March 2017 by SMCMA

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MARCH 2017 - VOLUME 6, ISSUE 3

www.PhysiciansNewsNetwork.com EDITORIAL COMMITTEE

Russ Granich, MD | President Alexander Ding, MD | President-Elect Sara Whitehead, MD | Secretary- Treasurer Michael Norris, MD | Immediate Past President Janet Chaikind, MD Uli Chettipally, MD Mamatha Chivukula, MD Paul Jemelian, MD Alex Lakowsky, MD Richard Moore, MD Joshua Parker, MD Xiushui (Mike) Ren, MD Brian Tang, MD Dirk Baumann, MD | AMA Alternate Delgate Scott A. Morrow, MD | Health Officer, County of San Mateo www.SMCMA.org facebook.com/smcma | twitter.com/SMCMedAssoc. EDITORIAL

San Mateo County Physician is published ten times per year by Physicians News Network (PNN) and the San Mateo County Medical Association. Opinions expressed by authors are their own and not necessarily those of PNN or SMCMA. San Mateo County Physician reserves the right to edit contributions for clarity and length, as well as to reject any material submitted.

On The Inside 2................President’s Letter | Russ Granich, MD Reflections 4................Healthcare 2017 Is MACRA Actually a Good Idea? Webinars and Options 6................Healthy Financial Planning | TAXES 10..............The Gift of Life The Dead-Donor Rule and Organ Donation By Judy Chang, MD 12..............SMCMA New Member Updates

Acceptance and publication of advertising does not constitute approval or endorsement by the San Mateo County Medical Association of products or services advertised.

M A RC H 2017 | S A N M AT E O C O U N T Y P H Y S I C I A N 1

PRESIDENT’S MESSAGE

REFLECTIONS BY RUSS GRANICH, MD I have never watched as much news as I do now. I crave it; every day my TV is tuned to news as is my XM radio. We all have had a lot to ponder, regardless of our political views. In my musing, I found two things that piqued my curiosity. The first is the expression that says something like “May we live in interesting times.” And is considered a curse. I’ve heard this bantered around recently. But why a curse? Change can be good; boring is not always good. It all depends on your perspective. This line has been used many times by famous people, for example: There is a Chinese curse which says ‘May he live in interesting times.’ Like it or not, we live in interesting times. They are times of danger and uncertainty.

PHOTO BY SCOTT BUSCHMAN

“The biggest taxi company in the world does not own a single cab. The largest lodging company

However, I wanted to find out where this really came from. My sinophile friends denied any Chinese curse, so I resorted to another source, namely TheQuoteInvestigator.com. It turns out that the first reference to this expression was over 100 years ago and had nothing to do with a Chinese saying. Most likely the “curse” part was a misinterpretation or rather an inaccurate recollection of another Chinese saying by a British diplomat in the 1930s. The actual first use of it basically says interesting times are exciting but, like all change, can be anxiety provoking: I think that you will all agree that we are living in most interesting times. I never remember myself a time in which our history was so full, in which day by day brought us new objects of interest, and, let me say also, new objects for anxiety. -In a speech given by British statesman Joseph Chamberlain in 1898 (He was the father of future Prime Minister Neville Chamberlain.)

does not own any rooming facilities.”

-Robert Kennedy, 1966, Day of Affirmation speech, South Africa

The second reflection I find ironic. When President Trump’s expression “Make America Great Again” was widely used, I saw some interviews of supporters and basically the America they described was the 1950s. The economy was strong and manufacturing was the backbone. In many ways his other campaign promises roll back some of the progress we have made in women’s rights and the right to vote. He promises to bring back industrial jobs. But, if we look at society, it grows and changes, and we moved from an industrial age to the information age and now to the social media age. The biggest taxi company in the world does not own a single cab. The largest lodging company does not own any rooming facilities. But they both, Uber and Airbnb, have leveraged information and social media. What’s ironic? Social media was an important reason for Trump’s victory and still an important part of his presidency, yet he wants to bring America back to a period when it didn’t exist. Personally, and this is all my opinion, not that of your medical society, I don’t think we can ever go back; we can only go forward. We certainly do live in interesting times.

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Healthcare 2017

MACRA

Is Actually a Good Idea?

By Sierra Hersek

The implementation of MACRA (Medicare Access and CHIP Reauthorization Act of 2015) is under way, and the California Medical Association (CMA) and experts across the country agree that MACRA is the number one reimbursement issue facing physicians in 2017. Physicians are concerned not only about how MACRA will impact their practice but also how it will be tied to their patients’ outcomes. But could it actually be the best solution to the complex issue of reimbursement? “MACRA replaces the old, unsustainable program and substitutes it with a payment formula that physicians can decide how and what they will do to impact their payment,” Lisa Esch, chief population health innovation officer for technology solutions company CSC, told Physician Magazine. “Physicians actually have a real opportunity to thrive under MIPS [Merit-based Incentive Payment System], with the help of established incentive programs such as Chronic Care Management (CCM). CCM provides reimbursement for consistent and effective communication with high-risk Medicare patients outside of the clinical setting. Implementing a comprehensive care coordination process through consistent patient engagement not only improves patients’ well-being but also offers a financial upside, if done at scale.” “Furthermore,” Esch added, “this population health strategy also checks off many of the clinical and quality measures MIPS requires, helps you succeed under MACRA starting year one, and positions the provider on the positive side of the competitive peer compensation spectrum.” Esch added that, with 2017 under way, “getting started does not need to feel ominous. Flexibility incentives, positive standings, and performance bonuses are all pretty attainable. Whether leveraging the tools already in possession or working with a partner to walk alongside during these changing times, it’s imperative to do something today that can help both the practice and the patients on the journey to value-based care.” To that end, Physician Magazine asked Cheryl Bradley, CMA’s Medicare reimbursement specialist, what physicians can do to stay informed. “A great resource for physicians trying to understand MACRA is CMS’ Quality Payment Program website [qpp.cms.gov],” according to Bradley. “The website is very user-friendly, offering great information and clear instructions in one place. It takes a complicated, 2,400page rule and makes it easier for physicians to understand.” In addition Bradley recommended that physicians explore the noridianmedicare.com website, which offers a variety of resources and information, including a fee schedule to better understand what physicians are reimbursed for, as well as medical review options and required documentation checklists. “These tools will help physicians avoid timely appeals that often happen when reimbursement requirements are not understood. That slows their revenue and diverts office staff to the appeals process,” said Bradley.

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Healthcare 2017

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) ends the sustainable growth rate formula and transitions physicians to the Quality Payment Program. According to the Centers for Medicare and Medicaid Services (CMS), this change offers new tools, models and resources to help physicians give patients the best possible care. The Quality Payment Program offers two participation options that physicians can choose based on their practice size, specialty, location or patient population. The first option, Advanced Alternative Payment Models (APMs), is meant for physicians who bill Medicare more than $30,000 a year and provide care for more than 100 Medicare patients a year. Both requirements must be met to participate in the program. This is a change in the original proposed rule; CMS raised the minimum billing requirement from $10,000 to $30,000, relieving nearly a third of Medicare physicians from participating in an effort to ease reporting requirements for rural and smaller practices. With the second option, MIPS, MACRA’s Merit-Based Incentive Payment System, which is anticipated to initially apply to more than 90% of eligible clinicians, participants earn a payment adjustment based on evidence-based and practice-specific quality data composed of four components: • Quality • Clinical Practice Improvement Activities • Advancing Care Information • Resource Use The use of electronic health records (EHRs) is required for participation and reporting.

As of 2018, physicians must use EHR technology that is certified for 2015. This forces physicians to upgrade EHR systems that, according to the Office of the National Coordinator for Health Information Technology, which establishes the certification criteria, more than 75% of providers participating in the Medicare EHR Incentive Program as of July 2016 had 2014-certified edition technology, which is now out of date. If you’re considering purchasing or upgrading your existing EHR, you should discuss the EHR certification timeline with your vendor, according to Matt Reid, senior health IT consultant, in an AMA podcast. For example, he explained, ask your vendor: • How they plan on transitioning your EHR from 2014 to 2015 edition • What system downtime the transition might include • Whether your staff will require new or additional training following the transition • What costs are associated with upgrading the EHR to the 2015 edition • What new or enhanced features you will receive with the upgrade • How 2015 edition EHRs will change your current workflow • With Meaningful Use being replaced, how different will your dashboards look • What CPIAs [Clinical Performance Improvement Activities] will the EHR help you more easily accomplish • What steps and costs are associated with connecting your EHR to both a clinical registry and a health information exchange.

CMA offers several webinars on MACRA implementation. These webinars are free to CMA members and $99 for non-members. CMA webinars: • Medicare Changes: 2017 and Beyond (Recorded 1/25/17) • MACRA: The Final Rule and How to Get Ready (Recorded 12/7/16) • MACRA Implementation: A Review of CMS Final Rule (Recorded 11/30/16) The AMA also offers a MACRA assessment tool, the Payment Model Evaluator, for physicians to determine which program fits them best, MIPS or APMs.

MACRA Options

M A RC H 2017 | S A N M AT E O C O U N T Y P H Y S I C I A N 5

TAXES Healthy Financial Planning for Doctors

IN THIS NEW SERIES, Physician Magazine will provide expert insight into a variety of financial planning topics extensively and specifically researched and written for physicians. We begin this month with the timely topic of taxes and will dive into other financial planning topics, including retirement and investing, in coming months.

6 S A N M AT E O C O U N T Y P H Y S I C I A N | M A RC H 2017

Healthy FINANCIAL PLANNING

BY W. BEN UTLEY, CFP, PRESIDENT OF PHYSICIAN FAMILY FINANCIAL ADVISORS

Tax planning for doctors helps hardworking physicians take advantage of all the tax deductions, tax credits and tax exemptions that Congress and the Internal Revenue Service (IRS) will allow. These tax breaks and tax strategies offer ways physicians can reduce their taxable income.

PHYSICIAN TAX DEDUCTIONS One way physicians can pay less tax is by careful tax planning to reduce the amount of taxable income, taking all the allowed deductions and protecting those deductions from being phased out. Common deductions include: • Pre-tax contributions to retirement plans such as a 401(k), 403(b), 457 plan or, in certain cases, tax-deductible contributions to Traditional IRAs. Many physicians will not be able to deduct their IRA contributions and should consider a “backdoor Roth IRA contribution” strategy. • Charitable donations of cash or used items can save taxes but most physicians forget that they can also donate securities from their taxable accounts. By donating appreciated securities, physicians gain a double tax benefit by getting the tax deduction for the gift and by sidestepping the capital gain on the sale. • Tax-loss harvesting is the act of selling a losing investment in a taxable account to intentionally realize the loss. While this may not sound so good, physicians can use the first $3,000 of losses to offset ordinary income, saving the average physician $1,000 to $1,500.

Home mortgage interest is a common tax deduction for physicians, especially those with large homes and larger mortgages. Physicians can also deduct the interest on up to $100,000 worth of a home equity line of credit (HELOC).

• Home mortgage interest is a common tax deduction for physicians, especially those with large homes and larger mortgages. Physicians can also deduct the interest on up to $100,000 worth of a home equity line of credit (HELOC). • Student loan interest is not deductible for most physicians since high incomes cause this deduction to be disallowed. However, physicians can use a HELOC (above) or a cash-out refinance to get cash to pay down student loans, thereby converting the interest into a tax deduction. This works for consumer debt too.

Student loan interest is not deductible for most physicians since high incomes cause this deduction to be disallowed.

All of these deductions are subject to limits, so physicians should consult their tax specialist.

M A RC H 2017 | S A N M AT E O C O U N T Y P H Y S I C I A N 7

Healthy FINANCIAL PLANNING

SELF-EMPLOYED DOCTORS TAX DEDUCTIONS It seems like most of the tax code is written to benefit doctors who own their practices. For example, self-employed physicians receive a virtually unlimited tax deduction for business-driven expenses like travel, lodging, airfare, computers and mobile phones, office equipment, office supplies, medical equipment, board exam fees, licensing fees, continuing medical education expense and membership dues. Doctors who are not self-employed can still deduct these expenses, but they are allowed to deduct only the portion that exceeds 2% of their adjusted gross income, a limitation that means most employee physicians get no tax benefit at all. To gain these same tax benefits, physicians who are not self-employed can easily form a small business (sole proprietorship or LLC, for example) to receive income from their locum tenens work as well as payments received from drug companies and medical device manufacturers in exchange for research, teaching and other services rendered to healthcare organizations as contractors. For rules about deducting business expenses, see IRS Publication 535.

TAX STRATEGIES FOR DOCTORS WITH FAMILIES

Over time, the tax-free compound growth can help the children of physician families get a great start on retirement with no taxes due.

Physicians who own their own business, even a nonmedical one — including a sole proprietorship, partnership, Self-employed or working as a contractor to another business — can add their physicians can children to the payroll in order to shift income out of their own save taxes by high tax brackets and onto their child’s tax return, where the hiring their kids standard deduction can zero out the tax liability. For example, a physician who hires her three children can pay each child up to $6,300 in wages, an amount equal to the standard deduction amount, and that deduction will shelter all of these earnings from taxes. So if that physician is in the 39.6% federal income tax rate, the total tax savings can amount to $7,484 each year. Wages must be reasonable given the child’s age and skill Roth IRA for level, and this tax move must be fully documented so that it physicians’ kids will survive an audit. offers tax-free Physicians who have children who are employed by them growth (see above) or who have W-2 earnings from a summer job or any other source can contribute to a Roth IRA. Contributions can grow tax-deferred, and the account can grow tax-free with no required minimum distributions and no taxes due on qualified distributions under the current tax laws. Over time, the tax-free compound growth can help the children of physician families get a great start on retirement with no taxes due. The Uniform Transfer to Minors Account (known as a Uniform Gift to Minors Account in some states), or UTMA/UGMA, is an investment account that a physician can establish as the custodian of a minor child. If the child has only unearned income (such as interest, dividends and capital gains) and that income is less than $1,050, those earnings can be received UTMA accounts without the need to file an income tax return or pay federal reduce taxes on income tax, according to IRS Publication 929. investments for While the tax savings might be small, physicians may find physicians with these accounts to be ideal when teaching kids how to save, children particularly when the account balance does not exceed $10,000.

8 S A N M AT E O C O U N T Y P H Y S I C I A N | M A RC H 2017

Healthy FINANCIAL PLANNING

ADVANCED TAX STRATEGIES While these strategies can save physicians thousands in taxes, they require advanced tax planning, special documentation, complex legal documentation or the involvement of tax experts including tax attorneys or Certified Public Accountants who specialize in these areas. Seek legal and/or tax advice before proceeding. • Tax-free rental income is permitted by U.S. Tax Code Section 280A(g), allowing physicians to Doctors who are rent out their homes tax-free for up to 14 days self-employed can each calendar year. For example, physician rent all or part of families in Eugene, Ore., sometimes rent their homes to out their homes when sports events (like the their business Olympic Trials) come to town. Doctors who are self-employed can rent all or part of their homes to their business (board meetings, for example), giving them a business tax deduction and tax-free income. This tax-saving strategy requires both a business purpose for the rental and careful documentation. • Conservation easements offer tax deductions to physicians who donate the right to develop their land to a special charity known as a “land trust.” While most doctors will not want to do this with their primary residence or vacation home, they can purchase shares of a partnership that holds property and donates those development rights to the charity. Section 170(a) and (h) of the Internal Revenue Code contains rules about the income tax deduction, while Sections 2031(c) and 2055(f) contain the estate tax benefits. California, Colorado, Connecticut, Delaware, South Carolina, Virginia and other states offer tax benefits for physicians who donate conservation easements, and some of these tax credits may be transferable. While this strategy is complex, it has the potential to save doctors two dollars in taxes for every dollar applied to the strategy. • Defined benefit retirement plans (also known as “pension plans” or cash balance plans) allow self-employed physicians and doctors who are shareholders in their medical practices to deduct contributions to these plans and defer income tax to a later date. In addition to contributions to 401(k) plans, younger physicians might contribute an additional $30,000 to a defined benefit plan, while doctors approaching retirement might contribute up to $180,000 per year, deferring somewhere between $12,000 and $72,000 in federal income taxes (assuming the 39.6% tax bracket). This tax strategy requires careful business planning and often involves the services of a pension actuary or “third party administrator,” ERISA attorney and a registered investment advisor. We hope that our Guide to Tax Strategies for Doctors can help you make sense of the personal finance issues that affect doctors while helping you avoid mistakes and seize opportunities as you and your family plan for financial security that can last a lifetime.

Tax-free rental income is permitted by U.S. Tax Code Section 280A(g), allowing physicians to rent out their homes tax-free for up to 14 days each calendar year.

W. Ben Utley, CFP, is president of Physician Family Financial Advisors, a fee-only firm helping doctors save taxes and time while managing student loans, financing a home, saving for college and investing for retirement. To learn more, call (541) 463-0899 or visit www.physicianfamily.com.

M A RC H 2017 | S A N M AT E O C O U N T Y P H Y S I C I A N 9

The Gift of Life

The Dead-Donor Rule and Organ Donation

By Judy Chang, MD

The dead-donor rule states that vital organs may be harvested only from persons who are dead. Patients meeting criteria for brain death are considered to be dead.1 The American Academy of Neurology updated an evidence-based guideline regarding determining brain death in adults.2 The American Academy of Neurology guideline is accepted nationally. Locally, California adopted the Uniform Determination of Death Act, which recognizes brain death as death.3 There have been cases of donors or their families wanting to donate organs, but they were unable to do so, because by the time they died, their organs were no longer salvageable. Given how many people die waiting for an organ transplant, ethical questions include: • Should we continue to follow the dead-donor rule? • Whose interests come first, the donor’s or the recipient’s? • Must patients give direct consent for living donation, or is an advance directive sufficient? While people may disagree, thinking about the ethical and moral issues at stake can help clarify why we believe what we do.

1 Truog RD, Miller FG, Halpern SD. Perspective: The Dead-Donor Rule and the Future of Organ Donation. N Engl J Med 2013; 369:1287–1289. 2 Wijdicks EFM, Varelas PN, Gronseth GS, Greer DM. Evidence-based guideline update: Determining brain death in adults: Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2010;74:1911–1918. 3 California Legislative Information. Cal. Health & Safety Code §§ 7180–81. https://leginfo.legislature.ca.gov/faces/ codes_displaySection.xhtml?lawCode=HSC&sectionNum=7180. Accessed January 24, 2017.

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BRAIN DEATH REQUIRES A PHYSICIAN TO DOCUMENT:

Prerequisites (all must be checked) Coma, irreversible and cause known Neuroimaging explains coma CNS depressant drug effect absent (if indicated toxicology screen; if barbiturates given, serum level < 10 μg/mL) No evidence of residual paralytics (electrical stimulation if paralytics used) Absence of severe acid-base, electrolyte, endocrine abnormality Normothermia or mild hypothermia (core temperature > 36°C) Systolic blood pressure ≥ 100 mm Hg No spontaneous respirations Examination (all must be checked) Pupils nonreactive to bright light Corneal reflex absent Oculocephalic reflex absent (tested only if C-spine integrity ensured) Oculovestibular reflex absent No facial movement to noxious stimuli at supraorbital nerve, temporomandibular joint Gag reflex absent Cough reflex absent to tracheal suctioning Absence of motor response to noxious stimuli in all 4 limbs (spinally mediated reflexes are permissible) Apnea testing (all must be checked) Patient is hemodynamically stable Ventilator adjusted to provide normocarbia (PaCo2 34–45 mm Hg) Patient preoxygenated with 100% FiO2 for > 10 minutes to PaO2 > 200 mm Hg Patient well-oxygenated with a PEEP of 5 cm of water Provide oxygen via a suction catheter to the level of the carina at 6 L/min or attach T-piece with CPAP at 10 cm H2O Disconnect ventilator Spontaneous respirations absent Arterial blood gas drawn at 8–10 minutes, patient reconnected to ventilator PCO2 ≥ 60 mm Hg, or 20 mm Hg rise from normal baseline value OR: Apnea test aborted Ancillary testing (only 1 needs to be performed; to be ordered only if clinical examination cannot be fully performed due to patient factors, or if apnea testing inconclusive or aborted) Cerebral angiogram HMPAO SPECT EEG TCD

M A RC H 2017 | S A N M AT E O C O U N T Y P H Y S I C I A N 11

SMCMA New Members

Marissa Aillaud, MD

Shalin Amin, MD

Latifat Apatira, MD

Kerri Ashling, MD

Jennifer Boldrick, MD

Ellie Chan, MD Johnny Chang, MD

Hina Chawla, MD

Christopher Chin, MD

Theodore Crum, MD

David Daniels, MD

Diana Divanji, MD

Nina Hansra, MD

James Kang, MD

Victoria Kelly, MD

Janice Kim, MD

Garyun Kong, MD

(no photo)

Jessica Ellerman, MD

Christopher Evans, MD

Oloruntoyin Falola, MD

Kathleen Forcier, MD

Neelufar Ghaderi, MD

Sonia Ghei, MD

Radmila Grin, MD

Shenghua Lang, MD

Claire Larson, MD

Christopher Y. Cheryl Lau, MD Leung, MD

Yi Lin, MD

Aleda Longwell, MD

Kiki Lwin, MD

Mona LukeZeitoun, MD

Sarah Nanni, MD

Owen Palmer, MD

Jay Pandey, MD

Ashwini Peruri, MD

Ginger Roehrig, MD

Uta Shimizu, MD

Parveen Shiraz, MD

Derek Steele, MD

Sima Sura, MD

(no photo)

Jeffrey Kwan, MD

Joseph Lacy, MD

Whitney Landa, MD

Neera Narang, MD

Rashmi Vivian Narayana, MD Ng, MD

Marija Petrovic, MD

Retirements:

(no photo)

Mary Brzostowicz, MD Joseph Ta, MD

Vanessa Tang, MD

Jessica Tan, MD

Piia Thomas, MD

Swetha Thota, MD

Andrea Tom, MD

Jerry Tsai, MD

Carol Chan, MD Manjul Dixit, MD Elizabeth Murphy, MD Brian Roach, MD Daniel Siedler, MD Roland Vallecillo, MD

Aviva Luke Weinberg, MD White, MD

Janet Wiese, MD

Christina Wong, MD

Suzanne Woo- Jennifer Sims, MD Ziskin, MD

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A Fond Farewell to Ray Kauffman, MD, DDS By Sharon Ann Clark, MD. FACS

The San Mateo County Medical Association lost a treasured member this January 16, and the family hosted a luncheon celebration of the remarkable life of Ray Kauffman, MD, DDS, on Saturday, February 11, 2017. Ray, a native of Northern California, joined the Association in 1954, a plastic surgeon trained at Stanford University Medical School (in San Francisco at that time), followed by his being the first Plastic Surgery Resident to graduate from the UCSF program. Before becoming a plastic surgeon, however, he had completed his dental studies at UCSF and was sent by the military to the Philippines. Thus began a lifelong devotion to taking care of patients with general plastic surgical needs as well as maxillofacial problems. In an effort to understand how to better treat these complex wartime injuries, he decided to study medicine and plastic surgery. He then began a full career in private practice. In addition to his private practice, he became Chief of Surgery at Peninsula Hospital; the district hospital opened in 1954. He also operated at Mills Hospital, expanded in 1950, and at the County Hospital of San Mateo. He set high professional and personal standards, which we all in Plastic Surgery continue to try to maintain for excellence. He has taught many of the residents in the programs at Stanford and UCSF Medical Schools, as well as throughout the nation, about maxillofacial challenges. Gilbert Gradinger, MD, later joined Dr. Kauffmanâ&#x20AC;&#x2122;s private practice with the formation of a partnership. Dr. Kauffman became the President of the California Plastic Surgery Society and of the American Society of Maxillofacial Surgery. Through these many years he remained humble, patient, happy, and kind to all. At the celebration of his life, the comments of those friends, colleagues, and family members show that he, a true example of the Greatest Generation, is much missed. He treated every person he met as a precious individual. We in the San Mateo County Medical Association are losing a part of ourselves with Dr. Kauffmanâ&#x20AC;&#x2122;s death just short of 100 years old.

For further details please see the Obituary in the San Francisco Chronicle http://hosting-1085.tributes.com/obituary/read/Raymond-R.-Kauffman-104370681

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