2009 March/April

March / april 2009 | Volume 15 | Number 2

Now, more than ever.

In the current economic climate, spending more than you have to for workers’ compensation insurance doesn’t make sense. Workers’ compensation premiums are on the rise again, right at a time when reducing practice expenses must be a priority for every physician.

The Association sponsored Workers’ Compensation program, with its 5% member discount (15% depending upon where you place your group health insurance) will be even more important to members this year.

When you place your coverage with Employers Compensation Insurance Company, the sponsored program insurer, chances are your savings will exceed the 5% program discount.

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THE

BULLETIN

A PUBLICATION OF THE SANTA CLARA COUNTY MEDICAL ASSOCIATION

Message From the President.......................................................................5 Howard Sutkin, MD

From the Editor’s Desk.................................................................................6 Joseph S. Andresen, MD The OIG recommends that practice audits be conducted at least annually, and that they be used to identify risk areas such as coding and billing, reasonable and necessary services, and documentation requirements.

More on page 8

How to Perform a Physician Practice Internal Billing Audit.....................8 CMA’s 35th Annual Legislative Leadership Conference . .......................12 Addressing Climate Change in the Health Care Setting: A New Climate of Action.........................................................................14 Cindy Russell, MD

Survey of Pregnant Patients Found Significant Risk Factors Associated With Tobacco, Alcohol, And Other Drug Use........................................15 Santa Clara County Public Health Department

“You’ve Been Served:” Despite these symptoms, the physician is expected to manage the lawsuit, prepare for a trial if necessary, and carry on with his or her practice.

More on page 16

Coping With the Stress of Malpractice Litigation.................................16 NORCAL Mutual Insurance Company

Awards Banquet Invitation.......................................................................20 Coding Q&A................................................................................................22 Sandie Becker, CMC

New Obesity Resources..............................................................................23 Welcome 89 New Members.......................................................................25 Currently, we spend obscene amounts of money trying to influence our “elected” officials and those who wish to be elected.

More on page 32

MEDICO News.............................................................................................28 Now is the Winter of Our Discontent........................................................32 Lawrence Daniel Stern, MD

Classified Ads..............................................................................................36 PAGE 3 | THE BULLETIN | MARCH / APRIL 2009

The Santa Clara County Medical Association Officers

House Officer Representative

Councilors

President Howard Sutkin, 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

Jacob Ballon, MD

Community Hospital of Los Gatos: Judith Dethlefs, MD El Camino Hospital: Michael Curtis, MD Good Samaritan Hospital: Eleanor Martinez, MD Kaiser Permanente Hospital: Allison Schwanda, MD O’Connor Hospital: Jay Raju, MD Regional Med. Center of San Jose: Emiro Burbano, MD Saint Louise Regional Hospital: John Saranto, MD Santa Teresa Community Hospital: Efren Rosas, MD Stanford Univ. Medical Center: Peter Cassini, MD Santa Clara Valley Medical Center: Patrick Kearns, MD

AMA Trustee - SCCMA John D. Longwell, MD

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)

Chief Executive Officer

John D. Longwell, MD (Hospital Based Physician)

William C. Parrish, Jr.

THE

BULLETIN

A PUBLICATION OF THE SANTA CLARA COUNTY MEDICAL ASSOCIATION

Printed in U.S.A.

Editor Joseph S. Andresen, MD

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 2009 by the Santa Clara County Medical Association.

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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.

Y MEDIC UNT A CO

C AL

IAT SSOC ION • LA

Pam Jensen

TA CLARA SAN

Managing Editor

IF O R N IA

MEMBERSHIP AS OF MARCH 23, 2009 Active Members....... 2,610 Retired Members........ 871 Students....................... 352 TOTAL MEMBERS......3,833

PAGE 4 | THE BULLETIN | MARCH / APRIL 2009

MESSAGE FROM THE PRESIDENT

change is all around us Some Change is Good, Some is Clearly Bad

By Howard Sutkin, MD, FACS Change is all around us. We California physicians are being attacked from all angles. New court rulings make billing for emergency services with noncontracted HMO patients—unlawful.

New challenges on our historic “corporate bar” on medicine may allow physicians to be hired by hospitals and insurance companies. New governmental interest in single payor is coming—“like it or not.”

(Sound familiar?) All of this in a time of diminishing prosperity in the local and national economy. What is the appropriate response to all of this? Fear? Despair?

Give up? No way!—Prepare. There is a real urgency, right here and right now, to

physician-of-their-choosing and have that physician direct their diagnosis and treatment program with a minimum of interference by outside interests and parties. Knowing this, our elected officials have had a hard time siding with the anyone who would undermine this notion.

Our second strength is our numbers. At this time, the CMA only represents about 42% of physicians in the state. In order to be effective, we need to grow. By becoming part of the local and state associations, you

participation. We will be having our House

add your voice to the solid, yet potentially

of Delegates meeting on October 17-19,

stronger, collective body of medicine in the

2009. This is our opportunity to effect the

state. If we had the kind of numbers that

kind of change we want, as compared to

other lobby groups had, we would have

the kind others want to effect on us. Please

everything our way.

contact your hospital councilor—who is your representative at the SCCMA—if you

organize and direct our futures. Organized medicine, particularly the SCCMA and CMA, is now more important than ever before, at least as far back as I can ever remember. The intention of our local group is to be the voice of sanity to our elected representatives and we invite you all to help out. What are things you can do?

First, encourage all of your

have any suggestions for legislative action

Organized medicine, particularly the SCCMA and CMA, is now more important than ever before, at least as far back as I can ever remember.

non-member colleagues to join us. Our strength is twofold. First, we have the moral highroad. Our collective goals do not revolve around fat salaries for docs, but rather in preserving the nobility of medicine. Our highest goal is the efficient delivery of the best health care the world over. The patient is the focus of our efforts, and centers as our top priority.

Every citizen should be able to see the

Howard Sutkin, MD is the 20082010 President of the Santa Clara County Medical Association. He is board certified in plastic and reconstructive surgery and is currently practicing in the Los Gatos/San Jose area.

As a member, please feel free to lean on us and share your problems, as you see them. This spring, we will be organizing meetings to address the myriad of obstacles we face. We have a countywide delegation to the CMA to bring these problems to the state level. Tanya Spirtos, MD is our delegation chairperson. She and I both welcome and appreciate your PAGE 5 | THE BULLETIN | MARCH / APRIL 2009

or regulatory changes which will help you to serve your patients more effectively.

Some change is good, some is clearly bad. We can no longer afford to sit back and let stuff just happen to us anymore. Let’s take charge!

FROM THE EDITOR’S DESK

it was 1993

By Joseph Andresen, MD It was 1993: Louise: But this was covered under our old health insurance plan.

Moderator: To send Congress a message on flat community rating, call today.

Twenty-six years later, Louise and Harry reappear a bit older, but with much different concerns:

Harry: Yea, that was a good one, wasn’t it?

Moderator: Things are changing and not all for the better. The government may force us to pick from a few health insurance plans designed by Washington bureaucrats.

Louise: Having choices we don’t like isn’t having any choices at all.

Harry: And they choose.

Louise: And we lose.

Moderator: For reforms that protect what we have, call toll free 1-800/285-HEALTH. Know the facts. If we let the government choose, we lose. Call today.

Harry: Health care costs are up again.

Small companies are being forced to cut their plans.

Louise: Tell me about it. You know, Lisa’s

Harry: Louise, Todd was just telling me that his state has community rating.

Louise: Everyone pays the same rate, no matter what their age, if they smoke, or whatever. Does it work?

Todd: My health insurance went from $1,200 to $3,200 a year.

Harry: More than doubled?

Todd: Yea, thousands dropped their insurance. We actually have fewer covered now than before.

Harry: Congress can do better than that.

Louise: If we send them that message.

husband just found out he has cancer.

Harry: But he’s covered, right?

Louise: No, he just joined a start-up and can’t afford a plan.

Harry: Too many people are falling through the cracks.

Louise: Whoever the next president is, health care should be at the top of his agenda.

PAGE 6 | THE BULLETIN | MARCH / APRIL 2009

Joseph Andresen, MD is the editor of The Bulletin.

He is board certified in anesthesiology and is currently practicing in the Santa Clara valley area.

We are now in a very different time than the early 1990s of the Clinton administration, when health care reform was proposed and failed. Then, the American Medical Association, manufacturers, insurance companies, and private industry were all in opposition.

Many experts agree that there is a much different mood now. Private insurance companies see their business declining.

Hospitals and physicians are struggling with increasing numbers of uninsured patients. Small businesses are hoping for help with the continually rising costs and the financial burdens of providing health care coverage for their employees.

Uwe Reinhardt, professor of economics and public affairs at Princeton University, spoke recently about the hidden costs of the health care bureaucracy in a timely and very informative interview (http://www.npr.org/templates/story/story. php?storyId=101706614). Reinhardt is the James Madison Professor of Political Economy and has been a member of the Institute of Medicine and National Academy of Sciences since 1978. He has served on the editorial boards of many publications, including the Journal of Health Economics, the New England

Journal of Medicine, and the Journal of the American Medical Association.

In a wide-ranging discussion, Professor Reinhardt probes the complexity and pitfalls of our current medical billing system where costs and charges may have little connection, large staffs are needed by hospitals to haggle over bills with insurance payers, and doctors are overwhelmed and deeply frustrated with the current resources and requirements to receive reimbursement for services rendered. “It is tragic when we spend as much as we do and Americans rate our health care lower than other systems elsewhere. It’s not doctors or our delivery system, but how we pay for health care.”

He also discusses the “cognitive dissonance” of the public regarding the individual’s rightful expectation of livesaving emergency treatment, yet the fact that many reject the personal obligation to chip in to pay for it.

Professor Reinhardt feels that the Obama health plan objectives: universal,

affordable, portable, and emphasis on prevention are honorable and ideals that we all can agree upon. Even his former opponent, Senator McCain, would agree with these goals. Yet there will be substantive disagreement on how we achieve these goals. This public debate will heat up over the coming months and there will be a great deal of horse-trading between the various interest groups in shaping the final legislation.

the re-emerging debate on health care reform. In this case, incremental change is far more likely as he explains in the following comments. “It’s probably the only way to get there from here. Given our history, politics, and national character, sweeping health care reform would be too big a pill to swallow. But change in some form certainly seems inevitable; there’s just too much dissatisfaction with the current situation.”

What is his advice to all Americans? “Stay away from people who simplify the debate into clichés such as ‘socialized medicine.’” Try to think through the substantive issues and have a meaningful discussion of the alternative

Senator Sheldon Whitehouse, D-R.I., bluntly concludes, “We are past the ‘Harry and Louise’ moment. We are at the Thelma and Louise moment. We are in the car. We are headed for a cliff.”

solutions. “Ask yourself, what kind of country do you want to live in? Do we want to be a nation where families who have members with cancer lose their homes and their savings?”

“National character or will” is what Arnold J. Rosoff, Wharton professor of legal studies and business ethics, calls

PAGE 7 | THE BULLETIN | MARCH / APRIL 2009

As fellow physicians and informed citizens, we have a duty to our patients and communities to keep our hands on the steering wheel and help guide our nation through this time of turmoil and potential opportunity.

PRACTICE MANAGEMENT

How to Perform a Physician Practice Internal Billing Audit An Internal Billing Audit Can Help Ensure Appropriate Payment and Compliance With Applicable Laws Reprinted With Permission From the AMA Private Sector Advocacy Department Auditing physician charges and billing practices is burdensome, but it will typically yield improved claims management processes, cash flow, and compliance with applicable laws and regulations. An annual audit allows physicians and practice staff to identify specific coding issues that may recur in similar claims submissions. Careful pre-submission monitoring and review of these similar claims may safeguard against errors that could result in a claim denial.

An internal audit allows the physician and practice staff to identify incorrect billing patterns before claims are denied or outside auditors assess penalties.

What is a billing audit?

A prospective or retrospective physician practice billing audit is commonly performed to ensure the physician is submitting appropriately coded claims according to Current Procedural Terminology (CPT®) codes, guidelines and conventions, and payer payment policies, as the physician is ultimately responsible for claims submission, even if a billing service or clearinghouse is used for claims submission to payers.

•

In a prospective billing audit, a designated practice staff person or internal compliance officer reviews the claims before they are submitted to the payer to ensure the appropriateness of the coding, documentation, and

•

adherence to health plan medical payment policies.

personnel are hired, to identify and address potential errors promptly.

In a retrospective audit, a designated person reviews claims for appropriateness after they are paid.

Who should perform the audit?

All overpayments and billing errors identified during a retrospective audit should be handled according to the payer’s repayment guidelines.

If the audit reveals a pattern of repeated billing errors, the physician should obtain legal advice from a health

The OIG recommends that practice audits be conducted at least annually, and that they be used to identify risk areas such as coding and billing, reasonable and necessary services, and documentation requirements.

law attorney to determine possible responsibilities. Additionally, the physician practice should determine and take the necessary steps to ensure the billing error doesn’t recur. A physician practice should perform a prospective audit annually, or when new physicians or billing staff

PAGE 8 | THE BULLETIN | MARCH / APRIL 2009

Physicians and practice staff should participate in the audit process for best results. As a physician, you are entitled to be paid for the services you provide when they are coded and documented appropriately. Physicians and practice staff with a strong knowledge of CPT codes and guidelines, the Resource-Based Relative Value Scale (RBRVS), as well as payer’s medical payment policy, contracts, fee schedules, and reimbursement guidelines, are invaluable to a successful audit.

Designate a practice staff person to be responsible for the audit process and consider hiring a consultant specializing in billing and collections to assist in specified audit tasks. The consultant’s contract should ensure confidentiality and compliance with the Health Insurance Portability & Accountability Act of 1996 (HIPAA).

How do I prepare for a billing audit?

1. Adopt a compliance audit and monitoring program for the practice.

Obtain a copy of “Compliance Program Guidance for Individual and Small Group Physician Practices,” published in 2000 by the Office of the Inspector General (OIG) of the Department of Health and Human Services (www.hhs.gov/oig). This audit recommendation can be adapted

to a physician practice’s internal claims review procedures.

The American Medical Association (AMA) encourages physician practices to implement a compliance plan, in the document titled “Physician Compliance Planning” (www.ama-assn.org/ ama/pub/category/ print/4598. html).

“The existence of an effective compliance plan provides evidence that any mistakes were inadvertent, and this evidence could be considered by the federal government in determining whether reasonable efforts have been taken to avoid and detect fraud and other misbehavior. A compliance plan also will detect undercoding and improve communications within a practice setting.”

2. Review a report of physician services and how frequently they have been performed over a one-to-sixmonth period. Most computerized medical software can produce this report. A physician’s evaluation and management (E/M) frequency data usually is distributed according to a bell-shaped curve because different patients in different settings receive different services. The E/M frequency data differs among different specialists because of variability in practice

populations and other factors.

According to the Medicare data, (See Figures 1 and 2 on next page) for example, neurologists generally perform proportionally more higherintensity E/M services than all specialties combined.

3. Obtain the most current Medicare E/M frequency data from your Medicare carrier or fiscal intermediary for your state and medical specialty nationally. Comparison of your E/M frequency data with that of your peers may be helpful — both before any audit and in the event of an audit. The comparison may help you to determine whether you are over or undercoding E/M services compared with your peers. If you are audited by an external agency or payer, a comparison of your claims history with that of your peers (by state and specialty or other appropriate geographically defined area) may be appropriate.

In consultation with your counsel, consider obtaining the most current Medicare E/M frequency data by CPT code from your Medicare carrier or fiscal intermediary for your state and specialty.

Know which set of Centers for Medicare and Medicaid Services’ (CMS) E/M guidelines—the 1995 or 1997 version — the payer follows under its medical review guidelines, since it will impact the payer’s E/M frequency data. The physician may report E/M services based on one of the two sets of CMS E/M guidelines.

4. Review the E/M supporting documentation and indicate why the distribution of your E/M

PAGE 9 | THE BULLETIN | MARCH / APRIL 2009

frequency data is different than the Medicare E/M frequency data for your peers by specialty and state or other appropriate geographically defined area.

How often should you audit?

The OIG recommends that practice audits be conducted at least annually, and that they be used to identify risk areas such as coding and billing, reasonable and necessary services, and documentation requirements.

What are the steps to perform a billing audit?

1. Determine who in the practice will be responsible for auditing the health plan payments. Assign staff, physicians, and an outside consultant (if appropriate) to perform the audit.

2. Review the recommended OIG audit process previously referenced, and adapt it to your practice. Address concerns including: • Will the audit be performed retrospectively or prospectively?

• What type and size of sample will be drawn: Continued on page 10

Performing a Physician Practice Billing Audit, continued from previous page random, controlled, select payers, all payers?

• What audit tools will be used to determine the appropriateness of claims?

• What risk areas should be closely monitored?

The OIG recommends auditing five or more medical records per federal payer (i.e., Medicare, Medicaid), or five to 10 random medical records per physician. Additionally, the OIG suggests three methods of drawing a random sample: from paid claims, claims by payer, or claims containing one of the top 10 denials by payers.

3. Use a claim analysis checklist to identify the appropriateness of coding, documentation, and completeness of a claim. Sample checklist items include: • Was the service performed and documented appropriately?

• Are the correct physician and practice identification numbers listed on the claim?

• Is there a CPT code that would more accurately reflect the service performed?

• Is the appropriate modifier appended to the CPT code to

more exactly reflect the service performed?

• If this medical record was reviewed by an outside auditor who does not know the patient, does the record support the CPT codes selected?

4. The medical record should substantiate that each service provided by the physician was medically necessary and reasonable. Physicians and practice staff should carefully review the payer’s medical service agreement for the specific definition of medical necessity. Payers, and even employer groups, may have their own definitions of medical necessity. AMA policy defines medical necessity as: “Health care services or products that a prudent physician would provide to a patient for the purpose of preventing, diagnosing, or treating an illness, injury, disease, or its symptoms in a manner that is: (a) in accordance with generally accepted standards of medical practice; (b) clinically appropriate in terms of type, frequency, extent, site, and duration; and (c) not primarily for the economic benefit of the health plans and purchasers or for the convenience of the patient, treating physician, or other health care provider.”

5. Ensure that the patient’s chart documentation is appropriate to the billed service. The physician may report E/M services based on one of the two sets of CMS E/M coding guidelines. Know which set of CMS E/M coding guidelines — the 1995 or 1997 version — the health plan follows under its medical review guidelines.

(Note: The 1995 or 1997 CMS E/M guidelines may be downloaded from the CMS Website, http://cms.hhs.gov/ medlearn/emdoc.asp.) All the required components of the E/M service must be met and appropriately documented in the medical record.

6. Compare the Medicare E/M frequency data for the practice’s state and specialty on which the payer may base its E/M audit with the physician’s E/M frequency data. Explain any significant variance based on patient population or other factors.

7. Identify and maintain a list of claims not accurately processed by the payer.

Determine for each claim listed the practice staff’s internal follow-up action to prevent similar non-payments from recurring. New staff should be presented with this information before billing. Additionally, current staff should remain aware and routinely review this information.

Figure 1: Established patient office visits, 2002 Medicare data for Neurology compared to all specialties PAGE 10 | THE BULLETIN | MARCH / APRIL 2009

8. Hold a meeting with the practice’s claims submission and auditing team, including physicians, to discuss any claims processing issues that can be resolved through staff and physician education or through the adjustment of the practice’s claims submission process. Document the practice’s efforts to improve its claims submission process.

9. Never stop improving the practice’s claims submission and auditing processes.

For more information, go to the American Medical Association Private Sector Advocacy Website at www.amaassn.org/go/psa.

For additional information, you may also visit the American Academy of Neurology’s Website at www.aan.com.

The content for this article was taken from an informational flyer that was developed through a cooperative effort between the American Medical Association and the American Academy of Neurology. © 2008 American Medical Association.

2009 Physician Membership Directory Update Please insert the following physician listing on page 195 in your 2009 SCCMA Membership Directory

Richard A Mahrer, MD IM Case Western Reserve Univ Sch Of Med 1950

2206 B Business Cir San Jose 95128

Figure 2: Office consultation, 2002 Medicare data for Neurology compared to all specialties PAGE 11 | THE BULLETIN | MARCH / APRIL 2009

408-293-0779

Fax: 408-293-4002

CALIFORNIA MEDICAL ASSOCIATION 35th Annual Legislative Leadership Conference DATE & LOCATION Tuesday, April 14, 2009– Sacramento Convention Center, 1400 J Street, Sacramento

TENTATIVE AGENDA 8:00 am 9:00 am 9:30 am 10:00 am 11:00 am

12:15 pm 1:30 pm 5:00 pm

Registration/Continental Breakfast CMA Welcome Health Issues and Policy Agenda Briefing • Dustin Corcoran, Vice President, CMA Government Relations Legislative Panel, moderated by Dustin Corcoran • Senator Alex Padilla (D-Los Angeles) - Invited Optional breakout sessions • Medical Student Section • Ethnic Medical Organization Section • Peer Review • Scope of Practice Luncheon and Keynote Speaker • Attorney General Edmund "Jerry" Brown (confirmed) Meetings with Legislators (scheduled by county medical societies) Adjourn

HOTEL, TRAVEL & REIMBURSEMENT Travel, hotel arrangements, and expenses for the Legislative Leadership Conference will be the obligation of each individual participant, unless other arrangements are made through your county medical society.

The CMA room block is at the Residence Inn at Capitol Park, 1501 L Street, Sacramento, CA. You may make reservations by calling 916/443-0500 or through the website, www.marriott.com/hotels/travel/sacdt-residence-inn-sacramento-at-capitol-park. If you book online, please use the code CMACMAA in the group code box.

CMA will provide meals and conference materials to all participants free-of-charge.

Three ways to RSVP: Email: jean@sccma.org Fax: 408/289-1064 Phone: 408/998-8850 Ext. 3010

“FAX BACK” 408/289-1064 RSVP TODAY! SCCMA Student, Resident, Alliance, and Physician members are invited to attend CMA’s 35th Annual Legislative Leadership Conference. We will meet with local legislators to discuss pending resolutions/bills that will affect the future of medicine. This is your chance to make your voice count and to see what CMA is doing for you! SACPAC will provide transportation to and from Sacramento on a chartered bus. Breakfast and lunch also provided. To RSVP for Legislative Day and/or a seat on the chartered bus, please RSVP ASAP to Jean Boileau Cassetta.

We will leave from the SCCMA parking lot at 6:00 AM and return to the parking lot at approximately 6:30 PM. Seats are limited. Agenda packets will be mailed to you, if you RSVP

by March 27, 2009.

Name:

Ph: I will meet you there

I will ride the bus

PAGE 12 | THE BULLETIN | MARCH / APRIL 2009

PAGE 13 | THE BULLETIN | MARCH / APRIL 2009

ENVIRONMENTAL HEALTH

ADDRESSING CLIMATE CHANGE IN THE HEALTH CARE SETTING A NEW CLIMATE OF ACTION

By Cindy Russell, MD Chair, SCCMA Environmental Health Committee The question has finally changed from “Is global warming real?” to “What can we do about global warming?” Our culture is at the same time shifting from a culture of living “for the moment” to a culture that is thinking about the next generation and the problems they have already inherited. In every aspect of our lives, from recycling to the food we buy and the products we purchase, sustainability and “life cycle” are now questioned.

Will our garbage continue to be toxic landfill in the future? How can we prevent pharmaceuticals and personal care products from entering the water we drink? Why is there mercury in high fructose corn syrup and plastics in our infant formula? We will be gone, but what about our kids? Asking questions and then beginning to answer them is real progress. Hooray! We are all, as individuals and institutions, part of the solution. Changing habits is essential.

Health Care Consumes $5.3 Billion in Energy Per Year Global warming is, of course, our largest and most urgent concern.

Many of you and our Environmental Health Committee at the SCCMA are also now asking, “What can we do as a community of private practitioners, hospitals, medical groups, and HMOs to reduce energy consumption and climate change?” As it turns out, there is a lot. Many health care facilities occupy aging, energy inefficient buildings. Health care spends $5.3 billion on energy every year (www.eere.energy.gov/buildings/ info/health/). Health care facilities also consume a large amount of other resources,

which means energy consumption as well.

One medical center in the San Francisco Bay Area generates six tons of waste per day. Health care is responsible for oneseventh of the U.S. economy, thus reducing emissions from the health care sector is of national importance. The Environmental Health Committee has decided to focus attention on what we all can do to mitigate global climate change in our own county.

Dr. Cindy Russell has served as chairperson of the Environmental Health Committee since 1987 and is also currently serving on the Executive Committee as Vice President, Community Health.

A Greening Checklist Health Care Without Harm, an international coalition in the health care sector, has created a wonderful survey to address the state of “Greening” of health care facilities. As one goes through this checklist, it becomes obvious that some things have been done, but there is still a lot of opportunity to take more action. This is a useful tool along with the other resources of Health Care Without Harm and Practice Greenhealth. Hospitals in the county will be asked to take this survey. It is interesting that many of these changes have been instituted already by several large Silicon Valley businesses. Health care institutions are a bit behind the curve, but want to change that, and many are already actively working on these issues. We hope that both large institutions and private practitioners will want to participate.

Areas to address include: Transportation • •

• •

Help commuters reduce emissions with carpooling/carshare/bike racks.

Reorganize hospital fleets, ambulances, shuttle vans with hybrid/ high fuel efficiency vehicles.

Choose local suppliers to reduce transportation costs.

Institute purchasing preference for less packaging and energy efficient modes

PAGE 14 | THE BULLETIN | MARCH / APRIL 2009

of transport (many large businesses in Silicon Valley are already doing this).

Energy-Operations •

Dedicate personnel to energy conservation.

• Install occupancy sensor switches.

• Upgrade equipment.

• Reduce “standby” energy use.

• Buy green power.

Waste • •

Recycle and buy recycled products.

Collect and recycle nitrous oxide gases.

• Dispose of waste locally.

• Prevent waste by eliminating packaging and using compostables.

• Divert and reuse construction waste.

Food Service •

Reduce amount of meat protein on the menus.

• Buy local and seasonal foods.

• Buy organic food when possible.

• Compost food waste.

• Switch to reusable items for patients, staff, and visitors.

• Eliminate bottled water.

For more information, you can visit www.noharm.org, and Practice Greenhealth at www.practicegreenhealth. org.

SANTA CLARA COUNTY PUBLIC HEALTH DEPARTMENT

SURVEY Of PREGNANT PATIENTS FOUND SIGNIFICANT RISK FACTORS ASSOCIATED WITH TOBACCO, ALCOHOL, AND OTHER DRUG USE Neena B. Duggal, MD, Vice Chair Obstetrics & Gynecology, Santa Clara Valley Medical Center, partnered with the Coalition for Alcohol & Drug Free Pregnancies (CADFP), to conduct a research study to understand the prevalence of Alcohol, Tobacco, and Other Drugs (ATOD) use. The survey was developed based on a standardized screening tool, 5 P’S1, designed to quickly identify patients at-risk for ATOD use.

Results of this survey indicate a current ATOD2 abuse rate of 20.1%. About 16% of respondents admitted to smoking tobacco in the past three months, 8.5% reported alcohol or drug use in the past month, and 7% admitted to having difficulties in the past due to alcohol or other drugs.

Over 45.4% of women respondents were at-risk 3 for substance use. At-risk was analyzed based on combined responses to adverse mental health, violence, and 5 P’S (Parents, Peers, Partner, Past, Present, and Smoking).

Key Findings Three hundred ninety-nine (399) women participated in the study, representing a 34% response rate (1158 surveys distributed). The survey was administered in Spanish to 40% of the respondents (remaining surveys were in English). The majority (62.4%) of the respondents were Latinas.

The prevalence rate of current ATOD use during pregnancy was 20.1% in the women surveyed, or one in five respondents. Nearly 45% of the respondents were at-risk for 5 P’S, adverse mental health, and family violence. There was no significant difference between Hispanic and Whites in reporting current substance use. However, Hispanics and Whites reported significantly higher rates

of ATOD use, as compared to Blacks and Asian/Pacific Islanders. Significantly fewer Hispanic mothers (9.7%), compared to mothers of other race ethnic groups (27.5%), reported smoking tobacco within the last month. There were no differences between Hispanic mothers (20.4%) versus mothers from other race ethnic groups (19.5%) about having a problem with adverse mental health issues.

Discussion Dr. Duggal, principal investigator of the research, stated that these results are significant because current screening protocols do not capture these considerable numbers of vulnerable patients and babies. Dr. Duggal stated, “As doctors, we know that prenatal exposure to ATODs is the leading preventable cause of birth complications, defects, and developmental disabilities. We plan to use the results of this study to improve screening and intervention programs at Santa Clara Valley Health & Hospital System’s CPSP Program.”

Dr. Martin Fenstersheib, Santa Clara County’s Health Officer, stated that these findings demonstrate the need for all physicians and their staff to become more comfortable addressing substance use issues. He stated that patients do not volunteer information about substance use unless specifically asked. Best practices recommend asking screening questions of all women and providing a brief intervention by having information and counseling resources readily available.

Dr. Fenstersheib emphasized, “The practitioner can make a major difference in the health of the baby throughout his or her lifetime by helping the patient with alcohol and/or drug use.” He encourages other medical providers to review best practices, PAGE 15 | THE BULLETIN | MARCH / APRIL 2009

revise office protocols, and utilize local resources.

Limitations of the Study The survey was anonymous.

Therefore, follow-up of patients to evaluate pregnancy outcomes was not part of the survey methodology.

Footnotes 1. 5 P’S: The Institute for Health & Recovery adapted the nationally known 4 P’s (Ewing, 1990) to develop the 5 P’S screening tool. The screening questions are broad-based and highly sensitive, and one positive answer to any question is considered a positive screen.

2. Current ATOD use: Use of alcohol and other drugs, including prescription medications, within the past month and within the past three months for tobacco.

3. At-Risk: Any positive response for the 5 P’S (parents, partner, past, present, peers), smoking, adverse mental health, and family violence.

Acknowledgements We gratefully acknowledge funding support provided by the Santa Clara County Department of Alcohol & Drug Services, and institutional support from the Santa Clara County Public Health Department.

Special thanks to Santa Clara Valley Health & Hospital System’s Obstetrics & Gynecology Department for their resources and collaboration in the success of this project.

For a more detailed report, or for a copy of the survey instrument, please contact Raj Gill, Perinatal Substance Abuse Coordinator, at 408/494-1555 or at raj.gill@hhs.sccgov.org.

PRACTICE MANAGEMENT

“You’ve Been Served” Coping With the Stress of Malpractice Litigation Submitted by NORCAL Mutual Insurance Company As a physician, the odds are greater than 50/50 that you will be sued for malpractice at least once during the course of your career.1 A majority of malpractice lawsuits never go to trial, but the stress of being served can lead to serious emotional, and even physiological, consequences.

Researchers have been redefining the way we think about the physician’s experience of being sued for malpractice, exploring professional and economic ramifications in addition to personal and emotional effects.

This research is helping physicians manage the short- and long-term impact on their practices and personal lives.

The Myth of Infallibility: Why So Many Physicians Get Sued Physicians today are held to seemingly impossible standards by patients, the public, and themselves.

According to Frank B. Kelly, MD and Mark C. Gebhardt, MD, members of the American Academy of Orthopaedic Surgeons’ (AAOS) Physician Stress Project Team, “more and more, the public is expecting perfection. The line between an unfortunate outcome and perceived malpractice is blurring. Many patients believe that a less-than-perfect result justifies a lawsuit.”2 Many do not realize or appreciate the extent to which a claim can disrupt a physician’s life. A malpractice suit often irrevocably alters the way physicians practice medicine. Because they tend to

be self-critical and often possess an acute sense of responsibility, they are especially vulnerable to feelings of doubt and guilt when something goes awry.3

Despite these symptoms, the physician is expected to manage the lawsuit, prepare for a trial if necessary, and carry on with his or her practice.

Emotional Impact Studies show that emotions experienced by physicians being sued are comparable to those that accompany any catastrophic life event, and typically include shock, denial, shame, anxiety, anger, and depression. Physicians often experience the following: •

Disillusionment

•

A magnification of self-doubt

•

Persistent negative feelings

•

Isolation, frustration, and the feeling of being unjustly singled out

•

Massive guilt, even if their performance wasn’t to blame

•

An onset of physical symptoms such as GI and chest pains, or an exacerbation of preexisting conditions4

Despite these symptoms, the physician is expected to manage the lawsuit, prepare for a trial if necessary, PAGE 16 | THE BULLETIN | MARCH / APRIL 2009

and carry on with his or her practice.

Many physicians find themselves unable to cope. Researchers have found that two factors commonly contribute to physicians’ feelings of vulnerability, when faced with a malpractice suit: a lack of legal training and a lack of training in how to deal with emotions.5 According to Sara C. Charles, MD, a pioneer in the field of litigation stress, when a physician is unable to cope with the stress associated with litigation, he or she is likely to take counterproductive measures.3 The physician may begin to practice defensive medicine, engage in obsessive record keeping, avoid patients with a greater risk of experiencing adverse outcomes, become emotionally distant from patients, work fewer hours, and even retire early. Personally, the physician may feel isolated and withdraw from family, friends, and social activities.4

Methods for Coping Studies have shown that the following strategies can help physicians cope with the stress of a lawsuit more effectively: •

Accept that litigation is an occupational hazard of practicing medicine.

“It’s important to accept the fact that no matter how good you are and how hard you try, there will be bad outcomes under your care.”6 Numerous studies have debunked the notion that incompetent doctors get sued and competent ones do not. It’s important to note that compensation

commonly lies at the heart of malpractice law, not competence.1 •

•

•

•

Familiarize yourself with your case and be ready and willing to share the burden.

It is difficult when dealing with a malpractice suit to allow your legal team to take the lead. Doing so does not mean that you relinquish control of your case. You simply share the burden with professionals who are there to help you.

Restore mastery and self-esteem.

Use this opportunity to identify areas of your practice that cause you doubt or anxiety, and find ways to change or diminish them.

Maximize pleasurable downtime.

Some physicians overwork to compensate for a perceived lack of competence. During this difficult period, it is important to balance work with pleasure and engage in enjoyable, stress-relieving activities.

Ask for emotional support from family, friends, support groups, and your malpractice insurer.

A good defense attorney will tell you not to talk about the case, but that doesn’t mean you can’t talk to trusted confidantes about your experience.

Experts agree that is the single most effective coping mechanism. It may also be helpful to seek support from organizations dedicated to assisting physicians in your situation. Support can be found at the nonprofit Physician Litigation Stress Resource Center at www.physicianlitigationstress.org.

Additionally, physicians should look to their medical malpractice insurer for support.

Emergency Physicians. Available at www.acep.org/webportal/ membercenter/ aboutacep/careers/ residentsres/profskills/GettingSued. htm. Accessed December 12, 2005.

The coping suggestions presented may significantly mitigate the emotional impact of a lawsuit and help physicians to maintain an optimistic outlook.

Endnotes 1. Brazeau MD, Chantal M.L.R. “Coping with the Stress of Being Sued.” Family Practice Management, May 2001.

2. Kelly MD, Frank B., and Mark C. Gebhardt MD. “The Liability Stress Syndrome.” American Academy of Orthopaedic Surgeons Online Bulletin, December 2004.

Printed by permission of NORCAL Mutual Insurance Company. NORCAL is the premier provider of professional liability insurance for physicians, medical groups, community clinics, hospitals, and medical facilities. To access additional articles published by NORCAL, visit www.norcalmutual.com.

3. Charles MD, Sara C. “Coping with a Medical Malpractice Suit.” Western Journal of Medicine, 2001; 174:55-58.

4. Wu, Albert W. “Medical Error: The Second Victim.” BMJ, March 2000; 320:726-7. Available at www.bmj.org.

Accessed December 8, 2005.

5. Hobbs PhD, Thomas, and Gregory Gable. “Coping with Litigation Stress.” Physician’s News Digest, January 1998.

6. Thurman MD, Jason R. “Getting Sued: A Resident’s Perspective.”

American College of

Redefining the Malpractice Lawsuit No physician is immune to the threat of a malpractice claim. It is one of the risks of practicing medicine today.

PAGE 17 | THE BULLETIN | JANUARY / FEBRUARY 2009

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PAGE 18 | THE BULLETIN | MARCH / APRIL 2009

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Neda Pakdaman, MD Pathways Hospice Medical Director Learning Objectives: • Examine how diversity influences end-of-life decision making • Increase your cultural knowledge by understanding how cultural values and assumptions influence delivery of care • Learn how hospices are incorporating traditional practices and alternative therapies at the end-of-life

For more information or to register: call 408.481.3220, press 6, enter ext. 6365, #, or visit www.pathwayshealth.org/teleconference.html PAGE 19 | THE BULLETIN | MARCH / APRIL 2009

An Invitation To All SCCMA Members, Alliance Members & Guests The Santa Clara County Medical Association and Alliance Invite You to Attend the...

2009 Annual

Awards Banquet and Installation Tuesday, June 2, 2009 6:30 pm Social 7:00 pm Dinner & Program The Fairmont Hotel, San Jose Installation Howard Sutkin, MD, President 2009-10 Award Honorees Bernadette Loftus, MD; Thomas M. Krummel, MD; George P. Kent, MD; Martin L. Fishman, MD; Seham F. El-Diwany, MD; and Peggy Fleming Jenkins Please mark June 2 on your calendar now.

Formal invitations will be mailed in April.

All members are asked to please consider hosting a medical student or resident.

★ ENTERTAINMENT ★

Dean Martin

•

TA CLARA SAN

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Serving Physicians Since 1876

Phone (408) 998-8850

Not a Member of Santa Clara County Medical Association or CMA?

Why Not! Here are just a few of the benefits you’re missing…

Vast CMA Resources: • • • • • •

Contract Analysis Legal Hotline Legislative Hotline HIPAA Compliance Seminars and Conferences Extensive Online Resources including over 200 letters, agreements, forms, etc.

• Plus - Free Legal Advice with CMA ON-CALL Documents!

Santa Clara County Medical Association Resources: • • • • • • • • • • •

Annual Directory Member Seminars Cost-Saving Benefits Bi-Monthly Publication Classified Advertising Insurance Savings Alliance Membership Annual Social Events Patient Referrals Practice Resources Reimbursement Advocacy

Federal, State, and Local Advocacy: Your dues are an investment which supports our efforts in protecting your rights.

If We Don’t Fight for You… Who Will?

PAGE 21 | THE BULLETIN | MARCH / APRIL 2009

CODING & REIMBURSEMENT NEWS

coding Q&A Your Reimbursement Specialist Has the Answers!

By Sandie Becker, CMC SCCMA Coding/Reimbursement Specialist Q: If blood is drawn from a vein using a butterfly catheter (for purposes of obtaining a laboratory specimen), would it be appropriate to code 36415 or code 36000?

Per CPT, code 36415, collection of venous blood by venipuncture, should be reported because it describes venipuncture to obtain a blood specimen using either a butterfly or another type of blood collection apparatus. It would not be appropriate to report code 36000, introduction of needle or intracatheter, vein, because code 36000 involves not only placement of a needle or intracatheter into a vein, but is specifically used when a venous injection procedure is being performed. If the venipuncture requires a physician’s skill, then a code from the 36400-36410 series may be appropriate.

Q: I’m suddenly getting denials from Palmetto GBA, the new Medicare carrier for California, on my claims for allergy skin testing stating “the

Would you like to receive updated coding & reimbursement news by email? If so, please call the SCCMA office to provide your email address at: 408/998-8850 ext. 3007 or email: sandie@sccma. org. You may also visit our website at: www.sccma.org.

number of days or units of service exceeds our acceptable maximum.”

We are billing 95004 with 93 units. We never had this problem before; do you know what we can do to get proper reimbursement?

Effective 7/1/2008, CPT code 95004 is on CMS’s Medically Unlikely Edits (MUE) list with 80 units being the limit to bill. Although CMS publishes most MUE values on its website (http://www.cms.hhs.gov/ NationalCorrectCodInitEd/08_MUE.asp), other MUE values are confidential and are for Medicare Contractors’ use only. This one, I found out after contacting Palmetto, is not made public. CMS developed MUEs to reduce the paid claims error rate for Part B claims. An MUE for a HCPCS/ CPT code is the maximum units of service that a provider would report under most circumstances for a single beneficiary on a single date of service. Also on the CMS website, located under the MUE FAQ’s link, I found the answer to reporting medically reasonable and necessary units of service in excess of an MUE value. Here is what it says: “Since each line of a claim is adjudicated separately against the MUE value for the code on that line, the appropriate use of Current Procedural Terminology (CPT) modifiers to report the same code on separate lines of a claim will enable a provider/supplier to report medically reasonable and necessary units of service in excess of an MUE value. CPT modifiers such as -76 (repeat procedure by same physician), -77 (repeat procedure PAGE 22 | THE BULLETIN | MARCH / APRIL 2009

For coding questions and reimbursement issues, contact Sandie @ 408/9988850 ext. 3007 or email sandie@ sccma.org.

by another physician), anatomic modifiers (e.g., RT, LT, F1, F2), -91 (repeat clinical diagnostic laboratory test), and -59 (distinct procedural service) will accomplish this purpose. Modifier -59 should be utilized only if no other modifier describes the service.”

In this case, you would report 95004 on one line with the number of units as 80 and on a second line, report 95004 with the appropriate modifier and remaining units of 13.

Q: How do I bill for a failed IUD insertion? The physician tried for 30 minutes, but was unable to insert the IUD. You may bill the IUD insertion, 58300 with the modifier -53 appended.

You may also consider contacting your representative that supplies the IUD and ask if they will replace it, since it cannot be used again. If the patient returns at a later date for the insertion, and it is successful, you may bill again for the insertion and the IUD as well.

CMA FOUNDATION

NEW OBESITY RESOURCES CMA Foundation in Collaboration With California Association of Health Plans Offers New Obesity Prevention Provider Toolkits www.calmedfoundation.org for easy-to-find and easy-to-use materials Former Surgeon General Richard Carmona, MD has called obesity “the fastest growing, most threatening disease in America today.”

It is no surprise that many physicians feel overwhelmed and frustrated by the daunting task of addressing weight issues with their patients given the physical, emotional, social and environmental factors associated with obesity and weight management. Providers hear a variety of messages about prevention, treatment and management of obesity that make it increasingly difficult to determine the best plan of action to take with patients.

In an effort to address and improve these issues, the California Medical Association (CMA) Foundation and the California Association of Health Plans (CAHP) collaborated with commercial and MediCal managed care health plans, practicing physicians and other health provider organizations to complete an Obesity Prevention Provider toolkit, in an effort to address the prevention, early identification, weight management education and prepost-bariatric surgery care of overweight and obese individuals. As a result, the project brought together leaders from health plans, academic medical centers, physician practices and other health care providers to share their daily experiences

of working to address the growing obesity epidemic in their practice and community.

Once established, this expert panel divided into three work groups that identified practical information and

medical offices, strategies for managing overweight patients, billing and procedure codes and clinical guideline abstracts. In addition, these toolkits equip health care providers with strategies to assess and treat overweight and at-risk for overweight patients, and offer pertinent information for providers to consider when discussing healthy lifestyles and weight management with patients.

For more information about the Obesity Prevention Provider Toolkits, visit: http://www.calmedfoundation.org/projects/ obesityProject.aspx or contact Alisa Matthews, Obesity Prevention Project Director at 916.779.6632.

approaches for health care providers and resulted in a set of toolkits addressing prevention and effective management of overweight children and adolescents, overweight and obese adults and pre/post bariatric surgery patients.

The toolkits include effective communication techniques, resources for

PAGE 23 | THE BULLETIN | MARCH / APRIL 2009

The

2009 Physician Membership Directory is now available!

To order additional copies ($30 members; $60 for non-members) Contact Maureen at 408/998-8850 or maureen@sccma.org

NEW THIS YEAR!

The 2009 Directory will be available in electronic format (CD-ROM or Flash Drive) in May 2009

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Asset Protection

MEMBER NEWS & HAPPENINGS

Welcome 89 New Members!

Name Mala Ahluwalia Roomana Akhtar Yumi Ando Catherine Baker Lawrence Basso

Specialty FP IM IM FP *IM *EDM *NM Myriam Bertoldo P Preete Bhanot OBG Aleksandra Bokszczanin-Knosala A Lily Boris IM Lidia Brown N Josipa Bubalo IM Emily Cabebe IM Marisa Cappiello PD Kimberley Carlson IM Nichola Carpendale UC *FP Juan Carrillo *PD Peter Cheng IM Ryan Collins IM Josephine Concepcion PD Susan Connolly OPH James Cowan R Ellen De Coninck D Arul Doraiswamy AN Charlotte Drew PD Rebecca Fazilat PD Solon Finkelstein *R DR Joycellen Floyd *FP Maisie Fung FP David Gershfield N Umamaheswari Gopalrathnam AN Richard Greene *PD PDC Devina Grover FP Linda Harris FP Tina He OTO David Hemsey US Mathew Hernandez IM T Warner Hudson FP Trupti Kapadia IM Gregory Kato IM Sangeeta Kopardekar IM GEN Ian Kroes FP Steve Lai *GER *IM Alison Lam PD Sophia Lee GS Lynette Lissin CD IM Melissa Liu IM

City Mtn View San Jose Palo Alto Palo Alto Palo Alto San Jose San Jose San Jose Campbell San Jose San Jose Santa Clara Sunnyvale Mtn View Palo Alto San Jose Palo Alto Mtn View San Jose Palo Alto Mtn View Mtn View San Jose Palo Alto San Jose Palo Alto Palo Alto Mtn View Palo Alto San Jose Palo Alto San Jose Palo Alto San Jose Palo Alto Palo Alto San Jose San Jose Mtn View Mtn View Palo Alto San Jose San Jose San Jose Palo Alto San Jose

Name Joanne Markle Sreedevi Menon Celia Mercado Ma Aye Moe Aliza Monroe-Wise Amy Muzaffar Thomas Nachbaur Girish Narayan Myduyen Nguyen Peter Nguyen Neda Pakdaman Manisha Panchal Sejal Patel Thao Pham Albert Pisani Sandhya Prabhakar Vijaya Ram Cheena Ramrakhiani Manasi Rana Diego Ruiz Annapurna Sathi Ellen Schneider Kathleen Serventi Allen Shah Nikhat Shaik Nicole Simpson Tej Singh Catherine Snively Beck Soderberg Rita Sohlich Elizabeth Swenson Lai Tan Christine Thorburn Mamta Thukral Conrad Vial Janet Volpe Erica Weirich Faith Wells Karen Whang Todd Yao Patricia Yeh Khin Yi Afshin Zeighami *Board Certified

PAGE 25 | THE BULLETIN | MARCH / APRIL 2009

Specialty P US OBG IM Student IM US CD PD *FP IM PD IM OM GO FP IM CD P DR NM IM FP IM *PMR IM GE GS IM IM DR OBG IM RHU IM GS PD FP *IM GS FP IM IM US

City San Jose San Jose San Jose San Jose Stanford Los Altos San Jose Palo Alto San Jose San Jose Sunnyvale Santa Clara San Jose San Jose Los Gatos Sunnyvale Mtn View Palo Alto San Jose Palo Alto San Jose Palo Alto San Jose Mtn View San Jose Mtn View Mtn View Gilroy San Jose Palo Alto Palo Alto San Jose Palo Alto San Jose Palo Alto Palo Alto Palo Alto Los Altos Palo Alto Mtn View San Jose San Jose San Jose

US - Unspecified

Y MEDIC

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SAN

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Santa Clara County Medical Association

Presents Two Special Half-Day Workshops to help you manage your practice more effectively San Jose—April 15, 2009—Wednesday Two sessions: 8:30 a.m.–11:45 a.m. and 1 p.m.–4 p.m.

Association Headquarters 700 Empey Way, San Jose (408) 998-8850

Morning Session: 8:30 a.m.–11:45 a.m.

How to Negotiate with Payers to !

New Maximize Your Reimbursement

Presented by Susan Charkin, President

Learn how to get paid the reimbursements your practice deserves.

Workshop leader—Susan Charkin, President, Healthcents—leading experts in negotiating with plans.

Afternoon Session: 1:00 p.m.–4:00 p.m.

Presented by George S. Conomikes, CEO

How to Improve Your Practice ! w Ne Financial Performance Learn the proven steps to take to increase your revenues and practice profitability.

Workshop leader—George Conomikes, CEO, Conomikes Associates, Inc.— nationally-recognized practice consultants.

PAGE 26 | THE BULLETIN | MARCH / APRIL 2009

Y MEDIC

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Santa Clara County Medical Association

•

•

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We are happy to sponsor two important half-day workshops for our member physicians, their managers and key staff.

The morning program features Susan Charkin, President of Healthcents, showing you how to deal with your problem payers. She will take you, step-by-step, through the techniques that she and her colleagues have effectively used for their clients. Susan knows the secrets of the payers’ procedures and will be sharing her knowhow with you.

The afternoon program brings us George Conomikes, CEO of Conomikes Associates, nationally- recognized practice consultants. He is known for his pragmatic approach to sharing his firm’s experiences in helping over 1,800 practices improve their performance and bottom-line profitability. His emphasis is in providing you with usable ideas that you can put to work and showing you how to do it – with take home materials as a valuable tool-kit.

We are pleased to recommend these programs to you and to encourage you to consider enrolling promptly.

3 Easy Ways to Enroll Fax

(858) 720-0437

Mail

Conomikes Associates, Inc. 990 Highland Drive, Suite 320 San Diego CA 92075

How to Negotiate With Payers to Maximize Your Reimbursements San Jose—April 15, 2009 8:30 a.m.–11:45 a.m.

Santa Clara County Medical Association, 700 Empey Way, San Jose

How to Improve Your Practice Financial Performance San Jose—April 15, 2009

1:00 p.m.–4:00 p.m.

Santa Clara County Medical Association, 700 Empey Way, San Jose NOTE: To register more than one person, copy and complete information on separate sheet.

Enrollee Name ______________________________________ Practice Name _______________________________________

Call Toll-Free

(800) 421-6512

Registration Fee: $143 per person, per seminar.

Special discount: you will receive a discount for enrolling in both seminars at a per person price of $261, a saving of $25.

Please make check payable and send to: Conomikes Associates, Inc.

990 Highland Drive, Suite 320, San Diego CA 92075 Telephone (800) 421-6512, Fax (858) 720-0437 Check enclosed • Credit Card:

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Exp. Date

Signature

Please check here if you are disabled and require special services. Attach a written description of needs.

Address ____________________________________________ City ________________________ State ___Zip ___________ Tel. (

) __________________ Fax ___________________

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Guarantee: It’s this simple: If you attend, and for any reason decide the workshop doesn’t live up to your expectations, we will refund all of your money or arrange for you to attend another workshop free. Whichever you choose.

PAGE 27 | THE BULLETIN | MARCH / APRIL 2009

MEDICO NEWS

MEDICONEWS

Stimulus Package Provides $87 Billion for Medicaid Programs; $19 Billion for HIT California’s Medi-Cal program is expected to receive more than $11 billion over three years as part of the $787 billion economic stimulus package signed into law by President Obama. This number is significantly higher than originally anticipated.

The stimulus bill increases federal funding for state Medicaid programs provided that the programs’ eligibility requirements are not more restrictive than they were on July 1, 2008. To receive the funds, California would have to reverse a recent policy change that requires parents to verify children’s eligibility for the program twice annually, rather than just once a year. The state would have to rescind the change by July 1, 2009, to maximize available matching funds.

The economic stimulus package also provides approximately $19 billion in incentives over five years, including bonus payments upwards of $40,000 for each Medicare provider who

demonstrates “meaningful use” of an EHR system. Physicians with significant Medi-Cal patient loads (20% or more for pediatricians, 30% or more for other specialties) may be eligible for additional bonuses paid through state Medicaid programs. As eligibility is based on usage, even physicians who already use EHR systems will be eligible. While the bill does include Medicare payment reductions (starting at 1%) for physicians who do not implement HIT systems, these do not take effect until 2015 and there are exceptions for significant hardship cases.

This is the first substantial federal funding provided to help physicians implement HIT systems—systems that will generate benefits across the health care spectrum.

CMA is currently analyzing the HIT provisions of the bill, and we will provide physicians with details and guidance on how to take advantage of the incentives soon.

The bill also establishes HIT Policy and Standards Committees that are comprised of public and private stakeholders (including physicians) to provide recommendations on the HIT policy framework, standards, implementation specifications, and certification criteria for electronic exchange and use of health information. The bill requires the U.S. Health and Human Services Department to adopt through the rule-making process an initial set of standards, implementation specifications, and certification criteria by December 31, 2009.

CMA continues to work closely with members of Congress and the Administration to ensure the voices of physicians and patients are heard and considered as new health care policies are developed.

(CMA Alert, February 23, 2009 issue)

Joint Commission Requires Ongoing Collection of Physician Performance Data The Joint Commission is now requiring medical staffs to collect physician-specific performance data on a regular basis, in addition to the every two-year credentialing cycle. The goal for this “ongoing professional practice evaluation” (OPPE) is to ensure that all physicians with medical staff privileges are monitored routinely and regularly— regardless of whether there are specific

performance issues— to find problems in a timelier manner and take appropriate steps to improve quality. The specific data to be collected is to be determined by individual medical staffs, but the Joint Commission has suggested that it could include, among other things: procedures performed and their outcomes, pharmaceutical usage, diagnostic tests ordered, length of stay patterns, and morbidity and mortality data.

PAGE 28 | THE BULLETIN | MARCH / APRIL 2009

More information on the Joint Commission’s OPPE standard (MS.08.01.03) is available in CMA ON-CALL Document #1498, “Ongoing Professional Practice Evaluation.” ONCALL documents are free to members at http://www.cmanet.org/member.

(CMA Alert, February 23, 2009 issue)

MEDICO NEWS

Obama Gets the Health Reform Ball Rolling; Promises SGR Fix President Obama has in recent weeks taken several steps towards his goal of achieving comprehensive health reform.

The president’s recently released 2010 budget proposal directs $634 billion to a “health care reserve fund” over the next decade to finance expanded health insurance coverage and other health care investments. Of particular importance to physicians, the budget proposal includes $330 billion to “…effectively eliminate the enormous deficit and scheduled Medicare physician payment cuts of 40% over the next seven years.”

The proposed budget also signals the Administration’s willingness to consider further modifications to the Medicare sustainable growth rate (SGR) formula, stating that “as part of health care reform, the Administration would support comprehensive, but fiscally responsible, reforms to the payment formula,” adding that “Medicare and the country need to move toward a system in which doctors face better incentives for high-quality care rather than simply more care.” The

President made a significant commitment to physicians to fix the Medicare physician payment system this year.

Approximately half of the health care reserve fund would be generated by increasing taxes on couples earning more than $250,000 a year and individuals earning more than $200,000. Other funding would come from Medicaid and Medicare cuts. Physicians, however, would come away largely unscathed compared to the rest of the health care sector. The proposed budget would cut Medicare Advantage funding by an expected $177 billion over 10 years by establishing a “competitive bidding” process for health plans that want to participate in the Medicare Advantage program. Hospitals, home health care, and pharmaceutical companies are also slated for multi-billion dollar cuts. Unfortunately, the proposal would ban future physician-owned hospitals.

Obama also recently convened 120 stakeholders − including physicians, hospitals, senior citizens, labor, business,

Republicans, and Democrats − to begin the discussion of how to overhaul the nation’s health care system, citing it as the key to shoring up the economy. Obama is setting an ambitious timeline to enact “comprehensive health care reform” by year’s end. Although he has not offered up a specific reform plan, Obama has outlined general principles that he believes are central to health care reform, which include increasing coverage, improving quality, and controlling costs.

CMA continues to ensure the voices of physicians and patients are heard and considered as new health care policies are developed. CMA physician leaders will meet with key Congressional representatives, including California Committee Chairmen Pete Stark and Henry Waxman, and House Speaker Nancy Pelosi who will be writing the Medicare and Health Reform legislation.

(CMA Alert, March 9, 2009 issue)

Obama Signs Children’s Health Insurance Bill President Obama signed legislation last month reauthorizing the State Children’s Health Insurance Program (SCHIP) and expanding its coverage, bringing California a total of $1.5 billion in much-needed funding for 2009.

CMA praised the measure, which will help meet the growing need for children’s health coverage, and encouraged state lawmakers to commit the state funding required to get the maximum federal dollars. Under the legislation, the federal government provides $2 for the program for every $1 spent by the state.

In California, SCHIP funds the Healthy Families program. It currently serves 900,000 kids but is growing by 30,000 a month, as job losses mount and the ranks of uninsured swell.

This extremely successful program currently provides affordable health coverage for 6.6 million children nationwide. The reauthorization bill aims to cover at least 4.1 million additional children and is funded primarily by a 62-cent increase in the federal

tax on cigarettes and other tobacco products. The final version of the bill does not include the controversial ban on physician-owned hospitals.

The bill also waives the 5 year waiting period for legal immigrant children and pregnant women. California currently covers them with state-only money.

President Obama also rescinded a Bush administration policy that has impeded state efforts to provide health insurance to children from low- and middle-income families. Under the Bush policy, states were not allowed to cover children from families with annual incomes above 250% of the poverty level — $53,000 for a family of four — unless 95% of eligible children in families making less than 200% of the poverty level were already enrolled in Medicaid or SCHIP. This nearly impossible standard has blocked or delayed the expansion of coverage in several states.

PAGE 29 | THE BULLETIN | MARCH / APRIL 2009

(CMA Alert, February 9, 2009 issue)

MEDICO NEWS

New Law Limits Markup for Radiologic Services CMA On-Call has been updated to discuss a new California law that restricts the circumstances under which physicians may bill for diagnostic imaging services. Effective January 1, 2009, physicians may no longer bill patients or insurers for the technical component of diagnostic imaging services (CT, PET, or MRI) that were not rendered by the physician or someone under his or her supervision. This means that radiologic facilities or imaging centers must now directly bill the patient or the responsible third-party payor.

Physicians are also reminded that it is a violation of law to allow physician assistants or other staff to perform x-rays without proper certification. The California Department of Public Health strictly enforces this provision and physicians found to be in violation will be cited and may be subject to additional enforcement action.

For more information, see CMA On-Call document #1335, “Mammography Facilities and X-rays.”

On-Call is CMA’s online library of medical-legal information.

It contains most of the content available in the California Physician’s Legal Handbook (CPLH). This book, an annual publication written

by CMA’s legal department, the seven-volume book contains legal information on a variety of subjects of everyday importance to practicing physicians. CPLH is available in a 7-volume softbound format or on an interactive CD-rom. To order the 2009 CPLH, call 800/882-1262.

(CMA Alert, March 9, 2009 issue)

U.S. Supreme Court Rules Against Drug Maker in Liability Case The United States Supreme Court last month upheld a $6.7 million ruling against the pharmaceutical manufacturer Wyeth for failure to provide adequate warning about the dangers of its antinausea drug, Phenergan. This was an important case for doctors: had the Court ruled for Wyeth, pharmaceutical companies would have been protected from many state-based failure-to-warn claims, potentially increasing the risk that doctors would get sued for harm caused by pharmaceutical products.

CMA had filed a brief in this case, Wyeth v. Levine, telling the justices that preemption of pharmaceutical failure-to-warn claims would obstruct physicians’ access to complete and truthful information about prescription drug safety and efficacy and would compromise patient safety.

“In order to best serve patients, physicians must have complete and truthful information about the risks and benefits of the drugs they prescribe,” said Francisco Silva, CMA vice president and general counsel. “This ruling protects patient safety and allows doctors to do their jobs.”

Wyeth was appealing the Vermont Supreme Court’s decision to uphold a jury award to Diana Levine after the drug caused serious complications and ultimately resulted in the amputation of her arm. The issue on appeal focused on whether FDA approval of a drug should preempt state legal actions against the pharmaceutical company for failure to warn of known risks.

(CMA Alert, March 9, 2009 issue)

Schwarzenegger Signs Budget Deal; Medi-Cal Largely Unscathed Governor Arnold Schwarzenegger recently signed into law a mid-year budget adjustment meant to close the state’s projected $41 billion shortfall for the next 16 months. The bill includes $14.9 billion in spending reductions, $12.5 billion in new revenues, $5.4 billion in borrowing, and a conservative estimate of $7.8 billion in new federal money. The budget deal will leave the state with a $1 billion reserve.

Among the spending cuts are $183.6 million in savings from the elimination of optional benefits in the Medi-Cal program (adult dental, acupuncture, audiology and

speech therapy, chiropractic, optometric and optician services, podiatry, psychology, and incontinence creams and washes).

Although there are no additional cuts to Medi-Cal rates for physicians beyond the 1% Medi-Cal cut scheduled to take effect March 1, reimbursements to public hospitals would be reduced by 10%. All of these cuts would take effect July 1, 2009.

These and other spending cuts may be averted, however, if California takes advantage of the increased federal matching funds available via the economic stimulus plan signed by President Obama.

PAGE 30 | THE BULLETIN | MARCH / APRIL 2009

Under the legislation, a state’s eligibility and renewal procedures for the Medicaid program cannot be more limiting than they were on July 1, 2008. As part of the budget deal enacted last September, California moved from annual to semi-annual reporting for children in Medi-Cal. If that provision is lifted, California will receive $3.7 billion in additional Medi-Cal funds this year, and $11.2 billion total over the next three years.

Contact: David Ford, 916/551-2554 or dford@cmanet.org.

(CMA Alert, February 23, 2009 issue)

THE DIABETES SOCIETY IS THE ANSWER TO EFFECTIVELY MANAGING BLOOD GLUCOSE LEVELS IN YOUR DIABETIC PATIENTS The Diabetes Society is an independent non-profit organization founded in San Jose as a one-stop shop for diabetes education and support in the communities you serve!

Services Offered: • ADA certified 3-step diabetes self-management program • Nutrition education and counseling • Free meters and instruction • Group classes (English and Spanish) • Support Groups (English and Spanish) • Insulin start appointments and pump training • Weight loss consultation and carb counting • Children’s diabetes camps throughout California Easy referral process with a variety of fee options including most insurance plans, Medicare and local IPA’s

> If you never thought about us for your patients, now is the time < For more information or brochures: 1165 Lincoln Avenue, Suite 300, San Jose, CA 95125 (408) 287-3785 Fax: (408) 287-2701 Email: info@thediabetessociety.org

When you have questions about eating disorders...

Eating Disorders Resource Center Medical education (CMEs) for you and your staff to help you address the needs of patients with eating disorders Advocacy for insurance issues Professionally-facilitated support groups for your patients and their family members (no fee; twice a month)

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An online and printed directory of local professionals who specialize in treating anorexia, bulimia, and other eating disorders. Our website provides useful links and information for patients

PAGE 31 | THE BULLETIN | MARCH / APRIL 2009

GUEST COMMENTARY

NOW IS THE WINTER OF OUR DISCONTENT

By Lawrence Daniel Stern, MD “Now is the winter of our discontent Made glorious summer” (“Richard The Third,” William Shakespeare) We have ached for this and finally got it—a change of administration and a leader with potential. Now what?!

We now have the results of our behavior for the past century; military intrusion by the U.S. in the affairs of a multitude of nations, a debt that will impoverish our grandchildren, and the despair of nations, who at one time revered this haven of liberty founded on justice.

Words issued to justify our actions, such as “democracy” and “lack of colonial intent,” have been used previously by the British when they occupied Mesopotamia in 1917.

Nothing is new under the sun.

Perhaps a reappraisal of who we are as humans might be in order.

Why, for example, when Moses came down from Sinai, did he enunciate things that any mother would demand of delinquent children? Because his itinerant group of refugees from Goshen were getting restless and doing naughty things, even going so far as to worship the Golden Calf, as they attempted to understand how they had come to this dreadful place in a burning desert far from the lush fields of the Nile Delta, now dreamily remembered as a wonderful place despite the harsh overseers, etc.

While the Golden Calf might have offered solace to some, Moses had other ideas, some of which eventually found their way into the Constitution of the United States.

We have, at this period in human history, found ourselves once again at a crossroads. There have been plenty of crossroads throughout history, but this one is facing us here and now. Though we are temporarily distracted by efforts to prevent a worldwide depression, our goals transcend economic policy.

Homo sapiens, at the onset, was a frightened biped who looked on any stranger as a potential enemy. To this day, one finds that people tend to get irritable, and even hostile, when their numbers increase or when “strangers” of any hue come into contact with their settlement.

We like things to remain the same, for

Currently, we spend obscene amounts of money trying to influence our “elected” officials and those who wish to be elected. in repetition and cooperation with fellow citizens, one develops an ability to adapt to these environmental influences and, thus, to “survive.”

Shakespeare, as in so many previous instances, had some words to explain this: “Who would fardels bear, to grunt and sweat under a weary life, but that the dread of something after death, the undiscover’d country from whose bourn no traveler returns, puzzles the will, and makes us rather bear those ills we have, than fly to others that we know not of?”

PAGE 32 | THE BULLETIN | MARCH / APRIL 2009

Dr. Lawrence Stern has been an active member of the Santa Clara County Medical Association since 1960. He is board certified in general surgery and is currently practicing in the Los Gatos/San Jose area.

Some societies do just fine by killing strangers, or chasing them away, thus perpetuating the conditions that existed before these interlopers arrived.

In small tribe-like societies, this form of behavior can work and may persist for long periods of time. It does not, however, lead to evolution into a sophisticated modern society. Where there is plenty of food, life is simple and uncomplicated; there is always more from where it came. No problem… not very interesting.

Other societies, however, either because of population increase, bad weather, or diminishing resources, have developed techniques that permit survival.

Sometimes they can do this rationally, and sometimes, owing to a capricious nature, they invent gods to explain variations in behavior of the elements. And, they look with hostile eyes on newcomers.

Moses tried Sinai and the tablets plus fear. It worked for awhile.

Arriving at our current imbroglio, we must reinvent the wheel, and try once again to bring peace and abundance to our environment, and there has been a singular absence of inspiration amongst our leaders. This is no sin, since our chosen

leaders should not be expected to have all the answers. But I ask you, and others before me have also asked, “why not ask the people?”

Aristotle thought about this, at some length, and came to the conclusion that most people have innate political sense, though they may lack expertise in all things. In democratic Ancient Greece, numbers of people, chosen at random, served well to resolve weighty issues.

Currently, we spend obscene amounts of money trying to influence our “elected” officials and those who wish to be elected. Why we expect them to represent us is a mystery to me. It should not be a mystery, since they are merely doing the bidding of those who bought them and permitted them to be “elected.”

For awhile, the ancient Greeks did what seems rational, though they admittedly gave their women no civic rights and held many people in bondage to do their heavy work.

The city of Athens had perhaps 20,000 citizens, uncounted women and children, and perhaps 200,000 slaves. Yet they had a method of decision-making that was a vast improvement on our very corrupt system of choosing representatives, called random selection, and mandatory service by those chosen. Athenian law dictated obedience to the laws of Athens and participation in its civic activities.

Repayment was given to the society for the benefits received as citizens, including military service, should that be necessary, and contribution to the debates in the public forum of one’s expertise, as needed.

A citizen could not escape the requirements of citizenship.

The Athenians, between the fifth and the third century B.C., tried a method of conduct that may offer guides to a more satisfactory life than our current winnertake-all mentality. We started in the U.S.A. with a somewhat “elitist” government of

very well-educated and thoughtful men who used the Greek model to create the ideal state in North America. What they did was borrow from Plato’s state ruled by “philosopher kings,” and codified it in such a way that it permitted evolution, but hampered participation by the governed.

We have almost sanctified our constitution to the point that any real reform is being stifled by those who feel that our founders did enough, and though minor improvements might be permitted, real participatory democracy has never been given a chance to succeed.

Because we have been fortunate to have a huge number of well fed, literate citizens, like it or not, we have an obligation to this society that should be obvious to us all. We cannot continue to look apathetically at Sacramento or Washington, D.C. and shrug as we go about our daily tasks and mutter, “a plague on all their houses,” leaving “them” to manage our world problems. I believe that our population yearns, silently for the most part, to suffer if need be, but to contribute in a meaningful way to help us out of our troubles.

We have grown used to this form of government, but recent events have clearly demonstrated that unless the majority of the “masses” are represented in the halls of power, we can expect more of the same, ad infinitum. The internet was one method recently employed to bring the people into the decision-making process.

Following Athenian tradition, they want to repay the polis, or the nation, for the benefits accruing from residence in this blessed place. One of the last lines of Pericles’ Funeral Oration reads, “a man may at the same time look after his own affairs and those of the state… we consider anyone who does not share in the life of the citizen, not as minding his own business, but as useless.”

Our founders, probably realistically, did not trust the mostly illiterate masses to know the right path to workable government. However, with current increased literacy and universal education, it should be reasonable to expect that meaningful changes in government are worth considering. For example, though recent surveys may bely this, we have in this country a standard of living distributed fairly widely that cannot be matched in most countries. We have, to be sure, recent changes in energy and food cost, and an unsatisfactory war that has no predictable end, and a debt that will create hardship for generations. There is reason enough to believe that we can overcome this temporary set of issues, but we need more input from those who will have to pay for it.

PAGE 33 | THE BULLETIN | MARCH / APRIL 2009

We need to start early, training our young people in discipline and languages, as well as in senior and child care, such that they appreciate the fact that these are real problems that all will face. We have not served our young and elder population properly. Fear haunts nearly every family regarding health and education of the young, and near Continued on page 34

Now is the Winter of Our Discontent, continued from previous page panic when our seniors no longer can earn a good livelihood; will they get ill or disabled, and then who will care for them?

These are huge problems that occupy ever larger segments of the population. Our Congress talks a lot, but no real solutions lie immediately at hand.

We have had enough of war this past 100 years, with dead Americans lying on foreign soil in 50 countries around the world, and mutilated wounded eating up billions of dollars in obligatory care that will persist for generations. No matter that some feel that some of these wars have been necessary and some not. There will be times when taking up arms will be necessary to defend ourselves or our friends, or those too powerless to defend themselves. This burden is the price of citizenship, and our position of leadership in the world. It should be divided amongst ALL of us. When a representative citizen army is created, ALL of us feel the need to justify the potential death or mutilation of members of our families. We really take an interest, and begin to ask probing questions of those who will take our sons and daughters and possibly kill them. At present, we are living as if the ghastly carnage in the Middle East does NOT EXIST. We talk a lot, but most of us are not bleeding. When our own sons and daughters lie wounded and dying, THEN we will take notice.

How to change?

Well, this ponderous vehicle that we call the United States of America is not going to try anything new very quickly; “who would fardels bear”….etc. Rather, it seems within the bounds of possibility that one can make a beginning in two areas simultaneously, kindergarten and the town council.

In the kindergarten, one can begin to involve the youngsters in selfmanagement by assigning duties to everyone in class, based on random

selection. That will eliminate bullying and favoritism. When the pupils realize that their place in the power elite will depend on chance selection, based on the obligation of each member of the class to serve for a period of time during the class year, it will change the dynamic of the institution.

The search for power will cease to be the driving force; obligation to the community will become part of the lifestyle and will, for the first time, permit competition with no restrictions based on size, color, or gender. In a class of 30 students, one can easily create 30 tasks so that each student will have something constructive to do.

Let this change daily, weekly, or monthly, to give a better distribution of duties.

Immediately, normal passivity will be altered; the teacher-to-student relationship can become a relationship of partners, so that members of the class develop a much clearer relationship to the functioning of the organism, than ever before. Do this for 12 years, with each succeeding class, and participation in government will become much more acceptable to an entirely new voting population.

Regarding the town council, debate can be inserted into the agenda, as well as mandatory attendance for a number of town meetings; the idea of universal participation will cease to be a threat and become a necessary part of life in a community. Eventually, a lotterydriven committee, like the Council of 500 in Athens, can be the means by which issues of the day are debated, after hearing experts on all sides of a question for a period of days or weeks. A vote on whatever questions have been debated will lead to a 51+% majority for something. Imagine a thousand such town councils and one develops national consensus.

Party affiliation will cease to be a necessary part of the perpetually divisive nature of current politics, and will be replaced by majority decisions based on the merits of the arguments presented PAGE 34 | THE BULLETIN | MARCH / APRIL 2009

during debate. Translating this to larger regional matters, one can make a case for developing a working agenda for the country as a whole, with the Congress tasked by the people to IMPLEMENT the decisions of the people, rather than initiation of programs. Reelection of the members of the Congress then begins to have meaning: members will be reelected based on performance, on success or failure to implement the WILL of the citizenry.

There will always be differences of opinion as to what is or is not important; these are matters that should be debated, intensively, at the local community level.

Voices pro and con should be heard and arguments raised as to the need, feasibility, etc. of the issues. After reasonable debate, a vote settles the matter for that period of time. The results of the debate and vote can be sent to the Legislative Assembly, where the subject will be reexamined, synthesizing votes from town councils in an entire region.

The ideal society is, thus, NOT an easy place in which to live. Benefits of living in a society, where rights are clearly a part of the unwritten contract with each citizen, are not without cost. Though many citizens customarily volunteer their energy and wisdom to activities that benefit the society in a variety of ways, unless ALL are involved, there cannot be an atmosphere of active virtuous obligation associated with the delights of citizenship. Only in such a society can one then demand actions by the leaders based on integrity, rather than naked greed. To expect leadership to adhere to strict standards of behavior, ALL citizens must demand the same of themselves. Understandably, this will not happen quickly, but until it does, we will deserve what we get from our government.

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CLASSIFIED ADS office space for rent/lease MEDICAL OFFICE SPACE FOR LEASE • East San Jose 1,380 sq. ft. excellent medical suite across from Regional Medical Center. Available October 2008. First floor, with lab and xray suites in the building, to make it convenient for your patients. Lots of parking available.

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OFFICE SPACE FOR SUBLEASE • MTN VIEW Two exam rooms and one doctor’s office, five days a week, shared waiting room, in Mountain View, on South Drive. Call 650/967-7471.

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PAGE 36 | THE BULLETIN | MARCH / APRIL 2009

Two nice and large exam rooms (dedicated), shared waiting room. Available five days a week, 2585 Samaritan Drive, San Jose. Please call 408/356-7788 for more information.

MEDICAL OFFICE SUITE FOR RENT • SAN JOSE Medical office suite for rent at 93 N. 14th St. San Jose 95112. Contact Dr. Sajjadi at 408/294-1825 or 408/867-1111.

ELEGANT AND SPACIOUS LOS GATOS MEDICAL OFFICE Available to share with prominent aesthetic dermatologist. This upscale office has seven exam rooms, a lab, two large administrative offices, and a marble and granite waiting room with comfortable seating for eight patients. Call Irene at 408/358-5757 to schedule your private showing. Price is negotiable.

ATHERTON SQUARE MEDICAL/ DENTAL BUILDING A newly upgraded Class A building offers a variety of spaces from 1,166 sq. ft. and up for medical/dental use at 3301-3351 El Camino Real, Atherton. Tenant improvement allowances available to design suite to meet your needs. Excellent onsite parking, close to Stanford and Sequoia. Trask Leonard, Bayside Realty Partners, 650/282-4620 or Alice Teng, Colliers, 408/282-3808.

PRIME MEDICAL SPACE • PRIME SAN JOSE LOCATION 2,048 sq. ft. ready to occupy medical office, previously occupied by RAMBLC Pediatric Group. Located at 6140 Camino Verde Dr, San Jose, in the Santa Teresa Medical/Professional Center across from Kaiser Hospital. Call Virginia at 408/5280571.

OFFICE SUITE AVAILABLE Location is highway 85 at De Anza. One suite available. Currently configured with 6 tx rooms/offices, entry, large master office with balcony. Street signage to 100,000 cars a day. Marble entry. Zoned medical/ office. No variance required. Looking for established business/practice that values prime location in beautiful building.

Please be qualified. No start ups. Contact Dr. Newman at 408/996-8717. Brokers welcome if you have a client. Compare with space by Good Sam at $3.50 sq. ft.

MEDICAL OFFICE FOR LEASE • LOS ALTOS Medical office for lease, 1,050 sq. ft., three exam rooms and a doctor’s office. Large waiting and reception room. Located on Altos Oaks Drive near El Camino Hospital.

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MEDICAL OFFICE FOR SUBLEASE • LOS GATOS Close proximity to Good Samaritan Hospital. Reception, two exam rooms, doctor’s office, and kitchen to share with existing Internist. Please call 408/3562900.

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Continued on page 38

PAGE 37 | THE BULLETIN | MARCH / APRIL 2009

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Close to great hiking and biking trails.

Close to Hwy 85. One large bedroom, living room, kitchen, and bath. Private driveway and fenced yard. Rent $1,290 per month.

Available mid-August. Contact Carolyn Silberman 408/867-1815, or cell 408/2217821, or email wwswolfe@aol.com.

FOR SALE BEAUTIFUL HAWAIIAN CONDO Poipu Beach, Kauai. Lovely 2 BR/2 BA condo, across street from ocean. Recently remodeled bathroom and kitchen with granite countertops, new carpeting throughout. Three lanais with ocean and mountain views, and the tropical gardens which make the Nihi Kai complex so special. $885,000. Call 650/949-3353.

OAK MEMORIAL PARK CEMETERY PLOTS Oak Hill Memorial Park--single plots for sale by owner in sold-out hillside section.

Selling two for $10,000 or all four for $18,000 (transfer fees included). No brokers involved. Contact Joyce at 408/3772459.

WANTED

San Jose Rotacare Adult Free Clinic needs physician volunteers.

Time: Wednesday nights from 6-9 p.m.

Where: Washington Elementary School (in the clinic building on Edwards between Almaden and First, a residential neighborhood about a mile from the Fairmont).

Patient mix: uninsured, many workers, many diabetics, many Hispanics. Small free medicine dispensary.

Need: Internal Medicine, Family Practice, General Medicine.

Malpractice insurance and evening snack provided. Can you help out once a month?

Email: nedde@earthlink.net. Phone: 408/354-7613.

Pajaro Dunes Beachfront Condo

PEDIATRIC PRACTICE Will buy Pediatric practice in South Bay. Call 408/4552959.

PHYSICIAN VOLUNTEERS NEEDED

Shorebirds #58 2 Bedroom -- 2 Bath Top Level -- Great Ocean View Great for Families Owners Bill & Debbi Ricks 408-354-5613

Rental Agent Pajaro Dunes Company 1-800-564-1771

CHIEF MEDICAL OFFICER, HOSPICE OF THE VALLEY 4850 Union Avenue; San Jose, CA 95124 Hospice of the Valley is an innovative and growing non-profit hospice organization operating in the Santa Clara County of Silicon Valley. We are currently looking to complete the executive leadership team with the appointment of a Chief Medical Officer. The CMO will oversee a team of Assistant Medical Directors and have the overall responsibility for the medical direction, program development, and supervision of patient care. This is an excellent opportunity for a dynamic leader looking to expand both palliative and hospice care operations.

Experience and Qualifications: License to practice medicine in California and hold an M.D. from an accredited medical school.

Board certification in Hospice and Palliative Medicine is required. Proven leadership experience in the health care sector along with a background in palliative and hospice care program development is preferred. Full benefits and compensation commensurate with qualifications and experience.

For more information and to apply, please send cover letter and resume to: Becky Kellogg at bkellogg@hospicevalley.org.

PAGE 38 | THE BULLETIN | MARCH / APRIL 2009

WHere dO YOu send Your Patients with end-stage Heart disease?

California Pacific Medical Center’s Adult Heart Transplant and End Stage Heart Disease Programs offer leading-edge therapies plus quality care and compassion for patients needing: • • • • •

Late stage heart failure diagnosis and therapy Temporary percutaneous total cardiac support Heart transplantation First- and second-generation LVAD devices for bridge-to-transplantation Permanent implantable cardiac support devices

Acute and chronic heart failure, acute myocardial infarction with shock, cardiovascular collapse, heart-based secondary organ failure and post-cardiac surgery acute heart failure are now all selectively treatable with good results using a variety of recent drugs and devices – but timing is crucial.

California Pacific is a certified CMS destination therapy center for patients with end-stage heart failure who are ineligible for a transplant due to age, additional health problems or other complications. We go “beyond medicine” by being the only Bay-area hospital to provide a dedicated nursing unit for heart failure, VAD and transplant patients, featuring: • • • • •

Private rooms Beds available 24/7 for your emergency transfers Family room outfitted for patient and family’s use with exercise and video equipment A dedicated, specially-trained nursing staff > 90% patient satisfaction scores

We also go beyond medical care and provide our patients and families with disease counseling, spiritual support and reduced rates for patient and family housing.

Heart transplant Outcomes Patient survival graft survival

1 Yr cPmc

1 Yr national

3 Yr cPmc

3 Yr national

82.61

85.15

88.24

82.13

84.00

84.81

89.47

Source: SRTR Data released 07/2007 and CPMC internal data

79.28

For more information: 888-637-2762 The Adult Heart Transplant and End Stage Heart Disease Program is associated with California Pacific’s Heart and Vascular Center, which offers quality, comprehensive, patient-centered cardiovascular care by a team of pioneering physicians integrating leading-edge technology.

Our team Of surgeOns & cardiOlOgists combined have over 80 years of heart failure, heart transplant and Vad experience:

J. donald Hill, m.d. g. James avery, m.d.

Preben Brandenhoff, m.d. ernest Haeusslein, m.d.

www.cpmc.org

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What’sEarned the Big Straight Deal withA’s NORCAL’s We’ve for 25 CME? Years Last year participation in NORCAL’s Continuing Medical Education program reached a record 21,734 – nearly double NORCAL has achieved an “A” financial rating from A.M. Best, the leading provider of insurance industry ratings, for the past the number of our policyholders! Why? Because NORCAL physicians use our unparalleled CME activities time and again. quarter century. Our financial stability has allowed us to return $358 million in dividends to NORCAL policyholder owners.

Visit www.norcalmutual.com today, or call 800.652.1051. NORCAL. Your commitment deserves nothing less.

Visit www.norcalmutual.com today, or call 800.652.1051. NORCAL. Your commitment deserves nothing less.

NORCAL is proud to be endorsed by the Santa Clara County Medical Association NORCAL isasproud to be endorsed by the Santainsurer Clarafor County Medical Association the preferred professional liability its members. as the preferred professional liability insurer for its members.

You practice with passion. Our passion protects your practice.

You practice with passion. Our passion protects your practice.