February 2013 by SMCMA

S a n M at e o C o u n t y

Physician

February 2013 | Volume 2, Issue 2

A publication of the San Mateo County Medical Association

Dense Breasts:

The Myths, the Facts and the Law

Being an Internist Prevention & Wellness, Communication & Continuity of Care

Vitrification New â&#x20AC;&#x153;flash fleezingâ&#x20AC;? procedure changes the face of assisted reproduction

Care Coordination and Integration Strategies for Small Physician Practices

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Editorial Committee Russ Granich, MD, Chair; Sharon Clark, MD; Edward Morhauser, MD; Gurpreet Padam, MD; Sue U. Malone, SMCMA Executive Director; Shannon Goecke, Managing Editor

Contributing Authors Sashi Amara, MD; Harriet Borofsky, MD; Shannon Goecke; Russ Granich, MD; Gregory Lukaszewicz, MD; Sue U. Malone; Christo Zouves, MD

SMCMA Leadership Gregory C. Lukaszewicz, MD, President Amita Saxena, MD, President-Elect Vincent Mason, MD, Secretary-Treasurer John D. Hoff, MD, Immediate Past President Raymond Gaeta, MD; Russ Granich, MD; Edward Koo, MD; C.J. Kunnappilly, MD; Michael Norris, MD; Michael O’Holleran, MD; Irwin Shelub, MD; Chris Threatt, MD; Kristen Willison, MD; David Goldschmid, MD, CMA Trustee; Scott A. Morrow, MD, Health Officer, County of San Mateo; Dirk Baumann, MD, AMA Alternate Delegate

Editorial and Advertising Inquiries San Mateo County Physician is published ten times per year by the San Mateo County Medical Association. Members are encouraged to submit articles, commentary and Letters to the Editor. Opinions expressed by authors are their own and not necessarily those of the SMCMA. San Mateo County Physician reserves the right to edit contributions for clarity and length, as well as to reject any material submitted. Advertising in San Mateo County Physician is a great way to reach out to the San Mateo County medical community. Classified ads begin at $40 (for up to five lines) for members. Acceptance and publication of advertising does not constitute approval or endorsement by the San Mateo County Medical Association of products or services advertised. For more information, contact Shannon Goecke at (650) 312-1663 or sgoecke@ smcma.org. Visit our website at www.smcma.org, like us at facebook.com/, and follow us at twitter.com/

S a n M at e o C o u n t y

Physician

February 2013

Editor’s Intro | Russ Granich, MD Welcome to the February issue of San Mateo County Physician. Our cover story this month comes from Harriet Borofsky, MD, medical director of breast imaging at Mills-Peninsula Women’s Center. The recently passed Senate Bill (SB) 1538 requires doctors to inform women if a mammogram reveals they have dense breasts. While increased knowledge can help empower patients to be proactive about their care, some fear that the new law, which goes into effect on April 1 of this year, may lead to confusion about follow-up, increase the potential for false-positives, and create additional healthcare costs. Dr. Borofsky’s article, “Dense Breasts: The Myths, the Facts, and the Law,” helps to demystify some of the issues. This issue also includes another entry in our occasional series on how our members chose their specialties. New SMCMA member Sashi Amara, MD, explains what attracted her to the practice of internal medicine. Also, longtime member Christo Zouves, MD, director of Zouves Fertility Center, explains the benefits of vitrification, a new procedure for flashfreezing eggs and embryos. Vitrification literally means “turning into glass” and it is changing the way physicians practice assisted reproduction. In fact, data shows that the frozen embryo pregnancies appear to have fewer complications than fresh. Finally, we include an excellent primer from the AMA aimed at helping small practice physicians achieve their professional goals in the ever-changing health care delivery environment.

President’s Message | MLK’s Legacy: Lessons for Physicians. . .................. 5 Gregory Lukaszewicz, MD Executive Report | SMCMA Goes to Washington....................................... 7 Sue U. Malone Dense Breasts: The Myths, the Facts, and the Law.................................... 8 Harriet Borofsky, MD Being an Internist . . .................................................................................... 13 Sashi Amara, MD Vitrification.. .............................................................................................. 14 Christo Zouves, MD Retaining Independence While Embracing Accountability:................... 15 Part I: Care Coordination and Integration Strategies for Small Physician Practices AMA Staff Index of Advertisers. . ................................................................................ 18

President’s Message | Gregory Lukaszewicz, MD

MLK’s Legacy: Lessons for Physicians

few weeks ago, our country commemorated the life of Martin Luther King, Jr. The holiday made me reflect upon what his legacy means to me, both as a person and as a physician. Dr. King is best remembered for his role as a leader of the Civil Rights Movement, an impassioned orator, and a champion of non-violent resistance to oppression. Despite the constant threat of violence against himself and his loved ones (demonstrated by the bombing of his home in Montgomery in 1956), he courageously led a movement that dramatically altered for the better the course of the nation. As a physician, I have been influenced by Dr. King’s altruism and service, his commitment to social justice, and his vision of a better future. Dr. King’s willingness to put his own needs aside to work for the good of others has inspired many, myself included, to go to medical school in the first place: An individual has not started living until he can rise above the narrow confines of his individualistic concerns to the broader concerns of all humanity. “Remaining Awake Through a Great Revolution,” Address at Morehouse College Commencement, Atlanta, Georgia | June 2, 1959 As physicians we can get caught up in the struggles of maintaining a practice, struggling with insurance companies, keeping up with changing governmental regulations and requirements, and worrying about whether cuts based upon the Sustained Growth Rate will actually go through. We can forget what led us to pursue a career in medicine in the first place. Though certainly important, these responsibilities should not divert our attention and focus from our patients’ needs. It can be difficult at times to remember that our profession is not simply a business, but a sacred trust between healer and patient. Most health care providers can look back and count numerous examples of their actions having a profound, sometimes lifesaving, effect upon their

patients and their families. Remembering these experiences can bolster our commitment to help others in spite of the day-to-day struggles of operating a modern medical practice. Dr. King’s commitment to social justice should remind us that access to affordable health care is a basic human right. It is easy to focus solely on rising health care costs and the effects on our economy, but access to care is not simply an economic issue. As the Physician Charter of the American Board of Internal Medicine Foundation states, physicians have a responsibility to help improve access to care: Medical professionalism demands that the objective of all health care systems be the availability of a uniform and adequate standard of care. Physicians must individually and collectively strive to reduce barriers to equitable health care. Within each system, the physician should work to eliminate barriers to access based on education, laws, finances, geography, and social discrimination. A commitment to equity entails the promotion of public health and preventive medicine, as well as public advocacy on the part of each physician, without concern for the selfinterest of the physician or the profession. Dr. King started out as a Baptist minister. Armed with a vision for a better future, he used his talents and his position in the community to rise become one of the leaders of the Civil Rights Movement. As physicians, we too have the opportunity to act as leaders in our communities and influence events larger than ourselves. We are able to accomplish this both within medicine and, for some physicians, in fields such as politics, science and business. Practicing medicine can at times be incredibly demanding. The life of Dr King is a heroic example of struggling against adversity to bring about far-reaching change, reminding us that altruism and social service lies at the very foundation of our profession. ■8

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Executive Report | Sue U. Malone

SMCMA Goes to Washington

resident-Elect Niki Saxena, a pediatrician in Redwood City, and Sue Malone, your Executive Director, headed to Washington, DC recently for an AMA National Advocacy Conference and the opportunity to meet with our local Congressional representatives in their D.C. offices. During the conference we heard from members of Congress, top administration officials, a journalist and other experts on health policy issues affecting the medical profession.

encourage incremental changes with positive incentives and rewards during a defined timetable, as well as provide a way to measure progress and show policymakers that physicians are taking accountability for quality and costs. Chuck Todd, NBC News’ political director and chief White House correspondent, offered his insight into what the next six months might look like. He observed that the federal budget sequester, if Congress does not stop it, will harm the economy, and the sequester’s two percent cut to Medicare payments will harm physicians’ practices. Mr. Todd expressed concern that the partisan nature of politics in Washington likely will prevent lawmakers from reaching a solution. He did express hope for resolution of the budget crisis, but what remains uncertain is how long it will take Congress and the White House to resolve the budget problem and what the solution may look like.

Rep Fred Upton (R-Mich), who chairs the U.S. House Energy and Commerce Committee, announced that the committee is on track to submit a plan to fix the broken Medicare payment system before Congress’ summer recess, with a goal to have it on the House floor before the end of summer. The Also addressing the group proposal would eliminate was DHHS’ Secretary Kathleen the sustainable growth rate SMCMA Executive Director Sue Malone, Congresswoman Jackie Speier, and SMCMA Sebelius. She pointed to dozens (SGR) formula and transition President Elect Niki Saxena of new payment and delivery over a period of time to fees models that are taking shape based on quality and clinical across the country, with improvement. Working physician leaders playing a key role to improving the with the AMA, Rep Upton noted that the transition plan health care system for physicians and patients. needs to include core elements that reflect the diversity of physician practices and provide opportunities for Atul Grover, the chief policy officer for the Association physicians to choose payment models that work for their of American Medical Colleges, noted that while U.S. patients, practice, specialty and region. The plan will medical school have increased the number of students Continued on page 18

February 2013 | SAN MATEO COUNTY PHYSICIAN 7

DENSE Breasts: The Facts, the Myths, and the Law Harriet Borofsky, MD

In accordance with the recently passed Senate Bill (SB) 1538, women in the state of California with mammographically dense breasts, based on the American College of Radiology’s (ACR) BIRADS criteria, will receive the following notice in the written summary of their mammogram report they receive by mail: “Your mammograms show that your breast tissue is dense. Dense breast tissue is common and is not abnormal. However, dense breast tissue can make it harder to evaluate the results of your mammogram and may also be associated with an increased risk of breast cancer. This information about the results of your mammogram is given to you to raise your awareness and to inform your conversations with your doctor. Together, you can decide which screening options are right for you. A report of your results was sent to your physician.” This law, written by Senator Joe Simitian (D-Palo Alto) and signed by Governor Jerry Brown, takes effect on April 1, 2013, and is similar to laws passed in the states of Connecticut, Virginia, New York and Texas, in response to the growing concern amongst lay women and women’s health advocates about the decreased sensitivity of mammograms and the reported increased risk of breast cancer in women with dense breasts.

Mammographic Breast Density The radiographic appearance of women’s breasts on mammograms is inherently heterogeneous due to

the varying distribution and proportion of fatty and fibroglandular tissue. It is the fibroglandular tissue, composed of epithelium (ducts and lobules) and fibrous, connective tissue stroma that imparts density, or whiteness, on a mammogram. The American College of Radiology’s Breast Imaging Reporting and Data System (BIRADS) categorizes breast patterns into four main types: • Type 1: Fatty – <25% fibroglandular tissue; almost entirely fatty tissue • Type 2: Average – 25%-50% fibroglandular tissue • Type 3: Heterogeneously dense: 50%-75% fibroglandular tissue • Type 4: Extremely dense: >75% fibroglandular tissue Breast density is a determination made by the interpreting radiologist and, under the Mammography Quality Standards Act (MQSA) of 1998, must be included in all mammography reports. Dense breast tissue, types 3 and 4 patterns, is common, seen in approximately 40% of all mammograms.

Breast Density and Age While there is a widely-held myth that premenopausal women have dense breasts and postmenopausal women have fatty breasts, breast density is, in fact, predominantly a genetic trait, altered some with advancing age. In a recent retrospective review of 7,007 mammograms at New York University Langone Medical Center, Checka et al (AJR, March 2012; 198, 3: W292-W295) reported

Mammogram Images: “Mammograms Showing Dense And Fatty Breasts” released by the National Cancer Institute, 1994. used with permission, for artistic puropses only.

8 San Mateo county physician | February 2013

the following data regarding the relationship between breast density and age:

AGE Range

% with Dense breasts

40-49

74%

50-59

57%

60-69

44%

70-70

36%

While overall sensitivity is decreased in women with heterogeneously and extremely dense breasts compared to average and fatty breasts, mammograms are still quite effective in detecting most cancers in all women. Even in women with dense tissue types, mammograms are invaluable in assessing for interval changes, architectural distortion and calcifications, and should be performed in all age-appropriate women.

Breast Density and Increased Risk for Breast Cancer

While there is a generalized, overall decrease in breast density with age, there are a significant number of postmenopausal women with dense breasts, and a significant number of premenopausal women with fatty breasts. Breast density is also altered significantly by hormonal changes, such as those due to pregnancy and lactation, and by hormonal therapy, especially estrogen and progesterone combinations, and tamoxifen.

Mammographic Sensitivity and Breast Density The ability of mammography to detect breast cancer, its overall sensitivity, is inversely related to breast density. Mammograms are less effective in detecting some cancers in women with dense breast tissue due to lack of contrast between the inherently dense, “white” tissue and similarly dense “white” lesions that may be cancerous. In a 2000 study, Mandelson (J Natl Cancer Inst 2000; 921:1081-1087) reported a mammographic sensitivity of 80% in women with fatty breasts and a sensitivity of 30% sensitivity in women with extremely dense breasts. The odds ratio for interval cancers, (breasts cancers diagnosed after a normal mammogram) among women with extremely dense breasts was 6.14 compared with women with fatty breasts. Mills-Peninsula’s Breast Program data, 20042008, analyzing mammographic sensitivity and breast density is as follows: Breast Density Type

% of Patients

Mammographic Sensitivity

Fatty

5.9%

93%

Average

56.9%

88%

Heterogeneously Dense

33.7%

84%

Extremely Dense

3.5%

71%

The association between dense breast tissue, as an independent risk factor, and breast cancer is debatable and difficult to establish with certainty. Several retrospective studies have reported a 2-6 fold increased risk of breast cancer in women with dense breasts. Boyd et al (NEJM 2007; 356: 227-236) reported that breast cancer risk is increased 5 fold in women with dense breasts. Harvey et al (Radiology 2004; 230: 29-41) found a 4-6 fold increase in breast cancer in women with extremely dense breast tissue. In a meta-analysis of all published studies investigating the association between breast density and risk of breast cancer, McCormack et al (Cancer Epidemiol Biomarkaers Press 2006; 15: 1159-1169) showed the following relationship between relative risk of breast cancer and breast density:

% Density

RR of Breast Cancer

Fatty: 5%-24%

1.79

Average: 25%-49%

2.11

Heterogenously Dense: 50%-74%

2.92

Extremely Dense: >75%

4.64

The validity of all these studies has been questioned due to the inherent subjective nature and variability in determining and reporting breast density and due to inherent inaccuracies in measurement of density based on 2D images. While the studies certainly suggest an association between dense breast tissue and elevated risk of breast cancer, the degree and importance of the association is unclear and the mechanism by which breast density may affect risk is not known.

Continued on next page

February 2013 | SAN MATEO COUNTY PHYSICIAN 9

Supplemental Imaging The decreased sensitivity of mammography, combined with elevated risk for breast cancer in women with dense breasts, begs the following questions: Are mammograms enough? What is the role for supplemental imaging, such as ultrasound, MRI and Digital Breast Tomosynthesis (DBT)?

Ultrasound

law, (Weigert et al; The Breast Journal 2012; 18;6: 517-522 and Hooley et al Radiology 2012; 265;1: 59-67), both show an increase in breast cancer detection of 3.2/1000 by adding ultrasound to mammograms in women with dense breasts. The rate of biopsies prompted by ultrasound was 5% with positive predictive value (PPV) when biopsies were recommended ranging from 6.5% to 6.7%. Clinical confidence and accuracy with ultrasound interpretations will likely improve with experience.

Readily accessible, well-tolerated and safe, ultrasound Magnetic Resonance Imaging (MRI) provides cross-sectional images, not limited by overlapping or dense tissue. Advances in high MRI screening, in addition to mammograms, is frequency, 14MHz, currently indicated for a select transducers have improved subset of high-risk patients. image resolution, which It is a costly exam, less The decreased sensitivity of has led to a markedly tolerable than mammography increased utilization of mammography, combined and ultrasound, requiring breast ultrasound, as an intravenous administration with elevated risk for breast invaluable, complementary of contrast and 30-45 minute imaging modality to scan times. The American cancer in women with dense mammography. Cancer Society established

MRI screening guidelines breasts, begs the question: Numerous studies in 2007 and has recommend have established that Are mammograms enough? annual MRI, in addition to adding ultrasound to mammography, in the following mammograms in highhigh risk women: risk women with dense breasts increases breast cancer detection. Six single 1. Known BRCA1/BRCA2 carriers institution and three multi-institutional trials have 2. First degree relatives of BRCA1/BRCA2 shown an increase in breast cancer detection (yield) carriers, but not tested of 3.5-4.4/1000 and an increase in breast cancer 3. Greater than 20% lifetime risk for breast detection rates of 13%-28% by adding ultrasound to cancer, based on computer models (Gail, mammograms. The overwhelming majority of these Claus, BRCAPRO, and Cuzick-Tyrer) ultrasound-detected cancers are early stage, lymph node, negative invasive tumors. 4. Prior chest radiation, between the ages of The major concerns about screening ultrasound include the large resources of time, effort, equipment, expertise, skill and cost required to provide high quality supplemental ultrasound screening to women with dense breasts, particularly as insurers are not mandated to cover screening beyond mammography. In addition, the increase in breast cancer detection achieved by adding ultrasound to mammograms is offset by the many false positives and biopsies required. The ACRIN 6666 study (JAMA 2008) found that adding ultrasound to mammography resulted in 4 fold as many false positives. Two early studies evaluating the three year Connecticut experience with the â&#x20AC;&#x153;dense breastâ&#x20AC;?

10 San Mateo county physician | February 2013

10-30 (most frequently Hodgkins Disease)

5. Li-Fraumeni, Cowden and Bannayan-RileyRuvalcaba syndromes and first degree relatives Nine studies have reported a supplemental breast cancer detection yield of MRI in addition to mammography in high-risk women of 11/1000, increasing to 14/1000 in a subset of women who also had screening ultrasound, (Berg; AJR2009;192;2:390399 and Warner; JAMA. 2004;292;11:1317-1325. There are currently no studies evaluating the efficacy of MRI in women with dense breasts, as an independent risk factor.

Digital Breast Tomosynthesis (DBT) An advanced application of digital mammography, digital breast tomosynthesis (DBT), is in early phases of clinical evaluation, improves upon the major limitations of mammography: overlapping tissue leading to missed cancers and false positive leading to call back imaging. This technology utilizes multiple, limited angle tomographic images through a compressed breast during a short exposure, which are reconstructed at 1 mm thin sections and displayed on high resolution monitors along with the standard views. Early studies show a reduction in call backs by 40% and suggest an increase in breast cancer detection. There are no studies, to date, evaluating the efficacy of DBT specifically in women with dense breasts.

Summary Screening mammography is an undisputedly effective way of reducing mortality from breast cancer; however, its sensitivity, or effectiveness, is not the same for all women and varies with breast density. The recently passed California state law, SB 1538, is meant to be a way of empowering women with information about their breast density, along with the knowledge that their risk of breast cancer may be elevated and that mammograms are less effective in breast cancer detection. As there are no current established guidelines addressing the role of additional imaging in women with dense breasts as an independent risk, we must counsel our many patients with dense breasts and normal mammograms, about their specific, overall risks for breast cancer and concerns they may have about additional imaging, which may improve detection of early stage cancers, but may also lead to additional evaluations, biopsies, follow-up exams and expense. To date, insurers are not mandated to cover additional imaging beyond screening mammograms. Screening options will likely become increasingly tailored for the individual woman, based on age, breast density and other risks. Ultrasound may be the most effective approach in improving early stage breast cancer detection in the many women with dense breast tissue, especially in those at intermediate risk who do not meet criteria for MRI. Future studies will likely confirm the important role of digital breast tomosynthesis in improving overall breast cancer

detection in all breast types. As we move forward and experience the impact of this new law, we must remain focused on our patients and on our mutual goal: to detect breast cancer at its earliest stage, thereby saving lives. ■

About the Author Harriet Borofsky, MD, is medical director of breast imaging at Mills-Peninsula Women’s Center, the first of its kind in the region to provide expert diagnosis, treatment and education for health issues that are specific to women. She attended Brown University and Harvard Medical School and completed her radiology and fellowship at Stanford Medical Center. Her last article for San Mateo County Physician was “Mammography and Radiation Risk,” published in September 2011.

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February 2013 | SAN MATEO COUNTY PHYSICIAN 11

Who said that?

Can you match the following quotations about medicine on the left with its author on the right? To help you out, we’ve indicated the physicians with an asterisk. 1. “Isn’t it a bit unnerving that doctors call what they do ‘practice’?”

A. Cicero

2. “The physician should not treat the disease but the patient who is suffering from it.”

B. Abraham Verghese*

3. “Medicine is my lawful wife, and literature is my mistress. When I get fed up with one, I spend the night with the other.”

C. Anton Chekhov*

4. “Though the doctors treated him, let his blood, and gave him medications to drink, he nevertheless recovered.”

D. Emily Dickinson

5. “‘Tell us please, what treatment in an emergency is administered by ear?’....I met his gaze and I did not blink. ‘Words of comfort,’ I said to my father.”

E. Erma Bombeck

6. “The aim of medicine is to prevent disease and prolong life, the ideal of medicine is to eliminate the need of a physician.” 7. “In nothing do men more nearly approach the gods than in giving health to men.” 8. “Surgeons must be very careful / When they take the knife! / Underneath their fine incisions / Stirs the Culprit - Life!” 9. “He is the best physician who is the most ingenious inspirer of hope.” 10. “Never go to a doctor whose office plants have died.”

F. Leo Tolstoy G. George Carlin H. Samuel Taylor Coleridge I. William J. Mayo* J. Maimonides*

1: G; 2: J; 3: C; 4: F; 5: B; 6: I; 7: A; 8: D; 9: H; 10: E ANSWERS: 12 San Mateo county physician | February 2013

Being an internist Prevention and Wellness, Communication and Continuity of Care

Sashi Amara, MD I grew up wanting to be a doctor and I am very happy to be an outpatient general internist—or, as most people put it, a “primary care doctor for adults.” I know that this sounds unreal in today’s age of low reimbursements for primary care, long hours and paper work. Here are some of the reasons why it is the perfect choice for me. Preventive Medicine is finally getting recognized. I feel privileged to be part of this change as I strongly believe that preventive medicine is the key to decreasing health care costs and towards a healthier generation. I feel blessed that I am uniquely positioned to counsel patients on their lifestyles and recommend preventive testing. I get to see a variety of patients—men and women, young and geriatric—and a variety of medical problems —acute, chronic and preventive. It makes my day fun and challenging. Of course, not everything I see is interesting, but being able to find that one thing “needle in a haystack” makes it all worthwhile. I enjoy the continuity of care. Getting to know my patients for who they are is incredibly rewarding. I am truly humbled by the strength and courage some of my patients exhibit during illness and recovery. I also see how precious lives can be wasted by poor choices. Being part of the patient’s personal journey is a great learning experience for me.

Communication and Coordination: Coordinating care takes time, and time is something we physicians never have enough of. However, with this effort comes the opportunity to interact with and learn from consultants, which help to keep my skills up-to-date. It has strengthened my belief that, when doctors collaborate, they can serve patients better. I am happy to be an internist, and I am excited about the recognition Preventive Medicine has received in the recent past. ■

About the Author Sashi Amara, MD, FACP, NCMP, is a board-certified internist at Palo Alto Medical Foundation in Burlingame. Her clinical interests include women’s health, preventive medicine, and chronic disease management. She completed her internship at Sacred Heart Medical Center and her residency at Virginia Mason Hospital Medical Center.

February 2013 | SAN MATEO COUNTY PHYSICIAN 13

VITRIFICATION: New “flash freezing” procedure changes the practice of assisted reproduction. Sashi Amara, MD

Christo Zouves, MD Vitrification is a new technique for egg and embryo cryopreservation that was developed and perfected in Japan. The traditional “slow freeze” method of cryopreserving eggs and embryos was tedious to perform, and survival rates for eggs was only 10% and for embryos approximately 70%. The new technique of vitrification literally means “changing into glass” and is similar to what is commonly known as “flash freezing”.

the fresh embryo transfer has the best chance of success, to knowing that the frozen embryo transfers are now producing higher success rates and. as a result, physicians will be performing very few fresh embryo transfers when women provide their own eggs through stimulation. All advanced embryos will be vitrified and transfer will be performed once the negative effects of the fertility drugs have left the body, usually by the very next cycle.

With vitrification, the egg or embryo goes from room temperature to -196° Celsius in a matter of milliseconds, too fast for any significant ice crystal formation, and this has increased the survival rate to approximately 98%. This has resulted in two major changes in the way that physicians practice assisted reproduction.

Another added bonus of vitrification is the recent analysis of pregnancy outcome when a fresh embryo transfer was performed in a stimulated cycle versus a frozen embryo transfer. The data shows that the frozen embryo pregnancies appear to be less complicated by problems such as bleeding in pregnancy. Pregnancies tend to last two weeks longer, and babies are approximately 200 grams heavier for the same gestational time. ■

The first major change is the ability to freeze unfertilized eggs that can be thawed and fertilized at a later stage, resulting in very good quality embryos and ongoing pregnancies. This has huge implications for women to be able to bank their unfertilized eggs, allowing them to pause the biological clock to have their own genetic children at an age when their fresh eggs may have deteriorated, or even when they have become menopausal. When embryos are vitrified and thawed, survival is approximately 98%, and the quality of the thawed embryos is almost as good as fresh. Pregnancy rates from frozen embryo transfers have been rising steadily over the last year, and we are now at the point where the success rate of frozen cycles exceeds that of fresh transfers when a woman is stimulated and supplies eggs for her own IVF cycle. This has resulted in the second major change in the way that we practice. We have moved from believing that 14 San Mateo county physician | February 2013

About the Author Christo Zouves, MD, is medical director of Zouves Fertility Center in Foster City (www.goivf.com). He studied medicine at the University of Cape Town in South Africa and completed residencies and fellowships in OB/GYN and General Surgery at Royal Colleges in London, England. Prior to opening Zouves Fertility Center in 1999, Dr. Zouves was the Medical Director of Pacific Fertility Center in San Francisco for seven years.

Retaining Independence While Embracing Accountability: Part I: Care Coordination and Integration Strategies for Small Physician Practices Physicians throughout the country are trying to figure out how to best achieve their professional goals in the changing health care delivery environment. Physician payments are increasingly being structured in a way that incentivizes quality and cost effectiveness over volume, and many place physicians at financial risk. In addition, public reporting of physicians’ performance will now be the norm, rather than the exception, with Medicare’s expansion of its Physician Compare website in 2013. Will physicians need to be employed by a hospital or a large medical group or health system in order to provide the quality and manage the costs that these payment and reporting systems require and take advantage of the emerging opportunities resulting from health system reform?

Three steps to improve quality

Not necessarily. While some physicians may ultimately decide that formal alignment with a large medical group or hospital system is their best option, others are actively working to integrate new care coordination and accountability capabilities into their smaller practices. Indeed, there are a number of avenues that physicians in smaller practices can take that will allow them to retain their independence while also achieving the new capabilities they will need to succeed in this new environment.

For example, in “Achieving Clinical Integration with Highly Engaged Physicians,”1 the authors point to Consultants in Medical Oncology and Hematology (CMOH), a ten-physician independent hematology practice in Delaware County outside of Philadelphia. These physicians were dissatisfied with their inability to contract on acceptable terms with managed care plans, and therefore began collecting their own data that would demonstrate the practice’s value by measuring performance on issues such as keeping their patients out of the hospital, and producing high satisfaction scores. They implemented an electronic health record to track their patients’ utilization of services and provided standardized approaches to care. With collaboration among its clinical support teams, the practice adhered to evidence-based guidelines, provided enhanced patient access to care through same day/next day visits, and educated patients to improve medication, evaluation, and treatment compliance, etc. According to the study, the results of these efforts were impressive, as the practice:

Developing new capabilities to coordinate care and improve results AMA has published a new resource to assist physicians in small and solo practice in taking advantage of the opportunities presented by the changing health care delivery environment, entitled “Retaining independence while embracing accountability: care coordination and integration strategies for small physician practices,” available at www.ama-assn.org/go/ACO. This resource identifies the core capabilities physician practices will likely need to enhance to be successful in the future and describes how small physician practices can attain these capabilities, which are summarized briefly below. The resource also discusses options small practices may have to collaborate with other physicians and to obtain financing for practice enhancement, which will be covered in a subsequent article.

There are at least three things that even the smallest of practices can do to improve care: •

Standardize care through the use of accepted guidelines, policies and procedures;

•

Facilitate better coordination and interaction among all the parties involved with the care, including the patient; and

•

Develop and analyze data to change behavior, produce better outcomes, and provide care more efficiently.

One practice’s success story

•

Increased its financial margin by lowering its fulltime employee staffing requirements by 10%;

•

Lowered the number of emergency room referrals for its patients;

•

Reduced hospital admissions for its patients;

•

Increased the number of patients seen within 24 hours of a telephone call five-fold. Continued on next page

February 2013 | SAN MATEO COUNTY PHYSICIAN 15

Care Coordination and Integration Strategies for Small Physician Practices By 2010, the group’s clinical integration program resulted in it receiving the first oncology patientcentered medical home designation by the National Committee for Quality Assurance. (Id. at 10-11.)

Tools for small practices Tools are available for physicians to help them make changes to their practices and manage patient referrals and transitions necessary to support coordinated care. For example, the Institute for Healthcare Innovation, funded by the Commonwealth Fund, has provided a toolkit entitled “Reducing Care Fragmentation” that introduces four key concepts for enabling change, and offers activities, model documents, and other tools to support their implementation. This toolkit is available at www.improvingchroniccare.org. Similarly, there are a number of tools that small physician practices can use to aggregate and evaluate their data efficiently: Flow sheets. The American Medical Associationconvened Physician Consortium for Performance Improvement (PCPI) has developed prospective data collection flow sheets for a number of clinical conditions that incorporate evidence-based performance measures. See www.ama-assn.org/ama/pub/physician-resources/ clinical-practice-improvement/clinical-quality.page. These prospective data sheets can serve as a reminder checklist to ensure that all care team members know what needs to be done when the patient is in the office. Registries. The ability to generate and use registries, that is, lists of patients with specific conditions, medications, or test results, is also considered a proxy for high quality health care.2 Such registries help office staff identify patients who are overdue for recommended services and facilitate contacting them and arranging for office visits, lab monitoring, referrals and other needed care. Some registries can even be developed using free software. The AMA has provided guidance on patient registries, including information on how to create them. See “Optimizing Outcomes and Pay for Performance: Can Patient Registries Help?” a copy of which can be found at www.ama-assn.org/ama1/x-ama/upload/ mm/368/pt_registries_102005.pdf. In addition, the California Health Care Foundation’s resource “Chronic Disease Registries: A Product Review,” available at www. chcf.org may also be helpful.

16 San Mateo county physician | February 2013

Electronic Health Records. Electronic health records (EHR) can also assist with care coordination. Physicians in smaller practices may be particularly interested in investigating some of the newer, cheaper cloud-based EHR systems. “Cloud computing” refers to a number of technology solutions that: (1) operate over the Internet; (2) use shared resources such as storage, processing, memory and network bandwidth with other users; and (3) are “on-demand,” meaning capabilities such as network storage can be adjusted virtually, eliminating the need for on-site IT staff. For more information on health information technology, including the Medicare/ Medicaid EHR incentive programs, go to the AMA’s website at www.ama-assn.org/go/HIT. Claims data. Another potentially valuable source of information is claims data. AMA has published a toolkit to help physicians use these data for practice improvement activities, whether they are received from health insurers associated with their physician profiling reports or directly from a physician’s practice management system or clearinghouse. This helpful resource, “Taking Charge of your Data,” is available at www.ama-assn.org/go/physiciandata.

Potential benefits Finally, this resource outlines the benefits which accrue from engaging in quality measurement programs and using practice data to monitor, report, and improve: Increased quality. Measurement drives behavior.3 Measurement can result in both improved outcomes for patients and lower health care costs generally due to the avoidance of duplicative and/or unnecessary health care services. For example, in 2000, “U.S. patients were much more likely—three or four times the benchmark rate—than patients in other countries to report having had duplicate tests or that medical records or test results were not available at the time of their appointment.”4 Improved “profiles” (and more patients). Private third-party payers have ranked physicians for years. And now, Medicare has gone into the “quality reporting” business by launching a Medicare Physician Compare site which, starting in 2013, will include Physician Quality Reporting System (PQRS) results based first on the 2012 reporting year.5 Increasingly, anyone who has access to a website can find out information about his or her physician, and how that physician “compares” to other physicians.

Care Coordination and Integration Strategies for Small Physician Practices While many physicians have been concerned about such public ranking, physicians who are acknowledged as recognized providers in these programs have gotten more patients to treat than non-recognized physicians and often get the opportunity to participate in more networks.6 Consequently, despite their drawbacks, performance measures can mean that those who score well will be in a better position to obtain: (1) higher payment; (2) increased consumer attention, and (3) better branding opportunities. Increased financial benefits. The National Priority Partnership, convened by the National Quality Forum, has identified four activities which require physician involvement that reduce costs substantially and improve quality. The opportunity for estimated savings can be summarized as follows:

OPPORTUNITY

SAVINGS

Preventing Hospital Readmissions

$25 billion

Improving Patient Medication Adherence

$100 billion

Reducing ER Overuse

$38 billion

Prevention Medication Errors

$21 billion

Notes 1.

See Alice G. Gosfield, JD, and James L. Reinertsen, MD, “Achieving Clinical Integration with Highly Engaged Physicians,” a copy of which can be found at https://www. wsma.org/Media/PRC-pdf-STEPS/STEPS_Achieving_ Clinical_Integration_GR.pdf

See Fleurant, et al., “Massachusetts e-Health Project Increased Physicians’ Ability to Use Registries, and Signals Progress Towards Better Care,” Health Affairs, July 2011, 30:7.

Asch, McGlynn, et al., “Comparison of Quality of Care in the Veterans’ Health Administration and Patients in a National Sample,” Ann.of Int.Med. Vol. 141, No. 12, December 21, 2004, pp. 938-345.

The Commonwealth Fund Commission on a High Performance Health System, Why Not the Best? Results from the National Scorecard on U.S. Health System Performance, 2008, The Commonwealth Fund, July 2008. http://www.commonwealthfund.org/Publications/ Fund-Reports/2008/Jul/Why-Not-the-Best--Resultsfrom-the-National-Scorecard-on-U-S--Health-SystemPerformance--2008.aspx.

See 42 U.S.C. §280j-2. Further, although the PQRS was once voluntary, if eligible professionals do not satisfactorily submit data on quality measures for covered professional services for the quality reporting year beginning in 2015, the Medicare Fee Schedule amount for such services will be reduced. (42 U.S.C. §1395w-4.)

See Berry, Emily, “Narrow Networks: Will You Be In or Out?” AMedNews, Oct. 4, 2010.

The AMA Private Sector Advocacy Unit created “A Physician’s Guide to Evaluating Incentive Plans” that physicians can use to evaluate such plans for their financial and patient care implications http://www.ama-assn.org/ resources/doc/psa/x-ama/pfp_brochure.pdf.

See www.nationalprioritiespartnership.org. Thus, not only is performance measurement likely to improve patient care, it may also serve as a foundation for financial incentive and reward programs in value-based purchasing strategies. In California alone, since 2004 approximately $400 million dollars have been distributed to physicians by certain health plans participating in a pay for performance initiative.7 See Results of Integrated Healthcare Association Pay for Performance Program, at www.iha.org. In the end, physician practices that enhance their competency with respect to the three core areas outlined above, (1) standardization, (2) care coordination, and (3) data evaluation, will likely perform better, both clinically and financially. ■

Access AMA Resources Online This is the first in a series of three articles published by the American Medical Association. “Retaining Independence While Embracing Accountability: Care Coordination and Integration Strategies for Small Physician Practices,” is available as part of the AMA resource, ACOs, Co-Ops and Other Options: A How-To Manual for Physician’s Navigating a Post-Health Reform World, at ama-assn.org/go/ACO. Stay up-to-date with new resources from the AMA, by signing up to receive the free AMA Practice Management Alerts emails at www.ama-assn.org/go/pmalerts.

February 2013 | SAN MATEO COUNTY PHYSICIAN 17

Executive Report | Sue U. Malone

SMCMA Goes to Washington (continued from page 7) they accept each year (about 30%), Congress has limited the number of residency slots since 1997, even while demand for the growing patient population have multiplied. The number of U.S. medical school graduates will exceed the number of available residency slots by early 2015. Dr. Saxena join a group of physicians from California meeting with the Senate Health Legislative Assistant to Senator Barbara Boxer. Dr. Saxena and Sue Malone visited with Congresswoman Jackie Speier and Eric KatzelnickWise, Congresswoman Anna Eshoo’s House Legislative Assistant. In these meetings, we urged our representatives to vote to replace the failed Medicare physician payment formula (SGR) with a system that rewards quality and achieves cost savings. With the recent announcement by the Confessional Budget Office (CBO) that the cost of

repealing the SGR has dramatically decreased, the cost is now $138 billion rather than $238 billion. Having already pent $146 billion on short-term fixes to the SGR, now is the time to act. Also on our agenda was the need to retain Medicare funding for graduate medical education programs and lift the cap on Medicare-supported residency slots. Liability reform and the elimination of the Independent Payment Advisory Board (IPAB) that was created by the Affordable Care Act were also on our agenda.. This annual meeting is a terrific opportunity for the SMCMA leadership to gain the experience of visiting Senate and Congressional representatives on the Hill. It also provides a close-up look at the workings of our government. ■

Ensuring faster physician payment

The American Medical Association is proud to work with the San Mateo County Medical Association to educate physician practices on how to streamline their claims process. Getting billing information quicker— and paid faster—is a prescription for efficiency. The AMA and the SMCMA support physicians in your practice, in the state house and in the courthouse. Working together with the SMCMA, the AMA will continue to make a difference.

Be a part of it. ama-assn.org/go/memberadvocate

Index of Advertisers American Medical Association...........................................18 The Magnolia of Millbrae........................................................ 4 Marsh........................................................... Inside Front Cover

18 San Mateo county physician | February 2013

MEIC............................................................................................... 6 NORCAL Mutual Insurance................Outside Back Cover Tracy Zweig Associates..........................................................11

San Mateo County Medical Association

- Educational Webinar -

O wner vs . E mployee MD? I s Y our S trategy for the F uture ?

W hat

There are many practice opportunities for physicians to consider for the future. Will you remain in solo practice? Merge with others to form a bigger single specialty, multi-specialty group or ACO? Join a Foundation or University Affiliation? This webinar will present a balanced discussion of options and issues for physicians to consider before making these important practice decisions. Topics Include: Is solo or small group practice viable for the future? • •

How to survive and thrive with savvy management and marketing Is the “concierge” model right for me?

Merger Mania – Should you merge with others? • •

•

Single Specialty or Multi-Specialty—pros & cons Can merging reduce expenses/increase net income, maintain independence, increase contracting power to remain in private practice? Will merging position the group for future acquisition?

• • • •

Wednesday, March 30, 2013 12:00 - 1:30 p . m .

COST:

$49 SMCMA Members/$99 Non-members

Upon receipt of your registration form, SMCMA will register you for your selected webinar in the GoToMeeting webinar system. You will then receive a unique webinar link via email from GoToMeeting for webinar. Please do not share this webinar link—it is unique to your email address as well as an exclusive SMCMA member benefit.

Joining a Foundation, University Affiliation or Hospital Outpatient Clinic • •

WHEN:

How will tangible assets be valued? Will goodwill or intangible asset value be included? How will it be valued? How many years should the contract be guaranteed? Compensation models including base salary and $ per WorkRVU What will it be like being an employee? What if I want to leave?

Presenter Debra Phairas, President of Practice & Liability Consultants, LLC, is an experienced consultant who has advised physicians in making these critical transitions including shoring up solo/small groups, merging practices, consulting on being acquired and negotiating compensation for physicians.

Please fax your completed registration form to (650) 312-1664, email to sgoecke@smcma.org or mail to SMCMA, 777 Mariners Island Boulevard, Suite 100, San Mateo, CA 94404. Physician Name: Name and Address of Medical Practice:

Phone:

Fax:

Email:

Payment Method:

Check Enclosed

Charge my Visa/Mastercard/Discover (please circle your card type)

Card Number:

Expiration:

3-Digit Security Code:

777 Mariners Island Boulevard, Suite 100 San Mateo, California 94404

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22,689 To improve patient safety, you need to stay on top of best practices. Thatâ&#x20AC;&#x2122;s why, as shown by the 2011 numbers above, we provide you the risk management advice you need, when and how you want it. Itâ&#x20AC;&#x2122;s why we provide industry-leading CME online and through Claims Rx, our monthly publication based on closed claims. And why we tailor solutions to help with your specific risk issues. The results include 98% policyholder retention, the highest-level CME accreditation and reduced risk for you.

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