2009 May/June

May / June 2009 | Volume 15 | Number 3

ELECTRONIC HEALTH RECORD BUYERS BEWARE Balanced Billing Gone… Not Necessarily!

See Page 14

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, FACS

From the Editor’s Desk.................................................................................6 Joseph S. Andresen, MD “If America’s physician practices suddenly rushed to install the systems of their choice, it would only dramatically intensify the (tower of) Babel that already exists.”

More on page 8

Electronic Health Record Buyers Beware...................................................8 Stephen H. Carson, MD

The American Recovery and Reinvestment Act of 2009 (HR1)...............12 American Medical Association

Balanced Billing Gone… Not Necessarily!...............................................14 SCCMA New Officers for 2009-2010..........................................................15 Medical ID Theft Spawns New Compliance Requirements....................16 Matt J. Morris Proper training should also impact behavior related to how information is handled, and go a long way towards data theft and breaches that are increasingly common.

More on page 16

Opting Out of Medicare.............................................................................18 Sandie Becker, CMC

Member News & Happenings...................................................................23 Create a Code of Conduct..........................................................................24 Jeffrey J. Denning

An Ounce of Prevention Could Save a Pound of Cure.............................26 NORCAL Mutual Insurance Company Create a Physician Code of Conduct for the group. This may seem unnecessary, but there were several anecdotes of physician behavior that apparently breached your assumptions of good conduct.

More on page 24

Member Spotlight: David F. Chang, MD The Greatest Challenge in Cataract Surgery........................................28 Michelle Dalton

MEDICO NEWS ...........................................................................................30 Classified Ads..............................................................................................34 PAGE 3 | THE BULLETIN | MAY / JUNE 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 Foundation Hospital - San Jose: Efren Rosas, 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 Stanford Hospital & Clinics: 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

Managing Editor

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

TA CLARA SAN

•

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.

C AL

IAT SSOC ION • LA

Pam Jensen

Y MEDIC UNT A CO

IF O R N IA

MEMBERSHIP AS OF MAY 25, 2009 Active Members.......2,528 Retired Members........ 871 Students....................... 352 TOTAL MEMBERS...... 3,751

© Copyright 2009 by the Santa Clara County Medical Association.

PAGE 4 | THE BULLETIN | MAY / JUNE 2009

MESSAGE FROM THE PRESIDENT

change is all around us

By Howard Sutkin, MD, FACS Greetings members. Last month I wrote to you about all of the changes coming down on us (doctors and medicine). Well that theme continues.

At last, the Community Hospital of Los Gatos has closed its doors, closing a chapter on decades of fine service to our community. It was a sad few days at the end, where folks walked the halls, the lots, and the streets from lack of patients.

From all of us at SCCMA, we wish good luck and success to the tireless nurses, respected physicians, and friendly staff of the hospital. We very much look forward to the reopening under the El Camino banner. Hopes are high about El Camino’s investments in the campus, which are sure to pay dividends of top notch medical and surgical services there.

Recently, I, along with some members of our District 7 CMA Delegation and Bill Parrish, attended the CMA-sponsored 12th Annual Leadership Academy. It was a fascinating meeting held in Los Angeles, which highlighted the strong potential, almost inevitability, of a large health care bill coming from Washington. Some leaders, such as John Noseworthy, MD of the Mayo Clinic, have advocated for a government-regulated guarantee of insurance for all individuals.

In contrast, guest speaker Howard Dean, MD (prior Vermont governor) indicated it may be a government-sponsored program set up to compete with the private sector – kind of like a Medicare for youth. All of this is scheduled to happen this year!

Finally, lots of talk centered at the meeting on the adoption of Health Information Technology. The federal government is pushing for the adoption of electronic health records in hospitals and doctor’s offices and has even scheduled subsidies in these areas for physicians who go with it. There are also Medicare rate reductions for those who resist. Well, yours truly, as a private doc in a small

It was a fascinating meeting held in Los Angeles, which highlighted the strong potential, almost inevitability, of a large health care bill coming from Washington. Some leaders, such as John Noseworthy, MD of the Mayo Clinic, have advocated for a government-regulated guarantee of insurance for all individuals. office, was invited to speak to the CMA Board about the potential pitfalls of using electronic records. In my research of the topic, I have found, generally, that these systems are expensive, time consuming, and problematic. However, for large group practices it makes a lot of sense and has paid off in many ways, including accumulation of lots of medical data, tracking and improving PAGE 5 | THE BULLETIN | MAY / JUNE 2009

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. preventative care, convenience for doctors seeking information, and management of chronic disease. For the rest of us in smaller practices, I ask you the following questions: 1. Will my EMR talk with your EMR? 2. Will my EMR speed up my day or slow it down? 3. Will my record of a patient encounter be easy to read and meaningful to those physicians who request my consultation? 4. Will EMR help my patients?

The conclusion I have taken from the meeting is to go slow. Lots of vendors have begun to develop their offerings and it will be quite some time before the clear leaders in the field are established. I for one, don’t want to be the guy who purchased too early, for too much money, for an inferior product from a company which may not exist in a year or two.

As always, I encourage all members to let me know how they feel about this topic or anything else on your minds.

FROM THE EDITOR’S DESK

What’s new in Washington?

By Joseph S. Andresen, MD

Quote of the Day: “We have 900 billing clerks at Duke (medical system, 900-bed hospital).

I’m not sure we have a nurse per (each) bed, but we have a billing clerk per bed…it’s obscene.” -Dr. Uwe Reinhardt, hearing on health care reform, U.S. Senate Finance Committee, November 19, 2008 What’s new in Washington?

It’s less than 90 days until health care reform legislation is predicted to be on the President’s desk and ready to sign into law.

There is a frenzy of lobbying and legislative activity taking place right now. The Senate and the House of Representatives are working on separate bills with the goals of providing universal coverage, affordable premiums, portability, and removal of limitations on pre-existing medical conditions. There is also recognition of the importance of preventative care and streamlining the flow of medical information for increased patient safety, efficiency, and cost saving.

The most heated debate involves inclusion of a competing “public plan” that would be available for all citizens and offer an alternative to private insurance coverage. The insurance industry is lobbying heavily against this possibility, claiming that the government would be an unfair competitor because of its size, lower administrative costs, and ability to set pricing. Proponents for the “public plan” claim that the benefits include introducing competition to previously limited

markets, reducing costs, driving quality advancement and innovation, and serving as a benchmark for the insurance market.

Where are physician organizations weighing in? The American College of Physicians has not yet taken a position until more details are available regarding the “public plan” option. Certainly the hesitation revolves around the fear of a “Medicare for all” system, where hospitals and physicians are further squeezed for cost reductions to meet annual budget deficits with reimbursement falling below the costs of providing care.

We do know that private insurance companies spend 12% to 30% of their dollars on non-medical costs vs.

Medicare that spends about 5%. So when one removes the cost of underwriting, marketing, and profits, there are more dollars to spend on medical care. The real question is whether the legislative architects are able to look beyond the flaws of our current Medicare system, a system that undervalues primary care, doesn’t cover most preventative services, rewards fragmentation and volume of services, and has a sustainable growth rate formula (SGR) that triggers physician payment cuts every year. This is remedied only with a last minute Congressional stop-gap measure that passes on the problem to the following year’s budget.

Is it possible to design a “public plan” that will control costs, improve quality, and increase access that private insurance companies will be forced to emulate while continuing to attract the best and the brightest to our profession? The PAGE 6 | THE BULLETIN | MAY / JUNE 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. answer is yes, but only with the guidance, shared wisdom, and experience of our physician community.

In 1993, health care reform was attempted behind closed doors without significant physician or public input and failed. This time is different. Contact your medical organization and legislative representative today.

Here are the key players. Now it’s your job to take action. Call or email them today!

Senate Finance Committee Baucus, Max (D - MT) 511 Hart Senate Office Building, Washington DC 20510 (202) 224-2651 baucus.senate.gov/contact/emailForm. cfm?subj=issue

Wyden, Ron (D - OR) 223 Dirksen Senate Office Building, Washington DC 20510 (202) 224-5244 wyden.senate.gov/contact/

Grassley, Chuck (R - IA) 135 Hart Senate Office Building, Washington DC 20510

(202) 224-3744 grassley.senate.gov/contact.cfm

Senate Health, Education, Labor and Pensions Committee Kennedy, Edward M. (D - MA) 317 Russell Senate Office Building, Washington DC 20510 (202) 224-4543 kennedy.senate.gov/senator/contact.cfm

Dodd, Christopher J. (D - CT) 448 Russell Senate Office Building, Washington DC 20510 (202) 224-2823 dodd.senate.gov/index.php?q=node/3130

Sanders, Bernard (I - VT) 332 Dirksen Senate Office Building, Washington DC 20510 (202) 224-5141 sanders.senate.gov/comments/

House Energy and Commerce Committee Waxman, Henry In Washington, D.C. 2204 Rayburn House Office Building, Washington, DC 20515 (202) 225-3976 (phone) (202) 225-4099 (fax) http://www.house.gov/waxman/contact.htm

Harkin, Tom (D - IA) 731 Hart Senate Office Building, Washington DC 20510 (202) 224-3254 harkin.senate.gov/c/index.cfm

Single Payer Bills

Sanders, Bernard (I - VT) 332 Dirksen Senate Office Building, Washington DC 20510 (202) 224-5141 sanders.senate.gov/comments/

PAGE 7 | THE BULLETIN | MAY / JUNE 2009

Conyers, John Washington Office: (202) 225-5126 Detroit Office: (313) 961-5670 Trenton / Downriver Office: (734) 6754084 Email: john.conyers@mail.house.gov You can also post on his blog. http://conyers.house.gov/

United States Senator, California Feinstein, Dianne 331 Hart Senate Office Building, Washington DC 20510 Phone: (202) 224-3841 Fax: (202) 228-3954 http://feinstein.senate.gov/public/index. cfm?FuseAction=ContactUs.EmailMe Boxer, Barbara 112 Hart Senate Office Building, Washington DC 20510 (202) 224-3553 https://boxer.senate.gov/contact/email/ policy.cfm

FEATURE ARTICLE

Electronic Health Record Buyers Beware

By Stephen H. Carson, MD In a recent open letter to President Obama, David Kibbe, a senior adviser to the American Academy of Family Physicians and expert on health information technology (HIT), described the current electronic health records (EHRs) as costly, difficult to use, and unable to allow hospitals, physician offices, or pharmacies to easily share information about patients’ medical histories and treatments. He wrote, “If America’s physician practices suddenly rushed to install the systems of their choice, it would only dramatically intensify the (tower of) Babel that already exists.”

The following points should help physician buyers understand why physicians should approach EHRs and e-precribing tools with extreme caution: •

•

Affordability. Most standalone EHRs cost a minimum of $10,000 per physician for purchase, installation, and staff training. Maintenance and upgrades can easily run up to $2,000 per year, per physician. Subscriptions for EHRs typically cost $400 per month per physician.

Return on Investment: Although the government and health plans reap 90% of the financial benefit of EHRs, physicians are expected to pay for the efforts in time and money.

For example, the current incentive dollars for e-prescribing and pay-forperformance may not amount to more than $3,500 per physician, per year — hardly enough to offset the costs, let alone the headaches. Many of the incentives are not guaranteed for more than four years.

•

•

Reduction in Productivity: The average primary care physician will experience a 20% reduction in productivity and collections in the first year of using a full-blown EHR. Beyond the first year, productivity rarely surpasses what it was with paper records for PCPs.

•

Unexpected Downtime: Solo and small practices cannot afford dedicated technicians to solve problems inherent with electrical outages, computer glitches, and server crashes.

•

Changing Requirements: EHRs will need to incorporate ever-changing requirements for clinical decision support, order entry, data capture, and information exchange between stakeholders. Physicians will be regularly forced to spend additional dollars to modify their information systems.

Based upon the current incentive timetables, it is my recommendation that physicians should NOT start shopping for hardware or software until the fall of 2010, with the goal of launching in January 2011. Although some physicians may want to proceed sooner, my rationale for waiting is as follows:

•

Cost of both hardware and software will continue to drop over the next two years.

•

Functionality of fully integrated practice management and EHR systems is dramatically improving from month to month. EHRs of the next decade will need to include modules for population health improvement, clinical decision support, eligibility verification, charge capture, claims adjudication, HEDIS reporting, and interoperability.

Although there are some excellent products on the market today, none of the products are ready to meet the requirements that are expected to be in place within two years.

•

MicroSoft Windows 7 is likely to replace Windows Vista in early 2010.

Interoperability: Physicians who buy an independent e-prescribing tool or EHR that is not fully integrated with their practice management system for demographic data, billing, and collections will be frustrated with the ongoing costs and headaches of making the two systems work

“If America’s physician practices suddenly rushed to install the systems of their choice, it would only dramatically intensify the (tower of) Babel that already exists.” seamlessly. Anytime there are upgrades to one system, there are unanticipated costs and glitches with the second system. There are also major interoperability issues between physicians and their hospitals, labs, and radiology vendors. This connectivity is necessary to eliminate the errors and the time associated with having to re-key patient data into your EHR.

PAGE 8 | THE BULLETIN | MAY / JUNE 2009

•

Open source platforms are likely to heat up the competition among vendors and drive the price of EHRs downward. New adaptations of Vista for the ambulatory physician will stimulate disruptive innovation.

•

Inexpensive and energy-efficient thin client hardware will become an attractive option for physician offices.

•

Incentives for innovative programs run by state, federal, regional, health plan, and independent practice associations will continue to evolve.

•

Standardized patient ID cards and card-readers that interface with practice management systems are a priority for the Medical Group Management Association (MGMA).

MGMA estimates that machinereadable patient ID cards could save physician offices, health plans, and hospitals as much as $1 billion a year by eliminating unnecessary administrative efforts and denied claims.

•

•

•

•

Real-time claims adjudication through the EHR will allow physician offices to determine eligibility, deductible thresholds, and CPT codes for immediate adjudication and reimbursement of the office visit. This feature is where the real long-term financial reward is for physicians.

Standards: Under the stimulus act, the Office of the National Coordinator (ONC) for Health Information Technology will require EHRs to adopt new sets of standards, specifications, and certification criteria

by December 31, 2009. These new standards will result in unanticipated upgrade costs for those who have already purchased an EHR. ICD-10 code sets are likely to be required by October 2013 and require tighter integration between clinical and billing functions.

FDA Barriers: The FDA still prohibits the use of e-prescribing

modules to submit prescriptions for controlled substances. This explains why fewer than 5% of all prescriptions in the United States have been filed electronically over the last year.

What about the HITECH Act in the American Economic Recovery and Reinvestment Act? It is estimated that $17.2 billion of the $20 billion dollars set aside to stimulate IT adoption will be in the form of incentive programs under Medicare and Medicaid. As currently written, ambulatory physicians participating in Medicare will be eligible if they can demonstrate that they are “meaningful users” of certified EHR technology (standards are to be established before December 31, 2009). “Meaningful use” is defined as being connected in a way that improves the quality using measures selected by the ONC. Incentives will be limited to 75% of Medicare-allowed charges in any year and up to $44,000 over five years. Physicians practicing in health professional shortage areas can receive an additional 10%. Physicians who start after 2014 will not receive any incentives.

receive 100% of the payment outlays of their programs and 90% of their costs of administering such programs. Payments to physicians cannot exceed 85% of average allowable costs for certified EHR technology and are capped at $25,000 for the first year and $10,000 for subsequent years. These amounts will be reduced by two-thirds of that amount for pediatricians.

Eligible providers must have at least a 30% Medicaid patient load, and pediatricians must have at least a 20% Medicaid patient load. Federally qualified health center or rural health clinics must see at least a 30% load of patients classified as “needy,” which is broader than Medicaid beneficiaries.

For those of you who are ready to make the leap despite the challenges, I would offer the following advice: •

Purchase a fully integrated practice management system and EHR. Do not buy separate systems in the hope that they will always work well together. Make sure the integrated system supports the full set of HIPAA transaction standards, appointment scheduling, patient reminders, electronic eligibility verification, advanced claims editing (including health savings accounts), automated payment posting with electronic remittance advice, integrated credit card processing, configurable reporting, the ICD-10 code sets, and, if necessary, specialized MediCal claims processing that addresses medical home requirements. In addition, do not forget to research the ability of the system to interface with health plans and clearinghouses.

•

Do not waste your time on standalone e-prescribing — you are only going to have to dump it later for an EHR. Remember, the incentives from Medicare for e-prescribing drop to 1% in 2012, to 0.5% in 2013, and then they disappear.

•

Pick an EHR suited to your specialty. Get advice from your colleagues and your specialty society.

Continued on page 10

For Medicare-covered services rendered during 2015 or after by a professional who cannot demonstrate meaningful EHR use, the Medicare physician fee schedule will be reduced by 1% for 2015, 2% for 2016, and 3% for 2017.

There is an escape clause for professionals who can demonstrate significant hardship, but that clause will apply to a professional for a maximum of five years.

Unfortunately, the money from the Medicare and Medicaid programs will be paid out over four or five years and won’t be available until 2010 or 2011. The Act provides for comparable incentives and disincentives for professionals providing substantial services through Medicare Advantage plans.

The Act also provides for payments to those states that have approved Medicaid plans and programs to encourage the adoption and use of certified EHR technology. Specifically, these states will PAGE 9 | THE BULLETIN | MAY / JUNE 2009

Electronic Health Record Buyers Beware, continued from previous page For example, voice recognition in the EHR is often a big plus for surgeons and enables savings on transcription costs. Look for software that automatically flags common tasks that are unique for your specialty (e.g., cancer screenings for internists and family practitioners).

•

•

•

Vendor Reputation: Pay attention to the vendor’s track record for service and support.

Interoperability: If possible, find an EHR that can receive data from your preferred lab and hospital and deliver patient-specific data into the correct field in each of your patients’ electronic charts.

Application service providers using a subscription model for maintaining and servicing your office is the best approach for physicians in small- and medium-sized practices.

•

Workflow Planning, Staff Training, and Implementation: An experienced vendor will work with physicians and their staff to map out the ideal workflow for the office and develop a carefully planned out schedule for training and implementation. Physicians should not underestimate the time or importance of these efforts.

•

Check the 2008 Best in KLAS Awards based on customer satisfaction with health care information technology vendors and consultants.

About the Author: Dr. Carson earned his medical degree from McGill University, where he was awarded the Alexander Stewart Prize in Medicine. He completed his internship and residency program at Children’s Hospital in Boston and fellowship training at Harvard.

When you have questions about eating disorders...

He served as chief resident in pediatrics at UCSD’s School of Medicine and then served as the medical director of UCSD’s pediatric teaching program at Scripps Mercy Hospital from 1980 until 1992. For the last 25 years, he has served as a consultant for health systems, schools of medicine, health plans, hospitals, and medical groups. In 1992, Dr. Carson founded Primary Care Associates (PCA), an independent practice association of 80 primary care physicians and over 300 specialists serving the north coastal region of San Diego County. He continues to practice pediatrics and pediatric pulmonary medicine in Hillcrest.

Reprinted with permission of San Diego Physician, the official publication of the San Diego County Medical Society.

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PAGE 10 | THE BULLETIN | MAY / JUNE 2009

PAGE 11 | THE BULLETIN | MAY / JUNE 2009

Health Information Technology

The American Recovery and Reinvestment Act of 2009 (HR1) Explanation of Health Information Technology Provisions (1)

By American Medical Association The “American Recovery and Reinvestment Act of 2009” (ARRA) provides substantial financial incentives ($19 billion over a specified five-year period) that will help physicians purchase and implement HIT systems. Beyond adequate financing, a key element to the widespread adoption and use of HIT is the development of uniform electronic standards that allow various HIT systems to communicate with each other. ARRA requires the Department of Health and Human Services (HHS) to develop such standards by December 31, 2009.

Beginning in 2011, Medicare physicians who implement and report meaningful use of electronic health records (EHR) will be eligible for an initial incentive payment up to $18,000. While ARRA includes a provision that will reduce Medicare payments (starting at 1%) for physicians who do not use EHR systems, this does not take effect until 2015, and there are exceptions for significant hardship cases.

As noted below, some of the details on the implementation of ARRA’s HIT incentive provisions will be worked out through the regulatory rule-making process in the coming months. AMA will be closely monitoring and providing input to ensure that the HIT provisions are implemented in a manner consistent with the intent of ARRA. HIT Incentive and Penalty Program ARRA provides financial incentives through the Medicare Part B program to encourage physicians to adopt and use qualifying EHRs in a meaningful way. Meaningful use of EHRs will be

defined by HHS during the rulemaking process and may include reporting requirements on quality measures. ARRA also authorizes HHS to provide competitive grants to states to make loans available to health care providers to assist them with HIT acquisition and implementation costs.

Physicians (non-hospital based) are eligible for Medicare incentive payments based on an amount equal to 75% of the allowed Medicare Part B charges — up to a maximum of $18,000 for early adopters whose first payment year is 2011 or 2012. The secretary of HHS will define the reporting period(s) with respect to a payment year. Incentive payments would be reduced in subsequent payment years, eventually phasing out in 2016. Physicians who do not adopt/use an EHR system before 2015 will face a reduction in their Medicare fee schedule of -1% in 2015, -2% in 2016, and -3% in 2017 and beyond. The secretary of HHS has the authority to make exceptions to this reduction on a case-bycase basis for physicians who demonstrate significant hardship (e.g., a physician who practices in rural areas without sufficient Internet access).

First Payment Year 2011 2012 2013 2014 2015 2016 2017 & thereafter

The table below shows how the incentives and potential reductions are expected to work from 2010-2017 (2, 3).

Incentives under the Medicaid program are also available for physicians, hospitals, federally qualified health centers, rural health clinics, and other providers; however, physicians cannot take advantage of the incentive payment programs under both the Medicare and Medicaid programs.

Eligible pediatricians (non-hospital based), with at least 20% Medicaid patient volume, could receive up to $42,500, and other physicians (non-hospital based), with at least 30% Medicaid patient volume, could receive up to $63,750, over a six-year period.

In the event that the secretary of HHS finds that the proportion of health care providers who are meaningful users of EHRs is less than 75%, the secretary is authorized to increase penalties beginning in 2018, but penalties cannot exceed -5%.

ARRA Will Establish HIT Policy and Electronic Standards ARRA formally establishes the role and functions of the Office of the National Coordinator for Health Information Technology (ONCHIT)

First Payment Year Amount and Subsequent Payment Amounts in Following Years $18k, $12k, $8k, $4k, and $2k $18k, $12k, $8k, $4k, and $2k $15k, $12k, $8k, and $4k $12k, $8k, and $4k $0 $0 $0

PAGE 12 | THE BULLETIN | MAY / JUNE 2009

Reduction in Fee Schedule for Non-adoption / Use $0 $0 $0 $0 -1% of Medicare fee schedule -2% of Medicare fee schedule -3% of Medicare fee schedule

within HHS, which is to promote the development of a nationwide interoperable HIT infrastructure. (ONCHIT was already created by Executive Order in 2004.)

ARRA establishes the HIT Policy and Standards Committees, which are comprised of public and private stakeholders (e.g., physicians) to provide recommendations on the HIT policy framework, standards, implementation specifications, and certification criteria for EHRs. HHS is required to adopt, through the regulatory rule-making process, an initial set of standards, implementation specifications, and certification criteria by December 31, 2009, for qualifying EHRs. ONCHIT is authorized to make available a qualifying EHR system to health care providers for a nominal fee.

The Hospice of the Valley team members I have worked with, in transitioning patients and family from aggressive care to comfort and hospice care, have demonstrated compassion, flexibility, and a desire to “turn every stone” in their efforts to meet the needs and wishes of the patient and their family.

— Kathleen Fahey, RN, CNS,

clinical nurse specialist, Palliative Care, El Camino Hospital

Brad Leary, director social services and counseling Pam Nates, chaplain

Deni

AMA will be seeking clarification from HHS on the cost of such a system and the date it will be available. Physicians do not need to purchase the government’s EHR system; they can purchase any qualifying system (i.e., meets certain standards, including interoperability) from a vendor of their choice.

AMA policy strongly supports positive financial incentives for physicians to acquire and implement HIT. Throughout the legislative process, AMA urged flexibility in the timeline for HIT adoption and use, given the uncertainties surrounding the readiness of standards, the availability of EHR systems that are interoperable, secure, and affordable, and the rule-making process. AMA will continue with efforts to ensure that physicians obtain the funds and assistance they need to transition their practices from paper to electronic-based systems.

Notes: 1. This summary will be updated when additional details become available during the rule-making process.

2. Physicians in rural health professional shortage areas who adopt/use EHRs are eligible to receive a 10% increase on the incentive payment amounts described above.

3. Physicians who report using an EHR system that is also capable of e-prescribing will no longer be eligible for the e-prescribing bonuses established by the “Medicare Improvements for Patients and Providers Act” (MIPPA); they will be eligible for HIT incentives only to avoid “double-dipping.” Also, e-prescribing penalties sunset after 2014, so that no physician will be subject to penalties for failing to both e-prescribe and use an EHR.

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Monique Kuo, MD, medical director

4850 Union Avenue, San Jose, CA 95124 408.559.5600 l hospicevalley.org

PAGE 13 | THE BULLETIN | MAY / JUNE 2009

Clients of BME never pay a fee unless there is a recovery… we do the work and we take the risk, including court and attorney fees!

The Bureau of Medical Economics (BME), a 55-year-old subsidiary of the Santa Clara County Medical Association and a non-profit medical collection and billing company in business to serve the financial needs of physicians, is taking a novel approach to balanced billing. Under the leadership of seasoned attorney Mark Christiansen, BME is fighting back by taking the insurance companies through the collection process, up to and including legal action.

•

•

BME clients and SCCMA members will receive free EOB analysis and consultation by Mr. Christiansen and one of BME’s certified billers to explore viable options, including assignment.

Members of organized medicine in California (CMA and their county affiliates) will receive a discount on any and all accounts assigned.

•

Clients of BME never pay a fee unless there is a recovery…we do the work and we take the risk, including court and attorney fees!

•

BME was formed to insure physicians receive full reimbursement of their fees for the professional services provided.

•

BME’s motto is “NEVER GIVE UP.” It’s been said, “the best defense is a good offense.” So, let’s not appeal (DMHC’s process), let’s fight for what is owed (BME’s process)!

•

Consider utilizing BME to preserve and protect your assets by fighting for the full reimbursement of your fees. Our results over the last 55 years prove the value and benefit. Join your colleagues in fighting back; you have much to gain and nothing to lose!

Let us help you, contact BME at 408/998-5811.

PAGE 14 | THE BULLETIN | MAY / JUNE 2009

SCCMA NEWS

New Officers and Councilors for 2009-2010 Report of the Nominating Committee, February 25, 2009 (Approved by SCCMA Council on May 5, 2009)

The Nominating Committee met on February 25, 2009. Members in attendance were: Drs. Tanya Spirtos (Chair), Jerry Callaway, Peter Cassini, Judith Dethlefs, Dean Didech, Martin Fenstersheib, Elliot Lepler, John Longwell, Eleanor Martinez, Joseph Mason, and Marshall Yacoe.

Officers

Councilors

President: Howard Sutkin, MD

Emiro Burbano, MD (Regional Medical Center of San Jose)

President-Elect: Thomas Dailey, MD

Jay Raju, MD (O’Connor Hospital)

Secretary: Sameer Awsare, MD

Patrick Kearns, MD (Santa Clara Valley Medical Center)

Treasurer: Martin Fishman, MD

Efren Rosas, MD (Kaiser Foundation Hospital – San Jose)

VP Community Health: Cindy Russell, MD

Peter Cassini, MD (Stanford Hospital & Clinics)

VP External Affairs: William Lewis, MD

John Saranto, MD (Saint Louise Regional Hospital)

VP Member Services: Judith Dethlefs, MD

Michael Curtis, MD (El Camino Hospital)

VP Professional Conduct: James Crotty, MD

Rives Chalmers, MD (Hospital in Los Gatos) Eleanor Martinez, MD (Good Samaritan Hospital) Allison Schwanda, MD (Kaiser Permanente Hospital)

# CMA Delegates

15. Eleanor Martinez, MD

15. Allison Schwanda, MD

16. Sameer Awsare, MD

# CMA Alternate Delegates

1. Martin Fenstersheib, MD 2. Joseph Mason, MD

17. William Lewis, MD

1. Judith Dethlefs, MD

17. Jay Raju, MD

3. Tanya Spirtos, MD (Chair)

18. David Campen, MD

2. Sian Lindsay, MD

18. Kirk Zimmer, MD

19. Howard Sutkin, MD

3. John Saranto, MD

19. Seham El-Diwany, MD

4. Efren Rosas, MD

20. Elliot Lepler, MD

4. Robert Norris, MD

20. Michael Curtis, MD

5. Jeffrey Coe, MD

21. Scott Benninghoven, MD

5. Peter Cassini, MD

21. Andrea Rudominer, MD

6.

22. Thad Padua, MD

6. Patrick Kearns, MD

22. Amir Hadid, MD

7. W. James Silva, MD

23. Kristina Hobson, MD

7. Ed Liu, MD

23. Ngai Nguyen, MD

8. Rives Chalmers, MD

24. Rajan Bhandari, MD

8. Ted Chu, MD

24. An Pham, MD

9. Cindy Russell, MD

25. Marshall Yacoe, MD

9. Jennifer Maw, MD

25. Don Mordecai, MD

10. John Huang, MD

10. Susan Wilturner, MD

26. Seema Sidhu, MD

11. Art Basham, MD

11. Bien Nguyen, MD

12. Thomas Dailey, MD

12. Heather Linebarger, MD

13. Robert Gould, MD

13. Len Doberne, MD

14. Amara Balakrishnan, MD

14. Naresh Kapoor, MD

Jim Crotty, MD

PAGE 15 | THE BULLETIN | MAY / JUNE 2009

16. Dipali Apte, MD

ID Theft Red Flag Program

Medical ID Theft Spawns New Compliance Requirements

Health Care Required to Have a Program to Police Medical ID Theft Effective August 1st

By Matt J. Morris, Certified ID Theft Risk Management Specialist Identity theft is the #1 crime in America. Medical identity theft, where individuals receive medical care using stolen or false identities, is widely considered to be the fastest growing type of this crime. An increasing number of people are falling victim to this crime and are having their lives turned upside down, while being forced to spend hundreds of hours to clear their good name. The cost to business has most recently been estimated at nearly $50 billion dollars per year.

In response to this growing problem, the Federal Trade Commission is now requiring an ID Theft Red Flag Program be in place for any medical practice that does not collect complete payment at the time it provides services to a patient. Any practice that is billing insurance on behalf of its patients, where

the patient is ultimately responsible for the payment, is now being considered a “creditor” by the FTC, and falls under these requirements. The deadline for having a program in place is August

Proper training should also impact behavior related to how information is handled, and go a long way towards data theft and breaches that are increasingly common.

1, 2009; the penalties include civil and monetary penalties per infraction.

Although the AMA and other medical associations have argued that they should not fall under this rule, the FTC in recent weeks has responded with a nine-page letter making it clear they would not be granting an exemption to these requirements for health care providers.

The purpose of these requirements is to minimize the risk to individuals that have had their information stolen for the purpose of identity theft.

While having to comply with a new law may at first seem frustrating, practices will be reducing their liability and minimizing the expense of providing services where payment would otherwise go uncollected. Medical identity theft can often go unnoticed, mixed in with practices’ bad debt from services that are unable to be collected when the actual patient is unknown. Third-party payors can also demand a refund from physicians, if identity theft is discovered after the payment has been applied. Ultimately, the financial cost of this growing problem is most often born by the practice, and good policies and staff awareness can reduce that cost.

The “Red Flag Rules” requires practices to develop an identity theft program that contains written “reasonable policies and procedures” to: •

• • •

Identify relevant patterns, practices, and specific forms of activity that are “red flags,” signaling possible identify theft; Detect these patterns, or “red flags;” Respond to those detected to prevent and mitigate identity theft; and Ensure the program is updated periodically to reflect changes in risks.

In administering such a program, a practice would need to: • Illustrate approval of the program from its board or board committee; • Appoint a designee(s) as a red flag officer;

PAGE 16 | THE BULLETIN | MAY / JUNE 2009

• •

Train staff on awareness, red flags, and appropriate responses; Exercise oversight of service provider arrangements.

While some heath care practices have begun to check identification prior to providing services, this will now be a necessary step for all providers that have patients covered under this rule. The identity theft red flags that need to be identified in a policy fall under these categories: • • • •

Suspicious documents; Suspicious identifying information; Unusual or suspicious activity related to patient; and Notices from patients, victims of identity theft, insurance investigators, law enforcement, about possible identity theft.

Training of staff is a very important element to this program as not only new procedures will need to be adopted, but a new awareness among staff needs to be created to adequately follow policies. Most employees within

the health care industry know very little about this problem and will find it difficult to identify the red flags, follow proper reporting requirements, and recognize the appropriate responses if their thinking and behavior have not been impacted by this training.

Proper training should also impact behavior related to how information is handled, and go a long way towards data theft and breaches that are increasingly common. This is especially true when 61% of current data breaches are a result of administrative error.

It is important to make efforts to establish some measures as soon as possible. According to Betsy Broder, Assistant Director, Division of Privacy and Identity Protection at the Federal Trade Commission, the FTC will be looking for “reasonable efforts” at this initial point of enforcement. According to Broder, “What we’re looking for is good faith efforts on their part to develop programs.”

policies established (available to members only at http:/www.cmanet.org). It is important that any templates are properly customized to fit the risk level and unique red flags of a specialty. It is also very important to document employee training that educates on medical ID theft, the cost to the victims and the practice, and trains in proper detecting and responding to red flags.

About the Author: Matt J. Morris is a certified ID Theft Risk Management Specialist, and is a managing partner with TBG-Fraud Solutions. He has worked for over a decade helping organizations prevent issues of data breaches and identity theft, and provided training for hundreds of organizations. He is currently providing documentation and specialized training designed specifically for the Red Flags legislation at no charge for qualifying practices.

If you would like more information, please contact TBG-Fraud Solutions directly at 888/985-1890.

The CMA has developed a Red Flag Rule toolkit for assistance with getting

(November 2008 Issue, www.memag.com)

PAGE 17 | THE BULLETIN | MAY / JUNE 2009

CODING & REIMBURSEMENT NEWS

Opting Out of Medicare

By Sandie Becker, CMC SCCMA Coding/Reimbursement Specialist In recent years, more and more providers are choosing to opt-out of the Medicare Program. This is not to say that these providers are not participating.

A non-participating provider carries a different connotation altogether. Apart from never enrolling in the Medicare Program, providers have three options available.

1. Participating – Providers must bill the Medicare contractor and accept Medicare’s allowed charges as payment in-full for all of their Medicare patients; 2. Non-participating – Providers are able to decide on a case-by-case basis whether to accept assignment or to have their patients be responsible for payment up to the limiting charge. (Medicare has these amounts listed in the third column of the fee schedule http://www.cms.hhs.gov/ FeeScheduleGenInfo/.) Providers must bill the Medicare contractor for their

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.

patient and the patient will receive payment directly from Medicare; 3. Opt-Out – Providers opt-out of the Medicare Program entirely and contract with their Medicare patients privately. Neither the provider nor the patient can bill Medicare for any services provided for two years.

Unfortunately, opting-out is not just an “I say, therefore, I am” decision.

There are procedures that must be followed and rules that must be maintained. If a physician fails to maintain “opt-out” status by following the proper guidelines and fails to demonstrate within 45 days of a notice from the carrier of a violation of the optout rules that he or she has taken good faith efforts to maintain opt-out status, effective 46 days after the date of the notice, and for the remainder of the opt-out period: 4. All of the private contracts between the physician and beneficiaries are deemed null and void; 5. The physician’s opt-out of Medicare is nullified; 6. The physician must submit claims to Medicare for all Medicare covered items and services furnished to Medicare beneficiaries; 7. The physician or beneficiary will not receive Medicare payment on the Medicare claims for the remainder of the opt-out period; 8. The physician is subject to limiting charges provisions; and 9. The physician may not attempt to once more meet the criteria for properly PAGE 18 | THE BULLETIN | MAY / JUNE 2009

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

opting-out until the two-year opt-out period expires.

As a member of SCCMA/CMA, physicians may access On-Call document #0151 entitled “Medicare Participation (and Non-Participation) Options.” This document provides answers to questions pertaining to opting-out of Medicare as well as providing requirements for affidavits and a sample private contract with physicians. To access this and many other On-Call documents, sign on to www.cmanet.org and click CMA OnCall to access the library. You may also email sandie@sccma.org and request an electronic copy.

Other Resources: 10. http://www.palmettogba.com/ palmetto/Providers.nsf/DocsCat/ Jurisdiction%201%20Part%20 B~Enrollment-%20Opt%20Out%20 Providers 11. http://www.cms.hhs.gov/Manuals/ downloads/bp102c15.pdf

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The Doctors Company built its reputation on the aggressive defense of our member physicians’ good names and livelihoods.

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To learn more about our medical professional liability program, call The Doctors Insurance Agency at (415) 506-3030 or (800) 553-9293. You can also visit us at www.doctorsagency.com.

Robert D. Francis Chief Operating Officer The Doctors Company

PAGE 19 | THE BULLETIN | MAY / JUNE 2009

TA CLARA SAN

•

IAT SSOC ION • LA

expertise

Y MEDIC UNT A CO

A Risk Management CME Presentation

C AL

IF O R N IA

Presented by NORCAL Mutual Insurance Company

A jointly-sponsored CME activity with

Santa Clara County Medical Association

The Medical Family: More Fun and Less Stress Santa Clara County Medical Association and NORCAL Mutual Insurance Company invite you and your spouse/significant other to attend this special Saturday morning activity featuring Dr. Ron Hofeldt, a psychiatrist from Salem, Oregon, who specializes in wellness issues pertaining to physicians and their families. This CME workshop will combine didactic teaching elements and interactive discussion. Breakfast and lunch will be provided.

When + Where Saturday, September 19, 2009, 8:00 am – 2:00 pm Palo Alto Medical Foundation 701 E. El Camino Real Mountain View

How to Sign Up $25 per couple for SCCMA members and NORCAL Mutual Insurance Company policyholders. $50 per couple for non-members.

Faculty Ron Hofeldt, MD is a psychiatrist in Salem, Oregon with a private practice specializing in the treatment of physicians since 1976. He consults with physicians, physician organizations, and malpractice insurance companies on issues relevant to physicians. Over the last several years, Dr. Hofeldt has conducted lectures and seminars on the topics of litigation stress, physician burnout, physician-patient communication, physician-physician communication, boundary violations, medical error, and coping with the current changes in medicine.

Educational Objectives At the conclusion of this activity, you should be able to: • Articulate the medical definition of burnout, its stages, as well as the impact of unaddressed burnout on physician mental health, physician work/life balance, professionalism, patient safety, and malpractice risk exposure.

• Analyze and mitigate your risk for burnout utilizing primary prevention (e.g., education, re-inventory, limit setting, trust building, organizing, prioritizing).

• Minimize the negative impacts of burnout by utilizing secondary prevention (e.g., early detection, identifying sources of stress, commitment to change, intervention).

• Implement strategies to improve communication at work and at home.

CME Information and Disclosure This activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of NORCAL Mutual Insurance Company and Santa Clara County Medical Association. NORCAL Mutual Insurance Company is accredited by the ACCME to provide continuing medical education for physicians. NORCAL Mutual Insurance Company designates *If you require reasonable accommodation in accordance with the Americans with Disabilities Act (ADA), please make arrangements when you enroll.

this educational activity for a maximum of 4.5 AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

The faculty member—Ron Hofeldt, MD—has no relevant financial relationships to disclose. The planners for this activity are listed below, and have no financial relationships to disclose: Rebecca Powers, MD (Chair, SCCMA Physicians Well-Being Committee) William Berquist, MD (Chair, Stanford & Lucile Packard’s WBC) Jerry Callaway, MD (Chair, Good Samaritan Hospital’s WBC) Ramon Jimenez, MD (Chair, O’Connor Hospital’s WBC) Gene Kansky, MD (El Camino Hospital’s WBC) Jyoti Rau, MD (Chair, Kaiser’s WBC) Simran Singh, MD (Chair, Santa Clara Valley Medical Center’s WBC) Howard Sutkin, MD (Chair, Regional Medical Center’s WBC) Siggie Stillman (SCCMA Alliance) Jo Townson (NORCAL Mutual Insurance Co) Pam Jensen (Santa Clara County Medical Association) Special thanks to Dr. Stuart Menaker, Palo Alto Medical Foundation for use of their conference room.

Seating is Limited ☞ Register Today!

To attend, please complete the information below and mail with credit card number or a check made payable to “SCCMA” to 700 Empey Way, San Jose 95128, or fax to 408/289-1064, Attn: Pam. 1. Name of Physician: ____________________________________ Phone: _______________________ 2. Name of Spouse/S.O.: __________________________________Phone: _______________________ 3. Fax: ________________________________________________ Email: ________________________ $25.00 per couple for SCCMA Members OR NORCAL Policy holders $50.00 per couple for Non-Members Visa or Master Card # __________________________________ Exp. Date________________________ Amount of payment _________________ Signature _________________________________ Name on card________________________________

SCCMA DISCOUNT TICKET PROGRAM Regular Gate Price

Discounted Price

CALIFORNIA GREAT AMERICA Adult Admission $53.99 Child Admission (3-6 years) $35.99 Season Pass $69.99 Gold Season Pass (includes Gilroy $94.99

$34.99 $34.99 $64.99 $84.99

Garden) Parking Pass

$12.00

$10.00

GILROY GARDENS Adult Admission Child/Senior Admission

$41.99 $31.99

$23.00 $23.00

$29.95 $27.95 $27.95 $17.95

$26.00 $24.00 $24.00 $14.00

$30.99 $22.99 $50.99

$22.99 $22.99 $41.99

SIX FLAGS DISCOVERY KINGDOM General Admission $44.99 Child Admission (under 48”) $29.99 *Under 2 years FREE!

$26.00 $26.00

(3-6 years or over 64)

MONTEREY BAY AQUARIUM Adult (18-64 years) Senior (65+) Student (13-17 years) Child (3-12 years) RAGING WATERS Adult Admission Child Admission (under 48”) Season Pass *Under 3 years FREE!

SEE’S CANDIES 1 lb. Gift Certificate

$15.60

$12.00

If you purchase 4 or more tickets, SCCMA will deliver to your office for a $5.00 delivery fee on Fridays only. Tickets must be pre-paid via credit card prior to delivery, or you can remit payment upon delivery with exact cash. (NO CHECKS) To order call Jacquelyn Mentz at 408/998-8850 Ext. 3008.

Thank you!

PAGE 22 | THE BULLETIN | MAY / JUNE 2009

MEMBER NEWS & HAPPENINGS

Welcome 40 New Members!

Name Suszanne Bernat Lauren Brave Lawrence Bruguera Priyamvadha Chakravarthi Michael Champeau Sumitra Chari Andrew Chong Vickie Chou Chris Chung Michael Cluck Natalia Colocci Sharon Drost Jerome Gabriel Jennifer Gillett Cindy Hsu Sherry Huang Irena Ilic Priyanka Jain Megan Karnopp Clete Kushida Chyh-Woei Lee Anna Levin-Shohat

Specialty PD PD IM ON

City Palo Alto Palo Alto Santa Clara Palo Alto

Name Ann Lewis Uma Mohanasundaram Janesta Noland Neelakshi Patel

PD IM *EM PD *FP *SM ORS ON N OBG IM FP IM IM IM PD N, SDM A IM

Stanford Palo Alto San Jose Mtn View San Jose Campbell Palo Alto San Jose Milpitas Palo Alto Los Altos Palo Alto Palo Alto Santa Clara Palo Alto Redwood City Palo Alto Santa Clara

Toby Ratanasiripong Chitra Reddy Nicole Rimpel Veronica Rivera Jennifer Roost Alan Rosenthal Scott Rudy Anthony Saglimbeni Suzanne Soriano Michael Stein Claribel Taylor Gayathri Thirumalaiselvan Rahul Verma Ying Zhu

Specialty PD CCM PD *RHU, *IM PMR NEP IM OBG GE P AN *IM, *PD, *SM FP IM GE IM

City Santa Clara Santa Clara Menlo Park Los Gatos

GE ON

Palo Alto Santa Clara

Palo Alto Santa Clara Palo Alto San Jose Palo Alto Palo Alto Palo Alto San Jose Los Altos Campbell Palo Alto Santa Clara

In Memoriam Victor M. Burkman, MD Family Practice 1/16/20 – 1/20/09 SCCMA member since 1951 David B. Downie, MD *Otolaryngology 7/17/42 – 4/16/09 SCCMA member since 1977 Robert B. Kaster, MD *Anesthesiology 5/30/15 – 4/2/09 SCCMA member since 1960

Leslie W. Knott, MD Public Health & Gen Preventive Medicine Physical Medicine & Rehabilitation 6/14/11 – 1/4/09 SCCMA member since 1967 Jerauld J. LaBarber, MD Internal Medicine Hypnosis 9/13/30 – 4/16/09 SCCMA member since 1965

PAGE 23 | THE BULLETIN | MAY / JUNE 2009

Barry Rosen, MD Addiction Medicine ? – 3/09 SCCMA member since 2007 Jerome D. Tossy, MD *Orthopaedic Surgery 2/28/32 – 2/18/09 SCCMA member since 1966

PRACTICE MANAGEMENT

Create a Code of Conduct

Creating a Code of Conduct Can Help You Deal Effectively With Problem Co-workers

By Jeffrey J. Denning Sometimes, we arrive at group practice consulting engagements only to find out the real agenda is for us to “do something about Harry.” It’s surprising how many surgeons can stand for hours at an operating table without any backbone.

Here’s one of our recommendations to a surgery group near here: Create a Physician Code of Conduct for the group. This may seem unnecessary, but there were several anecdotes of physician behavior that apparently breached your assumptions of good conduct. When you have a code that is agreed upon, it is easier to ask the question, “How did your behavior fit the code or help the group?” You make assumptions about each others’ motives, often erroneous, and resentment has built up among you. If behavior is unacceptable, make a motion to deal with it in some specific way.

Record the vote, and if anyone votes no or refuses to vote, consider it an indication you’re dealing with a non-member individual. And, if you can’t get a second, move on.

A group that continues to accept “unacceptable” behavior by not acting on it has a problem with definitions. Good groups are the ones that create a culture of interdependence, trust, and friendship where no physician would countenance mistreating a practice or hospital employee or colleague. But plenty of practices have just these kinds of malignantly narcissistic personalities among the physicians and do nothing about it, beyond complaining (privately) about it, or maybe, calling a consultant. They’re seeking the magic pill

that will make Harry change or “go away,” without having to actually do anything requiring gumption.

•

Ethics: We will do what we know is right and not do what we know is wrong.

Creating a Code of Conduct

•

Excellence: Quality care, quality staff, quality patients, and quality of life.

•

Professionalism: We will perform our roles and responsibilities with the highest level of professionalism.

•

Customer Service: We treat patients (and those who refer them to us) right.

We meet their needs and are always friendly and courteous.

•

Productivity: We strive to do more with the same or fewer resources.

•

Efficiency: We do things right.

•

Effectiveness: We do the right things.

•

Safety: We want no harm to come to our patients or ourselves.

First step: Make clear just what really is unacceptable behavior. You can’t deal with a problem fairly, if you haven’t put the group on record defining terms and listing what can get a physician into hot water. Michael Josephson’s Character Counts! coalition (www.CharacterCounts. org) lists six key “pillars of character” that form a good place to start: 1.

2.

3.

4.

5.

6.

Trustworthiness Respect Responsibility Fairness Caring Citizenship

Here are some example values and prescribed and proscribed behaviors we’ve collected from groups we’ve visited, adopted in an effort to deal with problem physicians preemptively.

Values •

Honesty & Integrity: We will always be honest with ourselves, patients, suppliers, and clients, and we will continuously demonstrate integrity in our profession and our business. We will do what we say we will do, and we will not do what we say we will not.

PAGE 24 | THE BULLETIN | MAY / JUNE 2009

• Compliance: We follow the rules and obey the laws; even the unwritten ones.

•

Accountability: We will accept responsibility for our actions and behaviors.

What We Do: •

• •

• •

We use appropriate channels to express dissatisfaction or grievances with any practice staff or physician, and always in privacy.

We display respect for the dignity of others.

We respond to on-call responsibilities by dedicating the time for that purpose and fulfilling those responsibilities with a willing attitude. Call coverage is a critical reflection on the group in the community.

We are candid about our opinions and participate fully in policy discussions.

We follow the policies set by the group, even if we personally prefer not to.

What We Do Not Do: • • • • • •

Make negative assumptions of motives of our colleagues.

Show disrespect or discourtesy.

Make degrading or sarcastic remarks.

Manipulate the staff or other providers.

Engage in social relationships with staff apart from practice functions.

Discuss our dissatisfactions and criticisms of our group, our staff, our hospital, our referral sources, or our competition with non-management staff or outsiders.

Forget about charging each other fines for bad behavior. This just puts a money value on it. If fines were the only penalty for speeding, David Letterman would always drive 130 MPH. The job of the traffic court is to stop high speed driving, not just make it expensive, so

expect other sanctions—some really distasteful ones—if you keep it up.

A code of ethics or good conduct won’t work in a vacuum, though.

Publishing one and hanging it on the wall without the willingness to confront physicians can actually do more harm than good. A group that goes on record in this way, but doesn’t actually enforce the code, sends the message loud and clear to employees: group ethics is a pretense without a practice here.

About the Author: Jeffrey J. Denning is a principal management consultant with Practice Performance Group. PPG provides high-performance medical practice management services for physicians, including consulting, expert witness, workshops, speaking, and a monthly newsletter. Visit PPG online at www.ppgconsulting.com for further information.

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www.1027design.com • 530.941.4706 PAGE 25 | THE BULLETIN | MAY / JUNE 2009

NORCAL Mutual Insurance Company

AN OUNCE OF PREVENTION COULD SAVE A POUND OF CURE Healing Health Care Through the Patient Safety Movement

Submitted By NORCAL Mutual Insurance Company When the Institute of Medicine (IOM) published its groundbreaking report To Err is Human in November 1999, it shocked the general public and sparked a heated debate within the medical community. The report exposed the high incidence of medical errors occurring in hospitals and health care facilities throughout the U.S., and stated that as many as 98,000 deaths occur each year as a result of these errors.1 Several decades ago, the health care industry was markedly different than it is today. According to health care journalist Robert M. Wachter, “When the tools of medicine were the doctor’s intellect, the nurse’s empathy, and a few simple surgical procedures and potions, there was little price to be paid for absent safety systems and lack of coordination.”2 As health care technology advanced, more complicated systems and organizational hierarchies were needed to deliver patient care.

As the complexity of new systems grew and the number of adverse patient outcomes rose, the number and severity of lawsuits brought by patients against physicians or institutions increased. Over time, medical liability became the troubled core of the damaged health care system in the U.S., fostering what is now commonly known as a “culture of blame.”

A Culture of Blame Physicians began to practice costly defensive medicine in an attempt to protect themselves from claims. Hospital administrators supported this practice.

Patients became more wary of physicians and began to view health care providers with fear and distrust. Trial lawyers began to hold individual physicians financially

accountable for virtually any unanticipated outcome and pursued larger settlements for patients. Medical liability insurers, faced with a sharp rise in claims severity, were forced to raise their policyholders’ premiums to cover growing claims losses.

This culture of blame, accompanied by physicians’ fears of retaliation for errors and other unanticipated outcomes, ultimately fostered an institutionalized “wall of silence” that now pervades the health care industry.

According to Rosemary Gibson, author of Wall of Silence: The Untold Story of the Medical Mistakes That Kill and Injure Millions of Americans, “Many doctors and nurses privately express deep concern about medical mistakes, yet they remain silent. If they speak out publicly, their jobs and professional standing may be at risk.”3

Safety (NCPS), established in 1999 by the Department of Veterans Affairs (VA), was formed to reduce adverse medical events throughout the VA’s health care system. The Leapfrog Group, a coalition of Fortune 500 employers who purchase health care, formed in November 2002 to foster breakthroughs in the safety and quality of health care for Americans. The Josie King Foundation, also established in 2002, was created by Sorrel and Tony King, the grieving parents of a toddler who died due to a series of medical errors.

In addition to these patient safety coalitions, numerous experts in the health care field joined the debate, advocating for change. Some of the overarching systemic changes suggested include: •

The Patient Safety Movement: Working Toward a Culture of Safety

•

The patient safety movement was well underway several years before To Err Is Human was published. The National Patient Safety Foundation (NPSF) was established in 1997, two years in advance of the report. In an exclusive interview with NORCAL, Diane Pinakiewicz of the NPSF stated, “We’ve been beating the drum of patient safety since the organization was formed. Even in the years before the IOM report came out, we were doing everything we could to promote the discovery of new knowledge and new approaches to improving patient outcomes.”

•

The IOM report galvanized the patient safety movement and shocked its founders and proponents into action. Other patient safety organizations joined the crusade. The National Center for Patient PAGE 26 | THE BULLETIN | MAY / JUNE 2009

•

•

Implementation of a system that allows for non-punitive reporting of errors; Creation of a federal regulatory agency, akin to the National Transportation Safety Board, to oversee health care; Federal funding for safety-focused organizations; Introduction of “human factors engineering” concepts into the health care system; and A shift in focus from litigation to dispute resolution/mediation for patients.

Many patient safety leaders believe little has changed in the years since the IOM report was published. According to Lucian Leape, coauthor of the IOM report and a leading advocate for patient safety, “While the progress that has been made in improving patient safety is encouraging, it has been much too slow.

Hospitals need to have crash programs to implement the many safe practices that we now have evidence work. We will not become safe until we put that knowledge into practice.”4

Most experts agree that the number-one obstacle to progress is an industry-wide resistance to change.

According to many patient safety advocates and health care professionals, factors inhibiting change in the U.S. health care system include: • • • • • •

Lack of leadership support Resistance or skepticism from medical professionals Fear of litigation and of reporting unanticipated outcomes Reluctance to invest time and money Staff shortages Waning commitment

According to Dr. Don Berwick, Institute for Healthcare Improvement founder, “The capability that is key to the proper allocation of resources and development of the proper workforce is leadership, and that’s where we still lack traction. It’s not that we don’t have capable executives and committed boards. It’s that the capable executives are still devoted to maintaining the status quo.”5 Without leadership support, other obstacles will remain firmly entrenched.

Many have argued that tort reform, not a cultural shift, is a more reasonable response to the patient safety crisis. Medical liability tort reform—like California’s Medical Injury Compensation Reform Act (MICRA)—is movement in the right direction, but it’s only part of the total solution. William M. Sage, MD, JD, a professor of law at Columbia University, argues that although he is comfortable with caps on damages, “Real reform is not based on litigation. It has to be based on having the systems in place to detect errors, to tell patients about these errors, to offer reasonable compensation right away, and then to have panels in place to deal with the small number of disputes that will inevitably arise.”6

Working Together to Change the System As mentioned, hospitals and health care facilities have begun to make crucial systemic changes. Specialty organizations have likewise made strides toward improving patient safety. The Society for Critical Care Medicine and the American College of Cardiology have

taken steps toward change by discussing patient safety openly and honestly with their member physicians. The American Academy of Orthopaedic Surgeons (AAOS) has also targeted patient safety as a top priority by establishing a committee devoted to developing best practices for surgeons, educating physicians, and increasing public awareness of the issue.7 The AAOS was the first medical specialty organization to address the issue of wrong site surgery and steps towards prevention.

In 2003, a universal protocol addressing wrong site surgery was developed for all operative and invasive procedures. The following year it became effective for all accredited hospitals, ambulatory care, and office-based specialties.8 Although anesthesiology was once considered one of the riskiest specialties for medical liability insurance companies to cover, over the past 20 years insurance premiums have decreased for anesthesiologists nationwide.9 Patient deaths due to anesthesia have dropped substantially. A June 2005 Wall Street Journal article stated that these changes have taken place “mainly because some anesthesiologists chose a path many doctors in other specialties did not. Rather than pushing for laws that would protect them against patient lawsuits, these anesthesiologists focused on improving patient safety. Their theory: less harm to patients would mean fewer lawsuits.”

In the U.S., the Leapfrog Group is designing and marketing new, innovative health care technologies to decrease the risk of adverse outcomes.

Physicians must communicate more openly with colleagues and patients.

Patients must take on greater accountability for their own health and safety. And most importantly, hospital administrators and other health care leaders and executives must spearhead and initiate systemic change.

Notes 1. Kohn LT, Corrigan JM, Donaldson MS. To Err Is Human: Building a Safer Health System. Washington DC: National Academy Press; 2000.

2. Wachter, Robert M. “The End of the Beginning: Patient Safety Five Years PAGE 27 | THE BULLETIN | MAY / JUNE 2009

After To Err Is Human.” Health Affairs Web Exclusive, November 30, 2004 W4-534–W4-545.

3. Gibson, Rosemary and Janardan Prasad Singh. Wall of Silence: The Untold Story of the Medical Mistakes That Kill and Injure Millions of Americans. Washington, DC: LifeLine Press; 2003.

4. Harvard School of Public Health.

“Leading Patient Safety Advocates Assess Progress in Reducing Medical Error Five Years After Landmark IOM Report, To Err Is Human,” press release, May 17, 2005.

5. Galvin R. “A Deficiency of Will and Ambition: A conversation with Donald Berwick.” Health Affairs, January 24, 2005.

6. DeNoon, Danial. “Doctors’ Malpractice Fears Hurt Health Care.”

WebMDHealth. Available at www. webmd.com. Accessed on July 17, 2008.

7. American Academy of Orthopaedic Surgeons. “Patient Safety Top Priority for American Academy Orthopaedic Surgeons,” press release, August 18, 2005.

8. Commission on Accreditation of Healthcare Organizations. “Facts about the Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person SurgeryTM.” Available at http://www. jcaho.org/accredited+organizations/ patient+safety/universal+protocol/ up+facts.htm. Accessed July 17, 2008.

9. Hallinan, Joseph T. “Once Seen as Risky, One Group of Doctors Changes Its Ways.” The Wall Street Journal Online. Available at http://webreprints.

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.

MEMBER SPOTLIGHT: DAVID F. CHANG, MD

The Greatest Challenge in Cataract Surgery This year’s Binkhorst Medal recipient, David F. Chang, MD, describes how a 5-minute, $15 procedure can dramatically reduce cataract blindness in the developing world.

By Michelle Dalton Both peer-reviewed and trade journals continually update us on exciting advances and new technologies that are making cataract surgery even better for ophthalmologists and patients.

“In North America and Europe, most cataract surgeons would say that our greatest remaining challenge is to develop the ideal accommodating lens,” said David F. Chang, MD, clinical professor of ophthalmology at the University of California San Francisco, and in private practice in Los Altos, California. “The forgotten irony is that cataract is still the leading cause of global blindness, and more than half of all blindness in the world is reversible through cataract surgery.” Dr. Chang will deliver the Binkhorst Lecture at this year’s American Society of Cataract and Refractive Surgery (ASCRS), and will focus on the global backlog of cataract blindness.

“Who, other than Western ophthalmologists, can better appreciate just how daunting the challenge of reducing global cataract blindness is,” he said.

“In the developing world, the obstacles include the high cost of phaco and foldable IOL technology, a critical shortage of ophthalmologists, and insufficient educational infrastructure to train novice

phaco surgeons, let alone those skilled enough to tackle the advanced and mature cataracts typically encountered,” he added.

“I hope to highlight what I believe is the single greatest accomplishment in cataract surgery – the combination of a low-cost procedure within a high-volume surgical delivery system that can help stem the epidemic rise in cataract blindness in the developing world,” he said. “When you think about cost effectiveness and impact on human suffering, there are very few medical interventions in the developing world that can match cataract surgery,” Dr. Chang explained. “The key, however,

I hope to highlight what I believe is the single greatest accomplishment in cataract surgery – the combination of a lowcost procedure within a high-volume surgical delivery system that can help stem the epidemic rise in cataract blindness in the developing world is to train local eye surgeons to perform low cost cataract operations in efficient hospital settings that are financially selfsustaining.”

The procedure itself is a manual, sutureless, small incision extracapsular PAGE 28 | THE BULLETIN | MAY / JUNE 2009

procedure that employs reusable equipment and low cost supplies, he said. Referred to as manual SICS (small incision cataract surgery), David F. Chang, MD the five Aravind is the 2009 Binkhorst Eye Hospitals in Medal recipient. southern India have used this technique for years to provide charitable cataract surgery at a cost of less than $15 per case. Charitable manual SICS accounts for roughly 70% of the 200,000 annual cataract surgeries performed within the Aravind system. Dr. Chang explains that this amazing volume is accomplished by streamlining the surgical process through the use of standardized protocols executed by well-trained ancillary staff. Costs are reduced by manufacturing affordable, low-cost PMMA IOLs, viscoelastic, supplies and eye medications in their own in house facility. “I wish that every cataract surgeon could observe the speed, skill, and efficiency of this procedure first hand, as it is practiced at Aravind,” said Dr. Chang. “I will show a video of the remarkable teamwork and orchestration of an Aravind O.R. where a single surgeon performs 12-16 procedures per hour.”

A similar system on a smaller scale is succeeding in Nepal at the Tilganga Eye Center, under the direction of Dr. Sanduk Ruit who also embraces the manual, sutureless SICS method. While Tilganga is a modern eye hospital serving the urban

population of Kathmandu, Dr. Ruit and his team have pioneered a portable highvolume cataract surgery system in order to reach the rural regions of Nepal. Some of these areas can only be reached by foot and all of the equipment must be carried in by the surgical team. He co-founded the Himalayan Cataract Project with University of Utah ophthalmologist, Geoffrey Tabin, MD, in order to train other cataract surgeons from developing countries throughout mountainous Asia. “In the U.S., we are accustomed to solving so many medical problems with new technology, but the solution to global cataract blindness is to go low tech,” said Dr. Chang. He noted that historically, many have questioned whether quality is being sacrificed with non-phaco procedures, and he will report on the first randomized, prospective comparison of phaco and manual SICS in a charitable cataract surgical population. In the study, which was conducted in Nepal, patients either underwent phaco by Dr. Chang or manual SICS performed by Dr. Ruit, and the results proved that manual SICS can achieve excellent outcomes with advanced cataracts, at a fraction of the cost of phaco.1 Dr. Chang will also discuss Project Vision, coordinated by Dennis Lam, FRCS, FRCOphth, in Hong Kong.

Despite its exploding economic growth, China has one of the worst cataract blindness rates in the world, according to Dr. Chang. Project Vision is a creative collaboration of private philanthropy, academic ophthalmology, and the Chinese government to overcome institutional and demographic barriers to reducing cataract blindness in China.

Dr. Chang is hopeful that Binkhorst Lecture attendees “will be educated about the scope of global cataract blindness, and be inspired by the wonderful progress that’s been made at eye hospitals like Aravind and Tilganga.” Having an affordable procedure is an important

start, but Dr. Chang stresses that the real accomplishment was in developing these streamlined systems of delivering high-volume surgery and maximizing the productivity of the scarcest asset – the cataract surgeon. Slowly but surely, Aravind and Tilganga are training surgeons from other developing countries in these high-volume, manual SICS methods.

“Only another cataract surgeon can truly appreciate what these model centers are achieving,” he said. “And the only way to make a significant impact toward reducing cataract blindness is through the ripple effect of teaching more and more local cataract surgeons how to organize and replicate these model systems,” Chang said.

“Aravind, Tilganga, and Project Vision are three different, but complimentary models that offer real hope for reducing the burden of global cataract blindness, and we in the West need to help sustain this movement with financial and educational support.”

“Every year, Congress and insurance companies keep telling us that what we do is less and less valuable, and it is easy to feel demoralized and underappreciated as a result,” said Dr. Chang. “The tireless dedication of our colleagues in developing countries, however, reminds us of just how profound the impact of cataract surgery is, and how incredibly precious our skills and knowledge truly are.”

The Binkhorst Lecture and Medal were established in 1975 in honor of IOL pioneer Cornelius D. Binkhorst. Each year, ASCRS awards the medal to an individual who has followed in Dr. Binkhorst’s footsteps with outstanding contributions to the understanding and practice of cataract surgery and IOL implantation. Honorees, who present the Binkhorst Lecture during the annual ASCRS Symposium on Cataract, IOL and Refractive Surgery, include some of the world’s most prominent pioneering surgeons.

PAGE 29 | THE BULLETIN | MAY / JUNE 2009

Dr. Chang is serving a fiveyear term as chairman of the AAO Annual Meeting Program Committee. He is chair for the AAO Cataract Preferred Practice Pattern Panel, past chair for the AAO Practicing Ophthalmologist Curriculum Committee on Cataract, and chair of the ASCRS Cataract Clinical Committee. He served for five years as co-chief medical editor of Cataract and Refractive Surgery Today.

Dr. Chang was the inaugural recipient of the UCSF Department of Ophthalmology’s Distinguished Alumni Award (2005), and in 2006 became only the third ophthalmologist to ever receive the Charlotte Baer Award honoring the outstanding clinical faculty member at the UCSF Medical School. He was the third recipient of the Strampelli Medal from the Italian Ophthalmological Society (2007), and has been invited to give 17 named and keynote lectures, including the Lim Lecture at the 2009 Asia Pacific Association of Cataract & Refractive Surgery Meeting. Dr. Chang serves on the medical advisory board of two global humanitarian organizations, Himalayan Cataract Project and Project Vision, and is also on the board of directors for the Pan American Association of Ophthalmology.

REFERENCE: 1. Ruit S, Tabin G, Chang D, et al. A prospective randomized clinical trial of phacoemulsification vs manual sutureless small-incision extracapsular cataract surgery in Nepal. Am J Ophthalmol. 2007;143(1):32-38.

Reprinted with permission of Eyeworld.

MEDICO NEWS

MEDICONEWS

CMA Advises MDs to Begin EHR Needs Assessment Process Now The 2009 federal economic stimulus package includes $19 billion for health information technology (HIT), the vast majority of which will be directed to physicians to subsidize the purchase and usage of electronic health record (EHR) systems. Beginning in 2011, qualifying Medicare providers stand to gain up to $44,000 under the program; qualifying Medi-Cal providers stand to receive as much as $64,000.

Many of the standards governing the subsidies will be worked out in the coming months. Given the lack of clarity about what EHR systems will qualify a physician to receive the federal subsidy, CMA believes that now is not the time to rush out and purchase a system. In the meantime, CMA advises physicians to

begin the process of assessing their EHR needs, with an eye on what will work best for your specialty, the size of your practice, the stage in your career, and your comfort level with technology.

Because of the complexity and cost involved with selecting and implementing an EHR, it is imperative that physician practices plan accordingly. To help, CMA has created an HIT Resource Center at http://www.cmanet.org/HIT. There, you will find the latest information, answers to frequently asked questions, and links to HIT-related resources for physicians.

CMA is closely monitoring the HIT standards development process, and will be updating the resource center as new information becomes available.

(CMA Alert, March 23, 2009 issue)

FTC Delays Enforcement of Red Flag Rules for 3 Months

The Federal Trade Commission (FTC) recently announced it would delay enforcement of its new Red Flag Rule, which requires “creditors” – including many physicians – to develop and implement identity theft detection and prevention programs. The new regulations will now take effect on August 1, 2009, so that creditors and financial institutions have more time to develop and implement written identity theft prevention programs.

For more information on the Red Flag rule, see CMA’s Red Flag Rule toolkit and webinar, available to members only at http://www.cmanet.org.

(CMA Alert, May 4, 2009 issue)

State Budget Update: The Good, The Bad, and The Ugly There has been some recent action related to the state’s ongoing budget deficit, and, unfortunately, it hasn’t all been positive.

The Good: Medi-Cal Eligibility The Governor recently signed a bill (SB 3X 24), which will temporarily rescind the semi-annual renewal requirement for children in Medi-Cal and allow the state to receive over $10 billion additional dollars from the federal government over the next 27 months. As a condition of the deal, semi-annual eligibility renewal will be reinstated once the increased federal dollars expire. (As part of the budget signed last September, California moved from annual to semi-annual reporting for children in Medi-Cal.) The Bad: Medi-Cal Optional Benefits The state treasurer and the Department of Finance recently announced that California’s share of the federal economic stimulus dollars that will be in place by June 30, 2010 will fall short of the $10 billion “federal trigger.” Because of this shortfall, a number of optional benefits will be cut from the Medi-Cal program effective July 1, 2009 (including adult dental, acupuncture, audiology and

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

The “federal trigger” is a provision in the recently-passed state budget that would have authorized the elimination of a number of planned spending cuts and tax increases, if California’s share of the economic stimulus money was forecast to be equal to or greater than $10 billion, by June 30, 2010.

The Ugly: Ballot Measures The Public Policy Institute of California recently released a poll showing that five of the six ballot propositions slated for the May 19 special election have less than 50% support. If those five are defeated, California’s projected budget deficit for the remainder of this year would go from $8 billion to more than $14 billion.

The largest single source of revenue among the six measures is Proposition 1C, The Lottery Modernization Act. This proposition would allow the state to borrow against future lottery revenues. This measure alone would cost the state more than $5 billion if it is defeated.

PAGE 30 | THE BULLETIN | MAY / JUNE 2009

(CMA Alert, April 6, 2009 issue)

MEDICO NEWS

Swine Flu Guidance for Physicians The Centers for Disease Control and Prevention and the California Department of Public Health are encouraging physicians to consider the possibility of Swine Influenza A (H1N1) in patients presenting with febrile respiratory illness.

Priority should be given to patients with influenza-like illness, patients who have recently traveled to Mexico, and patients who have been in close contact with someone who has tested positive for swine flu. Below are general testing and treatment guidelines for health care professionals.

Infection Control Any patient that presents for care at a doctor’s office or other health care facility with suspected, probable, or confirmed cases of swine flu should be placed directly into an individual room with the door kept closed. The ill person should wear a surgical mask to contain secretions when outside of the patient room.

Health care personnel interacting with the patient should follow standard infection control guidelines, including wearing an N95 respirator or surgical mask/gown/ gloves. Dispose of used gowns, gloves, and masks in a biohazard bag. And don’t forget to wash your hands thoroughly with soap and water or alcohol-based hand gel (and remind your staff to do the same).

Testing for Swine Flu If you suspect a patient to be infected with swine flu, do a nasopharyngeal swab, put it in viral transport media, and ship to your local county health department per their usual protocol.

Specimens should be collected within the first 24 to 72 hours of onset of symptoms and no later than five days after onset of symptoms. The specimens should be kept refrigerated at 4º Celsius and sent on cold packs if they can be received by the laboratory within five days of the date collected. If samples cannot be received by the laboratory within five days, they should be frozen at -70 º Celsius or below and shipped on dry ice. (Additional details on specimen collection are available at http:// www.cmanet.org/swine_flu.)

Physicians are also reminded to take a travel history from anyone with significant acute respiratory illness.

Treating Swine Flu With Antivirals As this is a new virus, people who received flu vaccine this year are not protected. Antiviral treatment should be considered for confirmed, probable, or suspected cases of swine flu. Antiviral treatment should be initiated as soon as possible, as antivirals are most effective when started within 48 hours of the

onset of symptoms. Antivirals zanamivir (Relenza)or oseltamivir (Tamiflu) are effective against this virus, but should not be used prophylactically except in very narrow, specific instances (see the CDC website for treatment recommendations).

Educating Patients Physicians should urge patients to use normal precautions to prevent the spread of germs that cause respiratory illnesses like influenza. These precautions include: • Cover nose and mouth with a tissue when you cough or sneeze. Throw the tissue in the trash after you use it.

• Wash hands often, especially after a cough or sneeze. Wash hands for at least 15-20 seconds with soap and hot water. Alcohol-based hand cleaners are also effective.

• Avoid touching your eyes, nose, or mouth.

• Try to avoid close contact with sick people.

• If you get sick, stay home from work or school and limit contact with others to keep from infecting them.

More information is available at http:// www.cmanet.org/swine_flu.

(CMA Alert, May 4, 2009 issue)

Physicians Beware of Deceptive PPO Solicitations CMA has learned of a possible scam targeting physicians.

Physicians report receiving, via fax, a request to confirm their participation in Three Rivers Provider Network (TRPN). The deceptive and misleading notice, formatted to mimic a HIPAA compliance document, implies that the physician has treated one or more TRPN patients, and that in order to authorize the patients’ eligibility the physician must agree to the terms described in the document.

This is merely an underhanded attempt to get providers to join the TRPN network and agree to accept its discounted rates as payment in-full. CMA urges physicians to alert their office staff about this solicitation and to be wary of requests for physician information from unknown payors.

Physicians are advised, before signing any new contract, to review it carefully. Among other things, physicians should ensure that the proposed compensation, including the payor’s payment policies and the rules it uses to adjudicate claims, will be sufficient to maintain the medical practice. Without doing this analysis, you cannot make an informed decision about signing the contract.

To help physicians negotiate and manage complex thirdparty payor agreements, CMA has published a contracting toolkit, Taking Charge: Steps to Evaluating Relationships and Preparing for Negotiations—A Focus on Payor Contracting. The toolkit is available free to members at www.cmanet.org.

PAGE 31 | THE BULLETIN | MAY / JUNE 2009

MEDICO NEWS

Physicians Face 21% Medicare Rate Cut in 2010 to reflect different modes of practice and to ensure that doctors At the beginning of 2009, it appeared as though the annual have a choice in determining how and whether they participate in kabuki theater of threatened Medicare cuts might not materialize Medicare, and should they do so, receive a fair compensation for this year. The Obama Administration became the first presidential their work. administration to release a budget that would eliminate the SGR, at The highlights: a cost of $380 billion. Also, the House Budget Committee agreed in • CMA will continue to support the elimination of the SGR March to waive Congressional pay-as-you-go rules (which require payment formula; new federal spending to be offset by budgetary cuts or tax hikes) for • CMA will urge Congress to provide a Medicare payment the SGR, further clearing the path towards a permanent Medicare update of at least 10% in 2010 as a catch-up for the last 7 years fix. of inadequate updates; However, the House recently reversed itself, and voted to • CMA will support a new Medicare physician payment system uphold the pay-as-you-go rules for all programs, effectively that allows physicians to voluntarily select a payment track requiring an additional $285 billion. Therefore, Congressional based on five options that reflect their mode of practice. The leaders may scale back their plans to completely eliminate the SGR five options include a solo/small group physician track that pays and only reverse the cuts for a few years at a time. If no changes are physicians based on the Medicare Economic Index, a medical made, physicians face a 21% cut in Medicare rates in 2010. home track, and a track that allows physicians to organize into The Senate Finance Committee released a paper recently on virtual or real groups to coordinate care and receive bonus Medicare payment reform. It is the first of three papers they will payments based on the hospital savings they achieve in their be releasing this month on health reform. In brief, because of the region. The plan also allows physicians to privately contract enormous cost to eliminate the SGR ($380 billion), the finance with Medicare patients for certain services. committee plan stops the SGR cuts for three years and gives • CMA will advocate for physicians to be granted anti-trust relief physicians a 1% payment increase in the first two years. Physicians to collectively negotiate contract terms with the private health who provide 60% of their services in ambulatory settings would plans. receive 5% bonus payments for five years for E&M services for new and established patients. General surgeons practicing in designated (CMA Alert, May 4, 2009 issue) rural areas would also receive 5% bonus payments.

These bonuses would be paid for by reducing payments across the board for all other services.

While there are numerous initiatives in the proposal, A REGISTRY & PLACEMENT FIRM the major one is the proposed establishment of a shared savings program whereby physicians who affiliate and form coordinated care organizations may receive bonus payments based on the savings achieved in the Medicare program (Part A and Part Nurse Practitioners ~ Physician Assistants B) in their area.

While CMA appreciates the commitment the Senate is making to pay for the gradual elimination of the SGR without imposing larger cuts in future years, the proposed 1% payment increase and the net reductions in other services are completely inadequate to cover rising physician practice costs.

CMA is supportive of the substantial increases for E&M services, however, CMA strongly opposes cuts Locum Tenens ~ Permanent Placement to other services to pay for those gains. CMA met with the Senate Finance Committee in Washington, V oi c e : 8 0 0 -9 1 9 -9 1 4 1 or 8 0 5 -6 4 1 -9 1 4 1 D.C., recently to discuss this proposal.

FAX : 8 0 5 -6 4 1 -9 1 4 3 With Medicare reform discussions in Congress providing the backdrop, CMA’s Board of Trustees t z w e i g@ t r a c y z w e i g. c om recently adopted new policy dealing with the issue w w w. t r a c y z w e i g. c om at its April meeting. The new policy is designed

Tracy Zweig Associates Physicians

PAGE 32 | THE BULLETIN | MAY / JUNE 2009

MEDICO NEWS

Medical Board Changes Licensing Fees for Physicians Physician licensing and renewal fees assessed by the Medical Board of California will increase by $3, from $805 to $808, effective July 1. The increase is the result of a $22 licensing fee decrease associated with the termination of the Diversion Program and a new $25 licensing fee increase to fund the Steven M. Thompson Physician Corps Loan Repayment Program.

Prior to its termination, the medical board’s Diversion Program had been funded by a $22 surcharge on physicians’ licensing fees. Although the diversion program ended on June 30, 2008, the medical board postponed the effective date of the associated licensing fee reduction to July 2009. In August, CMA objected to the delay, arguing that the medical board was violating state law by continuing to collect this surcharge to support a nonexistent program. In response to CMA’s concerns, the medical board has now agreed to refund “diversion surcharges,” collected between July

1, 2008 and July 1, 2009, in the form of a licensing fee credit. The credit will be applied at physicians’ next renewal application.

The $22 licensing fee reduction resulting from the closure of the Diversion Program will be offset by a new $25 licensing fee increase, which will be used to fund the Steven M. Thompson Physician Corps Loan Repayment program. The loan repayment program provides newly licensed physicians with medical school loan repayment grants of up to $105,000 in exchange for three-year commitments to serve in medically underserved areas of the state.

The $25 fee increase will be incorporated into the total renewal fee paid by any physician (including retired physicians) whose license expires on or after April 30, 2009.

(CMA Alert, April 20, 2009 issue)

Sign Up for CMA’s Legislative Hot List CMA’s Legislative Hot List, distributed weekly during the legislative session, follows the progress of CMAsponsored bills and other bills of interest to physicians as they move through the legislative process.

Among the bills being followed this year: Unlawful Health Insurance Cancellation (AB 2): This CMAsponsored bill requires insurers to obtain approval from an independent review organization before rescinding a patient’s health insurance. This review would use a clear legal framework to determine whether the rescission is appropriate, while protecting the patient’s rights during the review process. This is a reintroduction of AB 1945, which was vetoed in 2008.

Car-Pool Lane Access for Physicians (AB 497): This CMA-

sponsored bill would allow physicians to use high occupancy vehicle (carpool) lanes on the freeway when responding to an emergency. This bill would expand current law, which allows physicians in certain circumstances to exceed speed limits when responding to emergencies.

Education Disclosure for Health Care Practitioners (AB 583): CMA is cosponsoring this “truth in advertising” legislation with the California Society of Plastic Surgeons. It would require health care practitioners to display their educational degree, license type and status, and board certification on either their nametag or in their offices, to help patients better understand the credentials of their health care practitioner prior to receiving treatment.

Nurse Practitioner Scope of Practice (SB 294): CMA is opposing

PAGE 33 | THE BULLETIN | MAY / JUNE 2009

this bill, which would expand the scope of practice for nurse practitioners, allowing them to admit patients to the hospital and be designated as primary care providers.

Corporate Medicine Bar (AB 648 and SB 726): These CMA-opposed bills would erode the ban on the corporate practice of medicine in California by allowing certain hospitals to hire physicians. Under current law, hospitals are barred from hiring physicians as employees. This important law was created to prevent corporations or other entities from unduly influencing the professional judgment and practice of medicine by licensed physicians.

For more information on these and other bills of interest, see CMA’s Legislative Hot List, http://www.cmanet. org/news/hotlist.asp.

(CMA Alert, April 20, 2009 issue)

CLASSIFIED ADS office space for rent/lease OFFICE SPACE FOR SUBLEASE • SARATOGA Starting at $600/unit/mo, this 900 sq. ft. office provides adequate space for a small practice at least four days per week. Three units available: two treatment rooms (9’10” x 8’8”), one large consultation room (12’4” x 8’11”). Call Lisa at 408/516-4537.

OFFICE SPACE FOR LEASE Medical suite near O’Connor Hospital. 630 sq. ft., $2.30 per ft. Contact Dr. Michael Lambert at 408/296-2190 or toothtastic@ yahoo.com.

MEDICAL SUITES • LOS GATOS – SARATOGA Two suites, ranging from 1,000 to 1,645 sq. ft., at gross lease cost. Excellent parking. Located next door to Los Gatos Community Hospital. Both units currently available. Call 408/355-1519.

MEDICAL OFFICE FOR LEASE/ SUBLEASE/SALE Office in close proximity to O’Connor Hospital for lease/sublease/sale. Please call 408/923-8098 for more information.

MEDICAL SUITES • GILROY First class medical suites available next to Saint Louise Hospital in Gilroy, CA. Sizes available from 1,000 to 2,500+ sq. ft. Time-share also available. Call Betty at 408/848-2525.

OFFICE SPACE FOR LEASE • SAN JOSE 600–1,900 sq. ft. in West Valley Medical Building, second floor, elevator, separate entrance. Call Helen at 408/243-6911.

MEDICAL OFFICE SPACE FOR LEASE • SANTA CLARA Medical space available in medical building. Most rooms have water and waste. Reception, exam rooms, office, and lab. X-ray available in building. Billing available. 2,500–4,000 sq. ft. Call Rick at 408/228-0454.

LOS GATOS OFFICE $2.00 NNN/$2.60 FULL 1,500 – 9,000 sq. ft. of offices and/ or rehab in heart of Los Gatos. www.536NSantaCruz.com. 408/656-8265.

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.

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

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 408/528-0571.

OFFICE EXAM ROOMS TO LEASE 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.

PAGE 34 | THE BULLETIN | MAY / JUNE 2009

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 $2.00 sq. ft. + 3 N.

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

MEDICAL OFFICE FOR LEASE • LOS ALTOS Fantastic location. The unit is 1,050 sq. ft. Four + exam rooms, plus an additional doctor’s office. Large reception and waiting room. Includes basement for storage.

Located on Altos Oaks near El Camino Hospital. Two private parking spaces. Call 650/575-6889.

OFFICE FOR RENT • MORGAN HILL 10 minutes from South San Jose. 1,150 sq. ft. , excellent location, next to MDs and lab. $1,500 per month. Call or fax 408/7797349. Agent welcome.

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.

MEDICAL OFFICE • O’CONNOR HOSPITAL AREA Office in elegant medical office building with ample parking, within one block of O’Connor Hospital. 1,600 sq. ft. to share, 800 sq. ft. per physician. Common bathroom and waiting room, no triple net, $2.75 per square foot. Call 408/292-3609 and leave a message.

PRIVATE PRACTICE/ OFFICE for sale PRIVATE PRACTICE FOR SALE IM/FP/GP. Primary care practice for sale, including inventory and equipment. Close to O’Connor Hospital. If interested, please call Stacy at 408/297-2910.

PRACTICE FOR SALE • SAN JOSE Internal Medicine practice. Well established. Grossing $360k-plus; 1,300 sq. ft. condo location with three exam rooms.

Sees 200 patients/month. Seller is moving.

Priced to sell. 100% financing available.

Contact 888/277-6633 or info@promedfinancial.com.

PRIVATE PRACTICE FOR SALE Available immediately. Urgent Care/Family Practice in West Valley area. Established 30 years, $0 down. Contact Helen at 408/4763450.

LOS GATOS OFFICE FOR SALE Luxurious 9,000 sq. ft. office with seven offices, full kitchen, 3,700 sq. ft. physical therapy floor, lockers, showers. www.536NSantaCruz.com. or 408/6568265.

OFFICE CONDOMINIUM AND PRACTICE FOR SALE 1,054 sq. ft. 1,300+ active patients and 2,000+ inactive patients. No Medi-Cal, HMO, PPO, Medicare. Asking $370,000 (office condominium and practice). Call Dr. Chang at 408/926-2420.

Continued on page 36

BRAND NEW HIGH END MEDICAL CONDOS– DOWNTOWN LOS GATOS Design/build-to-suit opportunities for sale/lease. On-site parking. In the heart of prestigious downtown Los Gatos. Unit sizes 1,400 sq. ft. and up.

Contact Matt–408/282-3835. www. colliersparrish.com/losgatos.

A+ TRANSCRIPTION SERVICE Providing Clinicians Quality Medical Transcription Since 1995 � Dictation Using 800 Phone System or Your Hand-Held Recorder � 24-Hr. TAT - STAT 2-Hrs. � HIPAA Compliant Testimonials “ A+ Transcription makes us feel like we are their only client. Great work in terms of accuracy and rapid turnaround time.”

Wendy Perston, Administrator – Cardiovascular Institute of Southern Oregon “A+ Transcription has provided my Physiatry and Pain Medicine practice with prompt, accurate transcription for many years. I strongly recommend this service to any clinician.” Mark J. Sontag, M.D. “Transition was seamless, prompt, accurate and very easy to work with. All my doctors are completely satisfied with A+ Transcription Service!” Ilona Garton, Administrator – Altos Oaks Medical Group “A+ Transcription Service has good turnaround time. Their team is accurate in transcribing what we dictate and most importantly, A+ is reliable!”Anthony DuBose, M.D. – Director, Workforce Medical Center A+ Transcription Service 888 589-8283 e-mail: apluspat@aol.com

PAGE 35 | THE BULLETIN | MAY / JUNE 2009

Classified Ads, continued from page 35

EMPLOYMENT OPPORTUNITY OCCUPATIONAL MEDICINE PHYSICIANS • PRIMARY CARE, ORTHOPEDICS, & PHYSIATRY Our occupational medical facilities offer a challenging environment with minimal stress, without weekend, evening, or “on call” coverage. We are currently looking for several knowledgeable and progressive primary care and specialty physicians (orthopedist and physiatrist) interested in joining our team of professionals in providing high quality occupational medical services to Silicon Valley firms and their injured employees. We can provide either an employment relationship including full benefits or an independent contractor relationship. Please contact Dan R. Azar MD, MPH at 408/790-2907 or e-mail dazar@allianceoccmed.com for additional information.

MEDICAL DIRECTOR POSITION Facility is in need of Medical Director who desires to build from our clientele a practice for Botox and other fillers/treatments.

If desired by physician, opportunity to build from our client base for additional procedures. Call 408/592-8300 or email: rcc0928@yahoo.com.

condo/COTTAGE rentals BEACH HOME • RIO DEL MAR/ APTOS Two story, three bedroom, remodeled home, 1½ blocks from beach, available for weekend or weekly rental. Email bystrong@yahoo.com for details.

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 PEDIATRIC PRACTICE Will buy Pediatric practice in South Bay. Call 408/455-2959.

Pajaro Dunes Beachfront Condo Shorebirds #58 2 Bedroom -- 2 Bath Top Level -- Great Ocean View Great for Families

Owners Bill & Debbi Ricks 408-354-5613

PAGE 36 | THE BULLETIN | MAY / JUNE 2009

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

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

Thinking about electronic medical records?

What about your paper records?

If you are planning going to do with all those records into records to a CD alternative:

to move to an electronic medical record system, what are you your paper patient charts and billing files? Consider scanning a digital database with deliverExchange™. Let us scan your or DVD, and realize the benefits of this cost-effective

Safe secure storage that you control • Records are accessible 24/7 Files can be printed out or electronically transmitted • Save time spent filing and retrieving records • Eliminate lost or misfiled records • Save space and storage costs • Keep a copy for backup, security •

•

We pick up your records, scan them at our imaging unit in San Jose, produce quality images on CDs or DVDs, and handle the destruction of the paper records.

2054 Zanker Road San Jose, CA 95131 Contact: Liz Allan phone 408.436.1701 ext.131 fax 408.436.1625

You may not know our name, but if you practice in Santa Clara county you know our service. For over 30 years, SOURCECORP Deliverex has been the vendor of choice for record management in the Bay Area.

PAGE 37 | THE BULLETIN | MAY / JUNE 2009

PRACTICE MANAGEMENT

Medical Practices Face Rising Workers’ Compensation Costs 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 Workers’ Compensation Insurance Rating Bureau is recommending a 24.4% average increase in rates effective July 1, 2009, following its recommended 16.0% increase for January 1, 2009. The Department of Insurance countered that increase with a 5% recommendation.

Neither the WCIRB’s or DOI’s recommendations are binding on insurance companies.

The Association’s sponsored Workers’ Compensation program, with its 5% member discount, (possibly 15% depending upon where you have your group medical coverage) will be even more important to members this year. The program is underwritten by Employers Compensation Insurance Company (rated “A-” by AM Best).

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)

PAGE 38 | THE BULLETIN | MAY / JUNE 2009

Rather than guess what your savings could be, take a moment to contact Marsh. Let them show you how your association membership can translate into savings. Call a client service representative at 800/842-3761.

CA#0633005 d/b/a in CA Seabury & Smith Insurance Program Management 42528 (4/09) ©Seabury & Smith Insurance Program Management 2009

When was the last time a doctor came to YOU?

I’m Dr Dan Nathanson, Endovascular Surgery Director at the Vascular Institute at California Pacific Medical Center, a unique program with specialists from four areas— interventional radiology, cardiology, vascular surgery and neurosurgery — working together to provide the most sophisticated array of treatment options for all aspects of vascular disease.

With the minimally-invasive endovascular repair of abdominal aortic aneurysms, long incisions and lengthy hospital stays are no longer necessary. Patients are ambulating one day post-op and discharged the second day. Over 350 endovascular AAA repairs have been performed at the California Pacific Vascular Institute. This remarkably successful technique requires a high level of experience and technical expertise.

I’d like to make an appointment to see you in your office. Why? I’d like to take just a few minutes to familiarize you with our facilities, equipment, staff — and discuss treatment options for your next aneurysm patient.

The Vascular Institute offers: • Board certified, fellowship trained vascular specialists • Unparalleled care for patients with vascular disease • Endovascular abdominal and thoracic aortic aneurysm repair • Minimally invasive lower extremity revascularization • Renal and visceral stenting procedures • Carotid stenting and endarterectomy • Endovascular and open options available and recommended without bias • In 2008, HealthGrades® ranked California Pacific “Best in the San Francisco Area for Cardiology and Overall Cardiac Services.”

PAGE 39 | THE BULLETIN | MAY / JUNE 2009 Call me at 415-600-7459 • www.cpmc.org/services/heart

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A PUBLICATION OF THE SANTA CLARA COUNTY MEDICAL ASSOCIATION

700 Empey Way, San Jose, CA 95128-4705

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Does Your Insurance Company Have the Strength to Endure?

We’ve Earned Straight A’s for 25 Years

Strength and flexibility. That’s what your practice needs to thrive during NORCAL has achieved an “A” financial rating from A.M. Best, the leading provider of insurance industry ratings, for the past challenging economic times. NORCAL Mutual Insurance Company has received quarter century. Our financial stability has allowed us to return $358 million in dividends to NORCAL policyholder owners. an “A” (Excellent) financial rating from A.M. Best, theor leading provider of insurance Visit www.norcalmutual.com today, call 800.652.1051.

NORCAL. Your commitment deserves nothing less.

Our passion protects your practice.

industry ratings, for the past quarter century.

Ourtofinancial stabilityby hastheallowed NORCAL is proud be endorsed Santa Clara County Medical Association is proud to be endorsed by the as the preferred professional liability insurer for its NORCAL members. us to return more than $372 million in dividends to our policyholders.

Santa Clara County Medical Association as the preferred professional liability insurer Visit www.norcalmutual.com today, or call 800.652.1051. for its members.

You practice with passion. Our passion protects your practice.