July / August 2008 | Volume 14: Number 4
EXPLORING THE COSTS OF GOING DIGITAL
..They seem happy now, but... can you identify the one who may sue you for: ...Wrongful termination? ...Discrimination? ...Sexual harassment by a fellow employee?
Is that in my job description? .How was I supposed to know I wasn’t supposed to say that?z
I should have had that job! If he doesn’t stop telling me those awful jokes... Neither can we. But let’s look at the facts*: 1. Six out of ten employers have faced employee lawsuits within the last five years.
2. 67% of all employment cases that litigate result in a judgment for the plaintiff. 3. The median compensatory award in EPLI cases is $218,000. 4. Defense of the average EPLI case through trial costs over $45,000. 5. The average amount paid for out-of-court settlement is $40,000. Through the Santa Clara County Medical Association endorsed Employment Practices Liability Program, members may not only receive important coverage for judgments and defense costs up to $1,000,000 but will also have access to risk management tools. Web-based training for you and your office managers is included as well as access to employment attorneys for advice on how to properly handle employment issues to mitigate potential future claims.
Contact Marsh at 800-842-3761 for information on the SCCMA endorsed special First-Time Buyers program. * Society for Human Resource Management – 2002
© 2008 Seabury & Smith Insurance Program Management • CA License #SL0633005
777 South Figueroa Street, Los Angeles, CA 90017 • 800-842-3761 • CMACounty.Insurance@marsh.com • www.MarshAffinity.com • 7/08 Marsh is part of the family of MMC companies, including Kroll, Guy Carpenter, Mercer, and the Oliver Wyman Group (including Lippincott and NERA Economic Consulting).
Santa Clara County Medical Association Bulletin
Table of Contents the Editor’s Desk 4 FromJoseph S. Andresen, MD
5 2008-2009 Election Results 6 Did You Know? POLST Form is Available the Costs of Going Digital 10 Exploring Chris Womack
Printed in U.S.A.
Clara Valley Medical Center–An Essential Community Asset at Risk 14 Santa Phuong H. Nguyen, MD in PQRI and Pay for Performance 16 Participating K. Gabrielle Gaspar, MD and Sherellen B. Gerhart, MD
18 Membership Benefits Leadership Academy—A Whirlwind Tour Through Whirlwind Times 24 CMA’s David Slater, MD 26 2008 Legislative Day in Sacramento 28 Alliance News Questions & Answers 30 Coding Sandie Becker, CMC and Green: Reducing Your Risk of Asthma and Cancer 32 Clean Cindy Russell, MD the Blanket 34 Under J. Kent Garman, MD
36 Classified Ads Officers
President Jerry A. Hanson, MD President-Elect Howard Sutkin, MD Past President Atul S. Sheth, MD VP-Community Health Cindy Russell, MD VP-External Affairs William Lewis, MD VP-Member Services James G. Hinsdale, MD VP-Professional Conduct Jim Crotty, MD Secretary Thomas M. Dailey, MD Treasurer Martin L. Fishman, MD
William C. Parrish, Jr.
House Officer Representative
Jacob Ballon, MD
AMA Trustees - SCCMA Donald J. Prolo, MD John D. Longwell, MD (Alternate)
SCCMA/CMA Delegation Chair
Tanya W. Spirtos, MD
CMA Trustees - SCCMA
Martin L. Fishman, MD (District VII) Susan R. Hansen, MD (Solo/Small Group Physician) James G. Hinsdale, MD (District VII) John D. Longwell, MD (Hospital Based Physician)
Joseph S. Andresen, MD
Managing Editor Pam Jensen
Opinions expressed by authors are their own, and not necessarily those of The Bulletin or the Santa Clara County Medical Association. Acceptance of advertising in The Bulletin in no way constitutes approval or endorsement by the Santa Clara County Medical Association of products or services advertised. Address all editorial communication, reprint requests, and advertising to: Pam Jensen, Managing Editor 700 Empey Way San Jose, CA 95128 408/998-8850, ext. 3012 Fax: 408/289-1064 email@example.com Copyright 2008 by the Santa Clara County Medical Association.
Community Hospital of Los Gatos:
Judith Dethlefs, MD El Camino Hospital:
Michael Curtis, MD Good Samaritan Hospital:
Eleanor Martinez, MD Kaiser Permanente Hospital:
Allison Schwanda, MD O’Connor Hospital:
Jay Raju, MD Regional Medical Center of San Jose:
Hossein Habibi, MD Saint Louise Regional Hospital:
Joseph Andresen, MD Stephen Jackson, MD George Lundberg, MD Atul Sheth, MD
John Saranto, MD Santa Teresa Community Hospital:
Efren Rosas, MD Stanford Univ. Medical Center:
Peter Cassini, MD Santa Clara Valley Med. Center:
Patrick Kearns, MD
JULY / AUGUST 2008
What can we do to improve medical care and services? A contingent of SCCMA members spent April 15 in Sacramento for the 2008 Legislative Day. This was a time to educate legislators on important issues.
the bulletin JULY / AUGUST 2008
Longer sunlit days have arrived. The garden sprouts new greenery every day and an array of colors paint flowering blossoms. The laughter of children and teens is now a familiar sound. Graduation gatherings occupy the threshold between youth and adulthood. This is a good time of our year’s continuous annual cycle, where rejuvenation, new challenges, and new possibilities await us. Amidst these celebrations and lazy days of summer, life’s uncertainty and fragility is ever present. Tim Russert, award winning NBC commentator, died unexpectedly of an acute MI at age 58. His internist, Dr. Michael Newman, presented the autopsy results to a shocked and grieving world of journalists, political figures, and millions of viewers. This occurred despite a recent physical exam, normal exercise treadmill test, conscientious medical treatment of hypertension and hyperlipidemia, including a weight reduction and exercise program. Mr. Russert was not a smoker and had no significant family history of heart disease. This tragic outcome has left millions of middleaged men, who have similar risk factors for heart disease, anxious that they may suffer the same fate, despite seeing their doctor regularly. There has been a heated debate in the media as to whether Mr. Russert’s death could have been prevented. “Could a Defibrillator Have Saved Tim Russert?,” by Tara Parker-Pope in the NY Times, cites out-ofhospital cardiac arrest survival at only 1% to 5%. With the prompt use of AEDs (Automatic External Defibrillator), the survival rate has been reported to be as high as 80%. However, there is a 10% drop in survival for every minute that use of an AED is delayed. Bill Haylen’s article in the American Chronicle entitled, “Western Medicine Fails Tim Russert,” gives a grim indictment of modern medicine’s shortcomings. Events like these remind us, that as physicians, we don’t have all the answers, nor can we always control the outcome of those whose lives to whom we are entrusted. “From a Prominent Death, Some Painful Truths,” Denise Grady’s NY Times second
opinion article confronts these uncertainties. “A doctor’s care is not a protective bubble, and cardiology is not the exact science that many people wish it to be.” And as Dr. Sidney Smith, past president of the American Heart Association states, “It’s the real dilemma we have in cardiology today… Is it possible to identify the group at higher shortterm risk?” The positive outcome of this discussion and debate is greater awareness of heart disease and risk factors among the public. Lifestyle and dietary changes can significantly reduce our patient’s cardiac risk, but often require strong motivation and guidance. We physicians need to be leaders of promoting education and new medical information as it becomes available. Ongoing learning, discussion, and dialog are part of this important responsibility. In this regard, you will find many interesting and timely articles in this issue of the SCCMA Bulletin. What can we do to improve medical care and services? A contingent of SCCMA members spent April 15 in Sacramento for the 2008 Legislative Day. This was a time to educate legislators on important issues. This included stopping the proposed 10% Medi-Cal cuts that would forfeit a half-a-billion federal dollars of matching funds. There would be fewer primary doctors able to care for patients, who would turn to the last safety net of our already overloaded emergency rooms. Read on to learn about the many other issues that were discussed. How about in our household? Dr. Cindy Russell enlightens us to the fact that baking soda and vinegar are tried, true, and healthy alternatives to the many household cleaners that intrude into our households. Did you know that those who used cleaning sprays at least once a week were 50% more likely to have an increase in asthma symptoms or use asthma medications? Do you want a glimpse into our future? A significant physician shortage, Wal-Mart health clinics, and inevitable white water rapids of change as medicine represents 17% of America’s GDP. Dr. David Slater will give you much more to contemplate in his CMA Leadership Academy report. How costly is it to go digital with electronic
Election Results Below are the Officers and Councilors for the upcoming fiscal year. The ballots of the recent SCCMA Officer and Councilor election were officially reviewed, validated, and counted by a committee of members chosen by the President. The official results of that election are displayed in bold.
OFFICERS AND COUNCILORS Past President President President-Elect Vice President for Community Health Vice President for External Affairs Vice President for Member Services Vice President for Professional Conduct Secretary Treasurer Councilor #1 (Regional) Councilor #2 (San Jose) Councilor #3 (O’Connor) Councilor #4 (VMC) Councilor #5 (Santa Teresa) Councilor #6 (Stanford) Councilor #7 (St. Louise) Councilor #8 (El Camino) Councilor #9 (Los Gatos) Councilor #10 (Good Sam) Councilor #11 (Santa Clara)
Atul Sheth Jerry Hanson Howard Sutkin Cindy Russell William Lewis James G. Hinsdale Jim Crotty Thomas Dailey Martin Fishman Hossein Habibi Closed Jay Raju Patrick Kearns Efren Rosas Peter Cassini John Saranto Michael Curtis Judith Dethlefs Eleanor Martinez Allison Schwanda
SCCMA/CMA DELEGATES AND ALTERNATES POS.
#1 #2 #3 #4 #5 #6 #7 #8 #9 #10 #11 #12 #13 #14 #15 #16 #17 #18 #19 #20 #21 #22 #23 #24 #25 #26
Martin Fenstersheib Joseph E. Mason Tatiana Spirtos Michael Hirschklau Jeffrey Coe Jeffrey Anderson W. James Silva Jane Chen Cindy L. Russell John Huang Arthur Basham Thomas Dailey Robert M. Gould Amara Balakrishnan Eleanor Martinez Shaku Nagpal Sandra Mangiapia David Campen Howard Sutkin Elliot Lepler Scott Benninghoven Thad Padua Kristina Hobson Rajan Bhandari Marshall Yacoe James Crotty
Judith Dethlefs Sian Lindsay Jerry Hanson Robert Norris Saul Eisenstat James Lilja Ed Liu Ted Chu Jennifer Maw Susan Wilturner Bien Nguyen Heather Linebarger Len Doberne Efren Rosas Peter Nose Dipali Apte Jay Raju Kirk Zimmer Seham El-Diwany Michael Curtis Andrea Rudominer Amir Hadid Ngai Nguyen An Pham Don Mordecai Seema Sidhu
From The Editor’s Desk, from page 4 medical record keeping and what are the benefits and drawbacks? Read on to find out the answers to these questions. What is the latest regarding physician quality reporting initiative? Did you know that many insurers have incentive programs that assign bonuses based on patient satisfaction surveys, laboratory values suggestive of effective disease management, and other proxy measures of clinician performance? For example, Hill Physicians Medical Group paid $32 million in performance compensation to participating physicians in 2006, up from $13.5 million in 2003. Similarly, Blue Cross of
California announced a distribution of $69 million in physician bonus incentives in August 2007. Drs. Gasper and Gerhart present some sobering and encouraging assessments of this trend. Who are your officers and councilors for 2008-2009? Dr. Phuong Nguyen gives us a Santa Clara County Medical Center update. Dr. Kent Garman shares his first-hand experience as a patient. Don’t miss the latest! Respectfully submitted, Joseph Andresen, MD | Editor
the bulletin JULY / AUGUST 2008
IN ASSOCIATION WITH THE DIABETES COALITION OF SANTA CLARA COUNTY
14TH ANNUAL DIABETES SYMPOSIUM FOR HEALTH PROFESSIONALS Biltmore Hotel & Suites • Santa Clara, CA
Saturday, November 8, 2008 • 8:00 AM to 4:00 PM Symposium Description
This one day symposium is designed for physicians, podiatrists, nurses, dietitians,pharmacists, and other health professionals to enhance the knowledge of the practitioner in the management of diabetes. Experts in the ﬁeld will cover the challenges of managing diabetes providing both practical and theoretical information related to diabetes. Although the ﬁnal agenda is pending, the presentation will cover cultural competency in diabetic care; diabetes and kidney disease; continuous glucose monitoring and artiﬁcial pancreas; obesity and diabetes; gestational diabetes/TIDM/pregnancy & celiac disease ; and more. Tuition just $50.
For more information and to register please visit: http://www.diabetessociety.org/Events/sympSC.html Los Angeles Symposium: November 1, 2008 Past Sponsors providing unrestricted educational grants to the Diabetes Society:
The California POLST Form Is Now Available Throughout the State The California Physician Orders for Life-Sustaining Treatment (POLST) form is a new tool that transforms patients’ wishes for medical treatment into medical orders. It is specifically designed to be available throughout the spectrum of long-term care that may be used when patients move between nursing homes, hospitals, and emergency rooms. The form is primarily intended for patients on downward disease trajectories that are expected to result in death. The POLST form is now available for use throughout the state.
JULY / AUGUST 2008
The one-page form is available in a convenient letter-sized format and can be downloaded from the California Coalition for Compassionate Care’s website at www.finalchoices.org. Although faxed and photocopies are acceptable and legal, in order to maintain continuity, it is recommended that the form be copied/ printed on 65# cover pulsar pink paper stock.
HIPAA PERMITS DISCLOSURE OF POLST TO OTHER HEALTH CARE PROFESSIONALS AS NECESSARY Last Name
for Life-Sustaining Treatment (POLST)
First Name/Middle Initial
First follow these orders, then contact physician. This is a Physician Order Sheet based on the person’s medical condition and wishes. Any section not completed implies full treatment for that section. Everyone shall be treated with dignity and respect.
Date of Birth
CARDIOPULMONARY RESUSCITATION (CPR):
Person has no pulse and is not breathing.
Attempt Resuscitation/CPR Do Not Attempt Resuscitation (DNR/no CPR) When not in cardiopulmonary arrest, follow orders in B, C and D. Person has pulse and/or is breathing.
Comfort Measures Only Use medication by any route, positioning, wound care and other measures to
relieve pain and suffering. Use oxygen, suction and manual treatment of airway obstruction as needed for comfort. Do not transfer to hospital for life-sustaining treatment. Transfer if comfort needs cannot be met in current location.
Limited Additional Interventions Includes care described above. Use medical treatment, IV fluids and cardiac monitor as indicated. Do not use intubation, advanced airway interventions, or mechanical ventilation. Transfer to hospital if indicated. Avoid intensive care.
Full Treatment Includes care described above. Use intubation, advanced airway interventions, mechanical ventilation, and cardioversion as indicated. Transfer to hospital if indicated. Includes intensive care.
ANTIBIOTICS No antibiotics. Use other measures to relieve symptoms.
ARTIFICIALLY ADMINISTERED NUTRITION: Always offer food by mouth if feasible.
No artificial nutrition by tube.
Determine use or limitation of antibiotics when infection occurs.
Defined trial period of artificial nutrition by tube.
Use antibiotics if life can be prolonged.
Long-term artificial nutrition by tube.
Additional Orders:_____________________ ____________________________________
SUMMARY OF MEDICAL CONDITION AND SIGNATURES Discussed with:
Summary of Medical Condition
Health Care Representative
Parent of Minor
Other: ________________________ Print Physician Name
MD/DO Phone Number
Physician Signature (mandatory)
Office Use Only
Signature of Patient, Parent of Minor, Guardian, or Surrogate By signing this form, the surrogate acknowledges that this request regarding resuscitative measures is consistent with the known desires of, and with the best interest of, the individual who is the subject of the form. Signature (required)
Relationship (write “self” if patient)
SEND FORM WITH PERSON WHENEVER TRANSFERRED OR DISCHARGED © California Coalition for Compassionate Care – www.finalchoices.org
HIPAA PERMITS DISCLOSURE OF POLST TO OTHER HEALTH CARE PROFESSIONALS AS NECESSARY
Patient Name (last, first, middle initial)
Date of Birth
Contact Information Surrogate (optional)
Health Care Professional Preparing Form (optional)
Directions for Health Care Professional Completing POLST Must be completed by health care professional based on patient preferences and medical indications. POLST must be signed by a physician and the patient/surrogate to be valid. Verbal orders are acceptable with follow-up signature by physician in accordance with facility/community policy. Use of original form is strongly encouraged. Photocopies and FAXes of signed POLST forms are legal and valid. Using POLST Any incomplete section of POLST implies full treatment for that section. No defibrillator (including AEDs) should be used on a person who has chosen “Do Not Attempt Resuscitation.” Oral fluids and nutrition must always be offered if medically feasible. When comfort cannot be achieved in the current setting, the person, including someone with “Comfort Measures Only,” should be transferred to a setting able to provide comfort (e.g., treatment of a hip fracture). IV medication to enhance comfort may be appropriate for a person who has chosen “Comfort Measures Only.” Treatment of dehydration is a measure which prolongs life. A person who desires IV fluids should indicate “Limited Interventions” or “Full Treatment.” A person with capacity, or the surrogate of a person without capacity, can request alternative treatment. Reviewing POLST This POLST should be reviewed periodically and if: (1) The person is transferred from one care setting or care level to another, or (2) There is a substantial change in the person’s health status, or (3) The person’s treatment preferences change. Draw line through sections A through E and write “VOID” in large letters if POLST is replaced or becomes invalid.
California Coalition for Compassionate Care
The California Coalition for Compassionate Care is the statewide leader for implementation of POLST in California. California health care professionals interested in using POLST are strongly encouraged to use this form. As data becomes available, the California Coalition for Compassionate Care will lead the process of further revisions to the California form. For more information on POLST in California, visit <www.finalchoices.org>.
SEND FORM WITH PERSON WHENEVER TRANSFERRED OR DISCHARGED May 16, 2008
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Exploring the Costs of Going Digital
Exploring the Costs of Going Digital By Chris Womack There are options for defraying the cost of installing an electronic medical record system in your practice, but you’ve got to know where to look.
organization—or QIO—for California. Asked what doctors can do to save money on or subsidize an EMR, Clarke and other sources tick off a surprisingly short list of options, three of which we delve into here. But for those physicians with the time and inclination to take advantage, they might well be worth the effort. One option is the recent relaxation of regulations resulting from a 1972 anti-kickback
I would never go backwards,” says Valencia ophthalmologist Craig
law and 1993 legislation by California Rep. Pete Stark. Another
Helm, MD. “Having gone through the transition, I am sold on the
option, alternative pricing schemes, results from technological and
benefits of electronic medical records.” As with every story of a
organizational innovation among vendors. And then there is the
doctor’s office converting over to EMR from paper records, Dr.
mixed bag of quality reporting initiatives, which although capable of
Helm’s experience involved a great deal of pre-purchase study. Then
encouraging EMR adoption, is not entirely beloved by doctors.
followed the headaches of installation, implementation, and training. But in the end, his office wound up with a system that works well.
The Costs of EMRs
“It was difficult, and I would say it slowed us down at first. We lost
The typical cost to implement an EMR system for a small office is
efficiency initially, but by three months afterwards, we were running
around $10,000 to $40,000 for software and basic equipment, but
smoothly,” Dr. Helm says. “We have been using more and more of
those figures fluctuate wildly depending on several factors. “I think
the features of the software as time has gone on … for instance,
initially our outlay was about $45,000, but when we expanded to a
there’s internal messaging within the system, which I find to be very
new office, the licensing was an additional $20,000 to $25,000,” Dr.
beneficial—we don’t have stickies all over my office door or my desk
Helm says about his practice’s expansion from about 8 terminals to
anymore. It’s been great.”
So what took Dr. Helm so long to implement an EMR? After all,
“We have eight doctors—in a year’s time, we probably budgeted
electronic medical records systems are not exactly new. The answer
$100,000 for this, and the software was about $10,000 or $12,000,”
is simple: “I would say cost,” Dr. Helm responds. As every doctor
says Chester Griffiths, MD, a Los Angeles-based otolaryngologist. And
knows, adopting an EMR is an enormous undertaking. Finding
like mushrooms after the rain, the sudden nonsoftware costs spring
any mechanism to help defray the upfront cost would go a long
from a large number of sources. “You have to have your printers,
way toward encouraging more offices to take the step into digital
your scanners, your computers … the actual software itself is like an
medicine. But help is hard to find.
afterthought. Then you need IT support for all of that—you need to have a technician who’s available 24 hours a day, because if you go
“That’s a question that we get a lot from the physician offices we
down, you don’t have a medical record,” he says. “You need to have
work with that have not yet adopted a system,” says Jennifer Clarke,
everything backed up [with] fairly immediate-access recovery systems
a health care information technology consultant with Lumetra, a San
to get yourself back online. If you don’t have that, you lose a whole
Francisco-based health care consultancy and quality improvement
day of patients and you’re [in trouble],” he adds.
JULY / AUGUST 2008
Exploring the Costs of Going Digital
EMR by the Numbers
Dr. Griffiths also mentions the significant
direct cost of training staff how to use a
Perhaps the most popular EMR money-saving
new EMR system, as well as the cost of lost
option among people knowledgeable in
productivity due to time the practice takes out
EMR policy and health care IT is a recent
of the workday for training. Simply weighing
change in the regulations that descended from
the EMR options can take a real toll. “It’s like
the Anti-Kickback Statute and Pete Stark’s
going to buy a car and having four wives with
Physician Referral law. The 2006 regulatory
you trying to decide which one would be
re-working by the U.S. Department of Health
about 33% of physicians say
the right one to get,” says Erik Zeegen, MD,
and Human Services’ Centers for Medicare and
they will adopt or upgrade an
an orthopedic surgeon based in a seven-
Medicaid Services and Office of the Inspector
EMR system within the next 12
physician practice in Los Angeles. Since
General allowed hospitals and certain other
the market doesn’t offer any EMR systems
organizations to provide EMR systems to
specialized for orthopedic surgery, Zeegen
physicians, with subsidies limited to 85% of
hospitals through Stark relaxation,
and his team worked hard to create templates
software and implementation costs. Physicians
57% of doctors say they are
that were geared toward their day-to-day
must pick up the tab for hardware costs, but
likely to adopt or upgrade an
work. “The other issue is, at the beginning,
prior to Stark relaxation, as it’s called, hospital
EMR system within the next 12
it totally changes the workflow,” continues
support for physicians’ EMR systems was quite
Dr. Zeegen. “I was used to seeing a patient,
physician offices and 20% to 25% of U.S. hospitals had EMR systems in place.* •
walking out of the room, picking up my
In 2005, between 15% to 20% of
Even without financial support,
With financial support from
Should a hospital donate an EMR system, 56% of physicians say they
Dictaphone and dictating a quick little note,
“That’s probably the most important way of
then moving on to the next patient. For the
defraying the costs available to physicians,”
first three months, there was a lot of sitting in
says Debra Stottlemeyer, MD, an assistant
front of the computer and trying to figure out
professor, internal medicine specialist,
what I have to click next, how I can get this
and health care IT expert at Loma Linda
screen to pop up, how I incorporate this into
University. “So, the practice plans don’t have
to cough up the [whole] software cost of
physicians in favor of installing an
getting onto the enterprise’s electronic medical
EMR system are: improved patient
But if your practice manages to make it
records,” she says. “That’s a huge win for
documentation; workflow benefits;
through to the other end, there are eventual
physicians across the nation—hospitals and
and remote access to patient
savings to be had, both in direct dollars and
the medical staff of hospitals can direct the
efficiency. In addition to eliminating the
development of a hospital medical record
cost of transcription, “once you get [menu
[system] that physicians can join in on.”
are reluctant to share financial data with the hospital, while 27% say they are reluctant to share clinical data. •
The three top reasons cited by
The top four most commonly cited barriers to EMR implementation
navigation] down, it becomes a little smoother.
are: lack of adequate funding or
There are certain situations where it’s actually
But obviously hospitals don’t have unlimited
resources; difficulties changing to
faster than the old way,” says Dr. Zeegen. “You
money to burn. “There has to be a business
an EMR system; difficulty creating
invest in it the first year, you break even the
case,” says Mark Dente, MD, vice president
a migration plan from paper to
second year, and then you make some money
of health care solutions at GE Healthcare. “I
electronic documentation and
or cost-save in the third year,” Dr. Griffiths
speak to some of these facilities, and I’d love
recordkeeping; inability to find an
says, describing the approach his practice has
to say that everyone recognizes the value
EMR solution or components at an
taken. While scanning soon-to-be-obsolete
to the patient for utilizing this technology,”
paper records into an EMR can be expensive,
he says, noting EMR advantages, such as
and using the two systems at the same time
reduced paper use and reduced medical
harms efficiency, there are eventual savings
errors. “Unfortunately, it hasn’t been the boon
that can balance out the costs, he says. For
that everyone thought it was going to be,” Dr.
example, space formerly devoted to paper
Dente adds. “If you’re running on a 2% margin
records can become productive clinic or office
in the hospital, just because the government
space. An EMR allows many doctors to stop
says you can do it, doesn’t mean you have the
retaining a medical record specialist. “I think
money to do it.”
it’s probably a break-even at the end of the day,” Dr. Griffiths concludes.
Sources: *“The State and Pattern
of Health Information Technology Adoption,” RAND 2005. +“Stark Physician Attitude Study,” GE Healthcare, 2007. ++“Ninth Annual Survey of Electronic Medical Records Trends and Usage,” Medical Records Institute, 2007
JULY / AUGUST 2008
Exploring the Costs of Going Digital
The eMeds Bill
For physicians hoping to take advantage of Stark
practices may find a never-ending, but consistent
The eMeds bill aims to
relaxation, Dr. Dente’s advice is to work together.
ongoing cost more attractive. “We work with Misys
improve physician adoption
If individual physicians approach a hospital
[Healthcare Systems],” says David Merritt, project
of electronic prescribing by
and ask about how they can get help buying an
director for the Center for Health Transformation,
providing an incentive of
EMR system, hospitals are likely to turn them
a Washington, D.C. think tank closely associated
about $2,000 and a 1% per-
down, he says. “However, if 20 physicians, or the
with several health care technology vendors and
prescription bonus payment
local medical society, or even some of the large
other interested parties. “They’re rolling out a new
to physicians using it regularly
employers got together and said, ‘What’s going
product that is basically just a hosted [EMR] with
by 2009. For the next two
on, you guys are here to serve the community—
minimal stuff on-site—most of the storage, most of
years, the incentive decreases.
what’re you doing?’” then hospitals will have to
the data systems and servers are offsite—and that’s
Physicians not using electronic
going to run $500 a month per physician,” he says. “So, for $5,000 or $6,000 a year [per physician],
prescribing in 2011 begin to incur a small per-prescription
Alternative Pricing Models
The typical EMR system is purchased with a big
you’re talking about having a world-class system.”
upfront payment for software licenses, hardware,
GE Healthcare has been offering its application
“If any health IT legislation
and other necessary items and services. Smaller
service provider model for longer than a year, and
moves this year, which is
ongoing charges for things like IT support, data
Dr. Dente holds the company out as something
unlikely, this is the one
backup, and hardware repair and replacement
of a trailblazer—but not a pioneer. Clarke cites
with the greatest likelihood
follow. As with any other large purchase, EMR
the smaller companies as having begun the trend
of moving,” says Christine
system buyers can put some money down, borrow
more than two years ago, with more-established
Bechtel, vice president of
more, and pay back finance charges over time.
players giving weight to the efforts by joining recently.
public policy and government relations at the e-Health
But fairly recent technology and business
Initiative, a group of non-
developments can change an EMR system into
profit organizations working
more of a utility, with services purchased as part
The link between financing an EMR system
to improve quality, safety,
of a monthly bill. Under an application service
and quality reporting initiatives is not perfectly
and efficiency of health
provider model, “It’s a monthly fee now. There
straightforward, and clearly these programs exist
care IT. But there’s an even
are some training costs that are independent of
mostly to gather data, rather than encourage
better reason for doctors to
that, and maybe one or two interfaces, in case
adoption. But most of the small-office doctors
watch this one. “The CBO
you want to connect up a couple of laboratory
enrolled in Lumetra’s Medicare Care Management
is extremely likely to score
systems, so the lab results just flow in,” explains
Performance demonstration pilot program, which
it into savings,” because of
GE Healthcare’s Dr. Dente. “But overall, it’s like
offers additional reimbursement money for
the disincentive provision,
your telephone bill—it’s just the monthly costs
reporting details of their medical care, say that
says Bechtel. “That sets up
associated with [your EMR].”
they plan to reinvest that money into health care IT of some sort, says Clarke. “They definitely plan
a situation where, when you look at the [Medicare
“It’s a trend,” says Lumetra’s Jennifer Clarke. “I
to use the funds to invest in an EMR, or to invest
strategic growth rate] fix that
think part of it is a shift from traditional client-
in reporting modules in cases where they already
is going to expire in July, they
server software to web-based software and more
have an EMR, or to purchase other devices for
need to again find a way to
flexible tools,” she says. “We’re seeing more and
their office. There definitely seems to be a close
fix it. Congress never gives
more EMR vendors enter that space, and those
relationship in the minds of the physicians who
the doctors something for
services are largely subscription based. Initially,
signed up for the program.”
there’s less up front cost, but then you pay a monthly fee for this company to maintain your
Moreover, the program gives a 25% bonus to
data and push out upgrades.”
doctors who report data using an EMR system that is certified by the Certification Commission
Such a pricing trend might not be attractive to
for Healthcare Information Technology, a public-
larger practices, which may have their own IT
private effort to make EMR systems compatible
departments and the resources to obtain most of
by establishing basic standards. Unfortunately,
the other necessary EMR components up front,
MCMP’s enrollment is closed.
leaving relatively small ongoing costs. But small
JULY / AUGUST 2008
Exploring the Costs of Going Digital Lumetra’s Doctors’ Office Quality-Information
behavior toward automating as much of this as
Technology pilot, which has now gone
we possibly can,” she says.
national, set up 265 California physician offices with health care IT consultants to help them
In a clear case of cost versus benefit, Dr.
establish electronic systems—including EMR
Stottlemyer and colleagues have decided not to
systems—or tailor their existing systems to
take part in a pay-for-performance plan until
the practice’s needs. Enrollment to DOQ-IT is
they have an EMR system up and running in
also closed, although Lumetra will publicize
all their clinics. “It costs you as much or more
upcoming programs on its website on August
to generate the report than you get back in
1 at www.lumetra.com/doq-it. Since it hosted
returns,” she explains, citing a case study in
the similar MCMP pilot, California will be
which a large medical group made $530,000
left off the list of states that can participate
in additional reimbursement, but incurred
in Medicare’s Electronic Health Record
$600,000 in costs related to quality reporting
Demonstration Project. “The Secretary expects
to announce the 12 communities that will be selected as the pilot sites this month,” says
Another complication of quality reporting is
Brynn Barnett, a spokesperson for the U.S.
related to its main purpose—not EMR adoption,
Department of Health and Human Services.
but data gathering and sifting. Dr. Griffiths, the
The project aims to choose 1,200 physician
Los Angeles-based otolaryngologist, harbors a
practices, with each physician eligible for
skeptical view of the initiatives that’s not too
incentives of as much as $58,000—or $290,000
hard to pry from many physicians. “If medicine
per practice—over five years.
were a cookbook, everybody would be doing it—there are so many variables, and I think
There are also a variety of private quality-
the biggest variable is patient compliance,”
reporting initiatives, such as those administered
he says. “When they can tell me that when
by health plans taking part in the Integrated
I tell a patient to do something, 100% of the
Healthcare Association’s pay for performance
time, they’ll do it—OK, measure me. But until
program, which includes Aetna, Blue Cross,
someone can tell me that my patients will be
Blue Shield, CIGNA, Health Net, PacifiCare,
100% compliant with my recommendations,
Western Health Advantage, and Kaiser
pay-for-performance to me is a sham.”
Permanente. Each plan determines its own budget and methodology for calculating bonus payments to the medical groups, but uses the common IHA set of performance metrics, the association says. According to a public statement, physician groups participating in the program increased their use of information technology between 2005 and 2006, the most recent years for which data is available. But there is still a complicated relationship between EMR adoption and quality reporting. “You can’t really do good P4P without a good electronic medical record. It’s just too time-consuming,” says Loma Linda’s Dr. Stottlemyer. “To the degree that [physician offices participating in pay-for-performance] found out how much sheer, stupid clerical work it is to generate the P4P information without a computer to help, it would certainly drive
Reprinted with permission of the Southern California Physician (www.socalphys.com)
CCHIT, EMR, and the Tower of Babel Part of the reason most doctors and hospitals have failed to adopt electronic medical records systems is that no one is sure whether today’s software and communications bundles will fit into tomorrow’s world. And of course, no one wants to get left holding the bag. So, in 2005, the U.S. Department of Health and Human Services bestowed $2.7 million in grants upon three industry groups, with the mandate that they establish standards that EMR systems and their communications should meet. The Certification Commission for Health Information Technology, as it’s now known, continually updates the standards that EMRs must meet to receive certification. For example, in 2006, the body required ambulatory EHR to meet 151 requirements, and it added 96 criteria in 2007. These criteria include features such as electronic prescribing, security features, and interoperability with laboratory data systems. “At some point, the discussion of regional or national health banks will come into play,” says Dr. Debra Stottlemyer, an assistant professor at Loma Linda University. “Down the road farther, certain insurance companies are going to direct their patients to doctors who have an EMR that will talk to their regional health bank,” she says. While jumping into the market is a matter of “when,” not “if,” she adds, “There hasn’t been a consolidation of the vendors and the best-practice kind of tools—we’re in the process of that, so if I were still in an office, I would stay on paper a little bit longer.”
JULY / AUGUST 2008
Our public health care system, like other public systems in California, has had to deal with reduced budgets while the demand for services just continues to grow.
Santa Clara Valley Medical Center
An Essential Community Asset at Risk
By Phuong H. Nguyen, MD, MMM Past SCCMA Councilor Santa Clara Valley Medical Center (SCVMC) is the cornerstone of Santa Clara County’s health care delivery system, serving as this community’s safety net hospital and providing some of the region’s most specialized services.
five births in Santa Clara County! •
The state-of-the-art Level III Neonatal Intensive Care Unit took care of over 600 babies this past year.
It is Santa Clara County’s busiest emergency department.
Did you know that SCVMC plays a central role in the education and training of the next generation
As our public hospital, SCVMC provides medical
of Santa Clara County’s health care professionals?
care to Santa Clara County residents who don’t
Nearly 1,000 nurses train at SCVMC annually.
have health insurance. When people in our
In addition to its accredited residency training
community have limited options in getting health
programs in medicine, Ob-Gyn and radiology,
care services, SCVMC is here to provide quality and
SCVMC serves as a teaching hospital for Stanford,
UCSF, and other medical school residents. At last count, one in four physicians in Santa Clara County
In addition to essential services, Santa Clara Valley
received some training at the medical center.
Medical Center (SCVMC) provides some of the
Important allied health professionals, such as
most specialized treatment and care to Santa Clara
physician assistants, pharmacists, and Emergency
County residents. With a Neonatal Intensive Care
Medical Services (EMS) staff, also rotate through
Unit, Regional Burn Center, Rehabilitation Center for
spinal cord and traumatic brain injuries, as well as a top rated emergency department and trauma center,
Our public health care system, like other public
SCVMC provides critical care when people need it
systems in California, has had to deal with reduced
budgets while the demand for services just continues to grow. In the last seven years, the health
As you may know, SCVMC is the busiest and biggest
and hospital system dealt with budget reductions
hospital in our county. One of four county residents
to the tune of $675 million. Our public health
went to this hospital or one of its clinics over a
care system responded by cutting expenses and
four-year period. Here are some other points to
generating new revenues. Throughout, their priority
has been to ensure the quality of patient and client services.
• • •
JULY / AUGUST 2008
Every year, SCVMC provides 700,000 adult and 143,000 children outpatient visits.
And just when you think things can’t get much
The Trauma Center treats some of the most life-
worse, they do. The older hospital buildings – a
threatening and catastrophic injuries every day.
total of 250 beds – will soon be out of seismic
The pediatric trauma center is one of only two
compliance. Because of California state law, these
in the entire county.
structures have to be seismically safe and rebuilt
The burn trauma center is one of only two
by 2013. The price tag is a staggering $1.4 billion,
north of Los Angeles and treated over 250
money Santa Clara County does not have. At 1.3
patients this past year.
hospital beds for every 1,000 people, Silicon Valley
The nationally recognized 76-bed Rehabilitation
has one of the lowest bed ratios in the state. We
Center treats some of the most complicated and
cannot afford to lose these beds.
serious cases. •
The hospital is the eighth busiest birthing
On June 12, the Santa Clara County Board of
center in California and expects to deliver over
Supervisors voted to place a 30-year $840
6,000 babies in 2008. That is almost one out of
million general obligation bond measure
What You Should Expect from a Collection Agency:
OUR RECOVERY RATE IS MORE THAN TWICE THE NATIONAL AVERAGE
The Bureau of Medical Economics (BME) specializes in health care and is skilled in the delicate art of preserving the level of confidentiality expected in the medical field and in exhibiting caution so as to not damage doctor/patient relations. Does your collection agency...
• Provide you with an early out program with a discounted rate for early payments? • Offer extensive skip tracing on your accounts? • Collect more than twice the national average and return more than double the amount other physicians receive?
If you have never tried the BME, it’s time that you should. We are the only collection agency endorsed by the Santa Clara County Medical Association and have been for more than fifty years.
Bureau of Medical Economics
700 Empey Way, San Jose, CA 95128 | 408 998-5811 | Fax: 408 998-5850 | e-mail: firstname.lastname@example.org
Santa Clara Valley Medical Center, from page 14
directory updates Rashid Elahi, MD
on the November ballot. If passed by a
two-thirds majority, the money will be
Dow Medical College 1986
used to fund a major phase of SCVMC’s
175 North Jackson Ave Ste 103 San Jose 95116 408-937-9009
seismic safety project and assist in replacing
downtown San Jose medical clinics. SCVMC is our community’s safety net
Stanley A Shatsky, MD
hospital and an integral partner in the providing of health care services to our patients and our community. The loss of SCVMC beds and services will impact every other hospital in Santa Clara County. Every medical professional will feel the impact, if the unimaginable were to occur. Let’s not let this happen. Join me in protecting this vital health care resource and support the bond measure.
2008 Membership Directory Updates Please cut and paste over the existing listing, or insert on the appropriate page, these physician listing changes in your 2008 SCCMA Membership Directory.
New York Univ School of Medicine 1969
123 Di Salvo Ave Ste E San Jose 95128 408-297-1191
Fax: 408-292-9910 email@example.com
Donald C Silcox, MD *RHU Wake Forest University 1962
700 W Parr Ave Ste A Los Gatos 95032 408-866-1135
JULY / AUGUST 2008
CMS has been unapologetically increasing its efforts to identify and reward quality medical care. Inherent in its shift toward VBP is using tools and programs for promoting better quality while avoiding unnecessary costs.
Participating in PQRI and Pay for Performance By K. Gabrielle Gaspar, MD, and Sherellen B. Gerhart, MD
included 74 quality measures. HealthCare Consulting, is board certified in family
For the second reporting period, providers may
medicine. Dr. Gerhart, a practicing physician
select from 119 quality measures addressing
board certified in internal medicine, geriatrics,
the management of acute and chronic illness,
and palliative care, is a co-founder and president
preventative care, resource utilization, and use of
of Gage HealthCare Consulting.
information technology. The program is provider-
The Physician Quality Reporting Initiative (PQRI) began its second reporting period on January 1, 2008. This program from the Centers for Medicare & Medicaid Services (CMS) represents the agency’s transition into pay for performance (P4P) and physician profiling. Launched in July of 2007, the initiative has drawn providers are unaware of the program’s intent or design. While poor visibility has likely contributed to low participation, there are other factors to consider. Many physicians are unfamiliar with the concepts of quality reporting and performance-based incentives — and the concepts themselves are rapidly evolving. Of providers aware of these trends, some hesitate to participate due to philosophical or logistical concerns. We acknowledge arguments for and against the growing trend in performance-based incentive programs, and we encourage physicians to become informed and take part in the debate. Whether or not they participate in this round of PQRI or
JULY / AUGUST 2008
period was July through December 2007 and
Dr. Gaspar, a founding partner and CEO of Gage
relatively little physician attention. Many health care
Care Act of 2006 (TRHCA).1 The initial reporting
in similar programs, physicians need to be active stakeholders in efforts for increased quality and transparency in health care.
Medicare’s Transition Into P4P PQRI is a voluntary program that allows physicians and other individual providers to submit data on specified quality measures for eligible patients. This initiative was mandated by the Tax Relief and Health
driven, evidence-based, and designed to capture data at the claims level. PQRI focuses on reporting measures, rather than achieving clinical outcomes, and is linked to a bonus payment for meeting reporting requirements. PQRI is part of Medicare’s transition into the P4P arena. The federal government and CMS have been moving toward a value-based purchasing (VBP) model of health care, since 2001. This model attempts to measure and reward value. (Similar trends can be seen in private industry, where costcontainment is arguably as much a motivation as is improved patient care.) CMS identifies improving quality and avoiding unnecessary cost in health care delivery as primary goals of value-based purchasing.2 Medicare’s shift toward value-based purchasing is evident in several earlier CMS quality initiatives, including the Nursing Home Quality Initiative (in 2002), the Quality Initiative (2004), and the End Stage Renal Disease Quality Project (2005).3
PQRI and Individual Physicians PQRI stands apart from these initiatives in that it focuses on data capture at the individual clinician level. Any physician or other eligible provider with a National Provider Identifier (NPI) may participate. From the outset, the program raises concerns regarding physician profiling, difficulty, acuity adjustments, and whether quality measures can ever be translated into meaningful information about patient care. There are worries about a lack of transparency in the development of program specifics, the
challenges of obtaining program information in a timely manner, and
patient satisfaction surveys, laboratory values suggestive of effective
the impression that providers are required to do more work while
disease management, and other proxy measures of clinician
being subjected to diminishing reimbursements.
Nonetheless, PQRI should not be dismissed. It can be argued that
For example, Hill Physicians Medical Group paid $32 million in
PQRI is, in terms of U.S. health care policy, a unique opportunity
performance compensation to participating physicians in 2006,
for providers to participate in reshaping the delivery and funding
up from $13.5 million in 2003.4 Similarly, Blue Cross of California
of medical care. It may be viewed as fair or unfair, elegant or
announced a distribution of $69 million in physician bonus incentives
burdensome, quality-driven or cost-motivated, temporary or
in August 2007.
permanent. However, PQRI allows participating providers to weigh in on the important issues of medical reimbursement, best practices,
Despite the increasing availability of performance and quality-related
cost, outcomes measurement, and resource use. Clinicians can
data, there is little to ensure the accuracy or proper use of such
contribute in this giant experiment in national health care data
information. There are controversies surrounding the use of physician
performance data, including lawsuits against third party payers.
They do so by choosing measures which are relevant to their
A notable example is the suit filed in November 2006 by physicians
practices and patients, giving a good faith effort to report on those
and the Washington State Medical Association against Regence
measures, providing feedback to CMS and related parties on the
BlueShield. The plan was accused of unfairly dropping over 500
design and relevance of the measures, and publicly commenting
providers from its preferred network in that state due to poor ratings
on the value of the provider feedback reports and bonus awards.
in the “quality and efficiency of their practices.”6 This policy allegedly
The development of a meaningful quality measurement system will
affected over 8,000 patients and their physicians. The American
require committed efforts from all stakeholders in health care, and it
Medical Association joined the case, and when Regence discontinued
is extremely important that health care providers be involved.
its use of a Select Network the following month, it was noted to be “a good first step toward eliminating arbitrary measures that do not
accurately reflect physician quality.”
CMS has been unapologetically increasing its efforts to identify and reward quality medical care. Inherent in its shift toward VBP is using
Fortunately, the need for standardized measurement of provider
tools and programs for promoting better quality while avoiding
performance is gaining recognition. While the debate on these issues
unnecessary costs. The agency notes that these include “explicit
will likely continue, we can expect to see more physician rating
payment incentives to achieve identified quality and efficiency goals,
systems made public without guarantee that they will be fair or
such as pay for reporting, pay for performance, gain-sharing, and
competitive bidding.” The programs mentioned earlier illustrate this effort.
While the landscape still offers relatively more ranking systems for hospitals and organizations (such as hospitalcompare.org, or
PQRI is the first large scale CMS provider program. Participation
healthgrades.com), individual physician profiling is clearly a growing
involves reporting on selected measures using codes that indicate
phenomenon. Physician profiles are only useful if they are reliable
performance of certain clinical tasks or administration of therapies
and accurate, yet there is little research which demonstrates that
premised on evidence-based medicine. Included are mechanisms for
existing programs are either.
clinicians to report without penalty when a clinical action has not been completed or documented.
This is largely due to a lack of standardization in quality data measurements. Few studies have been done which have the
With regard to the bonus, providers are measured on their level
necessary adjustments for risk and large enough numbers of
of reporting rather than directly on patient care, even though data
participating providers to produce useful data. The literature has
on the latter is being captured. Presumably, this design allows for
yet to show that outcomes for patients can be consistently linked to
program revisions before actually attempting to measure and reward
measurements of physician actions in the clinical setting.
“performance” or “quality.” In this way, PQRI is more accurately a “pay-for-reporting” than a pay-for-performance program.
Clearly, for health care incentive programs, including PQRI, the value of data depends ultimately on their translation into meaningful
While P4P programs in the public sector have focused on the hospital
changes in practice. Inherent in this process is the capture of
or organization level and are recently shifting to the individual
appropriate data and accurate interpretation, followed by the
provider, private industry has been using them for decades. Many
development and implementation of viable policies.
insurers have incentive programs that assign bonuses based on
Continues on page 28
JULY / AUGUST 2008
Tropical Costa Rica
March 25 - April 2, 2009
9 Days ● 17 Meals: 8 Breakfasts ● 2 Lunches ● 7 Dinners with optional Jungle Adventure Post Tour Extension
Highlights...San Jose ● Poas Volcano ● Cano Negro Refuge ● Arenal Volcano Hot Springs Monteverde Cloud Forest ● Guanacaste
Per Person Rates: Double $2,289; Single $2,809; Triple $2,229 Included in Price: Round Trip Air from San Francisco Intl Airport, Air Taxes and Fees/Surcharges of $380 (subject to increase until paid in full), Hotel Transfers
Not included in price:
Cancellation Waiver and Insurance of $150 per person
COLLETTE EXPERIENCES Learn about Costa Rica’s unique vegetation on a guided nature walk through the cloud forest. Spot indigenous wildlife on a river boat cruise in a covered canoe. Participate in a local reforestation effort by planting a tree in the cloud forest! Day 1: Wednesday, March 25, 2009 Arrive San Jose, Costa Rica Lush forests and stunning waterfalls…rumbling volcanoes and endless coastlines…Costa Rica is truly a slice of paradise. Your tour begins in the colorful capital city of San Jose. Upon arrival, relax and soak up the sights of your new surroundings. Day 2: Thursday, March 26, 2009 San Jose - Poas Volcano - La Fortuna (Arenal Volcano) This morning leave behind the hustle and bustle of the city and travel through the verdant countryside of the Central Valley. Travel past tropical landscapes and the ancient Poas Volcano, said to be the widest crater in the world. Later in the day you arrive in the charming town of La Fortuna. Here you will enjoy a two night stay at a typical lodge with breathtaking views of the majestic Arenal Volcano, which has been generating constant lava for the last 30 years. Today breakfast and dinner will be included. Day 3: Friday, March 27, 2009 La Fortuna (Arenal Volcano) - Cano Negro - La Fortuna (Arenal Volcano) Of all Costa Rica’s nature preserves, the remote 20,000-acres of Cano Negro are home to the largest viewable selection of indigenous wildlife. During your visit, embark on a guided river boat trip in a panga (covered canoe), making frequent stops to watch and photograph the wildlife around you. Crocodiles, river otters, sloths, river turtles, exotic birds and rare butterflies are all known to live in the area. After your adventure through the preserve, relax at a family-owned hot springs oasis in the geothermal region that surrounds the Arenal Volcano. Stroll through the beautiful grounds, soak in the soothing mineral waters, or take advantage of the first-class spa services. Today breakfast and dinner will be included. Day 4: Saturday, March 28, 2009 La Fortuna - Monteverde You won’t believe your eyes as you travel into the Monteverde Cloud Forest, where trees grow to heights of 100 feet! In this spectacular ecosystem, you will encounter many incredible species of flora and fauna. Then you continue on to Selvatura Park*, a cloud forest preserve
in the heart of Monteverde. Your visit includes an exciting opportunity to fly through the cloud forest on a zip line canopy tour or to take a guided walk among the treetops on a series of hanging bridges! After your activity of choice, participate in a reforestation effort by planting a tree in this spectacular nature preserve. Finally, you will learn about some of the region's most beautiful wildlife with a visit to one of the world’s largest butterfly gardens. You’ll also see the hummingbird gallery containing more than 14 different species! Today breakfast and dinner will be included. Day 5: Sunday, March 29, 2009 Monteverde A morning nature walk allows you to discover the natural beauty of the cloud forest first hand. This forest is the home of the world’s largest population of the endangered quetzal, celebrated for its gorgeous jewel-toned plumage. It is an elusive bird but keep your eyes peeled and you may get lucky! This afternoon, visit a local coffee production facility to see how a potent Costa Rican coffee bean is transformed into your morning cup of joe.Today breakfast and dinner will be included. Day 6: Monday, March 30, 2009 Monteverde - Playa Hermosa (Guanacaste) Fun in the sun is in store as you travel to the spectacular Guanacaste region on the northwest Pacific coast. En route, make a special stop at a small cooperative where locals showcase their colorful handmade products. This afternoon, arrive at Playa Hermosa, known for its breathtaking beauty and fine sandy beaches. Here, rest and relaxation go hand-in-hand with mesmerizing ocean views and lush tropical greenery. Today breakfast, lunch and dinner will be included. Day 7: Tuesday, March 31, 2009 Playa Hermosa (Guanacaste) The day is yours to simply enjoy this tropical paradise. Explore the nearby marina and beaches or simply relax by the pool and take advantage of the amenities offered by your all-inclusive resort. Today breakfast, lunch and dinner will be included. Day 8: Wednesday, April 01, 2009 Playa Hermosa - Sarchi - San Jose Take a leisurely ride through the countryside to Sarchi. This charming town is known for its authentic handicrafts. During your visit you will have the chance to tour the local oxcart factory, perfect for picking up unique souvenirs! Continue on to San Jose where you will enjoy a wonderful farewell dinner. Today breakfast and dinner will be included. Day 9: Thursday, April 02, 2009 San Jose - Tour Ends Today you depart for home with fabulous memories of your adventure in Costa Rica. Today breakfast will be included.
Experience It! _______________________________ Monteverde Cloud Forest There are only four places in the world with an ecosystem so unique that it produces a cloud forest. The Monteverde Cloud Forest in Costa Rica is one. Situated high on a mountain, the cloud forest is created when the arid air from the forest below the mountain combines with the moist, hot air of the rainforest. The result is a blanket of misty, wispy clouds that linger low in the forest, making it feel as if it were raining. This rare environment breeds a diverse world of exotic flora and fauna. One of the cloud forest’s most famous residents is the endangered resplendent quetzal. A remarkably colorful bird, this creature sports a golden beak that protrudes from a green-hooded head. The breast is a vibrant scarlet and the tail feathers are gray, black and white. A highly-elusive bird, quetzal sightings are rare but absolutely unforgettable.
For more information contact
Jean Cassetta ● Santa Clara County Medical Association ● (408) 998-8850 ext. 3010 YOUR ITINERARY AT A GLANCE Day Day
1 2, 3
6, 7 8
Herradura Hotel, San Jose Volcano Lodge, Arenal or Arenal Springs Lodge, Arenal Heliconia Ranch Cabicera, Monteverde Cloud Forest or Hotel Belmar, Monteverde Cloud Forest Villas Sol Hotel & Beach Resort, Guanacaste Herradura Hotel, San Jose On some dates alternate hotels may be used.
Vacation Tours for All Ages-Collette Vacations Thursday, August 21, 2008 at 6:00 PM (Wine & Cheese Provided) During the past few years, many of you asked if SCCMA works with a travel agency. We do now! SCCMA and Collette Vacations are now partnering to bring the SCCMA membership some excellent trips. Collette Vacations has been in business since 1918, and they are dedicated to fulfilling travel dreams. They help create wonderful travel experiences in 60 countries on all seven continents. They offer escorted tours, independent vacation packages, and custom tours – to all four corners of the globe. On Thursday, August 21, 2008 come join us for a brief slide show about Costa Rica, presented by Collette Vacations’ District Sales Manager Dan Smart. We will meet at 6:00 PM at the SCCMA headquarters for a brief slide presentation and Q & A. Also, if you are interested in other trips, please join us, and Dan can help with the arrangements and details. This is an informational event only. To RSVP, call Jean Cassetta, 408/998-8850 Ext. 3010, or firstname.lastname@example.org.
“WHO IS PRACTICING MEDICINE IN YOUR OFFICE?”
SCCMA OFFICE MANAGERS’ LUNCHEON
WEDNESDAY, JULY 30, 2008 12:00 – 2:00 pm SCCMA HEADQUARTERS 700 EMPEY WAYSAN JOSE (Lunch provided by SCCMA) Please join us for a presentation about the changes in regulations for Allied Health Professionals — Scope of Practice and Appropriate Supervision for: Medical Assistants, Nurse Practitioners, Physician Assistants, and more…
This presentation addresses common problems physicians and office staff encounter with allied health staff that often create liability exposure, with issues such as: 1. Breach of Duty 5. Lack of Supervision 2. Duty of Care 6. Unauthorized Practice of Medicine 3. Vicarious Liability 7. Outside Scope of Service/Practice 4. Inadequate Supervision The presentation will focus on minimizing risk exposures discussing the “Do’s and Don’ts,” relating to Scope of Practice issues and Allied Health Professionals, as well as discussing the most frequently asked questions and answers to: 1. Can MAs call in prescriptions or refills? 2. Can an RN, instead of an MD, supervise an MA? How about an NP or PA? 3. Can MAs give phone advice? The class will be presented by one of NORCAL’s Risk Managers, Brooke Z. Bledsoe, ARM, AIC, CPHRM. Brooke is a former teacher who was attracted to medical malpractice Risk Management as a means of educating health care providers and staff. She earned the insurance designations Associate in Risk Management and Associate in Claims after completing her BA and California Teachers’ Credential. Recently, Brooke has added the Certified Professional in Health care Risk Management (CPHRM) from the American Hospital Association to her professional designations. She has worked in the insurance industry for the past 18 years as a Risk Manager for various professional liability companies. Her clients have been physicians, dentists, clinics, and hospitals. Brooke has written, developed, and presented numerous Risk Management programs and articles to teach practitioners and their staff current regulations, effective communication skills, and lessons from losses in order to reduce liability risks while at the same time improve patient care. “The patient is central to our work. If the patient is safe and secure, my client (the health care provider) is also safe and secure to practice medicine without constant fear of recrimination.”
---------------------------------------------------------------------------------- Please “Fax Back” RSVP to Jean Boileau Cassetta by July 28, 2008 408/289‐1064 or email@example.com
July 30, 2008 Yes, I will attend Physician Name Office Manager Ph
JULY / AUGUST 2008
TA CLARA SAN
Presented by NORCAL Mutual Insurance Company
IAT SSOC ION • LA
A Risk Management CME Presentation
Y MEDIC UNT A CO
IF O R N IA
“Who Is Practicing Medicine in Your Office?” A jointly-sponsored CME activity with Santa Clara County Medical Association Free to SCCMA Physician Members and Dinner Is Provided When and Where Wednesday, July 30, 2008 at 6:00 PM Santa Clara County Medical Association 700 Empey Way, San Jose, CA 95128
Who Should Attend Santa Clara County Medical Association physician members.
Educational Objectives With the goal of utilizing allied health professionals to the greatest benefit of the practice, participants will: � Differentiate and apply varying levels of physician supervision; and � Implement administrative strategies to reduce professional liability exposure (e.g., written job descriptions, standardized procedures, protocols, delegation of services agreements as well as other communication and documentation practices).
Faculty Brooke Z. Bledsoe, ARM, AIC, CPHRM** Risk Management Specialist, NORCAL Mutual Insurance Company
CME Information This activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of NORCAL Mutual Insurance Company and the Santa Clara County Medical Association. NORCAL Mutual Insurance Company is accredited by the ACCME to provide continuing medical education for physicians. NORCAL Mutual Insurance Company designates this educational activity for a maximum of 2 AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with the extent of their participation in the activity.
Please “Fax Back” RSVP to Jean Boileau Cassetta, 408/289-1064, or firstname.lastname@example.org ASAP. Wednesday, July 30, 2008 SCCMA Member’s Name: Fax:
Yes, I will attend *If you require reasonable accommodation in accordance with the Americans with Disabilities Act (ADA), please make arrangements when you enroll. **The faculty and planners of this activity have no relevant financial relationships to disclose. This activity does not contain discussion of unlabeled or unapproved uses of medications.
JULY / AUGUST 2008
SCCMA OFFICE MANAGER’S LUNCHEON WEDNESDAY, AUGUST 27, 2008 (12:00 - 2:00 PM) COME JOIN US FOR LUNCH 700 EMPEY WAY, S.J., CA 95128
Harassment and Discrimination: the real issues in medical offices. This class goes beyond the legal requirement that larger companies (50+ employees) provide at least two hours of harassment and discrimination prevention training, every two years to managers. This isn't just about “sexual harassment,” but also encompasses harassment and discrimination based on age, race, religion, pregnancy, etc. It goes to the real issues in today’s workplace such as: multiple languages in the workplace, patient requests for certain “types” of care providers, blurring the line between friendly and inappropriate behaviors, and that is just a start!
Melissa Irwin, SPHR-CA Sr. Consultant/Training Specialist Melissa is a nationally-certified Senior Professional in Human Resources and earned a BS in Business Administration from CSUSacramento. She is versatile in her presentation and facilitation techniques, and is equally comfortable discussing employment regulations, as well as communication and leadership techniques, with both employees and key managers. Melissa has a generalist’s perspective of human resource management and works with business owners and managers, offering a broad spectrum of consulting services including: the auditing of current and desired practices; the identification of areas of exposure and opportunity; and the development, implementation, and ongoing support of sound employment policies and practices. Whether creating employment policies, conducting training, or providing one-on-one consulting, she takes pride in simplifying employment issues for business managers who may lack the time, desire, or expertise to address and resolve human resource issues on their own. Melissa authors many articles for publication and contributes to TPO’s eNews and eCompliance Updates. TOPICS TO BE DISCUSSED:
State & Federal Anti-Discrimination Laws Definitions of Unlawful Harassment Descriptions & Examples of Unlawful Conduct Employer Obligations
Company & Management Liability Company Policy Procedures The Internal Complaint Process Responding to Complaints
Please “Fax Back” RSVP to Jean Boileau Cassetta, 408/289-1064, or email@example.com ASAP.
Wednesday, August 27, 2008 Name(s): SCCMA Member’s Name:
Yes, I will attend
JULY / AUGUST 2008
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A representative from Blue Shield California added another perspective. Blue Shield does not have any plans to create any tiered panels, but it is collecting data in cooperation with other insurers, to make a large enough data set to have validity.
CMA’s Leadership Academy
A Whirlwind Tour Through Whirlwind Times By David Slater, MD It was my privilege in early May to attend CMA’s 11th annual California Health Care Leadership Academy in Anaheim. This event was like drinking from a fire hydrant – contentrich, exhilarating and fast-paced, and somewhat painful. Here is a whirlwind tour of some highlights, as I heard them. Hold on…..
profiling of physicians used to create “tiered networks” of physicians: 1. These tiered networks really function to shrink the physician panel and transfer cost to the patient, since patients wishing to receive care higher fee. 2. Data is exclusively claims-based and does not
Dr. Kevin Fickenscher, a plain-speaking
large problems in knowing which care resources
North Dakota FP, who is now EVP and CMO
to assign to which physician taking care of a
of Healthcare Transformation, Perot Systems,
complex patient, and studies show a 25% to 45%
kicked things off with “Transformational Megatrends
chance of significantly misclassifying primary
in Health Care.” Some of them: 1. Informational technology will be the central
care doctors. 3. New York Attorney General Andew Cuomo,
enabler of change in health care – it will
with the help of organized medicine,
drive cost-saving efforts, it will guide quality
successfully sued to halt profiling activity there.
measurement, it will guide patient-centeredness
Of note was that the suit was filed on behalf of
of care, and it will enable remote-care
the public who stood to be harmed by it, not
efficiencies and wide-reaching centers of
on behalf of physicians. The New York action
has been highly beneficial, as standards have emerged for what must be in place, before any
curve – rising units (N) lead to lower price/value
profiling can be used by insurance companies,
and for what claims can and can not be made based on such data.
services and manufacturing industries have –
4. A representative from Blue Shield California
along the lines of building systems and multi-
added another perspective. Blue Shield does
part processes that function as tightly integrated
not have any plans to create any tiered panels,
units. At the same time, there will be greater
but it is collecting data in cooperation with
value on everyone having a “medical home.”
other insurers, to make a large enough data set
4. Our reliance on international medical graduate
to have validity. He asked us to remember two
physicians may be close to an end. Medico-
economic opportunities in countries like China
a) insurers are being pressured by their
and India, will and may already, exceed what
desperate corporate customers to apply tools
the U.S. can offer. We may have a net loss of
common in other industries, to find out what
physicians to those countries and others.
(and who) is high cost, but does not add
5. As his closing “This group may not want to hear this” comment, CMA member Dr. Fickenscher
flaws in most current insurance company efficiency
measure quality – only “efficiency.” There are
3. Health care will evolve as so many other
JULY / AUGUST 2008
CMA for many years, raised cautions regarding deep
from a doctor who is not “preferred” must pay a
2. Physicians cannot escape the price vs. quantity
AMA Attorney Catherine Hanson, formerly with
value; and b) physicians should remember the association
cautioned that physicians, and organized
between intensity of care and quality of
medicine in particular, risk being further
care is very non-linear. We should welcome
marginalized if we “insist on the old ways” (his
information that shines a light on what does
not add value.
Mr. Edward Salsberg, director of
in order to make it profitable, at these
input. The MEC-controlled rules and
Workforce Studies at the Association
regulations can house procedural details
of American Medical Colleges, spoke on “Who Will Staff the Front Lines.” Some pretty compelling MD workforce and scope of practice things: 1. There is certainty of a significant
2. Wal-Mart is the business world’s IT leader, and IT is what will drive medicine. 3. More than 50% of Wal-Mart shoppers
for some critical medical staff functions, but cannot be where the process resides. 4. Hospitals have expressed concern that MS.1.20 will weaken MECs and leave
have no health insurance – this
hospital boards unclear about who
physician shortage in the U.S. in the
is a population in need of access,
represents the medical staff. However,
next 20 years – over a wide range of
convenience, and transparency of cost of
physicians should welcome these Joint
assumptions that still holds.
care. (One would think the intent would
2. Enrollment in U.S. medical and osteopathic schools will increase 30% by 2016, from 2000 levels. The bottleneck will be in post-graduate training.
be to also have the clinics be part of major provider panels to capture insured
Dr. David Carlisle, director of
California’s Office of Statewide Planning
4. Wal-Mart has made many public relation
and Development (OSHPD), discussed
Current threats to federal funding of that
blunders, so they want to get this right.
“Population Diversity: Challenges and
education may make the bottleneck a
They likely will partner with local
Opportunities for California’s Health Care
providers – hospitals or clinics – to
co-brand their clinics. That would also
1. We are on the bleeding edge of diversity
3. Internal Medicine graduates (IMGs) are 25% of the current U.S. physician workforce and 27% of those in U.S.
facilitate referrals. 5. America has a love/hate relationship
in this state. 2. Data shows that some chronic disease
post-graduate training now are IMGs.
with Wal-Mart, but a large slice of the
outcomes – when controlled for
This is not likely to be sustained – as Dr.
American populace votes with its feet
prevalence and economic status – sort
Fickenscher also said.
and its dollars every week.
with race and ethnicity. There are many
4. Younger physicians have different
potential explanations, but we need to
personal goals and priorities. This will
Attorney Elizabeth Snelson, an expert
drive scope of practice practicalities and
in Hospital Medical Staff Governance,
will also drive the hiring of specialist
alerted the audience to a new Joint
in physician density in the Los Angeles
physicians by hospitals to staff acute care
Commission Standard intended to strengthen
hospitals and emergency departments.
the independence of the medical staff:
keep this in mind. 3. Data presented showing huge disparities
4. California’s physician workforce race
5. The number of physician assistants has
1. Medical staff governance is not what
tripled in the past 15 years (heading for
it used to be – physicians are busier,
population’s profile – with large Latino
a five-fold increase) and the number of
meetings are fewer, the number of
and African-American imbalances.
nurse practitioners has risen 25%.
physicians having paid-relationships with
6. The relationship between MD and
and ethnicity is far different from the
hospitals is higher, and the medical staff-
All that, and we haven’t even discussed the
non-MD clinicians should be governed
related regulatory stakes for hospitals are
lunchtime speakers – Congressman Pete
by the question: “What can non-MD
Stark, on one day (he wants to toss out
clinicians do as well as or better than
2. In 2007, the Joint Commission
sustainable growth rate (SGR) and stop the
MD clinicians?” The very real cost and
announced a new standard (MS.1.20)
looming Medicare cuts), and Dr. Arnold
access issues – that will get worse –
to strengthen the independence of the
Relman, many-year editor of the New
argue for maximizing non-MD providers
medical staff. MS.1.20 takes effect July
England Journal of Medicine (NEJM) and
so long as that question is always central
2009. It offers the medical staff at-large
author of a 2007 book that has garnered
better defined authority over and the
much attention: “A Second Opinion: Rescuing
ability to act independently of its own
America’s Health Care,” the next day. There
Medical Executive Committee (MEC).
is just too much to say about Dr. Relman’s
Mr. Ronald Galloway, the world authority on all things Wal-Mart, made
3. MS.1.20 (you can easily search this
passionately presented ideas – search on-line
it clear that medicine is about to become yet
on-line) codifies that certain critical
processes (such as credentialing and
1. Wal-Mart has 3,700 U.S. stores, and
privileging) must be described in the
After drinking at the Leadership Academy
around 2,000 of them are likely to have
bylaws – and be subject to approval by
fire hydrant, I was very glad to be part of our
in-store, nurse-staffed clinics in the
the entire medical staff – rather than live
county medical association, as well as CMA
next five years. Less than 0.5% of daily
in “rules and regulations” that can be set
and AMA. The issues and decisions facing us
shoppers would need to use the clinic
and changed by the MEC with no other
the many interviews with him.
Continues on page 33
JULY / AUGUST 2008
2008 LEGISLATIVE DAY IN SACRAMENTO
2008 Legislative Day in Sacramento Santa Clara County Medical Association and Alliance members joined over 400 physicians from around California to meet at the California State Capitol for the CMA’s 2008 Legislative Day, which was held on April 15. The contingent met with members of the Assembly and Senate, which provided physicians an opportunity to educate elected officials about how pending legislation will impact patients and physicians. While there are many bills under consideration in the legislature that affect doctors and patients, emphasis was placed on five key issues of concern:
application. Additionally, the plans and insurers must show willful misrepresentation. Notwithstanding existing law, it is well publicized that health plans and insurers pay large bonuses to their employees for rescission of policies, practice illegal rescission, and put patients in harms way by yanking their health coverage when they need it most, based on the fines and lawsuits that have occurred since 2006. AB 1945 is intended to stop the HMO’s unscrupulous practice of dumping policyholders after their policy has been approved. This legislation will ensure that health plans and insurers do not act as “judge and jury” whenever they want to rescind or cancel a policy. The time has come to have an unbiased analysis on whether a
The Budget: Stopping the 10% Medi-Cal Cuts In response to a $16 billion projected deficit and the Governor’s declared fiscal emergency, the Legislature passed and the Governor signed legislation to slash Medi-Cal provider reimbursement rates by 10% beginning July 1, 2008. This $1.2 billion cut will further undermine California’s struggling health care system. CMA is trying to reverse the cuts in the 2008-2009 budget. On May
policy should be rescinded or cancelled, and to provide the utmost protection to patients whenever their health plans and insurers want to yank their health coverage away from them. AB 1945 provides consumers two protections whenever health care service plans and insurers attempt to rescind or take away their health coverage. Key points included: •
analyze and adjudicate on any rescission of a policy, similar to
5, a coalition of health care providers led by CMA filed a class action
the current Independent Medical Review process now in place
lawsuit to seek an immediate injunction to block the reduction in Medi-Cal reimbursement rates. The lawsuit contends that the cuts violate state and federal laws which require that Medicaid (MediCal) payments “must be sufficient to enlist enough providers so that services under the (state’s Medicaid) plan are available to recipients at least to the extent that those services are available to the general public.” According to the complaint, the reimbursement cuts authorized in February were implemented “solely due to state budgetary woes, without regard to the impact on the availability of Medi-Cal services.” Such cuts are illegal, according to the complaint, and are “being imposed on a system already in crisis, wherein inadequate payment levels have resulted in a scarcity of willing providers, creating serious access hurdles for Medi-Cal beneficiaries.”
AB 1945: Preventing Unlawful Health Plan Rescissions and Cancellations (CMA-Sponsored Bill) Current law prohibits plans and insurers from post claims underwriting, which includes rescinding, canceling, or limiting a plan contract due to the plan’s failure to complete medical underwriting and resolve all reasonable questions arising from the
JULY / AUGUST 2008
Protects physicians. Allows regulators to independently
Prevents confusion in application process. Requires regulators to develop a standardized application that health plans and insurers must use.
SB 1406: Optometry Scope of Practice Expansion (CMA Oppose) Current law related to optometry allows optometrists with appropriate training to provide treatment of certain disorders of the eye. It prohibits surgical intervention and stipulates the types of medicinal treatments that an optometrist may prescribe. Current law also provides an appropriate clinical pathway whereby optometrists can treat and manage patients suffering from glaucoma. This includes the development of collaborative treatment protocols with optometrists and eye physicians and surgeons. SB 1406 would dramatically expand the scope of practice for optometrists in California by allowing them to independently diagnose and treat the human eye or any part of the visual system, as well as perform minor surgical procedures not requiring general anesthesia. The bill removes statutory specifications of the types of
2008 LEGISLATIVE DAY IN SACRAMENTO disorders that an optometrist may treat and
Los Angeles to farm
also provides them unmitigated prescriptive
worker health clinics
authority. SB 1406 would eliminate the
in the Central Valley to
mandatory collaborative relationship
rural health facilities in
between optometrists and ophthalmologists
relating to the treatment of such disorders as glaucoma and AIDS-related infections of the
Funding for the STLRP has
eye. The bill places the oversight for such
been unpredictable and
authority under the purview of the Board of
insufficient. Every year,
Optometry, rather than the Medical Board.
demand for the program
In essence, the bill provides the optometrist
far exceeds available
the discretion to decide the limits of their
own education and scope of practice. This bill would close a
CMA coordinated a silent march to the capitol, which placed awareness and emphasis on the impact of the 10% Medi-Cal physician funding cuts.
Key points included:
loophole in current law
Overly Broad. Allows optometrists
that rewards insurers for
Although no legislation has been introduced,
to diagnose and treat glaucoma, eye
breaking the law by allowing fines and
it was important to use the meetings with
infections brought on by AIDS-related
penalty assessments to offset the fees they
legislators as an opportunity to educate
complications, and treat eye infections
pay to support the Department of Managed
them about this important program and how
in children. Allows optometrists to
Health Care (DMHC). This bill would instead
the decision to terminate the program will
perform nearly all eye surgery, including
use these fines and penalties to help get
compromise patient safety.
LASIK and cataract surgery. Provides
doctors into underserved communities by
prescriptive authority, including the
providing funding for the STLRP.
use of injectables and oral medications.
SCCMA Members in Attendance The SCCMA wishes to acknowledge and
Without fundamental medical education
Key points included:
thank the following members and Alliance
and training, these powers will
This bill will make sure insurance
members who participated in the CMA
jeopardize patient safety.
companies don’t benefit from breaking
Legislative Leadership Conference in
Lack of Oversight. Requires the
Sacramento on April 15:
This bill will help address doctor
Amara Balakrishnan, MD
shortages in underserved communities.
California State Board of Optometry and not the Medical Board to determine
the appropriate education, training,
Judith Dethlefs, MD
and certification for optometrists to
Diversion Program Closure
Alexander Ding, MD
essentially practice medicine.
On July 26, 2007, the Medical Board
Len Doberne, MD
of California (MBC) abandoned their
Martin Fishman, MD
SB 1379: Funding for Physician Loan Repayment Program (CMASponsored Bill)
responsibility to the public by voting to
end the Physician Diversion Program after
James Hinsdale, MD
27 years. This program was designed to
Elliot Lepler, MD
In response to physician shortages in
help rehabilitate physicians with drug,
Bien Nguyen, MD
underserved areas, in 2002 the Legislature
alcohol, or mental health problems without
passed the California Physician Corps Loan
placing the public in danger. Instead of
Donald Prolo, MD
Repayment Program (later renamed to honor
addressing problems in the administration
the late Steven M. Thompson). Physicians
of the program, as advocated by the CMA,
selected for the program are eligible for
the MBC chose the easier course and voted
Howard Sutkin, MD
medical school loan repayment grants of up
instead to end the program completely. The
to $105,000, in exchange for a 3-year service
CMA is working with other stakeholders,
The CMA has been very effective this
commitment in a medically underserved
including the California Society for Addiction
year on the legislative front. All legislation
area of the state. Steve Thompson Loan
Medicine and the California Psychiatric
opposed by CMA was defeated in 2007, and
Repayment Program (STLRP) recipients
Association, to reconstruct a physician health
most supported legislation has either passed
work in a variety of settings all over the
program that will protect the public and
or remains under active consideration.
state, from community clinics in downtown
allow physicians to address their diseases.
JULY / AUGUST 2008
Debbi Ricks Installed as President of the California Medical Association Alliance 2008-2010 “Changes... Keeping the Alliance Relevant in the 21st Century” is the theme for the California Medical Association Alliance for 2008-09.
states, “The changing make-up of
On May 3, 2008, Debbi Ricks, from the Santa Clara County Medical
relevant in today’s climate? Do we
Association Alliance, was installed as the 79th president of the
have programs relevant for our male
California Medical Association Alliance at the CMA Alliance’s Annual
members, our younger members, our
Session in Sacramento. Past AMAA and CMAA President Ann Hansen,
ethnic members, and our physician
of San Luis Obispo, California, and current AMAA president Dianne
members? Do we want to encourage
Fenyk, of Golden Valley, Minnesota, performed the installation. Over
expanding our membership and
70 Alliance members, spouses, friends, and Debbi’s family members
promoting the Friends of Medicine
shared in the festivities. Jean Cassetta, SCCMA membership director,
category? Are we doing our best
presented Debbi with a bouquet of flowers on behalf of the Santa
to support our physicians in these
Clara County Medical Association. Debbi gave special thanks to
difficult times? Are we doing all we
SCCMA Alliance members Carolyn Miller, Suzanne Jackson, Meg
can to promote healthy lifestyles in our communities? All of these
Giberson, Siggie Stillman, Jean Cassetta, and Leela Tabari for their
are things for us to consider seriously, if we want to remain vital
participation in the evening. A champagne reception preceded the
and effective. The Strategic Directions Committee has been given
installation dinner, featuring jazz harpist Motoshi Kosako. More
the challenge to guide the CMA Alliance in this process of going
photos from the evening and Debbi’s installation speech may be
from a good organization to a great one, a winning one that will
found on www.cmaa.net.
be a recognizable force for quality health in California. With open
Under Debbi’s leadership, the CMA Alliance has begun the strategic
minds, ready to change with the times, we will not only keep the
planning process with a professional facilitator to help determine
Alliance relevant in the 21st century, but we will be a strong force for
a relevant future for the Alliance. In her installation speech, Debbi
continuing the rich traditions set forth by our founders.”
our target membership requires us to rethink our approach. Is the Alliance
Participating in PQRI and Pay for Performance, from page 17 Using the Data
misleading statistics and potentially damaging clinician rating
Assuming that the measures for PQRI 2008 address a fair sampling of
clinical issues and corresponding appropriate clinical actions, there
On the other hand, participation in efforts to increase quality and
remains the question of how the data will be used. This is perhaps
high reliability in health care delivery can be empowering for
one of the greatest obstacles. In general, the data obtained may have
practitioners and may lead to improved outcomes for our patients.
a negative impact on physicians as an artifact of program structure, or it may be used to discourage clinical resource use. Providers are also concerned that measures may fail to account for patient acuity, effectively penalizing those who take care of more ill and complicated patients. While acuity is being addressed in other CMS programs in the inpatient setting, it is not a factor in current assignments of the bonus in PQRI, and it remains unclear how the issue will be addressed in later iterations of the initiative. Concerns about physician profiling, however, are both immediate and substantiated. The PQRI feedback reports will be provided directly to the practitioner in a confidential manner for the 2007 and 2008 reporting periods, but it is expected that data in later years will be public domain. In the meantime, we have an opportunity for our profession to promote continuous quality improvement. Physician profiling may seem inconsequential in the current environment, but the trend is toward increased profiling by payers
firstname.lastname@example.org; email@example.com Reprinted with permission of Sierra Sacramento Valley Medicine 1. MEIA-TRHCA final rule on PQRI 2008. http://www.cms.hhs.gov/ physicianfeesched/downloads/CMS-1385-FC.pdf 2. CMS public communication regarding Hospital Acquired Conditions and Present On Admission initiatives (HAC-POA) 3. Quality Initiatives General Information, Centers for Medicare & Medicaid Services http://www.cms.hhs.gov/ QualityInitiativesGenInfo 4. Way beyond Vitals. Hills Physician Medical Group 2006 Annual Report 5. Blue Cross of California Pays Out Over $69 Million in Physician Bonus Incentives. August 24, 2007 Blue Cross Website Press Room. http://www.bluecrossca.com 6. Regence calls off flawed physician profiling. Statement attributed
and awareness by consumers. As a profession, our failure to
to: William G. Plested, MD, AMA President. www.ama-assn.org/
participate in an objective and critical manner may leave us with
JULY / AUGUST 2008
Santa Clara County Medical Association Alliance Hosts
CMA Alliance Fall Conference 2008 Debbi Ricks, President
Creating a Healthy Balance… Physical, Fiscal, & Family September 18-21, 2008, Toll House Hotel, Los Gatos, California
Speakers Chris Crowley, co-author of the New York Times’ Bestsellers, “Younger Next Year” & “Younger Next Year for Women” www.crowcreative.com Juliet Funt, Success Skills for the Overwhelmed “Overcommitted, Overwhelmed, and Over It!” www.julietfunt.com Richard Frankenstein, MD, President, California Medical Association Dustin Corcoran, Chief Lobbyist, California Medical Association David Pruitt, Executive Director, CALPAC Rachel Smith, VP Membership, California Medical Association
Workshops “Balancing Your Family’s Assets…The 13 Wealth Management Issues” Anne Gardner, CFP; Ray Regale, ComericA Bank Workshop presented by NORCAL “Juggling Life’s Stresses” Stephen Jackson, MD
Trainings “Leadership Secrets of Attila the Hun” Marilyn Kezirian, Past President, CMAA Leadership Training AMAA Leader TBA Navigating the Web…A Look at Local Alliances, CMA Alliance, and AMA Alliance Websites
Activities Thursday night libations in the President’s Suite Friday night light dinner & wine tasting at the home of Dr. William & Debbi Ricks Saturday night dinner at the California Café, Old Town, Los Gatos
Visit www.cmaa.net to download a registration form and for detailed information.
JULY / AUGUST 2008
For coding questions and reimbursement issues, contact Sandie at 408/998-8850 ext. 3007 or email sandie@sccma. org
By Sandie Becker, CMC SCCMA Coding/Reimbursement Specialist
Q: I have to bill for an unlisted procedure. Any advice on how to go about it and what to expect for reimbursement? A service or procedure may be provided that is not
Q: What codes do I use for second opinions?
listed in the CPT codebook. When reporting such a
Since the deletion of confirmatory consult codes
may be used. Here’s what you need to keep in mind:
service, the appropriate “Unlisted Procedure” code
99271-99275 in 2006, there are a couple of different ways to code for second opinion services depending
Payment will be slower, as the claim must be
on the circumstance. A “confirmatory consultation”
processed by hand. The carrier decides the
requested of a physician by another provider
may be coded with the appropriate consultation code from the 99241-99255 series, as long as all the
A special report to describe the exact procedure is
requirements for billing a consultation are met. See
required and must include:
the following guidelines below.
✔✔ An adequate definition or description of the
1. The consultation request, 2. The reason for the request,
nature, extent, and medical necessity of the procedure.
3. The services rendered,
✔✔ Time, effort, and equipment used.
4. The report from the consulting physician
✔✔ Other items, such as complexity of symptoms, diagnosis, pertinent physical findings,
The first two items must be documented in both the
concurrent problems, complications, and follow-
requesting physician’s and the consulting physician’s
patient chart. It should also be documented as to how the request was made (e.g., phone, fax, or
TIP: When sending in documentation along with
the claim for an unlisted procedure, it would be wise to include a separate cover letter indicating
The consultation services rendered should be
what CPT code relates closest to the unlisted service.
documented following the E/M guidelines.
Then, indicate how much effort and complexity was involved in the unlisted procedure in comparison
The consulting physician should provide a written
to the established CPT. This will help the claims
report to the referring physician. If the referring
reviewer, and the physician will more likely receive
and consulting physicians share a patient chart, the
the most appropriate reimbursement.
findings and recommendations can be included in
the patient’s progress notes. You must bill patient-initiated second opinions using an appropriate E/M visit code, instead of the
JULY / AUGUST 2008
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“Asthma surveillance studies have shown that 12% of asthma in the workplace is due to cleaning products and 80% of those cases were new onset of asthma.”
Nonylphenol, a breakdown product of synthetic detergents, stimulates the growth of human estrogensensitive breast cancer cells.
Reducing Your Clean and Risk of Asthma Green: and Cancer By Cindy Russell, MD Vice President, Community Health; Chair, Environmental Health Committee
adverse health effects. The label highlights the fact
Ever read Hints From Heloise? She provided quick, simple, and inexpensive household advice passed down from grandmothers everywhere. The ingredients for cleaning products came from the kitchen cupboard. Baking soda and vinegar were key elements. Guess what? Non-toxic cleaning products are having a comeback. With all the emerging scientific information on the hazards of our synthetic cleaning products, moms and maids are ready to go back to basics.
there are no CFCs, but doesn’t warn the user of the respiratory dangers. Some boldly state they are VOC-compliant. Most people don’t know that there are only outdoor, not indoor, VOC requirements for
Using Cleaning Sprays Once a Week Can Increase Asthma A new European study published in the American Journal of Respiratory and Critical Care Medicine, October 2007,1 showed that those who used cleaning sprays at least once a week were 50% more likely to have increased asthma symptoms, wheeze, or use asthma medications. The author’s study felt that the sprays not only triggered asthma, but in many cases caused new onset of asthma. Of the products researched, air fresheners, glass cleaners, and
Recent studies now show that many cleaners and air
furniture sprays had the strongest association. Glycol
fresheners contain chemicals which may cause or
ethers (linked to reduced sperm counts) are also one
trigger asthma, have carcinogenic effects, and may
of the chemicals of concern in glass cleaners.
be endocrine disruptors with short and long term health implications.
Use of Air Fresheners in Pregnancy May Be Hazardous
Many of the 100,000 or so synthetic chemicals
Research on asthma has demonstrated that early
produced each year for industry, home, and
exposure (in pregnancy or early childhood) to
agriculture have little testing for long-term health
cleaning products and air fresheners is associated
effects. Some synthetic chemicals are not deliberately
with persistent wheezing in preschoolers.2
added, but are by-products of manufacturing (i.e.,
Workplace exposure to cleaning products is
carcinogens such as formaldehyde, 1,4 dioxane, and
ubiquitous. Asthma surveillance studies have shown
benzene) found in cleaning products.
that 12% of asthma in the workplace is due to
Asthma in Kids and Adults Is Linked to Cleaning Products
cleaning products and 80% of those cases were new
Air “fresheners” used to improve air quality have
such as janitors and other housekeeping staff in
been shown to pollute indoor air and induce
medical settings, hotels, and schools.3 Some common
asthma. Common components of air fresheners
agents that are suspect are monoethanolamine
are carcinogens, such as 1,4 paradichlorobenzene
and disinfectants with quaternary ammonium
(mothballs and toilet cleaners), as well as volatile
organic compounds (VOCs), such as acetone,
A study in Environmental Health Perspectives 2006
isobutene, butane (lighter fluid), propane, and ethers,
looked at more than 950 adults in the U.S. and
JULY / AUGUST 2008
which trigger asthma along with synthetic fragrances
showed high blood levels of 1,4-dichlorobenzene,
which all contain phthalates, a known endocrine
found in air fresheners and deodorizers, were
disruptor which allows the fragrance to “stick.” Many
associated with measurable decreases in lung
popular and highly advertised name brands never
even list the ingredients, although they may cause
onset of asthma. The highest risk were regular users,
Unfortunately, we are all exposed to asthma triggers when we use
reduced sperm counts and also has been associated with asthma.
many public or business restrooms. Automatic air fresheners squirt
Not all “natural” fragrances are without problems. Lavender and
our air space with toxic VOCs.
d-Limonene in citrus may be respiratory irritants to sensitive
Endocrine Disruptors in Cleaning Products: Gender Bending Cleaning
individuals. Fragrance free products are the best solution if an
Many commonly used household cleaners contain synthetic chemicals
It’s Easy Being Green: Soap, Vinegar, and Baking Soda
which act like or block hormones. These could effect reproduction
Going back to the basics works well. You can tell your patients to
or thyroid function. Ethylene glycol butyl ether, 2-Butoxyethanol or
make their own glass cleaner, furniture polish, and other cleaners
EGBE, is on California’s list of toxic air contaminants and animal
with only a few items. Add some pure oil of lavender or lemon for a
studies show it can cause testicular damage and infertility.
refreshing scent. Recipes can be found in many books now, including
It is difficult to know what chemicals are in your favorite cleaning product, as there is no labeling requirement for manufacturers. Material Safety Data Sheets (MSDS) may contain the information. A Missoula non-profit group looked at MSDS and found that EGBE was
individual has a predisposition to asthma.
the classic “Clean and Green: The Complete Guide to Non-Toxic and Environmentally Safe Housekeeping.” Newer books like “Vinegar” and “Baking Soda” provide an entertaining abundance of recipes. I can attest to their usefulness when I ran out of glass cleaner.
found in many all-purpose cleaners, such as Formula 409 and Simple
May the Precautionary Principle prevail in our daily decision-making.
Green, as well as in some carpet cleaners.5
This is sustainable and healthy living for our families, our patients,
Surfactants Cut Grease and Alter Fish
and our planet.
Surfactants that reduce the surface tension of water cut grease.
1. Zock, JP. The use of household cleaning sprays and adult
Synthetic surfactants are called detergents regardless of the source–
asthma: An international longitudinal study. American
animal, vegetable, or mineral. These compounds are synthesized by
Journal of Respiratory and Critical Care Medicine. 2007 Oct
ethoxylation with petroleum. Soap is also a surfactant, and the term soap is reserved for the old-fashioned product made from fat and lye.
15:176(8):735-41. 2. Sherriff, A. Frequent use of chemical household products is associated with persistent wheezing in preschool age children.
One commonly used synthetic detergent is nonylphenol ethoxylate (NPE). This “biodegrades” into nonylphenol, which mimics estrogen and has been shown in studies to stimulate breast cancer and
Thorax. 2005; 60:45-49. 3. Rosenman, K. Cleaning products and work-related asthma. Journal of Occupational and Environmental Medicine. 2003;
prostate cancer cells to grow. In wastewater with NPE, they have been shown to cause intersex fish (i.e., male fish with female characteristics). Unfortunately, phenolethoxylates are found in most streams and rivers in the U.S. and in house dust.
Fragrance Free Please Synthetic “fragrances” are also part of the mix. These fragrances are mixed with phthalates, which allow the scent to stick. We find phthalates in many cleaning products, such as fabric softeners, laundry detergents, and glass cleaners. Phthalates are also frequently used in pesticides to allow adherence to the plant or insect. Phthalate is also a major component of all PVC plastic (#3) and flooring. This chemical has been shown to be an endocrine disruptor linked to
Elliot, Leslie. Volatile Organic Compounds and Pulmonary Function in the Third National Health and Nutrition Examination Survey, 1988-1994. Environmental Health Perspectives. Volume 114, Number 8, August 2006.
5. “Household Hazards.” Women’s Voices for the Earth. www. womenandenvironment.org. 6. Clean and Green: The Complete Guide to Non-Toxic and Environmentally Safe Housekeeping by Annie Berthold Bond. 7. Vinegar. Vicki Lansky. 8. Baking Soda. Vicki Lansky.
A Whirlwind Tour Through Whirlwind Times, from page 25 the next 10 years are massive. The transformational trends, that many
Dr. Fickenscher of Perot Systems lives a life at the very pinnacle of
speakers could not resist comparing to a tsunami, will be disruptive
medical technology and sophistication. But he related that the best
(I use that as a value-neutral term), and impossible to reverse.
part of each day during a recent ICU stay was when his doctor sat
Physicians need to understand that the measure of our success in
down, took his hand, and spoke to him kindly and with reassurance.
organized medicine cannot be how well change is resisted. We live
Whether such moments will live on is a good litmus test for any
in a time of transformational disruption of nearly everything around
tsunami heading our way.
us, and medicine is 17% of America’s gross domestic product (GDP). But we must be there – as a uniquely qualified voice – to educate about change, to guide change, and to sometimes champion change. Principles of medical professionalism and the social contract between America and its physicians must be preserved.
The CMA Leadership Academy is open to all physicians. The 2009 session will be April 24 to April 26 at the Disneyland Hotel. I urge all colleagues to consider attending it. Reprinted with permission of Vital Signs, June 2008 Issue
JULY / AUGUST 2008
Lying in bed, you focus on funny things sometimes, so I wondered just how well the protocols we are being taught to follow are being carried out. I had time to watch the nurses and aides wash their hands, and, generally, compliance with our hand hygiene protocols was excellent; in fact, almost compulsive.
Under the Blanket By J. Kent Garman, MD, MS Dr. Garman was president of the Stanford Medical Staff, past president of the California Society of Anesthesiologists, and past councilor of the Santa Clara County Medical Association. He now lives in Folsom. This article appeared in the April 2007 Stanford University Medical Staff Update and was reprinted in the Summer 2007 CSA Bulletin. I’m going to waive my HIPAA rights, whatever they may be, and tell you what I saw on the other side of the syringe, scalpel, oxygen mask, and the rest of the gadgets we physicians use with patients. It’s a personal story, but I hope it transcends the selfindulgent hospital tale we all prefer to avoid. My professional and personal worlds collided and gave me some thoughts as a practitioner. In February, I responded to an advertisement seeking normal controls for an MRI study sponsored by vascular surgery. Since I was older than 55, without aneurysm or spinal cord disease, I was eligible to have a free MRI of my abdominal vasculature. What a deal. Why would I not do this? (By the way, they may still need some “normal controls.”) So, I signed up and got the contrast injection MRI. When the researchers finished the study, I learned I was no longer a “normal control.” First, the good news was that there was no obvious adenopathy or
renal vein invasion. My CXR was normal. The bad news: I had a large (6-7 cm) left renal cell carcinoma, and in an instant I went from being as healthy as
JULY / AUGUST 2008
possible for 67 years to the victim of a potentially lethal cancer. Symptoms? I had no hematuria (the most common symptom). I did have left back pain, more severe
after working a full day in the OR, but otherwise, I had nothing that would have made me seek medical help. So, in late February, I elected to have surgery and underwent a radical left nephrectomy. The final cell type turned out to be a chromophobic carcinoma, instead of the more common and more lethal clear cell carcinoma. But before that answer came down, I learned a number of things about Stanford patient care delivery: in the clinic, bed, but not bedside.
Customer Satisfaction I was very impressed with the efficiency and attention I experienced in the Stanford Clinics and from the outpatient labs. The new facilities in the Cancer Center are especially impressive. And the personnel all seemed to enjoy their jobs.
Internet Access Why can’t we finally have access for patients? We have the wireless infrastructure, and surely our need to communicate while hospitalized remains stronger than ever. Also, Lucile Packard Children’s Hospital has had free Internet access for a year for patients and visitors.
Protocol Compliance Lying in bed, you focus on funny things sometimes, so I wondered just how well the protocols we are being taught to follow are being carried out. I had time to watch the nurses and aides wash their hands, and, generally, compliance with our hand hygiene protocols was excellent; in fact, almost compulsive. Are we as physicians doing as well, showing leadership? Another current patient safety rule calls for checking patient identification in two ways— usually a wristband check and a verbal inquiry as to name or birth date. I may have missed a double check or two when I got my meds, but my mental scorecard ticked off full compliance with the labs.
Noise and Sleep and More
supplemental oxygen, they came up into the
patients. Maybe this concept needs to be
The complaints I’ve heard from other
mid 90s. If I used the incentive spirometer
patients seemed to be true. I was in a
vigorously (and that hurts), I could get the
double room converted to a “private room”
room air sat into the low 90s for a short
Nurses and COWS
by installing a plywood panel and door so
time. It took me concerted effort with deep
I have only the deepest appreciation for the
thin you could easily hear quiet conversation
breathing for several hours to get rid of the
nursing staff and nursing aides with whom
on the other side. And overall, the alarms
atelectasis I had developed during the night
I came in contact. They all were genuinely
going off continually, conversations,
and maintain room air sats in the mid 90s.
concerned and helpful. However, they
footsteps, motors, and the like persistently
Good thing I know what I’m doing, I guess.
did seem to be struggling with the new
inhibited any attempt at solid sleep. But
Most patients would simply lie there and be
wireless mobile data entry devices, called
the distractions didn’t stop there. I had the
COWS, which they wheel from patient to patient to use in lieu of carrying a clipboard.
misfortune to wear compression boots from foot to knees. These inventions of the devil
Interestingly, a recent article by the
Fancifully, I imagined we could put a bicycle
at first seem like a good idea (after all, who
Anesthesia Patient Safety Foundation (APSF)
seat and pedals on the COWS so the nurses
wants to get DVT?). However after several
points out a high incidence of morbidity
could maneuver them more easily.
hours, the constant inflation-deflation cycle,
caused by hypoventilation with atelectasis,
coupled with the noise of the compressor
hypercapnea, and respiratory acidosis from
motor, start to drive me crazy—not to
the effects of PCA and epidural narcotics.
The biggest impact of my hospitalization
mention contributing to sleep deprivation.
The APSF says that monitoring oxygen
was psychological. I have had deep thoughts
The incessant noise, however, is a serious
saturation with a pulse oximeter gives a
about what to do with the rest of my life,
problem, and perhaps we should take a look
false sense of security when supplemental
accompanied by a fair amount of depression
at some corrective measures.
oxygen is administered. The O2 sat will be
and fatigue. I’m more optimistic now that
OK, but everything else is going south. The
my diagnosis is actually quite favorable. An
bottom line is that the APSF will probably
earlier than previously planned retirement
and at least this component of my stay was
recommend that exhaled CO2 monitoring
from clinical medicine may be in the cards,
quiet—but only at first. I was offered from
should be added to pulse oximetry as
since I have discovered that daily high stress
0.2 to 0.4 mg of hydromorphone with a
mandatory monitoring for postoperative
in the OR is not necessarily a good thing.
lockout of 10 minutes and no basal rate. This
patients receiving narcotics. Unfortunately,
Coming face-to-face with your mortality is a
is where the rubber hit the pavement for
our technology is not quite good enough yet
real eye opener.
me as I transitioned from anesthesiologist
to do this well on nonintubated patients.
I was placed on a hydromorphone PCA,
More important, I hope that I can transcend
to patient. Although I should know better, I hit the button whenever I felt any pain.
Playing doctor on myself probably
the clichés and truly be more empathetic
I became confused and had a number of
contributed to stress, but I’m convinced
with the experiences patients have. I hope I
very bizarre dreams and nightmares. Yet,
the stress would have been worse if I had
can find ways to put that knowledge to work
whenever I awakened, I hit the button again.
remained ignorant. Think of the anxiety a
in practical ways that will incrementally
Then it got noisy. Strangely, I discovered that
patient without a medical background must
improve the hospital experience for those
whenever I took off or lost my nasal oxygen
feel. Trust the doctor? Easier said than done
patients who can’t read a pulse oximeter.
cannula, the pulse oximeter alarm would
when you are feeling terrible in a noisy bed.
They’re scared in a noisy environment and trust us to do what’s right, both on a
go off and wake me up. Fortunately, I could stop the alarm by keeping my nasal oxygen
So after one night as an inpatient, I decided
hospital-wide basis and in the patient room
cannula in place. The next morning I felt
if I were to get some sleep, I’d have to leave.
itself. We need to make sure we do just that.
absolutely terrible—confused, disoriented,
Fortunately, I was able to do so. Thanks very much for reading. Go ahead
nauseated, with pain. That’s when I figured out that PCA was to blame, so I decided to
VIP Status—The Red Blanket
and use my thoughts to apply to your more
stop using the device. Things cleared rapidly
Stanford gave me a red blanket, telling
general musings and discussions. I welcome
after I made that decision.
everyone who came in my room and saw
your comments about this article.
it that I was a “VIP” patient. While I felt But even after discovering the truth about
honored, my caregivers weren’t so sure
PCA, I continued to play doctor. I turned the
this was a good idea. Some of the nurses
pulse oximeter around so I could see it. My
and others asked if the blanket meant they
saturations were not good. On room air, my
should treat me better or differently, and if
sat would drift down to the mid 80s. With
so, whether this sent the right message to
JULY / AUGUST 2008
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JULY / AUGUST 2008
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Units range from 1,071–4,150 sq. ft.,
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JULY / AUGUST 2008
classified ads, FROM PAGE 37
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