March 2012 | Volume I /No. 2
A Publication of the San Mateo County Medical Association
SAN MATEO COUNTY PHYSICIAN | page 1
2012
You still need to make important decisions now about rising health insurance premiums. So what can you do? • 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. Includes: • News and analysis of important benefit issues. • Compliance Link tool to assist with health care and group benefit plan administration.
* Marsh and the Association do not provide tax, investment or legal advice. Please consult with your professional advisors for guidance on these issues.
Please call Marsh at 800-842-3761.
We serve members who want assistance in evaluating the medical insurance choices before them. We can assist you with the information you need to make the critical choices on the road ahead.
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SMCMA services
SMCMA Offers Solutions to Improve Your Practice The San Mateo County Medical Assocation can serve as the first point of contact for any practice management questions you may have on the day-to-day functions of a medical office. We can help with ways to improve practice efficiency, coding issues or inquiries, EHR implementation assistance and navigating governmental regulations, such as HIPAA. Our goal is to provide you with the resources you need to keep your practice running smoothly. Did you also know that the San Mateo County Medical Association and the California Medical Association will work directly with commerical and government payers to resolve reimbursement or other disputes on your behalf? Call us regarding untimely payment, unreasonable requests for medical records, claim denials despite prior authorizations/eligibility verifications and other matters. Let us focus on handling these hassles so that you can pay attention to
San Mateo County Physician March 2012 Vol. I / No. 2
what matters most - your patients. In addition, the SMCMA offers a variety of educational programs that address the above issues. We have hosted customer service/patient relations seminars, coding classes as well as a variety of programs to improve your practice’s
Table of Content President’s Message...........................5
bottom line. Be sure to take a look at the events section of our website at
Executive Report..................................7
www.smcma.org for upcoming courses. You may also have an idea for an
Alzheimer’s Disease - Updates on Symptoms, Diagnosis and Treatment.............................................9
educational program that we should offer. We would love to hear your suggestions, so please contact us! To utilize these services and get the practice help you need, contact Reina O’Beck, Director of Economic Services at (650) 312-1663 or robeck@smcma.org.
San Mateo Hep B Free Campaign............................................11 In Memoriam Charles Geraci, MD............................12 Genetics and Epidemiology of Melanoma.......................................13
About the Cover:
The photo was taken by Christopher White MD, an Emergency Medicine physician practicing in Burlingame. It is titled, Hints of Spring, and captures the ice receding off of Mirror Lake in Yosemite Valley.
Membership Update and Classified Ads.....................................18
SAN MATEO COUNTY PHYSICIAN | page 3
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president’s message
A Look at the County’s Health By gregory Lukaszewicz, MD Recently, I saw a copy of Outside magazine with the caption, “How Getting Outside Makes You Smarter, Happier and Want to Fix the Planet.” Automatically, my brain added the word, “healthier”. Looking at my patients, those who seem both the happiest and healthiest are certainly the most active, continuing to hike, walk, bike, golf, play tennis, garden, etc., well into their 70s and 80s - things they have been doing most of their lives. This headline also led me to consider the general level of health of those living in San Mateo County. We have a number of opportunities that allow for improved health, which include a relatively mild climate that permits frequent outdoor activity; vast open space areas - 40 percent of San Mateo County’s area is considered protected open space, compared to 29 percent of Santa Clara and 60 percent of Marin Counties; easy access to beaches, hiking trails, mountains, and parks; numerous farmers’ markets that feature local, healthy foods; and increasing use of public transportation. Have all of these opportunities for improved health really lead to a more healthy population? Unfortunately, the answer is not cause for optimism.
on the decline in the County. However, we are unfortunately seeing a rise in conditions such as diabetes, hypertension and elevated levels of cholesterol. As a result, we may see a reversal in the trends related to cardiovascular disease. In fact, the number of people with diabetes (almost entirely Type II diabetes, as in the rest of the country) has grown from almost four percent in 1998 to over eight percent by 2008. In addition, we know that these conditions are in part related to personal behavior and practicing a healthy lifestyle. Yet many in our community do not follow the basic guidelines for a healthy life, such as refraining from tobacco, drug and excessive alcohol use, exercising 30 minutes a day, and maintaining a healthy weight and diet. Arthritis and asthma are the most common chronic illnesses in the County. The rate of arthritis is relatively stable and particularly important as we consider what services with be needed as our population ages, as falls are a major cause of morbidity and mortality for the elderly. Conversely, the rate of asthma has increased from eight percent in 1998 to 14 percent in 2008.
According to the 2011 Community Assessment, sponsored by the Healthy Community Collaborative of San Mateo County, and our public health officer, Scott Morrow, MD, the County is doing fairly well overall. Deaths due to cancer, the leading cause of death among our population, and heart disease are currently
One additional very important and disturbing statistic that the report sites is years of potential life lost (YPLL), which is the difference between the average life expectancy in a population and the number of years a population would be expected to live without dying prematurely. This statistic is used to measure the
impact of premature death on a given population. Though the overall YPLL has decreased in the County from 631 potential years per 10,000 residents between 1992-1994 to 420 years between 2006-2008, the YPLL for African American residents was a markedly elevated at 853 per 10,000 residents in 2006-2008, compared to 394 for Asian, 378.7 for Caucasian, and 407.8 for Hispanic residents. Looking at a number of markers (cancer deaths, cardiovascular deaths, etc), African Americans are fairing much worse than other ethnic groups in the County. The community health data represents very clear disparities, but also provides an opportunity to address these gaps. As physicians we play only a part in the health of our patients. Many factors come together that include genetics/family history, personal health behavior, the surrounding environment and education just to name a few. But in order to care for our patients and understand the barriers they may face regarding their health, I would recommend taking a look both at the 2011 Community Assessment (http:// tinyurl.com/6wvlhmy) and the 2011 Sustainable San Mateo County report (http://tinyurl.com/83mros4), which provides a broad array of data regarding our County. These reports make for sobering reading, but help shed light on ways to intervene with regard to some of the disturbing trends that we are now seeing.
SAN MATEO COUNTY PHYSICIAN | page 5
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EXECUTIVE REPORT
Billing Service Contracts By sue u. malone
Association has been receiving quite a few
submitting complete and accurate information for bill preparation and paying the company’s fees.
calls from our members regarding billing
The Scope of Services
This month’s column is written by SMCMA’s legal counsel, Phillip Goldberg, Esq. The
service contracts. We hope that this information can provide clarification on this area of practice management.
Although physicians are often attentive to the terms and conditions of their contracts with third party payors, my experience has been that many physicians give little time or attention to their billing service contracts. The lack of concern or interest in billing service contracts is surprising considering the potential significance to the medical practice. This article will describe what should and should not be in the billing service contract. Who is Working for Whom? In my experience, many billing service contracts are written backwards. That is, they are written so it appears the physician is working for the billing service, as opposed to the other way around. The billing service contract is first and foremost a service contract with the billing company acting as the service provider and the physician as the service recipient. As such, the terms should focus on the services the billing company provides to you and not on your obligations to the billing company. Indeed, your obligation should be limited to working cooperatively with the billing service in
Although the scope of services from one billing service contract to another can vary significantly, and many companies provide what might be more appropriately described as consulting or practice management services, it is essential that the basic billing services be set forth clearly in the contract. The services might be described as “appropriate bill preparation, transmittal to responsible payors, follow up as commercially reasonable, and posting and deposit as collections are received.” Beyond these basic billing services, physicians often contract for credentialing services even if they do not get more comprehensive (and costly) consulting or management services. In all events, the contract should clarify that it extends to billings to patients and third party payors defined broadly to include any and all payors. In deference to the billing company, details on the complete and accurate information you are to provide may be included, as well. The hours during which the billing company will be in operation should be stated clearly in the contract. This is important not only for communications from you but also for the convenience of patients and third party payors. Beyond generating and following up
bills and posting and depositing collections, the billing company should also generate reports. These reports give the physician an understanding of what type of job the billing company is doing, keep the physician informed about cash flow, and help identify problems with specific payors. At a minimum, the reports specified in the billing service contract should include aged accounts receivables which may be sorted by payor, service location, or other classification. The billing company should provide reports on a periodic basis as stated in the contract, but they should also be available as “reasonably requested,” for which an additional fee may apply. The Standard of Care Physicians are well aware that a certain standard applies to the services they perform and that there are consequences if they fall below that standard. The same should be true for billing services. Accordingly, an essential element of every billing service contract is a statement of the standard applicable to the billing company’s services with references to both expertise and care. For instance, the billing company might be required to utilize “staff qualified to furnish the billing services with appropriate levels of education, training and experience.” The volume and depth of services continued on page 14
SAN MATEO COUNTY PHYSICIAN | page 7
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Practices affiliated with Hill Physicians Medical Group retain their independence while enjoying the support of a large, well-integrated network of providers. Hill’s advantages include: • Fast, accurate claims payments • Free eReferrals, ePrescribing and secure online doctor-patient communications • Experienced RN case management for complex, time-intensive cases • Deep discounts on EPM and EHR solutions to help you meet the federal mandate • Easy preventive care and disease management reminders for patients • Extensive health resources that boost patient engagement • High consumer awareness that builds practice volume That’s why 3,700 independent primary care physicians, specialists and healthcare professionals have made Hill Physicians one of the nation’s leading Independent Physician Associations. Get more for your practice and your patients by affiliating with Hill Physicians Medical Group.
Get more information at www.HillPhysicians.com/Providers or contact: Bay area: Jennifer Willson, regional director, (925) 327-6759, Jennifer.Willson@hpmg.com San Joaquin area: Paula Friend, regional director, (209) 762-5002, Paula.Friend@hpmg.com Sacramento area: Doug Robertson, regional director, (916) 286-7048, Doug.Robertson@hpmg.com
Hill Physicians’ 3,700 healthcare providers accept commercial HMOs from Aetna, Alliance CompleteCare (Alameda County), Anthem Blue Cross, Blue Shield, CIGNA, Health Administrators (San Joaquin), Health Net, United Healthcare WEST and Western Health Advantage. Medicare Advantage plans in all regions. Medi-Cal in some regions for physicians who opt-in.
Alzheimer’s Disease - Updates on Symptoms, Diagnosis andTreatment By craig hou, md Alzheimer’s disease (AD) is becoming a major health issue as the population of the United States ages. The Alzheimer’s Association estimates 5.4 million Americans have AD. Not only does AD affect the patient, but the impact is also felt by the family, caregivers, and the society as a whole. The total cost of health care, long-term care, and hospice care for AD and other dementias is estimated to be $183 billion dollars in 2011. This cost does not include unpaid caregiving and the loss of productivity as the person’s cognition and function decline. This article will first provide an overview of dementia and AD, with a focus on AD symptoms, diagnosis, pathology and treatment. The next section will be a review of mild cognitive impairment (MCI), which is viewed by many dementia experts to be “incipient AD”. This will be followed by the emerging technology of amyloid imaging with positron emission tomography (PET) that may assist in diagnosis. The final topic will be the theory of immunotherapy for AD. AD is the most common cause of dementia. Dementia is defined as decline in memory or other cognitive abilities such as language, visual processing, judgment, reasoning, and behavior. In dementia, the decline is sufficient enough to affect daily life and usual activities. Other neurodegenerative causes of dementia are vascular dementia, dementia with Lewy bodies, Parkinson’s disease dementia, and frontotemporal lobar degeneration. The most common presenting symptom of AD is trouble with short term memory. This often manifests as repetitive questioning, rapid forgetting
of conversations or events, misplacing objects, or disorientation to time. Other early symptoms can include trouble with navigating, problem solving, and completing familiar tasks. As the disease progresses, the person’s cognitive abilities decline, leading to increasing problems with usual and daily activities. In the later stages of disease, the person develops problems with ambulation, mobility, swallowing and continence. The diagnosis of AD is based on a clinical evaluation that includes a history, physical examination, and cognitive assessment. Laboratory studies and brain imaging are used to exclude other possible causes to the person’s cognitive symptoms. At this time, there are no specific tests that makes a pre-mortem diagnosis of AD with 100% certainty or accuracy. The neuropathology of AD is abnormal accumulation of beta-amyloid protein outside of neurons and tau protein within neurons, leading to plaques and tangles respectively. As the proteins accumulate, neurons become increasingly dysfunctional which then causes selective brain regions atrophy. This leads to progressive decline in the person’s cognitive abilities and function. There are several approved medications for AD. The two classes of medications are the cholinesterase inhibitors and an NMDA-receptor antagonist. The cholinesterase inhibitors are donepezil (Aricept), rivastigmine (Exelon) and galantamine (Reminyl). These work by increasing brain levels of acetylcholine, which is important for cognitive function. Memantine (Namenda) blocks the N-methyl-D-aspartate (NMDA) receptor
which, when activated, contributes to the degeneration of neurons. It is important to note that these medications are symptomatic therapies. In other words, they only temporarily improve or stabilize the person’s cognitive and functional abilities. They do not affect the pathology of AD, so the person will eventually decline as the disease progresses. There are no diseasemodifying drugs that are approved and clinically available at this time, but such therapies are in clinical trials as will be discussed later. Mild cognitive impairment (MCI) is defined as cognitive changes, most often short term memory problems, that are noticed by the person or informant and that are detectable by cognitive testing. However, the cognitive decline in MCI is not enough to affect the person’s daily life or usual activities, thus not meeting the criterion for a diagnosis of dementia. In several longitudinal studies, individuals with MCI are at higher risk for developing dementia with AD being the most likely diagnosis. Those with amnestic MCI (those with prominent memory deficits relate to other cognitive deficits) very likely have AD pathology within the brain, even during the MCI stage. This supports the concept that there is a pre-clinical stage of AD where a person can have normal or mildly impaired cognition, yet have AD pathology on post-mortem analysis. At this time, there are no approved or effective medications for MCI. Recommended interventions for those with MCI are aerobic exercise, mental stimulation, and addressing vascular risk factors. continued on page 17
SAN MATEO MATEO COUNTY COUNTY PHYSICIAN PHYSICIAN || page page 9 9 SAN
The SMCMA Community Service Foundation invites you to attend the...
1st Annual
Spring Gala To Benefit the
San Mateo Hep B Free Campaign Thursday, April 26, 2012 6:00—9:00 PM South San Francisco Conference Center 255 S Airport Blvd. · DINNER · COCKTAILS · RAFFLE GIVEAWAYS · SILENT AUCTION · · GUEST OF HONOR, ASSEMBLYWOMAN FIONA MA · LIVE ENTERTAINMENT · · SPECIAL GUEST PROFESSIONAL BOXER, ANA JULATON · $100 per person San Mateo Hep B Free—A Community Service Program of
San Mateo County Medical Association Please submit payment with this registration form and mail to 777 Mariners Island Blvd, Ste 100 · San Mateo, CA 94404 or fax to (650) 312-1664 Name : ____________________________________
Guest Name: _______________________________
Address: ___________________________________
City/Zip: ___________________________________
Phone : ____________________________________
Email : ___________________________________
I am unable to attend but please accept my tax-deductible donation in the amount of $________ I would like to purchase a table at the event for $800 (8 people at a table)
Payment Information (We accept Visa, MasterCard, Discover, and Checks) Card Number : ____________________________________ Exp: ____/_____
CCV:_____
Billing Address: ____________________________________ City/Zip: __________________________ *Signature : ____________________________________ Date: __________ (Make Checks Payable to SMCMA Community Service Foundation) Meal Selection (please select item & quantity): ______ NY Steak ______ Chicken Parmigiana
Amount: $_______
______ Salmon Provencale
For questions regarding the event, please contact Whitney Wood at 650-312-1623 or wwood@smcma.org
San Mateo Hep B Free Campaign By dirk baumann, MD In 2009, the San Mateo County Medical Association’s Community Service Foundation along with a strong steering committee pooled their resources to begin a program called San Mateo Hep B Free Campaign. Modeled after the highly successful San Francisco Hep B Free program, its goal is to raise awareness about the severity of hepatitis B in San Mateo County. San Mateo County has an incredibly diverse population, of which 26 percent (176,000) are Asian and Pacific Islander (API). Approximately, 17,600 APIs in San Mateo County are chronically infected with Hep B and two-thirds do not know it. Liver cancer rates are 2.3 times higher in API men versus non-API men and 3.3 times higher in API women versus non-API women. Since its founding, San Mateo Hep B Free has sponsored dozens of educational, screening and vaccination events. Additionally, San Mateo Hep B Free has published several informational articles and held educational forums on Hepatitis B for the public and healthcare providers. Hepatitis B is a serious disease of the liver caused by the hepatitis B virus which can lead to cirrhosis, liver failure and liver cancer. The API populations bear a disproportionately higher incidence of chronic hepatitis B, as ten percent are infected versus less than one percent of Caucasian Americans, according to the CDC. There are often no symptoms, and most of the chronically infected are unaware that they have the virus until it is too late. One quarter of infected patients die of liver failure or cancer, the leading cause
of cancer death in certain Asian populations. For this reason, hepatitis B is often referred to as the “silent killer.” Establishing a community-wide program like San Mateo Hep B Free is necessary to raise awareness of hepatitis B and liver cancer and to offer potentially life-saving services for at risk populations in San Mateo County.
Campaign was awarded a Certificate of Special Congressional Recognition from the US Congress for outstanding and invaluable service to the community of San Mateo County.
The collaboration behind this program is comprised of four vital parts including: San Mateo County Medical Association, the Hospital Consortium of San Mateo County (in which Mills Peninsula Health Services participates), San Mateo County Health System, and Asian Liver Center at Stanford University. Recently both the Mills Peninsula Community Benefits Foundation and the Peninsula Health Care District have agreed to continue to support San Mateo Hep B Free financially with grants. The San Mateo County Medical Association provides administrative and financial support, utilizing its members to serve as advocates and educators of basic hepatitis B prevention and treatment. SM Hep B Free has already gained the support of legislative representatives such as Assemblywoman Fiona Ma, Congresswomen Jackie Speier and Anna Eschoo, and City of Millbrae Councilman Wayne Lee. SM Hep B Free has garnered backing from community organizations such as the San Francisco and Millbrae Lions and Leos Clubs, Self Help for the Elderly, the San Francisco State and Canada College of Nursing as well as community leaders like Ted Fang. In 2009, the San Mateo Hep B Free
San Mateo Hep B Free is comprehensive and includes education for the community and health care providers, awareness campaigns, and clinical services. The educational aspect seeks to raise public awareness about the threats of hepatitis B in the API population. The clinical components include routine screening and vaccination of API adults as well as assisting those who tested positive for chronic hepatitis B in obtaining further treatment. Joining efforts with the San Mateo County Medical Association, San Mateo Hep B Free has arranged for specialty physician management of these identified patients, irrespective of insurance coverage.
San Mateo Hep B Free seeks to unite community and medical stakeholders to promote awareness of hepatitis B. This goal is being accomplished by:
On the evening of April 26, 2012, the 1st Annual San Mateo Hep B Free Spring Gala will be held at the South San Francisco Convention Center. All interested are encouraged to attend this gala. RSVP to Director Whitney Wood at wwood@smcma.org. If you require any additional information about the San Mateo Hep B Free campaign or are interested in participating, please visit our website at SMHepBFree.org or do not hesitate to contact me. Dr. Baumann is a Vascular Surgeon and practices in Burlingame and is the Chairman of the Hep B Free Campaign
SAN MATEO COUNTY PHYSICIAN | page 11
In Memoriam Charles Geraci, M.D. By michael o’holleran, md Charles Geraci was the modern day Renaissance man. His title states M.D., however his life tells much more. How does one summarize a lifetime in a few paragraphs? Charlie graduated from Bellarmine High School in 1940 and from Stanford University in 1944. He then continued on to medical school at Stanford and upon completion, he joined the Air Force and served at the Veterans Hospital in San Francisco. After his military commitment, he returned to Stanford to complete his surgical residency. He worked under such notable surgeons as Roy Cohn, who rarely gave out praise. However, when I informed Roy that I was joining Charlie in practice he told me how lucky I was, as Charlie was truly a great surgeon. Charlie finished his training at Stanford and started a private surgical practice at Sequoia Hospital in 1953, until he retired in 2008. Throughout Charlie’s career, there were many situations that showed not only demonstrated his excellent surgical skills, but also the compassion and understanding he portrayed to each and every patient. His very first case at Sequoia Hospital was a burn patient that he would take to the operating room every night to change and debride their wounds. When Charlie described this patient and their progress, even fifty years later, he would light up with excitement. This was truly the definition of a surgeon who was passionate about his work and treatment of patients. He performed the first heart surgery at
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Sequoia Hospital when there were no cardiac surgeons and covered the Emergency Room before emergency doctors existed. He also volunteered for Project Hope, serving in Peru, Ceylon, and an Indian reservation in Arizona. One of Charlie’s greatest assets was his technical ability in the operating room. He was able to write with both hands simultaneously and used this ambidextrous skill when operating. If another surgeon had a difficult case, Charlie was the one they would call for assistance. Fellow physicians, nurses, and co-workers always referred themselves and their family and friends to Charlie. After an automobile accident limited Charlie’s ability to perform primary surgery, he would cherish the chance to be in the operating room. His assistance made other surgeons better due to his calm demeanor that instilled confidence in those around him. Charlie was never flustered by events in or out of the operating room and his clinical judgment was second to none. Charlie’s ability to communicate with his patients was exceptional and his calm, caring nature that instilled absolute confidence in his patients separated him from others. Patients believed, “Dr G” would get them through anything. He could explain complicated problems in easy to understand terms. His gentle manner made hearing difficult news of cancer or a terminal illness much more acceptable and patients felt that they were not alone. Charlie would sit at the
bedside and hold a patient’s hand and then explain what was going on and answer any questions they might have. This made the patient feel that they were his only concern. Charlie was also extremely active in the political arena of medicine. He served two terms as president of Sequoia Hospital, was president of the San Mateo County Medical Association, was on the California Medical Association Board of Directors, and was the first Medical Director of Sequoia Hospital. In addition to his medical skills, Charlie was a pianist and an artist. He also enjoyed hiking, skiing, traveling, and San Francisco fine arts events. He was a skilled craftsman who built grandfather clocks, which I was lucky enough to be gifted. He was a devoted brother, husband, father and grandfather. Not a week goes by in the office that a former patient or family of a patient doesn’t ask about “Dr G”. Each patient has a different experience, however, the story line is the same. They describe Charlie as a person who provided confidence during the most difficult time, had exceptional bedside manner, a sense of humor and was the “best doctor ever.” Charlie was the ultimate role model for me. He was a father, confessor, and tutor. With the loss of Charlie Geraci the mold was broken. This has been said many times, however, this time it is true. Dr. O’Holleran is a General Surgeon and practices in San Carlos
Genetics and Epidemiology of Melanoma By janet maldonado, MD Melanoma is the most frequent cause of death from skin cancer and the most common overall cancer in men over the age of 50 (more prevalent than colon, prostate and lung). It is also the second most common cancer in women aged 20 to 29. One in 51 people will be diagnosed with melanoma during their lifetime -- up from one in 65 just eight years ago. This is thought to be due not only to increased detection, but also to a shift from outdoor to indoor occupations leading to more intermittent sun exposure and increased tanning bed use. Melanoma most commonly presents on the back in men and the back of the legs in women, which leads to much confusion about how the sun exactly causes melanoma. Much of the uncertainty stems from the implicit assumption that all cutaneous melanomas arise through the same pathologic pathway. There is a dramatic variation in incidence and anatomical distribution of melanoma in light and dark skinned people. Melanoma is much more common in light skinned individuals who tend to get them on sites that receive more sun exposure. Dark skinned people get melanomas on relatively sun protected areas such as the palms, soles and mucosal sites more frequently than anywhere else on their body. These phenotypic differences already speak to the question of whether there are different genetic pathways to melanoma. The development of melanomas on sun shielded areas is probably less related to sun exposure, and instead more to
genetic pathways unaffected by UV exposure. The MAP-Kinase pathway is activated in the majority of melanomas. BRAF is a critical serine/threonine kinase in this pathway that was found to have a high frequency of mutations in melanoma. It was found that BRAF mutations are highly unevenly distributed among the four major subgroups of melanomas-melanomas on intermittently sun damaged skin such as the trunk and extremities, melanomas on chronically sun damaged skin such as the face, acral melanomas and mucosal melanomas. BRAF mutations were found in 59% of the melanomas on the trunk and extremities, but in only 11% of the melanomas on chronically sun damaged skin. Individuals who develop melanomas on intermittently exposed skin tend to be younger as compared to individuals who develop melanomas on chronically sun damaged skin. This supports the existence of at least two distinct genetic pathways to melanoma—one that is BRAF dependent in susceptible individuals who need less UV exposure, are younger and develop their melanomas on intermittently sun exposed sites; and the other that is BRAF independent, in resistant individuals who need more UV exposure, are older and develop their melanomas on sites that are chronically sun-exposed. The goal of anti-cancer therapies now is to target causative proteins in a specific manner to minimize sideeffects. The innovation of Vemurafenib, a small molecule inhibitor of BRAF, has been
revolutionary in treating melanoma. Although many patients eventually build a resistance to it, Vemurafenib has been shown to prolong overall survival in patients with BRAF mutated metastatic melanoma. It has also become clear that uncontrolled activity of c-kit contributes to the formation of melanoma. Melanomas on the head and neck, mucosal and acral melanomas have a higher percentage of c-kit mutations than those arising on the arms and trunk. Multiple case series have been published of metastatic melanoma containing kit-activating mutations being successfully treated with c-kit blockers such as imatinib. The newest of the genetic discoveries concerns the rare, but often fatal ocular melanoma. 80% of all uveal melanomas have been found to contain mutations in the alpha subunit of the G proteins GNAQ or GNA11 which result in MAP Kinase pathway activation. Clinical trials are underway for targeted therapies. It is exciting that we are finally moving away from traditional chemo to finding the silver bullet for a patient’s particular condition. A continued effort towards the precise determination of the molecular and genetic mechanisms underlying melanoma pathogenesis is crucial. However, it is important to remember that metastatic melanoma is still virtually always fatal. Early detection, screening and counseling on sun protection will always remain paramount. Dr. Maldonado is a Dermatologist and practices in Burlingame
SAN MATEO COUNTY PHYSICIAN | page 13
Executive Report continued from page 7
should be that “reasonably required and customary for similar medical practices.” Additionally, the billing services should be provided with “due care, prudence and judgment” and “in compliance with all applicable third party payor rules and regulations both commercial and governmental.” Ideally, the service should be rendered to the physician’s “reasonable satisfaction.” Most disputes between physicians and their billing services involve circumstances where the physician is unhappy with the service and the billing company asserts it has complied fully with the contract. The reasonable satisfaction standard can be very helpful in such cases. Ownership and Custody of Records The billing company should take responsibility for maintaining custody of all documentation relating to the services it provides and the bills it generates, as well as its communications with patients and third party payors. More importantly, the billing service contract should specify that all such records “are and will remain the sole property of physician.” Disputes over ownership of records can be particularly frustrating. If you have not clearly established your ownership of records along with the billing company’s obligation to maintain them and make them available to you on request, you may run into problems when the relationship with your billing company terminates. Although you may not want to take custody of what may be a substantial volume of records, this is far preferable to being denied access to those records. For similar reasons, the billing service contract should cover what protocols the billing company employs to preserve and back up electronic data.
page 14| San Mateo county physician
Related to ownership and control of records is the physician’s right to audit those records. The billing service contract should specify that the physician has the right to review and audit, through an agent hired by physician if desired, “all billing and collection information in the custody or control of the billing company.” It is reasonable to require you give advance notice to the billing company, not disrupt the billing company’s operations, and conduct the audit during regular business hours. The billing company may have legitimate concerns if the audit is conducted by a competing service, may reasonably request that a direct competitor not conduct the audit, and require a confidentiality agreement from any auditor. Conversely, the billing company should offer its full cooperation with any audit. The right of audit is essential to ensure the billing company has performed up to the standard set forth in the billing service contract. Collections and Payment of the Billing Company Fee The billing service contract should not include a provision on the billing company paying the physician because the collections are (or certainly should be) the exclusive property of the physician. The accounts receivables before they are collected, the checks by which payments are made, and the account into which the checks are deposited are the property of the physician and the billing service contract should make this perfectly clear. The contract should also indicate that funds received by the billing company should be immediately deposited into your account. Clarifying ownership of accounts receivables, checks and deposits would be a good idea in all events, but it also helps ensure compliance with Medicare rules on billing services. Under Medicare rules, a “lockbox” account into which
payments are deposited and over which you have exclusive access should be established. A review of the Medicare rules on billing service arrangements could lead to the conclusion that the commonplace “percentage of collections” fee arrangement is not allowed. However, the Center for Medicare and Medicaid Services indicates (rather cryptically) that percentage of collections fee arrangements are acceptable when a lockbox account is used. The billing company should not have access to the lockbox account and should receive payment of its fee from the physician as opposed to taking it out of collections. Although fees based upon a percentage of collections are not the only means for calculating compensation, they are by far the most common. The billing service contract should specify the percentage of collections (and not billings) on which the fee is calculated as well as specifying the time for payment. Ideally, the billing company should generate a “true and correct” invoice because it has information available on collections. Monthly calculation and payment of the fee is common, but a more or less frequent basis is allowed. It is also a good idea to specify the collection on which the percentage fee is based. For instance, capitation payments may be excluded or may be subject to a lower rate since they involve less effort on the part of the billing service. Confidentiality and HIPAA Compliance The billing service contract should make clear that all information provided to the billing company is to be considered and maintained as confidential and not just that information which constitutes
“protected health information” or “PHI” under HIPAA. The billing service contract should include standard “business associate” language to ensure compliance with your obligations under HIPAA. The billing company should be well aware of these requirements and familiar with the obligations imposed under the law on its use of PHI. In addition to the HIPAA Privacy Rule, the billing must also comply with the HIPAA Electronic Transaction Rule. Term and Termination Whether or not there is any express term to the billing service contract, it should allow you to terminate the relationship without cause on a reasonable period of notice. The right to terminate without cause may not be exercisable during the first year when the billing company is getting “up to speed” and has a legitimate interest in recovering start-up costs. When you are terminating the relationship, you probably want the notice period to be as short as possible. Thirty to 60 days might be appropriate. Conversely, if it is the billing company terminating the relationship, you may want a longer period of notice to find a substitute. In this case, 90 to 120 days might be more appropriate. There is no legal requirement that the notice period for termination by one party be the same as the notice period for termination by the other party, but this is the most common arrangement. The billing service contract should specify a much shorter notice period for termination for cause. Typically, a notice of default giving rise to termination would be given and the defaulting party afforded an opportunity to cure within a relatively brief period of time. If the physician’s obligations are properly limited to reasonable cooperation and paying the fee, it is much more likely that the physician will be the one terminating for cause. Accordingly, the
cure period might be as brief as five to ten days. The billing service contract should specify the causes for termination which, most importantly, include breach of the contract. The breach by the billing company will almost always involve some degree of subjectivity. Including a standard for the services rendered helps to establish a basis for termination for cause by the physician when the services have not been as expected. The failure to meet that standard will constitute a breach, giving you the right to provide notice of the default which will result in termination if not cured in short order. Except in the case where the billing service contract is terminated because of a breach by the physician, he or she should have the option of having the billing company continue to provide services after the effective date of termination. That is, you may require the billing company to “run off” the receivables for dates of service prior to the date of termination. On the other hand, you should be free to collect information on your accounts receivables from the old billing company and transfer it to the new billing company if you do not exercise your option to have the old billing company run off the receivables. In most circumstances, you will want the run off performed by the old billing company since payors would have received instructions to deliver payment (or at least payment information) to the old billing company’s address. It is important to clarify the special compensation arrangements, if any, that apply during the run off period and on termination.
billing service contract should specify that the old company shall cooperate in good faith with any new company. This cooperation should include, at a minimum, the “transmittal of accounts receivable and other information to the replacement service in such form and format as the replacement service may reasonably request.” This language is intended to facilitate an electronic transfer of data to avoid the need for the new service to input information manually into its system given the time and inaccuracy associated with this exercise. It does not mean the old company has to incur unreasonable expenses to transfer data electronically from one system to the other, but it certainly means that the old billing company cannot refuse to make an electronic transfer that only involves in a few keystrokes. HIPAA’s Electronic Transaction Rule should make electronic transmission from one company to another relatively simple. Conclusion Many physicians comparing their current billing service contracts with the comments in this article may find little connection between the two. Obviously, some of the provisions I suggest are more important than others. Similarly, some of the provisions will be easier for a billing company to accept than others. Nevertheless, there are good reasons for each of the provisions suggested. What may be more important than the terms of your billing service contract is the strength and quality of your relationship with the billing company. When that relationship deteriorates you will want billing service contract terms that protect your interests.
No matter how or when the relationship with the billing company is terminated, you should expect some collections will be lost when moving from one company to another. In order to help diminish this inevitable loss, the
SAN MATEO COUNTY PHYSICIAN | page 15
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Alzheimer’s
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continued from page 9
Since the diagnosis of MCI and AD is a clinical diagnosis, there is increasing attention on ways to identify amyloid and tau deposits in vivo at the earliest stages of disease or even before clinical symptoms appear. “Amyloid imaging” utilizies radiolabelled compounds that bind amyloid deposits within the brain and create an abnormal signal on a PET scan. This field has reached the point where a company applied for FDA approval of their compound for clinical use. The FDA denied approval over concern about inter-rater reliability of the interpretation of the scans. Concern about the clinical use of amyloid imaging comes from the fact that there are no disease-modifying therapies available. A dilemma arises when someone has an abnormal amyloid imaging study but is cognitively normal or has MCI, but these individuals may never develop or have a long time before they reach the point of a clinical diagnosis of AD. These false-positive diagnoses could have a major impact on the person and their families. The current focus of research in disease-modifying therapy for AD is on immunotherapy directed against the amyloid protein that accumulates in the brain and causes AD. Early trials involved infusing fragments of the amyloid protein to trigger an immune response that would target and lower the amyloid burden. This worked well in mice models of AD. But in 2002, a clinical trial of an amyloid vaccine was stopped when some patients developed meningoencephalitis. Drugs in on-going clinical trials do not use an active vaccine theory, but rather involve passive immunization where monoclonal antibodies directed against the AD-causing amyloid proten are infused. Results of these clinical trials should be forthcoming. Dr. Hou is a Neurologist and practices in S. San Francisco
2012 Physician Art Exhibit at Hillsdale Mall from May 3 through May 10. Join Us for an Opening Reception on May 3 at 6:00 pm For more details, call Gina Cromosini at (650) 312-1663 or gcromosini@smcma.org
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SAN MATEO COUNTY PHYSICIAN | page 17
Membership Update New Members
Editorial Committee Barry B. Sheppard, M.D., Chair Russ Granich, M.D. Edward G. Morhauser, M.D.
Sharon Clark, M.D. Gurpreet K. Padam, M.D. Michael Stevens, M.D
Aifa Ahmed/ *IM Redwood City
Jonathan Lam/ ORS Redwood City
Manjita Bhaumik/ *OBG Redwood City
Linda Leung/*IM Redwood City
David Chou/ *PSY, *GPSY S. San Francisco
Stephanie Lin/ *GS, *VS Burlingame
Henry Chun/ *IM, *GE Redwood City
Amon Liu/*DR Redwood City
Sean Cullen/ *DR, *NR Redwood City
Raghu Midde/PUD Redwood City
Kimberly Dalal/ *GS Burlingame
John Ngai/ *GS Redwood City
Garrett Eggers/ EM Redwood City
Andrew Nguyen/ *PMR Redwood City
Patricia Fung/ *PD Redwood City
Stephen Nguyen/ *IM, *GE Redwood City
David Goldschmid, M.D. ......................................CMA Trustee Scott A. Morrow........................Health Officer, San Mateo Co. Barry B. Sheppard, M.D. ..................AMA Alternate Delegate
Gary Heit/ *NS Redwood City
Tina Nguyen/ *N Redwood City
Article Submission
Mamatha Hiregoudar/ *IM Redwood City
Jamie Nuwer/ *FM, *SM Burlingame
Sawsan Kara/ PD San Carlos
Rujeko Nyachoto/ *FM Redwood City
Lorin Kreitzer/ *IM Redwood City
Olga Onay/ *PD Redwood City
Eric Kwon/ U Redwood City
Todd Osinski/ *DR Redwood City
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, 650342-3030 x212. 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
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.
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.
Š Copyright 2012 San Mateo County Medical Association
SAN MATEO COUNTY PHYSICIAN | page 19
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