Marin Medicine Spring-Summer 2016

Volume 62, Number 1

Spring/Summer 2016 $4.95

DEATH AND

DYING END-OF-LIFE Guidelines and Resources

Marin Medicine Six Decades of Publication

The magazine of the Marin Medical Society

MIEC Belongs to Our Policyholders!

Toni Brayer, MD Board of Governors

Service and Value Keeping true to pride ourinmission MIEC takes both. For over 35 years, MIEC has been

steadfast in ourpolicy protection of California physicians.

With conscientious Ask anybody - MIEC has a dividend that is vastly superior to those of our competitors.

We certainly don’t hold back profit returns in “Loyalty Programs” to retirement.

We “dis-tribute” profits in dividends.

Underwriting, excellenttied Claims management and hands-on Loss And in the past 6 years our taxes have consumed only 1% of profits...unlike many policyholders of our competitors have paid taxes Prevention services, we’ve partnered with towho keep of 20% or more of their profits over the same time period, while adding hundreds of millions to surplus - money premiums low. we believe belongs in doctor’s pockets.

Added value: Added value: n No profit motiven andZero-profit low overheadcarrier with n Dividends — anlow average premiums savings of 34% overhead over the last 5 years for Californiawith physicians* n Dividends an average savings 2011 premiums of For more information or to on apply: n n n

www.miec.com 40.4%* Call 800.227.4527 Email questions underwriting@miec.com Fortomore information or to apply:

www.miec.com

* On premiums at $1/3 million limits. Future dividends cannot be guaranteed.

n n

Call 800.227.4527

MIEC 6250 Claremont Avenue, Oakland, California 94618 • 800.227.4527 • www.miec.com MMS_newsletter_04.29.16

MIEC Owned by the policyholders we protect.

Volume 62, Number 1

Spring/Summer 2016

Marin Medicine The magazine of the Marin Medical Society

FEATURE ARTICLES

Death and Dying

5

EDITORIAL

Death, Dying, the Grim Reaper . . . and Woody Allen

“A friend mordantly observes that life is a mortal condition. Today, it might ironically be added: perhaps only in our lifetime! ”

Howard Daniel

7

PHYSICIAN AID IN DYING

The Pros, Cons, and Protections for Patients and Physicians “I knew what she was going to ask me even before the words came out.”

Kristen Brooks, MD

11

ADVANCE CARE PLANNING

Thinking Ahead About End-of-Life Care “Advance care planning should be a partnership between patients and the medical community.”

Raymund Damian, MD

13

IT MAY BE OPTIONAL, BUT . . .

Hospice Is Plain Good Medicine

“Talking to patients about their options at end of life is part of a physician’s commitment to excellent care.”

Molly Bourne, MD

17

AN APPROACH TO DEATH AND DYING

RESPECT at the End of Life

“‘The conversation you are about to have is all that matters right now.’

Unfortunately, that was the full extent of the training I received during residency in being with death and dying.”

Scott Schmidt, MD

21

DEATH CERTIFICATES

Certification of Death: Whose Responsibility?

“Some physicians believe that their simple refusal to sign the death certificate obligates the coroner to assume jurisdiction. In fact, the coroner is under no such obligation.”

24

Marin Medicine Editorial Board Irina deFischer, MD Chair Dustin Ballard, MD Peter Bretan, MD Sal Iaquinta, MD Naveen Kumar, MD Michael Kwok, MD Jeffrey Stevenson, MD Staff Howard Daniel Editor Cynthia Melody Publisher Linda McLaughlin Graphic Designer Susan Gumucio Advertising Representative Marin Medicine (ISSN 1941-1835) is the official semi-annual magazine of the Marin Medical Society, 2312 Bethards Dr. #6, Santa Rosa, CA 95405.

Periodicals postage paid at Santa Rosa, CA, and additional mailing offices.

POSTMASTER: Send address changes to Marin Medicine, 2312 Bethards Dr. #6, Santa Rosa, CA 95405.

Opinions expressed by authors are their own, and not necessarily those of Marin Medicine or the medical society. The magazine reserves the right to edit or withhold advertisements. Publication of an advertisement does not represent endorsement by the medical society.

A. Jay Chapman, MD

E-mail: mms@marinmedicalsociety.org

INFORMATION ON END-OF-LIFE ISSUES CMA Guidelines to the End of Life Option Act and Resources for end-of-life decisions for physicians and patients

The subscription rate is $9.90 per year (two issues). For advertising rates and information, contact Susan Gumucio at 707-525-0102 or visit marinmedicalsociety.org/magazine.

California Medical Association Table of contents continues on page 2.

Cover photo: © photohamburg, 123RF.com.

Printed on recycled paper. © 2016 Marin Medical Society

Marin Medicine The magazine of the Marin Medical Society

DEPARTMENTS

27

OUT OF THE OFFICE

Tale of a Suicide: A Life-Ending ‘Option’ We All Deplore “. . . they were pointing . . . at a person holding his head in his hands and seated on the ledge outside the railing.”

John Maa, MD, FACS

28 31

BOOK REVIEWS

Working Stiff and When Breath Becomes Air “Distilling these two books into one sentence looks like this: “Working Stiff intrigues the brain; When Breath Becomes Air touches the soul.”

Michael Kwok, MD President-Elect

2016 HEALTH CARE LEADERSHIP ACADEMY

Naveen Kumar, MD Secretary/Treasurer

From Death to Medical Satire

PUBLIC HEALTH UPDATE

Vaccines, Policy and Dialogue in Marin “While SB 277 promises to increase vaccination rates among children attending school, it’s important to keep in mind that those children who entered school unvaccinated in the past can remain in school unvaccinated.”

Matt Willis, MD, MPH

34

HOSPITAL UPDATE

Marin General Hospital: A Bright Future

“We look forward to the new hospital being completed in 2020.”

Gregg Tolliver, MD, MPH

36

PRESIDENT’S REPORT

AMA House of Delegates “Your California delegation to the AMA is in the forefront of the discussions that help mold health care policy at both state and national levels. These policies often lead to laws.”

Peter Bretan, MD, FACS

38

Board of Directors Peter Bretan, MD President

Sal Iaquinta, MD

“The surprising hit of the conference was Las Vegas internist, comedian and rapper ZDoggMD.”

32

Our Mission: To enhance the health of our communities and promote the practice of medicine by advocating for quality health care, strong physician-patient relationships, and for personal and professional well-being for physicians.

OUR MAGAZINE’S MANY METAMORPHOSES

Marin Medicine Marks Six Decades

“The board of directors is proud to share this retrospective look at the many changes and modifications to our publication over the years.”

Cynthia Melody, MNA 40 NEW MEMBERS 40 CLASSIFIEDS 40 AD INDEX

2 Spring/Summer 2016

END- OF -LIFE

GUIDELINES

&

RESOURCES P. 24

Jeffrey Stevenson, MD Immediate Past President Larry Bedard, MD Irina deFischer, MD Imran Junaid, MD Jason Nau, MD Lori Selleck, MD Matt Willis, MD Staff Cynthia Melody Executive Director Rachel Pandolfi Executive Assistant Howard Daniel Editor Linda McLaughlin Graphic Designer Susan Gumucio Advertising Representative Alice Fielder Bookkeeper Membership Active: 249 Retired: 104 Contact Us Marin Medical Society 2312 Bethards Dr. #6 Santa Rosa, CA 95405 415-924-3891 Fax 415-924-2749 mms@marinmedicalsociety.org www.marinmedicalsociety.org Marin Medicine

2016

You and your spouse or guest are invited to the

Outstanding Contribution

“Celebrating exemplary service to medicine.”

WEDNESDAY, SEPTEMBER 28, 2016 JASON’S RESTAURANT • 300 DRAKE’S LANDING ROAD • GREENBRAE

Please join your colleagues in honoring the achievements of:

David Witt, MD • Outstanding Contribution to Community Health Lori Selleck, MD • Outstanding Contribution to MMS Jeffrey Schneider, MD • Outstanding Contribution to Marin County Medicine Gail Altschuler, MD • Article of the Year RxSafe Marin • Recognition of Achievement SPONSORS

HEALTHY MARIN

PARTNERSHIP

The evening begins with a social hour at 6 p.m., followed by dinner and the awards presentation.

To RSVP, or to purchase tickets:

Dinner choices include baked salmon, brandy chicken, ribeye steak or penne rose with broccoli.

• Contact Rachel at 415-924-3891 or rachel@scma.org, or

Tickets for MMS members: FREE Spouses, guests and nonmembers: $59 each

• Send check to SCMA: 2312 Bethards Drive #6 Santa Rosa, CA 95405 Please indicate dinner choice.

Photo by Windsor Riley

The CMA/MMS’s exclusive new Workers’ Compensation program can help your practice save money!

Savings

CMA members qualify for an additional 5% discount* on top of Preferred Insurance’s already competitive rates. Preferred’s rates are set for long term consistency, and are managed by focusing on safety and injury prevention, fraud prevention and the control of medical costs for your practice by getting employees back to work as soon as practical.

Service Mercer’s team of insurance advisors is knowledgeable about the needs of physicians and is available to walk you through the application process. Preferred’s claims examiners are experts in helping members with an employee injury or illness claim. Plus Preferred’s payroll management and flexible payment plans help you manage your premiums in the way that works best for you and your practice’s cash-flow needs.

Safety In addition to mandatory CalOSHA information and videos on workplace safety, Preferred’s team of Risk Advisors are available for consultations when you need them. They also have a strong fraud prevention policy and as a California-based carrier, they know exactly what it takes to do business successfully in this state.

Stability Preferred Insurance prides itself on its stability, which includes maintaining some of the best and most consistent pricing available for CMA members. And because of its Medical Provider Network of credentialed medical professionals, claim costs can be closely monitored and managed while providing quality care to injured employees.

Call Mercer today at 800-842-3761 for a premium indication.

CMACounty.Insurance.service@mercer.com or www.CountyCMAMemberInsurance.com.

See how CMA/MMS’s Workers’ Compensation team can help you save!

Sponsored by:

Underwritten by:

Administered by:

Scan for info:

*Most practices will qualify for group pricing and receive the 5% discount; however some practices will need to be underwritten separately when they do not qualify for the special program terms and conditions. A minimum premium applies to very small payrolls.

Mercer Health & Benefits Insurance Services LLC • CA Ins. Lic. #0G39709 • Copyright 2016 Mercer LLC. All rights reserved. • 75197 (4/16) 777 South Figueroa Street, Los Angeles, CA 90017

•

800-842-3761

•

www.CountyCMAMemberInsurance.com • CMACounty.Insurance.service@mercer.com

EDITORIAL

Death, Dying, the Grim Reaper . . . and Woody Allen Howard Daniel

F

ilmmaker Woody Allen once remarked, “I don’t want to achieve immortality through my work. I want to achieve it through not dying.”

If that thought elicits even a flicker of a smile on the face of anyone reading this editorial, then this issue of Marin Medicine—whose featured topic, Death and Dying, is inescapably depressing— will have unexpectedly opened on a less gloomy note.

While the next seven articles offer virtually nothing mirthful (except for a few grins in Dr. Sal Iaquinta’s review of Working Stiff), their authors do give readers any number of heartening thoughts.

Such as, for example, in their discussions of the End of Life Option Act, the wondrous benefits of hospice care, end-of-life planning, and progress in learning to ease, for patients and their families, the last hours of life.

None of this affects the inevitability of death, of course, but it might be argued that the efforts described in the following articles to soften—in various ways—the end-of-life transition represent significant progress as compared with the way death was handled not too many years ago.

Of course, the contemporary “American way of death” is often negatively compared with the good, old-fashioned—and perhaps somewhat idealized—way in which some people used to pass away (and many of those in hospice care now do): in the comfort of their own home and bed, surrounded by loving family members.

What such critiques, stingingly accurate Mr. Daniel edits Marin Medicine.

Marin Medicine

in many respects, sometimes overlook are the enormous advances that modern medicine brings to the alleviation of the dreadful suffering that too often precedes the arrival of the Grim Reaper.

Also frequently overlooked in critiques of the way we die is the breathtaking rise in lifespan wrought by advances in public health and modern medicine.

While dying patients often pray for the Grim Reaper’s speedy arrival, we all welcome the decades-long delay with which he makes his appearance in modern times and in economically advanced countries, as compared to the early age at which he used to appear. In Hippocrates’ day, life expectancy at birth is estimated to have been about 30 years. In ancient Rome, those who didn’t die in childhood could expect to live to their late 40s. In the United States, average lifespan—now in the upper 70s, depending on socioeconomic circumstance—rose by more than three decades over the course of the 20th century.

A friend mordantly observes that life is a mortal condition. Today, it might ironically be added: perhaps only in our lifetime! And Woody Allen’s. Who knows what the future will bring!

S

hifting gears briefly, following is a short preview of the rest of this issue.

Dr. Kristen Brooks begins with a survey of the pros and cons—and protections for physicians as well as patients—of the End of Life Option Act, which enters into force on June 9, almost simultaneously with the publication of this issue. Dr. Raymund Damian discusses end-of-life

planning and care. Hospice care is sensitively and touchingly treated in an article

by Dr. Molly Bourne. Dr. Scott Schmidt tells us about the RESPECT Project for patients going through end-of-life transition, which he helped develop for Kaiser San Rafael Medical Center. “Everything you ever wanted to know about death certificates, but were afraid to ask” would be a good alternative title for an article

by Dr. A. Jay Chapman. Following these articles is a two-page spread on CMA end-of-life resources.

The issue’s Out of the Office article, by Dr. John Maa, provides a somber look at a different aspect of death and dying. It is a retelling of a suicide and its aftermath that he chanced to witness at the Golden Gate Bridge. Dr. Sal Iaquinta then gives us engaging reviews of a pair of books: Working Stiff and When Breath Becomes Air. The theme concludes with “From Death to Medical Satire,” a report on the 2016 Health Care Leadership Academy.

Four upbeat articles complete the issue: Dr. Matt Willis brings us good news about the upward trend in the Marin County vaccination rate. Dr. Gregg Tolliver provides an update on the transformation of Marin General Hospital. Dr. Peter Bretan gives us a report on last November’s AMA House of Delegates meeting. And MMS Executive Director Cynthia Melody closes with a tour through Marin Medicine’s metamorphoses over six decades. Worthwhile reading, all of it.

Email: howard@pen4rent.com

Spring/Summer 2016 5

Good Things Come In Threes.

For the third consecutive year, Marin General Hospital has earned Healthgrades Distinguished Hospital Award for Clinical Excellence — putting us in the top 5% in the nation!

We are proud to be your healing place. Count on us to deliver the highest quality care using state-of-the-art technology, along with integrative therapies to help heal body, mind and spirit. Our expert team provides exceptional care in an exceptionally healing environment recognized by patients, their families, and this leading, independent resource.

Learn more about our services and programs or find a doctor today!

1-888-99-MY-MGH (1-888-996-9644) | www.maringeneral.org

PHYSICIAN AID IN DYING

The Pros, the Cons, the Protections for Patients and Physicians Kristen Brooks, MD

I

knew what she was going to ask me even before the words came out. Though young, she had been struggling for months with pain and debility on top of years of fighting to live. She was tired of struggling and terrified of dying on any terms but her own. “What if I want to choose when I die?” she asked. “How would it work with that new law? Who do I even talk to about this?” And so began our discussion of her options, including the option to end her own life.

The End of Life Option Act is a new law—signed by Governor Jerry Brown in October 2015 and taking effect June 9, 2016—that allows physicians to provide a competent and terminally ill patient a lethal dose of a medication for the purpose of ending his or her own life.1 Physician aid in dying, formerly called physician-assisted suicide, does not equate to euthanasia, to withdrawal of life-sustaining treatment or to palliative sedation (none of which, I hasten to add, are comparable to each other). Neither does physician aid in dying refer to the “double effect” of hastening death by adequately controlling pain or discomfort at the end of life. The law is very clear that this is Dr. Brooks is a psychiatrist focusing on consultation-liaison psychiatry, in particular delirium. She is co-chair of the Kaiser San Rafael Medical Center Ethics Committee.

Marin Medicine

not suicide, but patients and physicians are sometimes not entirely comfortable with this distinction, and certainly there are complex ethical issues on both sides of this law.

There are strong ethical arguments in favor of this legislation. Patient autonomy is a proud hallmark of the American medical system. We value a patient’s right to choose, given the capacity to do so, the nature and course of their treatment as guided by their own personal values and morals. As Governor Brown said in his remarks on signing the bill (photo above), I do not know what I would do if I were dying in prolonged and excruciating pain.

I am certain, however, that it would be a comfort to be able to consider the options afforded by this bill. And I wouldn’t deny that right to others.

F

or the purpose of relieving unnecessary anguish, we allow patients to refuse or withdraw life-sustaining treatments knowing that this will result in death. Is it so different to allow patients to end their suffering actively rather than passively? Compassion dictates that we

alleviate distress for our patients, and we have all seen the suffering that comes as some patients near the end of life. Pain, indignities, confusion, agitation and fear are all unfortunate realities for many patients in their final days.

Having open and honest conversations with our patients about death and their choices promotes honesty and transparency in the physicianpatient relationship. The reality is that for decades, and really centuries, patients have planned ways to end their life if suffering becomes too great. Instead of these choices being pushed into the shadows, California patients can now have open and honest discussions about ways to take control of their own death and know that if they choose to end their life, they can do so in as controlled a way as possible.

Compelling as these arguments are, there are strong and reasonable ethical arguments against physician aid in dying.

On a very fundamental level we can all acknowledge that there is a sanctity to life. Lives are of value and purpose, and many people believe that it is not in our purview to determine when that purpose has ended. The act of deliberately ending one’s own life is often seen as different from refusing life-sustaining treatment and letting nature take its course—a more passive action.

Critics argue that it is not our role as physicians to facilitate death but rather that the integrity of our profession is rooted in the fight against disease and the easing of suffering as disease eventually Spring/Summer 2016 7

wins. Several groups representing those with physical and cognitive disabilities, the elderly and the dependent express concern that these vulnerable groups might be taken advantage of and that decisions about the end of life might be made for them rather than by them.

The law is very clear in this regard.

The decision must be by patients themselves—and without undue influence.

But how do we ensure this? Further, we must acknowledge that our profession is fallible and we sometimes get things wrong. Patients get well that we never thought would recover, and prognostications for how long a patient will live can be woefully incorrect.2 These inaccuracies and uncertainties are part of the job, but when one is involved, however indirectly, in a life-or-death decision, the stakes grow much higher.

A

mong the new law’s many challenges for physicians is the change in how we talk with our patients. We are accustomed to having complex discussions about medical diagnoses, treatments and

difficult decisions. This law creates a situation in which we talk with patients not just about our objective knowledge and experience but about ethical issues and perhaps even our personal moral beliefs.

These may be difficult, and perhaps uncomfortable, conversations to have, especially when patients’ stances on this law and these issues differ from our own.

The law protects the personal values of both physicians and patients in two ways. To protect patients, physicians are prohibited from presenting this, on their own initiative, as an option to patients.

The law is very clear that any discussion about this option must be initiated by the patient him- or herself without any undue influence by family, physicians or care providers.

To protect physicians, there is no obligation to participate in any activity (e.g., prescribing medications) that would follow from a patient’s decision to end his or her life. If doctors choose not to participate, they are obligated only to refer patients to someone who will. While these protections are important, this also

“ I’m so glad that we got hospice as soon as we did.”

We provide hospice care that helps enrich the lives of our patients – as well as their friends and loved ones – in immeasurable ways, every day. Any patient, family member or friend can contact us anytime, 24/7.

415.472.2637 heartlandhospice.com 8 Spring/Summer 2016

means that physicians and patients who may have been working together for decades will have to part ways in this, a patient’s most difficult and vulnerable hour. Furthermore, this creates a new way in which our personal values affect how we work together with colleagues, as patients move between providers who participate and those who do not.

There are several additional protections for patients and physicians inherent in this law. A sunset clause is built in whereby this law ceases to be operative in 10 years, forcing legislative re-evaluation and action—extending or amending it, or allowing it to die—depending on how it is seen to have served its intended purpose.

The goal is to protect against abuses and avoid the “slippery slope.” The reality is that despite the fear, that slippery slope has not been a problem in Oregon, a state that now has 15 years of experience and on whose laws the California legislation was based. Patients rarely ask for assistance in dying—less than 0.05% of deaths follow from physician aid. Demographically, those who make this choice are similar to those who do not in terms of sex, race, health insurance coverage and hospice enrollment. Notably, those who opt for physician aid in dying tend to have higher levels of education.3 Ultimately, decisions at the end of life are deeply personal and should be made in partnership with a trusted physician.

As physicians, we strive to provide our patients the best possible quality of life while respecting their individual choices and values. This law provides one more option in that process, and we hope it will offer comfort to those facing their final days.

Email: kristen.b.brooks@kp.org

References 1. Orentlicher D, et al, “The changing legal climate for physician aid in dying,” JAMA. 2014; 311(19):1961-1962.

2. Christakis N, et al, “Extent and determinants of error in physicians’ prognoses in terminally ill patients,” West J Med, 172(5): 310-313 (2000).

3. Hall M, et al, Health Care Law and Ethics, Wolters Kluwer (2013).

Marin Medicine

N O R C A L

G R OU P

OF

COMPANIES

GUIDE GUARD ADVOCATE

MEDICAL PROFESSIONAL LIABILITY INSURANCE

PHYSICIANS DESERVE Offering top-tier educational resources essential to reducing risk, providing versatile coverage solutions to safeguard your practice and serving as a staunch advocate on behalf of the medical community.

Talk to an agent/broker about NORCAL Mutual today. © 2015 NORCAL Mutual Insurance Company. nm0681

NORCALMUTUAL.COM | 844.4NORCAL

About Our Publications The Marin Medical Society has a long history of producing quality publications for the local medical community. Whether you’re an advertiser trying to reach local doctors, a business needing access to medical resources, or a reader interested in medical topics, MMS has a publication for you. Our magazines, newsletters and directories are widely distributed throughout Marin County and beyond.

TARGET YOUR MESSAGE

to physicians and medical professionals in . . .

MARIN MEDICINE Each issue of this semi-annual magazine focuses on a particular medical theme, with articles by local experts. To see the current issue, visit marinmedicalsociety.org and click on Marin Medicine, where you can view an interactive PDF and also searchable, text-only versions of previous issues.

MARIN COUNTY PHYSICIAN DIRECTORY Our annual reference book provides contact information for physicians in Marin County, plus detailed specialty indexes and medical resources. For ad rates, or to purchase a copy, visit marinmedicalsociety.org and click on the Directory link.

NEWS BRIEFS The monthly e-newsletter covers local medical news and events, along with top CMA benefits and news. To view current and archive issues, go to marinmedicalsociety.org and click on MMS News Briefs.

AWARDS DINNER PROGRAM Published in early fall, the annual Awards Dinner program offers a once-ayear opportunity to reach an influential group of Marin health care leaders.

To reserve space as a sponsor or program advertiser, call Susan Gumucio.

TO ADVERTISE

OR

SUBSCRIBE—in print and online:

Contact Susan Gumucio at susan@scma.org or 707-525-0102

A D VA N C E C A R E P L A N N I N G

Thinking Ahead About End-of-Life Care Raymund Damian, MD

R

e ce nt adva nce s i n medicine are vast and amazing. Beginning with medical school, physicians are trained to save lives.

Ongoing medical research seeks and finds treatments that decrease risks for chronic medical conditions, develops surgical procedures to correct physical anomalies, and creates cures for cancer. If patients are ill, the medical profession concentrates its efforts on finding ways to cure them and, in the most serious cases, to prolong and save their lives. A challenge that physicians face is how best to deliver care when all reasonable life-prolonging treatments have been exhausted or when terminally ill patients have decided not to pursue further therapy.

In 2015, the end-of-life discussion came to the forefront in California with the Legislature’s passage—and Governor Jerry Brown’s signing—of the End of Life Option Act. The new law comes into effect on June 9, 2016. It allows physicians to go Dr. Damian is co-MD lead of the Life Care Planning Program at the Kaiser San Rafael Medical Center.

Marin Medicine

beyond providing comprehensive information and counseling to terminally ill patients regarding end-of-life options, which have traditionally been limited to palliative treatments. It now also allows physicians to accede to the request of such patients to be helped—with the prescription of an aid-in-dying drug—to end their lives when they choose.

Whether people agree with the principles and intent of the law, they are now having an open dialogue about end-oflife. A 2012 report by the California Healthcare Foundation showed that 79% of patients wanted to talk to their physicians about end-of-life issues, but only 7% of them actually did.1 Physicians

have been reluctant or unable to have these discussions for a variety of reasons, but now they have a responsibility, and more importantly, an opportunity to do so.

But even before such delicate and in-depth end-of-life conversations occur, the medical community has a responsibility to inform patients about advance care planning and engage them in it early on.

Patients have their individual paths of health and trajectory of life. Discussing advance care planning more “upstream” can significantly affect how patients view and choose their care well in advance of death’s becoming imminent.

Advance care planning is a systematic approach that encourages patients to reflect on their values, beliefs and goals regarding a healthy life and to decide how medical care should be delivered when life’s trajectory is altered. Since 2013, Kaiser Permanente Northern California has implemented advance care planning through its Life Care Planning program. This program is a three-step staged approach that allows adult patients to make important medical decisions in advance of need. It encourages them to have an open dialogue with their physician and to share their decisions with family and friends.

Spring/Summer 2016 11

T

he initial phase of the Life Care Planning program is called First Steps: My Values. Patients ref lect upon and choose a reliable health care agent—a person whom patients trust, who will respect their values and wishes, and who can make sound medical decisions at difficult times. A result of First Steps is the completion of a thoughtful advance directive.

The second stage (Next Steps: My Choices) invites patients with chronic progressive medical conditions who have had a significant functional decline in their health or a prolonged hospitalization review their goals regarding future treatment options. Along with their health care agent, patients reflect on and discuss a series of medical scenarios that might prevent them from returning to their baseline of good health. The product of Next Steps is a Treatment Preference document.

The final stage (Advance Steps: My Care) helps patients who are frail and elderly or have a life-limiting illness to reflect upon care when life-sustaining

treatment options need to be addressed.

Based on this discussion, patients and physicians complete a Physician Orders for Life-Sustaining Treatment (POLST) document.

With the End of Life Option Act, physicians now have an added layer of complexity to consider when terminally ill patients voice their wish to die on their own terms. Kaiser Permanente Northern California recognizes this legal responsibility and is actively engaging in conversations and meetings to develop and implement policies and procedures that will respect and honor such requests.

In addition to having these rich conversations in all three steps, an important component of the Life Care Planning program is to collect these medical decisions and completed documents to make them easily retrievable in patients’ electronic medical records for review and future use. Advance care planning should be a partnership between patients and the medical community. The goal of Kaiser Permanente Northern California is to educate all physicians and staff about

Life Care Planning and encourage them to discuss advance care planning with all adult patients who visit any Kaiser Permanente medical center.

To date, a review of the Life Care Planning program at Kaiser San Rafael has resulted in 1,426 First Steps encounters, 92 Next Steps conversations, and 1,030 Advance Steps (POLST) discussions. 2 The Life Care Planning program is an active component of patient care throughout the medical care continuum. The hope is that all health plans in Marin County will adopt and implement their own advance care planning program so that every adult patient’s medical decisions are honored and acted upon with respect.

Email: raymund.m.damian@kp.org

References 1. California Healthcare Foundation, “Final Chapter: Californians’ attitudes and experiences with death,” CHF report (2012).

2. Internal data of Life Care Planning at Kaiser Permanente San Rafael Medical Center.

FERNWOOD

CEMETERY CEMETERY

FUNERAL HOME FUNERAL HOME

MORTUARY MORTUARY

A memorial landscape where natural burials and cremation rituals A memorial landscape where natural burials and cremation rituals are interwoven with land restoration and preservation are interwoven with land restoration and preservation Natural Burial Funerals Cremation Pre-need Arrangement Lifestories Memorialization Natural Burial Funerals Cremation Pre-need Arrangement Lifestories Memorialization 301 Tennessee Valley Rd. Mill Valley, CA 94941 301 Tennessee Valley Rd. Mill Valley, CA 94941 (415)383-7100 Fernwoodcemetery.com FD 1281 (415)383-7100 Fernwoodcemetery.com FD 1281

12 Spring/Summer 2016

Marin Medicine

I T M AY B E O P T I O N A L , B U T . . .

Hospice Is Plain Good Medicine Molly Bourne, MD

D

eath is not optional.

Even in Marin. Talking to patients about their options at end of life is part of a physician’s commitment to excellent care. It is not a question of whether our patients will die. They will. Nor is it about whether they want to die. They don’t. It is about providing good medical care to people in their final years.

When I hung my shingle in Point Reyes 17 years ago, I thought the Hippocratic Oath meant I would keep people from dying.

So long as I knew how to discuss when to have a colonoscopy and the risks and benefits of Lipitor, I figured I could safely “do no harm.” But when I met my patients, I discovered only some of them had high cholesterol, and even fewer, colon cancer.

Yet, all of them would eventually die. It struck me then: I was a full-fledged physician with no training in the one thing that would affect every single one of my patients.

Dr. Bourne is chief medical officer of Hospice by the Bay.

Marin Medicine

Of course, in medical school I saw people die. I stared in fright at their grieving families, then at the body in the morgue and finally at a daunting crowd of physicians in Grand Rounds. We all wanted to know how the death could have been prevented—what we had missed, or worse, done wrong. Certainly, no one suggested how the death might have gone better.

Nor did it occur to me that this person might have preferred to die somewhere else, accompanied by someone he or she actually knew. Honestly, in my exposure to death during training, I was most aware of wanting to be somewhere else myself.

For this reason, those first few years in practice were the most humbling in all my

training. In particular, the education I received from Hospice of Marin (now Hospice by the Bay) provided the biggest lessons. I don’t recall exactly how I started referring patients. It was likely someone else’s idea, perhaps a desperate family member or an experienced caregiver. But before long, I found myself with a handful of patients who, in addition to my care, had a transdisciplinary hospice team visit them at home. This close surveillance ensured early symptom management, medication compliance, family support and patient-centered education. The team members knew what to expect, what to say and what to do. With both chagrin and excitement, I saw excellent end-of-life care for the first time.

More humbling though was that a substantial number of my patients were actually discharged from hospice alive. The team’s good old-fashioned medical care seemed to lengthen prognoses, in some cases beyond six months (the hospice benefit cutoff). Ironically, my patients flourished with end-of-life care. Furthermore, when I gave my “graduating” patients the good news that they didn’t need hospice Spring/Summer 2016 13

Dr. Molly Bourne (right) confers with Anitra Palmer, intake nurse at Hospice by the Bay.

anymore, they begged for the team to keep coming. These patients had initially feared hospice, thinking it would hasten death with drugs like morphine. Yet now they were enjoying better quality and quantity of life and, at this rate, could not imagine letting go of the hospice benefit.

Sheepishly, I began studying hospice care in earnest. I discovered studies that show that patients on hospice, regardless of diagnosis, live weeks to months longer than patients without hospice.1 In addition, they rate their quality of life higher, spend less of their last six months in the hospital, have fewer invasive procedures and cost less to insurance providers.2 Fifteen to 20% of patients are discharged from hospice alive (and improved) because of the attentive medical care from the transdisciplinary team.3 Hospice is a Medicare and Medicaid benefit and is also covered by most medical insurance plans. At Hospice by the Bay, services are provided regardless of insurance coverage, citizenship, housing, caregivers or code status.

14 Spring/Summer 2016

A free service that allows patients to live longer and better? Why had I not heard about this before? I was now prepared to refer everyone who was eligible.

T

hen came the final discomfiting jolt to my ego. One of my patients, a man in his 50s with cardiomyopathy, died while considering participating in a heart surgery study. He was survived by a wife and son. Privately, I had known he was dying. I hadn’t known when it would be, but he was short of breath at rest despite medical therapy, and he was not getting better. The surgical trial showed modest benefits for a fraction of the patients enrolled, so whether or not they accepted him, my patient had had a good chance of dying from heart disease within the next six months. But even if I had thought of referring him to hospice, I didn’t want to get in the way of his hope. I didn’t think he was ready to hear he was dying. I believed, and still do, that he would have preferred not knowing his prognosis.

His wife found him at home after a

long day at work. She dialed 911 and then me. When I arrived, I spent the first 10 minutes of my visit convincing the police that a forensic investigation was not necessary. His wife heard me tell them that the death was expected. Through tears, she cursed all doctors across the United States who had failed her husband. More than not fixing him, she lamented, they had not told her the truth. Had she known he was dying she would have taken time off work to be with him. She didn’t say it, but I too was guilty of protecting her from the truth. Later that week, their son returned from college and came to my office. Like his mother, he was careful not to blame me directly, but he also felt robbed. I was pleased that Hospice by the Bay had a community bereavement program to which I could refer them both; they had so much to process.

Of course, I had my own feelings to reckon with too. I knew I was not responsible for his death, yet I felt I should have said something earlier. Was hope for an improbable cure more important than a Marin Medicine

Do you know What, When Do you and How to know ReportWhat, ChildWhen Abuse? and How to Report Child Abuse?

FREE ONLINE COURSE! FREE ONLINE COURSE! 

Course developed by the Child Course the Child Abuse developed Preventionby Center Abuse Prevention Center Approved for 1.25 AMA PRA Approved 1.25 AMA PRA Categoryfor 1 Credits™ Category 1 Credits™ Approved for 1.25 CE credits Approved for 1.25 CE credits 











Course available 24/7 Course available 24/7 

Pre-register Pre-registerNOW NOWat: at:

http://www.imq.org/education/caprrc.aspx http://www.imq.org/education/caprrc.aspx http://www.imq.org/education/caprrc.aspx

family’s opportunity for closure? Could they have had both? Could I have offered the support of hospice without sabotaging my patient’s quest for life?

Unable to sleep that night, I reread the Hippocratic Oath. Interestingly, it does not say “Do no harm.” That is a myth.

Rather, it includes the following promises: 1. I will not be ashamed to say “I know not.”

2. I will avoid those twin traps of overtreatment and therapeutic nihilism.

3. I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being.

Around that time, coincidentally, I bought a new car, the first one I had ever owned with airbags. When I signed the paperwork, I imagined commuting to my office, taking trips with my family, and driving to home visits all over West Marin. I was thinking of where my new car would take me, not about airbags. I wasn’t planning to crash, and if asked, I would have said I was not “ready” to crash.

The airbags were just tucked into my new car, inconspicuous, just in case.

Perhaps sleep deprivation played a role, but something about that Greek covenant and my automobile’s safety features triggered an overnight change in the way I practiced medicine. I discovered I could follow the Hippocratic directions while allowing my patients to dream about where they are going rather than about crashing. I could have frank conversations about the hospice benefit and wholeheartedly foster hope. Offering hospice was like slipping those airbags into the dashboard, just in case death is not optional. I did not ask whether the patient was ready for the conversation; I asked whether he was eligible. And when a patient’s prognosis flirted below a year, I touted hospice for what it was: a team of experts that knows more about death than any of us is expected or wants to know. A team that can help navigate end of life. Just in case.

In medical school, I committed not just to treat people, but to treat them well, as human beings. As humbling as it had been for me as a young doctor to admit “I know not,” I learned to provide the best care at end of life.

Is it Time for Hospice?

• Covered by Medicare, Medi-Cal, private insurance • Personalized end-of-life care for your patients • View our video “Is it time for hospice?” at www.hospicebythebay.org For Day, Evening and Weekend Admissions

(888) 720.2111 • FAX (888) 767.1919 Serving the counties of Marin, San Francisco, San Mateo, Sonoma and the City of Napa 16 Spring/Summer 2016

Here’s what I wish I had said six months before my patient died: On paper, you meet the criteria for the hospice benefit. This means a team of experts can come to your home and help you manage your symptoms, get your affairs in order, and provide tools for you and your family to process the incremental losses that come with an illness like yours. If you decide to do the heart surgery, you can come off hospice with no penalty. But if you don’t, hospice will provide better care than I can alone because they are a phone call away anytime, day or night. I will remain your doctor, and they will keep me abreast of what is going on without your having to come to the office, which I know is getting harder and harder. And if you aren’t sure you want a bunch of people coming into your house, remember you don’t have to meet the team all at once, just at your convenience. And they are as much for your wife and son as for you. I think it is a good idea to do this now, when you are doing well, because the better the hospice team knows you, the better they do their job. And if you get your heart surgery—when you get your heart surgery—should something go wrong, hospice can sweep back in, already aware of who you are and what your goals are. Just as you might hire experts to help with your taxes, to educate your son in college, or even to train your dog, hospice is the expert for this part of your medical care. And to be honest, I wish all my patients could have this service. It is just plain good medicine.

Email: mbourne@hospicebythebay.org

References 1. Temel J, et al, “Early Palliative Care for Patients with Metastatic Non-Small Cell Lung Cancer,” NEJM; 363:733-742 (2010) and Connor S, et al, “Comparing Hospice and Non-Hospice Patient Survival among Patients Who Die Within a Three-Year Window,” 33:238-246 J Pain & Symptom Management (2007).

2. Carlson M, et al, “Impact of Hospice Disenrollment on Healthcare Use and Medical Expenditures for Patients with Cancer,” J Clinical Oncology, 26:1818 (2010).

3. “NHPCO Facts and Figures: Hospice Care in America,” National Hospice & Palliative Care Organization (2012).

Marin Medicine

A N A P P R OAC H TO D E AT H A N D DY I N G

RESPECT at the End of Life Scott Schmidt, MD

I

t was a busy Saturday night at Harbor UCLA Medical Center just outside South Central LA. A young man arrived in cardiac arrest after multiple gunshot wounds to the chest, and despite our best efforts he died.

After the code, I ran through what we did in my mind. We’d made all the right moves. I knew we’d done everything possible to save his life.

I was a second-year resident, and I was learning to take the lead.

The last thing on the list, of course, was to tell the shooting victim’s wife that he’d died. I was on my way to speak with her when a senior resident pulled me aside and said, “The conversation you are about to have is all that matters right now.”

It was a teachable moment and he was absolutely right. Unfortunately, that was the full extent of the training I received during residency in being with death and dying. The emphasis was on saving lives—not on how to speak and be with patients and families at the end of life.

That experience and a constellation of others around that time led me down a path of ever-deepening interest and passion to learn more. It is now 20 years since that night, and what folDr. Schmidt is an emergency physician with a subspecialty in hospice and palliative medicine at the Kaiser San Rafael Medical Center.

Marin Medicine

lows is part of what’s come out of my journey down that path.

The RESPECT Project is an interdisciplinary approach to death and dying that we first implemented in the Emergency Department at Kaiser San Rafael in December 2013. It is a distillation of some of what I’ve learned in 20 years as an ED physician and 10 as a hospice and palliative medicine physician. It is by definition interdisciplinary because it takes the entire health care team to do this work well, and it provides a set of tools intended to help providers of all types care for the dying and their loved ones. With the support of the Kaiser San Rafael Medical Center physician leadership, the ED nurse management team, and the many compassionate colleagues I have the honor of doing this work with,

the project has helped shift the culture around death and dying in our ED. And throughout our hospital.

The RESPECT Project has since been adopted hospital-wide as an approach to death and dying and has been expanded to include information for families about the dying process—a list of bereavement resources, a quick info card, and expanded nursing resources information including a comfort care manual and a guide to relevant community resources.

The RESPECT Project consists of the Emergency Department Comfort Care Protocol (EDCCP) and the RESPECT Practice Tool (both on page 19).

The EDCCP pertains to imminently dying patients (prognosis of hours to days) for whom treatment goals are comfort-focused only. It emphasizes the importance of both pharmacologic and non-pharmacologic means of promoting comfort and minimizing suffering, and it establishes a method for nonverbally communicating to all staff that a patient is in the process of dying. When an imminently dying patient whose treatment goals are comfort-focused only presents to the Emergency Department, the attending physician initiates the EDCCP with a Nursing Communication Order listing a series of suggested interventions and orders appropriate medications for symptom management.

The RESPECT Practice Tool is used when a patient dies, whether unexpectedly Spring/Summer 2016 17

The E stands for Explain What Happened and Who Was Involved. In some cases, providing information about what happened between when Mom collapsed and when resuscitation efforts stopped and about who assisted with her care can be helpful to those who’ve suffered a loss. But it is useful to ask permission before providing such information, since it’s important not to get mired in details that can stand in the way of the emotions we are seeking to make space for.

The S stands for Stop and Set Aside Other Activities. Perhaps this should go without saying, but I know I still sometimes forget to hand off my phone when doing this kind of work. This is also a reminder to nurses to get a manager or other team member to look after his or her other patients in order to give full attention to the family and loved ones involved. This work can and should be considered higher priority with appropriate adjustments in nurse-to-patient ratios to ensure the work is done well.

The P is to remind us to be Present.

Individuals facing the loss of a loved one

or as the natural conclusion of a terminal illness or a long life. It provides a structured approach to what can be an emotionally and professionally challenging experience. When a death occurs, the RESPECT Practice Tool helps support providers care for the patient and his loved ones in the best way possible.

I

n the RESPECT acronym, the R stands for Restore Order. A nurse colleague tells the story of having cared for a teenage girl killed in a motor vehicle accident whose father tearfully asked as he cleaned the blood from his daughter’s face, “Why am I the one that has to do this?” In some cases, the way a dead or dying patient looks when the family is brought to the bedside is how she will be remembered for the rest of their lives. Cleaning vomit from a patient’s face or removing unnecessary medical equipment or trash from the resuscitation suite is not to pretend death hasn’t happened. Rather, it is one small way we can respectfully begin to put the pieces back together just as the family will have to do in the months and years ahead.

Tracy Zweig Associates INC.

A

REGISTRY

&

PLACEMENT

FIRM

Physicians

Nurse Practitioners ~ Physician Assistants

Locum Tenens ~ Permanent Placement V oice: 800-919-9141 or 8 0 5 - 6 4 1 - 9 1 4 1 FA X : 805-641-914 3

tzweig@tracyzwei g. com www.tracyzweig. com 18 Spring/Summer 2016

deserve our undivided attention. Cultivating presence, especially in the face of another’s suffering, requires practice. To simply bear witness can be profoundly healing.

The second E stands for Empathy.

Staff are reminded to step out of their roles and imagine what the people they’re caring for are going through. A dear friend of mine whose daughter tragically drowned many years ago said to me, “There is nothing anyone could have said or done that could possibly have made it OK.” A willingness to imagine what it’s like, to open our hearts to what is part of our shared human experience, is sometimes all we can offer.

The C stands for Chaplain/Clergy and it reminds us that for some, spiritual support is the most important support needed around the time of death. In addition to soliciting religious or spiritual help if desired, our hospital social workers also provide psychosocial support in many cases.

The T stands for Time. Family and loved ones are encouraged to take as much time as they need with their loved one. One family not long ago wanted to hold vigil for several hours even though the Emergency Department desperately needed the bed. Nurses, managers, clerks, maintenance staff and the chaplain all collaborated to find, clean and make available a vacant room elsewhere in the hospital so as to honor the family’s wishes.

The T also stands for Take Care of Each Other. After bringing our full selves to the task of caring for a patient who has died and her loved ones, it is essential that we take care of each other.

Whether a patient is imminently dying on comfort care or has died, the RESPECT Project Placard is placed outside the room. This beautiful image (page 17) serves as a visual reminder of the important transition occurring inside. On the back of the Placard both the Comfort Care Protocol and the RESPECT Practice Tool are outlined for quick review.

The primary nurse involved is temporarily relieved of other duties and the entire interdisciplinary team shares in the responsibility of caring for the patient and his or her loved ones at this difficult Marin Medicine

RESPECT Project: Kaiser SRF ED Emergency Department Comfort Care Protocol (EDCCP): • Goals of care for an imminently dying patient (hours to days) are established as comfort measures only • Post RESPECT Project placard outside patient’s room to advise all ED staff of the important transition occurring for patient/loved ones in the designated room • Place patient in private room and provide seating for family/loved ones whenever possible • Provide compassionate and empathetic bedside presence and support whenever possible • Discontinue routine vitals. Note: VS not indicated after medications in this exceptional situation • Remove all unnecessary medical equipment not directly related to patient’s comfort or agreed upon limited interventions • Avoid blood draws • Adjust room temperature per patient and family request • Provide warming blanket, dim lights, lower bed, offer food/drink as appropriate • Encourage family/loved ones’ presence at bedside • Offer telephone for family use while in ED • Offer to contact chaplain if available or spiritual care provider of patient or loved ones’ choice • Recognize nonverbal signs of pain or distress: furrowing of the brow, facial grimacing, calling out, tensing muscles, agitation; may use Health Connect Pain Assessment Tool for Nonverbal Patients • Reassess every 30 minutes and after each intervention and document response to treatment • Inform physician if symptoms not well controlled or patient appears in distress

RESPECT Practice Tool: An Approach to Death in the ED • R: Restore Order (and prepare loved ones for coming to the bedside).

• E: Explain: What happened and who was involved in patient’s care.

• S: Stop and Set Aside Other Duties: Other things can wait.

• P: Be Present: Give your full awareness to what’s unfolding before you.

• E: Empathize: Take a moment to acknowledge that a life has just ended.

• C: Chaplain/Clergy: Offer to call for spiritual support.

• T: Time: Allow family time with their loved one before moving on to other business. ★ Designate

a point person primarily responsible to loved ones’ needs if possible.

★ After

taking care of the patient and family, be sure to take care of each other as well.

★ Refer

to RESPECT Practice Tool Narrative for further discussion.

Marin Medicine

Spring/Summer 2016 19

Value of Membership

3

Professional resources. Stay up to date and connected on vital health care issues that affect Marin County physicians with online and print media including Marin Medicine magazine and News Briefs e-newsletter. CMA also produces a number of publications for members.

4

Practice resources. There are 10 million reasons to be a member. CMA has recouped $10 million from payors on behalf of physician members over the past five years!

time. While many of the interventions proposed in the EDCCP and the reminders outlined in the RESPECT acronym are common sense and might arguably happen naturally, consistently caring for the dying according to the principles of the RESPECT Project in the midst of a busy Emergency Department is easier said than done. The RESPECT Project Placard on the door helps everyone remember what’s important during an experience that survivors will remember for the rest of their lives.

In addition to early training of all staff, several nurses did further training and became Palliative Care Nurse Champions.

They serve as a resource for any questions that arise and model the kind of care the RESPECT Project seeks to promote. We periodically bring in professional actors to help in communication training for physicians, with the actors in the role of family members going through the labyrinth of late-stage illness and death. We all understand that this is not the kind of thing one masters quickly, if at all. It is deeply humbling and is some of the most meaningful work we do.

One incident stands out in my mind.

I was caring for an extremely elderly man with Parkinson’s disease and dementia presenting with recurrent pneumonia and sepsis. His family arrived soon after he did, and I learned that the patient had been a musician. His family was absolutely certain that confusion and dependence on others for activities of daily living in a nursing home did not constitute a life he would want to continue. They asked us to provide comfort-focused treatment only. We removed the medical equipment from his body, adjusted the room light and temperature as his family felt best, and provided Tylenol for fever and a touch of morphine for his air hunger.

The RESPECT Placard was placed on his door and all staff were made aware of what was going on. The social worker, chaplain and primary nurse supported the patient and family in wonderful and complementary ways. And as he slipped away, his family could be heard quietly singing him his favorite songs.

5

Save time and money. MMS and CMA offer a variety of member-only discounts and services. Most members can save more than the cost of their dues.

Email: scott.schmidt@kp.org

PRACTICE

PROFESSIONAL

PERSONAL

I am a member of the Marin Medical Society and the California Medical Association because

working together, we are strong advocates for all physicians and for medicine.

MEM

of ST

MPLETE LI CO

BENE BER FITS p

MICHAEL KWOK, MD Internal Medicine MMS President-Elect mkkwok5@gmail.com 925-3617

a ge

26

Why SOLO and SMALL GROUP PRACTICE PHYSICIANS should be MMS/CMA members:

1 2

Fighting for you and your patients. As a member, you are hiring a powerful professional staff to protect you from legal, legislative, and regulatory intrusions into your medical practice.

Help shape the future of medicine. MMS, the voice of Marin County physicians, together with CMA, relies on your involvement to transform health care in California.

20 Spring/Summer 2016 Join MMS/CMA Now!

• 415-924-3891 •

Marin Medicine cmanet.org/membership

D E AT H C E R T I F I C AT E S

Certification of Death: Whose Responsibility?

A. Jay Chapman, MD

M

any patients with fatal disease follow a predictable course through their illness that ultimately results in their death. Having one’s patient die is always discomforting, but in most of these instances, the physician is prepared for the event. For these cases, there is almost never a question that the patient’s physician is responsible for the certification of death and completing the death certificate (DC).

In addition to providing data for leading causes of death and other public health statistics, DCs most immediately allow arrangements for the disposal of the body. Thus, if the family cannot promptly obtain a valid DC, they will at a minimum be terribly inconvenienced.

At the other extreme, families can even be shoved into financial ruin if the DC is delayed for a prolonged period since it is necessary for life insurance claims, pension benefits, settling of estates (wills, trusts, accessing bank accounts, real estate holdings), Medicaid benefits, and even future marriages where proving the death of a previous spouse may be necessary.

Some patients have Dr. Chapman is a forensic pathologist at the Sonoma County Coroner Unit.

Marin Medicine

risk factors for sudden demise, and their death is quite often unexpected to family, friends and physicians. The most common and obvious risk factors are hypertension, obesity, diabetes mellitus, hyperlipidemia and seizure disorders.

Despite the unexpected nature of these natural deaths, nearly all are under the purview of the attending physician—not the coroner—if there are no suspicious circumstances. By statute, the attending physician must complete the DC. Physicians may not avoid this responsibility by making a “policy” that is contrary to state law.

One common misconception is that the physician must be in physical attendance at the time of death. A physician is considered to be the attending physician if the patient was being seen by that physician or designee in the physician’s office or the patient’s home, or if the patient was using or refilling prescriptions written by the physician. There are no specified limits as to the time when the patient was last physically seen by the physician.

Patients seen in the emergency room are a different matter. If the emergency physician only performs resuscitative measures and pronounces the patient dead—and the emergency physician was not otherwise seeing the individual as a patient—he or she is only the “pronounc-

ing” physician and is not responsible for completing the DC. The responsibility for death certification still falls to the physician who has been treating or “attending” the patient, provided the death is due to natural means and didn’t occur under valid suspicious circumstances.

In some cases, the emergency physician diagnoses and treats a natural illness unrelated to trauma or suspicious means.

If the patient succumbs to that illness, the emergency physician is responsible for signing the DC, regardless of any “policy” established by the hospital or other entity.

In these cases, the emergency physician is considered to be the attending physician, no matter how long he or she has been treating the patient.

The Coroner’s Role

California law specifically provides that the coroner has the discretion to determine the extent of inquiry to be made in any given case. The law further provides that if the inquiry determines that the “physician of record” has sufficient knowledge to reasonably state the cause of death, the coroner may require that physician to sign the DC. The coroner is notified in most cases of sudden and unexpected death. The case is then investigated to the extent that the coroner deems necessary. The attending Spring/Summer 2016 21

physician is responsible for completing the DC when the coroner determines that the death was due to natural causes, that there are no suspicious circumstances, that there is a physician of record, and that the death was reasonably due to a condition or conditions for which the deceased had been seen by that physician.

The identity of the physician of record is determined most often via history given by family or friends or through medical records or prescriptions possessed by the deceased.

Physicians notified by the coroner’s office of their responsibility to sign the DC sometimes object because they were not present when the patient died. This misconception has been discussed above and is not a valid reason for refusing to sign the DC. The only valid reason for not completing the certificate is that trauma or overdose initiated the process that led to the patient’s demise, or that the attending physician is also deceased.

Some physicians believe that their simple refusal to sign the DC obligates the coroner to assume jurisdiction. In fact, the coroner is under no such obligation. The practical effect of such refusal in many instances is to create a great inconvenience for the patient’s family.

Another reason given for not wanting to complete the DC is that the physician cannot state the exact cause of death. An exact cause of death is not required on the DC. The DC only requires that the cause of death be based upon reasonable medical probability. If the physician feels more comfortable doing so, he or she can qualify the cause of death with a modifier such as “probable.”

IHM

Autopsies

Some physicians may believe that their absolute or adamant refusal to sign the DC will result in an autopsy; but that is highly improbable. What is much more likely to happen is the following: • Taxpayers will incur considerable expense for bringing the body to the morgue, where an autopsy is unlikely to be performed. Instead, the pathologist will only undertake an external examination of the body.

• The family of the deceased will be inconvenienced and may have to pay an increased fee for the funeral home to retrieve the body from the morgue.

• The cause of death will be determined by the pathologist who examines the body.

• The pathologist will determine the most probable cause of death by investigating the circumstances of death and the medical records. These records will be subpoenaed by the coroner and must be provided from the physician’s office or other treatment facility—another inconvenience and expense for the physician or facility.

In these cases, the attending physician is in a much better position to provide the medically probable cause of death, thereby eliminating the inconveniences and expenses that are otherwise involved.

The coroner’s office does not exist to provide autopsies that should properly be done by hospital or private pathologists.

If the coroner notifies you, as the attending physician, that your patient has died, that the death has been investigated, and that the death is due to natural means, you should have no hesitancy in completing the DC—unless you know of

INSTITUTE FOR HEALTH MANAGEMENT

A Medical Clinic / Robert Park, M.D., Medical Director THE SAFE EFFECTIVE APPROACH TO RAPID AND PERMANENT WEIGHT LOSS • Medically Supervised • Nutritional Counseling • Registered Dietician • Long Term Weight Maintenance 715 Southpoint Blvd., Suite C Petaluma, CA 94954 (707) 778-6019 778-6068 Fax

22 Spring/Summer 2016

350 Bon Air Road, Suite 1 Greenbrae, CA 94904 (415) 925-3628

some valid circumstance that the coroner did not investigate. I don’t know of any case in which a physician has been sued for a cause of death stated on the DC. Another misconception regarding the DC is that it may be signed at your leisure. California law provides that the DC must be signed and made available to the funeral director no later than 15 hours after the time of death.

Bear in mind that if you have been treating a patient for a potentially fatal condition, you have obviously been billing with a code for that condition. It goes without saying that if you are capable of billing for the patient’s condition, you are quite capable of placing that condition on the DC! Completing the DC

The cause of death is the disease, injury or abnormality that, either alone or in combination, caused the sequence of events that ultimately led to death. The terms initiating, proximate or underlying cause of death may also be used—all with the same meaning. In assigning a cause of death, you should use a simple statement of the underlying cause: the event without which the chain of events leading to death would not have occurred.

The mechanism of death is the process by which an organ or organ system fails when there is fatal disease, injury, abnormality or chemical insult: the pathophysiologic change(s) set in motion by the cause of death. The mechanism of death represents the physiologic or anatomic change that is incompatible with life after the body sustains a lethal event. For instance, a dissecting aneurysm of the aorta may cause a laceration of the aortic wall and produce massive hemopericardium with cardiac tamponade, followed by brain death due to anoxia. Death in this case was due to 1) hypoxic/anoxic encephalopathy due to 2) circulatory failure due to 3) cardiac tamponade due to 4) massive hemopericardium due to 5) aortic wall perforation due to 6) dissecting aneurysm of the aorta. All of the “due to’s” except the sixth are mechanisms of death. The sixth and final due to is the cause of death.

Manner of death must be distinguished from cause of death. The manMarin Medicine

ner of death designations specify how the cause of death came about. The designation can refer to social relationships and personal causation. The customary designations are natural, suicide, accident, homicide, undetermined and pending. A special designation for people dying from military actions is operations of war— with the exception of situations arising in military actions that constitute homicide.

In California only the coroner or medical examiner can certify deaths in which the manner of death is other than natural. Any physician who treats a victim of gunfire, blunt force trauma, poisoning, sharp force injury, or any other kind of violence—or whose death occurred under suspicious circumstances—cannot certify the death and is required to notify the coroner.

Sometimes the underlying cause of death may be overlooked but should properly require that the coroner be notified. A few examples are 1) sepsis due to decubitus ulcers due to paraplegia due to remote gunshot wound to spine; 2) pneumonia complicating acute ethanol

or drug toxicity; 3) seizure disorder due to closed head injuries due to remote motor vehicle accident, blow to the head or a fall; 4) anaphylaxis due to bee sting; 5) pulmonary thromboembolism due to deep vein thrombosis due to hip fracture due to unwitnessed fall; 6) pneumonia complicating subdural hematoma due to trauma.

Helpful Hints

When completing death certificates, the most important thing to remember is that the statement of the cause of death most often should not include the mechanism of death, although it is sometimes employed for clarity in a particular situation. When the cause of death is stated, it should be the underlying cause—the culprit that initiated the entire series of events leading to death. Terms such as cardiac arrest, asystole, cardiopulmonary arrest, respiratory arrest, electromechanical dissociation and ventricular fibrillation are all mechanisms of death and cannot be used as the statement of the cause of death.

Simple statements of cause of death include: • Arteriosclerotic cardiovascular disease • Hypertensive cardiovascular disease • Obesity-related heart disease • Sequelae of diabetes mellitus • No n-t r a u m a t i c i n t r a c e r e b r a l hemorrhage In summary, death certificates need to be as accurate as possible, and completing the DC should be accomplished with the least expense and inconvenience to taxpayers and the family. The coroner’s staff, including the pathologist, are always willing to assist in completing the DC. Physicians can call the office at 415-473-6043 at any time with questions or problems that arise.

For more information on completing death certificates, consult the CDC’s Physician’s Handbook on Medical Certification of Death at www.cdc.gov/nchs/data/misc/ hb_cod.pdf.

HAVE YOU REGISTERED YET? DEADLINE IS JULY 1!

CMA CAN HELP! VISIT WWW.CMANET.ORG/CURES Marin Medicine

Spring/Summer 2016 23

CALIFORNIA MEDICAL ASSOCIATION

24

HOU

R ONL

CMA

IN

E

HE

AL

TH

RY

On-Call L AW L I B

RA

GUIDELINES

I N F O R M AT I O N

to the End of Life Option Act, ABX2-15 The California Medical Association has published new legal guidance intended to help physicians and patients understand requirements of the End of Life Option Act. The document, #3459 in CMA’s extensive On-Call Health Law Library, is in a question-and-answer format. It is available as a free download to CMA members and to nonmembers who register with cmanet.org. Below are the questions addressed in the 15-page guide. To download the complete Guide with answers, go to:

1. When does the End of Life Option Act become effective?

2. Who can make an aid-in-dying request under the Act?

3. How does a patient make an aid-in-dying request?

4. Are there documentation and witness requirements for oral and written requests?

5. Are there additional documentation requirements?

6. Are particular forms required by the Act? 7. Can an interpreter be used?

8. Who is a “health care provider” under the End of Life Option Act?

9. Can any physician receive a request for an aid-in-dying drug?

10. What are the obligations of the attending physician who receives a request?

11. What is required for an initial determination that a patient is “qualified” to request an aidin-dying drug?

12. Can a terminally ill patient with a mental disorder be “qualified” to request an aidin-dying drug?

13. Does a patient’s request for an aid-in-dying drug mean the patient needs someone else to make decisions for them?

14. Are there specific requirements to ensure that the patient is making an informed decision?

24 Spring/Summer 2016

15. Is a referral to a consulting physician required for every patient?

16. Does the Act contain safeguards against coercion and undue influence?

17. Will the patient be counseled about taking an aid-in-dying drug?

18. What are the final steps before an aid-in-dying drug can be prescribed?

19. How does a qualified patient obtain the aid-indying drug?

20. Who can be a consulting physician and what are their responsibilities?

21. Is a mental health specialist assessment required for every patient who requests an aidin-dying drug?

22. Who can serve as a mental health specialist under the Act and what are their responsibilities?

23. Can a patient change his or her mind to use an aid-in-dying drug?

24. Does the patient have any additional obligations once the aid-in-dying prescription is written?

25. Does the Act specify what aid-in-dying drug can be prescribed?

26. What should be stated as the official cause of death on the death certificate?

27. What are the attending physician’s reporting requirements?

28. What are the aid-in-dying data collection and publication requirements?

Marin Medicine

ON END-OF-LIFE ISSUES Contact CMA with questions about the Health Law Library or how to access documents: 800-786-4262

RESOURCES for Physicians and Patients

http://www.cmanet.org/resource-library/detail/?item= the-california-end-of-life-option-act. To download the Act itself, go to: http://goo.gl/LGhG33.

ADVANCE HEALTH CARE DIRECTIVE: CMA Advance Health Care Directive Kit in English (rev. 3/14) CMA Advance Health Care Directive Kit in Spanish (rev. 9/14)

The Resources in the column at right can be found at www.

PHYSICIAN ORDERS FOR LIFE-SUSTAINING TREATMENT (POLST): 2016 POLST form (effective Jan. 1, 2016) CMA POLST Kit in English (rev. 12/15) CMA POLST Kit in Spanish (rev. 10/14) CMA On-Call #3451: Decisions Regarding Life-Sustaining Treatment—Advance Directives and POLST (2015) CMA On-Call #3450: Decisions Regarding Life-Sustaining Treatment for Patients Without Advance Directive or POLST (2015)

cmanet.org/about/patient-resources/end-of-life-issues/.

29. What happens to unused or excess aid-indying drugs?

30. Are physicians required to participate in the End of Life Option Act?

31. Are there legal protections if a physician chooses not to participate?

32. Can medical staff members, employees, and others be prohibited from participating?

33. What is considered “participation” in activities authorized by the Act?

34. Does the Act require notice of a prohibiting employer or health care provider’s policy prohibiting participation in activities under the Act?

35. Are there limits on a prohibiting employer or health care provider’s ability to prohibit participation in activities under the Act?

36. Can a physician be disciplined for violation of a prohibiting employer or health care provider’s policy prohibiting participation in the Act?

37. Can a physician be reported to the medical board solely for violation of a policy prohibiting participation under the Act?

38. Are there protections and immunities for physicians who choose to participate?

39. What is considered criminal conduct under the Act?

40. How does the Act impact insurance policies and contracts?

Marin Medicine

DO NOT RESUSCITATE FORM: Do Not Resuscitate Form in English Do Not Resuscitate Form in Spanish CMA On-Call #3453: Decisions Regarding Resuscitative Measures—DNR Requests & Orders and Cardiopulmonary Resuscitation (2015) OTHER RESOURCES IN THE CMA HEALTH LAW LIBRARY: On-Call #3452: Documenting Decisions Regarding Life-Sustaining Treatment On-Call #3454: Decisions Regarding Life-Sustaining Treatment and the Patient Self-Determination Act and Joint Commission On-Call #3455: Physician-Assisted Suicide On-Call #3456: Responding to Request for Non-Beneficial Treatment On-Call #3458: CMA Model Policy: Responding to Requests for Non-Beneficial Treatment On-Call #3400: Autopsies On-Call #3401: Organ and Tissue Donation On-Call #3402: Pronouncement of Death and Death Certificates On-Call #3403: Pronouncement of Death Diagnosis of Death by Neurologic Criteria FOR PATIENTS Coalition for Compassionate Care of California website, www.coalitionccc.org.

The booklet “Finding Your Way,” written by the Center for Healthcare Decisions as a useful guide to thinking about and discussing end-of-life issues. To order a copy, visit the Coalition for Compassionate Care website.

POLST California, www.capolst.org.

Spring/Summer 2016 25

MEMBERSHIP HAS ITS BENEFITS!

Free and discounted programs for MMS/CMA members BENEFIT

PROVIDER

Auto/Homeowners Insurance Save up to 8% on insurance services

Mercury Insurance Group 888-637-2431 • www.mercuryinsurance.com/cma

Car Rental Save up to 25%

Avis or Hertz 800-786-4262 • www.cmanet.org/groupdiscounts

CME Certification Services Discounted CME certification for members

CMA’s Institute for Medical Quality 415-882-5151 / www.imq.org

HIPAA Compliance Toolkit Various discounts

PrivaPlan Associates, Inc. 877-218-7707 • www.privaplan.com

ICD-10-CM Training Deeply discounted rates on several ICD-10 solutions, including ICD-10 Code Set Boot Camps

AAPC www.cmanet.org/aapc

Insurance Services Save up to 25% on workers’ comp insurance and receive special pricing and/or enhanced coverage for life, disability, long term care, medical, dental and more

Mercer Health & Benefits Insurance Services LLC 800-842-3761 cmacounty.insurance.service@mercer.com www.CountyCMAMemberInsurance.com

Legal Services FREE access to CMA On-Call (online health law library), access to CMA legal staff through the legal information line and more

CMA’s Center for Legal Affairs 800-786-4262 • legalinfo@cmanet.org www.cmanet.org/legal

Magazine Subscriptions Save up to 50% on all subscriptions

Subscription Services, Inc. 800-289-6247 • www.cmanet.org/magazines

Medical IDs Discounts on 24-hour emergency identification and family notification services

MedicAlert 800-253-7880 • www.cmanet.org/medicalert

Medical Waste Management Save 30% or more on medical waste management and regulatory compliance services and 50% on the Compliance Portal

EnviroMerica 650-655-2045 • www.cmanet.org/enviromerica

Mobile Physician Websites Save up to $1,000 on unique website packages

MAYACO Marketing & Internet 209-957-8629 • www.cmanet.org/mayaco

Office supplies, facility, technology, furniture, custom printing and more . . . Save up to 80%

Staples Advantage 800-786-4262 • www.cmanet.org/staples

Physician Laboratory Accreditation 15% off lab accreditation programs and services

COLA 800-786-4262 • www.cmanet.org/cola

Physician Smartphone App FREE secure messaging application

DocbookMD www.cmanet.org/docbookmd

Reimbursement Assistance FREE assistance with reimbursement and contracting issues

CMA’s Center for Economic Services 800-401-5911 • economicservices@cmanet.org www.cmanet.org/ces

Security Prescription Products 15% off tamper-resistant security subscription pads

RxSecurity 800-667-9723 • www.cmanet.org/rxsecurity

Webinars and Seminars CMA works with industry experts to offer timely, high-quality education programs, including FREE webinars and deep discounts on live seminars

CMA www.cmanet.org/events

PUBLICATIONS CMA Publications http://www.cmanet.org/news-andevents/publications/ CMA Alert e-newsletter CMA Practice Resources

CMA Resource Library & Store http://www.cmanet.org/resource-library/ list?category=publications

Advance Health Care Directive Kit California Physician’s Legal Handbook Closing a Medical Practice Do Not Resuscitate Form HIPPA Compliance Online Toolkit Managed Care Contracting Toolkit Model Medical Staff Bylaws Patient-Physician Arbitration Agreements Physicians Orders for Life Sustaining Treatment Kit

MMS Publications www.marinmedicalsociety.org Marin Medicine (semi-annual) Marin County Physician Directory (annual) MMS News Briefs (monthly)

CONTACT MMS/CMA: 415-924-3891 • mms@marinmedicalsociety.org

May 2016

OUT OF THE OFFICE

Tale of a Suicide: A Life-Ending ‘Option’ We All Deplore John Maa, MD, FACS

O

n the Friday evening of Me mor i a l Day weekend in 2015, I was driving into San Francisco across the Golden Gate Bridge.

Northbound traffic was heavily congested around mid-span, as the right lane was closed. Emergency vehicles with f lashing lights redirected traffic to the left lanes. As I approached the bottleneck, I noticed a backpack leaning against the railing and saw two bridge security officers who appeared to be gesturing in the direction of Alcatraz. I quickly realized that they were pointing not at the prison, but instead at a person holding his head in his hands and seated on the ledge outside the railing.

I drove to the southern end of the bridge as police cars with sirens blaring raced toward the scene. I parked in the south lot, and began walking back toward Marin. The skies were gray, and the red lights of the patrol vehicles colored both the water below and the clouds above. As I approached the toll plaza I noticed a new color flickering on the water’s surface. It was from the distinctive white flare that Dr. Maa, a surgeon at Marin General Hospital, is past president of the Northern California chapter of the American College of Surgeons.

Marin Medicine

kept walking toward the site of the bottleneck, I saw that traffic had again begun moving normally. A grim-faced bridge security officer drove past in a small white vehicle that was otherwise empty.

I reached the site of the disturbance, which was now deserted without any trace of the preceding events. As I turned and walked back to San Francisco, I passed joggers, pedestrians and tourists who likely knew nothing of what had just taken place. On returning to the south plaza, I noticed that the ambulance had not left Fort Baker.

I had with me the trauma surgery call pager for Marin General Hospital, where bridge victims are brought if there are Wikimedia Commons (Grombo) still signs of life after their is dropped by Bridge security to mark the extraction from the cold waters of the spot where a person has fallen and guide bay. The trauma pager was never activated search-and-rescue efforts by tracking the in the hours after this event. direction of the currents.

In 2014, the Golden Gate Bridge A gray Coast Guard vessel matching board of directors unanimously approved the color of the sky could now be seen rac- the installation of a safety net to deter suiing westward to the scene from Fort Baker, cide attempts and raised funds in hopes just past the north end of the bridge. It of beginning construction by late 2017. paused near the smoke of the flare and Thank you to those who have dedicated then continued to the other (i.e., west) their time and efforts to erecting a safety side of the bridge, where it stopped and barrier on the bridge. Before long, hopecircled. It lay motionless on the water fully, events like this will be only a distant for about four minutes and could then memory. be seen rushing back toward Fort Baker, where an ambulance was waiting. As I Email: maaj@marigeneral.org Spring/Summer 2016 27

BOOK REVIEWS

Working Stiff and

When Breath Becomes Air Sal Iaquinta, MD

W

orking Stiff: Two Years, 262 Bodies, and the Making of a Medical Examiner (by Judy Melinek, MD, and T.J. Mitchell) is an interesting glimpse into the life of a medical examiner. The author stresses that she worked in the “real world” of Manhattan. She clearly states that in no situation outside of television does a sexy medical examiner show up at the scene of the crime wearing high heels and spouting off subtle clues to the homicide detectives between sexual innuendos and witty remarks.

That might disappoint some readers.

But for those of us who wish Mary Roach had devoted more time to forensics in her fun book, Stiff, Dr. Melinek’s book fills the void. Don’t look for plot or fancy writing. Instead, get absorbed in details that you’ve never dreamed about.

Dr. Melinek isn’t solving murders (though there are more than a few homicide victims); she’s examining dead bodies day after day. She details the elements of decompensation, the telltale signs of disease or injury, such as how the strap muscles of the neck exhibit different signs depending on whether the person Dr. Iaquinta is a San Rafael otolaryngologist.

28 Spring/Summer 2016

hanged him- or herself or was strangled.

Her anecdotes aren’t for the fainthearted and don’t make for dinner conversation, but I found them irresistible.

I love filling my brain with factoids that I’ll never use again . . . that’s one of the reasons I went to medical school. So when Dr. Melinek described a case of transfusion-related acute lung injury and a case of anthrax, I was excited. She got to see diseases I’ll never see—how cool.

Dr. Melinek gives the book a (living) human touch. From the very beginning she talks about her father’s suicide. She draws on that horrible experience when meeting the family members of other suicide victims. The average reader won’t be expecting a pathologist who spends time

talking to the families of the deceased.

There’s just enough sentiment in the book to remind us that she’s been dealing with real people, not simply giving us disembodied “case reports.”

The final chapters focus on September 11, 2001. The book is not in chronological order—this tragedy took place early in her training. But saving it to the end is better, when the reader already understands the lingo and how an autopsy is performed.

Her story is one that never quite hit the popular press. No one really wants to know that the Manhattan Medical Examiner’s office was overwhelmed and required a series of refrigeration trucks parked outside to hold all the body parts.

But we live in a world that is becoming increasingly aware of disaster preparedness, and the Office of the Medical Examiner is part of that response. Even without the unforgettable descriptions of mangled bodies (they found a woman’s hand inside the limbless torso of a man), just the logistics of responding to such a mass casualty event are interesting.

Lastly, and unintentionally, the book helps end the battle between dog lovers and cat lovers. In Dr. Melinek’s experience, your dog will sit and mourn next to your dead body. Your cat, however, will start eating you within hours of your death.

Marin Medicine

Value of Membership

P

Email: salvatore.iaquinta@kp.org

PRACTICE

PROFESSIONAL

PERSONAL

Victories like saving MICRA and ending SGR couldn’t have happened without the help of organized medicine.

And it’s the county societies and CMA that provide the backbone for these efforts.

NAVEEN KUMAR, MD

CO M

Interventional Radiology MMS Board Member naveen.n.kumar@kp.org 444-4957

ETE LIST o PL

BER MEM ITS EF

f

aul Kalanithi’s When Breath Becomes Air is the true story of a young doctor who is diagnosed with Stage IV lung cancer during his final year of neurosurgical residency at Stanford. This is a very different book from Working Stiff. When Breath Becomes Air is a literary exploration into what is important about life itself.

Dr. Kalanithi ’s fascination with the brain was lifelong. After getting his master’s degree in English, he realizes that writing is a way in which our brains communicate, but the brain itself is the organ that lets us interact with the world. At the same time the brain both has free will and is governed by all the laws of physics. Somewhere biology, morality, literature, and philosophy intersect. And that somewhere is within our skulls. This realization inspires him to become a neurosurgeon. But his time and his dreams are cut short by a deadly diagnosis.

His description of neurosurgical residency is almost unnecessary except for his first brushes with death. His cadaver, a dying patient and a neurosurgeon discussing a dire situation with family members all give him insight into the sacredness of being a physician.

This book’s strength is its introspection into what it means to be alive. Paul is given choices at age 36 that most of us will never face. As he undergoes treatment, he realizes that even a great response might mean he will live five to 10 years. He ponders, with a life cut short, what will he do with his remaining time? Should he even bother to finish his training? Finish and get a job? Or should he write? Should he have a baby with his wife? What is really important?

What separates this book from others like it is that he doesn’t dwell on the misery of the treatments. Nor does he ponder Why me? His answer: Why not me? Instead he asks questions like “If the weight of mortality does not grow lighter, does it at least get more familiar?”

Distilling these two books into one sentence looks like this: Working Stiff intrigues the brain; When Breath Becomes Air touches the soul.

BEN

p a ge 2

6

Why PHYSICIANS PRACTICING IN MARIN COUNTY should be MMS/CMA members:

1

By speaking with a united voice, physicians exert a powerful influence on the political process at the local, state and national levels. Organized medicine is the “one voice” that legislators and government hear.

2 3

MMS/CMA worked diligently to protect MICRA (Medical Injury Compensation Reform Act), leading a successful campaign defeating Prop. 46 in the 2014 election.

CMA faces down a slew of legal challenges to the practice of medicine throughout the year, with issues including scope of practice, Medicare audits, peer review and medical staff self-governance.

reasons to be a CMA member.” CMA’s reimbursement experts have recouped 4 “10$10million million from payors on behalf of physician members over the past five years! is involved in several initiatives to improve community health, including access for 5 MMS the uninsured, vaccination, anti-tobacco, oral health, end-of-life issues, safe prescribing of opiates, and much more.

Marin Medicine Join MMS/CMA Now!

• 415-924-3891 •

Spring/Summer 2016 29 cmanet.org/membership

Working together, the Marin Medical Society

REASONS

TOP

To Join MMS and CMA

COMMITMENT TO THE PROFESSION By joining MMS and CMA, physicians affirm their commitment to the profession of medicine and to preserving its honored place in modern society.

and the California Medical Association are strong advocates for all physicians and for the profession of medicine. Of the many reasons for joining MMS and CMA, 10 stand out:

PRESERVING MEDICARE Thanks to MMS, CMA and other medical associations, recent attempts in Congress to cut the Medicare reimbursement rate have all been rebuffed.

IMPROVING COMMUNITY HEALTH MMS is involved in several initiatives to improve community health in Marin County, such as increasing access for the uninsured and bolstering primary care.

LEGISLATIVE ADVOCACY

PROTECTING MICRA MMS and CMA work diligently to protect the Medical Injury Compensation Reform Act (MICRA), which safeguards low liability insurance rates for California physicians.

PRACTICE MANAGEMENT

By speaking with a united voice, MMS/CMA members exert a powerful influence on the political process at the local, state and national levels.

FOSTERING COLLEGIALITY

MMS and CMA offer a wealth of resources to help physicians manage their practices, implement electronic medical records and qualify for federal incentive payments.

STAYING IN TOUCH

MMS and CMA bring doctors from all parts of the medical community together—through leadership, cooperation and social gatherings.

FREE MEDICAL-LEGAL INFORMATION CMA offers free medical-legal information on contracts, subpoenas, employee relations, collections and many other topics.

ASK YOUR COLLEAGUES ABOUT MMS AND CMA

Through their magazines, newsletters and websites, MMS and CMA encourage physicians to stay in touch with each other and with current medical news and events.

IT’S EASY AND FUN To join MMS and CMA, go to www.cmanet.org/join. Once you belong, it’s fun to get involved in medical society projects and events.

One of the best ways to learn more about the benefits of membership in MMS and CMA is to ask your colleagues. The physicians listed below have leadership roles at MMS and would be happy to take your call.

President Peter Bretan, MD

President-Elect Michael Kwok, MD

Secretary/Treasurer Naveen Kumar, MD

Immediate Past President Jeffrey Stevenson, MD

Urology 415-892-0904 bretanp@msn.com

Internal Medicine 415-925-3617 mkkwok5@gmail.com

Diagnostic Radiology 415-444-4800 naveennkumar@yahoo.com

Occupational Medicine 415-897-5400 jeffreystevensonmd@gmail.com

DIRECTORS Larry Bedard, MD

Irina deFischer, MD

Imran Junaid, MD

Jason Nau, MD

Lori Selleck, MD

Matt Willis, MD

Emergency Medicine 415-332-1893 lbedard@aol.com

Family Medicine 707-765-3540 irinadefischer@gmail.com

Allergy & Immunology 415-899-7509 Imran.X.Junaid@kp.org

Emergency Medicine 415-444-2400 jason.r.nau@kp.org

Internal Medicine 415-899-7627 lori.selleck@kp.org

Internal Medicine 415-473-4163 mwillis@marincounty.org

RIGHT NOW is the best time to join MMS and CMA. Contact Rachel Pandolfi at MMS: 415-924-3891 or rachel@marinmedicalsociety.org.

Join online at www.cmanet.org/membership.

Hilton San Francisco Union Square

May 13 - 15, 2016

San Francisco, CA

2 0 1 6 H E A LT H C A R E L E A D E R S H I P AC A D E M Y

From Death to Medical Satire Physicians, nurses, medical practice managers and all other health care industry professionals—Join us in the heart of San Francisco to prepare for changes affecting your profession, your practice and your economic future.

T

he 2016 Western Health Care Leadership Academy welcomed nearly 500 attendees in San Francisco to hear about a range of topics from a dynamic lineup of speakers. These included Atul Gawande, MD, MPH, a MacArthur “Genius” Fellowship winner and a New Yorker columnist and author; Bennet Omalu, MD, the physician who identified chronic brain damage as a major factor in the deaths of NFL players; and entertainer, internist and founder of Turntable Health, ZDoggMD. Dr. Gawande, general and endocrine surgeon, Harvard professor and author of four New York Times bestsellers, including Being Mortal: Medicine and What Matters in the End, described how he learned to cope with mistakes he made in the operating room as a resident.

“I had to deal with my little imperfections and the complexities of the surgery itself,” said Dr. Gawande. Eventually he b e c a m e c o mfor table with t he surge r ie s and his own imperfections, but then faced an even more difficult phase of his surgical practice: How to treat those patients who did not do well after surgery.

“What do you do with those patients who do not get better? How do you help patients cope with death?” he asked the audience. “I am a surgeon. I want to fix Marin Medicine

everything in three hours.” But Dr. Gawa- rapper ZDoggMD (also known as Zubin nde said he found his medical education Damania, MD), who entertained and sorely lacking in dealing with mortality. educated the crowd with his unique, If you’ve read the articles by Drs. Molly insightful and hysterical health care rap Bourne and Scott Schmidt—“Hospice parodies. At his ZDoggMD website Is Plain Good Medicine” (page 13) and Health care power players will share strategies and resources for “RESPECT at the End of Life” (page 17), accelerating the shift to a more integrated, high performing and respectively—Dr. Gawande’ s observation sustainable health care system. Speakers include Dr. Atul Gawande, distinguished surgeon, teacher and writer – will sound familiar. named one of TIME magazine’s 100 most influential thinkers; As a forensic pathologist, Dr. Omalu Karl Rove, former Deputy Chief of Staff and Senior Advisor to dealt with peoplePresident after George death.W.In his Bush; and Donna Brazile, Al Gore campaign speech, he recountedmanager the story of how and Democratic National Committee Vice Chair. he was on call at the coroner’s office in Pittsburgh, Pennsylvania, on the Saturday when the 800.795.2262 body of www.westernleadershipacademy.com Pittsburgh Steelers Hall of Fame center Mike Web- Dr. Damania says, “During a 10-year ster was brought hospitalist career at Stanford, I someinto the patholo- how won clinical teaching awards while gy lab. It was this simultaneously maintaining a shadow encounter with career performing standup comedy for Webster that led medical audiences worldwide. . . . In Las to Dr. Omalu’s discovery—thanks to his Vegas, we’re making the leap from satire independent, self-financed tissue analy- to actionable change by implementing an ses—of chronic brain damage (chronic innovative model of health care delivery.” traumatic encephalopathy, CTE) as a Turntable Health, founded in 2013, is major factor in the early deaths of some a “membership model, team-based priNFL veterans. Dr. Omalu is currently the mary care ecosystem.” Dr. Damania’s chief medical examiner for San Joaquin TEDMED talk (http://goo.gl/uzvvA4) County and is a professor in the UC Davis from the 2013 conference presents a more Department of Medical Pathology and straightforward version of his ideas.

Laboratory Medicine. His story inspired We had a great time at this year’s a book, Concussion, and a 2015 Holly- Western Health Care Leadership Acadwood movie of the same name starring emy. Mark your calendars for another Will Smith. memorable gathering next year in San The surprise hit of the conference Diego: May 5–7, 2017. was Las Vegas internist, comedian and —Adapted from CMA’s May 16 News Release.

Spring/Summer 2016 31

P U B L I C H E A LT H U P DAT E

Vaccines, Policy and Dialogue in Marin Matt Willis, MD, MPH

A

t the end of my first day as a primary care physician in Marin in 2011, I remember being impressed by two common challenges with my new panel of patients. First, I was surprised by expectations of prescription medications as a first-line remedy for ill-defined pain, and second, many of my patients refused the vaccinations I recommended.

I realized my work was cut out for me as a communicator, navigating decisions with patients seeking potentially harmful agents with unproven effectiveness on the one hand, while refusing safe preventive measures on the other.

As public health officer, I see how the challenges experienced in the exam room are manifested on a communitywide scale. Prescription drug abuse and low vaccination rates are two of the most pressing public health challenges facing our community. Fortunately, since 2011, significant progress has been made in both areas. I have focused on prescription drug abuse in prior updates in Marin Medicine, and will continue to address the issue as we work to control this epidemic. Less visible, but equally important, has been our progress in vaccinations.

Dr. Willis is Marin County’s public health officer.

32 Spring/Summer 2016

Under longstanding California law, children enrolling in schools are required to have certain vaccinations. However, the public health benefit of this law has been significantly undermined by an exemption offered to parents opposed to vaccination on the basis of personal beliefs. Marin County had the Bay Area’s highest rate of personal belief exemptions (PBEs) to required childhood vaccinations. Of greatest concern is that we have several communities with clusters of unvaccinated school children. In some of these communities, astonishingly, vaccination rates are far below those of some developing countries.

Thanks to a new California law, all Marin communities will be better protected against disease outbreaks. Senate Bill 277, co-sponsored by our pediatrician senator, Dr. Richard Pan of Sacramento, eliminates personal belief exemptions from California law. Starting this year, no incoming kindergarteners will be exempt from required vaccinations without a medical contraindication.

Marin County has been the subject of national media attention regarding vaccinations and vaccine decisionma k ing among a f f luent, well-educated residents. On national TV, Jimmy Kimmel accused Marin of being “more afraid of gluten than smallpox,” and John Stewart said that our PBE rates were the result of “mindful stupidity.”

Those of us practicing in Marin know the picture is more nuanced than this.

In order to help our community adapt to the new law eliminating PBEs and predict its effects locally, it is necessary to understand baseline community beliefs and existing trends.

I

n 2013, to better understand local vaccination beliefs, Marin County Public Health partnered with the Marin County Office of Education to survey parents of kindergartners from 40 schools. Of the almost 500 parents who responded, 15% had children who were not current on required vaccinations.

We learned from the survey that most families with PBEs actually chose some, but not all, required vaccinations.

Some delayed due to concerns about too many vaccines, or believed that the risks of disease are low. Those who categorically refused all vaccinations were a small minority. This is important, because it suggests wide understanding of the value of vaccination even among parents with Marin Medicine

PBEs. I trust that these Marin parents can react thoughtfully to the new policy and will choose to expand the protection they already offer their children to the full range of vaccine-preventable diseases.

We also found limited understanding of the communitywide implications of vaccine decision-making. The term “personal belief exemption” is misleading because the effects of opting out of vaccinations are not only personal—they can carry profound consequences for our friends, neighbors and children’s classmates. Many parents did not understand that babies younger than 12 months and people who are medically fragile cannot be vaccinated. We learned that we needed to offer stronger messaging about vaccinations as a community responsibility, as something we do not only for our own children, but also for their friends, classmates and neighbors.

Additionally, SB 277 arrived during a trend of increasing vaccination uptake.

Perhaps because of a growing understanding of the community benefits of vaccination, or fueled by the 2014 measles outbreak, Marin County vaccination rates began improving even before the new legislation. The PBE rate in Marin has been declining since its peak in 2012. In fall 2015, 6.0% of kindergarteners entering school had a PBE, down from 7.8% in 2012. The last time this many Marin kindergarteners were fully vaccinated was 2007. Still, our opt-out rates remain well over twice as high as the statewide average of 2.3 percent.

While the new law promises to increase vaccination rates among children attending school, it’s important to keep in mind that those children who entered school unvaccinated under a PBE in the past can remain in school unvaccinated.

It will take several years, as new fully vaccinated cohorts of kindergarteners enter and advance through the grades, before any school—any community—will enjoy the full protection this law is meant to ensure. For this reason, we must remain vigilant for the possibility of preventable outbreaks of childhood diseases.

Before joining the Marin County Health Department, I worked for the CDC, helping control disease outbreaks Marin Medicine

in the developing world. We failed to control an outbreak of diphtheria in Haiti’s tent camps after the devastating 2010 earthquake. In that setting, the spread of disease was a sign of the total disintegration of the local health system and a historical lack of access to safe and effective vaccines. As Public Health Officer, I’m concerned that Marin could end up with similar outbreaks, but for very different reasons. In our case, an outbreak of preventable disease would be the result of choice, through vaccine refusal. Our risk is diminishing significantly thanks to SB 277 and recent increases in vaccine acceptance, but we remain divided—and the risk is still with us.

The so-called “vaccination debate” risks polarizing our community. We want to understand and help address any concerns in the context of three principles: preventable diseases are a real and growing risk; vaccines offer safe, effective protection; and vaccination is a matter of both personal and community responsibility. We unequivocally advocate vaccination as the best, safest way to keep our community free of preventable diseases and want to promote respectful dialogue to this end.

SB 277 is a very positive step. It shows that our community’s vaccine decisions are coming into line with Marin’s wellestablished values of prioritizing health. I hope that after being highlighted nationally for low levels of vaccination, Marin can serve as a national model for collective response as we come together to close a gap in our community’s health.

AWARD-WINNING WRITING & EDITING Marin physicians . . .

Would you like someone to lighten the burden of: Drafting engaging website content?

Writing to patients to— • Introduce a new physician in your practice?

• Recommend flu shots, childhood immunizations?

• Announce an office relocation?

I can help.

I’m the editor of Marin Medicine.

I’m also the principal at

I can help draft, edit, polish anything you need to write.

(Except prescriptions!)

Howard Daniel 707-888-4724 howard@pen4rent.com

www.pen4rent.com Check out my weekly “Braindrops” blog: http://goo.gl/C17G3r

Email: mwillis@marincounty.org

WEIGHT LOSS & WELLNESS Year after year, you advise your patients to lose weight.

Let us help you tackle this complex issue.

Even a little bit of weight loss can make a difference: • Prediabetes • Reflux • Snoring and Sleep Apnea

• Infertility • Back and Knee Pain

The Altschuler Center

Your new patient referrals can be cared for in person, by phone and online.

415-897-9800

Gail Altschuler, MD MEDICAL DIRECTOR

GREENBRAE • NOVATO • www.MarinWeightLoss.com

Spring/Summer 2016 33

H O S P I TA L U P DAT E

Marin General Hospital: A Bright Future Gregg Tolliver, MD, MPH

T

his is an exciting time to be practicing medicine at Marin General Hospital. Construction of our new state-of-the-art hospital has begun, and now that we see some definite changes—a new parking structure and a redesigned hospital entrance for example—clinicians are starting to feel very enthusiastic about practicing in our new facility.

As they should! The new building project, Dr. Tolliver is chief of staff at Marin General Hospital.

called MGH 2.0, will greatly enhance Marin General Hospital’s status as the North Bay’s premier health care facility. MGH 2.0 consists of twin four-story hospital towers, all private rooms built for patient-centric care, safety and efficiency.

The green design includes five new solariums, 13 spacious new operating rooms, an expanded ICU, and state-of-the-art emergency department—triple the size of our present one. With the goal of Marin County’s good health in mind, we look forward to the new hospital being completed in 2020. More information and ongoing updates about the project are available on our website, www.mgh2.org.

We are equally enthusiastic about what is going on inside the hospital.

Several strategic relationships are bringing the best physicians and resources to Marin General Hospital. We now collaborate with UCSF on four excellent programs: neurosurgery, cardiothoracic surgery, pediatrics and neonatal care. For vascular surgery we teamed up with Stanford Health Care. Marin General Hospital and the Marin Healthcare District work in concert with local physicians to make certain that primary and specialty care (cardiology, urology, endocrinology, internal medicine and vascular surgery) are available in our community. Our

homegrown adult, pediatric and OBGYN hospitalist programs ensure that the best doctors possible are at the bedside when patients need them most. As an infectious disease physician, I’m proud to work with the dedicated health care providers at Marin County Department of Public Health, Marin Division of Health and Human Services, and Marin Community Clinics to help provide best-quality care for the entire range of patients in our county, from those with the greatest socioeconomic constraints to those with many resources.

We are also excited about the hospital’s recent strategic partnership with Royal Philips, a Netherlands-based health care technology company that will provide Marin General Hospital with early and continual access to advanced medical technologies including imaging systems, patient monitoring, telehealth and clinical informatics solutions, as well as clinical education, and consulting and design services. The partnership, the first of its kind between Philips and an independent community hospital in this Artist’s renderings of the new hospital exterior (left) and main entrance (above).

Marin Medicine

country, will result in our patients having access to the best technology possible to support their care.

Although our medical staff is independent of hospital administration, we work in concert to ensure that hospital operations are run compassionately, safely and effectively. Hospital administration has vigorously supported new initiatives such as the hospital-wide Operation Safety program, the success of which is reflected in the hospital’s third consecutive “A” grade from the Leapfrog Group, an independent industry watchdog organization that rates how well hospitals protect patients from medical errors. Other initiatives include programs to promote hand hygiene and antimicrobial stewardship. We even have a new robot that helps sterilize patient rooms with UV light. We are also very proud of the fact that more than 90% of our hospital staff and physicians were vaccinated against influenza this year. This was no easy task.

Many brave staff rolled up their sleeves and got vaccinated for the first time in years. This reflects our organization’s growing knowledge that what we do in our hospital has profound effects on the health of the entire population of Marin.

As chief of staff, I’d like to thank the entire medical staff for the compassionate, get-healthy, stay-healthy care they provide the residents of our county. I’d also like to recognize them for the high quality of care they provide. Major rating and accreditation agencies such as Healthgrades, Leapfrog and the Joint Commission continue to recognize us with the highest-level awards for safety and quality. More than 200 of our physicians were named 2015 “Top Docs” by Marin Magazine and other regional publications.

These awards and recognitions for exceptional patient care and superiority in clinical excellence showcase the talents and skills of the hospital’s physicians and staff as well as reinforce Marin General Hospital’s commitment to excellence in patient care and safety.

High-level awards for quality patient care, access to state-of-the-art technology, and a major expansion and modernization project mean Marin General Hospital is well on its way to becoming the North Bay’s leading health care destination. For ongoing updates on our journey, visit us at www.maringeneral.org.

Email: tollivg@maringeneral.org

Spring/Summer 2016 35

PRESIDENT’S REPORT

AMA House of Delegates Peter Bretan, MD, FACS

D

uring the November 2015 HOD in Atlanta, I had the privilege of sitting with the leadership of our delegation and leaders of other prominent AMA coalitions in four separate in-person forums to discuss national “hot-button” issues—not just what was taking place on the floor of the HOD, but high-priority items for specific state medical societies (SMS). CMA leadership discussed these issues with its counterparts from the three other “Big 4” societies (New York, Florida and Texas) and the Southeast and Heart of America conferences. Together these coalitions represent 60% of all HOD members.

Among the issues discussed were payment models, “balance billing” and “narrow networks,” which cause extreme physician shortages and excessive surprise, out-ofnetwork charges. We were all in agreement that neither patients nor physicians should bear these surprise charges since they are caused by insurance companies, which often claim to have complete networks when in reality many of these networks do not provide adequate access to in-network care at contracted hospitals. Networks like these simply should not be sold to health care consumers. One proposed solution to these surprise charges for out-of-network care is to help arbitrate out-of-network cost using the 80th percentile level found on Fairhealth. org published charges.

Dr. Bretan, a urologist and transplant surgeon, is a District X alternate delegate to the AMA.

36 Spring/Summer 2016

Most are within patient deductibles.

With other AMA factions, such as Southeastern, we discussed SMS governance—for example, the recent downsizing of the CMA Board of Trustees (BOT) from 57 to 35. We noted that most of the smaller societies have BOTs of just 10-15 members. Even the AMA board has only 22 members. The North Carolina and Minnesota societies have abolished their HODs as well, in order to streamline their organizations and cut costs.

While this would not work for California, our new system of year-round resolution submissions, with testimony and BOT decisions made every quarter, will enable our HOD to more easily handle the review of the 250 annual resolutions during the shortened (from three days to two—leading to a 37% cost reduction) inperson HOD meeting. Most importantly, it has made possible more online testimony.

Maintenance of Certification (MOC): There was extensive testimony at the HOD that the cost of MOC as run by the American Board of Internal Medicine (ABIM) is “out of control,” with the cost of recertification sometimes exceeding $20,000 a year. In Georgia, MOC is accomplished simply with CMEs. Several large hospital systems have approved the newly formed National Board of Surgeons and Physicians (NBSAP) as their MOC-accrediting body. Dr. (and Senator) Rand Paul is starting his own ophthalmology board.

Medicaid expansion in California resulting from ACA is about 1.4 million new patients. Across the state, physician revenues are down 30–40%. Here

physicians are the losers, but this may be less related to Medicaid expansion than to insurance issues and artificially induced physician shortages caused by narrow networks. Kentucky, a “red state,” enjoys Medicaid expansion brought about by its state exchange, which is called “Not Obama Care.”

Code Modernization: Currently, the Council of Ethical and Judicial Affairs (CEJA) can only modify the code all at once, which is very inefficient, as every meeting for the past six years has not been able to produce a finished product.

Dividing this task into sections should be more efficient. Several coalitions wish to collaborate in this process. Unfortunately, CEJA has authority over the final product, and the HOD enjoys only advisory status in the modernization process. Nevertheless, HOD approval is required for code ratification. A call for process change, in which CEJA seeks code modernization, was brought forth by our California delegation and is gaining traction.

Other issues were discussed in debating resolutions—for example EMRMeaningful Use burdens on physicians, asking CMS for a delay in implementing the penalty phase of compliance, and a call to defund IPAD through MACRA (Medicare Reform Law and CHIP Reauthorization Act of 2015). The outcome of all significant resolutions can be found in the AMA Proceedings (http://goo.gl/ mcVjZn).

As a member of the California delegation to the AMA, I have learned a great deal in the past 15 years. For example, Marin Medicine

Health Care Policy (HCP) is never an accident, easy or simple. It is forged by dedicated leaders in the CMA and AMA. How your leaders work at each HOD is truly an amazing democratic process.

Your California delegation to the AMA is in the forefront of the discussions that help mold health care policy at both state and national levels. These policies often lead to laws. HCP also helps senators and representatives in Congress understand the thinking that goes into our very transparent process. The California delegation works hard for all of our practices in this time of rapid, difficult change. It fights to keep our profession independent of the purely financial forces that motivate large corporations. However, our delegation’s strength in accomplishing anything nationally depends on your membership.

Please continue your generous support of our CMA and consider joining the AMA, since together we are stronger.

Email: bretanp@msn.com

The California delegation to the AMA consists of almost 50 physicians, about 10% of the AMA’s total House of Delegates membership, making it the organization’s largest delegation. Delegates are elected by CMA delegates who are also AMA members.

Each district is entitled to elect at least one delegate and alternate, as well as additional delegates for every 1,000 AMA members in that district. The AMA HOD meets every six months—in Chicago every June for five days and again in November for four days in rotating cities. Last fall, this “interim” meeting was held in Atlanta. I have been helping represent District X at the AMA since 2003.

The CMA leads the AMA’s Pacific Rim Coalition, which also includes Alaska, Hawaii and Guam. Until 20 years ago it also included Oregon and Washington. However, those state societies’ delegates elected to leave the Pac Rim Coalition for perceived lack of representation. Nevertheless, talks have been taking place for the past 10 years to bridge this divide, and in the past month the talks have successfully led to the reconstitution of the PAC Rim Coalition. This will help it be more effective in determining AMA national health care policy and legislative matters.

Marin Medicine

Donate Today!

Shape Local Health Policy

by Supporting MMPAC Your support is needed to ensure that the Marin Medical Society (MMS) continues to be an effective advocate on your behalf on local and state health care issues.

Through the MMS’s political action committee—MMPAC— the MMS is able to support candidates for local office who are responsive to our concerns about health care issues in Marin. Often the impact of this support goes far beyond our local community, as these candidates move on to higher office in Sacramento.

MMPAC-supported candidates look to MMS for input on vitally important local health care issues. MMPAC’s success is dependent on your support.

Please support MMPAC by making a contribution.

Contribution Form Name _____________________________________________________________________________________ Address ___________________________________________________________________________________ City, State, ZIP___________________________________________________________________________ Phone ____________________________________ Email _______________________________________ Contribution:

$50

$100

$200

$500

Other $ _____________

Please make check payable to Marin Medical Political Action Committee.

Check enclosed

Visa or MC #__________________________________________________

Exp. date ___________ Signature _________________________________________________________ Mail to: MMS, PO Box 246, Corte Madera, CA 94976 —or— Fax to: 415-924-2749 —or— Email to: rachel@marinmedicalsociety.org.

Questions? Call Rachel at 415-924-3891.

MMPAC is a voluntary political organizaton that contributes to candidates for local office. Political law and MMPAC policy determine how your contribution to MMPAC is allocated. A decision not to contribute to MMPAC will not affect your membership status with the MMS. MMPAC is sponsored by the Marin Medical Society. Contributions are not deductible for income tax purposes.

Spring/Summer 2016 37

O U R M AG A Z I N E ’ S M A N Y M E TA M O R P H O S E S

Marin Medicine Marks Six Decades Cynthia Melody, MNA

F

ounded in 1898, the Marin County Medical Society issued its first publication 57 years later, in September 1955. According to Dr. Carroll A. Russell, the Society’s president at the time,

activities. We realize that our esprit de corps is extremely high, and we know the quality of the medical profession in Marin County is outstanding. Let us make this Bulletin reflect those high standards.

The officers of the Marin County Medical Society have considered publishing this type of bulletin for some years, and we feel that the recent rapid increase in our membership has made it imperative for some type of publication as means for disseminating information and keeping each member posted about our ever-expanding

—Bulletin, Sept. 1955, Vol. 1, No. 1.

As we celebrate the 60th anniversary of the Marin Medical Society’s publication, the 2015-16 board of directors is proud to share this retrospective look at the many changes and modifications that have occurred over the years.

1955 Bulletin of the Marin County Medical Society The first Bulletin featured a short biography of all medical society members to help everyone become better acquainted. Interesting and informative, the 6- by 9-inch monthly magazine, with a blue logo emblazoned on the cover, was primarily intended to be a scientific journal.

1967 Marin Bulletin

1972 Marin Physician

1976 New Marin Physician

The Marin Medical Society logo began being printed with a vertical band, and in a different color with each month’s issue.

The magazine got a new name, and the cover now featured a black-and-white photograph of Marin or of seasonal changes in Northern California.

A new name and format replaced Marin Physician, which ceased to be issued in 1974. The new publication was published monthly in tabloidnewspaper format.

38 Spring/Summer 2016

Marin Medicine

1983 MMS Bulletin Change continued with another new title and format. Still published monthly, the new Bulletin was an 8.5- by 11-inch newsletter.

1988 MMS Bulletin The newsletter saw a slight change to the masthead with a new logo.

1993 MMS Quarterly Bulletin Another adjustment to the masthead identified the publication as a quarterly.

2007 MMS Bulletin A new era was born as the publication underwent a metamorphosis and emerged as a full-color quarterly magazine.

2008 Marin Medicine The title was changed to reflect a wider audience and to appeal to advertisers. Each issue featured a topic of interest with articles written by and for physicians.

Ms. Melody is executive director of the Marin Medical Society.

Email: cmelody@scma.org

Marin Medicine

2015 Marin Medicine In its 60th year, the magazine began a semiannual publication schedule.

Spring/Summer 2016 39

WELCOME NEW MMS MEMBERS!

Robert Newbury, MD, Critical Care Medicine*, 75 Rowland Way #100, Novato, Boston Univ 1991 Gygory Pataki, MD, Internal Medicine*, 99 Montecillo Rd., San Rafael, Med Univ Pecs (Hungary) * board certified

CLASSIFIEDS San Francisco Financial District

Steal my practice. I’m retiring.

Medical office sublet for 1 or 2 days per week. Central location at Battery and Market. Jeffrey Binstock, MD, 415-956-8686.

Fall in love with practicing medicine again. Proven, profitable weight loss practice in Marin County. Multiple 6 figures, ready to take it to the next level. Work-life balance, time freedom, financial security, relationshipdriven practice.

I’m 100% committed to all the support necessary to ensure a smooth transition. Contact for more information or to schedule a visit. Gail Altschuler, MD, 415-309-6258 or drgail@marinweightloss.com.

Sublet Mill Valley medical office

535 Miller Ave. office available on Mondays. 2 exam rooms, adequate parking, beautiful space. Jeffrey Binstock, MD, 415-383-5475.

Medical condo for sale

SUPPORT

Located on South Eliseo Drive in Greenbrae. 415-435-8589.

Our Advertisers . . .

Altschuler Center . . . . . . . . . . 33 Classified ads . . . . . . . . . . . . 40 CMA CPR . . . . . . . . . . . . . . 40

Free classifieds for MMS members!

MMS members can place FREE classified ads in News Briefs or Marin Medicine.

Cost for nonmember physicians and the general public is $1 per word. To place a classified ad, contact Susan Gumucio at susan@scma.org or 707-525-0102.

CMA CURES deadline . . . . . . . . 23 Fernwood Mortuary and Cemetery . . 12 Heartland Hospice of Marin . . . . . . 8 Hospice by the Bay . . . . . . . . . . 16 Institute for Health Management . . 22 Institute for Medical Quality . . . . . 15 Marin General Hospital . . . . . . . . 6 Mercer . . . . . . . . . . . . . . . . . 4 MIEC . . . . . . . . Inside front cover MMPAC . . . . . . . . . . . . . . . .37

ARE YOU ARE YOU ARE YOU ARE YOU READING CPR? READING CPR? READING CPR? READING CPR?

CPR contains theManagement latest in Practice Management CPR contains the latest inthe Practice Management CPR contains latest in Practice Resources, the latest in Practice Management Resources, Updates CPR and contains Information.

Resources, Updates and Information.

Updates and Information.

Resources, Updates and Information.

CPR contains the latest in Practice Management Resources, Updates and Information.

MMS Awards Dinner . . . . . . . . . 3 MMS/CMA benefits . . . . . . . 26, 30 MMS membership . . . . . . . . 20, 29 MMS publications . . . . . . . . . . .10 NORCAL Mutual Insurance Company . . 9 Pen-for-Rent . . . . . . . . . . . . 33 Sutter Health . . . . Inside back cover The Doctors Company . . . Back cover Tracy Zweig Associates . . . . . . . .18

May 2012

In this issue: Aetna to require additional

accreditation requireMay 2012 ments in order to be paid for certain surgical pathology services

1 Update on two Anthem Blue on requireissue: Cross issues pending ditati In thiswith the addit ional accre Departmen cal

CMA Practice Resources (CPR)

May 2012 from the bulletin is hly bulletin in from the bulletin is a free mont omic Services. This practice (CPR) is This monthly bullet CMAReso In this issue: urcesResources improve er for Econ ) is a free Economic Services. ice Practice (CPR) ve practice CMA Practice is atheir rces (CPR free office staffbulletin iation’s Cent r for California CMA Pract staff impro Medical (CPR) Aetna tomonthly from the Practice ResouAssocResources is free office Associatio ciansn’sand require additional accreditatio iation’s Cente Medical Assoc monthly bulletin from Center and atheir Economic Services. sign n require- CMA rniaCalifornia Californiafull of tips Association to help physi 2012 the ments for Medical Medical in order physicians ’s Center for Economic to be up and toolsand tools to May help physicians paidtofordate,This bulletin is Califo full sign to help of toolsand Services. surgical and tools to help physicians To stay to date,This efficiency pathology full of tips and tips RS:their bulletin is office staff certain lity. improve practice and To stay up efficiency and full of tips and viabiand viability. R CMA NEWSLETTE services ity.viability.

LETTERS:their office staff improve practice ters. efficiency OTHE wslet Update gues. 1 ncy and viabil SUBSCRIBE TO CMA NEWS on two Anthem Blue andn collea ANYOR rg/nee: requireissu letters. efficie OTHER net.o this CPR OR CPR SUBSCRIBE Cross ditatio /news ANY ANY In TO issues .cma OTHER CMA colleagues.

OR CPR OR ANY cmanet.org rkers accre withNEWSLETT the cowo al pending Department TO CPR TO OTHER CMA NEWSLETTEcoworkers and up for freeriptio ns at www SUBSCRIBE ERS: youronal e additi of ToManaged n surgic subscripti stay up for freeriptio upHealth ns at www. tin to SUBSCRIBE to date, ons at Aetna to requir Care 1May for certai to your RS: To stay up to date, sign sign 1 2012 free subsc paid this bulle net.org/ne subsc subscriptions rd at www.cman be Meet rd www.cma bulletinet.org/new to Your free up forSPREAD wsletters.

CMA this forwa for Center order e for Economic Services up SPREAD THE sletters.

THE :WORD: forwa Pleas Please forward ments inAdvocate:es PleasePlease g WORD WORD:WORD: this servic Mark Lane ents pendin forward this bulletin ents issues irem SPREAD THE your pathology bulletin to coworkers to your requ irem Cross SPREAD THE 1 requ coworkers 2 and Blue n colleagues m CMAtwo and n Care colleagues.

Advocacy tatio .

Anthe at Work ed Health editatio e on redi

is a free monthly e-mail bulletin

t of Managed in surgi require Health Care 1 1 Aetna toMeet paid for certa to be CMA Center for Economic orderYour Services ments inAdvocate: Mark Lane pending services pathology Cross issues 1 the 2 CMAtwo Advocacy AnthematBlue is Workged Health Care etin from Mana Update on al acc s bulletin 2 nthly bull 2 ology seres itionUpdat tment of Manag Urgent tment of es itional accr ical pathology serUrgent survey pathrequested Aetna requ Aetna requ response mic Servic ire addadditio mic Servic a free mo nomic Services. Thi practice ical with the Deparsurvey response ire addaddition requested with the Depar 2 2 surg for Econo surg tation r for Econo to to require to to require nal ain 3 al accredi 3 accred (CPR) is AetnaCMA Center y terminates Aetna CMA Practic CMA Centeitation Aetn Aetn for certain requirem requireices ources in aorder in aorder Meet Your erroneously Meet Your erroneousl e Resour’sces ments ter foris Eco office staff improve paid per-tice Res ents 2Aetna perproviders from2 to paid for cert Lane terminates ,providers bebe Lane paid from Cen California toto (CPR) California for certain surgicastl1,patholo Marknetwork , practi network certain ate: Mark Prac to require ate: athei 2012 orderaddition freer monthly bulletin Aalces order to bebe paid for Advoc surgica ainvices 1, 2012 pract LaboraAdvoc ociation invices Califor CM Labor al accredithat, nial Ass 3 3 gy Workstl patholo ive Augu 3 3 Medica sergy cal 2 atAugu iveDocument, ser-ments ns and Clinic from the tation effectrequire Document, l Associa Clini effectacy Document, acy at Work siciation’s Advoc both that, Col-Medica sted s in be Document cians CMA phy nia 201 order Center ed to -be both with Colthe to sted s y Document cians CMA Advoc Document, Aetna reque vice physi to ifor the red for recently be requir help ed Aetna nse Ma reque vice physi paid full Econom be sign Cal notified recently 3 ited requi to tools to of toolsand ied physiciansg will y respo accredited with physicians certain notified United 3 tly notifi for g will Healthcare y response ers from patholo surve surgica United Healthcare tly notif t be recen and accred to date s.,This announces forming provid that, logy testin that, recen and tips and help physicians and To stay icupService Aetna effective bulletin is extension of HIPAA 3 announces providers from ates gy service certifiedlAugust forming 1, 2012, practices iedAugust logy testin Urgen )effective Urgent surve Aetna tips pathology ice patho in-office 5010 termin1, certifously sin-office of patho 2012, enforcemen testing the A)errone perpathology ts (CLIA in-off practices per5010 enforceme efficien fice will their . t ng full yntterminates extension of HIPAA 3 be with (CLI testing RS: required dmen the tory office ts in-of cy ility Improvem will formi eousl and stent to TTE be required staff improve practic be eboth Amen dmen Aetna tory ing nt Amendme Clinical Labora34 Improvement Amendme form is consi ). certified chang stent withUpdate to be eboth vemeent nts Aetna erron What’s (CLIA) (CAP Clinical 34 y and viab viability.ER CMA NEWSLE is consi ). rnia as an a netwo Impro COHS?rk chang ireLaboralege the 1accredited ovem Amen logist of ienc What’s network toryAnthem (CLIA) (CAP CAP on two American snts Califo requ of as an Impr certified Patho nssAetna Pathologist lege letters. theand accredited effic with Document of tory of es. e claims that and ican CAPHIPAA OTH American the ColBlue (CAP).

Californiaa COHS? tatio s that Pathologist 4 testSUBSCR Cross recognition ANYOR with Document Save claim icanPathologis issues Document, IBE TO ts, Aetna the OR CPR Col(CAP). legeInofal t.org/news a Amer Date acctoredi letter ent, 4 test-4 the Departm ion ofthe recognition es (CMS) anatomic pathology physicians,Aetna aneCMA and colleagu Save the , Document, tophysicians, Documces Servicpending ANY legeInofa Amer ition TO CPR (CMS)annou letter totophysicians ical OTHER nces extens pathologywith w.cm caidclaims l sion of HIPAA 4 aforletter physicians IBEfor that Inent surg ofcert 4 ire addCenters Medi DocumentDate theospita Servi Manage , Aetna NEWSLE r coworkers change at ww care tal anatomic Act ain Medicare nces exten caidclaims is nowHealth d Health care to avoid SUBSCR that && In aforletter Centers Medicaid 4 topen-requ n for withup the the 2013 Care hospi 1non-h change ptions ptions themen- free United for Medi care annou Services Act nowHealth e-prescribi Medicare & Medi alty 4 is consistent 1 consistent May 2012 (CMS) recognition approved Aetnang etin to youTTERS: To stay up to date, sign paid Centersfor n for nonthe imple n organizatio subscrisubscri with ement at www.c accreditatio Meet themenUnited to avoid tthe 2013 e-prescribing pen- 4 for Medicare& Medicaid Services Your n organizatio CAP r to be manet.

(CMS) CMA as anfree this bull approved 5010 enforc organizatio cafor Center Centersaccreditati n for non-hospit recognition ofwith alty org/newsletters. the orde concernsofwith emen ard ved accred foritatio up in ing.appro Econom onon 4 ditati CAP al anatomic tsasimple organizationPayor 5icaforw dual certifi ? d concerns anAdvocat has voiced ic SPREAD accre 5010 enforc se for Services pathology men for COHS Updates ved non-hospi a THE need iation testPlea izacertif ing. s WORD: tal appro Assocding to explain the 5 4 anatomic pathology ices What’ has voice e: Marking. the Please forward this cal pen The for dual test-y5 serv Payor Updates Californiarnia Lane itation organ COHS? Medies iation from THE WORD: Medical Aetna isolog pen- izaissu Association Assoc Health bulletin to your cowork in the needetin etin What’s a ved accred ngorgan EAD Califo s plan calbull Date on The California Medical path ing. explanewsletters theprovider scribi appro SPR tation Blue has asked has voiced 1 Medi to ditati anconcerns lty society ofThe ly bull Save this Cros 5 e-pre and as 2 s 5 policy accre ornia with Aetna pennth specia Associatio Health plan and 2013 the a ers CAP ved policy em has Thi implemening Calif ty CMA and Date mo asked the n has ices Care 5 Advoca nize to explain cation and colleagues.

Aetna scrib voiced appro tationisofThe Anthtion. of this Health has askedServ free anconcerns cy tation alty socie Save theprovider newsletters athis andasked as.avoid at Although policy andy has er, CMA the need fores. may recog Work witha the certifi now to speci on- two 2013 e-pre CMS CAP icAetna tice Furth implemen Actto R) tation aged may recognize 5 5 5 (CPtion. ate and certificanize a CLIA ugh CMS n prac nom Man of this polic Upd servic dual avoid the CAP recog explain Altho CMA icatio as anlogy e both CMARes Ecorecognize tion,oftion.

Although rove er, Urgent approved accreditamay CMS testin ent need fores. certifthe 2 g accreditatio requir forCMS ources does not Furth Act now to alty not Serv may f imp terCMS 5e Resour’sces CLIA the nCAP certificaices astaf organiza- itaugh both doesrequire survey a CLIA servic dual Cen ice patho CAP tice Practic dita-5artm (CPR) ce Altho Aetna to require addition as an CMS the certificatio c rm to obtain re both tion, tion. respons accreditatio approved accreDep CMS es is not testing accreditati tion, n n and omiperfo tion athei requi r offi the accred does not free to eperform request a specialty Updat logy alty month 2 cians CMA physi ocia Econ onCAP edin-off CMA PracCalifor society organiza- ditan thewith resourc to CAP, patho ly both doesrequire ing forconcerns al accreditation require bulletin nial Ass a CLIA and 5 fice Payor obtaietters Medica ability of testing .services. itation to in-office teraccred CMS certificatio to expressed ns newsl thepathology 3 ding accre Accor l accreditati erfrom Cen Associa ss of obtain the nesand rm in-ofWhen cians on theAetna sicia Medica Further, to perform a specialty provid withrns Updat tion’s - esCal CMAPayor physi thewith CMA you CAP, phytion, planthis erroneo abilityimpo to perfo in-office society of testing see resourc tosign conce y, the proce yHealth sed by Aetna Your CMA ning icon,rding for letters ssed es ifornia May 2012 ments in order to be paid for certain surgica that means ionall abilit tionusly full of tips termina Econom ditationCenter prior to helpexpressed obtain ine of physicians Mee expre thepathology to Acco tesdeadl the deadline accre .services. there the CAP accredita2toAddit icupService sst of obtai concerns provide are date Further, days. provider news Whenlyou see Lane withrns Aetna proce tices perto s.,the 90 thewith CMA byadditional from This resources pathology services by rs closeabilityimpo ely Californ and toolsand toolstiontoprior Aetna. help conce bulletin sed lly, prior to the imposed tion process availAccording practices. physicians physici Health planthis icon, thattips ximat e: Mar tion takes able tiona isiaknetwork stay means toAddi ans is working free obtain appro ineRS:of expre approxima 2012, prac to and to ssed To costly for to CAP, California the there are additionalfull of the CAP accreditaefficienviab their deadline CMA Advocating deadl tely 90can Medical accreditadays. office imposed be very ility.viabilit issue,the and 90 to the Additional process takes itatio TTE staff resources availby ices.Assoclose- a secondary thisprocess ciation Aetna. n days. k accreditatio tely improv SLE prior 3 on tiony.process e August 1, h Clinical Labora(CMA) According pract xima Wortion members e ispractic l other state 3ly, the tion for and cy and able free to1California work ctiv Aetna NEW of obtaining n can be very at to takes y CAP, accred appro y at Update on two Anthem approxima severa the e irethe with effe Docume costly s CMA accredita, costly ct dary CMA rs. ienc CMA and takes website. tely ocac ) To for very Medical nt, bot ss requ s 90 access urce practices.

ER In conta days. addition be Additiona n issues ciation (CMA) members lette issue, that a secon effic Assoany of (AMA mean proce es.Adv a secondary OTH reso to theirwith these this nt, their Bluetatio ews state and Docume todnt Docume on can tionaccreditati CMA resources, on the Cross sicians that be required to be eagu ANYOR ioncontact the ColCMA process s. other r icon, ditati visit Aetna IBE TO alobtaining ong/n coll Aetna lly, http://www OR CPR of additeste can accredi e Inrequ this cal Assoc on iation ly withons accre r detail at the recently be very this issue, sever with the add see ane s SUBSCR and CMA TO CPR MediAetna ified phy ct with daryt.or Gaul, senio furthe notified website.

ANY 3 CMA you rces availg/ces.

To access any of for.cmanet.or Departm itional ers is ctworking s A) andresou ical pending urce practices. resp the American In addition contacostly secon edited with w.cm will aOTHER physici Tammycloseork When ent of Manage United IBE ey specialty Americanider Association (AM from CMA tuned for reso to their theirwith ntly not these ing that, the Medical Healthc toNEWSLE cow SCR that atly ww surv contact resources ain surg iation r Assoc Assotestans up and accr d Health Care additional are announ and several CMA ntwebs ies.s Stay (AMA) require TTERS: ls. medical ly withsocieties.

SUB , visit icon, formean na rece Aetna are stay you formin http://ww free prov other state Aet societ ite.r To e August detai Medical cal on Urge 1 ptions ptions ces In addition alStay , senio with the American this er up es there g in-offic w.cmanet extensio 3 can conta the letter availrnia and see this Medi scrisubscri 1 tuned certified 1, 2012, practices perGaul g Aetna toMeet CMA medic furth etinicanto inatquestions paid for cert pathology ts (CLIA)effectiv n for date, ofabout isto further sub forissue, at www.c Medical HIPAA to Califo bull Practices 5010 the yCMA details. sign term ions Tamm When you .org/ces. closeAmer Associatio specia at freerces enforceusly ctworking @cmanet.orin-officee pathology testing tuned withlty r to be manet.

604.

CMA questthe the n (AMA) able free bers forresou ment Stay Center for Economic specialty medical conta org/new will be required to AssoordeYour visit withsocieties. or mlane and ing Medica with the ties. upional can men lythis ) mem ces withabout sletters letter (215)775-6 tory rces, a erroneo other state socie Medical THEwebsite.se forward Practi Improvement form contact . several SPREAD n (CMA 401-5911 Services there are addit Library ments inAdvocat the letter sistentl Labora and be is con Amendments tl-Legal tuned forabou ciatio at Aetna at canline, medicalStay at Aetna rg network these resouAetn Plea Please (888) Gaul, senior Clinica 34 Tammy CMAD:WORD: further alty at (215)775-6 to California at theWOR Practices e: Mark Lane details.

P). certifie cha ions ork manager s any of speci help s. What’s with ngeboth rk manager services e@cmanet.o netw rovement Amend 604.

Contact: forward questthe (CLIA) ent604. questions able free es pendingMedical-Legal acces bersTHE (Former rg/cemlan netwo To775-6 Imp visit about this ists (CA reimbursem ly net.o lege ) mem bulletin CMA ices with EAD d and accredi letter 911 tory of .cma CAP as an On-Call pathology helpursem Americ at (215) can network manager ntreimb Pract to that the line, (888) 401-5911 Cross issu SPR contact Californiaa COHS? CMA CMAent 1 your resources, 401-5 ) or senior /www Library Patholog Tammy ted of cowork 2 n (CMA ciatio ion In this at Aetna ger at Aetna with anPatholo http:/ Gaul, Docct:ume or publication ersreferences witherican of these gists Aet the yColematBlue CMAtwo and (CAP). na claims you will find colleag Advoca anet.org ding help line,, (888) Anthcy test6604. ument,Conta Contact: CMA ork mana at (215)775ent pen ofa Am S) recognit ic patholog access any net.org/ces.

Health Care (Formerly HIPAA 4 mlane@cm Work ns, Doc netw “medical-le es To CMA toSaveues. ursem In the on of reimbursem lege nt, Date (CM n aged letter sicia gal” issu ate reimb documents ent s .cma to On-Call help ume nsio phy ices Man Upd line, . The Californiaary Cros ) tophysicians, Aetna (888) Doc 401-5911 or mlane@cm Medical ent of In this publication 2http:/,/www id Serv ces exte Anthem Blue Contact: CMA Libr Association with are ann al anatom al medical-leg Urgent ’s (CMA) you will find references anet.org Ins aforletter Departm 44 lth Care Center survey online onoun thespit two Anthem change the & Medica claims that -ho c Services pen ical-Leg respons library Act ding Update two

In this issue:

: In this issue

In this issue:

from CMA’s Center for Economic Services. This bulletin is full of ts Aetna to

en on requirem accreditati thology sere additional cal pa

uir re additional surgiditati to reqrequi rtainaccre tnaorder on requirements in id for ce tips andAeinvices tools help physicians to pato order to bebe paid for certain surgical pathology

: In this issue

vices

ser-

and their office staff improve

uirements ditation req y serional accre cal pa tholog es Call) nowHeatolthc Medicare re “medical-l to to requi omi ed is consistent with the ene request with Med Cross issuOnon Blue Crossage uire ad 2 egal” documents. The Aetna d Hea avoid & Medica atee-presc re dit the Upd issues addit surgiditati for Econ 2013 id tion for non United for Medica ional the inaccre aryreq Departm Medical Associatio 3 n’s (CMA)Aetna of Man ly CMA e alty rtaAnthem ribing approv Librto ent of ent AetnaCMA Center alCalifornia Centers pen- 4 pending with edHealt the implem n organiza Services (CMS) recognitionsofwith Update hem Blue accredi h (Former artment on -Leg online atioorganiz for once d Health Ant tation requi usly terminates provide library 2contains Car s pertwo medical-le in ical id Care lthreme two order Meet Your erroneo gal the DepManage ) an ificapa ation for non-hospitaled concern CAP asl cert Med accredit 5010 enforcem on Blue nts Hea to over of Managed d Crossage be paid forUpd ate rs legal, issues fromregulatory, 4,500lypages Onrovedwith Californ of medicalDMHCS? Mark Lane practice app claims audit 5 4 the Departmenting. certa CMA erCallto be nces to the Departm g with of Man has voic anatomic patholo der claims, in surgi Payor and mer 2012,pendin ord ent of Manag s audit d for dua reimburse entedAug Updates Advocate: ia networkk 12, 2012 in gy ntesta COH cess provi cal ment will find refere oraartm ust 1,patho As hpreviously reported, t’s Healt youinformation rnia Medical-le Lab DMHConclaim . vices logy organizal Association to explain the nee editatio Whaged 3 3gal(For ted, on Jan. Blue Cross to repro e Health ation, Careh Clin documents are ical serthe Dep Thehealth Jan. repor at Wor ing. s. The Califo cal-legal Califor 2012 usly 12, free t of Mana Document,y Docume plansnia Medica Care In this public Departmen members and can be found na 5 -t of Managed Health larges nia Medica with(DMHC) ordered Anthe bot the Departmen docutoment DMHC claims s, Date that, effectiv As previo t edthe l Associa d accr Health nsaudit d Aet g. mpen in CMA’s claim order nt, Anthem t Col to be ) online medi calCalifor Docume CMA Advocac estednt tion der- plan ical-legal” es ety rove online sicia aske HC)Blue audi seven ribin provider the has Cross (CMA resource ired s 2012 thresh Aetna the provi “med The requ voiced app the tation interest, vic to phy library, (DM n’s has esc reprocess e newslet of the 12, medi cess recently s http://www dating with 2007 an claim requ of concern of Care provider ciatio Save As C this to back toters ified previously reported, policy and notified 3 e-pr 3 .cmanet.o s with specialty soci on Jan. C5auditclaims, with ents above P as 2007. cy and DMH be pages not respons g back editedto repro rg/resourc cal Asso al contains over 4,500 pages of medicallegal, regulatory, and nces to reimbursem will find refere youinformation Medical-legal documents ation,ent .California ents. The al-legal to members In this publicare free and can be found docum in ical-legal” ) online medic online resource “medCMA’s library, http://www iation’s (CMApages of medical.cmanet.or Assoc g/resource 4,500 -library.

Nonmembers canMedical information. purchase ins over ursement members reimb al documents for $2 per library contamedical-leg free to page. regulatory, and ents are legal, rce ted, Cross onously 4,500 al-legal docum online resou rary. e-library.

Jan. 12, Nonmembers canMedi repor st, datin The order is based information.(DMHC) 2012 Medic on 2008 DMH ions of claim paym intere the em Blue in CMA’s /resou h plans Departme purchase ins over on 2008 Anth ursement memCare healtin is basedaudits ntcan As previ t rce-lib edCenter of Managed DMHC bers violat ordered be found Health reimb CMA gal plans. ments for $2 per library contamedical-le larges order Anthem et.org docufound and California. to The order s of the seven h- These audits and Blue plans to pay Cross2007 page. regulatory, largesthealth thres . for Economi al-legal docuthe seven interest, dating back to reprocess (DMHC) 1201 health plans c/www s are free found Services s of .cman These audit medic Care provider at all seven , http:/ required the nstrate legal, aseents rnia.violations audit above the lawpayments to 2007. claims, of claim old allowed under California C J Street, #200, back to library purch with gal document ’s online resource ry. ve fines, in Califolaw can Sacrament paym above demo California rs claim st, dating economics the thresho, The 2008 DMH CA 95814 embeof Medical-le at all seven onervices@cm administrati intere in CMA that plans Nonm ions on 2008 As a result, DMHC allowed under ource-libra - order is based plans. assessed is basedaudits . per page. oldassessed DMHC Chealth violat anet.org 1 of 5 mandated CMA Center for and • 916/551-2 for $2 can be found .cmanet.org/res to pay h plans found , DMHtive California. These audits The order s of the seven administra 061 2012 • Page galindocu owed and mentsseven Econom providers were required As a result health plans ic/www the money found . These audit red the plans Services all largesthealt CPR • May medical-le theyfines,

practice efficiency and viability.

201 physici ing will effectiv and accr CA United Healthc ey are announ poli has asked ntly 5 and a the implem engnize to iders from 3 na rece n ofghthis formin explain tion.tatio e August 1, 2012, practice Act now to avoid the Urgent surv ology testans that, Aet es prov Althou g in-offic extensio the tion may recoAetna need for ther, CMA inatces n of HIPAA CMS A certifica patholo IA) certified 5010 enforce . Furcertific mayS recogni gy 5 h CM testing s perthe ts (CL in-officeepath aoug h a CLI mentterm awill servicesdual neously be required to be both sistent with botCAP men as an approv tory ing . Alth tion, tion ire ze Improv form CMS testing P accredit ed accredi ement Amendments does not Aetna erro alty Clinical Labora 34 s not requ the CA P). certifie cha organiz both a CLIApathology nge is con aintation rovement Amend What’s network (CLIA) S doerequire a-edita5 as an Imp to obt lege , CM accredition d and accredi tory of ologists (CA ationnsand CAP CMA American tation ates Californiaa COHS? nt, Document orm in-office certific Path to perform a specialt P, the accr ted of ms that the Upd with physicia or nstra the plans to pay at ion y y society gistsunder therequi to perf in-offic , http:/ of testing -Serv ase ericanPatholo iceste rces they slett 1201 J Street, resou to CA Pay were owed (CAP). nain clai lawgnit ers old allowed e patholo claim test purch reco California violations and mandated the mone payments aining yColabilitygy ofa.Am tive fines, S)ofornia Sacramen rs can Save the Date ns, Aet omic California above Docume demo Calif editatiosn that plans demonstra expressaccr olog the nistra providers Accord. ing threshn of HIPAA 4 #200,library law Econ CAIn ed concern letter to physicia plans 95814 at (CM ider new path admi all rseven for ed unde cess of obt that te ed ic Further s with Nonmembeto,lege erthe prov , CA 95814 When with Aetna.services Asans, allowices Document, ated a result, plans. assess Serv ,pro tom Cent CMA cernthe you per page a letter tophysici 4 cmanet.or byans Chealth plan Aetna 1 of 5icon, DMHC the ability idold ces extensio economicservices@ 61 mand see ana con lth CMA y, •Center claims Sacramento this assessed 916/551-2 of al • Page DMH and oun osed dica s forg$2 51-20 , physici ed Hea administra nall that In 061 #200, spit 2012 ann 4 Me that owed ment tion imp t, 916/5 result the ress CPR itio • a non-ho tive providers means May change prior • May 2012 • Page s for Medica are fines, •g Stree were required obtain the CAP accredi expto the deadlin Act now Jthe re&& the money they As dline is1201 net.or CPR there consist 1 of 5 y they s.toAdd tolthc re dica plans are avoid for ices ent to@cma were Medica additional resourc mone pay Me impose the 2013 e-prescribing enServ and mandated the the 90 day ta- king closeid tion United Hea for dmat lem r to the edea by ely micserviceswith 4 derssowed tices. omic Aetna. that plans ters es (CMS) imp approv prio econodemonstra provi 4 organiza Service tion availAccord prac Econ ent process Cen penrecogni ed alty the n 9581 for ing tion for accredi roxi able wor te rcem to CA atioorganiz tionsofwith takes approx er free -to California CAP, e,the tation A is tas app 90 days.

CAP as an ifica costly edit mento, accredi ation for non-hospitaled concern 5010 enfo CMA Cent Medical Asso, Sacra d accr 51-2061 issu CM rove cert Additiona ing.t, #200 process takeimately CPR • May 2012dua a secondary • 916/5 lciation thisprocess state and n can be very nally, 5 4 tionaccredi on the (CMA) has voic anatom ic patholo of 5 manet.org 1201 J Streeapp Payor Updates otherng tation d for • Page COHS? - members at the gy 1ntestcanatio accredit be verytact services@c seveofralobtaini with Aet ry s CMA website organizaany l Association to explain the nee editatio What’s a To access economic ing.

The California Medica practice In additio ource r con costly for a seco Medica s. A) and means. n nda of res to their na these 5ion (AM to theiwith resourc pen l Associa , that d accr Health plan d Aet CMAanet.or itioncontact California tion icones, Date newsletters visit availor Aetna has voiced l Asso http://w details. approve society tation ofThe onciat ly with the Americ has aske escribing In add this issue, ww.cm see this Save theprovider this policy ialty andasked Medica s Gaul, seni CMA s and further witha the cy has specimplem an AmericlanAssocia and is workin 2013 e-pr CAP as anconcern poli g close5 5 Tammy en- When you g/ces. gnize to al resource tuned for the Medica avoid the n ofghthis explain tion.tatio Stay (AMA) specialty medica Althou the tion and can contact may recoAetna ly with need for ther, CMA there are addition ia Medical Assoeties. tion CMS A certifica l societieical socituned Act now to . Furcertific mayS recogni 5 h CM s. Stay icesdual the letterseveral other state and website. aoug h a CLI aze iforn ut A serv CAP med bot for edit Alth Cal as abo CM further . ing tion, an ire ialty net.org to approv accr ns Practic CMS details. tion does not require P requ y test ed accredi the CA esspec free with questio s at the alty questio 75-6604. -5911 or mlane@cma organiz ns about aS does not both 5)7contact a CLIApathologationns to obtaintation a-editable Medi 5 the A) member resources, visit tices with , CM accredition at (21can network managePrac tation naletter 401 Gaul, ion (CM Libra orm in-office certific to perform P, the accrcal-L specialt ciategal r at Aetnaager at Aet75-660 CMAPayresou physicia and aing these or Updates y society , (888)Tammy to perf in-offic of testing to CA senior e patholo rces ainingaccess any ofry abilitygy editatiosn expressaccr 4. line Contact: CMA ork man at (215)7 newsletters the ent help of obterly Accord. Further,process ed concern g/ces. services (Form ider sem netw na.

To with t.or s reimbu bur prov When you with Aet ane CMA rsement the CMA cern byans planthis icon, that ability of osed .cm all) A reim On-C help line, (888) 401-59 y, the physici ed con Healthsee tion prior ://www ressthe itionall means th In this publica obtain expto http 11 or mlane@cmanet Contact: CM there are additional the CAP s.toAdd deadlin deadlinedimp tion, e- you will find .org nding wi 90 day ta- king clos resources availby ely tices. accredi Aetna. prior to the e impose tion process mat Accord prac tion takes for to al-legal” documents. references to able free to Californ is wor CAP, e,the approx s approxi90 A “medic costlying ss issues pe accredi ia Medical AssoThe Californrar ta-stat days. be very issu CM Medica e and tion’s Additiona process takeimately a secondary thisprocess ciation (CMA) membe l Associa Lib ia y n can nally, tionaccredi on the al medica Update on two Anthe two Anthem Blue Croalth Care otherng (CMA) tation online canatio accredit at the be verytact al-Leg seveofralobtaini with Aet ry s CMA websitens. library containsMe dic l-legal To access any of practice ll) In additio Blue Crossnaissue oursrce over r con costly for a seco s. A) and 4,500 pages of n nda res to their these ged He ion (AM On-Ca to theiwith resourc , that mea Updat te on m en Amedica s pending with CMAanet.or legal, regulato Ma l- references to the Departmen or and reimbur CM Aetna l Asso http://www.cm additioncontact y of details. this icones, visits availonciat seniry, ly with the Americ In t this dica l, erl her issue, see Me find Gau of rm CMA furt an Mana sement you g/ces. an Americl Associa will tion. fornia is workin g Medica resource Tammy When close- l-legal (Fo tuned for ion, youinforma tact ed Health the Medica Cali documentslicat Stay (AMA) specialty medica the Departm ged Health Care l additional Medical Assoandrseveral can con ly with are free ume eties. tion of Manag l societieical other stateand to nts. The socituned In this pub lette site. ia there are rs e medical-lega andcan benet.

DMHC claims audit ut thedetails. found ms, with med s. Stay al” doc membe org Department in CMA’s CMA web further l-legonline ialty to Californ nsforabo Practicesspec (CMeA) onlin of medicalresourc with questio ne@cma library, questio ims audit , on Jan. 12, 2012 the to reprocess provider clai able free A) members at the s, visit http://w “medica 75-6604. -5911 or mla ns about As ociation’s 5)7contact previou Medical-L es the tices with Assg/resou anet.or sly reporte .

DMd,HConcla at (21can network managePrac ical tion rted naletter 401 Gaul, Nonmembers ww.cm ion (CM Libraofrythese resource e Cross Jan.ly 12, r 4,500 pag repo2012 ciategal r at Aetnaager s ry. at Aet75-660 , (888)Tammy nt informa s overce-libra senior ious the canMed hem Blu Care (DMHC) ordered Depart purchasetain Ant ment of Managed Health largest health plan burseme medical-legal As prev 4. line Contact: CMA ork man at (215)7 reimdocuaccess any anet.org/ces.

(Formerly ments for $2 per library con sement help Anthem ) ordered netw members To CMA n reimbu Cross200 page.l, regulatory, and .cm all) On-C interest, dating back helpbur to 7.

(DMHCBlue are free to reprocess provide line, (888) 401-5911 e2007. of the seve ts above the threshCMA reim nts : rsement its Car ://www to tact lega ume aud k th In this publica urce r to claims, http Con bac doc or mlane@cmanet.org nding wi HC l with men e reso tion, you will find referenc The order is based rest, dating based on 2008 DM Medical-lega d in CMA’s onlin urce-library. of claim pay inteon s pe es to “medical-legal” docum 2008 DMHC is issueCMA violations ents. The Californrary u- nia. audits foun can be foun cmanet.org/reso legain to pay Center for and Califor lth plans.

The order l doc thed seven ia Medical Association’s These audits n hea Econo largest Blue Cross Care1201 Lib ww. es e medicalthe plans se audits of mic seve health plans m al ://w found Servic Upda all The ired (CMA) the violatio at http Leg te nia. requ online ry, on An e ns has law s, alof two old ifor medical-legal J Street, #200,libra o Cross d Health allowed under Califor nia paymentstrat library containsMe Anthe twBlue dic ive fine in Cal can purc Sacramento, ll) Califorclaim over s demonstrat the threshnia law at allerseven 4,500 pages of ge s pending with On-Ca members CA 95814 adminis abovedate economicservices@cm Updat te on m en e.

Non d that plan legal, regulatory, and erly Manaissue As a result, DMHC l- references to the Departmen allowed und CMAmedica plans. assessed oldassessed anet.org$2 per pag 1 of 5 t ofHealt HChealth man reimbursement of Mana rm lt, DM rtm ged will find admini 2012 • Page owed and ments for • 916/551-2061 strative fines, Medical-legal (Fo a resu providers the money tion.California ion, youinforma h Care ed Health documentslicat the Depa they were required the plans to payCPR • May l they As are free ume were owed of Manag to nts. The In this pub and can be found andey the mon ic Services rs e medical-lega mandated that plans DMHC claims audit ms, with al” doc membe Department in CMA’s l-legonline providers demonstrate (CMeA) onlin of medicalfor Economento, CA 95814 resourc “medica library, http://www.cm ims audit , on Jan. 12, 2012 the to reprocess provider clai As previously reporte ociation’s es Assg/resou anet.or DMd,HConcla CMsA Center ss rted 0, Sacram • 916/551-2061 Cro rce-libra rmation. e Jan. r 4,500 pag Nonmembers canMedical repo #20 12, ry. info ly Blu CPR et, ove 2012 nt s • May 2012 • Page 1 ious the hem ment of Manag Care Depart purchasetain lth plan Ant burseme medical-legal As prev of 5 1201 J Stre rvices@cmanet.org bers(DMHC) ordered reimdocuments for $2 per library con ed Health n largest hea Anthem ) ordered to mem shCross to 7. page.l, regulatory, and interest, dating back (DMHCBlue reprocess provide of the seve ts above the thre nts are free economicse Car lega toe2007. back to 200 HC audritsclaims, l docume with men e resource The rest, dating based on 2008 DM order is based Medical-lega d in CMA’s onlin urce-library. of claim pay inteon 2008 DMHC is violations CMA Center for and u- nia. audits can be foun cmanet.org/reso legain to pay foun Califor lth plans.

The order l doc thed seven its of These audits n hea Econo aud largest ww. es e medicalthe plans mic Servic health plans found These ns at all seve nia.violatio 1201 J Street, #200,library, http://w s, required of claim old allowed under Califor ifor nia lawpaymen purchas onstrate ifor ive fine in Cal can Sacramento, ts above dem Cal trat s er bers the nia inis threshlaw CA plan 95814 at all seven healthssed mem adm economicservices@cm that e.

Non As a result, DMHC allowed und oldassessed anet.org$2 per pag 1 of 5 HC asse plans.d and mandated lt, DM admini 2012 • Page owe ments for • 916/551-2061 strative fines, a resu providers the money they were required the plans to payCPR • May they As were owed andey the mon ic Services14 mandated that plans providers demonstrate 958 for Econom

CMA Practice Resources (CPR)

THEY SUPPORT THE MAGAZINE !

is a free monthly e-mail NOW bulletin SUBSCRIBE

CMA Practice Resources (CPR)

is a free monthly e-mail frombulletin CMA’s Center for Economic

Sign up now for a free subscription to our e-mail bulletin at

from CMA’s Center forwww.cmanet.org/news/cpr EconomicThis bulletin is full of Services.

Services. This bulletintips is and full tools of to help physicians tips and tools to help and physicians their office staff improve

40 Spring/Summer 2016

efficiency and viability. and their office staffpractice improve

, CA CMA Center Sacramento 916/551-2061 et, #200, • 1201 J Stre rvices@cmanet.org economicse

CPR • May 2012 •

Page 1 of 5

practice efficiency and viability.

Marin Medicine

CMA Practice Resources (CPR)

SUBSCRIBE NOW

Thank you physicians and medical staff.

Caring for our community in a way that has brought Sutter Novato Community Hospital great achievements.

novatocommunity.org

UNCOMPROMISING

IN CALIFORNIA, WE PROTECT OUR MEMBERS WITH THE BEST OF BOTH WORLDS: NATIONAL RESOURCES AND LOCAL CLOUT

As the nation’s largest physician-owned medical malpractice insurer, with 78,000 members, we constantly monitor emerging trends and quickly respond with innovative solutions. And our long-standing relationships with the state’s leading attorneys and expert witnesses provide unsurpassed protection to our over 20,000 California members. When these members face claims, they get unmatched litigation training tailored to California’s legal environment, so they enter the courtroom ready to fight—and win.

Join your colleagues—become a member of The Doctors Company.

CALL OUR NAPA OFFICE AT 888.536.5346 OR VISIT WWW.THEDOCTORS.COM

PROTECTION