme, a papaya extract, dissolved the disc herniation from within. After years

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of development and clinical trials, chymopapain got released for general use in 1982 and the procedure for injecting it came to be called “chemonucleolysis”.

The concept of chemonucleolysis was not widely accepted, and there were vocal objections to the procedure from various respectable sources. I remember a famous academic neurosurgeon from Boston proclaiming, “the only papaya I ever want in my life is the one on my breakfast table!”

I was a resident in Chicago when chemonucleolysis came along and performed the procedure with good results. Then, within several years of the release, came an FDA warning that shocked us all. It advised that chymopapain use carried the risk of intracerebral hemorrhage, as well as paralysis related to spinal cord injuries.

It turned out that inadvertent injection of this chemical, which indiscriminately dissolved any collagen based tissue, into CSF, had catastrophic central nervous system consequences. There was yet another, then lesser understood consequence of chymopapain use. Even if safely deployed within the confines of the disc, it not only dissolved the hernia but the disc itself, thereby accelerating the natural process of disc degeneration.

Within less than a decade of its introduction, chymopapain exposed the chaotic and unpredictable nature of the American medical marketplace.

Numerous non-qualified practitioners got into the act, given the simplicity of the procedure. In one particularly egregious example a Long Island neurosurgeon discovered a gastroenterologist in Manhattan injecting chymopapain.

With no understanding of the physiology and biomechanics of the spine, or the natural history of the condition they were treating, these lesser qualified practitioners loosened the indications for chemonucleolysis, performing them on any back pain patient.>>

spring 2012

The Sapien transcatheter heart valve was approved by the FDA in 2011 for the treatment of severe aortic stenosis.

SAN JOAQUIN PHYSICIAN 13

a message from the editor - Moris Senegor, MD

Locally I know of a prominent citizen who, seeking the latest and greatest advance in medicine ended up receiving indiscriminate chymopapain injections in all 5 of his lumbar discs. Decades later, when I saw him, the ravages of the degeneration it had engendered was evident clinically and on his MRI. The Wild West like nature of the U.S.

By the late 1990’s the spine surgery world took off, and reminded me of the rapidly changing world of computers, with a dizzying array of new implants and procedures coming in, and soonbecoming obsolete in no time.

medical marketplace was taken for granted in those days, and a “so what” attitude prevailed when abuse of the procedure

of the enzyme was discontinued in the U.S. The demise of chymopapain was slow compared to what happens nowadays. By the late 1990’s the spine surgery world took off, and reminded me of the rapidly changing world of computers, with a dizzying array of new implants and procedures coming in, and soonbecoming obsolete in no time.

Among these, the most “revolutionary” new advance that appeared in the horizon was the artificial disc. Compared to chymopapain this was a dramatically more complex advance, requiring years of development, mostly in Europe, and a complex surgical procedure requiring two different specialists to implant it in the lumbar spine. On the positive side, unlike chymopapain, the U.S. spine community was pre-sold on the concept of so called “total disc arthroplasty” as being a more “natural” intervention in the spine, restoring motion to diseased segments. It promised to do away with their fusion, a procedure it threatened to replace, which was considered

Charité

was discussed. The death knell for chemonucleolysis came from the potential for disaster in the event of accidental introduction into CSF, which, with numerous poorly qualified practitioners in the field, was not uncommon . After the FDA warning, chymopapain use sharply declined. By 2003 the sale and distribution

14

SAN JOAQUIN PHYSICIAN

“unnatural” and caused neighboring level degeneration in the long term.

The most used and best tested lumbar artificial disc was named Charité, and after extensive and successful implantation of this device overseas, and an FDA regulated U.S. clinical trial, the device was released in the U.S. in 2004. >>

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a message from the editor - Moris Senegor, MD

In those days, as we eagerly awaited the Charité, I heard yet another memorable quote from a well known British neurosurgeon who, in reference to the European experience with Charité said,

“don’t confuse European apples with American oranges.”

He was referring to the loosely regulated U.S. medical marketplace where uncontrolled widening of

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indications (euphemistically called “off label use”), and lack of tight credentialing in who implanted a given device, resulted in radically different outcomes across the Atlantic. The lesson of chymopapain, repeated several times over by other devices, was now understood.

Charité was purchased by De-Puy, a large manufacturer of diverse orthopedic implants, which poured an investment in excess of $ 1 billion into it.

After its roll-out in 2004, Charité became the most spectacular crash and burn I ever witnessed in my quarter century in the spine world. By 2011 the Charité business was dead, and DePuy had moved on to other devices, still in search of a stable marketplace for the lumbar artificial disc.

There were numerous problems with the device including unanticipated resistance against it by insurance companies who saw it as a financial threat, and successfully managed to keep it at bay by refusing to authorize arthroplasties. Additionally, it turned out that the anterior trans-abdominal approach required to insert the device was hazardous, especially to the great vessels immediately anterior to the lumbar spine.

In particular, surgery requiring revision of Charité was extremely risky to the aorta, vena cava, and iliac vessels in a scarred down environment. Furthermore the validity of the concept of total disc arthroplasty, after the initial euphoria for it passed, came to be successfully questioned by more sober minds. >>

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SAN JOAQUIN PHYSICIAN 17

a message from the editor - Moris Senegor, MD

How well it prevents neighboring segment problems remains an unanswered question today.

In the meanwhile, as with all precedent devices, off label use of the Charité

occurred in various enclaves. Deviations from the conservative FDA indications, at times led to serious complications.

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vibrant industry of malpractice litigation.

Big city billboards, and various Internet pages are now dotted with personal injury lawyers seeking plaintiffs injured by lumbar artificial disc surgery.

De-Puy gave up on Charité, but other devices are currently available for lumbar arthroplasty. The market for this procedure turned out to be a fraction of the size everyone expected it a decade ago. The future of artificial disc surgery in the U.S. is currently unclear.

This brief summary of spine implants which I know well is, I am sure, replicated with similar general outlines in other surgical and interventional fields.

Little wonder that Edwards Lifesciences which has made a huge investment in time and money to bring an extremely sophisticated, revolutionary device to the market, is now aiming to restrict and control its use only to those best qualified.

The executives of the company have learned the lesson that if they don’t regulate the use of their own product no-one else will, and the disordered marketplace in which their clientele reside threatens to swallow them up in no time, causing their product to fail like Charité and others. It will be interesting to see if such self-imposed control of who gets to use a new product will become more prevalent among manufacturers. My bet is it will, because the long term economic realities of complex implantable devices clearly demands this.

spring 2012

spring 2012

SAN JOAQUIN PHYSICIAN 19

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spring 2012

cma foundation news

key expectations of participating practices entail the following commitment: Are in a practice with < 6 physicians To learn more about this stamp please visit: www.diabetesmonitor.com/stamp.htm

CMA Foundation Kicks Off New Project to

Help Physicians Improve Diabetes Care in San Joaquin County The California Medical Association (CMA) Foundation is pleased to announce a new project, Teaming Up for Healthy Hearts, which addresses the ongoing concerns with diabetes and cardiovascular disease in San Joaquin County. San Joaquin County has the 3rd highest diabetes-related mortality rate and the 4th highest mortality rate attributed to coronary heart disease according to 2011 data from the California Department of Public Health.1 The CMA Foundation, the San Joaquin Medical Society and the California Diabetes Program have teamed up with several partners in efforts to reduce the burden of cardiovascular disease and improve outcomes among underserved patients with type 2 diabetes in the County.

Teaming Up for Healthy Hearts is a multi-year project that aims to strengthen the capacity of the care team to improve the delivery and management of diabetes care.

spring 2012

The project encourages the formation of multidisciplinary teams based on existing, local resources to support patient self management efforts. Training and technical assistance will be provided to approximately 20 solo and small group practices that provide care to Medi-Cal patients.

Physicians will be provided with opportunities for clinical education to improve adherence to diabetes standards of care. Medical assistants will receive training to assist physicians in the care of patients with diabetes. Finally, the project will identify and strengthen patient referrals to self-care services provided by certified diabetes educators, case managers, pharmacists and other care team members in the community.

On Thursday February 2, 2012, the CMA Foundation accepted an invitation to present the project goals and objectives to the San Joaquin Medical Society’s Public Health Committee. This was an excellent opportunity to generate enthusiasm for the project, provide feedback on the overarching strategies, and discuss areas in which there are opportunities to collaborate with other ongoing diabetes programs in the County. We look forward to a continued partnership with the San Joaquin Medical Society and partnering with local physicians to strengthen the delivery of care provided to patients with diabetes.

We invite physicians who can champion this project in their practice to please contact Julie Vedolla-Fuentes at (916) 779-6624 or jvedolla-fuentes@thecmafoundation.org.

Provide care to Medicaid beneficiaries Can report A1c, blood pressure, cholesterol and smoking status data on 35 patients every six months over two years Medical assistant or other office staff participation in diabetes team care training Physician participation in clinical education opportunities “Because solo and small group practices are such a vital component of the health care safety net, we are pleased to work with these practices in San Joaquin County to address diabetes care,” said Carol Lee, President and CEO of the CMA Foundation.

SAN JOAQUIN PHYSICIAN 21

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spring 2012

By Karen K. Davis, MA, CPHRM, NORCAL Mutual, a member of the NORCAL Group

Navigate your way Through High-Risk Issues Associated with Lawsuits

What are some of the riskiest areas associated with practicing medicine day-to-day? They may be more common place than you think, and some may be easier to guard against than you imagine.

Since issuing its first policy in 1975, NORCAL Mutual Insurance Company has grown from insuring a few hundred physicians in Northern California to serving over 20,000 physicians, medical groups, clinics, hospitals and ancillary healthcare facilities in California, Alaska and Rhode Island. The company has also evolved into the NORCAL Group, a group of malpractice insurance companies with policyholders in many states across the U.S. NORCAL Group companiesâ&#x20AC;&#x2122; policyholders have access to a wide range of risk management resources designed to help physicians and healthcare facilities identify risks and reduce the chances of incurring medical malpractice lawsuits.

To discover trends in professional liability, NORCAL Group relies on its extensive database of closed claims information. NORCAL Group also produces reports compiled from facts garnered during on-site risk assessments.

Analyzing statistics from these two sources can give a credible picture of the types of situations and actions that most often lead to litigation for physicians, medical groups, and hospitals. >>

spring 2012

SAN JOAQUIN PHYSICIAN 25

high risk issues

The Claims Perspective

The top 10 risk issues revealed in this study were linked to:

NORCAL Group’s closed-claims database can distinguish various nonclinical issues (that is, problems in processes or communication) that are associated with lawsuits. These associated issues have often complicated the defense of allegations made against doctors and healthcare facilities.

Closed-claims data for all NORCAL Group companies’ policyholders for the past two years (July 2009 through June 2011) show the top ten associated issues causing difficulties in claims were:

• Handling of after-hours telephone calls (including documentation and

• Problem with history, examination, or work-up.

• Error associated with interpretation or communication of radiology results.

• Communication problem between healthcare providers.

• Comorbid issues (comorbidities complicated treatment of patients).

• Informed consent issues.

• Problem with medical records.

• Failure to follow up on tests.

• Vicarious liability.

• Problem with a medical or surgical device.

• Inadequate facility or equipment.

The Perspective from the Field As a service to policyholders, NORCAL Group companies send Risk Management Specialists to perform on-site visits to identify risk issues in physicians’ offices and hospitals. The Specialists produce reports that recommend strategies for reducing the specific risks found. In September 2011, NORCAL Group studied aggregate data from a subset of 175 risk assessments conducted in the last two years (between July 2009 and June 2011).

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communication with covering physicians).

• Distribution of sample medications.

• Reporting test and consult results to patients.

• Use of therapeutic agreements with chronic pain patients.

• Follow-up processes after hospital discharge.

• Follow-up processes for return office visits.

• Documentation of allergies.

• Making corrections in medical records.

• Legibility of documentation.

• Authentication of medical record entries.

Looking for the Overlap While the issues from the field are more specific than those on the closed-claims list, there is a revealing overlap. By looking at the lists closely, we can identify four main areas in which physicians are likely to significantly lower their risk levels if they implement effective risk management strategies.

Those areas are: • Management of follow-up processes.

• Generation of documentation.

• Management of medications.

• Communication with other healthcare providers.

The remainder of this article will offer tips to help you and your staff members evaluate and decrease your liability exposure related to these four key areas.

Management of Follow-up Processes Follow-up systems are important because physicians have a responsibility to ensure that patients are informed about their conditions and get needed care. Here are some strategies for evaluating and honing your follow-up system.

When patients are sent for testing, three areas of concern are: • Did the patient comply with the recommendation for testing?

• Were test results received and reviewed by the ordering physician?

• Was the patient notified about the results?

An appropriate follow-up system provides answers to these questions.

Double-check your method for monitoring compliance with appointments.

There should be some mechanism in place that requires licensed personnel in the practice to review all no-show appointments to determine which patients must be called and rescheduled.

Don’t make the patient solely responsible for making appointments for tests or for calling the office to obtain results; assist them.

Your follow-up system for diagnostic tests should include not only a method for confirming that you received the test results but also a process for ensuring that you reviewed the results. The review should be timely. A test result should never be filed until you (as the ordering physician) have personally reviewed, dated, and initialed it.

Institute the policy of notifying all patients of all test results (rather than just reporting abnormals).

spring 2012

The purpose of the medical record is to communicate internally and externally about a patient’s health.

In addition, in a medical malpractice lawsuit, the patient’s record will be used as evidence.

Generation of Documentation The purpose of the medical record is to communicate internally and externally about a patient’s health. In addition, in a medical malpractice lawsuit, the patient’s record will be used as evidence.

Each patient’s chart should be an accurate account of the patient’s history and complaints, physical findings, diagnostic tests, diagnoses, and medical care and treatment.

Whether a record is paper-based or electronic, the documentation in it should show the patient’s active problems, data analyzed to understand the problems, and plans for further investigating and handling of the problems.

If you are handwriting medical record documentation, you should assess your entries to ensure that they are easy to read. If your notes are not clearly legible, you should consider methods to improve the notes, such as printing, dictation, or typing your notes into a computer-based medical record.

If you choose to use dictation, you should read all the typed notes to make certain the transcriptionist has accurately recorded the information before you sign and date the notes.

spring 2012

Allergy documentation is harder to miss if it is consolidated in a single area of the record. If the patient reports no allergies, the phrase “no known allergies” or the initials “NKA” should be written or typed in the area designated for documentation of allergies.

After conducting an informedconsent discussion with a patient, ensure that there is confirmation of the consent process in the medical record, including a consent form signed by the patient and a description of the content of the informed-consent discussion in the progress or preprocedure notes.

Telephone contacts should be documented in the medical record, including calls taken after hours.

Information from after-hours calls should be incorporated into the medical record as soon as possible.

If there is a mistake in the record, you should correct it by drawing a thin line through the inaccurate words. The original entry should still be readable. Then write the correction clearly and legibly nearby, and initial, date, and time it.

Never erase, white-out, or otherwise obliterate any entry in the medical record. Electronic health records should not allow you to delete

any previously entered material. Instead, they should have methods for correcting prior entries that preserve the original notes.

Once you are notified about a potential liability claim, you should not change, add to, or in any way revise a medical record.

Management of Medications The main medication management issues that have been discovered in office assessments have to do with distribution of sample drugs and establishment of pain management contracts. Some tips in these two areas follow: • You may lower your liability risk if the sample medications in your office are well controlled.

• Sample medications should be locked in a cabinet or closet.

• Limit access to samples by designating specific staff to organize and maintain the sample closet.

• Do not allow pharmaceutical representatives or other unauthorized people access to the sample closet.

• Document all dispensed samples in the appropriate patient’s medical record.

SAN JOAQUIN PHYSICIAN 27

high risk issues

Taking some time to appraise and strengthen vulnerabilities in your practice or facility will help protect patients and may keep you from a malpractice suit or help you defend against one.

• When you give out samples, labeling them with specific information, including name and quantity of medication, name of manufacturer, physician name and address, patient name, date, and instructions for use, will reduce the risk that a patient will make a self administration error. You can create label templates and fill in the appropriate information before applying a label to a sample box.

• When you are treating chronic pain patients with opioids, consider setting up written pain medication agreements with these patients.

Such agreements can help you and the patient define and agree on appropriate behavior and hinder addicts from obtaining an unlimited supply of medication.

Communication with Other Healthcare Providers Gaps in communication between treating physicians can cause problems that jeopardize a patient’s well-being and provide the impetus for litigation. Here are some suggestions for remaining aware of a patient’s situation when you are sharing that patient’s care with a colleague.

If you refer patients to other physicians, have some mechanism in place to see that your referral recommendations are carried out and that the patient was seen by the consultant (or another physician of the patient’s choice). Your follow-up

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mechanism for referrals should also track your receipt and review of the consulting physician’s report.

Communicate in writing with the consultant about the specific consultation request you are making. Preparing a fact sheet with the patient’s clinical information and your impression is an effective way to convey the significant details to another physician.

After a patient is seen by a consultant, there must be a clear understanding about who will be responsible for what aspects of the patient’s care and who will order further testing and consultations if these are necessary.

If you are a consultant, communicate urgent or significant findings directly to the referring physician and be sure that you both know who will provide clinical follow-up. The communication should be done by phone and in writing.

Conclusion Most of the risk management recommendations in this article are not expensive or hard to put in place.

Most focus on setting up systems or protocols and then adhering to them. Taking some time to appraise and strengthen vulnerabilities in your practice or facility will help protect patients and may keep you from a malpractice suit or help you defend against one. NORCAL Group Risk Management Specialists are always ready to help policyholders with risk issues and to support practice changes that lower risk and improve patient safety.

spring 2012

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in the news

IN THE

NEWS

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

York and did a fellowship in gastroenterology at the University of Washington in Seattle. He is board certified in both gastroenterology and internal medicine. “It is great to have another specialist join our team,” said Colon and Rectal Surgeon Peter Tuxen, MD. “We pride ourselves on collaborating in order to give our patients the best medical care.” Dr. Protell is new to St. Joseph’s Medical Group but has worked at St. Joseph’s Medical Center since arriving in Stockton.

A new specialty building is currently under construction across the street from St. Joseph’s Medical Center. The five specialists with SJMG will move to this office with room for up to eight physician specialists and their staff in the future. The building is scheduled to open later this summer.

Robert Protell M.D. Veteran Physician with Strong Community Ties Joins St. Joseph’s Medical Group St. Joseph’s Medical Group of Stockton, a service of CHW Medical Foundation, is pleased to welcome Robert Protell, MD, a specialist in gastroenterology. Dr. Protell joins a talented group of physicians that includes family practice, internal medicine, colon and rectal surgery, general surgery and urology.

Dr. Protell started practicing medicine in Stockton in 1986 and for now, will remain in his office located at 415 E. Harding Way, Suite G. “I am excited to be joining this group of well respected colleagues,” said Robert Protell, MD. “Joining St. Joseph’s Medical Group will allow me to dedicate more time and attention to patient care rather than the aspects of running a medical practice.”

The addition of Dr. Protell to St. Joseph’s Medical Group of Stockton is part of the continuing effort to expand specialty services.

“We are pleased that Dr. Protell is bringing his medical expertise to our organization,” said Jag Gill, ScD, FACHE, FACMPE, President and CEO of CHW Medical Foundation. “We are committed to providing residents access to quality healthcare which includes providing key specialty services.”

Dr. Protell attended Weill Cornell Medical College in New

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Brad Reinke M.D., New Dameron Hospital Chief Medical Officer Brad Reinke, M.D. Director of Dameron Hospital’s Emergency Medical Department has been appointed Chief Medical Officer at Dameron Hosptial.

Dr. Reinke will be responsible for all medical services with an involvement in Brad Reinke M.D. quality assurance, medical staffing and physician relations. Dr. Reinke has served as Director of the Emergency Department since 2003. Prior to his experience at Dameron, Dr. Reinke was an assistant clinical professor with UCSF in their teaching program in Santa Rosa, CA., as well as serving in numerous clinical and administrative roles. A graduate of Occidental College in Los Angles, Dr. Reinke received his medical degree from Oral Roberts University in Tulsa

spring 2012

and a residency in Emergency Medicine at Loma Linda University Medical Center Loma Linda, CA. Dr. Reinke then served a Fellowship in Emergency Medicine at Stanford University Medical Center.

He also holds a Masters in Business Administration from the University of California, Berkeley. Dr. Reinke will also remain Director of Dameron Hospital’s Emergency Department as well as assuming duties as the Hospital’s new C.M.O. St. Joseph’s Medical Center Recognized with Consumer Choice Award St. Joseph’s Medical Center has been recognized among the nation’s top hospitals as a 2011/2012 Consumer Choice Award winner. The award identifies hospitals that healthcare consumers have chosen as having the highest quality and image in over 300 markets throughout the U.S. This is the sixteenth year the National Research Corporation (NRC), an independent consumer-polling firm and recognized leader in healthcare performance measurement, has issued the award and St. Joseph’s Medical Center has been the recipient in this market for each of those sixteen years. The award places St. Joseph’s in a group of the most prestigious names in healthcare.

“Being chosen as the most preferred health care provider by community members in Stockton and Lodi, and receiving recognition for our physicians, employees and volunteers in the company of such distinguished providers as Stanford, Mayo Clinic, UCSF, UC Davis, Cedars-Sinai and Johns Hopkins Hospital is a fitting testimonial to their excellent work,” says Don Wiley, President, St. Joseph’s Medical Center.

spring 2012

Valley Emergency Physicians Medical Group Named “Best Place To Work” Valley Emergency Physicians, the medical group that services Dameron Hospital’s Emergency Department, have been awarded “Best Place To Work” through a Modern Healthcare Magazine survey. Modern Healthcare is a national publication serving the business of healthcare and is distributed to hospital and healthcare managers nationally. Modern Healthcare Magazine is ranked No. 1 in readership among U.S. healthcare executives. 2011 was the second consecutive year Valley Emergency Physicians Group has received this award.

Valley Emergency Physicians has provided the physician staff at Dameron Hospital ER for over 10 years. Steve Maron, M.D., President of Valley Emergency Physicians stated: “I truly believe that this same philosophy and attitude accompanies our clinicians as they provide medical care within the hospitals we serve.”

The emergency physician group is headquartered in Walnut Creek and serves over 35 hospitals in the West.

Dameron Hospital’s ER Department was recently awarded the “Kid Qualified” certification for its quick response and professional pediatric emergency services.

Dameron Hospital is Stockton’s community owned hospital and will be celebrating its 100th year of community service in 2012.

St. Joseph’s Recognized for Continued Environmental Efforts St. Joseph’s Medical Center’s environmental efforts have once again earned special recognition from the Department of Resources Recycling and Recovery (CalRecycle), awarding the hospital with its 2011 Waste Reduction Awards Program (WRAP) honor. The WRAP Awards are based on businesses’ efforts to reduce waste in their daily operations, including recycling programs, reducing packaging and using recycled or post-consumer materials.

Reducing waste has a significant impact

on overall waste diversion, which in 2010 was approximately 65 percent statewide.

While this diversion level is an outstanding achievement, California still threw away more than 30 million tons of municipal solid waste in 2010 - 4.5 pounds of trash per person, per day - and nearly 67 percent of this waste came from the commercial sector.

“This year’s WRAP winners are evidence that businesses and organizations of all sizes are achieving significant waste reduction and recycling goals, all while helping protect the environment and preserve our natural resources,” CalRecycle Director Caroll Mortensen said. “In 2011 we have 46 firsttime winners, and many organizations that have come back year after year with new and stronger waste prevention programs.”

The 2011 WRAP Award and continued recognition from Practice Greenhealth for Environmental Leadership honor the hospital’s environmental efforts, which include the recycling of cardboard, paper, cans, plastics, fluorescent light bulbs, batteries, ink jet cartridges and sterile wraps, and using reusable “sharps” containers that can be washed and reused up to 500 times.

In addition, the hospital has switched to using reusable isolation gowns; uses 100% post-consumer waste recycled paper for all office supplies; installed energy efficient washers in their Laundry Department; and has a vermicomposting unit, or worm composting, which turns kitchen waste into high-quality soil which is used by the hospital’s gardener as fertilizer.

Dameron’s Emergency Room Earns Cardiac Care Application STOCKTON: Dameron Hospital has been approved by County Emergency Medical Services, and the State of California to apply as a Designated STEMI Receiving Center. STEMI is an acronym for a severe type of heart attack. Key conditions of earning the right to apply is having an emergency room that has demonstrated the ability to save lives through speed and accurate stabilization of cardiac incidents.

Dameron’s emergency cardiac care has been measured from the field to a hospital bed.

SAN JOAQUIN PHYSICIAN 31

in the news

IN THE

NEWS

St. Joseph’s Community Grants Recipients The Hospital has worked diligently to have processes in place for rapid treatment and intervention for lethal heart attacks within the community of Stockton. The hospital’s emergency department has cardiac ER physicians combined with a skilled nursing staff specifically trained to deal with dangerous STEMI type conditions.

Dameron has also teamed with local ambulance service AMR to dramatically improve cardiac response with its new mobile LifeLine Technology. LifeLine is an emergency communication system that connects paramedics in the field with a reviewing physician located at Dameron Hospital’s emergency department. This new communication translates to critical

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timesaving analysis during transport.

The application process for receiving the Designated Receiving Center designation requires a two to three year history of efficiency. Strict requirements must be met prior to a hospital’s emergency department gains the right to have an application placed with local and state agencies.

What is commonly referred in hospital emergency departments as a STEMI is when the coronary artery is completely blocked off by a blood clot, and as a result, virtually all of the heart muscle being supplied by the affected artery starts to die. This type of heart attack is the more serious type because of the large amount of heart muscle being damaged. Earning the

application process, Dameron’s emergency department has demonstrated the speed and accuracy to vastly improve a patient’s chances of surviving a serious STEMI. One key element is the quickness of the Dameron team, which translates to a patient’s chance of surviving with as little coronary muscle loss as possible.

“Local residents can feel more secure knowing that Dameron Hospital is staffed and prepared for emergency cardiac care with the most modern state-of-the-art response procedures.”, says Cheri Shirey R.N. Director of Emergency Services. “This puts Dameron on a par with any majormarket hospital in the Nation”.

spring 2012

Business Financing At Your Speed St. Joseph’s Awards over $184,000 in Grants to Community Benefit Organizations

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STOCKTON, CA, February 7, 2012– St. Joseph’s Medical Center has awarded $184,000.00 in grant funding to eight local community benefit organizations that provide critical health and human services to residents in San Joaquin County. St. Joseph’s administration, mission, and community benefit representatives distributed the grants, ranging from $25,000 to $50,000, during a luncheon held at the medical center.

“We serve our mission beyond our walls and create healthier communities through our Community Grants program,” stated Sr. Abby Newton, Vice President-Mission Integration, St. Joseph’s Medical Center and Vice President, St. Joseph’s Foundation. “By collaborating with area agencies who support advocacy and social justice for the most vulnerable members of our communities, we further the health care ministry of our religious sponsor who has continuously worked to reach and serve those in need.”

The Community Grants Program was established in 1990 to provide funding to community-based organizations that provide services to individuals in need. Since its inception, the program has distributed over $2,003,000 in grant funding to deserving nonprofit community benefit organizations with an interest in building healthier communities by improving health and living conditions. The program encourages organizations attempting to address the underlying causes of illness as well as specific health issues. This year, special consideration was given to programs promoting early access to prenatal healthcare, health and nutrition for children and adolescents, and basic access to health care for the low-income population and homeless Veterans. These health conditions were targeted as a result of community health needs assessments conducted by a partnership effort including local hospitals, county public health departments, and other community agencies.

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ARCH-APRI

2012

Education Series

MARCH 7

Managing Difficult Employees and Reducing Conflict in the Practice 12:15 – 1:15 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.

MARCH 21

HIPAA Update 2012 12:15 – 1:15 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.

APRIL 4

A Guide to Managing Upset and/or Difficult Patients 12:15 – 1:15 p.m.

Handling difficult or upset patients is a learned customer service skill. Staff need specific training including role playing to feel confident in turning an unhappy patient into a happy one. Understanding the underlying emotions patients may be experiencing also brings empathy to successfully resolving issues.

APRIL 11

Medicare Audits: How and Why 12:15 – 1:15 p.m.

Learn more about the current medical review audits currently being conducted by Palmetto GBA, California’s Medicare accounting contractor, including how they’re being conducted and the reasons for this special study.

APRIL 18

Best Practices for Managing Your Accounts Receivable 12:15 – 1:15 p.m.

Receiving maximum reimbursement with quick accounts receivable (AR) turnaround is a goal of every medical practice Using AR reports effectively allows the billing department, manager and physician to keep on top of this consistently.

APRIL 23

California’s Public Health Insurance Programs 12:15 – 1:15 p.m.

This session will provide a brief introduction to California’s public health insurance programs. It will be a very high level overview of the programs broken down by population eligibility, including a short example of what it is like to navigate the public health insurance system. We will conclude with a short compare and contrast of the health system in Massachusetts and what lessons can be learned as we move forward into 2014.

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spring 2012

May 9: Marketing 101 Aamer Hayat • 12:15 – 1:15 p.m.

Learn about Marketing 101 for the medical practice. Attendees will learn how patients are making decisions on health care today, and how you can become part of that decision making process.

May 16: Telephone Etiquette for Medical Personnel Mary Jean Sage • 12:15 – 1:15 p.m.

Proper telephone etiquette is one of the hardest things for people working in a medical office to value highly. Each of us who work in a medical office uses the phone every day to communicate with patients, other healthcare professionals and partners, and vendors – all customers of your medical practice. The quality of your telephone contact with customers is vital to the quality customer services offered throughout the practice.

May 23: Strategic Planning for Solo, Small & Medium Group Practices Rachel Smith • 12:15 – 1:15 p.m.

Does this sound familiar? You wake up and are taking care of patients all day while resolving a staff conflict, handling the honey-do list when you get home and attending to your medical staff, community or medical society responsibilities.

Have you asked yourself lately if you’re living the life or having the practice you expected? Learn how strategic planning and performance coaching can get you, your practice or your organization where you want to go.

June 6: A Manager’s Guide to Lowering Practice Costs Debra Phairas • 12:15 – 1:15 p.m.

There are only three ways to realize increased net income: raise fees, increase productivity or decrease overhead. With managed care, and particularly capitation,

increased fees are difficult to achieve.

The doctor may already be working at maximum capacity, so increased productivity may not be an option. In many areas of California, practices have higher overhead costs than national norms. The only way to assure profitability is to control and reduce overhead expenses.

June 20: Writing Effective Appeals Mary Jean Sage • 12:15 – 1:15 p.m.

It is inevitable that occasionally some of your insurance claims will be denied or your reimbursement will be whittled down significantly. The appeals process will require you to make explanations, submit documentation and follow up with additional information as requested.

A proper appeal will either get a denial reversed or give you exact reasons as to why the claim was denied. Knowing how to write a effective appeal letter that will get positive results from the insurance company is an essential part of any medical practice.

July 18: Preparing for a Medicare and/or Medi-Cal Audit Mary Jean Sage • 12:15 – 1:15 p.m.

All third-party payers, including government health plans, have stepped up their audit activity. It is no longer a matter of “if” you go through an audit, but “when” you are selected for an audit. It is always preferential to be prepared.

Aug. 1: Coding for Medical Necessity Arthur Lurvey, M.D. • 12:15 – 1:15 p.m.

Medicare and private payers all recognize medical necessity as a deciding factor for claims payment and it is important that all practices know the rules.

Aug. 15: Program Integrity in Medicare and Medi-Cal – The Physician’s Role Bruce Tarzy, M.D. • 12:15 – 1:15 p.m.

This session provides physicians with information about the risks of becoming a victim of fraud and how to take preventive action. It also covers compliance with Medicare and Medi-Cal documentation requirements.

Sept. 5: A Guide to Reviewing Payor Contracts Kris Marck • 12:15 – 1:15 p.m.

Kris Marck from CMA’s Center for Economic Resources will offer you tips

to maximize success in negotiating with a high-level review on contract terms and provisions. She will identify top provisions practices should be aware of prior to signing or renewing an agreement, because a contract is so much more than just reimbursement rates.

Sept. 19: Creating and Implementing Financial and Office Policies Debra Phairas • 12:15 – 1:15 p.m.

In the medical office, office policies and procedures are handed down verbally from one staff person to another. Inevitably, important elements of policies are lost in translation. Creating written financial and office policies and procedures help staff learn their jobs faster, with greater accuracy, and relieves physician and manager frustration!

Oct. 3: Protect Your Practice From Payor Abuse Mark Lane • 12:15 – 1:15 p.m.

CMA sponsored legislation (AB 1455 The Health Care Provider Bill of Rights) includes many protections against unfair payment practices by health plans and insurers. Mark Lane from CMA’s Center for Economic Resources will discuss important California laws that protect physicians and their practices from payor abuse.

Oct. 17: Establishing Expectations for High Performance from Medical Staff Debra Phairas • 12:15 – 1:15 p.m.

Superstar staff members are made, not born. Staff usually rise to the owner or manager’s level of expectations.

This webinar will teach physicians/ managers how to set high expectations for performance, create monitoring tools to evaluate and reward staff who achieve stellar performance.

Nov. 7: Understanding ARC and CARC Revenue Codes David Ginsberg • 12:15 – 1:15 p.m.

The use of remark codes and claims adjustment reason codes became standardized under HIPAA. The recent introduction of the 5010 standards further emphasizes use of these codes on remittance advices and payments made to medical offices by health insurers. Understanding the codes can assist medical practices in more effective payment posting and follow up on denials or payment reductions.

MAY-NOVEMBE

May 2: Medicare: Top 10 Claim and Documentation Errors That Cost Your Practice Money Kevin Garrick • 12:15 – 1:15 p.m.

This webinar has been designed to provide guidance to you when you receive a denial (specifically, should you file a new claim or request an appeal). This webinar will address the most common reason/remark codes associated with each denial, as well as descriptions for each. Also, with each denial, an explanation will be provided to assist you with resolving the denials and avoiding them in the future.

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.

spring 2012

SAN JOAQUIN PHYSICIAN 35

SAN JOAQUIN MEDICAL

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SAN JOAQUIN PHYSICIAN

SPrINg 2012

SOCIETY MEMBERSHIP COMMuNiCATiON AND ONLINE RESOURCES Members stay informed about practice management, local healthcare related stories, public health and other society news through our quarterly publication San Joaquin Physician and our bi-weekly e-newsletter, which features, more up-to-the-minute news items affecting your practice.

Our website features information for running your practice, direct access to hundreds of healthcare links and resources, and a practical Buyerâ&#x20AC;&#x2122;s Guide for locating professional resources and vendors.

Visit www.sjcms.org

CME

SPrINg 2012

SAN JOAQUIN PHYSICIAN 37

DocBookMD ...A smartphone platform designed by physicians for physicians, that provides an exclusive HIPAA-compliant professional network to

connect, communicate and collaborate...

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DocBookMD is supplied at no charge to SJMS members thanks to the generous sponsorship of NORCAL Mutual.

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SAN JOAQUIN PHYSICIAN

DocBookMD.com SPrINg 2012

DocBookMD

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Case Study SITUATION:

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A patient arrives at the pulmonologistâ&#x20AC;&#x2122;s office with arrhythmia of unknown onset and duration. The pulmonologist diagnoses A.fib with RVR and advises the patient to go to the ER for a work-up in the hospital.

The pulmonologist contacts the cardiologist at the hospital to facilitate admission of his patient.

The ER is notified that the patient is en route. The ER physician examines the patient and orders a repeat EKG. Upon review of the EKG, the ER physician diagnoses supraventricular tachycardia (SVT) and asks for the on-call cardiologist to be paged.

Nearly 15 minutes later, the ER physician and the cardiologist consult by phone to discuss the EKG results. The cardiologist must determine whether to admit the patient to the hospital for invasive treatment or allow the ER doctor to medically manage the patient without being seen by the cardiologist.

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Submitted by: Dr. S., Emergency Medicine, Austin TX For more information: info@docbookmd.com (512) 468 2070 DocBookMD.com

SPrINg 2012

SAN JOAQUIN PHYSICIAN 39

CMA Center for Economic Services

inSidE Cma’S

CEntEr for ECo in a pErfECt world, thE rElationShip bEtwEEn payor and phySiCian would bE a SimplE onE.

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SAN JOAQUIN PHYSICIAN

SPrINg 2012

phySiCianS’ ClaimS in a pErfECt world, on-timE and abSEnt EvEn thE SimplESt Coding Error, would triCKlE out to payorS, whilE rEimburSEmEnt would flow baCK in without iSSuE. EaCh SidE would havE a full undErStanding of thE othEr’S nEEdS, and ConfuSion would almoSt nEvEr ariSE.

unfortunatEly, aS any phySiCian Can tEll you, thE world iS far from a pErfECt plaCE. instead, today’s reimbursement process forces providers to navigate complex coding systems, evolving electronic health record requirements and a myriad of other complications that go hand-in-hand with practicing modern medicine. as a result, even the most efficient practice may have to deal with a denial rate of somewhere around 15 to 20 percent, according to some estimates. luckily, somewhere in this world of confusion, thousands of physicians across the state have found a place to turn for help. since 1999, the california medical association’s center for economic services (ces) has been offering

one-on-one assistance for member physicians struggling with reimbursement issues. boasting more than 125 years of combined medical practice operations, the team at ces fields calls from practices across california, handling everything from individual payment questions to more widespread problems that can lead to hundreds – or in some cases thousands – of claim being denied. more than just a staff at your average help-line, however, the team of practice management experts at ces is committed to getting results, and has been doing so in impressive fashion.

BY: JAMES NOONAN

nomiC SErviCES SPrINg 2012

SAN JOAQUIN PHYSICIAN 41

CMA Center for Economic Services

Pictured above from left to right: Jodi black, mark lane, jennifer williams, kristine marck, francisco silva (CMA CHIEF COUNSEL), frank navarro, michele kelly

CES staff recouped more than $2.7 million from payors on behalf of their members.

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SAN JOAQUIN PHYSICIAN

T

wo years ago, the CES staff posted a then-record-breaking year in which they recouped more than $2.7 million from payors on behalf of their members.

In 2011, they topped that figure, with the latest count totaling over $2.8 million. The figure may grow larger as the year rolls on, as several cases open in 2011 are still awaiting final resolution.

For the more than 1,300 different practices that called upon CES’ services last year, knowing that a team of qualified advocates is willing to act on their behalf provides a welcome sense of security.

“Our goal is to take the noise out of the system so that the physician can actually go back to practicing medicine,” said Jodi Black, Senior Director with CES who has spent the last seven years serving as an advocate for California physicians.

Black, along with her colleagues Frank Navarro, Mark Lane, Michele Kelly, Kris Marck and Jennifer Williams, make up the team at CES, and are responsible for delivering one of the most immediate and

tangible benefits offered by CMA. For an organization that counts more than 35,000 California physicians as members – and embarks on dozens of legislative and legal campaigns in a given year – a service that caters to the needs of individual members can be an invaluable one.

“I think the ‘human’ aspect of it is important,” said Marck, who spent more than two decades providing contracting services for health plans before joining CMA. “Getting to speak with someone who understands can make a big difference.”

In a business with complex contracts and rapidly changing regulations, this sense of “understanding” can be hard to come by.

“The business of medicine is really changing every day,” said Navarro, a 13-year veteran of CES who has more than 35 years of practice management experience under his belt.

A majority of these changes, he adds, are purely economical, designed to limit the payment amounts that plans are obligated to pay out to providers.

spring 2012

CMA Center for Economic Services

Need assistance?

Members can contact CMA’s reimbursement help line at (888) 401-5911 or economicservices@cmanet.org Visit CMA’s Center for Economic Services online at www.cmanet.org/ces Subscribe to CMA’s Practice Resources at www.cmanet.org/cpr

Across the state, thousands of practices were reporting payment stoppages on Medicare claims, causing cashflow problems that had many physicians bracing for the worst.

spring 2012

“Keeping up with all of this is difficult for a lot of small and solo practices,” Navarro said, adding that CES staff are included on regular mailing lists and spend countless hours thumbing through medical publications to stay on top of the latest revisions.

“Even for us, it’s difficult to keep up with all these changes,” he said. “Can you imagine being in a practice where you only have three staff? For those offices, we really are a lifeline.”

In order to serve as that lifeline, however, the team often faces the challenge of figuring out where things went wrong in the first place.

Lane, who spent roughly 16 years processing claims and conducting provider relations for two large insurance plans before joining CES, was able to explain the reimbursement assistance process in the simplest of terms.

“It’s kind of like finding that one needle in the haystack, and then doing everything you can to get it fixed,” he said.

With causes for denials ranging from illegible or missing signatures to a lack of timely filing or incorrect procedure code, getting to the root of the problem can often require a fair amount of detective work, Lane said.

Marck agreed, noting that it can be “easy to give an easy answer, but difficult to find the right answer.”

“Sometimes we can make a phone call and get it fixed,” Black adds. “Other times we can’t. It’s just not that simple.”

In some instances, these less than “simple” cases wind up being tied to a larger trend, meaning one or two calls for help can soon snowball into dozens of different practices looking for answers on the same issue.

“We only know what’s going on out there when practices call and tell us,” Black said.

Navarro agreed, noting that having physicians report problems was “hugely important” to CES’ efforts, because, as he put it, “if it’s happening to one, it’s happening to many.”

Navigating a challenging transition Perhaps the largest of these so-called “trend” cases to hit CES in recent memory came back in 2008, when Palmetto GBA took over for the National Health Information Center (NHIC) as the state’s Medicare claims processor.

The switch came as part of a national effort to help increase efficiency in the processing of Medicare claims. For participating physicians, the results were anything but.

Differences between Palmetto and NHIC’s operations meant that a sharp learning curve was tied to the statewide switch. This, as well as a host of logistical

SAN JOAQUIN PHYSICIAN 43

CMA Center for Economic Services

problems that arose during the transition, resulted in a nightmare for California physicians, Navarro said.

Across the state, thousands of practices were reporting payment stoppages on Medicare claims, causing cash-flow problems that had many physicians bracing for the worst.

Luckily, by working with both payor and provider, CES was able to help physician members navigate a transition that seemed

insurmountable at first glance.

“We literally helped thousands of practices get paid,” Navarro said, noting that CES’ assistance to one large-group practice resulted in claims totaling roughly $11 million being fully processed.

CES staffer Michele Kelly, who had spent nearly four decades with Transamerica and NHIC, the contractors previously responsible for administering the Medicare program,

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(209) 957-3888 caring support guidance choices

before joining CMA in 2008, noted that issues stemming from the switch dominated the center’s call volume during that transition period.

“It was difficult, particularly for the small and solo practices,” she said.

An emphasis on education In the complex world of insurance reimbursement, however, not every denied claim is the result of a newly written rule or statewide service change. In some cases, an error or misunderstanding on behalf of the provider could just as easily be the cause.

“It’s not always the plan’s fault,” Black said.

In order to help cut back on such occurrences, a large part of CES’ mission is to “educate physicians and their staff” on how to improve the efficiency of their practice, she added.

Evidence of this portion of the Center’s mission can be found on CMA’s recently revamped website, where CES has carved out its own mini practice management resource library that features on-line tool kits, contract analyses for all of state’s the major plans and a special ‘know your rights” section designed to help empower physicians.

Once a month, the staff at CES boils down the latest in practice management news for “CMA Practice Resources” (CPR), a regular publication distributed to more than 1,000 California physicians.

“A lot of what we do is education,” said Kelly, who operates out of CMA’s southern California office and frequently addresses county medical societies on topics relating to Medicare.

While their mission may vary from day to day, each member of the CES team noted that one thing remains constant throughout the phone calls, presentations and countless hours of research.

“The gratitude is just amazing,” Navarro said. “There isn’t a day that goes by that I don’t hear ‘thank you.’”

Though much of the advice and education offered of the CES might be complicated and nuanced by nature, it’s the most frequent tip delivered by the team that ends up being the simplest – “If you need help, call us.”

“Don’t hesitate,” Marck said. “I mean, why not?”

SPrINg 2012

The clock is running on implementation of federal health reform. Health care providers and payers are jockeying to position themselves for the impending changes in health care coverage, delivery and reimbursement. Who will survive the demands of the new marketplace? Who will prosper?

15th Annual California Health Care Leadership Academy

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The Transformation of Medical Practice April 27-29, 2012 • Disneyland Hotel • Anaheim, California

Featured speakers include: • John Chiang, California State Controller • Peter V. Lee, Executive Director, California Health Benefit Exchange Workshops include

Multiple Registration & Early-Bird Discounts

• Roadmap to Optimize Practice Revenue • Practice Acquisition: Strategies for Success • Managing Employment Risk in Turbulent Times • Managing Change Strategically and Effectively • Using and Integrating ICD-10 into Your Practice • Health Policy Advocacy in the Political Arena

Save up to $200 per person Register by March 30

• Communication and Interpersonal Collaboration

To Register, call 800.795.2262 or visit caleadershipacademy.com.

SPrINg 2012

SAN JOAQUIN PHYSICIAN 45

Dear SJMS member, l of having a nationa

litan areas can boast po

ro es et iti t m r c lec te se ar w qu n a fe he head Only the physicians i . When we think of t

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tions originate righ ca bli pu (across ed lat re nd building in Brookside er nt Prescriber’s Letter a Ce ch ar se Re et from your ot Therapeutic and across the stre – ce ffi the 20,000‐square‐fo l O ica ed M our Stockton the St Joseph’s of our staff work in rs the parking lot from be em 0 m t 6 ou d Canada. ch Lane). Ab oughout the U.S. an hr SJMS office on Mar d t ea pr e s ar st ing and the re headquarters build

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tions, databases, ana da en m om ec l r ca ini cl We create unbiased ive webinars. d l an s, am gr ro CME p ccreditations rned it the highest a ea as

y h vit cti bje d o ysicians and evidence‐base bscriptions from ph Prescriber’s Letter’s su nd s a cie en ag to provide our E accrediting tanding relationships from the major CM g‐s on e l av e h . W er worldwide h institutions as Kais medical institutions credited CME to suc ac rary of or Lib ns al tio ion da at en N m D, scape, WebM unbiased recom ed M s, kin op s H hn plo ians em yed by derson, Jo ealth Canada, physic nationwide, MD An , H DA , F lth ea H of Institutes d now SJMS. Medicine, National lus many others – an , p .K. U he d t an lia Austra the governments of n Steenburgh, so whe

cutive Director, Mike xe r E e ou er r y w fo we rd s, ga gh re ysician We’ve always had hi fit for San Joaquin ph n to provide a bene tio ho have been sa s w er an nv ici co ys d a ph te he initia any San Joaquin e m th t Browne, te cia re pp e a of our Board: Rober rs be em pleased to do so. W M as rs ea ri, hing for so many y Ted Lee, Darius Noo integral in our publis k, Raymond Wong, ac rim ss Steele. n P Ru re nd Da i, a y, um oll oz nn ark, John Mor M ey Jerry Jones, John Co Gu o, ag rs ea Stadtner and y Sheela Kapre, David ysicians, all San ese San Joaquin ph th

of ns tio bu tri on rk, and the c rescriber’s Letter Thanks to Mike’s wo

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pl m I a e. im g t ors for a lon e we can help.

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Editor‐in‐Chief Jeff Jellin, PharmD,

95219 Ln, Stockton, CA , 3120 W March er nt Ce ch ar 49 se 2.22 Therapeutic Re 40, FAX: 209.47 TEL: 209.472.22 ch.com ar se Re tic eu ap Ther

46 JOAQUIN PHYSICIAN 20 SAN SAN JOAQUIN PHYSICIAN

spring2011 2012 SPRING

SJMS Is Proud to Announce an Exclusive Benefit for Its Membership – Prescriber’s Letter Online, Mobile Access, and 25+ hours of CME...

Dear SJMS member,

Search: (Help) Search: (Help)

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Unbiased Evidence and Advice You Can Trust on New Developments in Drug Therap

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Your board members and I are always looking for ways to improve the value of your SJMS membership – constantly on the lookout for benefits that can help you practice your profession, or save your time, or your money.

Unbiased Evidence and Advice You Can Trust on New Developments in Drug Therapy

Welcome!

Welcome!

Home

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Continuing Education

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Prescriber Resources Rumor vs. Truth

New Drugs Colleagues Interact Us Rumor About vs. Truth

We’ve had our eye on Prescriber’s Letter for some time now. We have often thought how great it would be to get this for SJMS members.

Email Us

Colleagues Interact

Manage My Account

About Us Mobile Tell Jeff Email Us Access Agreement

Manage My Account Mobile Tell Jeff Access Agreement

And now I am so pleased it is a reality. Not only that, but we were able to get our members the highest level of service Prescriber’s Letter offers – its VIP Member level. VIP stands for “Very Informed Prescriber” and that speaks volumes about the special nature of this member benefit. Other physicians throughout the nation pay $250 for this service, and it is now included in your SJMS membership, at no additional fee to you.

CME

CME

• Take CME-in-the-letter

Some experts are backpedaling on aspirin • Take CME-in-the-letter CME-in -i -the-letter -in Some experts are backpedaling on aspirin • View your CME history to prevent heart disease.

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We know that aspirin is beneficial for SECONDARY that aspirin prevent is beneficial for Colleagues Interact We know prevention...to • Read Messages recurrent cardiovascular events.... read Colleagues Interact SECONDARY prevention...to prevent • Start a Discussion more...

• Read Messages recurrent cardiovascular events.... read Table of Contents of Current Issue • Account Start a Discussion Manage My Previous Issue more...

• View/Change My Information Table of Contents of Current Issue • Change Email Notifications Search Issue Manage My Account Previous • Simple New Drugs• View/Change My Information • Browse • List of New •Drugs Change Email Notifications • Advanced Search

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• Patient Safety • Hematology / • Bone/Joint and • Pediatrics Oncology Rheumatology • Practice BasedRumor vs. Truth Infectious Diseases •Charts Cardiology Patient •Handouts Guidelines Issues • Men's Health • Dermatology Browse Comparison • Psychiatry • Natural Medicines Formulary/Drug • Diabetes andby Category • Neurology and Pain • Renal/Urology Endocrinology Safety • Hematology• /Respiratory•/ Patient •• Bone/Joint and • Nutrition/Obesity Allergy Drug Information • Pediatrics • Women's Health and • OTCs Oncology •Rheumatology Drug Interactions Ob/Gyn Gastroenterology • Practice Based • Infectious Diseases •• Cardiology • Ophthalmology

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You now get online access to each and every Prescriber’s Letter drug therapy recommendation as soon as they are posted. You also get all the evidencebased details behind each recommendation, and other practice tools such as the PL Drug Formulary Comparison tools, PL Patient Handouts in English and Spanish, Treatment Guidelines, and all the other PL Detail-Documents.

You can access all of this on your computer, or mobile device of your choosing, including iPhones and Android phones.

We were also able to reserve every SJMS member a space on the monthly webinars where the Prescriber’s Letter Editorial Board deliberates and decides upon the Recommendations to be published. Plus, if your schedule does not allow you to listen to these sessions when they are offered live, you will have access to listen to the archived recorded sessions whenever you want.

Through this new arrangement with Prescriber’s Letter, your SJMS membership now includes more than 25 CME credits per year at no fee to you. You can get these CME credits from reading the Recommendations – from getting your clinical questions answered online at the Prescriber’s Letter website – and by participating in the live webinars or listening to the recorded webinars.

To begin taking advantage of this members-only benefit, visit our website at www.SJCMS.org and click on the Prescriber’s Letter logo located on our homepage, or you can just call our office (209-952-5299) and we’ll handle the entire subscription process for you.

All the Best!

Mike Steenburgh Executive Director spring 2012 SPRING 2011

Prescriber’s Letter Is Now a Member Benefit of the

21

SAN JOAQUIN PHYSICIAN 47 SAN JOAQUIN PHYSICIAN

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SAN JOAQUIN PHYSICIAN

SPrINg 2012

seLLInG YoUr

practice

TO A HOSPITAL-BASED INTEGRATED DELIVERY SYSTEM by: elizabeth zima

the DeCiSiON tO Sell a meDiCal PRaCtiCe tO aN iNteGRateD DeliVeRy SyStem (iDS), iNClUDiNG maNaGemeNt SeRViCe ORGaNizatiONS (mSO) OR PhySiCiaNhOSPital ORGaNizatiONS (PhO), iS a COmPleX ONe.

PHySiCiANS SHOuLD TRy TO MAxiMiZE THREE THiNGS iN THiS NEGOTiATiON: (1) net income over the next 10 or more years, (2) control, and (3) flexibility to pursue other avenues if the IDS is unsuccessful.

QuESTiONS PHySiCiANS SHOuLD ASK WHEN JOiNiNG AN iDS iNCLuDE: • Do I need the hospital’s money in order to achieve my practice goals?

• How much do I need?

• Is the hospital the best source of funds?

• Will I end up repaying some or all of the money to the hospital? (consider management fees) • What controls or other concessions will the hospital demand for its money?

Physicians should retain their own, independent legal and financial advisors to help guide them through the complex process of forming and joining an IDS.

WHO iS THE BuyER? Because of the prohibitions against the corporate practice of medicine, private inurement and kickbacks, the identity of the purchaser can have a significant impact upon the terms of the purchase. The most common form of transaction is for a lay entity to buy the tangible assets of a physician’s or medical group’s practice. In almost all cases, a professional corporation owned by at least one California physician offers the physician, or physician members of a medical

SPrINg 2012

SAN JOAQUIN PHYSICIAN 49

Selling Your Practice

group, an individual employment agreement.

Physicians may or may not be offered shareholder status within the professional corporation.

What is being purchased?

Is the physician selling his or her practice assets (such as furniture, fixtures and equipment) or stock – assuming the physician is professionally incorporated?

(Please note that a PHO, MSO or “foundation” cannot purchase the stock of a professional medical corporation. The stock can only be sold to another professional medical entity.) Purchasers generally prefer to buy assets rather than stock in order to avoid assuming the selling physician’s liabilities. Whether the physician’s accounts receivable will be purchased can be a tricky issue in part because of the problem of valuing the receivables. In some cases, the receivables are not purchased; in others, physicians are required to turn over their receivables in order to help finance the startup costs of the IDS. Finally, will the physician be paid anything for goodwill?

What is the purchase price?

Physicians are often lured to join an IDS by the prospect of receiving a “premium” price for their practices. And, in fact, this may be possible in some cases. On the other hand, hospitals may have “inurement” problems (if they are tax-exempt), as well as fraud and abuse concerns that will prevent them from paying more than fair market value for a physician’s practice.

The price of a medical practice is usually a combination of the value of the tangible assets (such as furniture and equipment), accounts receivable (if sold), and the practice’s “goodwill.” Tangible assets can be valued at their original cost (such as for medical supplies), at “book” or depreciated value, or at fair market or replacement value.

Determining goodwill is much more difficult.

Goodwill refers to the “going concern” value of a medical practice. This generally means the ability of the selling physician to transfer to the purchaser the practice’s reputation,

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SAN JOAQUIN PHYSICIAN

patients and earnings stream. Among the methods used to determine goodwill are discounted percentage of net cash flow, capitalization of the practice’s net earnings in excess of those of the “average” physician in that specialty and geographic area, and market comparables, if any are available.

Post-sale management services agreement In most IDS arrangements, physicians enter into a long-term management services agreement (MSA) with their new hospital “partner.” The terms of the MSA can be more important than the terms of the practice sale.

Among the key issues physicians need to consider are: What services will be provided pursuant to the MSA? How much will the physicians be charged for these services?

Will the physicians retain control (as they should) over all clinical matters?

Physicians should also retain ultimate control over the selection and retention of the chief executive officer of the IDS. Other key issues include the length of the term of the MSA and under what circumstances it can be terminated. Finally, physicians need to have the flexibility to terminate the MSA if the relationship proves unsatisfactory.

The California Medical Board clarifies necessary physician control in an MSA agreement When physicians consider entering into an MSA with a hospital, they should be aware that the Medical Board of California has expressed some concern that such an arrangement has potential to violate California’s bar on the corporate practice of medicine. According to the medical board, the following “business” or “management” decisions and activities, resulting in control over the physician’s practice of medicine, should be made by a licensed California physician and not by an unlicensed person or entity:

Control of a patient’s medical records, including determining the contents.

Selection, hiring/firing (as it relates to clinical competency or proficiency) of physicians, allied health staff and medical assistants.

Setting the parameters under which the physician will enter into contractual relationships with third-party payors.

Decisions regarding coding and billing procedures for patient care services.

Approving of the selection of medical equipment and medical supplies for the medical practice.

While a physician may consult with unlicensed persons in making the “business” or “management” decisions described above, the physician must retain the ultimate responsibility for the approval of those decisions. The medical board cautions against “non-physicians owning or operating a business that offers

spring 2012

California Medical Association Political Action Committee CALPAC needs your help to support candidates and legislators who understand and embrace medicineâ&#x20AC;&#x2122;s agenda.

Fighting for you!

Our top priorities are: 1. Protect MICRA 2. Preserve the ban on the corporate practice of medicine 3. Provide solutions to our physician shortage crisis!

Please visit www.calpac.org for more information

spring 2012

SAN JOAQUIN PHYSICIAN 51

Selling Your Practice

patient evaluation, diagnosis, care and/ or treatment” or “management service organizations arranging for, advertising, or providing medical services rather than only providing administrative staff and services for a physician’s medical practice (non-physician exercising controls over a physician’s medical practice, even where physicians own and operate the business).”

(See http://www.mbc.ca.gov/licensee/ corporate_practice.html.)

SPECiAL CONSiDERATiONS WHEN SELLiNG TO A MEDiCAL FOuNDATiON California law authorizes certain medical “clinics” to operate without a license (Health & Safety Code §1206.) To qualify, the clinics, generally referred to as 1206(l) foundations, must: Conduct medical research and health education and Contain 40 or more physicians and surgeons who are independent contractors, representing not less than 10 board-certified specialties, at least twothirds of whom must practice full-time at the clinic; and be exempt from taxation in accordance with 501(c)(3) of the Internal Revenue Code (Health & Safety Code §1206).

Working on the theory that this law exempts 1206(l) foundations not only from licensure, but also from the corporate practice of medicine bar, hospitals and

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SAN JOAQUIN PHYSICIAN

health systems have sought to create foundations by purchasing all of a large physician group’s practice assets, applying for and obtaining tax-exempt status from the IRS and then contracting with the former physician-owners to provide medical care to what are now the foundation’s patients.

Will the medical group’s physicians be shareholders?

CONDiTiONS REQuiRED FOR TAx ExEMPTiON To be tax-exempt, a 1206 (I) foundation must:

How long does the contract between the foundation and the medical group run?

Accept, as participating providers, all Medicare and Medi-Cal patients, without discrimination.

Accept all indigent patients needing urgent care, potentially including necessary follow-up care to hospitalized indigents at free or discounted rates, depending on the patient’s financial status.

Negotiate to participate in Medi-Cal and Medicare contracts, including Medi-Cal managed care contracts.

Conduct “significant” programs of medical research and health education.

What will be the term of the physician’s employment agreement with the foundation-affiliated medical group?

How will non-physician directors be selected?

How much will the medical group be compensated and for how long?

Will the hospital have an unfair advantage in contract negotiations and the split of income from capitation and other contracts?

Will the compensation arrangement be adequate to cover the charity care, research and education obligations that the medical group is being asked to assume?

How much say will the group have in utilization and quality improvement standards and protocols, the adoption of practice parameters, the development of drug formularies, or he purchase of new technologies?

Ensure that its hospitals maintain an open medical staff but not require physicians who contract with it to refer to its hospitals.

Will the foundation or the medical group have the last word on credentialing, medical practice policies, and hiring and firing of the group’s own physician members?

QuESTiONS TO ASK WHEN SELLiNG yOuR PRACTiCE TO A FOuNDATiON How much control of the new foundation will the physician have?

What will happen to the physician group’s current compensation policies regarding individual group members?

Is the medical group physician (or physicians) joining a multiple physician shareholder medical group or a single physician shareholder medical group (i.e., a professional corporation essentially controlled by the lay entity)?

For additional discussion and background regarding 1206(l) medical foundations, see CMA medical-legal library document #0218, “Legal and Practical Considerations Concerning Medical Foundations.”

SPrINg 2012

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SAN JOAQUIN PHYSICIAN 53

Owned by the policyholders we protect.

CMA feature

FAQs: The bar on the

corporate practice of medicine by: elizabeth Zima

What is the bar?

The bar on the corporate practice of medicine prohibits lay individuals, organizations and corporations from hiring or employing physicians, or from otherwise interfering with a physicianâ&#x20AC;&#x2122;s practice of medicine. It also prohibits these lay professionals from engaging in the business of providing health care services by contracting with health care professionals to provide those services. The corporate practice ban does not apply to physician partnerships or professional medical corporations because they are controlled by physicians (Business and Professions Codes §2052 and 2400).

Can hospitals employ physicians?

The California Attorney General has concluded that hospitals may not employ physicians to provide professional services. For example, to the extent a pathologist practices medicine (i.e., prescribes, diagnoses, etc.) as a hospital laboratory director, the nonprofessional corporate laboratory that employs the pathologist is unlawfully engaged in the practice of medicine.

To prevent violating the bar, doctors who work in hospitals form physician groups that enter into contracting agreements with hospitals. The medical group is responsible for paying the physiciansâ&#x20AC;&#x2122; salaries, not the hospital. Conversely, the medical staff at the hospital is responsible for granting practice privileges and for oversight of that emergency room physician or pathologist.

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SAN JOAQUIN PHYSICIAN

spring 2012

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CMA feature

Physicians can enter into contracts to provide services at a hospital, but the ability for physicians to share revenue with a hospital is also limited.

This can only be done as long as a physician’s independent contract with a hospital does not impair the physician’s freedom of action, and the compensation received by the hospital is commensurate with its expenses incurred in connection with furnishing the facilities and services rendered. If the payments to the hospital exceed the actual value of services rendered, this would be considered fee splitting and is illegal.

Are there exceptions?

Yes. Under limited circumstances, a hospital may directly employ a physician: Teaching hospitals: Business & Professions Code §2401 allows a clinic operated primarily for the purpose of medical education by a private or public nonprofit university medical school to charge for professional services for “teaching patients” rendered by physicians who hold academic appointments on the faculty. As long as the facility is used primarily for the purpose of medical education and the services are for “teaching patients,” employment is authorized.

Hospital districts: The Legislature created an exemption for hospital districts to employ physicians under extremely narrow circumstances.

County hospitals: The laws prohibiting the corporate practice of medicine do not apply to counties given the broad “police powers” granted to them. Thus, counties may employ physicians.

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SAN JOAQUIN PHYSICIAN

Are there other ways to legally circumvent the corporate bar?

No. Lay entities have attempted to circumvent the corporate bar by engaging physicians in various types of business arrangements, but these strategies are still illegal. For example, a lay entity/hospital might agree to handle all business decisions and employ a physician handle all clinical decisions.

However, it is difficult if not impossible to isolate “purely business” decisions from those affecting the quality of care delivered to patients.

For example, the purchase of a piece of radiological equipment could be looked at as a purely business consideration (cost, gross billing to be generated, space and employee needs) or a medical decision (type of equipment needed, scope of practice, skill levels required by the operators of the equipment and medical ethics) or by an amalgam of both.

In addition from prohibiting lay entities from taking outright control over traditional medical decisions, California law presumes that certain business arrangements can result in the lay control of the practice of medicine and automatically prohibits most lay entities from, among other things: Having an economic interest in the net profits of a medical practice, and/or Contracting with physicians on an employment or independent contract basis for the provision of medical services.

If a lay entity has a financial interest in a physician’s “bottom line,” then the entity has a direct interest in and ability to control the medical side of the business, such as how many hours the physician will work, what medications the physician may purchase, and what type of medical technology should be utilized. This is illegal.

spring 2012

According to the California Medical Board, the following “business” or “management” decisions and activities resulting in control over the physician’s practice of medicine should be made by a physician licensed in the State of California and not by an unlicensed person or entity: Ownership of a patient’s medical records, including determining the contents.

Selection (hiring/firing as it relates to clinical competency or proficiency) of professional, physician extender and allied health staff.

Setting contractual arrangements with third-party payors.

Decisions regarding coding and billing procedures for patient care services.

Approval of the selection of medical equipment for the medical practice.

Extreme caution should be taken if a hospital is trying to integrate medical practices through a “friendly” physician who has a majority stock in a medical corporation. An affiliated professional corporation can be used by hospitals to circumvent the bar. The courts and attorney general’s office can and do find such arrangements in violation of the bar

spring 2012

where it appears that the lay entity is controlling the practice of medicine.

For example, an appellate court condemned the formation of “straw man” corporations as an attempt to facilitate compliance with the corporate practice bar. In this case, physician owners “friendly” with a hospital held 58 percent interest in a medical corporation. Their interest, however, was held in trust for the hospital. The court concluded that the hospital was engaged in the unlawful corporate practice of medicine.

What are the penalties for violating the corporate practice bar?

Individuals who are not licensed as physicians or entities that engage in the corporate practice of medicine can be found guilty of a misdemeanor. Any person found guilty of a misdemeanor can be punished by a fine of $200 to $1,200, or by imprisonment for a term of 60-180 days, or by both fine and imprisonment. If the practice risks great bodily harm, serious illness or death, the violator is subject to imprisonment for a term not exceeding one year.

Physicians who violate the corporate practice bar by entering into agreements that violate the law can be charged with aiding and abetting an unlicensed person to engage in the practice of medicine. This activity constitutes unprofessional conduct, which can result in loss of licensure.

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For more information, see CMA medical-legal document #0280, “Corporate Practice of Medicine Bar.”

SAN JOAQUIN PHYSICIAN 57

San Joaquin Medical Society and CMA Members Enjoy: Vast CMA Resources:

Serving the counties of San Joaquin, Calaveras, Alpine, and Amador

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Contract Analysis Reimbursement Hotline Legal Hotline Legislative Hotline HIPPA Compliance Free Monthly Webinars on various topics Extensive Online Resources including over 200 letters, agreements, forms, etc.

• Plus – Free Legal Advice with CMA ON-CALL Documents

San Joaquin Medical Society Resources: • Online Prescriber’s Letter subscription • DocBookMD phone app • Annual Directory • Free CME Seminars • Cost Saving Benefits • Quarterly Publication • Website/Online Resources • Insurance Savings • Alliance Membership • Annual Social Events • Patient Referrals • Office Manager Forum and Practice Resources

Your Membership Investment supports our Advocacy efforts on your behalf in Sacramento and Washington DC

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www.sjcms.org

SAN JOAQUIN PHYSICIAN

SPrINg 2012

giving back

Martin Luther King Jr. Quotes: All labor that uplifts humanity has dignity and importance and should be undertaken with painstaking excellence.

A genuine leader is not a searcher for consensus but a molder of consensus.

Trading in your white coat for gardening gloves Kaiser Permanente pediatrician Daksha Vaid, MD, traded in her white coat and stethoscope on Martin Luther King Jr., Day for gardening gloves and a rake.

By Elizabeth Schainbaum

She was among more than 50 than Kaiser Permanente physicians and employees volunteering at the Dorothy L. Jones Community Center in Stockton during a day that has turned into a call for community service. The community center offers low-income families a host of services, including basic health care and social services assistance, job training, tax preparation, and more.

Heeding that call, Kaiser Permanente has for many years organized numerous community service projects for its employees and physicians; this year more than 1,111 employees and physicians throughout Northern California volunteered. This was the first year, Kaiser Permanente coordinated a project in Stockton where volunteers gardened, painted and otherwise beautified the center.

Meanwhile, a 30-minute drive away in Modesto, dozens of employees and physicians, including Bill King, MD, Kaiser Permanente’s Assistant Physician In Chief of Hospital Operations for the Central Valley, worked on a Habitat Humanity project, building houses in a subdivision.

This past Martin Luther King Jr. Day, Jan. 16, was the third time in five years Dr. Vaid of Stockton has

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SAN JOAQUIN PHYSICIAN spring 2012

volunteered through Kaiser Permanente’s Day of Service.

During this particularly chilly morning, she was in front of the center weeding and cutting down shrubs in preparation for installing a lawn.

“We need to be a part and serve the community we live in,” said Dr. Vaid, who has been a San Joaquin Medical Society member since 1993. “I believe in serving the community.” She used to have her children volunteer alongside her but they are grown up now.

The 19-year KP doctor said this year’s project carries special meaning because it’s in Stockton, where she lives and works.

Dr. Vaid had just worked long shifts for several days in a row—but she said she was motivated to wake up early, tie her into a pony tail, and put her hands to the task.

“It’s so worth it. It’s relaxing. I’m working up a sweat,” she said with a smile. “I earned a nap.”

Martin Luther King Jr. Day isn’t the only time she volunteers. When Dr. Vaid returns to her native India she also sets up a clinic.

“There are a lot things we can do to help other people.

Anytime I can do something, I will. It’s a part of me,” she said. “Whenever I do, I feel good about it.”

A man can’t ride your back unless it’s bent.

A man who won’t die for something is not fit to live.

A nation or civilization that continues to produce soft-minded men purchases its own spiritual death on the installment plan.

A right delayed is a right denied.

A riot is the language of the unheard.

All progress is precarious, and the solution of one problem brings us face to face with another problem.

An individual has not started living until he can rise above the narrow confines of his individualistic concerns to the broader concerns of all humanity.

Source: www.brainyquote.com/quotes/ authors/m/martin_luther_king_jr.html

SPrINg 2012 SAN JOAQUIN PHYSICIAN 59

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2/20/12 4:07 PM

In Memoriam

In Memoriam James Popplewell • Alvaro Gaddi Punla, M.D. • Antonio R. Saqueton, M.D.

CLARENCE “JACK” LEARY JR. M.D. June 9, 1921 – January 2, 2012 Clarence (Jack) Leary, Jr. M.D. went peacefully to his rest on January 2, 2012, with his wife, Elsie, of 66 years at his side. Dr. Leary joined the San Joaquin Medical Society and the California Medical Association in 1957. His contribution to the health and well-being of Lodi area patients, to education and the improvement of medical care, spanned over 50 years.

Born in Lodi, Dr. Leary attended Harmony Grove School, and graduated from Lodi High in 1939. While at Pacific Union College, he excelled in Chemistry and was an Assistant Organic Chemistry Instructor. Dr. Leary graduated from Loma Linda University School of Medicine in 1945.

During World War II, the young Doctor served in the Army Specialized Training Corps and with the Veterans Administration. He mewt Elsie, then a student nurse and they soon married. The two lived in Washington, New Orleans, Pennsylvania and Stockton before moving to Lodi in 1959.

During his years as an orthopedic surgeon, Dr. Leary held a number of leadership roles; he served two terms as Chief of Staff and was an Executive Officer of the Board at Lodi Memorial Hospital, a Founder of the Lodi Outpatient Surgery Center, and a Chairman of an early day health Foundation. Dear to his heart was time he invested with Loel Center as Chairman of the Board. Interested in education, Dr. Leary served as Chairman on the SDA Elementary School Board and conducted “Stop Smoking Classes” over a period of time.

His “Dr. Jack” health column in the Lodi News-Sentinel held forth for seven years.

Although so busy, dedicated to his work, his patients, and certainly to his family and friends, Dr. Leary had a warm and loving heart, and was always willing to go the “second mile”.

Jack’s survivors include his wife, Elsie; son Kevin (Heidi) Leary; two daughters Jenanne (Robert) Rodriguez and Shauna (John) Unser. Grandchildren, Chase and Jacqueline Leary, Loni Unser, Trevor and Christopher Phan; two step grandchildren, Jonathan Rodriquez and Erica Hazlett; two greats, Madelina and Christian Hazlett. He was preceded in death by his parents, Clarence Sr. and Jennie Leary; his sister, Beverly; and his daughter Melissa Pahn.

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In Memoriam

JAMES POPPLEWELL 1946-2011 Dr. James Popplewell, a prominent Stockton family practitioner and leader in the treatment of the developmentally disabled, passed away on 12/24/2011 at age 64. Born in Oakland, Dr. Popplewell finished high school at age 15, and after graduating from Berkeley, enrolled at the famed Defense Language Institute in Monterey where he learned Japanese. After serving in Vietnam as an intelligence officer, he received a medical degree from the University of Hawaii in 1976. He completed his residency at San Joaquin General Hospital began his family practice career in Stockton.

Soon he joined Valley Mountain Regional Center and engaged in a lifetime endeavor to treat patients with various developmental disabilities, a field in which he became a recognized authority. He was known for his dedication to these patients, and his old fashioned bedside care which has become so rare nowadays.

Dr. Popplewell had many interests outside medicine including the Whale Watch Inn at Mendocino Country which he owned and ran, as well as photography and working outdoors. He is survived by his wife Kazuko and daughter Kristen.

ALVARO GADDI PUNLA, M.D. February 19, 1925 – January 4, 2012 Dr. Alvaro Punla passed away on January 4 surrounded by his loving family. He was 86 years old.The Doctor was a member of the San Joaquin Medical Society and the California Medical Association for over 40 years.

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Dr. Punla was a native of Masantol, Pampanga (PHIL), where he was the valedictorian of his class at Pampanga High School. As a 1954 graduate of the University of the Philippines, College of Medicine, Dr. Punla completed his internship at St. Clare’s Hospital in Schenectady, NY, and his residency in general surgery at Rhode Island Hospital in Providence, RI., where he served as the Chief Resident.

Dr. Punla then returned to the Philippines to practice medicine and surgery, and later immigrated to the United States with his family to continue his practice. In 1971, he established his clinic in Stockton, CA. Dr. Punla also served as a part-time physician at the Agricultural Workers’ Health Centers. After nearly 40 years as a physician he retired from his private practice in 1994.

Dr. Punla was an enthusiastic gardener who spent countless hours tending his gardens both in Stockton, CA and Princeville, Kauai (HI).

He enjoyed working on his garden projects, domestic and foreign travel and frequent visits with his children and grandchildren.

He is survived by his wife of 49 years, Carmen Punla; children, Victoria Mah (David) of Virginia, Oscar R. Punla, M.D., Maria Veronica Smith, D.D.S. (David) of Wisconsin, Joseph Punla; and grandchildren Ryan and Anthony Mah, and Samuel, Benjamin, Nicholas and Daniel Smith.

ANTONIO R. SAQUETON, M.D. Dr. Antonio R. Saqueton was a Filipino physician who was in practice in the 1970s and 1980s. He had a family practice at the Filipino Center on Center Street in downtown Stockton.

Saqueton completed his residency at San Joaquin General Hospital. He was instrumental in helping establish National Patient Week through Rep. John McFall, who introduced the resolution in Congress. It is observed every third week of October.

Another idea of his was to initiate Doctor’s Day, celebrated every year in March at St. Joseph’s and Dameron hospitals. He embarked on a blood-pressure screening during his tenure as president of FILMAPS, the Filipino Medical and Allied Professional Society.Saqueton, 73, passed away in January in Stockton. He will surely be missed.

Submitted by Graciela A. Barzaga, M.D.

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We are Seeking

YOUR LIFETIME ACHIEVEMENT AND YOUNG PHYSICIAN AWARD NOMINATIONS Don’t miss the opportunity to recognize a fellow colleague who has inspired or mentored you in your own medical career. Each year our society recognizes two outstanding physician members who have demonstrated exemplary care - not just for their patients, but also their community and the world in which they live.

We will accept nominations via fax or mail for each of these awards up to Friday, March 21, 2012. Please provide us detailed information on your nominee’s accomplishments and community involvement. The Young Physicians Award is exclusive to physicians under the age of 45. Nomination Forms are available online at www.SJCMS.org and have also been mailed directly to each member.

Our Nominating Committee (consisting of all past presidents and past LTA recipients, some of which are pictured here) will evaluate all submitted nominations for each of these awards.

The following criteria will be taken into consideration for these prestigious awards: • Dedication to high standards of medical practice.

• Dedication to the care and well being of the patients of their community.

• Dedication to the support of physician colleagues in the medical community.

• Involvement in humanitarian activities.

• Involvement in community civic activities.

• Leadership in the medical and/or civic communities.

Your input in this process is very important. To submit your nominations for the Lifetime Achievement Award and/or the Young Physicians Award please fax them to 209-952-5298 or, should you have any questions please call 209 952-5299.

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SAN JOAQUIN PHYSICIAN 63

New Memberts

39

NEW MEMBERS IN THE PAST 60 DAYS! ...

64

Seth Ackuayi, MD Internal Medicine Kaiser Permanente 1721 W Yosemite Manteca, CA 95337 • Office: (209) 550-1556 University of Science & Technology: 1993

Frances Allocco, MD General Surgery Kaiser Permanente 7373 West Lane Stockton, CA 95210 • Office: (209) 476-2000 University of Chicago: 2002

Michael Broyles, MD Obstetrics & Gynecology Kaiser Permanente 7373 West Lane Stockton, CA 95210 • Office: (209) 476-2000 University of Arizona: 2005

David Cornish, MD Gastroenterology Kaiser Permanente 7373 West Lane Stockton, CA 95210 • Office: (209) 476-2000 Boston University: 1980

Timothy Dixon, MD Anesthesiology Kaiser Permanente 7373 West Lane Stockton, CA 95210 • Office: (209) 476-2000 University of California School of Medicine - San Diego: 1985

Lisa Dorsey, MD Family Medicine Sutter Gould Medical Foundation 2545 W Hammer Lane Stockton, CA 95209 • Office: (209) 954-4040 University of Illinois: 1998

SAN JOAQUIN PHYSICIAN

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AND EVEN MORE ON THE WAY.

Rosamani D’Souza, MD Internal Medicine Kaiser Permanente 2185 W Grant Line Road Tracy, CA 95377 Siddhartha Medical College, University of Health Science: 1992

Loraine Escarcha, MD Pediatrics Kaiser Permanente 2185 W Grant Line Road Tracy, CA 95377 University of the City of Manila, College of Medicine: 1987

Roderick Estrada, MD Pediatrics Kaiser Permanente 2185 W Grant Line Road Tracy, CA 95377 Medical College of Wisconsin: 1999

Felecia Froe, MD Urology Kaiser Permanente 1777 W Yosemite Ave Manteca, CA 95337 University of Missouri School of Medicine: 1987

Oscar Galan, MD Internal Medicine Kaiser Permanente 7373 West Lane Stockton, CA 95210 Office: (209) 476-2000 • University of the East, Ramon Magsaysay Memorial Medical Center: 1997

Cheryll Gallardo-Villena, MD Internal Medicine Kaiser Permanente 7373 West Lane Stockton, CA 95210 • Office: (209) 476-2000 University of The Philippines College of Medicine: 1983

Kanwal Gill, MD Emergency Medicine Kaiser Permanente 1777 W Yosemite Ave Manteca, CA 95337 University of California School of Medicine San Francisco: 1999

Madhu Gupta, MD Family Medicine Kaiser Permanente 2185 W Grant Line Road Tracy, CA 95377 Lady Hardinge Medical College, Delhi University: 1985

Thailai Hyunh, MD Internal Medicine Kaiser Permanente 1777 W Yosemite Ave Manteca, CA 95337 Medical & Pharmaceutical University: 1991

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SAN JOAQUIN PHYSICIAN 65

New Memberts

Andrew Jaramillo, MD Emergency Medicine Kaiser Permanente 1777 W Yosemite Ave Manteca, CA 95337 University of New Mexico School of Medicine: 1976

Jevon Johnson, MD Psychiatry Kaiser Permanente 7373 West Lane Stockton, CA 95210 • Office: (209) 476-2000 University of Southern California School of Medicine: 2006

C Darryl Jones, MD Diagnostic Radiology Kaiser Permanente 2025 Morse Ave Sacramento, CA 95825 • Office: (916) 928-1488 University of California – SF: 1988

Sophie Kay, DO Emergency Medicine Kaiser Permanente 1777 W Yosemite Ave Manteca, CA 95337 New York College of Osteo Medicine of NY Inst of Tech: 2004

Khin Khine, MD Family Medicine Kaiser Permanente 7373 West Lane Stockton, CA 95210 • Office: (209) 476-2000 Institute of Medicine I: 2001

Darshana Kittur, MD Obstetrics & Gynecology Kaiser Permanente 7373 West Lane Stockton, CA 95210 • Office: (209) 476-2000 State University of New York Health Science Center at Syracuse: 2007

Chen Lang, MD Urology Kaiser Permanente 1777 W Yosemite Ave Manteca, CA 95337 Northwestern University Medical School: 2004

Ahmed Mahmoud, MD Thoracic Surgery San Joaquin General Hospital 500 W Hospital Road French Camp, CA 95231 • Office: (209) 468-6622 University of Alexandria: 1981

Rebecca Mammo, MD Ophthalmology Center for Sight 1805 N California St, Suite 101 Stockton, CA 95204 • Office: (209) 948-5515 Harvard Medical School: 2000

Kimberly McLaughlin, MD Obstetrics & Gynecology P Gill OB/GYN Medical Group 1617 N California St, Suite 2A Stockton, CA 95204 Office: (209) 466-8546 • Drexel University: 2004

Uday Nadgir, MD Sutter Gould Medical Foundation 2505 W Hammer Lane Stockton, CA 95209 Office: (209) 524-1211 Mysore University: 1998

Kevin O’Dell, MD Neurology Kaiser Permanente 7373 West Lane Stockton, CA 95210 • Office: (209) 476-2000 University of Illinois College of Medicine: 1997

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William Probst, MD Obstetrics & Gynecology Kaiser Permanente 2185 W Grant Line Road Tracy, CA 95377 University of Missouri School of Medicine: 1990

Madhavi Ravipati, MD Obstetrics & Gynecology Kaiser Permanente 2185 W Grant Line Road Tracy, CA 95377 Sri Venkatesvara Medical Coll, S V University: 1999

Bradley Reinke, MBA, MD Dameron Hospital 525 W Acacia St Stockton, CA 95203 Oral Roberts University: 1985

Jennifer Reyes-Ng, MD Family Medicine Kaiser Permanente 2185 W Grant Line Road Tracy, CA 95377 Fac of Medical & Surg-University of Santo Tomas: 1999

Peggy Saint-Croix, MD Family Medicine San Joaquin General Hospital 500 W Hospital Road French Camp, CA 95231 • Office: (209) 468-7457 University of Medicine & Dentistry of New Jersey : 1996

Prithipal Sethi, MD Urology 1805 N California St, Suite 303 Stockton, CA 95204 • Office: (209) 464-3627 St. Louis University School of Medicine: 1999

Marie Udekwu, MD Anesthesiology Kaiser Permanente 7373 West Lane Stockton, CA 95210 • Office: (209) 476-2000 University of Lagos Medical School: 1981

Beatriz Villabona, MD Pediatrics Kaiser Permanente 7373 West Lane Stockton, CA 95210 • Office: (209) 476-2000 National University of Colombia: 1986

Wilhelm Wang, MD Internal Medicine Kaiser Permanente 7373 West Lane Stockton, CA 95210 • Office: (209) 476-2000 Taipei Medical College: 1980

RESIDENTS:

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Gustavo Fernandez-Ranvier, MD General Surgery San Joaquin General Hospital 500 W Hospital Road French Camp, CA 95231 Office: (209) 468-6622 University of Buenos Aires: 1999

Shawn Fu, MD General Surgery San Joaquin General Hospital 500 W Hospital Road French Camp, CA 95231 Office: (209) 468-6000 Brown University Program in Medicine: 2010

Cora Hoover, MD Family Medicine San Joaquin Public Health 1601 E Hazelton Ave Stockton, CA 95205 Office: (209) 468-3859 University of California School of Medicine - San Francisco: 2000

SAN JOAQUIN PHYSICIAN 67

at a glance

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spring 2012

Our Future

Each summer brings forth a fresh crop of young students for our highly respected Decision Medicine program. Letters of personal invitation to participate as a mentor physician will be arriving later in the month. We hope you commit the time to make a difference in one of their lives. After all, they are our future.

Have a photo you would like to submit?

Email the photo along with your information to sherry@cmsservices.org

spring 2012

SAN JOAQUIN PHYSICIAN 69

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Clubhouse Amenities: - Grand Ballroom for events - Casual & Formal Dining Rooms - Grill Room overlooks 18th Green - Locker rooms with Spas/Steam Room

SPrINg 2012

STOCKTON MRI & Molecular Imaging Medical Center, Inc. 2320 N. California Street • Stockton, CA 95204 PHONE 209-466-2000 • Fax 209-466-2600 w w w. s to c k to n m r i . co m

The Most Advanced and Comprehensive Medical Imaging Center in San Joaquin County Just Got Better with the Addition of the Central Valley’s only 128 Multislice CT Scanner with Lowest Radiation Dose Imaging Services Include: • • • • •

The first PET-CT since 2003 Full service of Nuclear Medicine Most advanced G. E. High Field MRI (1.5 Tesla) Full service of Digital Radiography and Fluoroscopy New GE Logic 9e 3D & 4D Ultrasound Unit

All Board Certified Radiologists with fellowship: Javad Jamshidi, MD Jack L. Funamura, MD Benjamin Covington, Jr., MD Oscar Isidoro, MD Brij J. Kapadia, MD

The Fastest 128 Multislice High Resolution CT in community practice:

Siemens Somatom Definition AS+ (128) spring 2012

SAN JOAQUIN PHYSICIAN 71

San Joaquin Medical Society 3031 W. March Lane, Suite 222W Stockton, California 95219-6568

PRSRT STD. U.S. POSTAGE

PAID

Permit No. 60 Stockton, CA

in a row of a.M. Best “A” (ExcEllEnt) RAting

renewal rate

28

of last

95

or very satisfied

years

totAl DiviDEnDs DEclARED

Customers satisfied

total years deClared dividend

93%

32 34

$425M

RETURN SERVICE REQUESTED

To make a calculated decision on medical liability insurance, you need to see how the numbers stack up—and there’s nothing average about NORCAL Mutual’s recent numbers above. We could go on: NORCAL Mutual won 86% of its trials in 2010, compared to an industry average of about 80%; and we paid settlements or jury awards on only 12% of the claims we closed, compared to an industry average of about 30%.* Bottom line? You can count on us. *Source: Physician Insurers Association of America Claim Trend Analysis: 2010 Edition.

strenghten your Practice at norcalMutual.coM Proud to be endorsed by the San Joaquin County Medical Society.

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