February 2012 by SMCMA

February 2012 | Volume I/No. 1

A Publication of the San Mateo County Medical Association

SAN MATEO COUNTY PHYSICIAN | page 1

EDITOR’S INTRODUCTION

Changes By Barry Sheppard, MD It is hard to believe, but February is the last of the winter months, which means that Spring is virtually at hand. But before the first robin appears at the feeder or spring bloom pushes into the sunlight, the Editorial Committee of your county medical association presents for your evaluation the first sign of Spring. With a new appearance and a new name The Bulletin becomes the San Mateo County Physician beginning this month. It is a sign of rebirth and re-invention and is a visual reminder of our commitment to the membership to stay current by continuing to evolve. This hard copy of the San Mateo County Physician is also reproduced on our website and that version provides an interface for you to tell us if we got it right or how we got it wrong, or add clinical anecdotes or pose a question.

San Mateo County Physician

Spring is not simply change, though. It also promises a return of favorite things through renewal. The first signs of spring are exciting because of the promise they exemplify of longer days and warmer waters. No matter how bleak Winter may have been, Spring will be followed by Summer and Fall and with them our personal and varied favorite annual activities. So this edition of your county medical publication also promises a continuation of the quality, relevance and unwavering assessment of the issues facing San Mateo County physicians that you have come to expect from SMCMA’s flagship publication.

February 2012

This makeover is a new look to catch your gaze and prevent our being overlooked. Maybe it will remind you of that article you were going to submit to us, or at the very least stir you enough to fax, phone or electronically transmit your thoughts about our metempsychosis. Those missives will be happily fielded by the Editorial Committee.

Executive Report..................................7

We hope you enjoy your first issue of San Mateo County Physician! “Observe constantly that all things take place by change, and accustom thyself to consider that the nature of the Universe loves nothing so much as to change the things which are, and to make new things like them.” Marcus Aurelius Antoninus

About the Cover: The photo was taken by Poppy Richie. Poppy is the wife our SMCMA’s Controller, Jim Richie. It was taken in Half Moon Bay.

Vol. LXVII/ No. 2

Table of Content President’s Message...........................5 A Helpful Guide for Your Frail or Debilitated Patients..............................8 Heads Up on Sports Concussions.......................................10 Cost Containment and Delivery System Reform..................................13 Managing Your Online Presence............................................14 Evaluating and Negotiating Payment Models.................................17 Membership Update and Classified Ads.....................................18

SAN MATEO COUNTY PHYSICIAN | page 3

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president’s message

The Occupy Movement, Physicians and the US Health Care System By gregory Lukaszewicz, MD This past fall the Occupy Wall Street Movement dominated the news and captured the attention of much of the nation. Though the Occupy Movement may not seem particularly relevant to the lives of physicians, and it remains to be seen whether the movement has any long reaching effects, several key themes have emerged which are in fact particularly relevant to our profession and the health care system. First, one of the driving forces behind the Occupy Movement was frustration with the current economic system. People are feeling overwhelmed and angry as they struggle to keep afloat as their wages stagnate or they fail to find employment while the gap between the very wealthiest of the nation (the 1 percent) and the rest of country (the 99 percent) grows. Being a struggling physician is not the same as being an unemployed worker trying to survive with limited unemployment benefits. However, many physicians can share in the sense of being embattled with regards to maintaining fair reimbursements, the daunting number of regulations and the struggle to continue to provide care to their patients and maintain a viable practice. The ongoing threat of cuts secondary to the sustainable growth rate (SGR), diminishing Medicaid reimbursements, which do not even cover the cost of running a practice, battles with insurance companies over pre-approval for services and disagreements over reimbursements (while insurance

executives and CEOs pull in salaries in the millions of dollars) have led to frustration and despair in many physicians. Second, the lack of health care coverage emerged as a predominant theme of the Occupy Movement. Though physicians themselves have health care coverage, most of us have seen struggling patients who lose their jobs and health care coverage. Health care and insurance costs continue to rise and eat up a significant portion of a person’s or family’s monthly budget. Lack of adequate health coverage and a catastrophic illness is still a major cause of bankruptcy. We often hear that the health care system is broken and as a major component of that system, we take this personally. Yet we need to look beyond this sense of anger and frustration. In addition, we do need to recognize that our health care system is in crisis. As health care costs approach 17 percent of our total economic output, it has become what Warren Buffett has called “a tapeworm in America.” I heard many people interviewed in the Occupy Movement who had a sense not necessarily of optimism, but that a different vision of the world is possible. Though as a group physicians are usually thought of as fairly conservative, I would actually argue that medicine and the individuals that advanced our field were both radical and visionary. Consider all that has been

accomplished in the last 100 years alone: antibiotics, vaccinations, coronary artery bypasses, intra-cranial aneurysm clipping and endovascular coiling, dialysis, organ transplants, the mapping of the human genome. The list is almost endless. Though we tend to be quite enamored with modern information and telecommunications technology, frankly a smart phone just does not compare to what we have accomplished as physicians. We need to bring this same vision and boldness, which has led the exponential growth of medical knowledge, to the current dilemma that faces our profession and our medical system. Dr. Arnold Relman, former editor of The New England Journal of Medicine, in an article this past October in The New York Review of Books, has written persuasively as to why our political leaders are unable to contain rising medical costs, while physicians are actually in a position to fix the US health care system. Put simply, Dr. Relman discusses ways physicians can organize themselves to help control health care costs. Whether Dr. Relman’s solutions are the correct ones is a matter of debate. However, what does seem clear is that unless physicians as a group confront the current health care crisis with the same boldness and vision that we have used against disease, then we will most likely continue to watch health care costs continue to sky rocket while our political leaders and insurance executives determine our fate.

SAN MATEO COUNTY PHYSICIAN | page 5

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EXECUTIVE REPORT

DocBookMD: Smart Phone App.... A New Member Benefit By sue u. malone SMCMA is pleased to introduce DocBookMD, a HIPAA-compliant multimedia communication tool for our members. This app is a smartphone platform created by physicians to help enable physician-tophysician communication using technology that more physicians are using every day. The application is available for iPhone; iPad; iPod Touch, and Android platform users. Thanks to the generous sponsorship of NORCAL Mutual Insurance Company, SMCMA is offering all members this free service with DocBookMD for 2012. This app is available for free whether or not you are a NORCALinsured policyholder. With this application, you carry a directory of all active medical association members on your smartphone, including photos, specialty, and contact information, allowing you to exchange messages with other users. You can also look up a physician by specialty as well as by name. This new secure physicians-only app allows you to: • Send HIPAA-compliant text messages (if recipient’s cellphone is provided), including photos of wounds,

x-rays, or other diagnostics • Assign a priority setting to outgoing text messages so thee recipient knows how quickly you need a response • Search a complete listing of all pharmacies in the county • Search the SMCMA directory online, which includes the phone numbers, addresses, photos, and so forth. We purposefully did not include your e-mail addresses as we believe you may prefer making the decision with whom you want to share your e-mail address. However, you can easily add this information to a physician’s profile, or add comments to a particular profile that will only be reflected on your smartphone. The app will allow you to look up another doctor at the point of care, and either call or send a text message with room number, medical record number, even pictures of wounds and x-rays. The messaging priority system allows you to assign each message with a five-minute, 15-minutes, or normal 30-minute response time. If your message is not answered within the time frame specified, then you will

receive a message back stating that the original message was not opened. To register, use your device to download DocBookMD from the iTunes App Store or Android Market. Next complete the DocBookMD registration on your device. This app can be downloaded on up to two devices per member. To sign up you will need your SMCMA ID number, which can be obtained by calling SMCMA, 650-312-1663. By the way, you will be asked to sign a HIPAA compliance agreement before you start using DocBookMD. This app is only available to SMCMAmember physicians and it is not available for your nurse or PA. We hope you find this new benefit useful in your practice. In the January Bulletin we listed a compilation of benefits available to physicians who are SMCMA members, DocBookMD is just the latest in the panoply of benefits available to you.

SAN MATEO COUNTY PHYSICIAN | page 7

Assisting Your Frail and Debilitated Patients By Gurpreet K. Padam, MD I think of Mrs. Z with fondness and gratitude as she introduced me to her perspective beyond the four walls of a medical office. She was an 86-year-old woman who always sat on the chair waiting patiently while supporting her frail hunched over body with a walker. She was a regular patient and we were trying to get her restless leg syndrome controlled. She rarely missed an appointment while we were titrating medications. One day, she was a “no show” and I was quite surprised. Concerned, I called her at home to find out what happened. She picked up the phone with a weak “hello”. “How are you, Mrs. Z?” I asked inquisitively. “My daughter is sick today, so she couldn’t bring me and I didn’t have the strength to walk to the bus station”. Families in distress have to mobilize resources quickly to get support and assistance for not only the patient, but other family members, partners and caregivers as well. Adult children who provide support to their parents also experience psychological distress and increased risk of major illness.1,2 All the while I had known Mrs. Z, she had not mentioned anything regarding her difficulty with getting to the doctor’s office. She would show up on time and smile coming through the door. “I live alone so it takes me the entire morning to get myself ready and out of the house.” I asked her to tell me more… “We have to plan several days ahead, since my daughter has to request time off of work to bring me to my appointments. She lives two hours away so it is a long drive for her. If my daughter cannot bring me, then I start walking to the bus station an hour before so I do not miss my ride.

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The bus drops me off a few blocks away from your office and it is a tough walk to the campus. Even if I have planned my trip several hours in advance, I worry about being late for the appointment. If I am late, then I may have to wait until you can see me another time, and I have already missed my ride back home. It gets dark early these days and I do not feel safe waiting for the bus late in the afternoon and it is so cold outside. I get home a little before supper and the whole day has gone by.” I was stunned that it takes an entire day for one of my patients to orchestrate each 20-minute visit to the doctor’s office! Since my eye opening discussion with my favorite patient nine years ago, I have started asking my elderly patients openended questions such as, “how are things at home?” or “paint me a picture of what your typical day looks like.” A doctor’s appointment is a window of opportunity where a conversation can segue into an insightful dialogue into a patient’s functional status and activities of daily living. Five extra minutes spent upfront can go a long way in identifying red flags ahead of time and allowing a proactive approach. The dialogue can be continued via phone consultation, after the patient leaves the office. For Mrs. Z, we were able to link her with resources to bridge the gaps in her care and empower her with tools to help her maintain her perception of dignity and independence. Within a few days or our phone call, Mrs Z, with the aid of county transportation services, was able to get a ride for her next medical appointment and she proudly fashioned a life alert medallion on a necklace around her neck. She was

no longer afraid to be alone in the case of an emergency, since these services were now within her reach. Caregiver fatigue can also have a negative impact on the home bound elderly.3 Interventions such as referrals to social worker or home health may be helpful for both patient and caregivers and lead to improved patient satisfaction. In this case, Mrs. Z’s daughter elected to join a local support group for caregivers and supplemented her mother’s care with hired help in the early morning hours when Mrs. Z needed assistance getting out of bed and starting her day. About a year later, during one of our telephone appointment visits, it was determined that Mrs. Z could no longer leave her home, even with maximum assistance, was now wheel chair bound and her dementia had progressed. Some Health Care Systems, including the VA, offer Home Based Primary Care for homebound patients. A patient with Veteran status, may want to inquire with the VA regarding their eligibility. Mrs Z chose to move to a board and care closer to her daughter who lived out of the area and with limited access to health care. For those patients who may live outside the service area, thinking outside the box may yield referrals to retail medical clinics, or concierge medicine home visiting physicians.3 When health care affordability or loss of coverage limits access to care, then refer to community clinics, which provide low cost or free services to those who quality.4 Intervention can help relieve the burden of care giving, improve functional level and promote patient continued on page 16

Pocket Guide of Resources for Frail and Debilitated Patients Below you will find a list of helpful resources to photocopy and keep on your office wall or in your coat pocket when consulting with frail or debilitated patients:

211

Don’t Know Where to Turn? Call 211

A Guide To Assist San Mateo County Residents to Remain at Home

Help At Home Guide - http://cip.plsinfo.org/hah.htm Help at home guide published by the San Mateo County Commission on Aging has some resources which you may useful for your patients. To obtain a printed copy of this directory in English, Chinese or Spanish, call (650) 573-3910 or visit www.co.sanmateo.ca.us/portal/site/SMC.

Hospice End of Life Care

Kaiser -South San Francisco 1(415) 833-3655; Kaiser -Redwood City (650) 2993940; Mission Hospice and Home Care (650) 554-1000; Sutter Hospice (650) 685-2800; Palo Alto VA Hospice Care Program (650) 849-0550; Pathways Hospice 1(888) 755-7855; Hospice by the Bay 1 (415) 626-5900; VITAS 1 (866) 946-7742

Advance Care Planning

California Advance Care Directive - http://ag.ca.gov/consumers/pdf/AHCDS1.pdf Physician Orders for Life-Sustaining Treatment (POLST) - www.capolst.org

Emergency Response System

Medicalert 1 (800) 432-5378; LifeStation, Inc 1(800) 884-8888; Mills-Peninsula (650) 696-4823; Sequoia / St. Mary’s Hospital CHW 1 (800) 236-8550; Stanford Hospital (650) 723-6906; Vital-Link 1 (800) 752-5522

Adult Protective Services

1(800) 675-TIES (8437)

Utility Services

AT&T 1(800) 772-3140 PG&E 1(800) 743-5000 Special services for elderly and disabled.

Veteran Status

Home bound: Home Based Primary Care, VA Palo Alto - www.paloalto.va.gov/ hcbcfaq.asp or 1 (800) 455-0057 or 650-493-5000 End of Life: Palo Alto VA Hospice Care Program (650) 849-0550

Grocery and Food

Second Harvest Food Bank - www.shfb.org Food Hotline 1 (800) 984-FOOD (3663)

Grocery shopping

Assistance for Seniors who are Homebound (SASH)- Burlingame - (650) 5227494; Foster City - (650) 522-7494; San Bruno - (650) 616-7155; San Mateo - (650) 522-7494

Meals on Wheels

Home delivered meals for those who are unable to prepare their own meals or go out to eat, and have little or no assistance to obtain adequate meals. Belmont to East Palo Alto 323-2022 www.penvol.org; Coastside 726-9056 or www.seniorcoastsiders.org; Pacifica 738-7350; San Mateo to Daly City 1-800-6758437 Chinese meals are available. 342-0822 www.selfhelpelderly.org

Prescription Assistance

List of Prescription Assistance resources www.sanmateo.networkofcare.org/aging/links/display_links.cfm?id=38&topic=3

Identification Placard for the Disabled

Department of Motor Vehicles - 1 (800) 777-0133 for application and physician’s certification

Lawyer Referral Service

San Mateo County Bar Association - Makes referrals to local attorneys. www.smcba.org or (650) 369-4149 Legal Aid Society Senior Advocates - Provides free legal counsel and assistance to seniors age 60 or over. Call 1 (800) 381-8898 or visit: www.legalaidsmc.org

Low Cost or Free Clinics

For those who qualify: Fair Oaks Medical Clinic (650) 364-6010/ 2710 Middlefield Road, Redwood City; Samaritan House Clinic (650) 839-1447/ 114 5th Avenue, Redwood City. Also visit: www.stanford.edu/group/saphop/clinicreferral.pdf

SAN MATEO COUNTY PHYSICIAN | page 9

Heads Up on Sports Concussions By Michael Siegel, MD A 16 yo female high-school soccer star was momentarily dazed after heading the ball awkwardly, and immediately felt nauseated. However, after a rest, she only had a lingering headache. She did not mention the headache to anyone, and played the rest of the game. Her headache worsened and the nausea returned when she was running. Somewhat distracted, she clunked heads with another player and was unconscious for a minute. Her coach felt that she was soon oriented and coherent; he did a brief sideline check and saw no weakness, balance or eye movement abnormalities. She was advised to rest, take the next day off, and see her doctor and to report back for practice when cleared. In a medical office two days later, her mother says that she has been unusually quiet. She denies headache or nausea, but has not been eating as much as usual. She tried to go to classes yesterday morning, but says she “learned nothing”. She is concerned about upcoming final exams. Her parents tell you that she is a soccer scholarship candidate and needs to be active when her school plays in the state championships in two weeks. Her teammates think they have a good chance of winning if she plays. Is additional testing/consultation needed? What treatment beyond rest and common sense might there be? Recommendations are needed about returning to practice and play. Her parents would like to know about schoolwork and other activities.

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Recent, well-publicized sports-related head injuries have forced a reconsideration of our about management of sports concussion. The American Academy of Neurology (AAN) Practice Parameter on this topic is 15 years old, and contains paradigms that have since become outdated. Lately, the AAN has aired interviews with thought leaders, and made plans to update their Practice Parameter. Much of what they have discussed comes from the 3rd International Conference on Sports Concussion, held in Zurich, 2008. The interviews placed great emphasis on Second Impact Syndrome (SIS), and Chronic Traumatic Encephalopathy (CTE). SIS follows a head injury to someone who has not yet recovered fully from a prior concussion, resulting in a more severe condition, associated with cerebral edema, coma and potentially fatal outcome. Epidemiological studies have suggested an association between repeated sports concussions during a career and late-life cognitive impairment. Case reports have noted instances where neuropathological evidence of CTE was observed in retired football players. Family histories of degenerative CNS disease or dementia increase risk as well as the “dose” and frequency of trauma, i.e., higher for a starting linebacker who also plays tight end than for the backup kicker. In my opinion, identification and grading of concussion, and Return to Play (RTP) guidelines for injured athletes really need our focus;

appropriate guidelines can serve to prevent the occurrence of SIS and CTE. Eleven states have passed laws mandating licensed health professional assessments and clearance for young competitors sustaining concussions, as well as education for parents and coaches. Identifying Concussion In defining concussion as “a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces”, head injury experts are unanimous. Emerging constructs are that: 1. Concussion need not involve direct head trauma, but can occur after injury to face, neck or elsewhere on the body where force can be transmitted towards the head. 2. Loss of consciousness is not required. 3. Functional disturbance rather than structural injury is the most common observation; further, the symptoms are generally short-lived and resolve spontaneously. It is suggested that a concussion be suspected if one or more of the following is present: •

symptoms: somatic (e.g. headache), cognitive (e.g. feeling like in a fog) or emotional symptoms (e.g. lability)

•

physical signs (e.g. loss of consciousness, amnesia)

•

behavioral changes (e.g. irritability)

•

cognitive impairment (e.g. slowed reaction times)

•

sleep disturbance (e.g. drowsiness).

Players showing any features as above should be evaluated onsite, using emergency management principles with particular attention given to the cervical spine. The treating health care provider must determine appropriate disposition. If no provider is available, the player should be removed from practice or play and urgently referred to a physician. Once first aid has been given, an assessment should be made using the Sport Concussion Assessment Tool 2 (SCAT2) or similar test - www.cces.ca/files/pdfs/SCAT2[1]. pdf The player should be monitored for deterioration over the first hours following injury. A player with diagnosed concussion should generally not be allowed to Return to Play (RTP) on the day of injury. Sideline evaluation of cognitive function, including brief assessments of attention and memory function (included with SCAT reference), has proven to be practical and effective. Standard orientation questions (e.g. time, place, person) have been shown to be unreliable in the sporting situation when compared with memory assessment. These are not meant to replace comprehensive neuropsychological testing, which is sensitive to detect subtle deficits that may exist beyond the acute episode. It should also be recognized that the appearance of symptoms might be delayed several hours following a concussive episode.

Conference statement argues for a graduated return to play protocol according to the adapted table - see table 1. Additional Management Concerns The Zurich Congress participants advise psychological treatment where depression or anxiety is an injury sequela. Pharmacological therapy may be needed for specific prolonged symptoms, i.e., sleep disturbance or headache; however, concussed athletes need to be symptom-free without medications before RTP. A pre-participation concussion evaluation has become standard for some sports (amateur boxing), specifically getting at symptoms following prior head, neck and face injuries. Important factors such as disproportionate symptoms relative to impact severity, family history of concussion, history of prior headache and affective disorders, athlete aggressiveness and recklessness (increased by use of protective gear) all have a potential place.

Table 1: Return to Play Protocol Rehabilitation Stage

Loss of consciousness (LOC) greater than one minute remains a factor that may modify management, particularly prolonged LOC; briefer LOC has not been shown to correlate with injury severity. Retrograde amnesia varies with the time of post-injury measurement and is poorly reflective of severity. Immediately occurring seizures or posturing are benign and require no special considerations. Although most concussions in adults resolve in 7 to 10 days, children and adolescents may take longer to recover. Once identified, it is important that young concussed athletes have a period of rest, both cognitive and physical. The concept of ‘‘cognitive rest” involves a (child’s) need to limit exertion with activities of daily living and to limit scholastic and other cognitive stressors (e.g. text messaging, video games) while symptomatic. Many further recommendations are pertinent to children, especially those less than ten years old who may report and manifest concussion differently from older children. Dr. Siegel is a Neurologist practicing in San Mateo.

Functional Exercise at each stage

Objective of each stage

1. No activity

Complete physical and cognitive test

Recovery

2. Light aerobic exercise

Walking, swimming or stationary cylcing keeping intensity <70% MPHR. No reistance training

Increase HR

3. Sport-specific exercise

Skating drills in ice hockey, running drills in soccer. No head impact activities

Add movement

4. Non-contact drills

Progression to more complex training drills (e.g. passing drills in football and ice hockey). May start progressive resistance training.

Exercise, coordination, cognitive load

5. Full contact practice

Following medical clearance, participate in normal training activities.

Restore confidence, assessment of functional skills by coaching staff

6. Return to Plan

Normal game play

Return to Play The 1997 AAN Practice Parameter suggested that after a “simple” injury, RTP—i.e. resumption of competitionlevel activity--was possible the same day, with longer delays for more “complex” injuries. The Zurich

Other Issues

SAN MATEO COUNTY PHYSICIAN | page 11

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Cost Containment and Delivery System Reform By Patricia Lynch US health care costs make up 18% of the Gross Domestic Product, a significantly higher percentage than is spent in other industrialized nations. Despite these expenditures, the US has a higher infant mortality rate of almost 7 per 1000 than 37 other nations and a lower life expectancy rate of 78 years than 50 other nations, according to the CIA World Factbook. US health care expenditures are increasing. Most agree that the rate of increase in healthcare costs is not sustainable and may result in dramatic changes in the financing of public programs and in private insurance. It is generally recognized that 80% of US health care costs are spent on 10% of the patients, most of whom suffer from chronic conditions such as heart disease, obesity, depression, asthma and diabetes. Ensuring that these patients get appropriate care in the appropriate settings to help manage their conditions will not only improve lives, but could significantly reduce health care costs. If we are to avoid draconian price setting, we need to improve the quality and value of health care. We need to make the health care delivery system more transparent, more accessible to more people, and more cost effective. One of the most important elements to help ensure patients have access to care would be significant insurance market reforms. Requiring health plans to cover everyone, regardless of health status, and requiring everyone to be covered is a vital first step to improving care and reducing costs. The cost of

caring for the uninsured is significant. According to a Milliman, Inc. report commissioned by Families USA, $43 billion in unreimbursed care was provided by physicians, hospitals and other providers in 2008 to the approximately 47 million uninsured persons. Today, the number of uninsured has increased to 81 million people. In addition, standardization of comprehensive benefit packages to prevent insurance companies from limiting coverage of needed services by chronically ill patients would be an important market reform. A combination of comprehensive coverage and limited individual cost sharing would eliminate economic barriers for individuals who need medical care, helping to ensure people get the right care at the right time, rather than waiting until they suffer from an acute condition that results in an emergency department visit or more serious medical intervention. Making sure people have access to providers for health care and preventive services will help to prevent the onset of more serious, expensive conditions. Standardized benefits and cost-sharing should reduce administrative costs for physicians and hospitals. The development of publicly available, consumer friendly information relating the quality of the provider networks offered by each health plan could both improve the quality of clinical care and slow the rate of increase in cost. Private organizations, such as the

National Committee on Quality Assurance, and public programs, such as Medicare and Medicaid, are making information relating to clinical outcomes and customer satisfaction available to consumers. This information will help spread best practices across the entire clinical community Newly formed Exchanges, required to be established in each state by the federal health reform law, are required to collect and publicize information relating to the price of coverage and the clinical quality and customer satisfaction with the care provided. Most experts agree that improving the quality of clinical care will help to slow the rate of health care costs. Within Medicare and Medicaid, new federal programs have been created to support delivery system reform, quality and cost effective care, including the Accountable Care Pilots, the Medicaid Patient-Centered Medical Home program, and the pay for performance initiatives established for hospitals and for the Medicare Advantage program. These are all designed to maximize the ability of providers to care for patients in a collaborative way that makes it easier to ensure patients get the needed follow up and preventive care. Some of these reforms and programs are included as part of the federal health reform act and in the states. Others are happening through the efforts of the business community and policymakers. All of us in the health community need to work together to continued on page 16

SAN MATEO COUNTY PHYSICIAN | page 13

Managing Your Online Presence By Debra Phairas and Ashley Porciuncula Managing your online presence involves more than just creating a website. It also includes monitoring your patient reviews on sites such as Yelp and other MD rating websites, plus discovering and controlling what your own name produces when searched for on Google, Facebook, Twitter, blogs and other online resources. It is important to proactively manage your online presence and check the web frequently to determine patient perception of you and your practice. Marketing a practice now includes: 1. Assuring that information about you and your practice is accurate and up-to-date. 2. Knowing what your patients are saying about you, the physician or group, your staff and your practice. 3. Assessing and correcting misconceptions about your practice on review sites such as Yelp, HealthGrades or RateMDs, and responding proactively to patient complaints. 4. Conveying important information about your credentials, your practice, as well as helpful descriptions of medical conditions, surgeries, and procedures to your patients. 5. Create efficiencies for your practice and increase customer service by posting online patient registration forms and/or scheduling appointments.

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What do your patients find when they GOOGLE you?

and make this a part of performance reviews.

With the exception of the elderly (and even they are tech savvy today), most patients don’t use the telephone book or call information when locating their own physician or finding a new one. They use internet search engines to quickly find the telephone, address and website of a practice. If you move your practice, be sure to update your online information immediately. When referred to several doctors, patients will often make decisions based on the information they find online. Take a professional picture of yourself with a warm, smiling face and provide a brief but comprehensive list of your credentials. Include your philosophy of how you treat patients and make it patient friendly. You may wish to include your hobbies or interests to make yourself more approachable. Profiling staff members is also a good idea.

Branding your Image

Use Search Engine Optimization for your name to appear first on search engines. Registering with online directories will help your name, location and a map to be among the first results to appear. You don’t want the first item to pop up on a search engine to be a negative rating review site. Check your online presence once a month and use any negative reviews to correct bedside manner, staff customer service or office policies and procedures. Do not single out any staff members in meetings, but discuss negative reviews with problem solving for change. Reward positive feedback

Create a consistent brand that carries through your website and office materials. Choose a logo, colors, and style that create a standard for your practice. It can be as simple as the doctor or group name in a font, or a professionally designed logo with an image. For example, one medical oncology and breast surgery practice has a purple iris theme that was carried out in all logos, stationery, brochures, website, business cards, and includes giving the patient a vase with a purple iris after surgery. If you are profiled in TV, radio or newspapers or other on-line magazines, place a clip or link on your website. This allows your patients to view this “third party endorsement” which gives you additional credibility. Ostensible Agency If the group is actually an expense share arrangement of solo practices or combination or sole proprietor/ corporation but call themselves a group name, the group is creating ostensible agency/partnership and thus has the same liability as a true integrated group. Many physicians are unaware of this legal doctrine. This holds that if the public, patients and other physicians think the group is a true integrated group, then the group is all liable for each other just as if they were a true group. Review CMA on-call legal documents on this subject or contact your malpractice carrier. All websites, stationery, business cards, signs on walls and doors must be clear

that this is an association of independent practices. Social Media You may want to join one of the popular social networking websites such as Facebook, Twitter, LinkedIn and others that are relevant to your business. Joining these websites give you a face, and gives you the ability to more proactively manage your online image. Have new staff sign your office personnel policies and procedures stating that they will not utilize social media sites during work hours unless they are specifically charged with updating your website or profiles. Make it clear that harassment of staff or revealing patients of the practice via social media is a breach of confidentiality that can be grounds for termination. Blogs Writing short posts about something newsworthy or educational about you, your specialty or medical issues helps you stay relevant. Adding this to your website will increase your search ratings and get your message out. Links to Other Medical Websites

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Locum Tenens Permanent Placement V oice: 800- 919- 9141 o r 805- 641- 9141 FA X : 805- 641- 9143 t z we ig@t r a c y z we ig.c om www.t r a c y z we ig.c om

Why have patients view websites that may contain inaccurate or biased medical information when you can provide them with medical sites you know are trustworthy? Put links on your website to your medical or specialty societies, and organizations you would want patients to view.

San Mateo Co. Medical Association 06-18-09

SAN MATEO COUNTY PHYSICIAN | page 15

Frail or Debilitated Patients continued from page 8

independence.5,6,7 After all, we are here to help our patients live better and thrive! 1.

Routine Assistance to Parents: Effects on Daily Mood and Other Stressors J Gerontol B PsycholSciSocSci May 1, 2008 63: S154-S161

Health, Stress and Coping among Women Caregivers: A Review J Health Psychol January 1, 1999 4: 27-40

Cutland L. Concierge’ doctors growing in valley Movement part of nationwide trend: Silicon Valley / San Jose Business Journal, Nov10, 2005 http://www.bizjournals.com/sanjose/ stories/2005/11/14/story2.html?page=all

South Asian Preventative Health Outreach Program. http://www.stanford.edu/group/ saphop/index.html

Scanameo AM, Fillit H. House calls: a practical guide to seeing the patient at home. Department of Geriatrics and Adult Development, Mount Sinai Medical Center, New York. Geriatrics. 1995 Mar;50(3):33-6, 39.

Anna Cristina Aberg, BirgittaSidenvall, Mike Hepworth, Karen O’Reilly and Hans Lithell. On loss of activity and independence, adaptation improves life satisfaction in old age – a qualitative study of patients’ perceptions. Quality of Life Reserch Volume 14, Number 4, 1111-1125

Covinsky, K. E., Palmer, R. M., Fortinsky, R. H., Counsell, S. R., Stewart, A. L., Kresevic, D., Burant, C. J. and Landefeld, C. S. (2003), Loss of Independence in Activities of Daily Living in Older Adults Hospitalized with Medical Illnesses: Increased Vulnerability with Age. Journal of the American Geriatrics Society, 51: 451–458

Dr. Padam is a family medicine physician and practices with the Permanente Medical Group in Redwood City

Cost Containment and Delivery System Reform continued from page 13

improve the health of our patients, our community and to make health care more affordable and a higher value. Patricia Lynch is the Vice President of Government Relations with Kaiser Permanente.

page 16| San Mateo county physician

Evaluating and Negotiating Emerging Payment Models By Catherine Hanson The health care delivery system in the United States is undergoing a paradigm shift with regard to physician and other health care provider payment methodologies. In an effort to control the growth of health care costs, payment methodologies involving risk are slowly replacing fee-for-service as the predominant means through which physicians will be paid. These “pay for value” or risk-based models include pay-for-performance, withholds and risk pools, capitation, shared savings, and bundled payment arrangements. Because the terms “value-based” or “risk-based” do not clearly describe what makes these new payment systems different from fee-for-service, the term “budget-based” is used to make the distinction clear. In all these payment systems, the primary driver of the economic result to the physician practice is the extent to which the actual cost of providing care to a patient population varies from the projected budget for those costs – physicians who come in at or underbudget prosper, while physicians who exceed the budget are penalized. As complex as it is to manage fee-for-service payments, payments based on a “budget” raise a host of new issues that physicians must understand to successfully negotiate the evolving payment environment. Under “budget-based” payment systems, rather than being paid for each service provided, physician income is tied to the physicians’ ability to successfully predict and manage future utilization for a patient population by thoroughly understanding the past utilization for a similar patient

population as well as the costs of delivering these services efficiently. To determine whether any budgetbased payment proposal will be financially viable, physicians must first figure out whether the budget is “actuarially sound” for the patient population that the budget will cover. In other words, is it likely that the costs of providing the health care services covered by the budget to this patient population will be equal to or less than the budgeted amount? Because of the enormous skew in the utilization of health care services depending on the patient, this is not an easy task. Fully half the population spends less than $1,000 per year on medical care. At the other end of the extreme, the top one percent of spenders use more than $44,000 of health care services in a year. In the absence of state-of-the-art risk adjustment systems, physicians who are lucky enough to draw panels, which include large numbers of the low-utilizing patients, will do exceedingly well under budget-based payment systems, while those who draw the patients at the other end of the spectrum will be devastated by such systems. Contrary to every principle of medical ethics, the physicians who will be put at the greatest risk will be those who focus their practices on the poorest and sickest patients! However, with full transparency, actuarial soundness and state-of-the-art risk adjustment systems, budget-based payment systems can be constructed to promote the more efficient treatment of everyone, rather than to provide economic incentives to develop ever

more creative ways of discouraging sicker patients from selecting one’s health plan or medical practice. Thus, successful navigation of budgetbased payment systems requires mastery of concepts more commonly associated with health insurance than physician payment, including “actuarial soundness,” “risk adjustment” and “risk mitigation.” Physicians who are considering transitioning to one of these new payment models, whether by choice or payer request, will need practical information to enable them to evaluate the likely financial impact of these risk-based payment arrangements, negotiate the precise terms of these arrangements, if appropriate, and manage the revenue cycle associated with any new payment model to which they are ultimately subject. The American Medical Association (AMA) has developed a tool to help physicians understand these concepts and position themselves to succeed under budget-based payment systems, entitled Evaluating and Negotiating Emerging Payment Options. Visit www.ama-assn.org/go/payment to access this manual. This tool is comprised of chapters written by expert physician consultants and advocates. A new chapter concerning shared savings arrangements will be added to the tool in early February 2012. Catherine Hanson is the Vice President of Private Sector Advocacy & Advocacy Resource Center with the American Medical Association.

SAN MATEO COUNTY PHYSICIAN | page 17

Membership Update

Editorial Committee

New Members

Barry B. Sheppard, M.D., Chair Russ Granich, M.D. Edward G. Morhauser, M.D.

Mamatha Chivukula/ *PTH S. San Francisco Remington Fong/ *PD Menlo Park Shoshana Helman/ HPM, IM Redwood City Kim Harvey/ *PD Menlo Park Sonia Nader/ *PD Menlo Park Mira Sinha/ FM San Mateo Annette Hwang Tien/ *PD Menlo Park Jelena Vukicevic/ *PD Menlo Park Deceased Members Norman Graff John Kaster Charles Geraci

Classified Ads Burlingame Medical Building Location on El Camino, Burlingame; across from MillsPeninsula Hospital. Two office suites: 800+ square feet and 1700+square feet. Call Alipate Sanft, SC Properties, 650-342-3030 x212. Mills Square - San Mateo Medical Office For Sublease 101 S. San Mateo Drive, 3rd Floor, 1,234 useable square feet, 4 exam rooms, office, nurses’ station, large waiting room. Available Immediately on Mon., Wed., and Fri. For details, call (650) 688-8480 on a Mon, Wed, or Fri or send email to: blessmoore@earthlink.net Medical Office Space Available for Sublet Four exam rooms with running water and one MD office available for up to four days weekly. May be able to provide office staff if needed. Excellent location, opposite Peninsula Hospital. For details please contact Bonnie McGuire: Bonnilee@aol.com or 650-259-1480. Place a classified ad for $40 for up to five lines for members and $75 for up to five lines for non-members. Contact SMCMA at (650) 312-1663 or smcma@smcma.org. PAGE 18 | San Mateo county physician

Sharon Clark, M.D. Gurpreet K. Padam, M.D. Michael Stevens, M.D

Sue U. Malone.............................................Executive Director Reina O’Beck..................................................Managing Editor

2011-2012 Officers & Board of Directors Gregory C. Lukaszewicz, M.D...................................President Mary Giammona, M.D......................................President-Elect Amita Saxena, M.D...................................Secretary-Treasurer John D. Hoff, M.D...........................Immediate Past President Alberto Bolanos, M.D. Russ Granich, M.D. Edward Koo, M.D. Vincent Mason, M.D. Kristen Willison, M.D.

Raymond Gaeta, M.D. Robert Jasmer, M.D. C.J. Kunnappilly, M.D. Michael Norris, M.D.

David Goldschmid, M.D. ......................................CMA Trustee Scott A. Morrow........................Health Officer, San Mateo Co. Barry B. Sheppard, M.D. ..................AMA Alternate Delegate

Article Submission Members are always encouraged to submit articles, commentary and Letters to the Editor. Email your submission to the SMCMA Editorial Committee at smcma@smcma.org for consideration for publication in San Mateo County Physician. For editorial or advertising inquiries, please use the contact information provided below.

Editorial and Advertising Offices 777 Mariners Island Boulevard, Suite 100, San Mateo, CA 94404 Tel (650) 312-1663 Fax (650) 312-1664 smcma@smcma.org www.smcma.org Acceptance and publication of advertising in San Mateo County Physician does not constitute approval or endorsement by the San Mateo County Medical Association of products or services advertised. SMCMA reserves the right to reject any advertising. Opinions expressed by authors are their own and not necessarily those of the SMCMA. San Mateo County Physician reserves the right to edit all contributions for clarity and length, as well as to reject any material submitted.

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