2010 May/June by SCCMA/MCMS

MAY/JUNE 2010 | Volume 16 | Number 3

NEW HEALTH REFORM LAW WHAT YOU NEED TO KNOW No Preexisting Conditions • New Benefits Guaranteed Basic Benefits • Required Coverages State-run Insurance Exchanges • Tax Credits Financially-sound Medicare DR. ANDRESEN EXAMINES THE CHANGES, PAGE 6

The Santa Clara County Medical Association, Monterey County Medical Society and CMA are pleased to announce a new 10-year and 20-year Term Life program for members. You now have a choice of locking in your premium rate for the ﬁrst 10 or 20 years of your policy,* enabling you to achieve dramatic premium savings. And you can apply for limits of up to $1,000,000! Now is the time to take a good look at the SCCMA/MCMS/CMA plan if:

• You think you may be paying too much

• It has been more than one year since you last reviewed your life insurance protection • You had a change in lifestyle (e.g., married, had a child, adopted a child, taken out a mortgage or business loan or invested in a new practice) • The long-term assets that you once counted on for your ﬁnancial planning no longer seem as secure as they once did Sponsored by:

• The amount of coverage provided by your medical group isn’t enough and you can’t take it with you if you leave

Call Marsh today at 800-842-3761 for information on this new program and to determine how you can save on your life insurance! Underwritten by:

and 29 County Medical Associations & Societies

Administered by:

Insurance is provided by ReliaStar Life Insurance Company, a member of the ING family of companies.

*The initial premium will not change for the ﬁrst 10 or 20 years unless the insurance company exercises its right to change premium rates for all insureds covered under the group policy with 60 days advance written notice. 49815 (5/10) ©Seabury & Smith Insurance Program Management 2010 • d/b/a in CA Seabury & Smith Insurance Program Management 777 South Figueroa Street, Los Angeles, CA 90017 • 800-842-3761 • CMACounty.Insurance@marsh.com • www.MarshAﬃnity.com

CA Ins. Lic. #0633005 • AR Ins. Lic. #245544

BULLETIN THE

Official magazine of the Santa Clara County Medical Association and the Monterey County Medical Society

700 Empey Way • San Jose, CA 95128 • 408/998-8850 • www.sccma-mcms.org

MEMBER BENEFITS Legal Services/On-Call Library Reimbursement Advocacy/ Coding Services Billing/Collections

SCCMA’s New Slate of Officers....................................................................5 From the Editor’s Desk: Comprehensive Health Reform, What Does it Mean?...........................6 Joseph Andresen, MD

New State Laws of Interest to Physicians for 2010..................................10 CMA Staff

Discounted Insurance

Member Benefit Spotlight: Heartland Payment Systems.......................13

Referral Services With Membership Directory/ Website

CMA Legal Affairs Case List.......................................................................14

Legislative Advocacy/MICRA

The Void That Fills the Heart.....................................................................20 Michael T. Margolis, MD, FACS, FACOG

House of Delegates Representation

Just One Thing............................................................................................24

Practice Management Resources and Education

Survey of Bay Area County Medical Societies Regarding Medicare

Financial Services Professional Development Health Information Technology Resources Publications

Colin Kopes-Kerr, MD

Payment Policy to Physicians.................................................................30 SCCMA Committee Sign-Up Sheet............................................................31 Classified Ads..............................................................................................32 Member Spotlight: Gus Garmel, MD and Membership Directory Updates....................................................................................................34

CME Tracking

SCCMA Alliance News................................................................................35

Physicians’ Confidential Line

MEDICO News.............................................................................................36

Verizon Discount Human Resources Services PAGE 3 | THE BULLETIN | MAY / JUNE 2010

The Santa Clara County Medical Association Officers

AMA Trustee - SCCMA

Councilors

President Howard Sutkin, MD President-Elect Thomas Dailey, MD VP-Community Health Cindy Russell, MD VP-External Affairs William Lewis, MD VP-Member Services Judith Dethlefs, MD VP-Professional Conduct Jim Crotty, MD Secretary Sameer Awsare, MD Treasurer Martin L. Fishman, MD

James G. Hinsdale, MD

El Camino Hospital of Los Gatos: Rives Chalmers, MD El Camino Hospital: Open 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

Tanya W. Spirtos, MD (Alternate)

SCCMA/CMA Delegation Chair Tanya W. Spirtos, MD (District VII)

CMA Trustees - SCCMA Martin L. Fishman, MD (District VII) Susan R. Hansen, MD (Solo/Small Group Physician) James G. Hinsdale, MD (President-Elect) Randal Pham, MD (Ethnic Member Organization Societies)

Chief Executive Officer

Tanya W. Spirtos, MD (District VII)

William C. Parrish, Jr.

BULLETIN THE

Official magazine of the Santa Clara County Medical Association and the Monterey County Medical Society

Printed in U.S.A.

THE MONTEREY COUNTY MEDICAL SOCIETY OFFICERS

Editor

Joseph S. Andresen, MD

Managing Editor Pam Jensen

Opinions expressed by authors are their own, and not necessarily those of The Bulletin or the Santa Clara County Medical Association and the Monterey County Medical Society. Acceptance of advertising in The Bulletin in no way constitutes approval or endorsement by the Santa Clara County Medical Association or the Monterey County Medical Society of products or services advertised.

President William Khieu, MD, MBA Secretary Eliot Light, MD Treasurer John Clark, MD

CHIEF EXECUTIVE OFFICER William C. Parrish, Jr.

DIRECTORS Valerie Barnes, MD Ronald Fuerstner, MD David Holley, MD

Address all editorial communication, reprint requests, and advertising to: Pam Jensen, Managing Editor 700 Empey Way San Jose, CA 95128 408/998-8850, ext. 3012 Fax: 408/289-1064 pjensen@sccma.org

R. Kurt Lofgren, MD James Ramseur, Jr., MD Scott Schneiderman, DO

CMA TRUSTEE – MCMS

Valerie Barnes, MD

SCCMA’s Official slate of officers, councilors, delegates, & alternate delegates for fiscal years 2010-2012 Below are the Officers for the upcoming fiscal year 2010 to 2011 approved at SCCMA’s Annual Meeting, May 4, 2010. OFFICERS Past President Howard Sutkin President Thomas Dailey President-Elect William Lewis Vice President for Community Health Cindy Russell Vice President for External Affairs Rives Chalmers Vice President for Member Services Scott Benninghoven Vice President for Professional Conduct Eleanor Martinez Secretary Sameer Awsare Treasurer James Crotty Below are the Councilors for the upcoming fiscal years 2010 to 2012 (2-year term) approved at SCCMA’s Annual Meeting, May 4, 2010.

Below are the Delegates for the upcoming fiscal years 2010 to 2012 (2-year term) approved at SCCMA’s Annual Meeting, May 4, 2010. DELEGATES Del. #1 John Siegel Del. #2 Joseph E. Mason, Jr. Del. #3 Peter Cassini Del. #4 Efren Rosas Del. #6 James Crotty Del. #8 Rives Chalmers Del. #10 John Huang Del. #12 Thomas Dailey

Del. #14 Lynn Gretkowski Del. #16 Sameer Awsare Del. #18 David Campen Del. #20 Elliot Lepler Del. #22 Narciso Thad Padua Del. #23 Don Mordecai Del. #24 Rajan Bhandari Del. #26 Jeff Kaplan

Delegates retaining office for fiscal years 2009-2011: #5 Jeffrey Coe; #7 W. James Silva; #9 Cindy Russell; #11 Arthur Basham; #13 Robert Gould; #15 Eleanor Martinez; #17 William Lewis; #19 Howard Sutkin; #21 Scott Benninghoven; #25 Marshall Yacoe.

COUNCILORS Councilor #2 (San Jose) Councilor #4 (VMC) Councilor #6 (Stanford) Councilor #8 (El Camino) Councilor #10 (Good Sam)

Hospital Closed N/A John Siegel Peter Cassini Lynn Gretkowski Jeff Kaplan

Councilors retaining office for fiscal years 2009-2011: #1 (Regional) Emiro Burbano; #3 (O’Connor) Jay Raju; #5 (Kaiser-San Jose) Efren Rosas; #7 (St. Louise) John Saranto; #11 (Kaiser-Santa Clara) Allison Schwanda. #9 (El Camino-Los Gatos) is currently held by Rives Chalmers through 6/30/10. Effective 7/1/10, the President will select a replacement per the SCCMA bylaws.

Below are the Alternate Delegates for the upcoming fiscal years 2010 to 2012 (2-year term) approved at SCCMA’s Annual Meeting, May 4, 2010. ALTERNATE DELEGATES Alt. #1 Alt. #2 Alt. #4 Alt. #5 Alt. #6 Alt. #8 Alt. #10 Alt. #12

Emiro Burbano Bruce Wilbur Brian Bohman Tiffany Davies Leslie Sullivan Theodore Chu Dale Rai Kathryn Shade

Alt. #14 Alt. #16 Alt. #18 Alt. #20 Alt. #22 Alt. #24 Alt. #25 Alt. #26

Rebecca Powers Dipali Apte J. Kirk Zimmer John Costouros Amir Hadid An Pham Kathleen Serventi Seema Sidhu

Alternates retaining office for fiscal years 2009-2011: #3 John Saranto; #7 Ed Liu; #9 Jennifer Maw; #11 Bien Nguyen; #13 Len Doberne; #15 Allison Schwanda; #17 Jay Raju; #19 Seham ElDiwany; #21 Andrea Rudominer; #23 Ngai Nguyen.

PAGE 5 | THE BULLETIN | MAY / JUNE 2010

FROM THE EDITOR’S DESK

Now That We Have Passed Comprehensive Health Reform Into Law, What Does It Mean? By Joseph Andresen, MD On March 23, 2010, President Obama signed into law the Patient Protection and Affordable Care Act (P.L. 111-148). After more than a year of national debate, partisan bickering, and town hall meetings, a comprehensive health reform mandate is now a reality. But what does that mean for you and me, our doctors, and hospitals? The intent of this legislation is clear: to provide affordable health insurance to 32 million more Americans, to bend the cost curve of escalating heath care costs, to improve quality, and to bolster preventative health care services. How will this new law accomplish these goals? To answer this question, we must look more closely at the language and provisions of this new law.

INDIVIDUAL MANDATE Let’s look at the first goal that is to expand access to coverage. The new law will now require most U.S. citizens and legal residents to have health insurance. An individual mandate is an important element of this. With insurance coverage, those seeking treatment should enjoy improved access to care without the fear of financial ruin. Requiring the vast majority of citizens to participate broadens the risk pool so that average costs of premiums are reduced and those with chronic illnesses aren’t excluded. A healthy young person may ask, “Why should I be required to buy health insurance?” In the event of an accident or serious illness, the costs of treating those who are currently uninsured increases health insurance premiums $1,000 per year on average for all who are

insured. Everyone needs to participate to keep overall costs under control. A $95 individual tax penalty would begin in 2014. This would continue to be phased in and reach a maximum of $695 for individuals and $2,085 for families that continue to voluntarily remain uninsured in 2016. Certain exclusions would apply to those demonstrating religious objections, financial hardships, or who are American Indians.

EMPLOYER REQUIREMENTS There is no employer mandate in this law, but those employers with more than 50 employees that do not offer coverage would be assessed a fee of $2,000 per full-time employee. Employers with fewer than 50 employees would be exempt from these penalties.

EXPANSION OF PUBLIC PROGRAMS Another key component to expanding coverage to more Americans is the expansion of public programs. Medicaid will cover all non-Medicare eligible individuals under 65 with incomes up to 133% of the Federal Poverty Level ($26,000 for a family of 4). In California, 6.5 million people are currently uninsured. Medi-Cal will provide coverage for 1.7 million, 3.3 million will be newly enrolled in private health plans, and the remainder will not qualify because of immigration status. Medicaid has been chronically under funded and both physicians and hospitals find that reimbursement rarely meets the cost of providing care. In this case, the federal government will provide PAGE 6 | THE BULLETIN | MAY / JUNE 2010

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. states with 100% of the funds necessary to provide these additional services. This will be gradually decreased to 90% in 2020 and thereafter. Primary care physicians (family medicine, general internal medicine, or pediatric medicine) will receive Medicaid payments equivalent to 100% of the Medicare payment that begins January 1, 2013. States will be required to maintain coverage of children enrolled in the Children’s Health Insurance Program (CHIP) through 2015. Increased federal funding will be available to states under this program with a 23% increase in 2015.

PREMIUM AND COSTSHARING SUBSIDIES TO INDIVIDUALS We have briefly discussed how increased coverage of more Americans will take place. But what about affordability? Who will be eligible for help with premium costs and out-of-pocket expenses? U.S. citizens and legal immigrants residing in the U.S. for five years or more, and meeting certain income limits, will be eligible. Employees who find that their employer’s health insurance premium costs them more than 9.5% of their income or offer coverage that is less than 60% of the actuarial value would also be eligible. For those eligible individuals or families with

incomes between 133%-400% of FPL, a sliding scale of decreasing premium credits as income rises would be available to subsidize the cost of premiums for those in this income range. Cost-sharing subsidies would also be available in the same manner to help those in the lower income brackets with out-of-pocket costs. There is specific language ensuring that federal premium or cost-sharing subsidies are not used to purchase coverage for abortions if the coverage extends beyond saving the life of the woman or in cases of rape or incest (Hyde amendment). If an individual receiving federal subsidies chooses a plan that covers elective abortions, those funds are not permitted to be used to purchase coverage for abortion services and must be segregated from private premium payments.

Things You Need to Know About the New Law

Helps 32 million more Americans get insurance.

Makes preexisting medical conditions a thing of the past. Insurers can’t use them to deny coverage for children from this year on, or adults starting in 2014.

Guarantees basic benefits for everyone in Medicare, makes preventive services free for most, and gradually closes the “donut hole” in the Part D drug program.

Sets up a temporary program in July to help people with preexisting health conditions—who have been uninsured at least six months—obtain coverage.

PREMIUM SUBSIDIES TO EMPLOYERS Premium subsidies are also designated to employers. Small business employers with 25 or fewer employees will see relief in the form of a tax credit. From 2010 to 2013, 35% of the contribution toward health insurance will be rewarded with a tax credit. This will rise to 50% in 2014 and beyond. A temporary reinsurance program for programs will provide health insurance coverage to retirees over age 55 who are not eligible for Medicare.

TAX CHANGES RELATED TO HEALTH INSURANCE OR FINANCING HEALTH REFORM How will this comprehensive health plan be paid? With Medicare predicted to become insolvent by 2017, financial strengthening and restructuring is essential and will be discussed in more detail. Certain tax changes will result in increased revenue. This includes the tax on individuals without coverage and increasing the Medicare Part A (hospital insurance) tax rate on wages by 0.9% on individuals earning over $200,000 and married couples over $250,000, effective in 2013. There will be an excise tax on insurers

Provides new benefits for most people who already have insurance, such as coverage for adult children until age 26.

Leaves medical decisions in the hands of your doctor and you.

Requires most people to have coverage by 2014 but offers subsidies for those moderate or low income and makes more people eligible for Medicaid.

Creates state-run insurance exchanges offering a menu of private insurance plans for people who are uninsured, selfemployed or between jobs (in 2014).

Offers immediate tax credits to help small businesses buy insurance for employees.

Keeps Medicare financially sound for nearly 10 more years and reduces the U.S. deficit by an estimated $143 billion.

Source: From the AARP Bulletin print edition | May 1, 2010 http://bulletin.aarp.org/ yourhealth/policy/articles/a_user_s_guide_to_health_care_reform.html of employer-sponsored health plans with values exceeding $10,200 for individuals and $27,500 for family coverage, beginning in 2018. Most significant will be annual fees on the pharmaceutical and health insurance sectors. These fees will range up to $ 4 billion and $14.3 billion, respectively, each year. There will also be an excise tax of 2.3% on the sale of any medical device and a 10% tax for indoor tanning services.

HEALTH INSURANCE EXCHANGES PAGE 7 | THE BULLETIN | MAY / JUNE 2010

Health insurance exchanges are to be created to provide both individuals and small business employers greater purchasing power and choice of insurers. State-based exchanges will offer coverage to individuals and small businesses with up to 100 employees to purchase qualified coverage. Each exchange will contract with insurers to offer at least two multi-state plans with one non-profit offering and one without abortion coverage. Funds will also be made available to set up consumer-

Comprehensive Health Reform, What Does It Mean?, from page 7 operated and -oriented plans (CO-OP) to foster the creation of non-profit, memberrun health insurance companies. Six billion dollars will be available by July 2013 for this purpose.

group plans, enrollees are entitled to a rebate effective January 1, 2011. There will be a process for reviewing increases in health plan premiums and requiring plans to justify increases.

BENEFIT DESIGN

Preexisting condition exclusions of children will be prohibited within six months of enactment and by 2014 for adults. Children up to age 26 will be allowed to remain on their family plan, effective September 2010.

What is the coverage that is available to me through the exchange? Four benefit categories plus a catastrophic plan will be offered. The Bronze, Silver, Gold, and Platinum plans vary in the coverage of benefits. As an example, the Bronze plan covers 60% of the benefit costs and limits individual out-of-pocket expenses to $5,950 per year and $11,900 for families in 2010 (limit equal to the Health Savings Account (HSA) current law). The Silver, Gold, and Platinum plans will cover 70%, 80%, and 90% of the benefit costs, respectively, of the plans offered and all will have the same HSA deductible limits. The catastrophic plan is available to those up to age 30 only in the individual market and will provide catastrophic coverage only, plus three primary care visits exempt from the deductible set at the HSA limits noted above.

CHANGES TO PRIVATE INSURANCE New rules and requirements of health insurance companies are significant. Policies must be guaranteed issue and rating variation can only be based on age (limited to 3:1 ratio), premium rating area, family size, and tobacco use (limited to 1.5:1 ratio). There will be no lifetime limits on benefits of coverage. Insurers must provide adequate networks, contract with essential community providers and be accredited with respect to performance on quality measures, and use a standard enrollment form. Health plans are now required to report the proportion of premium dollars spent on clinical services and care. If it is less than 85% for large group plans or 80% for individual or small

The essential benefits package defines the basic level of comprehensive medical services that all policies must include to be offered through the exchange. This includes outpatient, hospital services, drug and alcohol treatment, and mental health care. All grandfathered individual and group insurance plans must meet these new standards effective January 1, 2014.

COST CONTAINMENT How about bending the cost curve of escalating health care costs? The criticism has been made that the U.S. spends more than double per capita on health care ($13,000 per year) than any other industrialized country. Switzerland is the second highest at $6,500. Despite being the biggest spenders, we rank relatively low in many measures of public health and longevity. With Medicare predicted to be insolvent by 2017 and a record number of baby boomers nearing retirement, comprehensive health reform faces significant financial challenges to accomplish its goals. Cost containment will be essential in meeting the challenges of bending the cost curve. This new law includes adopting a single set of operating rules for eligibility verification and claims status, electronic funds transfers, and health care payment and remittance. The Medicare Advantage program was originally set-up before the Medicare Part D drug program PAGE 8 | THE BULLETIN | MAY / JUNE 2010

was enacted and offered seniors drug benefits and other services through private HMOs. The Medicare Advantage program currently is paid a 14% premium over fee-for-service rates by Medicare. These payment levels will be reduced over a threeyear period beginning in 2011 and will provide $150 billion in savings over a tenyear period. As the number of uninsured is reduced and less uncompensated care is provided by hospitals, Medicare Disproportionate Share Hospital (DSH) payments will decrease by 75% initially and be adjusted, based on the percentage of uninsured for whom a hospital provides care. Medicare payments will be reduced for excessive preventable readmissions and for hospital-acquired conditions. A 15-member Independent Payment Advisory Board will be established to submit legislative proposals to reduce Medicare spending, if certain target growth rates are exceeded. These proposals would be submitted to the President and Congress beginning in January 2014. The goal would be to contain costs within GDP per capita plus 1%. The Board would be prohibited from submitting proposals that would ration care increase revenues or change benefits for enrollees. Another strategy for cost containment includes the formation of accountable care organizations (ACOs). These organizations would be alliances of physicians with or without hospitals to provide comprehensive care to a designated patient population or community. They would need to meet quality measures, promote evidence-based medicine, and submit reporting on quality and costs. Any cost savings would be shared between the ACO and Medicare. Reduction of waste, fraud, and abuse is an essential part of cost containment. Medicare had a mandatory outlay of $485 billion in services in 2009.

With millions of claims paid and less than 5% audited each year, the potential for fraud is significant. Enhanced oversight, provider screening, enrollment moratoria, and the sharing of database information across federal and state programs will be the strategy adopted to combat these problems.

IMPROVING QUALITY/ HEALTH SYSTEM PERFORMANCE How will the law improve quality and health system performance? A new emphasis will be made on comparative effectiveness research. The establishment of a non-profit Patient-Centered Outcomes Research Institute will identify research priorities and compare the clinical effectiveness of medical treatments. The Institute’s research will not issue mandates, guidelines, or standards of care and will be clearly separated from influencing payments, coverage, or denial of care. Medical malpractice reform will be investigated with five-year demonstration grants to states to evaluate alternatives to current tort litigation. Medicare will establish a national program to investigate a bundled payment program for hospitalization, physician care, and post-acute treatment for single episodes of care. Establishment of Independence at Home demonstration projects for high-need Medicare patients, where primary care and support services are coordinated in a more effective manner, is also a strategy to improve quality. A much needed increase in Medicaid payments for primary care physicians to 100% of Medicare rates will begin January 1, 2013. A 10% bonus of Medicare payments to primary care physicians will begin January 1, 2011 for five years.

PREVENTION/WELLNESS

How does this law promote wellness and prevention? A National Prevention, Health Promotion, and Public Health Council will coordinate wellness, prevention, and public health efforts. To the individual patient, the biggest improvement will be the elimination of out-of-pocket expenses for preventative services that include colorectal cancer screening tests and immunizations. This would include behavior modification programs aimed at cessation of smoking. Small employers will be eligible for grants that establish wellness programs and offer employee rewards in the form of premium reductions for their participation.

Committee will be established to develop a workforce strategy. Unused residency slots will be redirected for primary care and general surgery training. Scholarships, loans, and support of primary care training and capacity building will be enhanced. The shortage of nurses is met with increased funding for training programs, loans, retention grants, and a career ladder to nursing. Eleven billion dollars are designated for community health centers and the National Health Service Corp. Additional resources will be available for strengthening and better coordinating the nation’s trauma and emergency care programs.

LONG TERM CARE

So, in summary, the Patient Protection and Affordable Care Act is a new law that provides a framework for comprehensive health reform. Its goals include expansion of coverage to 32 million more Americans, reforming health insurance eligibility and benefits, bending the cost curve of escalating costs, improving quality, and strengthening our wellness and preventative health services going forward into the future.

An optional national long-term care insurance program will be offered and financed through voluntary payroll deductions. Skilled nursing facilities will be required to disclose ownership, accountability, and financial data so that consumers may compare facilities.

OTHER INVESTMENTS Medicare Part D will see an increase in drug coverage beginning with a $250 rebate on January 1, 2010. The “donut hole” of non-covered drug expenses will gradually be reduced from 100% to 25% by 2020. Medicare will increase benefits for those who have been exposed to environmental health hazards from living in an area subject to an emergency declaration. Medicare will increase payments to primary care physicians and general surgeons practicing in health professional shortage areas by 10%, from 2011 to 2015. Many of us baby boomers are nearing retirement. Who will be there to take care of us? This law attempts to improve the workforce training and development. A Workforce Strategy PAGE 9 | THE BULLETIN | MAY / JUNE 2010

Any one of these areas is a significant challenge. Implementation will be the key, and guidance from our well-informed physician community will be essential, to see that the many positive benefits for our patients, hospitals, and medical community become a reality.

References: Kaiser Family Foundation Summary of New Health Reform: http:// www.kff.org/healthreform/upload/finalhcr. pdf Families USA, Health Reform Central; The Road to Implementation: http://www.familiesusa.org/health-reformcentral/ AARP Bulletin Today, A User’s Guide to Health Care Reform: http:// Continued on page 12

Bulletin featured article

NEW STATE LAWS OF INTEREST TO PHYSCIANS FOR 2010 By CMA Staff Below is a summary of some of the most significant new statutes enacted in California, along with references to the most relevant ON-CALL documents that discuss the topics more fully. For a more detailed summary of the new laws discussed below and for a summary of other new laws impacting the practice of medicine, see www.cmanet.org/newlaws.

Access to Health Care Coverage for Off-Label Medications  The law requiring health plans and insurers to cover “offlabel” medications was expanded to require coverage where the drug has been recognized for treatment of the condition by one of the listed compendia, if recognized by the federal Centers for Medicare and Medicaid Services as part of an anticancer chemotherapeutic regimen. For more information, see CMA ON-CALL #0507, “Drug Formularies, Prescription Drug Benefit Plans, and Pharmacy Benefit Managers,” and #1071, “Coverage Requirements/Pre-Existing Condition Exclusions.” (AB 830) Rescission of Individual Health Coverage Policies or Plans  This new law prohibits a health care service plan or health insurer from rescinding an individual health care service plan contract or individual health insurance policy for any reason, or from canceling, limiting, or raising the premiums of the plan contract or policy due to any

omission, misrepresentation, or inaccuracy in the application form, after 24 months following the issuance of the plan contract or policy. For more information, see CMA ON-Call #1025, “Denials of Necessary Medical Services,” and #0145, “Payment Denial After Treatment Authorization or Verification of Eligibility.” (AB 108) Medi-Cal Coverage  The new law imposes various obligations on hospitals, physicians, and other providers with respect to verifying a patient’s Medi-Cal eligibility, billing Medi-Cal beneficiaries, and the reporting of MediCal beneficiaries to consumer credit reporting agencies. (AB 1142) Authorization for Treatment  A new law that applies to the Workers’ Compensation system provides that, regardless whether an employer has established a medical provider network or entered into a contract with a health care organization, an employer that authorizes medical treatment shall not rescind or modify the authorization, for any reason, after that treatment has been provided. For more information, see CMA ON-CALL #1929, “Treating Physicians: Payment for Treatment (OMFS).” (AB 361)

Physician Liscensing, Discipline, and Oversight Disclosure to Medical Board  A new law requires osteopathic physicians (like those licensed by the Medical Board) to report to the Osteopathic Medical Board of California PAGE 10 | THE BULLETIN | MAY / JUNE 2010

(“Board”) at the time of initial licensure any specialty board certification and their practice status. The new law also allows the Board to collect information regarding osteopathic physicians’ backgrounds and foreign language proficiencies. For more information, see CMA ON-CALL #0220, “Disclosure Requirements - State and Federal.” (SB 620) Medical Board Enforcement  Clarifying that licensing boards for non-physicians have no jurisdiction to investigate or discipline physicians. For more information, see CMA ON-CALL #1605, “Medical Assistants,” and #0708, “MBC Enforcement Authority.” (AB 1535)

Medical Board - Medical Records Requests  Existing law establishes a licensee’s obligations to comply with requests or subpoenas for medical records from the Medical Board. That law was amended to apply to “certified medical records,” which are defined as a copy of the patient’s medical records authenticated by the licensee or health care facility. The amended law also allows for penalties of up to $10,000 for failure to comply with a request for a patient’s certified medical records, when accompanied by that patient’s written authorization for release of records to the board, or for failure to comply with a court order mandating the release of records to the Board. For more information, see CMA ON-CALL #1420, “Administrator and Board Access to Peer Review Files.” (AB 1070)

Allied Health Professionals Nurse Practitioners  The Legislature clarified the scope of practice of a nurse practitioner (NP) to provide that standardized procedures may also

be implemented that authorize a nurse practitioner to (1) order durable medical equipment, as specified; (2) certify disability after performance of a physical examination by the NP and in collaboration with a physician; and (3) approve, sign, or otherwise modify a treatment plan for individuals receiving home health services or personal care services, after consultation with the treating physician. For more information, see CMA ON-CALL #1615, “Nurses.” (SB 819) Physician Assistants  The law provides under which conditions a physician may delegate to a licensed physician assistant (PA) procedures using fluoroscopy and specifies the requirements a physician must meet to supervise a PA in performing the functions authorized by the Radiologic Technology Act. For more information on physician assistants, see CMA ON-CALL #1620, “Physician Assistants.” For more information on x-rays, see CMA ONCALL #1335,

PAGE 11 | THE BULLETIN | MAY / JUNE 2010

“Mammography Facilities and X-rays.” (AB 356)

Professional Liability Elective Cosmetic Surgery  A physician may not perform elective cosmetic surgery procedure on a patient unless the patient has received, within 30 days prior to the procedure, and confirmed as up-to-date on the day of the procedure, a physical examination by, and written clearance for the procedure from, any of the practitioners listed in the statute. For more information, see CMA ON-CALL #0790, “Grounds for Medical Board Discipline,” and #0202, “Surgicenters and Other Outpatient Facilities.” (AB 1116) Immunities for Psychiatric Release  The new law extends physician’s immunity from civil and criminal liability to cover the detention of any person who meets specified criteria, whether or not they qualify for a 72-hour evaluation, and for the actions after release of a person who was detained up to 24 hours and who meets specified criteria. For more information, see “Mental Health: §5150 Holds/72-Hour Detention.” (SB 743)

New State Laws of Interest to Physicians for 2010, from page 11 Patient Safety Hospital Security Plans  The 2009 amendments to existing law require, after July 1, 2010, that hospitals conduct a security and safety assessment annually and that the security plan be updated annually based on the assessment. In developing this plan, the hospital must consult with members of the medical staff, as specified. (AB 1083)

Medical Records Management of Medical Records  The law was clarified to require licensed clinics, among other licensed institutions (and now also home health agencies), to report instances of unlawful or unauthorized access to a patient’s medical information to the Department of Public Health and to the affected patient within five business days of detecting it. For more information, see CMA ON-CALL #1144, “Security Breach of Health Information.” (SB 337)

Health Reform, from page 9 bulletin.aarp.org/yourhealth/policy/articles/a_user_s_guide_to_ health_care_reform.html AARP Bulletin Today, The New Health Care Law and You: http://bulletin.aarp.org/yourhealth/policy/articles/reform_ splash.html CMA: The Pros and Cons of Health Care Reform: http:// www.cmanet.org/healthreform/applets/reform_pro_con_032510.pdf Congressional Research Summary: H.R. 3590: Patient Protection and Affordable Care Act: http://www.govtrack.us/ congress/bill.xpd?bill=h111-3590&tab=summary Amendment in the Nature of a Substitute to H.R. 4872, As Reported http://docs.house.gov/rules/hr4872/111_hr4872_ amndsub.pdf Timeline for Health Care Reform Implementation: http:// www.commonwealthfund.org/Content/Publications/Other/2010/ Timeline-for-Health-Care-Reform-Implementation.aspx

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PAGE 12 | THE BULLETIN | MAY / JUNE 2010

member benefit spotlight

heartland payment systems A new benefit for our members is provided by Heartland Payment Systems (www.heartlandpaymentsystems.com), a leading provider of credit card processing, payroll services, check management, and a patient payment management system called ConfirmPay. Heartland ConfirmPay provides SCCMA/MCMS members with a solution to ease the collection of patient payments and improve the practice’s bottom line. Four challenges that impact the bottom line of a medical practice include: •

•

Manual and slow processes used to verify patient insurance benefits creating resource issues, and increased staffing costs. Insufficient information at the point of care to determine a patient’s payment responsibility, delaying reimbursement and creating confusion for patients.

•

Delayed reimbursement impacting a practice’s cash flow and increasing patient A/R that goes uncollectible.

•

Manual processes to link payments to patients and posting into a practice’s billing system, causing errors and inefficient use of staff time.

Whether your practice is feeling the impact from one or all of the above, ConfirmPay can help. Through a comprehensive solution that helps practices to identify and manage the risk of multiparty reimbursement (payer and patient), the ability to collect any form of payment from anywhere your practice interacts with a patient before, during or after the visit, the tools to help you make it easier

to collect from patients and the ability to report and automatically post transactions back into your practice management system, ConfirmPay will positively impact your bottom line. ConfirmPay provides: •

Real time insurance eligibility verification to over 440 payers, including detail on a patient’s remaining deductible, co-pay and coinsurance.

•

The ability to “estimate” reimbursement from both payer and patient for specific procedures based upon contracted rates and a patient’s benefits.

•

The ability to provide a “patient friendly” printout of a patient’s benefits, enabling a practice to start dialogue with patients about what they will owe.

•

Acceptance of any form of payment (credit, debit, ACH, cash, check) from any location (point of care, telephone, mail, third-party billing partners, online).

•

A set of payment management tools to make it easier to collect from patients (secure card on file, recurring

PAGE 13 | THE BULLETIN | MAY / JUNE 2010

payments, online patient payment portal). •

Robust reporting to enable you to track and manage collections across multiple locations and through multiple parties.

•

The ability to automatically link all payments with a patient and to post all patient payments directly into your practice management or practice billing system.

SCCMA/MCMS members are entitled to receive a complimentary consultation of patient payment systems, credit card processing, payroll processing, and check management. We encourage you to contact our local Heartland representative, Patrick Wong, at 408/7334118 or patrick.wong@e-hps.com for more information and/or to arrange an appointment. We also encourage you to check out other member benefits as listed on our website, www.sccma-mcms.org or in the 2010 Physician Membership Directory.

CALIFORNIA MEDICAL ASSOCATION

CMA LEGAL AFFAIRS CASE LIST CMA’s Legal Affairs Case List provides a summary and current status of pending litigation filed to influence health policy in which the California Medical Association was a party or filed a brief as amicus curiae, or “friend of the court.” Cases marked with an asterisk (*) were filed on behalf of the California Medical Association, California Hospital Association, and California Dental Association pursuant to the direction of the CMA-CHA-CDA Amicus Curiae Committee. The Case List is circulated regularly on a monthly basis. For more information on a specific case, please contact the appropriate staff member identified at the end of each litigation summary by e-mail or by calling (916) 444-5532.

CMA Lawsuits Pending cases in which CMA is a named plaintiff

Status

Staff

INGENIX PRICE FIXING SCHEME: AMA, CMA et al. v. Wellpoint/Anthem Blue Cross (U.S. District Court, Central Dist. of California, filed 3/25/09, CV 09-2039, Master Consolidated Case File 2:09-ml-02074); AMA, CMA et al. v. Aetna Health Inc. (Dist. of New Jersey, filed 2/9/09, Master File 2:07-CV-3541); AMA, CMA et al. v. Cigna Health Corp. (Dist. of New Jersey, filed 2/9/09, 09-578) In three separate lawsuits filed in federal courts, the CMA, American Medical Association (AMA), other state medical societies and individual physicians challenged the use of Ingenix by Aetna, Cigna, and Blue Cross to underpay physicians for providing out-ofnetwork services to their enrollees. The lawsuits seek to collect past underpayments by the defendants on behalf of a nationwide class of physicians. These lawsuits still remain in the early stages of litigation.

The litigation is in the discovery stage. (The discovery stage is the pre-trial phase in a lawsuit in which each party through the law of civil procedure can request documents and other evidence from other parties and can compel the production of evidence.)

Francisco Silva

MEDICAL BOARD FURLOUGH: CMA v. Arnold Schwarzenegger, et al. (Court of Appeal, First District, A128172) On October 14, 2009, CMA filed a writ petition in San Francisco Superior Court to enjoin Governor Schwarzenegger’s furlough of the Medical Board of California (MBC) and to reverse a provision of the State Budget Act of 2008 that took $6 million away from the MBC’s Contingent Fund to aid the state’s General Fund. On March 4, 2010, the San Francisco Superior Court denied CMA’s petition. CMA has appealed the judgment and the appeal is pending. (Notably, shortly after the San Francisco decision was issued, the Oakland Superior Court made the opposite decision— holding that the Governor lacked the authority for the furloughs. The Governor appealed the Oakland judgment.) CMA also opposed Governor’s Petition in California Supreme Court to consolidate all pending appeals that challenge the furlough. The court denied the Governor’s petition to consolidate the appeals and CMA’s appeal will move forward.

Appeal Notice filed: 4/8/10

Long Do

MEDI-CAL LITIGATION: CMA et al. v. Shewry (Los Angeles Superior Court, BC390126); ILCS v. Shewry (Ninth Circuit Court of Appeals, 08-56061, 08-56422, 08-56551, 08-56554, 09-55692); CPA, CMA et al. v. Maxwell-Jolly (09-55532) In 2008, a coalition of health care providers led by CMA sued the state of California to stop a 10% cut in Medi-Cal reimbursements. A federal appeals court in 2008 ruled that Medi-Cal providers have standing to challenge the state’s rate cut. The same court in 2009 upheld the merits of the 2008 preliminary injunction that forced the state to immediately reverse the cut. The court held that the district court properly issued the injunction “because the Director [of DHCS] failed to rely on responsible cost studies, its own and others . . . in determining the effect of the rate cuts . . . on the statutory factors of efficiency, economy, quality, and access to care before implementing those cuts.” The State’s petition for rehearing by the full Ninth Circuit was denied in October 2009. On February 17, 2010, the State filed a cert petition with the U.S. Supreme Court.

State’s Cert Petition filed: 2/17/10

Long Do

CMA is appealing the superior court’s judgment before the Court of Appeal. Briefing should commence early summer.

CMA filed an opposition to the cert petition asking the U.S. Supreme Court (09-958) to deny the State’s petition to review the case.

PAGE 14 | THE BULLETIN | MAY / JUNE 2010

Francisco Silva

CMA Lawsuits Pending cases in which CMA is a named plaintiff

Status

Staff

SCOPE OF PRACTICE: California Society of Anesthesiologists (CSA) and California Medical Association (CMA) v. Arnold Schwarzenegger et al. (San Francisco Superior Court, 10-510191) On February 2, 2010, CMA and CSA filed a writ petition to require that the Governor withdraw his letter dated June 10, 2009 to the Centers for Medicare and Medicaid Services (CMS) where he purported to exercise the option to exempt the State of California from the requirement that CRNAs be supervised by a physician. The lawsuit contends that physician supervision of CRNAs who are administering anesthesia is required under California law and that the Governor’s request for exemption (“opt-out”) was therefore improper and must be withdrawn.

CMA and CSA Petition filed: 2/2/10

Francisco Silva

This lawsuit is in its early Long Do stages. The Governor answered the petition on 3/23/10 and the court is currently considering a motion to intervene by the California Association of Nurse Anesthetists.

CMA Amicus Curiae Briefs Pending cases in which CMA filed an amicus brief or letter

Status

Staff

ARBITRATION: Haworth v. Superior Court (Ossakow)* (California Supreme Court, S165906) This case involves a challenge to a published opinion of the California Court of Appeal vacating an arbitration award in a medical malpractice case based on a post-arbitration claim that the neutral party arbitrator failed to disclose an unrelated censure from the Supreme Court that occurred more than ten years prior to the arbitration. CMA, together with other amici, filed an Amicus Letter urging the Supreme Court to grant the Petition for Review. The California Supreme Court granted the Petition for Review, this case is now fully briefed and oral argument before the California Supreme Court is scheduled on May 6, 2010 in San Francisco.

CMA Amicus Letter filed: 11/13/08

Alicia From

ARBITRATION: Ruiz v. Podolsky* (California Supreme Court, S175204) In Ruiz v. Podolsky, the Appellate Court held that decedent’s adult children could not be compelled to arbitrate their wrongful death claims pursuant to the arbitration agreement their father signed at the request of Dr. Podolsky, his orthopedic surgeon. CMA filed a letter requesting depublication of the Appellate Court’s decision and a separate letter in support of the petition for review. The California Supreme Court granted the Petition for Review. CMA, together with other amici, filed an Amicus brief on the merits in February 2010. With all briefing now complete, the case should be set for oral argument by fall 2010.

Request for depublication filed: 8/24/09

BUSINESS PROHIBITIONS: National Association of Optometrists & Opticians; Lenscrafters, Inc. v. Lockyer (Ninth Circuit Court of Appeals, 07-15050) In this case, CMA filed an amicus brief at the trial level in support of the state’s motion for summary judgment. The trial court (the U.S. District Court, Eastern District of California) ruled in favor of Lenscrafters, invalidating state laws that govern relationships between ophthalmologists, optometrists, and opticians on the grounds they violated the United States Commerce Clause. The state filed an appeal with the Ninth Circuit Court of Appeals. CMA filed an amicus curiae brief on the merits in the Ninth Circuit supporting the state on appeal. In September 2009, the Ninth Circuit reversed and remanded the case back to the District Court. On April 28, 2010, the District Court upheld the constitutionality of the statutes, finding that they serve a legitimate government purpose and that the burdens they impose do not outweigh their benefit.

CMA Amicus Brief in district court filed: 1/21/04

Application to file amicus granted: 12/01/08 Oral Argument: 5/6/10 9:00 a.m.

Alicia From

CMA Amicus Brief filed: 2/3/10 Application to file amicus granted: 2/9/10 Briefing is complete and case should be set for oral argument by fall 2010.

Application to file amicus granted: 1/22/04 CMA Amicus Brief in Ninth Circuit filed: 7/2/07 The District Court upheld the constitutionality of the statutes, consistent with CMA’s position.

PAGE 15 | THE BULLETIN | MAY / JUNE 2010

Astrid Meghrigian

CMA Legal Affairs Case List, from page 15 CMA Amicus Curiae Briefs Pending cases in which CMA filed an amicus brief or letter

Status

Staff

CORPORATE PRACTICE OF MEDICINE & 1206(l) MEDICAL FOUNDATIONS: The Patient-Physician Alliance, Inc., v. The Hospital Committee for the Livermore Pleasanton Area, Inc., et al. (Alameda Superior Court, RG09471909) One of the issues raised by this case is whether the defendant medical foundation is properly constituted pursuant to Health & Safety Code §1206(l). The plaintiff in this case alleges, among other things, that the defendant medical foundation fails to meet the requirements of that statute and is practicing medicine illegally, in violation of California law, including the corporate practice of medicine bar set forth in Business & Professions Code § 2400. In its letter brief, CMA offered the court guidance regarding the corporate bar and the 1206(l) law.

CMA Amicus Letter received: 9/17/09

Astrid Meghrigian

DAMAGES: Howell v. Hamilton Meats* (California Supreme Court, S179115) This case involves the appropriate measure of damages in a personal injury case and the proper interpretation of “benefits” under the collateral source rule. In a published opinion, the Fourth Appellate District Court ruled that economic damages awarded to a personal injury plaintiff should reflect the full amount of her health care provider’s bills, not the rate the provider accepted as payment in full for the services rendered. Accordingly, CMA, together with other amici, filed a letter in support of the Petition for Review and Request for Depublication of the Court of Appeal’s opinion. On March 10, 2010, the Supreme Court granted review of the Howell decision.

CMA Amicus Letter received: 3/5/10

HEALTH PLAN REGULATION: California Department of Insurance v. Pacificare Life & Health Insurance Co. (California State Insurance Commissioner) CMA has provided significant assistance to the Department of Insurance (DOI) in its unprecedented prosecution of Pacificare. In 2006, CMA presented a lengthy complaint to the DOI from 40 physician members concerning a variety of problems they encountered with Pacificare. As a result, the DOI conducted a yearlong investigation that resulted in findings of hundreds of thousands of violations of the Insurance Code by Pacificare. Pacificare refused to settle and the DOI has been forced to take formal administrative action and seek the full extent of punishment allowable under the Insurance Code.

Trial commenced in early December 2009 and is expected to go into the early summer 2010.

Long Do

HEALTH CARE REFORM & ERISA: Golden Gate Restaurant Association (GGRA) v. City & County of San Francisco (Ninth Circuit Court of Appeals, 07-17370, 07-17372) CMA and the San Francisco Medical Society filed an amicus brief opposing the petition for en banc review. In this case, the local restaurant association challenged the City’s recently created health care program for uninsured residents. The restaurants argued that the City’s program is preempted under ERISA. The Ninth Circuit held that ERISA does not preempt the Sam Francisco health care ordinance. GGRA filed a petition for en banc review. CMA’s amicus brief argued that ERISA should not stand in the way of efforts to reform the health care system at the state and local level. On March 9, 2009, the Ninth Circuit ruled on the petition for en banc review, in favor of CMA’s side. GGRA filed a cert petition before the U.S. Supreme Court on June 5, 2009.

CMA and SFMS Amicus Brief filed: 12/15/08

Long Do

Hearing on pretrial motions set for July 2010. CMA is continuing to monitor this case.

Alicia From

This case is currently in the briefing stage before the California Supreme Court. The opening brief was filed on 4/9/10.

Cert Petition before U.S. Supreme Court filed: 6/5/09 The case now is pending for writ of certiorari before the U.S. Supreme Court. A decision is expected in its current session, by the beginning of summer 2010.

PAGE 16 | THE BULLETIN | MAY / JUNE 2010

CMA Amicus Curiae Briefs Pending cases in which CMA filed an amicus brief or letter

Status

Staff

MEDICAL RECORDS, PRIVACY & CONFIDENTIALITY: McKnight v. Children’s Hospital of Oakland (Court of Appeals, First District, A127580) CMA and the California Hospital Association filed an amicus brief in support of petitioner Children’s Hospital of Oakland. The Children’s Hospital seeks to prohibit the State of California Workers’ Compensation Appeals Board (WCAB) from proceeding with a discovery order requiring the Hospital to review medical records and disclose information about HIV infected children who were a part of a physical and occupational therapy program where McKnight worked for almost 20 years. This case is currently pending before the First District of the California Court of Appeal.

CMA Amicus Brief filed: 3/19/10

Lisa Matsubara

PEER REVIEW: El-Attar, M.D. v. Hollywood Presbyterian Medical Center (Court of Appeal, Second District, B209056) In this case, Dr. El-Attar’s medical staff privileges were not renewed by the hospital’s governing Board. Following a finding by the Medical Executive Committee (MEC) that there was no basis for the hospital to deny Dr. El-Attar’s reappointment to the medical staff, the hospital bypassed the MEC and picked its own panel and hearing officer over Dr. El-Attar’s objections. CMA filed an amicus brief in support of Dr. El-Attar arguing that medical staffs are required to abide by their bylaws and cannot designate their governing body to act on its behalf, except in rare circumstances.

CMA Amicus Brief filed: 5/19/09

REPRODUCTIVE ISSUES: Hoye v. City of Oakland (Ninth Circuit Court of Appeals, 09-16753) CMA and Alameda-Contra Costa Medical Association joined Planned Parenthood Affiliates of California and Planned Parenthood affiliates in the East Bay on an amicus brief to support the City of Oakland’s ordinance creating an eight-foot buffer zone or ”bubble” around people seeking access to reproductive health care centers within 100 feet of such a center.

CMA and ACCMA Amicus Brief filed: 2/23/10

TOBACCO CONTROL: Walgreen Co. v. San Francisco (Court of Appeal, First District, A123891) The drug store chain Walgreens challenged San Francisco’s ordinance banning tobacco sales in pharmacies. Walgreens claimed the ordinance violates equal protection laws because the ban exempts supermarkets and “big box” retail stores like Costco. CMA and the San Francisco Medical Society filed an amicus brief defending the exemption, telling the court that pharmacies, which market themselves as institutions where customers can receive trustworthy health care advice, should not implicitly endorse cigarette smoking. Oral arguments were held before the Court of Appeal on March 10, 2010.

CMA and SFMS Amicus Brief filed: 7/14/09

VICARIOUS LIABILITY: Allen v. Superior Court (St. Joseph’s Hospital)* (Court of Appeal, Fourth District Third Division, G042458) In this case, the trial court granted summary judgment in favor of St. Joseph’s Hospital on plaintiff’s claim that the hospital was vicariously liable for damages stemming from an x-ray technician’s alleged sexual molestation of the patient. CMA, along with other amici, filed an amicus brief supporting the hospital’s position that a professional health service provider cannot be held vicariously liable for an employee’s alleged sexual misconduct under Civil Code section 51.9. On March 8, 2010, the Court of Appeal issued its unpublished opinion granting the relief requested by plaintiff, made a limited ruling regarding corporate liability, and declined to address the issue of vicarious liability. The petition for review filed by St. Joseph’s Hospital before the California Supreme Court is pending (S181899).

CMA Amicus Brief filed: 11/23/09

Application to file amicus granted: 4/16/10 This case is currently pending before the Court of Appeal.

Astrid Meghrigian

Application to file amicus granted: 6/9/09 This case is currently pending before the California Court of Appeal. Lisa Matsubara

This case is currently pending before the United States Court of Appeals for the Ninth Circuit. Long Do

Application to file amicus granted: 7/16/09 A decision by the Court of Appeal is expected within 90 days of the 3/10/10 hearing.

Application to file amicus granted: 11/25/09 The petition for review before the California Supreme Court is pending (S181899).

PAGE 17 | THE BULLETIN | MAY / JUNE 2010

Alicia From

CMA Legal Affairs Case List, from page 17 Recently Resolved CMA Cases CMA cases which have been resolved within the past year

Outcome

Staff

DRUG TREATMENT PROGRAM: Gardner et al. v. Schwarzenegger (Court of Appeal, First District, A122920) CMA and the California Psychiatric Association filed an amicus brief opposing a state law that would undermine the criminal offender drug treatment requirements enacted by Proposition 36, California’s landmark drug-treatmentinstead-of-incarceration initiative. At issue was Senate Bill 1137, which would radically change Prop. 36 by allowing judges to incarcerate people who suffer drug relapses during treatment and limit the discretion of physicians to determine how drug offenders can best benefit from treatment. The Court of Appeal agreed with CMA and held that the State could not enforce its law to undercut physician discretion and control under Prop. 36.

CMA Amicus Brief filed: 6/12/09

Long Do

HEALTH PLAN RESCISSION: Nieto v. Blue Shield (Court of Appeals, Second District, B214669) CMA filed an amicus letter brief in the California Supreme Court supporting review or depublication of the Court of Appeals decision to educate the court about harms to providers and patients from retroactive rescission practices and encourage the court to adopt uniform standards for allowing plans to rescind based upon post-claims underwriting practices. The California Supreme Court denied the petition for review and request for depublication.

CMA Amicus Letter sent: 4/1/10

HEALTH PLAN RESCISSION: People of the State of California v. Anthem Blue Cross of California (Court of Appeal, Second District, B215035) CMA and the Los Angeles County Medical Association jointly submitted an amicus brief in support of a lawsuit filed against Blue Cross for illegally canceling patients’ health insurance policies. The suit, filed by the Los Angeles City Attorney, alleges that Blue Cross sold people false promises of coverage, while systematically canceling policies after policyholders got sick and filed expensive claims. Blue Cross is asking for the case to be dismissed, arguing that the Department of Managed Health Care (DMHC) has exclusive jurisdiction to enforce violations of the Knox-Keene Act. CMA and others in organized medicine strongly reject this argument. On December 15, 2009, the Court of Appeal, in a published opinion (essentially siding with CMA’s legal arguments), rejected Blue Cross and DMHC’s jurisdictional arguments and held that DMHC does not enjoy exclusive jurisdiction to enforce the Knox-Keene Act and Unfair Competition Laws. Blue Cross filed a petition to the California Supreme Court to review the case which was denied.

CMA Amicus Brief filed: 7/17/09

INFORMED CONSENT: Bergero v. University of Southern California* (Court of Appeal, Second District, B200595) Plaintiff brought a wrongful life lawsuit against the University of Southern California Keck School of Medicine (“USC”) and argued, in part, that USC should be held liable for wrongful life because it purportedly owed a duty to disclose information comparing USC’s experience with that of other facilities performing the medical procedure to which Plaintiff’s parents consented. The trial court ruled against the Plaintiff and he appealed. CMA submitted an amicus brief to the Court of Appeal urging the Court to recognize that Plaintiff’s position seeks to expand beyond reason the doctrine of informed consent by promoting a rule that health care providers must advise patients of specific types of information pertaining to the health care provider’s comparative training and experience with respect to other providers and success rates with relevant procedures. Such a rule falls outside the contours of the doctrine of informed consent as developed by the California Supreme Court, is grossly impractical and is not needed to provide due recourse to injured patients. On April 9, 2009, the Court of Appeal affirmed the decision of the lower court. Less than two weeks later, the parties filed a Joint Notice of Settlement.

CMA Amicus Brief filed: 12/8/08

Application to file amicus granted: 6/16/09 Opinion filed: 11/5/09 The Court of Appeal ruled in favor of CMA and the State decided not to further appeal. Long Do

Case Resolved: 4/28/10 The California Supreme Court denied the petition for review. Long Do

Application to file amicus granted: 7/28/09 Case Resolved: 3/10/10 The Court of Appeal agreed with CMA and Blue Cross’s petition to the California Supreme Court was denied.

Application to file amicus granted: 12/19/08 Case Settled: 4/20/09 After the Court of Appeal agreed with CMA and affirmed the trial court’s decision, the parties settled.

PAGE 18 | THE BULLETIN | MAY / JUNE 2010

Alicia From

Recently Resolved CMA Cases CMA cases which have been resolved within the past year

Outcome

Staff

MICRA: Van Buren v. Evans* (Court of Appeal, Fifth District, F054227) CMA filed an amicus brief to defend the noneconomic damages cap in medical malpractice cases. In this case, the plaintiff’s personal injury attorneys argued that MICRA’s $250,000 cap on noneconomic damages deprived Mr. Van Buren of his constitutional rights to a jury trial. They also argued that the cap violates constitutional provisions that prohibit the legislature from exercising judicial powers, as well as the equal protection clauses of the state and federal constitutions. CMA’s amicus brief opposed this attack on MICRA and argued to the court that MICRA’s limit on noneconomic damages is a key component of a complex and balanced legislative plan that has ensured the availability of medical care in California. The Court of Appeal sided with CMA and upheld the constitutionality of California’s landmark law, a decision that the California Supreme Court declined to review.

CMA Amicus Brief filed: 10/14/08

Alicia From

PEER REVIEW: Mileikowsky, M.D. v. West Hills Medical Center (California Supreme Court, S156986) CMA and the American Medical Association (AMA) filed an amicus brief against granting hearing officers the power to terminate a peer review proceeding. In this case, a hearing officer’s decree to terminate a peer review hearing led directly to the restriction of the physician’s privileges. By doing so, the hearing officer essentially made a medical determination that the physician is medically incompetent to practice at the hospital, thus depriving the physician of a fair hearing before his medical peers. CMA’s amicus brief argued forcefully that the granting of such powers to a hearing officer unlawfully deprives physicians of a fair hearing before his medical peers, and deprives patients of access to their physician of choice. The California Supreme Court agreed with CMA, and ruled that peer review hearing officers cannot unlawfully usurp the clinical decisions of a peer review body.

CMA and AMA Amicus Brief filed: 8/26/08

TOBACCO CONTROL: Philip Morris USA, Inc. v. City & County of San Francisco (Ninth Circuit Court of Appeals, 08-17649) CMA and the San Francisco Medical Society (SFMS) joined numerous other health and tobacco control advocates on an amicus curiae brief to support the City of San Francisco’s ordinance prohibiting the sale of tobacco products in pharmacies. Philip Morris challenged the ordinance in federal court on the basis that it violates the tobacco manufacturer’s commercial speech rights. Philip Morris lost at the trial level, and appealed to the Ninth Circuit Court of Appeals. CMA’s amicus brief was filed in the appeal. The Ninth Circuit affirmed the trial court’s ruling, in favor of CMA’s side.

CMA and SFMS Amicus Brief filed: 3/24/09

Application to file amicus granted: 10/16/08 Case Resolved: 8/19/09 The Court of Appeal agreed with CMA and upheld MICRA’s cap on noneconomic damages. The California Supreme Court declined to review the case. Astrid Meghrigian

Application to file amicus granted: 8/28/08 Final Opinion filed: 4/6/09 The California Supreme Court agreed with CMA and affirmed the judgment. CMA opposed the petition for rehearing and the Court denied the petition.

Case Resolved: 9/9/09 Ninth Circuit affirmed the judgment, in favor of CMA’s side.

PAGE 19 | THE BULLETIN | MAY / JUNE 2010

Long Do

MEMBER SPOTLIGHT: MEDICAL MISSION

THE VOID THAT FILLS THE HEART By Michael T. Margolis, MD, FACS, FACOG In June of 1992, I had the great fortune to spend a month during my pelvic surgery fellowship repairing vesicovaginal fistulas at a mission hospital in Northern Ghana. Located close to the Gambaga escarpment and hundreds of miles from the next available legitimate hospital, our team of American and Ghanian physicians provided surgical care for locals in the village of Nalerigu. The operating room conditions were primitive, but functional, and the patients were, for the most part, remarkably sick, many with advanced surgical pathology. My wife was in Atlanta, 25 weeks pregnant with our first child. Cell phone technology was not what it is today, so we hadn’t been able to speak with each other for a month. One rather beautiful night around 3:00 AM, a midwife knocked on the door of my guesthouse. Since I’m an OB/GYN, labor and delivery was requesting my help. The midwife informed me they had a patient with a problem. We walked together a hundred yards or so to the hospital, while I inquired about the problem at hand. “A patient has delivered her placenta,” she explained to me. “I’m sorry, what’s the problem?” I asked. “The patient delivered her placenta,” she repeated. Confused, I asked, “Why is it a problem that a patient has delivered her placenta?” “Because the baby won’t come out,” she said. Shaking the cobwebs out of my head, I remarked, “That’s not possible!” “Yes, it is,” she said. Examination of the early teenage patient showed an intact placenta down at

her knees. The umbilical cord entered her vagina, and the necrotic fetal caput was jammed against the introitus. I’d never seen or heard of anything like this before. The midwife asked what to do, so I put the patient in extreme McRoberts position, applied suprapubic pressure and asked her to instruct the patient to push! After several hard pushes, a macerated fetus delivered. I estimated that the term baby had been dead 2-3 days. The patient rested a couple hours, then in the morning got up and started walking back to her village, Lord knows how many miles away. The patient showed little emotion throughout her ordeal. Darwin’s theory was good to her that day and she survived. The baby wasn’t lucky. There was nothing else to say. She acted as if it was just a matter of fact, and indeed, it was. Unfortunately for the patient, though, what she just experienced was only the beginning of her problems. A brewing postpartum necrotic process was now underway. The problem, unbeknownst to this never-to-be-mother, was that her vaginal and bladder walls had been severely damaged during labor. Anatomy, primitive cultural practices, and limited access to health care would soon combine to produce in her a vesicovaginal fistula. In short, obstetric injury caused by several days of obstructed labor results in pressure necrosis to the vagina and bladder. In 7-10 days, her genitourinary tract would slough, resulting in a devastating vesicovaginal fistula. This fistula can loosely be thought of as a “void”

PAGE 20 | THE BULLETIN | MAY / JUNE 2010

Michael T. Margolis, MD, FACS, FACOG has been an SCCMA member since 1997. He is board certified in gynecology and is currently practicing in the San Jose area. of vaginal/bladder wall through which urine continuously leaks per the vagina. Soon, her physical, reproductive, and social life will change dramatically for the worse and she will begin to live a life of misery. She will leak urine continuously per her vagina; she will be unable to reproduce; she will be divorced by her husband, ostracized and thrown out of her village because she smells of urine; she will be alone. It will be said by some that she is being punished by God for sins she must have committed. That was an isolated moment of life in the fistula belt of Sub Saharan Africa in 1992. Bad as it was, the sad fact is, that scenario has been recurring continuously throughout the continent since man evolved in the Great Rift Valley of East Africa 100,000 years ago, and little has changed to this day. Examination of Egyptian mummy specimens from 2000 BC have provided the first documented physical evidence of ruptured bladder from pregnancy. Clearly, this problem dates back to the origin of our species and the biologic phenomenon known as vaginal delivery. It is estimated

Old and young fistula patients (age approx. 51 and 13 y/o respectively) that currently at least two million women live with obstetric fistula in Africa and an additional 50,000 to 100,000 new women are affected each year. Vesicovaginal fistula in Africa occurs almost exclusively as a result of obstetric injury and it is a widespread plague – if you will – throughout the entire continent. Some sources have the rate of fistula development at 1% of all deliveries. These fistulas are the result of a combination of obstetric, anthropologic, cultural, political, and financial factors that blend to form the “perfect storm” of conditions for female reproductive disaster. Of course, the tragic fact that goes without saying is, women who suffer from fistula are the ones who survived childbirth. You have to live to get the fistula. Furthermore, looking at the bigger picture, obstetric morbidity and mortality pales in comparison to other more ubiquitous disease processes in Africa.

Life expectancy for women in the United States is 81 years of age. Despite what some in the political arena might say, Americans live remarkably long and healthy lives despite the self-imposed poor lifestyle habits that many choose to perpetrate upon themselves. Compare this to Uganda, where the life expectancy for women is approximately 51 years of age, and much of Africa is roughly the same. To add perspective, China’s life expectancy is 75, Peru’s is 72, and India’s is 67. Maternal mortality in the U.S. is 8 deaths per 100,000. In Uganda, it is 510 per 100,000. Uganda has it easy compared to Eritrea, where the maternal mortality is 1,000 per 100,000. It’s even worse in Sierra Leone, where 2,000 out of 100,000 women die every year in childbirth. Why, then, is the maternal mortality rate in relatively “fortunate” Uganda 6,400% higher than here in the U.S., and what interest is any of this to you and me? The first question can be PAGE 21 | THE BULLETIN | MAY / JUNE 2010

answered easily. The answer to the second question the reader will, ultimately, have to decide for him or herself. The physical risk factors for birth trauma in African women start with age. Early marriage with childbirth at a young age, before growth of the pelvis is complete, is the most significant risk factor for injury. In fistula patients, the average age at the time of wedding is 13 years old. Ninetyeight percent of women are under the age of 18 when they marry. The average age at the time of first pregnancy is 16 years old, while 81% are under the age of 18. Young girls have first babies well before the bony pelvis is mature enough to accommodate a full-term fetus. The age of maximum fecundity in human females is roughly 22. That is the age that biologic factors most favor reproduction in our species. Other physical factors include a relatively high prevalence of the anthropoid and android type pelvis in Africans, neither of which favor easy vaginal

The Void That Fills The Heart, from page 21 delivery. Widespread malnutrition further contributes to the development of a pelvis, that is, when it comes down to it, too small to allow for safe passage of a baby.

Finally, poverty and no access to health care in third world countries is a problem of epic proportions. Poverty begets disease. As Americans, we simply do not know how amazingly fortunate we are to live as well as we do. We have an embarrassingly selfish habit of narcissistic preoccupation with “double decaf mocha lata frappa crappa fricken chinos….” At least, that’s what I believe.

The social factors causing this problem are rooted in the traditional custom of early marriage. Ironically, young girls are married off to prevent promiscuity and premarital pregnancy. This counterintuitive custom is so ingrained in the culture that change is not even a consideration. Much press was given to the tragic story of a 12-year-old Yemeni girl forced into marriage who died in labor. This phenomenon has been the way of life for such cultures historically, and it continues today. The press has only recently discovered it.

So then the question becomes, why is this of interest to anyone? I can only speak for myself. Eighteen years ago, I attended a lecture on vesicovaginal fistulas and at that time I knew I had to learn fistula repair so I could help those in need. I chose to leave my pregnant wife for a month so I could go gallivanting off to Africa, and she still lets me know her feelings about that to this day! On the other hand, the month I spent in Ghana and several subsequent missions in Peru and Uganda have been, without question, the happiest times of my professional career. The few times I’ve gone are nothing, however, when compared to Bay Area titans of mission service such as Henry Hamilton, MD, in Burlingame; Arthur Basham, MD, in San Jose; and

Add to this the generally held belief that parturition is regarded as a normal process not requiring medical attention until complications are at an advanced stage, and the knowledge that people who go to hospitals in Africa often die (mostly because patients are usually moribund with disease by the time they present to the inadequately equipped hospitals) and we start to see the problem.

Paul Hensleigh, MD (deceased), of San Jose. There are many others whose names are not mentioned for lack of space. These physicians have set the gold standard of humanitarian work for our profession. Clearly, vesicovaginal fistulas are not the only pathologic entities causing human suffering, indeed in the grand scheme, they are a drop of water (so to speak) in an ocean of pathology and suffering seen worldwide. Every disease entity known to man, and some unknown, afflicts the unfortunate poor of the world and, for obvious reasons, they cannot all be discussed here. Vesicovaginal fistulas are simply the pathologic process that called me into action. Physicians work hard and are often unappreciated. We spend countless hours caring for our patients and fighting for fair compensation. We miss out on time with our families and still take grief from various sectors. Still, medicine is and always will be an honorable profession. Furthermore, there is great need amongst our fellow beings for help. There is no written duty to help them, but we can help, therefore, in my opinion, we should. Like with the young woman at the beginning of this dialogue, it’s just a matter of fact. No emotion need be appended to this. Just do it. Why not? The opportunity to help those in need is not, by the way, limited to physicians. Those who have served on medical missions have included nurses whose heroic efforts cannot be overstated, respiratory technicians, businessmen, office workers, college students, and even musicians such as my own pianist brother from New York.

The fistula team with fistula patients, Uganda 3/09 PAGE 22 | THE BULLETIN | MAY / JUNE 2010

Furthermore, non-medical missions abound. Celebrities are well known to campaign for certain causes. Politicians have served as well, including Jerry Brown and our own

local Tom Campbell. Indeed, Tom and his wife Susanne have served numerous teaching missions to Africa, including volunteer work in Rwanda, Eritrea, and Ghana. They have taught on six different occasions during the summer, over the last ten years. Susanne teaches fundraising (to administrators of African universities that need desperately to supplement their budgets), and Tom teaches microeconomics and public finance. He believes his students include the future leaders of each country and hopes they will be more effective in creating real growth and personal opportunity because they obtained some grounding in basic economics. Such unselfish activity must be recognized as true and good work in the service of people in need. It’s wonderful to acknowledge that there are ethical politicians from both sides of the aisle, like Tom and Susanne Campbell, who care enough to help.

Approximately 20 post-op fistula patients with the only nurse caring for them.

support herself; also, she had developed bilateral drop feet. The very offensive smell was due to the continuous leaking of urine per vaginam from an extensive But if one is looking for a more urethrovesicovaginal fistula and to the subjective reason for volunteering, the passing of diarrheic stools per vaginam following passage from a little known thesis from an extensive rectovaginal fistula with on fistula may help to explain part of the total perineal rupture and sphincter ani reason that I choose to help: rupture; the cervix and uterus could not be “Carried by her mother and identified, most of the paraurethral, deep her grandmother, this 14-year-young girl transverse perineal and levator ani muscles was brought into the examination room were gone, and the labia minora were (sub) smelling offensively. Cachectic from the totally lost; in fact, she presented with one enormous effort and trauma it had taken big cloaca. She had, as well, deep pressure her to deliver over a period of four days, ulcers over the sacrum and both major a dead male infant, without professional trochanters; the wounds over the scapulae help in the bush, she was too weak to had healed off with scar tissue. She did not remember very much, as she had been unconscious or semiconscious most of the time. What a change from the proud girl who had been married three years ago to an elderly man who did not want to have his wife around anymore. The only proud thing about her now were her breasts, unbelievably still young and full, as if nothing had happened, reminding us that this Fistula patients, Ghana 1992. Pleasant, elegant (even in sickness), was a young girl whose appreciative, and always smiling. PAGE 23 | THE BULLETIN | MAY / JUNE 2010

adolescent and adult life had been wrecked at a time when it should have just started.” Personal Observations Kees Waaldijk, MD, PhD The (surgical) management of bladder fistula in 775 women in Northern Nigeria, 1989 How could one know of such suffering and not choose to do something? I don’t know. I think most of us are pretty much the same inside, decent human beings who happen to be physicians. I believe most of us could choose to help at some time or another in our careers, and I encourage everyone who hasn’t done so to do it, at least once. If you can’t go, please donate equipment, money, or supplies. There are many organizations accepting volunteers and some are based in the Bay Area. If you help, at least some avoidable human suffering will be alleviated, and the service to humanity that you provide will bless you with happiness and fulfillment words can’t describe. Go there – wherever there may be for you – with a sense of professionalism, service, and humility and feel for yourself; my guess is it will fill your heart, and you will get as much out of the experience as the patients you help, and perhaps even more. Safe travels.

FEATURE ARTICLE

JUST ONE THING By Colin Kopes-Kerr, MD This article is reprinted from the fall 2009 issue of Sonoma Medicine Dr. Kopes-Kerr is a family physician at Kaiser Santa Rosa. I want you to do just one thing. This one thing will reduce mortality from all causes, not just for yourself, but for all your patients. Whoa, you say. There’s nothing that simple in medicine. In fact, there is; let me tell you how it works. First, let’s think back to why we wanted to be physicians in the first place. Put simply, we wanted to help people live longer, healthier lives and to enjoy the relationships we made in that process. These three outcomes—longer lives, healthier lives, and relationships—are of roughly equal importance. But, if we want to look at our personal effectiveness as physicians, the mortality outcome (the length of life) is the simplest to measure. So let’s look there. Examining the causes of mortality is one of the first steps in setting up a new practice. You want to know what diseases or determinants are having the most effect on the patients in your community. Thanks to the CDC, this information is readily available; all you have to do is to type leadcause.html in Google, and the CDC WISQARS database for the leading causes of death by gender, age, race, and region of the country will pop up.1 Although you can get results that are fairly specific to your setting, let’s look at the Top 10 causes of death in the United States for 2006, the most recent year for which complete data are available. The results are shown in Figure 1. A look at this list should provide a guide to action for your practice. If the No. 1 cause of death is heart disease, maybe that Figure 1. Leading causes of death, United States, 2006 1. Heart disease: 631,636 2. Cancer: 559,888 3. Stroke: 137,119 4. Chronic lower respiratory diseases: 124,583 5. Accidents: 121,599 6. Diabetes: 72,449 7. Alzheimer’s disease: 72,432 8. Influenza and pneumonia: 56,326 9. Nephritis: 45,344 10. Septicemia: 34,234

is the problem you should attack first. It would even be reasonable to put a hold on all other preventive activities until this is done. Of course, a good case could be made for attacking cancer as a first priority, and that is a choice many have made. There are, however, several reasons to dissuade you from the cancer approach. The first problem is that “cancer” represents deaths from all cancers. Unfortunately, we don’t have good tools or tests that work against all cancers. Instead, you have to buy many mammograms (breast cancer), many sigmoidoscopies or colonoscopies (colon cancer), and many Pap smears (cervical cancer) to follow the conventional wisdom about how to reduce the effects of these cancers, to say nothing of all the other types of cancer. Such a strategy is only moderately effective because, at best, we can reduce the risk of dying of breast cancer by only a third among the 3% of women who will get it in any decade after 50.2 Likewise, we can reduce the risk of dying of colon cancer by only 16%.3 In contrast, cervical cancer screening can reduce deaths for the seven or eight invasive cervical cancers that occur per 10,000 of the population by greater than 90%. Because these cancers are relatively rare, however, and because the tools are relatively inefficient, a cancer-focused approach to reducing overall mortality tends not to work. A 2002 review article found no evidence that cancer screening, as currently conducted, reduces all-cause mortality.4 As shown by Figure 2, while traditional cancer screenings reduce a person’s risk of dying of cancer, they do not add a single day to the person’s lifespan.4 We need to find another number-one priority to rally around in primary care. That would be heart disease, the numberone 1 killer of Americans. But what is the screening intervention for heart disease? Many of us have overlooked it because it is so obvious and so simple. Screening for heart disease starts with the single intervention of doing a coronary artery disease (CAD) risk assessment systematically for your patients. Assessment tools include the Framingham tables and equation, the ATP III risk calculator,5 the Sheffield tables,6 and the most recent technique, the QRISK calculator.7 Since many of these tools can be downloaded for free into our smartphones, there are only a few barriers to implementation. The biggest one is time. When I started full-time practice again

PAGE 24 | THE BULLETIN | MAY / JUNE 2010

Figure 2. Effectiveness of cancer screening Disease

Screening

Change in disease-specific mortality

Change in all-cause mortality

Breast cancer

Mammography

33% reduction after 20 mammograms

Colon cancer

Annual FOBT, followed by sigmoidoscopy or colonoscopy

16% reduction after 12-18 years

Cervical cancer

Pap smears

80% reduction after ~17 Pap smears

in 2005, my goal was to make CAD risk calculations for all my adult patients using the ATP III calculator on my Palm Treo. The trouble turned out to be time. After thumbing back and forth through thick charts to find the relevant variables, and then having to put both hands back on the device to enter the data, the assessment was taking me five or six minutes per patient— time I didn’t have. To save time, I changed to a system where I preprinted 10 major cardiac risk factors on my progress note with checkboxes alongside them, as shown in Figure 3. This form, which takes only one or two minutes to fill out, allowed me to classify all my adult patients into three levels of risk: low, intermediate, or high. Where you draw the dividing lines between categories is not nearly as important as being consistent. In my practice, I consider a score of 0-3 to be low risk, 4-6 to be intermediate risk, and 7-10 to be high risk. Each patient’s test result should go right into the problem list so the physician can see it on every single visit. The intervention itself is relatively cheap. It requires little time and involves simple lab tests. Figure 3. Major cardiac risk factors Age: >55 males; >65 females Male gender Family history of CAD in firstdegree relative in 50s Smoking High cholesterol Hypertension Diabetes Sedentary lifestyle Metabolic syndrome

What to do with the results? The first assumption I make is that you’re offering some kind of healthy lifestyle advice to everyone (exercise, five servings of fruits and vegetables per day, relaxation/ meditation, and no smoking). You are, aren’t you? For patients at low cardiac risk, this advice is all that is needed. For patients at either intermediate or high risk, more is required. You need to systematically apply the best evidence for reducing cardiac risk. Potential candidates among a sophisticated and effective set of measures are shown in Figure 4. Patients at high risk may benefit from a formal Polypill approach.8 This strategy recommends daily intake of folic acid (or omega-3 fatty acids), a statin, and a baby aspirin, along with half-doses of three different antihypertensives (hydrochlorothiazide, a beta blocker, and an ACE inhibitor). Proponents claim that the Polypill strategy can reduce heart attacks and stroke by over 80% both in primary and secondary prevention. While there are no reported randomized controlled trials proving this yet for primary prevention, we have one study showing major benefit in secondary prevention.9 More studies are underway.10 Advances in conservative medical therapy for cardiovascular disease have kept pace with advances in the technology of heart disease (e.g., drug-eluting stents) with far fewer complications. The real power of the conservative approach lies in the synergies achieved with a systematic program. A health promotion program using only CAD risk assessment and the appropriate conservative responses listed above can achieve multiple synergistic benefits across a large spectrum of diseases.

Chronic renal insufficiency PAGE 25 | THE BULLETIN | MAY / JUNE 2010

By far the largest component of the intervention program described above is no more than promoting a healthy lifestyle. We all tend to believe in the positive health effects of such a lifestyle, but how much specific work are we doing to promote a specific lifestyle program in our practices? In my observations over the years, the impact from dedicated lifestyle promotion appears minimal, not because it doesn’t work, but because it is not being diligently tried. Perhaps the reason is that we did not have a good basis of evidence from the medical literature. The evidence situation has recently improved, yet few physicians seem to be aware of it. Four recent studies elevate lifestyle promotion to one of the most important of all practice priorities. In the Figure 4. Measures for reducing cardiac risk •

Not smoking or quitting smoking

•

Exercising >150 minutes/week

•

Five servings of fruits and vegetables daily

•

Stress reduction/relaxation 10 minutes/day

•

Aspirin 81 mg daily

•

Medication(s) for lowering cholesterol

•

An additional medication, if metabolic syndrome is present

•

Treating blood pressure to <135/80 mmHg

•

Screening for diabetes in patients with hypertension

•

Omega-3 fatty acids

•

Two servings of fish each week

•

Adequate vitamin D

•

Increased calcium intake

•

Increased fiber intake

•

Avoiding processed foods

Just One Thing, from page 25 HALE study, investigators analyzed the association of four healthy lifestyle factors with mortality in elderly men and women from 11 European countries.11 The first factor was a modified Mediterranean diet that included above-average consumption of polyunsaturated fatty acids, fish, grain, legumes, fruits, and vegetables, and belowaverage consumption of meat and dairy products. The other three factors were not smoking, limiting drinking, and getting exercise. To get the maximum score for all four factors, subjects had to meet all the dietary requirements; had to have never smoked or quit more than 15 years ago; had to drink the equivalent of one glass of wine per day; and had to exercise 30 minutes each day with an intensity at least equal to a brisk walk. The combination of all four factors reduced the risk of death (all-cause mortality) for this aging population by 65%! This result has been replicated in the United States at least three times. In the most interesting study, investigators used a slightly different definition of a healthy lifestyle (substituting the criterion of five servings of fruits and vegetables for the modified Mediterranean diet, and substituting BMI criteria of 18.5 to 29.9 for the alcohol criterion).12 Especially relevant to practicing physicians, investigators showed that getting 50-year-old patients to change from unhealthy to healthy lifestyles reduced all-cause mortality and cardiovascular mortality after only four years. The logical conclusion for primary care physicians is that people who newly adopt a healthy lifestyle in middle age Figure 5. Four Numbers Characterizing Health 0

The number of cigarettes that anyone should consume.

The number of servings of fruits and vegetables to eat in your diet every day.

The minimum number of minutes per day to spend in relaxation, meditation, or other stress reduction behavior.18

150

The number of minutes of exercise you need each week.19

experience a prompt benefit of lower rates of cardiovascular disease and mortality.

simple set of four numbers characterizing health, as shown in Figure 5.

Similar results were reported from the Women’s Health Study and the Harvard Health Professionals Follow-up Study.13,14 Among the 37,636 participants over age 45 in the first study, those who scored high on an index of five lifestyle factors (non-smoking, limited alcohol, exercise, BMI, and diet) had 55% lower risk for total stroke and 71% for ischemic stroke than the other participants. Among the 42,847 men in the second study, those who had all five healthy lifestyle factors had an 87% lower risk of developing cardiac events than the other participants.

That’s it. That’s all there is. It couldn’t be simpler. Maximum health is available to all at an affordable price and with impressive results. Isn’t it time you tried to become that kind of doctor?

Just published in 2009 are the findings from the European Prospective Investigation into Cancer and Nutrition.15 Using data from 23,153 German participants aged 35 to 65, investigators analyzed the effects of never smoking, having a BMI <30, performing 3.5 hours or more per week of physical activity, and adhering to healthy dietary principles (high intake of fruits, vegetables, and whole-grain bread, coupled with low meat consumption). During a mean follow-up of 7.8 years, individuals with all four factors at baseline had a 78% lower risk of developing a chronic disease than participants with no healthy factors. BMI reductions had the greatest impact, followed by never smoking, physical activity, and adhering to good dietary principles.

3. Hewitson P, et al, “Screening for colorectal cancer using the faecal occult blood test, Hemoccult,” Cochrane Database, Article CD001216 (2006).

Now it is time to return to the beginning of this article, where I asked you to do just one thing to reduce allcause mortality for yourself and your patients. This one thing is mere CAD risk assessment with appropriate followup. Such follow-up is mostly intensive lifestyle counseling, fortified by strong personal example and skills in motivational interviewing.16,17 As shown by the studies cited above, this strategy could reduce all-cause mortality for adult Americans by 60%. Moreover, the effects of this intervention could dwarf all our previous efforts to carry out cancer screening. For primary care physicians, your new prescription need consist only of a

PAGE 26 | THE BULLETIN | MAY / JUNE 2010

E-mail: colin.p.kopes-kerr@kp.org

References 1. webappa.cdc.gov/sasweb/ncipc/ leadcaus.html 2. Fletcher SW, Elmore JG, “Mammographic screening for breast cancer,” NEJM, 348:1672-80 (2003).

4. Black WC, et al, “All-cause mortality in randomized trials of cancer screening,” J Natl Cancer Inst, 94:167173 (2002). 5. National Cholesterol Education Program, 10-year CVD risk calculator, hp2010.nhlbihin.net/atpiii/calculator. asp?usertype=prof. 6. Wallis EJ, et al, “Coronary and cardiovascular risk estimation for primary prevention,” BMJ, 320:672 (2000). 7. Hippisley-Cox J, et al, “Predicting cardiovascular risk in England and Wales,” BMJ, 336:a332, www.qrisk. org (2008). 8. Wald NJ, Law MR, “A strategy to reduce cardiovascular disease by more than 80%,” BMJ, 326:1419 (2003). 9. Hippisley-Cox J, Coupland C, “Effect of combinations of drugs on all-cause mortality in patients with ischemic heart disease,” BMJ, 330:1059-63 (2005). 10. clinicaltrials.gov/ct2/show/ NCT00603590 11. Knoops KTB, et al, “Mediterranean diet, lifestyle factors, and 10-year mortality in elderly European men and women: The HALE Project,” JAMA, 292:1433-39 (2004).

12. King DE, et al, “Turning back the clock: adopting a healthy lifestyle in middle age,” Am J Med, 10:598-603 (2007). 13. Kurth T, et al, “Healthy lifestyle and the risk of stroke in women,” Arch Int Med, 166:1403-09 (2006). 14. Chiuve SE, et al, “Healthy lifestyle factors in the primary prevention of coronary heart disease among men,” Circulation, 14:160-167 (2006).

Tracy Zweig Associates A

REGISTRY

PLACEMENT

FIRM

Physicians

Nurse Practitioners ~ Physician Assistants

15. Ford ES, et al, “Healthy living is the best revenge,” Arch Int Med, 169:135562 (2009). 16. Rollnick S, et al, Health Behavior Change: A Guide for Practitioners, Churchill Livingstone (1999). 17. Bundy C, “Changing behavior: using motivational interviewing,” J Royal Soc Medicine, 97;S44:43-47 (2004).

Locum Tenens ~ Permanent Placement

18. Chopra D, Ageless body, Timeless Mind, Crown Publishers (1993).

V oi c e : 8 0 0 - 9 1 9 - 9 1 4 1 o r 8 0 5 - 6 4 1 - 9 1 4 1 FA X : 8 0 5 - 6 4 1 - 9 1 4 3

19. US DHS, Physical Activity Guidelines for Americans, health.gov/paguidelines (2008).

2001 Gateway Place, Suite 340 East San Jose, CA 95110 PH: (408) 452-7700 FAX: (408) 452-7470 Email: michelle@lwallc.com www.lwallc.om

tzweig@tracyzweig.com w w w. t r a c y z w e i g . c o m

We are Wealth Advisors and Financial Planners to high net worth individuals, families and institutions. By Managing Wealth by Design™, we create a unique financial plan for each client, addressing their retirement, estate and S.C.C.M.A. investment planning needs. 8-12-08 Legacy Wealth Advisors is pleased to announce that Michelle Graham, MBA has joined the firm as a specialist in client relations and portfolio administration. Michelle comes from the Wells Fargo Family Wealth Group and Private Bank where she focused on trust, portfolio and financial administration of high net worth clients.

PAGE 27 | THE BULLETIN | MAY / JUNE 2010

“There IS hope for the private practice of medicine in Monterey County.” YOU’RE INVITED! Monterey County Medical Society’s ANNUAL MEETING & INSTALLATION DINNER Tuesday, June 29, 2010 at the Pasadera Country Club, 100 Pasadera Drive, Monterey, CA

Please come hear from our guest speakers — “What is CMA doing for you and what can you do for CMA?”

Guest Speakers:

James Hinsdale, MD CMA President-Elect &

Dustin Corcoran

CMA Chief Executive Officer In Addition:

Honoring: Outgoing President — William Khieu, MD &

Welcoming: Incoming President — John Jameson, MD 6:30 p.m. 7:00 p.m. 7:30 p.m. 8:00 p.m. 8:15 p.m. 8:30 p.m. 9:00 p.m.

❧❧❧ Evening’s Agenda ❧ ❧❧ Cocktail Reception Welcome From William Parrish, CEO Followed by Dinner Guest Speaker — Dustin Corcoran Honor Outgoing President Welcome Incoming President Guest Speaker — James Hinsdale, MD Entertainment

Please fax your RSVP to Sheila Foley at 408/289-1064. Name(s): Questions:

PAGE 28 | THE BULLETIN | MAY / JUNE 2010

When faced with an illness such as my husband Paul’s, some seek to travel to far away places to fulfill personal dreams. Paul had traveled and experienced many wonderful adventures in his 44 years. In the end with the love, compassion, and guidance from our Hospice of the Valley “ family,” we as a family met our goal and were exactly where we needed and wanted to be... at home. — Mary S. Brad Leary, director social services and counseling Pam Nates, chaplain

Deni

Hospice of the Valley Celebrating 30 Years of Community Service When your patients are coping with advanced illness, they require expert care, compassion and personal attention. Whether it is spending time with loved ones, fulfilling dreams, or simply remaining comfortable and independent for as long as possible, Hospice of the Valley guides patients and their families to meet their goals. • For those dealing with grief and loss, our Community • The hallmark of hospice care is that it serves Grief and Counseling Center provides families and your patient wherever they live—be it in their home, individuals with one-on-one counseling and lossnursing home, hospital or assisted living facility specific support groups to adults, teens and children • Our interdisciplinary team members consist of • Since 1979, Hospice of the Valley’s legacy physicians, nurses, social workers, chaplains, of compassionate care, community hospice aides, volunteers, and grief counselors education, advocacy and outreach who are experts in palliative and hospice care, has set the standard for quality and who are here to assist you in the Wingate, RN hospice care state-wide and management of your patient’s nationally, and we are a locally end-of-life care needs based, run, and supported non-profit organization Margarita Vizcaya, hospice aide

For more information please contact us. Monique Kuo, MD, medical director

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

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MEDICAL SOCIETY SURVEY

Survey of Bay Area County Medical Societies Regarding Medicare Payment Policy to Physicians

Congress’s failure to stop future pay cuts by repealing the SGR payment formula will affect my Medicare FFS patients as follows

Alameda - Contra Costa Medical Association

Marin, Mendocino / Lake, and Sonoma County Medical Societies

Napa and Solano County Medical Societies

San Francisco Medical Society

No reduction in patients

22%

26%

15%

21%

24%

26%

22%

Reduced treatment time for patients

42%

32%

15%

30%

33%

37%

32%

Reduced # of existing patients

37%

19%

31%

21%

27%

42%

30%

Stop seeing all existing patients

12%

13%

15%

13%

10%

No reduction in new patients

10%

Reduced # of new patients

36%

32%

23%

33%

32%

47%

40%

No new patients

39%

35%

31%

39%

41%

53%

46%

Santa Clara Santa Cruz County County Medical Medical Average of Association Society all Counties

Existing Patients

New Patients

Will/have opted out of Medicare

PAGE 30 | THE BULLETIN | MAY / JUNE 2010

700 Empey Way, San Jose, CA 95128 (408) 998-8850 FAX (408) 289-1064

2010-2011 SCCMA COMMITTEE RESPONSE FORM

Listed below are the current SCCMA committees—all meet at the Medical Association building. Omitted are those where membership is by election (i.e. Council and Executive Committee), bylaw consideration, and/or existing protocol (i.e. Membership, Physicians’ Well-Being and Professional Standards/Conduct). SCCMA committees help recommend policies for the Association, standards for practice in Santa Clara County, and aid in the development of important relationships with governmental and public service organizations. Committee service commences on July 1, 2010. The majority of the committees will not meet during July and August, however. In accordance with SCCMA bylaws, committee appointments are made each year by the President and state that, “The terms of office of the chairs and members of all committees shall be at the discretion of the President, and, in any event, shall end with the term of office of the President by whom they were appointed…” Therefore, the terms of fiscal 09-10 committee members and chairs, having been appointed by Howard Sutkin, M.D., will officially end with his term of office — June 30, 2010.

Name:

(Please print)

Specialty:

Phone:

Fax:

Members currently serving, who seek reappointment, are also asked to return this form. Indicate first, second, & third choice:

❏ ❏ ❏ ❏ ❏ ❏

Awards (Yearly) To select and nominate to Council the prospective recipients of the Association’s annual awards. Bioethics (4 times a year, dinner) To educate its committee members regarding bioethical decision making and to discuss bioethical issues and cases. Environmental Health (Bi-monthly, dinner) To study and address environmental and occupational health concerns. External Affairs/Lunch With Legislators & Key Contacts (Lunchtime meetings, usually Fridays) To meet, interview, and serve as the Association’s liaison to the legislators. To influence legislation and regulations relating to the delivery of medical care and the public health. Leon P. Fox Medical History (Bi-monthly, 3rd Thursday, dinner) To identify, collect, and preserve archival material, memorabilia, and artifacts representing the medical history of Santa Clara County. Medical Review Advisory (Monthly, 3rd Thursday, dinner) To serve as a consultant to the attorneys for professional liability carriers by providing review and advice on malpractice claims.

❏

Mini-Internship Committee To organize and coordinate an annual mini-internship program whereby community leaders “shadow” practicing physicians for a day in order to increase awareness and understanding of the medical profession in the community.

❏

Mini-Internship Mentor Members are encouraged to participate in the “Mini-Internship” by volunteering to be “shadowed” by an “intern” (lay community leader) for one day, then attending a follow-up dinner. Check one: ❏ I’d like a “mini-intern” to shadow me. ❏ Please provide me with more information.

❏

Public Service (Dinner meeting, as needed) To evaluate and attempt to resolve disputes between physicians and patients.

FAX form to 408/289-1064 or mail to SCCMA by 7/15/10. Santa Clara County Medical Association 700 Empey Way San Jose, CA 95128 Phone: 408/998-8850; Fax: 408/289-1064

PAGE 31 | THE BULLETIN | MAY / JUNE 2010

CLASSIFIED ADS office space for rent/lease TWO UNITS AVAILABLE IN PRESTIGIOUS BUILDING • BY REGIONAL MEDICAL CENTER One has 1,200 sq. ft., at 244 North Jackson, with a big waiting room, spacious reception and secretarial area, with possible four examining rooms and private doctor’s consultation room, two bathrooms, carpet recently changed. Building has elevator, Quest Laboratories and xrays in the premises, and pharmacy on the corner of Montpellier for the convenience of your patients. Asking $2,400 per month, no triple net. The second one has 1,456 sq. ft. on the first floor, with a spacious waiting room and reception area, two bathrooms, with five examining rooms and consultation room. There is an area which was used for a full laboratory. The lease is not NNN. Please call Dr. Miranda about both units at 408/923-0257 for details.

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.

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

be qualified. No start ups. Contact Dr. Newman at 408/996-8717. Brokers welcome if you have a client. Compare with space by Good Sam at $3.50 sq. ft. Located at 1196 South De Anza at Rainbow.

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.

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.

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 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.

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. PAGE 32 | THE BULLETIN | MAY / JUNE 2010

MEDICAL OFFICE TO SHARE • SUNNYVALE One exam room plus one large office, shared waiting room and front office. Newly built, 1,280 sq. ft. Call 408/4381593.

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.

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.

DOWNTOWN MONTEREY OFFICE FOR SUBLEASE Spacious, recently remodeled, excellent parking, flexible terms. Call Molly at 831/644-9800.

MEDICAL/DENTAL CONDOMINIUMS FOR SALE OR LEASE Two-story, medical/dental condominiums for sale or lease located in Willow Glen. Beautiful building completely renovated and remodeled. Suites range from 1,376 sq. ft. to 6,000 sq. ft. or full building for 13,170 sq. ft. Elevator served. Plenty of on-site parking and great visibility. Call brokers to tour: Alice Teng at 408/2823808 or Steve Hunt at 408/282-3846.

MEDICAL OFFICE TO SHARE IN MEDICAL BUILDING OF O’CONNOR HOSPITAL One large exam room and one office, shared waiting room, and receptionist area. Email at minasehhat@yahoo.com.

Furniture Dining Room Table in Brazilian Rosewood (2 side/2 arm chairs/2 leaves), 64 x 41 x 28, Part of a set. Sideboard in Brazilian Rosewood, 75 x 19 x 30, Part of a set. Hutch in Brazilian Rosewood (Sliding Glass Doors), 70 x 14 1/2 x 33 1/2, $4,700.00 Sofa Table in Walnut, 47 1/2 x 16 x 25, $375.00 Drop Leaf Table in Walnut, 27 x 15 x 20 1/2, $350.00 Call Lee at 408/866-0558

MEDICAL/PROFESSIONAL OFFICE FOR LEASE Medical/Professional office 2,600 sq. ft, ground floor near Santana Row. $2.00 sq. ft. Available now. Email at sksiddiqui@ yahoo.com.

MEDICAL SUITE NEAR O’CONNOR 840 sq. ft. and 900 sq. ft. near O’Connor Hospital, Santana Row, and Valley Fair. Three operative rooms, private doctor office, reception area, waiting room, two bath, two entrances, modified gross lease, $2.00 sq. ft. Available immediately. Call 408/891-6453.

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

THREE OFFICES FOR SUBLEASE DOWNTOWN PALO ALTO Downtown Palo Alto: three consulting offices available now for FT/PT sublet. Beautifully remodeled building with charming ambience. Details and photos on Craigs list. Lytton at Kipling. Contact ebellows@idiom.com.

OFFICE SPACE NEEDED MD seeks office space for Quality Medical Evaluations on Saturday mornings, average once or twice a month, may be more frequent later. Please call 209/578-0476.

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

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.

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

PRIVATE PRACTICE FOR SALE Sports MemOrAbilia NAME & TITLE Joe Montana* Superbowl Legend: XVI-XIX-XXIII-XXIV

MEASUREMENT

PRICE

15 x 12

$495.00

Randall Cunningham* 13 x 24 Gameday 1992 Edition + Bonus Book Incl.

$250.00

Chicago Bulls, World Champions 1990-91, 1991-92, 1992-93

15 x 12

$175.00

Michael Jordan Retirement Photo & Program

8 3/4 x 11 1/4

$95.00

Michael Jordan, Blow up Card

10 x 11 1/2

$75.00

Joe DiMaggio*, Images of a Legend

12 x 15

$1,195.00

“The Kid”* meets “The Babe” 15 x 12 A young Ted Williams* meets George Herman “Babe” Ruth

$395.00

Pete Rose*, Hit King

12 x 15

$250.00

Nolan Ryan*, 27 Years of Excellence

15 x 12

$595.00

Players of the Decade, 1980’s Ltd. Edt. 12 x 15 $1,580.00 Nolan Ryan*, Joe Montana*, Larry Bird*, Wayne Gretsky* + Bonus Book Incl. Call Lee at 408/866-0558 PAGE 33 | THE BULLETIN | MAY / JUNE 2010

Primary care practice in Los Gatos. PPO and Medicare. No HMO. Available May 1, 2010. Call 408/398-2604.

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

Classifieds, from page 33

MEMBER SPOTLIGHT

contractor relationship. Please contact Dan R. Azar MD, MPH at 408/790-2907 or e-mail dazar@allianceoccmed.com for additional information.

UNUSUAL OPPORTUNITY ∙ MONTEREY COUNTY, CALIFORNIA Seeking experienced family/occupational medicine physician to practice family medicine, occupational medicine, and urgent care in custom built multispecialty clinic. EMR, digital x-ray, full medical lab. Excellent practice environment. Competitive pay with incentives. Please see our website: www.missioncenterhealth.com. Fax CV to Cynthia Martinez at 831/763-9901, or call 831/6788585, or email: cynymart@gmail.com.

condo/COTTAGE rentals OCEAN FRONT CONDO ON KONA COAST Beautiful setting on the big island of Hawaii. Sleeps four. Great views. Call 408/354-3253 for more info.

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. Price reduced to $785,000. Call 650/949-3353.

MEDICAL EXAM TABLES Hamilton exam table, $350. IE Industries power exam table, Model 110, $850. Contact Angie at 650/969-2116.

VOLUNTEER OPPORTUNITies MAKING A DIFFERENCE AT ROTACARE Rotacare in Mtn View is one of nine clinics in the Bay area serving uninsured patients. We have urgent need for more physicians and mid-level providers to provide care for adults and children. The clinic is held in the basement of YMCA building adjacent to El Camino Hospital in Mtn View. It is fully staffed with nurses, educators, translators, pharmacists, and other support staff. Malpractice insurance is covered by Rotacare. Hours of operation are Mon, Wed, Thurs evenings. Providers usually work 2.5 hours monthly, or according to availability. Specialists can see patients at Rotacare or arrange to have patients referred to their office. Our volunteers have found this a rewarding experience and a way to make a difference in our own community. For further information, please call Lila Steiner at 650/988-7948 or email Lila_Steiner@elcaminohospital.org.

Gus Garmel, MD Honored With National Award Gus Garmel, MD, SCCMA-CMA member since 1992, has been selected to receive the “PETER ROSEN AWARD” by the American Academy of Emergency Medicine. This national organization selects one academic emergency physician in the country who has made an outstanding contribution to AAEM in the area of academic leadership. Dr. Garmel is also a previous 2005 SCCMA award recipient of the “Outstanding Contribution in Medical Education” award. “I am very humbled by this award,” were words by Dr. Garmel. “It motivates me to work even harder for our residency program, its residents, our patients, and our medical center. I feel extremely fortunate to have the support of my physician colleagues at Kaiser Santa Clara and within our organization.” Congratulations, Dr. Garmel!

Corrections to 2010 Membership Directory

Listed below are changes/corrections to be made to your copy of the Directory. Please cut and paste the following additions into your SCCMA active member section of the directory. Allen McGrath, Jr, MD *IM CD U C School of Med–San Francisco 1946

340 Dardanelli Ln Ste 13 Los Gatos, CA 95032 408-379-8140 Fax: 408-370-0935

F Gilbert Gregory, MD *IM University of Rochester 1954

340 Dardanelli Ln Ste 13 Los Gatos, CA 95032 408-379-8140 Fax: 408-370-0935

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

Please delete the following address and phone number under Prisanna Krishnamshetty, MD’s listing:

3216 Cortona Drive San Jose, CA 95135 408-531-0892

PAGE 34 | THE BULLETIN | MAY / JUNE 2010

SCCMA ALLIANCE

SCCMA Alliance News (The Santa Clara County Medical Association Alliance is the philanthropic and volunteer arm of SCCMA that consists of physicians, physician spouses, students in training, and friends of medicine. Bettering the health in Santa Clara County is the main focus of the Alliance. In collaboration with other community groups, the Alliance provides health education, underwriting of projects, and legislative support for medical issues. To join, please visit the website at http://www.sccmaa. clubexpress.com. You will also find the most current updates and contact information on that site.) The current SCCMA project is a public information campaign titled, ”Not Even For a Minute.” Volunteers are creating and distributing 1,000 posters that remind drivers that it is unsafe to leave infants and children in a car alone. The posters have been prepared in three languages. The project is funded by grants provided through the SCCMA and the CMAA Foundation. The posters are

The California Medical Association Alliance held its annual session in Sacramento from April 29-May 1. William Lewis, MD, was honored as the SCCMAA Dedicated County Alliance Member at that meeting. CMAA President Debbi Ricks was also honored as she completed a two-year term as the CMAA president and is returning to work with the county organization as its membership chair. Grant proposals are still being accepted for county health programs. Any local health organization or project requesting funds of up to $1,000 may apply through contacting Alliance President Mary Hayashi at mjhayashi@msn.com or Jean Cassetta at jean@sccma.org. To learn more about the grant requirements and current projects, please visit the website at www.sccmaa.clubexpress.com.

SCCMA Alliance Events: May 10: SCCMA Alliance Luncheon Installation of officers for 20102011. The new officers are: Mary Hayashi, President; Debbi Ricks, Membership; Kathleen Miller, Secretary; Carolyn Miller, Treasurer; Meg Giberson, Legislation; Sally Normington, Health Projects; and Siggie Stillman, Webmaster. July 1: Registration begins for membership for 2010-2011. Registration is available online at www.sccmaa.clubexpress.com.

being distributed by Alliance volunteers in doctor’s offices, public health clinics, storefront windows, and school programs. Alliance volunteers are also spending one morning per month helping with the Food Basket Program in Santa Clara County. This program provides groceries for the county’s HIV/ AIDS population. Additionally, Alliance members visited Sacramento on April 27 to provide feedback to legislators regarding proposed and current medical legislation. Alliance volunteers have also supported the work of Stanford medical students and local physicians in their Saturday presentations to high school students who are exploring medical careers.

Mary Hayashi and Carolyn Miller help with the Food Basket Program PAGE 35 | THE BULLETIN | MAY / JUNE 2010

MEDICO NEWS

MEDICONEWS Lawmakers Working on a Five-Year Medicare Deal With the California Geographic Payment Fix While the House Democrats passed HR 3961 in November to repeal the SGR and replace it with a more stable payment system, the Senate has not been able to do likewise. Democratic leaders in the House and Senate are currently negotiating a five-year fix as part of a larger package of must-pass tax provisions in HR 4213, the so-called tax extenders bill. Although the details are still being hammered out, the deal will likely stop the projected 40% physician payment cuts (at a cost of $88.5 billion) over the next five years. The deal will also likely provide physician payment updates, although the exact amount of the updates is yet to be determined.

Because this is just a five-year fix, not a permanent repeal of the SGR, physicians could end up facing another significant cut in 2016. Lawmakers are aware of this eventuality and are currently discussing ways to minimize the 2016 cut. House and Senate leaders have already agreed to include a California geographic payment (GPCI) fix, which provides $300 million so that currently underpaid counties will be reimbursed based on more accurate geographic practice costs. Stay tuned for additional information as details of the agreement are finalized. (CMA Alert, May 17, 2010 issue)

Don’t Forget: FTC’s Red Flag Rules Take Effect June 1

The Federal Trade Commission will soon begin enforcing its new Red Flag Rule, which requires “creditors” — including many physicians — to develop and implement identity theft detection and prevention programs. The new regulations take effect on June 1.

For more information on the Red Flag Rule, see CMA’s Red Flag Rule toolkit and webinar, available free to members, at the members-only website, http://www.cmanet.org/member. Contact: Samantha Pellon, 916/551-2872 or spellon@cmanet. org. (CMA Alert, May 17, 2010 issue)

Physicians Can Now Claim Their Share of $350 Million UnitedHealth Settlement Physicians will soon be able to get their share of a $350 million settlement with UnitedHealth Group. The settlement is the result of a class action lawsuit, initially filed in 2000 by AMA and other health care provider and patient groups, alleging that United conspired to defraud consumers by manipulating out-of-network reimbursement rates and shortchanging physicians and patients by hundreds of millions of dollars over the past 15 years. Physicians will be paid based on their total “recognized loss” between 1994 and

2009, which is calculated based on the difference between a physician’s billed amount and the “allowed amount” that United actually paid for covered out-ofnetwork services. If the total amount of submitted claims exceeds the settlement fund, physicians will receive a pro rata share based on their total recognized loss. To help physicians understand the settlement and what they need to do to claim their share, CMA has created a settlement resource center at http://www.cmanet.org/ settlements. There you will find CMA’s PAGE 36 | THE BULLETIN | MAY / JUNE 2010

United Healthcare/Ingenix Settlement Guide, claim forms, and a number of other helpful resources. A hearing to determine final approval of the settlement is set for September 13 in U.S. District Court in New York. Doctors have until July 27 to file any objections to the settlement or opt-out. The deadline to submit claims for payment from the settlement fund is October 5. Contact: Samantha Pellon, 916/5512872 or spellon@cmanet.org. (CMA Alert, May 17, 2010 issue)

MEDICO NEWS

New Physician Signage Regs Take Effect June 27 California physicians will soon be required to inform their patients that they are licensed by the Medical Board of California, and to provide patients with the board’s contact information. Despite CMA objections, the Office of Administrative Law recently approved these regulations, which are intended to let consumers know where to go for information on or with complaints about California medical doctors. CMA believes these regulations are an unnecessary administrative burden, as state law already requires physicians to post their medical license or wear a name tag indicating their licensing status. The new regulations, which take effect June 27, 2010, require physicians to provide this notice by one of three methods: • Prominently posting a sign in an area of their offices that is conspicuous to patients, in at least 48-point type in Arial font.

•

Including the notice in a written statement, signed and dated by the patient or patient’s representative, and kept in that patient’s file, stating the patient understands the physician is licensed and regulated by the board. • Including the notice in a statement on letterhead, discharge instructions, or other document given to a patient or the patient’s representative; the notice must be placed immediately above the patient’s signature line in at least 14-point type. Regardless of which method you choose, the notice must read as follows: “NOTICE TO CONSUMERS: Medical doctors are licensed and regulated by the Medical Board of California, (800) 633-2322, www.mbc. ca.gov.” According to the medical board, physicians, not facilities, are responsible for compliance with this regulation. In group

settings, only one sign must be posted (should that option be chosen), but it must be posted in a location where it can be seen by all patients. Although CMA strongly supports patient access to information about a physician’s education, training, and other qualifications, we believe that it would be more useful to provide patients with specific information about the education and training of their physicians. To that end, CMA is cosponsoring a “truth in advertising” bill along with the California Society of Plastic Surgeons. Our bill would require all 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 a health care practitioner prior to receiving treatment. Contact: Yvonne Choong, 916/444-5532 or ychoong@cmanet.org. (CMA Alert, April 19, 2010 issue)

Medicare Changes Coming: Timely Claim Filing and Therapy Cap Exceptions Last month, President Obama signed into law the Patient Protection and Affordable Care Act (PPACA), which resulted in some important changes to Medicare rules. The Centers for Medicare and Medicaid Services (CMS) is announcing the changes that have the most immediate impact, and will continue to provide notice as implementation rules are developed. Following are two of the changes that have the most immediate impact on physicians: Time Limit for Submitting Claims Medicare fee-for-service claims with dates of service on or after January 1, 2010, must be submitted within one calendar year of the date of service. Claims with dates of service before October 1, 2009, must follow the pre-PPACA timely filing rules. Claims with dates of service from October 1, 2009, through December 31, 2009, must be submitted by December 31, 2010. Extension of Therapy Cap Exceptions Process The new law also extends the exceptions process for outpatient therapy caps through December 31, 2010. Under the exceptions process, which was originally enacted in 2006, Medicare will continue to pay for therapy services in excess of the cap if the services

DATE OF SERVICE

FILING DEADLINE

10/01/2008 to 09/30/2009

12/31/2010

10/01/2009 to 12/31/2009

12/31/2010

01/01/2010 and after

One year from date of service

are deemed to be medically necessary. Outpatient therapy service providers may continue to submit claims with the KX modifier, when an exception is appropriate, for services furnished from January 1, 2010, through December 31, 2010. The therapy caps were designed to put a limit on Medicare reimbursement for therapy services. In 2010, this limit is $1,860 for physical therapy and speech language pathology combined and $1,860 for occupational therapy. Deductible and coinsurance amounts applied to therapy services count toward the cap. CMA will provide additional updates as they become available. Contact: Michelle Kelly, 213/226-0338 or mkelly@cmanet.org.

PAGE 37 | THE BULLETIN | MAY / JUNE 2010

(CMA Alert, April 19, 2010 issue)

We fight frivolous claims. We smash shady litigants. We over-prepare, and our lawyers do, too. We defend your good name. We face every claim like it’s the heavyweight championship. We don’t give up. We are not just your insurer. We are your legal defense army. We are The Doctors Company.

The Doctors Company built its reputation on the aggressive defense of our member physicians’ good names and livelihoods. And we do it well: Over 82 percent of all malpractice cases against our members are won without a settlement or trial, and we win 87 percent of the cases that do go to court. So what do you get for your money? More than a fighting chance, for starters. 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 38 | THE BULLETIN | MAY / JUNE 2010

When was the last time a doctor came to YOU? Our program offers: • • • • •

Expert evaluation and treatment of patients with NYHA functional class III/IV heart failure and AHA/ACC stages C and D heart failure. Exceptional experience – with nearly 400 transplants and 200 ventricular assist device implantations since our program began. Access to the most current mechanical assist devices available: both short-term systems designed for treatment of cardiogenic shock and others designed for long-term left- and/or right-ventricular support. Urgent outpatient consultations and evaluations of your patients – within 48 hours. We can also accommodate same-day hospital transfers.

An experienced, highly-trained cardiac care team, comprised of Board certified, fellowship trained cardiologists, cardio vascular and thoracic surgeons, physician assistants, nurse coordinators, dieticians, licensed clinical social workers, psychiatrists, financial counselors and rehabilitation specialists.

At California Pacific Medical Center’s Heart Failure and Transplant Program we are committed to work-

ing with referring physicians to provide comprehensive patient care, focused on improved survival and quality of life for patients with advanced heart failure. We are heart failure cardiologist Ernest Haeusslein, M.D. and cardiothoracic surgeons James Avery, M.D. and Glen Egrie, M.D We would like to make

an appointment to see you in your office. Why?

We’d like the opportunity to acquaint you with our facilities, staff and advanced therapies, including destination therapy and “bridge to transplant.” We’d also like to review referral indicators to help identify your patients who may benefit from these advanced therapies.

To schedule our visit to your office – or to refer a patient: 415-600-1051

www.cpmc.org/services/heart

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Official magazine of the Santa Clara County Medical Association and the Monterey County Medical Society

700 Empey Way, San Jose, CA 95128-4705

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