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July / August 2008 | Volume 14: Number 4


..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.

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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.

Administered by:

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

Executive Director

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 pjensen@sccma.org Copyright 2008 by the Santa Clara County Medical Association.

Community Hospital of Los Gatos:

Judith Dethlefs, MD El Camino Hospital:

Editorial Board

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

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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



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


From the



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




#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

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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.


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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.


Physician Orders

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





Check One

Check One

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.

Additional Orders:


Check One

ANTIBIOTICS No antibiotics. Use other measures to relieve symptoms.


Check One

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:_______________________

Additional Orders:_____________________ ____________________________________




Summary of Medical Condition


Health Care Representative

Parent of Minor

Court-Appointed Guardian

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)

Name (print)

Relationship (write “self” if patient)

SEND FORM WITH PERSON WHENEVER TRANSFERRED OR DISCHARGED © California Coalition for Compassionate Care – www.finalchoices.org


Patient Name (last, first, middle initial)

Date of Birth

Contact Information Surrogate (optional)


Phone Number

Health Care Professional Preparing Form (optional)

Preparer Title

Phone Number

Date Prepared

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>.


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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.


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Exploring the Costs of Going Digital

EMR by the Numbers

Dr. Griffiths also mentions the significant

Stark Relaxation

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

my notes.”

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,”

affordable cost.++

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

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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

engage them.

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

Quality Reporting

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


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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.”

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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,

compassionate care.

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.

• • •

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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:



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: karen@bmesc.com

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

Fax: 408-937-9002

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 orneurodoc@aol.com

Donald C Silcox, MD *RHU Wake Forest University 1962

700 W Parr Ave Ste A Los Gatos 95032 408-866-1135

Fax: 408-866-7926

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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



period was July through December 2007 and

Dr. Gaspar, a founding partner and CEO of Gage

relatively little physician attention. Many health care

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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

Physician Profiling

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

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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


4, 5

Day Day

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 jean@sccma.org.



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 jean@sccma.org 

July 30, 2008   Yes, I will attend     Physician Name  Office Manager     Ph 


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Presented by NORCAL Mutual Insurance Company


A Risk Management CME Presentation




“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 jean@sccma.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.

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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 jean@sccma.org ASAP.

Wednesday, August 27, 2008 Name(s): SCCMA Member’s Name:


Yes, I will attend

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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,

per unit.

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


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

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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

stores’ volumes.

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

Commission changes.

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

shoppers, too.)

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

severe one.

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

metropolitan area.

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

to discussion.

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

more corporatized:

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

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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


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Protects physicians. Allows regulators to independently

(IMR). •

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

Northern California.

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

the law.

Sacramento on April 15:

This bill will help address doctor

Amara Balakrishnan, MD

shortages in underserved communities.

Jean Cassetta

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

Meg Giberson

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

Bill Parrish

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

Debbi Ricks

the late Steven M. Thompson). Physicians

of the program, as advocated by the CMA,

Siggie Stillman

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.

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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

kggaspar@gagehealth.com; sbgerhart@gagehealth.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



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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.

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For coding questions and reimbursement issues, contact Sandie at 408/998-8850 ext. 3007 or email sandie@sccma. org

Coding NEWS



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

reimbursement amount.

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

up care.

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

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the patient’s progress notes. You must bill patient-initiated second opinions using an appropriate E/M visit code, instead of the



consultation code.


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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.

these products.

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


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


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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

45:556-563. 4.

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

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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

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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



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

Psychological Impact

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

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ADS office space for rent/lease MEDICAL OFFICE SPACE FOR LEASE • LOS GATOS

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Hospital. Both units currently available. Call

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First class medical suites available next


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OFFICE FOR RENT • SAN JOSE Office for rent at 150 N Jackson Avenue. 862 sq. ft. $2,000 a month. Full service

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lease included. Please call Dr. Fishenfeld at

building. Most rooms have water and


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waste. Reception, exam rooms, office, and

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office suites located directly across from



Approx. 1,125 sq. ft., located in prestigious

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Building, second floor, elevator, separate

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Teng for more information: 408/282-3808. www.colliersparrish.com/ateng.

MEDICAL SUITES • LOS GATOS – SARATOGA Two suites, ranging from 1,000 to 1,645 sq.


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OFFICE SPACE FOR LEASE • SAN JOSE Six exam rooms available, in newly remodeled building. Located near O’Connor Hospital. Contact 408/292-0100.

and future Valley Medical Specialty Center. Suites range from 742 sq. ft. to 2,600 sq. ft. Easy access to Hwys 280 & 880. Call Ngoc Vu at 408/436-3606.

OFFICE TO SHARE • LOS ALTOS Options include two exam rooms plus office. Newly remodeled office space perfect for cosmetic dermatologist, facial plastic, or plastic surgeon. Near El Camino Hospital. Call 650/804-9270.

OFFICE EXAM ROOMS TO LEASE Two nice and large exam rooms (dedicated),


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Registered Nurses needed for contract



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contact Ms. Veronica Knight at 650/603-8236 to become part of our team.

FAMILY PHYSICIAN NEEDED A growing private practice in San Jose seeks

PRIVATE PRACTICE FOR SALE including inventory and equipment. Close to


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classified ads, FROM PAGE 37

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Mending the Smallest Hearts At California Pacific, our pediatric cardiac team provides a combination of experience, community outreach, research and individualized attention while mending the smallest hearts. Our cardiology team provides evaluation and therapy for: ■ Congenital heart disease in infants, children and adults ■ Acquired heart disease including Kawasaki Syndrome, myocarditis, cardiomyopathy and rheumatic heart disease ■ Evaluation of murmurs, chest pain and hypertension ■ Cardiac arrhythmias ■ Syncope ■ Marfan’s and other heritable cardiac syndromes We also offer cardiac catheter interventions for numerous conditions. Our pediatric cardiovascular surgery team repairs complex cardiac lesions in neonates, children and adults using state-of-the-art minimally invasive techniques and robotics.

PEDIATRIC CARDIOLOGY & CARDIOVASCULAR SURGERY 3700 California Street San Francisco, Calif. 94118 Referral Line: 1-888-637-2762 www.cpmc.org/pediatrics Care Centers: Santa Rosa San Mateo Marin Stockton

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