2012 January/February

JANUARY / FEBRUARY 2012 | Volume 18 | Number 1

MANAGING PROFESSIONAL RISK

NOT ONLY CAN A DISABILITY SLOW YOUR PACE…

IT COULD ALSO STOP

YOUR INCOME. Studies show that 43% of people age 40 will suffer a long-term disability before they are 65 1 and one in seven workers are disabled for five years.2

If you suffer a disabling injury or illness and can’t continue working, do you have a reliable financial source to replace your income?

Santa Clara County Medical Association and Monterey County Medical Society members can turn to the sponsored Group Disability Income Insurance Plan for help.

This plan is designed to provide a monthly benefit up to $10,000 if you become Totally Disabled from practicing your medical speciality.

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Statistic attributed to Insurance Information Institute, for Loeb, Marshall. “Excessive or Necessity: Is Disability Insurance Worth the Price?”

MarketWatch, Viewed 4/9/11.

2 NationalAssociation of Insurance Commissioners (NAIC). Article found at http://articles.moneycentral.msn.com/Insurance/ InsuranceYourHealth/DisabilityInsuranceCanSaveYourLife.aspx. “Disability Insurance Can Save Your Life” Viewed 4/19/11 1

58097 (1/12) ©Seabury & Smith, Inc. 2012 777 South Figueroa Street, Los Angeles, CA 90017 800-842-3761 • CMACounty.Insurance@marsh.com • www.MarshAffinity.com

d/b/a in CA Seabury & Smith Insurance Program Management CA Ins. Lic. #0633005 • AR Ins. Lic. #245544 2 | THE BULLETIN | JANUARY / FEBRUARY 2012

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 Discounted Insurance Referral Services With

6

From the Editor’s Desk

7

Message From the SCCMA President

Joseph Andresen, MD William S. Lewis, MD

8 Upcoming CMA Webinars 10 Judge Blocks a 10% Reduction in Medi-Cal Reimbursement Rate 11 Obama Administration Rejects State’s Request to Impose Mandatory Co-Pays 12 High Risk Issues Associated With Lawsuits—And What to Do About Them

Karen K. Davis, NORCAL

Mary-Lynn Ryan, NORCAL

Representation

Mary-Lynn Ryan, NORCAL

Practice Management

Fran Cain, NORCAL

Michael Shea, MD

Seham El-Diwany, MD

Membership Directory/Website Membership Directory iAPP for the iPhone Legislative Advocacy/MICRA House of Delegates

Resources and Education Financial Services Professional Development Health Information Technology Resources Publications CME Tracking Physicians’ Confidential Line Verizon Discount Human Resources Services

15 Behavior That Undermines a Culture of Safety 16 Legislative Leadership Conference 17 CMA Leadership Academy 18 Making Changes to a Medical Record: Corrections vs. Alterations 19 WiFi: The Good, the Bad, the Ugly 20 Medical Times From the Past: Orificial Surgery 22 Medicare Part B 2012 Important Changes: What They Mean to Your Practice 24 Medication Optimization in the Management of Chronic Pain 26 Member Spotlight: Running For a Better Cure 27 30 32 38 41 42

CMA Foundation Resources Available Marsh Insurance Benefits MEDICO News Welcome New Members!

In Memoriam Classified Ads JANUARY / FEBRUARY 2012 | THE BULLETIN | 3

The Santa Clara County Medical Association Officers President William Lewis, MD President-Elect Rives Chalmers, MD Past President Thomas Dailey, MD VP-Community Health Cindy Russell, MD VP-External Affairs Howard Sutkin, MD VP-Member Services Scott Benninghoven, MD VP-Professional Conduct Eleanor Martinez, MD Secretary Sameer Awsare, MD Treasurer James Crotty, MD

Chief Executive Officer

Councilors

William C. Parrish, Jr.

El Camino Hospital of Los Gatos: Arthur Basham, MD El Camino Hospital: Lynn Gretkowski, MD Good Samaritan Hospital: Jeff Kaplan, MD Kaiser Foundation Hospital - San Jose: Seham El-Diwany, MD Kaiser Permanente Hospital: Anh Nguyen, MD O’Connor Hospital: Michael Charney, MD Regional Med. Center of San Jose: Richard Kline, MD Saint Louise Regional Hospital: Diane Sanchez, MD Stanford Hospital & Clinics: Peter Cassini, MD Santa Clara Valley Medical Center: John Siegel, MD

AMA Trustee - SCCMA James G. Hinsdale, MD Tanya W. Spirtos, MD (Alternate)

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

BULLETIN THE

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

Printed in U.S.A.

Editor

Joseph S. Andresen, MD

Managing Editor Pam Jensen

Opinions expressed by authors are their own, and not necessarily those of The Bulletin, SCCMA, or MCMS. The Bulletin reserves the right to edit all contributions for clarity and length, as well as to reject any material submitted in whole or in part. Acceptance of advertising in The Bulletin in no way constitutes approval or endorsement by SCCMA/MCMS of products or services advertised.

Address all editorial communication, reprint requests, and advertising to: Pam Jensen, Managing Editor 700 Empey Way San Jose, CA 95128 408/998-8850, ext. 3012 Fax: 408/289-1064 pjensen@sccma.org © Copyright 2012 by the Santa Clara County Medical Association.

4 | THE BULLETIN | JANUARY / FEBRUARY 2012

THE MONTEREY COUNTY MEDICAL SOCIETY OFFICERS President James Ramseur, Jr, MD President-Elect John Clark, MD Past President John Jameson, MD Secretary Eliot Light, MD Treasurer Steven Vetter, MD

CHIEF EXECUTIVE OFFICER William C. Parrish, Jr.

DIRECTORS Paul Anderson, MD

R. Kurt Lofgren, MD

Valerie Barnes, MD

Jeff Keating, MD

Ronald Fuerstner, MD

Kelly O'Keefe, MD

David Holley, MD

Patricia Ruckle, MD

AMA Trustee - mcms David Holley, MD

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FROM THE EDITOR’S DESK

Joseph Andresen, MD Editor, The Bulletin

Our Joint Voice and Advocacy Is Essential…

By Joseph Andresen, MD Mortgage back security defaults, home foreclosures, the stock market collapse, the European debt crises, and euro-zone uncertainty. We are all aware of these recent and ongoing financial troubles here and abroad.

While we know that there is clearly a widening gap between the very wealthy and the middle class, how have physicians fared through this turmoil?

On one hand, our profession has the unique position in our society of being indispensable. After years of education and training, our profession continues to be in high demand that will only increase with the needs of our aging baby boomer population.

However, there are some dark clouds that now threaten the job security and financial stability of the practice of medicine. A recent news story shows how more and more physicians are living on loans to keep their doors open to be able to continue seeing patients.

The graph above shows the 10-fold increase in debt assumed by physicians, over the past decade, needed to keep their medical practices afloat. These figures represent small business loans that totaled $60 million in 2000, and ballooned to $675 million ten years later. There are many reasons for this widening financial gap and growing financial liability among physicians. Increased overhead costs, lower reimbursement and non-payment from insurance payers, and large medical school educational loans are just a few of the reasons. This has hit the independent and solo practitioner the hardest and has been especially true for primary care practitioners who, on average, receive much lower compensation than specialists.

Our primary care colleagues are the backbone of medical practice.

We need their wisdom and guidance as our patients’ best advocates.

Navigating the complex medical forest, being the first line of healing while expediting needed referrals are all crucial responsibilities of family practitioners, internists, pediatricians, obstetricians, and many others who fulfill this role. Moreover, all of us have, at one time or another, 6 | THE BULLETIN | JANUARY / FEBRUARY 2012

given thought to who will be there when we may need their care? This is an alarm bell that we cannot ignore. We need more energetic and talented young graduates joining our primary care ranks. A viable financial model is the only way that this will occur. And it is clear that our joint voice and advocacy is essential in ensuring that the practice of medicine has a healthy and stable future.

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.

MESSAGE FROM THE SCCMA PRESIDENT

william s. lewis, MD President, Santa Clara County Medical Association

CMA v. Medi-Cal

By William S. Lewis, MD It’s an election year, and the candidates are preaching with platitudes-a-plenty. The other day, I heard former Senator Rick Santorum say that America is not an economic enterprise, but a moral enterprise. Oh, really? Because judging from our experience with Medi-Cal, it seems quite the opposite.

But then, talk is cheap, and so too are federal codes, apparently. Did you know that Medi-Cal must “assure that payments are consistent with efficiency, economy, and quality of care and are sufficient to enlist enough providers so that care and services are available under the plan at least to the extent that such care and services are available to the general population?” Surprised? You ought to be, given how far reality falls short of this lofty statute.

The facts speak for themselves. California has the lowest per capita spending on Medicaid patients in the nation, 39% below the national average; and California ranks the 47th lowest amongst all states in physician reimbursement. As a result, 25% of California physicians are caring for over 80% of all Medi-Cal patients. Half of all Medi-Cal patients say they cannot get timely appointments, and 60% say they could only see a specialist if they went to the emergency room. Is it any wonder that Medi-Cal patients report recent visits to the emergency room at over twice the rate of Medicare or privately insured patients?

The California Medical Association has used the equal access statute to fight proposed cuts to Medi-Cal. In 2003, in response to a 5% cut in Medi-Cal, the CMA sued the state and won an injunction in federal district court. On appeal, the 9th Circuit agreed that reimbursement was inadequate, but reversed the lower

court’s ruling on the basis that Medi-Cal beneficiaries have no “private right of action” to enforce Medicaid’s equal access statute. This decision was contrary to many previous district and circuit court decisions, and it threatened to turn the clock back forty years on health care accessibility for the poor. Fortunately, the CMA was able to reverse the cuts through legislative action.

In 2008 and 2009, the legislature passed additional Medi-Cal cuts. The CMA sued again and won an injunction in federal district court. On appeal, this time the 9th Circuit affirmed the injunction on the basis of the “Supremacy Clause” of the Constitution, which obviated the need for a “private right of action.” This decision required reimbursement

after all. Those arguments were heard this past October, and a decision is expected by June.

Now, the future of Medicaid rests in the hands of nine justices wrestling over legal minutia.

Hopefully, for inspiration they will look to the Department of Justice’s own website, which prominently displays the above epigraph. With this mind, it’s hard to accept how “the people” have no right to legal recourse.

The stakes are huge. Medi-Cal patients account for a staggering 29% of California’s population. Under current federal health care reform, three million additional Medi-Cal patients will be added by 2014. That amounts to 38% of all Californians. Who will see them?

Well, if reimbursement doesn’t improve, the answer will be the same as it is now: practically no one. Medi-Cal waiting times will mushroom and emergency rooms will be perpetually flooded. That’s no way to run a program dedicated to providing equal access to health care. It’s neither efficient nor economic. Worst of all, it leads to poor outcomes. What happened to our “moral enterprise?” If only it were true.

But there may still be hope. Perhaps the Supreme Court Justices have been listening to Senator Santorum.

“The common law derives from the will of mankind, issuing from the life of the people, framed by mutual confidence, and sanctioned by the light of reason.”

Hartley Burr Alexander sufficient to achieve equal access to medical care with private insurance, and it expected rates to be reasonably related to costs. The state appealed to the U.S. Supreme Court, but the Supreme Court declined to hear the case.

This was a historic victory for the CMA over Medi-Cal. Game over. Thank you very much.

But wait. Two years later, at the urging of the Department of Justice, the Supreme Court changed its mind and decided to take the case

William S. Lewis, MD, is the 2011-2012 President of the Santa Clara County Medical Association. He is a board certified ENT physician and is currently practicing in the Los Gatos area.

JANUARY / FEBRUARY 2012 | THE BULLETIN | 7

CMA Center for Economic Services Upcoming Webinars Please note that this calendar does not include CMA’s ICD-­‐10 training courses to be offered in 2012.

March 7: Managing Difficult Employees and Reducing Conflict in the Practice Debra Phairas • 12:15 – 1:15 p.m.

March 21: HIPAA Update 2012 David Ginsberg • 12:15 – 1:15 p.m.

April 4: A Guide to Managing Upset and/or Difficult Patients Debra Phairas • 12:15 – 1:15 p.m.

April 18: Best Practices for Managing Your Accounts Receivable Mary Jean Sage • 12:15 – 1:15 p.m.

May 2: Medicare: Top 10 Claim and Documentation Errors That Cost Your Practice Money Kevin Garrick • 12:15 – 1:15 p.m.

May 16: Telephone Etiquette for Medical Personnel Mary Jean Sage • 12:15 – 1:15 p.m.

June 6: A Manager’s Guide to Lowering Practice Costs Debra Phairas • 12:15 – 1:15 p.m.

June 20: Writing Effective Appeals Mary Jean Sage • 12:15 – 1:15 p.m.

July 18: Preparing for a Medicare and/or Medi-­‐Cal Audit Mary Jean Sage • 12:15 – 1:15 p.m.

Aug. 1: Coding for Medical Necessity Arthur Lurvey, M.D. • 12:15 – 1:15 p.m.

Aug. 15: Program Integrity in Medicare and Medi-­‐Cal – The Physician’s Role Bruce Tarzy, M.D. • 12:15 – 1:15 p.m.

Sept. 5: A Guide to Reviewing Payor Contracts Kris Marck • 12:15 – 1:15 p.m.

Sept. 19: Creating and Implementing Financial and Office Policies Debra Phairas • 12:15 – 1:15 p.m.

Oct. 3: Protect Your Practice From Payor Abuse Mark Lane • 12:15 – 1:15 p.m.

Oct. 17: Establishing Expectations for High Performance From Medical Staff Debra Phairas • 12:15 – 1:15 p.m.

Nov. 7: Understanding ARC and CARC Revenue Codes David Ginsberg • 12:15 – 1:15 p.m.

The above webinars are being hosted by the California Medical Association. Please v isit www.cmanet.org/events for forthcoming registration information. Once your registration has been approved, you will be sent an email confirmation with details on how to join the webinar.

Webinars are FREE for CMA members, $99 for non-­‐members.

Questions? Call the CMA Member Help Center at 800/786.4262.

Please note: this calendar is subject to change. Visit www.cmanet.org/events for updates.

8 | THE BULLETIN | JANUARY / FEBRUARY 2012

•

TA CLARA SAN

C AL

IAT SSOC ION • LA

Y MEDIC UNT A O C

IF O R N IA Serving Physicians Since 1876

“My Membership provides me a Voice in Sacramento and Washington DC.” William S. Lewis, MD

Santa Clara County Medical Association, Monterey County Medical Society, and CMA Members Enjoy: Vast CMA Resources: • • • • • • •

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

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

Santa Clara County Medical Association and Monterey County Medical Society Resources: • • • • • • • • • • •

Annual Directory CMA Member Seminars Cost-Saving Benefits Bi-Monthly Publication Website/Online Resources Insurance Savings Alliance Membership Annual Social Events Patient Referrals Practice Resources Reimbursement Advocacy

Federal, State, and Local Advocacy:

Your dues are an investment which supports our efforts in protecting your rights.

If We Don’t Fight for You… Who Will?

Phone: (408) 998-8850 or (831) 455-1008 www.sccma-mcms.org JANUARY / FEBRUARY 2012 | THE BULLETIN | 9

LEGISLATIVE UPDATE

Medi-Cal Update Judge Blocks a 10% Reduction In Medi-Cal Reimbursement Rate On Tuesday, February 1, 2012, U.S. District Court Judge Christina Snyder issued a final order enjoining the State of California from implementing a 10% cut to the Medi-Cal reimbursement rate.

Last spring, the California Legislature passed and Governor Jerry Brown signed Assembly Bill 97, which authorized up to a 10% Medi- Cal reimbursement rate cut for physicians, hospitals, dentists, pharmacists, and other Medi-Cal providers. Federal approval was required before the state could implement its proposed cuts. The Centers for Medicare & Medicaid Services (CMS) approved the state plan amendment in December 2011.

The California Medical Association (CMA), California Dental Association, California Pharmacists Association, National Association of Chain Drug Stores, California Association of Medical Product Suppliers, AIDS Healthcare Foundation, and American Medical Response filed the lawsuit against the U.S. Department of Health and Human Services and the California Department of Health Care Services in November 2011, with financial support from the California Academy of Family Physicians and the Osteopathic Physicians & Surgeons of California.

The organizations argued that if the cuts went through, access to care for Medi-Cal patients would be eroded or cut off completely.

“This is tremendous news for the future of medicine,” said James T. Hay, MD, CMA President. “Judge Snyder’s prompt issuance of today’s ruling is evidence of the important nature of this case. The state’s repeat-

10 | THE BULLETIN | JANUARY / FEBRUARY 2012

ed attempts to slash Medi-Cal reimbursements have been halted, once again. Rather than focusing on Medi-Cal cuts as a short-term budget solution, we should be working together to find long-term solutions; our hope is that we can now move forward with those discussions.”

CMA believes that the information supplied by the state to CMS did not measure whether and how a patient’s access to care would be impacted or otherwise take into consideration, as required by law, the costs to provide the care.

Because California’s Medi-Cal rates are already extremely low and many prescription medications are reimbursed at breakeven rates, many providers cannot afford to participate in the Medi-Cal program as it stands today. A further reduction in the reimbursement rate would further decrease provider participation in the program. Kaiser State Health Facts lists California as the lowest reimbursed state in the nation (http:// www.statehealthfacts.org/comparetable.jsp?typ=4&ind=183&cat=4&su b=47&sortc=5&o=a).

(CMA Alert, February 6, 2012 issue)

LEGISLATIVE UPDATE

Obama Administration Rejects State’s Request to Impose Mandatory Co-Pays The Centers for Medicare & Medicaid Services (CMS) rejected the state’s request to impose mandatory co-payments for Medi-Cal patients. The co-pays, which would have included physician office and clinic visits ($5), emergency room (ER) visits ($50), and inpatient hospital stays ($100 per day up to a $200 maximum), was another attempt by the state to balance to budget by slashing Medi-Cal. “The Obama Administration has made the right decision. By federal law and our own ethics, physicians must treat patients that come to the ER, regardless of ability to pay. Imposing a mandatory co-payment would have done nothing to address costs or improve patient care. We are pleased that CMS understands that and has rejected the proposal,” James T. Hay, MD, President, California Medical Association said.

Medi-Cal payment rates are grossly inequitable for emergency care as is, and the proposed copayments exceeded the limits allowed by federal law for Medicaid cost sharing. The copayments would have exceeded federal maximums, particularly for non-emergency use of the Emergency Department.

“These co-payments would for all intents and purposes be uncollectable and would have made it even harder for Medi-Cal patients to gain access to the care and medication they need,” Dr. Hay added.

Often, copayments discourage low-income families from filling prescriptions for themselves or their children because they can’t afford it. When patients fail to take their prescription medications correctly, or stop taking their medications altogether, this seriously undermines their quality of life, quality of care, health care outcomes and the value of health care dollars spent.

The rejection comes just days after Federal Judge Christina Snyder issued her final ruling in CMA et al v.

Douglas. Her decision blocked the state from imposing a 10% reimbursement rate reduction to Medi-Cal physicians.

The Obama Administration has made the right decision.

By federal law and our own ethics, physicians must treat patients that come to the ER, regardless of ability to pay.

JANUARY / FEBRUARY 2012 | THE BULLETIN | 11

By Karen K. Davis, MA, CPHRM NORCAL Mutual, a member of the NORCAL Group What are some of the riskiest areas associated with practicing medicine day-to-day? They may be more commonplace than you think, and some may be easier to guard against than you imagine.

Since issuing its first policy in 1975, NORCAL Mutual Insurance Company has grown from insuring a few hundred physicians in Northern California to serving over 20,000 physicians, medical groups, clinics, hospitals, and ancillary health care facilities in California, Alaska, and Rhode Island. The company has also evolved into the NORCAL Group, a group of malpractice insurance companies with policyholders in many states across the United States. NORCAL Group companies’ policyholders have access to a wide range of risk management resources designed to help physicians and health care facilities identify risks and reduce the chances of incurring medical malpractice lawsuits.

To discover trends in professional liability, NORCAL Group relies on its extensive database of closed-claims information. NORCAL Group also produces reports compiled from facts garnered during on-site risk assessments. Analyzing statistics from these two sources can give a credible picture of the types of situations and actions that most often lead to litigation for physicians, medical groups, and hospitals.

The Claims Perspective

NORCAL Group’s closed-claims database can distinguish various nonclinical issues (that is, problems in processes or communication) that are associated with lawsuits. These associated issues have often complicated the defense of allegations made against doctors and health care facilities. Closed-claims data for all NORCAL Group companies’ policyholders for the past two years (July 2009 through June 2011) show the top ten associated issues causing difficulties in claims were: 1. Problem with history, examination, or work-up.

2. Error associated with interpretation or communication of radiology results.

3. Communication problem between health care providers.

12 | THE BULLETIN | JANUARY / FEBRUARY 2012

4. Comorbid issues (comorbidities complicated treatment of patients).

5. Informed consent issues.

6. Problem with medical records.

7. Failure to follow-up on tests.

8. Vicarious liability.

9. Problem with a medical or surgical device.

10. Inadequate facility or equipment.

The Perspective From the Field

As a service to policyholders, NORCAL Group companies send risk management specialists to perform on-site visits to identify risk issues in physicians’ offices and hospitals. The specialists produce reports that recommend strategies for reducing the specific risks found. In September 2011, NORCAL Group studied aggregate data from a subset of 175 risk assessments conducted in the last two years (between July 2009 and June 2011). The top 10 risk issues revealed in this study were linked to: 1. Handling of after-hours telephone calls (including documentation and communication with covering physicians).

2. Distribution of sample medications.

3. Reporting test and consult results to patients.

4. Use of therapeutic agreements with chronic pain patients.

5. Follow-up processes after hospital discharge.

6. Follow-up processes for return office visits.

7. Documentation of allergies.

8. Making corrections in medical records.

9. Legibility of documentation.

10. Authentication of medical record entries.

Looking for the Overlap

While the issues from the field are more specific than those on the closed-claims list, there is a revealing overlap. By looking at the lists closely, we can identify four main areas in which physicians are likely to significantly lower their risk levels, if they implement effective risk management strategies. Those areas are: 1. Management of follow-up processes.

2. Generation of documentation.

3. Management of medications.

4. Communication with other health care providers.

The remainder of this article will offer tips to help you and your staff members evaluate and decrease your liability exposure related to these four key areas.

Management of Follow-up Processes

include not only a method for confirming that you received the test results, but also a process for ensuring that you reviewed the results. The review should be timely. A test result should never be filed until you (as the ordering physician) have personally reviewed, dated, and initialed it.

• Institute the policy of notifying all patients of all test results (rather than just reporting abnormals).

Continued on page 14

Follow-up systems are important because physicians have a responsibility to ensure that patients are informed about their conditions and get needed care. Here are some strategies for evaluating and honing your follow-up system.

• When patients are sent for testing, three areas of concern are: Did the patient comply with the recommendation for testing? Were test results received and reviewed by the ordering physician?

Was the patient notified about the results? An appropriate follow-up system provides answers to these questions.

• Double-check your method for monitoring compliance with appointments. There should be some mechanism in place that requires licensed personnel in the practice to review all no-show appointments to determine which patients must be called and rescheduled.

• Don’t make the patient solely responsible for making appointments for tests or for calling the office to obtain results; assist them.

• Your follow-up system for diagnostic tests should

JANUARY / FEBRUARY 2012 | THE BULLETIN | 13

High Risk Issues Associated With Lawsuits, from page 13 Generation of Documentation

The purpose of the medical record is to communicate internally and externally about a patient’s health. In addition, in a medical malpractice lawsuit, the patient’s record will be used as evidence.

• Each patient’s chart should be an accurate account of the patient’s history and complaints, physical findings, diagnostic tests, diagnoses, and medical care and treatment. Whether a record is paper-based or electronic, the documentation in it should show the patient’s active problems, data analyzed to understand the problems, and plans for further investigating and handling of the problems.

• If you are handwriting medical record documentation, you should assess your entries to ensure that they are easy to read. If your notes are not clearly legible, you should consider methods to improve the notes, such as printing, dictation, or typing your notes into a computer-based medical record.

• If you choose to use dictation, you should read all the typed notes to make certain the transcriptionist has accurately recorded the information before you sign and date the notes.

• Allergy documentation is harder to miss if it is consolidated in a single area of the record. If the patient reports no allergies, the phrase “no known allergies” or the initials “NKA” should be written or typed in the area designated for documentation of allergies.

• After conducting an informed-consent discussion with a patient, ensure that there is confirmation of the consent process in the medical record, including a consent form signed by the patient and a description of the content of the informedconsent discussion in the progress or pre-procedure notes.

• Telephone contacts should be documented in the medical record, including calls taken after hours. Information from after-hours calls should be incorporated into the medical record as soon as possible.

• If there is a mistake in the record, you should correct it by drawing a thin line through the inaccurate words. The original entry should still be readable. Then write the correction clearly and legibly nearby, and initial, date, and time it. Never erase, white-out, or otherwise obliterate any entry in the medical record. Electronic health records should not allow you to delete any previously entered material. Instead, they should have methods for correcting prior entries that preserve the original notes.

• Once you are notified about a potential liability claim, you should not change, add to, or in any way revise a medical record.

Management of Medications

The main medication management issues that have been discovered in office assessments have to do with distribution of sample drugs and establishment of pain management contracts. Some tips in these two areas follow: • You may lower your liability risk if the sample medications in your office are well controlled. Sample medications should be locked in a cabinet or closet. Limit access to samples by designating specific staff to organize and maintain the sample closet. Do not allow pharmaceutical representatives or other unauthorized people access to the sample closet. Document all dispensed samples in the appropriate patient’s medical record.

14 | THE BULLETIN | JANUARY / FEBRUARY 2012

• When you give out samples, labeling them with specific information, including name and quantity of medication, name of manufacturer, physician name and address, patient name, date, and instructions for use, will reduce the risk that a patient will make a self-administration error. You can create label templates and fill in the appropriate information before applying a label to a sample box.

• When you are treating chronic pain patients with opioids, consider setting up written pain medication agreements with these patients. Such agreements can help you and the patient define and agree on appropriate behavior and hinder addicts from obtaining an unlimited supply of medication.

Communication With Other Health Care Providers

Gaps in communication between treating physicians can cause problems that jeopardize a patient’s well-being and provide the impetus for litigation. Here are some suggestions for remaining aware of a patient’s situation when you are sharing that patient’s care with a colleague.

• If you refer patients to other physicians, have some mechanism in place to see that your referral recommendations are carried out and that the patient was seen by the consultant (or another physician of the patient’s choice). Your follow-up mechanism for referrals should also track your receipt and review of the consulting physician’s report.

• Communicate in writing with the consultant about the specific consultation request you are making. Preparing a fact sheet with the patient’s clinical information and your impression is an effective way to convey the significant details to another physician.

• After a patient is seen by a consultant, there must be a clear understanding about who will be responsible for what aspects of the patient’s care and who will order further testing and consultations if these are necessary.

• If you are a consultant, communicate urgent or significant findings directly to the referring physician and be sure that you both know who will provide clinical follow-up. The communication should be done by phone and in writing.

Conclusion

Most of the risk management recommendations in this article are not expensive or hard to put in place. Most focus on setting up systems or protocols and then adhering to them. Taking some time to appraise and strengthen vulnerabilities in your practice or facility will help protect patients and may keep you from a malpractice suit or help you defend against one. NORCAL Group risk management specialists are always ready to help policyholders with risk issues and to support practice changes that lower risk and improve patient safety.

Karen K. Davis, MA, CPHRM, is a Risk Management Project Manager with the NORCAL Group, which includes NORCAL Mutual Insurance Company, San Francisco, CA; PMSLIC Insurance Company, Mechanicsburg, PA; and Medicus Insurance Company, Austin, TX. Copyright 2011 NORCAL Mutual Insurance Company. All rights reserved.

MANAGING PROFESSIONAL RISK

Behavior That Undermines a Culture of Safety

By Mary-Lynn Ryan, Risk Management NORCAL Mutual Insurance Company and the NORCAL Group Disruptive behavior by professionals in health care settings is well documented as a threat to quality care and patient safety. Managing disruptive behavior requires a coordinated effort based on a written policy and established procedures that cover reporting, confrontation, documentation, response, outside consultation, reprimand, follow-up, and monitoring, as well as support for subject physicians.

Although there is no universally-accepted definition of disruptive behavior, the American Medical Association (AMA) defines it as “personal conduct, whether verbal or physical, that affects or that potentially may affect patient care negatively.” It also includes “conduct that interferes with one’s ability to work with other members of the health care team.”1 Everyone who behaves inappropriately should be treated in the same manner, including excellent practitioners.2 This expectation should be clear in the policy.

All members of the health care team should be aware of the policy and the definitions of disruptive behavior it contains. Leaders who are expected to enforce the policy should be trained in the process for addressing disruptive behavior, as well as the legal ramifications of limiting a practitioner’s practice and the legal protections available to both parties in such an action.1 One goal of a disruptive-behavior policy is to create a safe and supportive environment where everyone knows what is reportable and feels empowered to make a report. Research indicates that many instances of disruptive behaviors are not reported because the wouldbe reporter is afraid of reprisal.3 To address this issue, the Joint Commission recommends making the process confidential and including non-retaliation clauses in the policy. Interviewing reporters in confidence assures them that their reports are being taken seriously.4 A history of delayed or hesitant respons-

es to disruptive behavior can discourage staff from reporting such behavior in the future.

Therefore, it is important to investigate and intervene as quickly as possible. Prompt response reassures witnesses and reporters that the problem is being addressed pursuant to the policy.

When the decision has been made to perform an “intervention,” the designated team should plan every step (even rehearsing, if necessary), taking into consideration the effects and consequences of planned actions. The planning, goals, and outcomes of an intervention should be carefully documented. If necessary, the resulting report can serve as evidence that the reported practitioner received due process.

An initial intervention, without follow-up, will generally not put an end to disruptive behavior, which tends to be triggered by ongoing circumstances in the health care environment (e.g., lack of equipment, understaffing, fatigue, or practitioner health issues). A reported provider should understand that he or she is being monitored for compliance.3 Treat the reported behavior as a problem with the physician’s behavior, not with the physician. In other words, the physician should not be labeled a “disruptive physician.”4 When it is too difficult to conduct an objective assessment in-house, an outside evaluation can assure the involved parties of the process’s fairness and objectivity. In some cases, the most prudent course will be to involve legal counsel for guidance.4 Disruptive behavior compromises patient care and increases professional liability risk. Although disciplining a health care provider for disruptive behavior can be difficult for a variety of reasons, it must be done in a timely, organized, and fair manner. Individual practitioners who struggle with anger/frustration management must also take responsibility for their disruptive behavior and seek help.

To create a culture of safety for patients and a supportive and productive environment for all members of the health care team, practitioners, Medical Executive Committee (MEC)

members, and administrators are encouraged to consider the risk-management recommendations offered in this article.

It should be noted that in many states (including California), disciplinary actions based on physician conduct are reserved exclusively to the medical staff, not hospital administration.5 1. AMA. Model Medical Staff Code of Conduct. Available on the AMA website at: www.ama.assn. org/amal/pub/upload/mm/21/ medicalstaffcodeofconduct. pdf (accessed 1/21/2010).

2. ECRI. Healthcare Risk Control.

Executive Summary. Medical Staff 8.

Supplement A. March 2009 Disruptive Practitioner Behavior.

3. Weber, DO. Poll results: Doctors’ disruptive behavior disturbs physician leaders. The Physician Executive 2004: 30 (4) 6·14. (2004). Available on the ACPE website at http://net. acpe.orglresources/publications/ On TargetDisruptivePhysician.pdf (accessed 1/18/2010).

4. Joint Commission. Sentinel Event Alert. Issue 40, July 9, 2008.

Behaviors that undermine a culture of safety. Available on the Joint Commission website at: http://www. jointcommission.org/SentineIEvents/ Sentineleventalert/sea40.htm (accessed 1/21/2010).

5. California Medical Association (CMA). Disruptive Behavior Involving Members of the Medical Staff. CMA On-Call Document #1241.

January 2009. Available on the CMA website at www.cmanet.org (accessed 1/21/2010).

Managing Professional Risk is a quarterly feature of NORCAL Mutual Insurance Company and the NORCAL Group. More information on this topic, with continuing medical education (CME) credit, is available to NORCAL Mutual insureds. To learn more, visit www.norcalmutual.com/ cme.

JANUARY / FEBRUARY 2012 | THE BULLETIN | 15

SAVE THE DATE! April 17, 2012 CALIFORNIA MEDICAL ASSOCIATION 38th ANNUAL LEGISLATIVE LEADERSHIP CONFERENCE April 17, 2012 • Sacramento Convention Center • 9:30 am - 5:00 pm

Keynote Address by Attorney General Kamala Harris Meet with legislators and their staff at the Capitol

Visit CMA’s Health Fair on the North Steps of the Capitol run by UC Davis Medical Students.

Register today for your chance to win a new iPad at www.cmanet.org!

Please check with your county medical society before making travel arrangements or making appointments with legislators.

For more information, please contact Nicole Madani at 916.444.5532 or visit www.cmanet.org.

16 | THE BULLETIN | JANUARY / FEBRUARY 2012

The clock is running on implementation of federal health reform. Health care providers and payers are jockeying to position themselves for the impending changes in health care coverage, delivery and reimbursement. Who will survive the demands of the new marketplace? Who will prosper?

15th Annual California Health Care Leadership Academy

Follow the Money…

The Transformation of Medical Practice April 27-29, 2012 • Disneyland Hotel • Anaheim, California

Featured speakers include: • John Chiang, California State Controller • Peter V. Lee, Executive Director, California Health Benefit Exchange Workshops include

Multiple Registration & Early-Bird Discounts

• Roadmap to Optimize Practice Revenue • Practice Acquisition: Strategies for Success • Managing Employment Risk in Turbulent Times • Managing Change Strategically and Effectively • Using and Integrating ICD-10 into Your Practice • Health Policy Advocacy in the Political Arena

Save up to $200 per person Register by March 30

• Communication and Interpersonal Collaboration

To Register, call 800.795.2262 or visit caleadershipacademy.com.

JANUARY / FEBRUARY 2012 | THE BULLETIN | 17

MANAGING PROFESSIONAL RISK

Making Changes to a Medical Record: Corrections vs. Alterations

By Mary-Lynn Ryan, Risk Management NORCAL Mutual Insurance Company and the NORCAL Group Appropriate, consistent, and accurate medical record documentation promotes quality patient care by providing a comprehensive patient history and facilitating continuity of care among different members of the health care team. The medical record is also the best evidence of care provided, should that care ever be questioned in medical liability litigation. Physicians can preserve the medical record’s effectiveness as a patient care tool and as a defense tool by resisting the temptation to inappropriately change the record. Whereas appropriately executed corrections are a relatively benign aspect of documentation, medical record alterations can cast doubt on the physician’s credibility and make an otherwise defensible case one that has to be settled.

Defining Alterations: When a physician receives notice of a lawsuit and goes back to the medical record to “clarify” certain points for the purpose of aiding the defense of the claim, it is an alteration. Medical record alterations are considered a deliberate misrepresentation of facts. When an alteration is discovered during medical liability litigation, it seriously impacts the ability to defend the claim. Additionally, many medical liability policies exclude coverage for claims in which the medical record was altered, which means the physician may end up paying for a judgment and defense costs out of pocket.

Defining Corrections: When a physician changes a patient’s medical record during the normal course of treatment, before the issue of a claim or lawsuit arises, it is a correction. Cor-

rections are acceptable, provided the changes are made appropriately.

Tips for Appropriate Medical Record Correction

• Develop a medical records correction policy that incorporates the following recommendations: ◆◆ Mark the original (erroneous) entry through with a single line.

Do not obscure the entry with correction fluid or ink. Do not attempt to write the intended number or word on top of the erroneous one(s) (i.e., “write over”). ◆◆ Sign, date, and time the new (correct) entry. Never “back date” an entry to the medical record. ◆◆ If appropriate, direct the reader’s attention from the original, erroneous entry to the corrected entry, especially if it is not readily apparent that the subsequent entry is a correction. ◆◆ After a corrected entry has been added, never physically remove or erase an erroneous entry from the patient’s chart. The earlier (erroneous) entry may have been relied upon by other members of the health care team. To physically remove it would, therefore, falsely represent the integrity of the record.

• Develop policies and procedures that address making an addendum (or late entry). Write a note as an addendum if there is a need to write an entry in the record that is not contemporaneous

18 | THE BULLETIN | JANUARY / FEBRUARY 2012

with the finding or treatment being described. Place this addendum entry chronologically in the record, based on when it is being entered in the record. At the beginning of the addendum, explain to what the addendum refers. Sign, date, and time the addendum entry.

ELECTRONIC HEALTH RECORDS

Users of electronic health record (EHR) systems should not be able to make changes to a computerized record indiscriminately or anonymously. When medical practices select an EHR system, they should ensure that once information is entered, it cannot be removed.

Although many software vendors claim that information cannot be removed or altered, practices should perform due diligence to confirm vendors’ security claims. In a properly functioning EHR system, any changes to the medical record must be made as addendums and dated appropriately, so that later they cannot be construed as alterations.

CONCLUSION

Physicians should never place themselves in the position of having to defend a medical record alteration. There is almost always a price to pay, and the price can be high.

Managing Professional Risk is a quarterly feature of NORCAL Mutual Insurance Company and the NORCAL Group. More information on this topic, with continuing medical education (CME) credit, is available to NORCAL Mutual insureds. To learn more, visit www.norcalmutual.com/ cme.

MANAGING PROFESSIONAL RISK

WiFi: The Good, the Bad, the Ugly Factors to consider before setting up a WiFi network in your office

By Fran Cain, Information Technology Department NORCAL Mutual Insurance Company and the NORCAL Group Have you considered introducing a wireless network to your practice? Commonly known as WiFi, wireless access to the Internet may be a boon for tech-savvy, iPad-toting patients waiting to be seen. Office staff may also benefit from a WiFi network. But before you install that wireless access point, or even if you already have, there are some risks to take into account.

THE GOOD:

WiFi Is a Great Tool With WiFi, it becomes possible for physicians and other health care providers to operate a laptop or mobile device, such as an iPad or smart phone, from many locations without needing ethernet cables. The result is untethered freedom to access the Internet or local network. In the home or office, it is inexpensive and easy to set up.

WiFi is becoming a standard for Internet access at coffee shops, parks, hotels, and airports. Public areas with WiFi are known as hotspots. WiFi is fast compared to the stodgy cellular network. Your smartphone or iPad can tap into the home or office wireless router, or a local hotspot, to increase the speed of Internet browsing. WiFi is also convenient because most laptops and mobile devices, smartphones, and even printers, come pre-equipped with wireless cards.

In the home or office, Internet service from a provider such as Comcast or AT&T is required for Internet access. But there is no extra charge for adding WiFi beyond the purchase price of the router.· Coffee shops and airports with hotspots may charge for WiFi access. Simply enter a credit card number at the prompt, to log on for a specified time period, usually an hour or a day.

it’s possible. A hacker could make private, sensitive, or legally protected information public, in the way the hackers known as Anonymous published confidential government papers. Or they can plant a key logger to collect keystrokes, transmit them to an overseas collection center, and pick out names, passwords, birth dates, and credit card numbers. The data collected could then be used for identity theft against you, your employees, your patients, or other associates, when sensitive information is shared electronically.

Eavesdropping is one example of a common hack. It could happen at the airport, when you log on and someone sitting near you has tools to view your data. Even at home, a neighbor can access your data, if your router is not secured.

What You Need to Know to Protect Yourself and Your Patients In short, start with the assumption that all WiFi connections are insecure. If you are using a public WiFi hotspot, avoid transmitting confidential data – such as protected patient information or credit card or Social Security numbers – across the Internet via a browser, unless you are sure the website uses SSL, a secure tunnel that is established to encrypt data as it travels across the Internet.

Always type the address to a website yourself, instead of clicking on a link from another web page or from within an email message. If you have a device such as an iPad or iPhone that supports SSL for email, be sure SSL is enabled in the device’s settings.

“With WiFi, it is possible to operate a laptop or mobile device, such as an iPad or smart phone, from many locations without needing Ethernet cables.”

THE BAD:

WiFi Can Be Risky Hotspots are generally not encrypted. While connected to an unencrypted hotspot, your laptop or mobile device becomes relatively easy to hack; therefore, protected health information and personal health records stored on the hard drive or transmitted over the WiFi connection can be accessed by intruders, as can such information as your credit card number. Similarly, WiFi in the home or office network, that’s not properly configured, renders computers vulnerable to hacking and viruses.

THE UGLY:

What Can Happen if You Are Compromised Free hacking tools are readily available to anyone desiring to compromise a WiFi connection. An ingenious hacker who has gained access to your computer might insert viruses such as Trojans just because

Best Practices for Securing Data Whether or not you use WiFi, there are best practices for securing data: • In the office, institute formal written security policies on how employees should handle protected health information. Be sure to update these policies annually or more often.

• Invest in security systems to monitor logs from firewalls, servers, and routers for intrusions.

• Keep computer operating systems updated monthly or more, if necessary.

• Use antivirus software and update it daily or more often.

• Be aware of social engineers, imposters seeking to pry private information from you or your staff.

• Use firewall software on all computers.

• Use intrusion detection/prevention software or services.

Fran Cain is in the Information Technology Department at NORCAL Mutual Insurance Company and the NORCAL Group.

This article is a high-level overview of some of the risks involved in using WiFi. It is intended to raise awareness and not to be a comprehensive technical article. © 2011 NORCAL Mutual Insurance Company. All rights reserved.

JANUARY / FEBRUARY 2012 | THE BULLETIN | 19

MEDICAL TIMES FROM THE PAST

Orificial Surgery

By Michael A. Shea, MD Leon P. Fox Medical History Committee The most influential of the nineteenth century American unorthodox medical sects was the homeopathic movement. It was founded by a German physician, Samuel Hahnemann (1755-1843), and became very popular among the middle and upper class of the United States.

One of the most interesting and bizarre practices to emerge from homeopathy was orificial surgery. The origin of this practice came from Edwin Hartley Pratt (1849-1930), an Illinois homeopathic general practitioner and surgeon. He believed that chronic diseases (physical and mental) could be cured by surgical procedures involving bodily orifices.

These openings were: nares, mouth, anus and rectum, introitus, urethra, vagina, and cervix. He believed that the basis for this theory was that the sympathetic nervous system, which terminated at all the above orifices, was responsible for the well being of all bodily functions. Any disturbance at these various portals (such as inflammation, cysts, sphincter rigidity, etc.) would cause disease in more distal parts of the body.

In 1886, Pratt published the first article on his philosophy, and one year later, a lengthy monograph followed. This new concept attracted a significant number of American physicians and led to the national organization of the American Association of Orificial Surgeons. In mid 1892, The Journal of Orificial Surgery began publication with Pratt as editor-in-chief.

Locally, Dr. R. E. Freeman, of Los Gatos, was known as one of the best orificial surgeons in our area. He graduated from The Hahnemann College of Philadelphia in 1886.

The surgical procedures practiced by Dr. Pratt and his followers included anal sphincter dilatation, rectal papillae scraping or excision, hemorrhoidectomy, male and female circumcision, hymenectomy, excision of the cervix, D-and-C, and vaginal hysterectomy. These operations were often done in combination, as Dr. Pratt’s theory espoused the idea that multiple sites of orificial irritation were the basis for the disease afflicting the patient.

The conditions ostensibly cured by the above operations were tuberculosis, asthma, constipation, eczema, dysmenorrhea, uterine atrophy, fundal malposition, dyspareunia, insanity, depression, epilepsy, paralysis, and others.

The appeal of orificial surgery was popular for two or three decades and paralleled the success of homeopathic therapeutics.

The decline of these practices began in 1901, when the Journal of Orificial Surgery abruptly stopped publication with little explanation.

Annual meetings of the American Association of Orificial Surgery continued through the early 1900s, but by the 1920s, they had ceased and the practice of this unusual branch of medicine was over.

20 | THE BULLETIN | JANUARY / FEBRUARY 2012

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- Deepak Chopra “I learned to embrace risk, as long as it was well thought out and, in a worst-case scenario, I’d still land on my feet.”

- Eli Broad The LWA team includes Michelle Hamilton, MBA as a specialist in financial planning and portfolio administration.

JANUARY / FEBRUARY 2012 | THE BULLETIN | 21

22 | THE BULLETIN | JANUARY / FEBRUARY 2012

On November 1, 2011, the Centers for Medicare & Medicaid Services (CMS) updated payment policies and Medicare payment rates for physicians’ services furnished in 2012.

Highlights of major changes in the fee schedule that impact payment policy and physician billing include:

E-prescribing

CMS finalized the rules for the 2012 and 2013 e-prescribing incentive payment, and the 2013 and 2014 payment penalty programs.

E-prescribing incentive payments will continue for 2012 and 2013. To qualify for an incentive payment, physicians: 1. May use claims, registry or electronic health record (EHR)-based reporting methods.

2. Must electronically prescribe on the same day as the denominator service, and submit 25 claims containing the e-prescribing measure code (G8553) with one of the denominator codes (90801-90802, 90804-90809, 90862, 92002, 92004, 92012, 92014, 9615096152, 99201-99205, 99211-99215, 99304-99310, 99315-99316, 9932499328, 99334-99337, 99341-99345, 99347-99350, G0101, G0108, G0109).

The incentive payment for 2012 is 1%, and for 2013 it is .5% of the total estimated allowed charges for professional services covered by Medicare Part B and furnished by an eligible professional during the reporting period.

There are three methods to avoid the penalty for 2013 and 2014: 1. Physicians who are successful e-prescribers in 2011 (those who receive the incentive payment) will be exempt from penalty in 2013.

Physicians who are successful e-prescribers in 2012 will be exempt in 2014.

2. Physicians who successfully report the measure code G8553 at least 10 times during the first six months of 2012 (for the 2013 calendar year penalty), and in the first six months of 2013 (for the 2014 calendar year penalty), will avoid application of the e-prescribing penalty. CMS improved the program to allow physicians to submit the measure code G8553 without linking to

qualifying visit (denominator) codes.

The measure code can be used with any fee schedule service during which an electronic prescribing event occurred. The claim must still be submitted to Medicare for payment.

3. Physicians will be allowed to apply for additional hardship exemptions online, but only from January 1 through June 30 of each calendar year.

Physician Quality Reporting System (PQRS)

As in prior years, there have been changes to the individual measures and measure groups. The final rule: • Finalized 211 individual measures, including 26 new ones • Retained 44 EHR measures currently reportable in the EHR incentive program • Finalized 23 new measure groups, including eight new measures groups for reporting: ◆◆ Cardiovascular Prevention ◆◆ COPD ◆◆ Inflammatory Bowel Disease ◆◆ Sleep Apnea ◆◆ Dementia ◆◆ Parkinson’s ◆◆ Elevated Blood Pressure ◆◆ Cataracts Check measures carefully for proper reporting. A complete listing of the 2012 measures will be posted to the CMS website, http:// www.cms.gov/PQRS//, in the near future.

CMS finalized its proposal to provide interim feedback reports for physicians reporting individual measures and measure groups through claims-based reporting for 2012 and beyond. These reports will be a simplified version of annual feedback reports that CMS currently provides and will be based on claims for the first three months of each program year.

The interim feedback reports will be provided to physicians during the summer of each program year.

The rule redefined “group practice” under the Group Practice Reporting Option (GPRO) as a group of 25 or more eligible professionals. Organizations wishing to use the GPRO method must, again, self-nominate.

CMS finalized its proposal to use 2013 as

the reporting period for the 2015 PQRS penalty. If CMS determines that a physician or group practice has not satisfactorily reported quality data for the 2013 reporting period, then its 2015 payments will be reduced 1.5%.

Now is a good time to become familiar with the PQRS reporting system, before your payments are negatively affected.

Advanced Imaging Services Multiple Procedure Pricing

CMS has finalized a proposal to apply a 25% reduction to the payment for the professional component of second and subsequent advanced imaging services such as CT, MRI, PET, and MRA furnished by the same physician, on the same patient, in the same session, on the same day.

The highest fee schedule service will be allowed at 100% of the fee schedule. Subsequent advanced imaging services will be allowed at 50% for the technical component, as in the past, and 75% for the professional component.

Lab Test Signatures No Longer Required

CMS has retracted the requirement for physicians to sign paper lab requisitions for clinical diagnostic laboratory tests.

Annual Wellness Visit (AWV) Changes

CMS has adopted criteria for a health risk assessment (HRA) to be used in conjunction with the AWV. The HRA is self-reported information which can be done by the patient alone or with assistance, takes no more than 20 minutes to complete, and addresses demographic data, psychosocial risks, behavioral risks, activities of daily living (ADL), and instrumental ADLs. CMS is increasing the payment for the AWV codes to recognize the additional office staff time required to administer an HRA to the Medicare population. CMS is also continuing its policy of not covering a routine physical exam as part of these services.

Additional information about coverage and payment changes will be published by CMS, over the next few months, through MLN Matters articles at http://www.cms.gov/MLNMattersArticles/.

JANUARY / FEBRUARY 2012 | THE BULLETIN | 23

Medication Optimization in the Management of Chronic Pain

By Melinda Brown, MD The use of opioids in the management of non-cancer related pain conditions has remained at the center of an ongoing controversy among physicians and other health care providers, patients and their families, insurance carriers, and even politicians. While some people with chronic pain are afraid to take opioids for various reasons, many become overly reliant on opioids despite marginal benefit, and in some cases major unwanted or devastating long-term effects.

Aside from concerns about physical dependence, tolerance, and addiction [see Figure 1]1, there is scientific data to support that opioids are generally not as effective as one would expect when it comes to long-term management of chronic non-cancer related pain, and may even increase pain and worsen function. The American Academy of Pain Medicine, the American Pain Society, and the American Society of Addiction Medicine recognize the following definitions:

Figure 1: Opioid dependence, tolerance and addiction Physical Dependence

A state of adaptation that is manifested by a drug class specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist.

Tolerance

A state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more of the drug’s effects over time.

Addiction

A primary, chronic, neurobiologic disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations.

It is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving.

It is not uncommon for people living with pain to experience the added challenge of opioid dependency. Research and our own clinical experience support better long-term outcomes when clients are not taking opioids or using them sparingly for major flare-ups that they cannot otherwise manage by other means. Benefits from this approach generally include improved mental and physical functioning, greater independence, and freedom from side-effects, addiction and other unwanted, life-altering consequences.

Gary Franklin and colleagues studied a cohort of 1,883 workers’ compensation claimants with back pain and performed interviews 18 days and one year after claims submission.2 The study found that 42% of claimants with back pain were prescribed an opioid, usually at the first physician visit. The majority of that group—59%—received opioids only 24 | THE BULLETIN | JANUARY / FEBRUARY 2012

in the first three months after their injury. However, for those that chose long-term use, opioids were clearly not a universal remedy or sole solution for the majority of individuals. Only 26.9% of those with long-term opioid prescriptions had significant improvement in pain—defined as at least a 30% decrease in pain scores, and only 15.9% reported a significant gain in physical function—with at least a 30% improvement in Roland Morris Disability Questionnaire scores.

Although some individuals may benefit from using opioids, some may experience unwanted effects such as constipation, nausea, sedation, impaired cognition, itching, sweating, sexual dysfunction, tooth decay, and urinary retention. Some may feel saddened or emotionally labile; a major concern since many people with chronic pain may already be experiencing some form of depression.

There is also scientific data to support the existence of a phenomenon referred to as “opioid hyperalgesia,” in which someone using highdose opioids actually develops an increased sensitivity to pain.3 In these instances, tapering and/or discontinuing the opioids usually results in improvement in pain and function.

If there is a decision to use opioid medications, starting them should be viewed as a “short trial,” with the decision to continue based on the extent of functional improvement. There are numerous tools for assessing function consistently and becoming familiar with them and using them routinely can help quickly objectify functional benefits. Examples include the Oswestry Disability Index and the Pain Disability Index, to name a few of the more popular and standardized ones. Regular monitoring for compliance, having an “Opioid Agreement” to avoid multiple prescribers, and consideration of periodic urine screening to assess for misuse and diversion is recommended by the American Pain Association and Medical Board of California. The California Department of Justice has developed CURES (California Prescription Drug Monitoring Program) that allows providers to search online regarding the usage of controlled medications by their patients and contains information on drugs dispensed, drug quantity and strength, pharmacy, and the physicians prescribing it.4 Many other states have similar drug monitoring programs.

The management of chronic pain can be quite challenging for patients and their physicians. Opioids are just “one tool in the toolbox” for treating and managing chronic pain. Personal and societal judgments of “good” and “bad” need to be redirected to determining whether it is “effective” and “tolerated.” With chronic non-cancer related pain, the determination as to whether a medication is effective should be primarily related to the extent that it improves or maintains a person’s functional abilities. Pain management strategies generally require a multi-pronged Dr. Melinda Brown is a board-certified physiatrist and a Qualified Medical Examiner (QME). Dr. Brown is a valuable member of the RehabOne Medical Group, with her office being located in Gilroy.

approach including the appropriate choice of medications, therapies, and procedures, with the ultimate goal being the promotion of self-management and reduced reliance on health care providers and resources, in order to achieve improved health and quality of living.

Endnotes 1. 2001 “Definitions Related to the Use of Opioids for the Treatment of Pain,” the American Academy of Pain Medicine, the American Pain Society, and the American Society of

Addiction Medicine.

2. Franklin GM et al., Opioid use for chronic low back pain, Clinical Journal of Pain, 2009; 25:743–51.

3. Mitra S., Opioid-induced hyperalgesia: pathophysiology and clinical implications. Journal of Opioid Management, 2008 May-Jun; 4(3):123-30.

4. CURES: https://pmp.doj.ca.gov/pdmp/index.do

JANUARY / FEBRUARY 2012 | THE BULLETIN | 25

MEMBER SPOTLIGHT

Running for a Better Cure

By Seham El-Diwany, MD I heard recently about Team In Training (TNT) of the Leukemia and Lymphoma Society (LLS). Its mission is to help find cures and more effective treatments for blood cancers. To be part of the team, one has to participate in a sports endurance event and raise a minimum of $2,500 through a personalized fundraising website.

I chose to run the Nike Women Half-Marathon (13.1 miles) in San Francisco, in honor of two special people, our very own William Parrish, Jr. and my friend, Janice Bremis.

In preparation for the BIG event, one regularly had to participate in the three-days-per-week physical training events. Although I have not been a runner in the past, the training and the camaraderie were unbelievable. Thanks to my assigned mentor, I was constantly able to show improvement and endurance. A few weeks before the real event day, together with the team, I was able to finish the 13.1 mile run at “Camp Sawyer;” this gave me a great boost of confidence for the real race.

The event day was a huge success for the thousands of runners and, most importantly, our mighty crew from the South Bay that smashed fundraising records and proudly crossed the finish line on Sunday morning, October 16, 2011!

The start was like a New Year’s Eve party!

Beneath the dark sky of the early morning, our TEAM found its way into the sea of runners and rode the energy and emotion as the miles turned like pages in a book. The climb up into the Golden Gate Park was breathtaking, and the runners persisted with strong legs and full hearts, conquering each hill that stood in their way. The last two miles were joyous ones as the hills tilted downward and the legs were able to unwind. The icing on the cake was the finish line where the journey had come to an end. The goal was accomplished successfully and rewarded with a little blue box! A Tiffany sterling chain with a pendant engraved with “NWM” (Nike Women Marathon) on one side, and “I run to be .....” on the other side. The blue boxes were delivered by firemen in tuxedos, from San Francisco!

Crossing the finish line was one of the most joyful moments in my life! I became a crowned half-marathoner at Nike. I will do it again; next time, I will go for the full marathon.

For more information, visit TNT website or contact Dr. El-Diwany at seham.eldiwany@kp.org.

26 | THE BULLETIN | JANUARY / FEBRUARY 2012

The day before the race, with the green bag containing the bib number, green wristband, etc.

The day of the race, with half of my teammates; the other half had started running earlier at 5:30 a.m.

JANUARY / FEBRUARY 2012 | THE BULLETIN | 27 Spanish language web pages

www.aware.md

www.ethnicphysician.org

Healthcare Reform Resources

California Ethnic Physician Organizations: Directory and Officer Listing

HIT Resources

NEPO Strategic Plan 2006– 2010

Network of Ethnic Physicians Organizations (NEPO)

Safe Routes to School Resources

Community Advocacy Resources

Obesity Prevention Monograph

Updated Child and Adolescent Obesity Provider Toolkit

Obesity Prevention Project

Visit us at www.theCMAFoundation.org

Diabetes and Cardiovascular Disease Provider Reference Guide

Self Management Tools

Practice Resources

Clinical Education

Clinical Practice Guidelines

Multicultural Patient Education Materials Database

Diabetes Quality Improvement Project

3835 North Freeway Blvd., Suite 100, Sacramento, CA 95834 (916) 779-6620

CMA Foundation

Multilingual Resources

Online CME Course

Cold and Flu Consumer Information

COPD Materials

T-DAP Patient Materials

Screen Yourself and Vaccinate Your Daughter and Son Provider Toolkit

Cough and Cold Patient Kits

Acute Respiratory Tract Infection Guidelines

Cervical Cancer/ HPV Project

Alliance Working for Antibiotic Resistance Education (AWARE)

providers are available on our website.

communities. Toolkits, directories, and resource materials for patients and

professionals with the tools they need to inspire change in their patients and their

pressing public health issues by equipping physicians and other health

The California Medical Association (CMA) Foundation is tackling today’s most

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PRACTICE MANAGEMENT

Becoming Totally Disabled Could Stop Your Ability to Earn an Income in a Split Second Make sure you have a reliable financial plan in place that includes long-term disability income protection. Members can turn to the Association/Society-sponsored Group Long Term Disability Insurance Plan that protects members in their medical specialty.

Important features of this plan include: • A monthly benefit of up to $10,000, if you become totally disabled. Members age 50–59 are eligible to apply for up to $6,000 per month.

• A 10-Year Medical Specialty Definition of Disability defined as the inability to work in your own medical specialty for the first 10 years after the waiting period (a very important distinction vs. many plans with a broad “inability to do ANY

30 | THE BULLETIN | JANUARY / FEBRUARY 2012

job” definition).

• Your monthly benefit payments are not taxable, when you don’t take your premium as a tax deduction under current tax law.

That’s not necessarily the case for employer-provided plans where you could lose up to 40% of your benefit to taxation.

(Always consult your tax advisor.)

• Group rates are negotiated exclusively for SCCMA/MCMS members.

Learn more about this valuable plan today, including: plan features, cost, eligibility, renewability, limitations, and exclusions. Please call a client service representative at 800/842-3761 or email CMACounty.Insurance@marsh.com.

PRACTICE MANAGEMENT

GROUP Level Term Life Program Looking for cost-effective life insurance?

Santa Clara County Medical Association and Monterey County Medical Society members may now apply for up to $1,000,000 of life insurance on either a 10-year level term or 20-year level term basis.

Rates for the first 10 or 20 years of your coverage are locked-in so that you do not have to experience increases in premium solely as the result of getting older.* This results in substantial premium savings during the term of the coverage. After the initial 10- or 20-year term period, you can reapply for coverage at your then-attained age or transfer to the regular term life program if you no longer qualify through underwriting.

You may also insure your spouse or domestic partner for up to $1,000,000 and your eligible employees for up to $500,000.

Each plan also includes two special member services: travel assistance services for medical emergencies when you are traveling away

from home;** and a funeral planning and concierge service, at no additional cost to you.*** Call Marsh for more information at 800/842-3761 or email CMACounty.Insurance@marsh.com. *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 policy with 60 days advance written notice. Underwritten by ReliaStar Life Insurance Company. Policy form LP08GP. **ING Travel Assistance Services provided by Europ Assistance USA, Bethesda, MD 20814. ***Funeral Planning and Concierge Services provided by Everest Funeral Package, LLC, Houston, TX 77056.

Health Care Reform No Solution to Rising Medical Premiums While the future of health care reform continues to be sorted out, members still have to make important decisions about health insurance for themselves and their employees, especially when it comes to managing premium costs. No matter which path health care reform follows, annual increases in health insurance premiums will likely be part of everyone’s immediate future.

So what can you do until then?

• If you are not enrolled in a qualified High Deductible Health Plan, which enables you to open a Health Savings Account, consider the significant savings this option provides. In 2012, with individual-only coverage, you are eligible to contribute up to $3,100 to your account, or $6,250 with family coverage, on a federally tax deductible* basis.

Members between the ages of 55 and 64 are eligible to add an additional $1,000 per year ($4,100 and $7,250 totals respectively) to their accounts. Many members utilize the savings from premiums to help fund their accounts. Funds may be accessed without penalty for health-related expenses.

• Investigate RAF Sales – Health plans offer incentives through discounts off their risk adjustment factors (RAFs) for you to change health plans. Instead of your medical rates increasing

this year, we might be able to help you offset some of that increase if you insure six or more physicians and employees.

• Mercer Select HRKnowHow – If you play a role in your medical group’s health care and benefit plan decisions, staying current on these challenging issues is critical. Access to this resource is included at no charge for members who purchase group (2 – 50 members and employees) health insurance through Marsh. It includes: • News and analysis of important group benefit issues and the latest information on health care reform • Compliance Link – tool to assist with health care and group benefit plan administration and samples of notices and forms We serve members who want assistance in evaluating their medical insurance choices. Call Marsh at 800/842-3761 for more information or a quote. And, depending upon where your group health insurance is placed, we may be able to save you 15% off your workers’ compensation insurance. *Marsh and the Association/Society do not provide tax, investment, or legal advice. Please consult with your professional advisors for guidance on these issues.

JANUARY / FEBRUARY 2012 | THE BULLETIN | 31

medico news

Blue Cross required to pay health care providers money owed to them, dating back to 2007 On January 12, the California Department of Managed Health Care (DMHC) ordered Anthem Blue Cross to pay health care providers money owed to them, with interest, for services provided dating back to 2007. The action is a result of Anthem’s refusal to remediate providers following a financial claims audit that identified errors in payment of medical claims.

California Medical Association (CMA) President James T. Hay, MD, applauded DMHC for their recent announcement. “We provide necessary care to our patients based on the assumption that the health plans will promptly and accurately reimburse us for services ren-

dered,” Dr. Hay said. “Anthem Blue Cross’s refusal to pay for a mistake on their end puts an undue burden on those of us who provide care.”

In 2008, DMHC launched provider claims audits of the seven largest health plans in California, due to a growing pattern of complaints from providers regarding late and inaccurate payments and inappropriate claim denials.

These audits found claims payment violations above the threshold allowed under California law at all seven health plans.

In response to the audits, DMHC required the plans to pay providers the money they were owed and to demonstrate improvements to the

plans’ claims processes to prevent future errors. In addition, each plan entered into settlement agreements to pay administrative fines.

To date, six of the seven plans have undertaken provider remediation efforts.

Anthem has refused to pay providers for the claims violations uncovered in the audit.

Now, Anthem Blue Cross has 30 days to submit to DMHC a corrective action plan to identify the claims that were not correctly paid and pay the providers as prescribed by law.

(CMA Alert, January 23, 2012 issue)

April 17, 2012: Save the date for CMA’s annual Legislative Leadership Conference When: 9:30 a.m. to 5:00 p.m.

Where: Sacramento Convention Center 1400 J Street, Sacramento The California Medical Association (CMA) is pleased to announce that California Attorney General Kamala Harris will be the keynote speaker for the 2012 Legislative Leadership Conference, to be held April 17. Members have the unique opportunity to join more than 400 physicians, medical students, and CMA Alliance members who come to Sacramento to lobby their legislative leaders as champions for medicine and their patients.

The morning includes speeches from a number of key legislative leaders. Attendees will go to the Capitol in the afternoon to meet with legislators on health care issues. The meetings will be scheduled and coordinated by local county medical societies. Medical students will be scheduled to meet with elected state officials, including the Governor, Lieutenant Governor, and Insurance Commissioner.

Photo shoot There will be a large group photo shoot with all the conference attendees on the west steps of the Capitol at 1:00 p.m. Please bring your white coats for the photo.

Health fair A health fair on the north steps of the Capitol is another feature of CMA Legislative Day. Physicians with a wide range of specialties will provide services and information to legislators and their staffs.

Capitol museum For the first time, CMA and the Sierra Sacramento Medical Society 32 | THE BULLETIN | JANUARY / FEBRUARY 2012

have obtained permission to display medical artifacts from Sierra Sacramento’s Medical History Museum in the Capitol Rotunda from April 16-20.

Legislative Day is offered at no cost to physicians. Please contact your local county medical society before making travel arrangements.

Otherwise, expenses will be the obligation of each individual participant.

Registration is free for medical students, and scholarships may be available to medical students for travel and accommodations through their county medical societies.

CMA is currently in the process of scheduling additional speakers and will keep you posted as the agenda is finalized. More information about legislative meetings, afternoon events, and the health fair will be coming your way shortly.

Medical student information CMA will host a special advocacy training session for medical students with CEO Dustin Corcoran from 8:15 to 9:15 a.m. Medical students will once again have a special afternoon schedule, separate from the regularly scheduled physician legislative meetings.

Hotel details CMA has again established a local rate agreement with the Sheraton Grand Sacramento for 2012. You may book a room there for the discounted rate of $159. Reservations can be made by calling 800/325-3535 or 916/447-1700 – ask for the California Medical Association corporate rate.

Register now at http://www.cmanet.org/events/detail/?event =legislative-leadership-conference!

(CMA Alert, January 23, 2012 issue)

medico news

California’s congressional delegation is in for a shake-up Highlights

• Redistricting will change California’s Congressional delegation in 2012 • Pundits predict nine newcomers in the next Congress • California Supreme Court to weigh-in on redistricting in face of Republican-backed referendum California, which has the largest congressional delegation in the country (53 members), will see big changes in 2012 as the direct result of redistricting and the public’s low approval ratings of Congress. Pundits are predicting at least nine newcomers in the next Congress.

These changes may also dilute some of California’s power in Washington, D.C., as a few long-term politicians, with decades of seniority that have gained them positions of power, may be gone.

The biggest change in the political landscape will take place in longtime GOP strongholds in Southern California, where newly redrawn districts will include citizens more inclined to the liberal side of politics.

Bowing out of national politics

Rep. Elton Gallegly (R-Simi Valley) announced his retirement January 7, after redistricting put him in competition against Rep. Buck McKeon (R-Santa Clarita), chairman of the House Armed Services Committee. Gallegly, 67, helped found Simi Valley and was once its mayor.

On January 12, Rep. Jerry Lewis (R-Redlands) announced his retirement from Congress after new boundaries drawn through redistricting promised to make the road to re-election more difficult. He is the longest-serving Republican member of Congress in California history, and the first Californian to chair the Appropriations Committee.

Rep. Wally Herger (R-Chico) announced his retirement January 9, ending more than three decades representing the Sacramento Valley in Congress and the state Legislature. He was the chair of the powerful

Ways and Means Health Subcommittee.

Three Democrats have also announced their retirements: Lynn Woolsey, who represented Marin and Sonoma counties for 19 years; fiveterm Rep. Dennis Cardoza of Merced County, who faced a race against San Joaquin Valley colleague Jim Costa; and Bob Filner, who has decided to run for mayor of San Diego.

In what is expected to be a tough race, two Democrats, Reps. Howard Berman and Brad Sherman, will face-off against one another in Los Angeles.

Speculation is also rife that Rep. David Dreier (R-San Dimas), chair of the House Rules Committee, which determines what amendments are allowed on legislation, may be next. Dreier faces a heavily Democratic new district.

Challenge to redistricting

A challenge to redistricting in the form of a ballot referendum is causing headaches for the California judiciary. The Republican-backed group Fairness and Accountability in Redistricting (FAIR) has been canvassing for signatures for its referendum, which would kill the Senate maps drawn by the Citizens Redistricting Commission and is likely to qualify for the ballot in the fall. In the meantime, state Senate candidates must file for the June primary, while the California Supreme Court is struggling with the technical aspects surrounding the spring elections.

The justices held an inquiry on January 10 and questioned attorneys for the redistricting commission, the secretary of state’s office, and FAIR about options if the court intervenes. A decision by the court is expected soon.

If the referendum qualifies for the ballot, the current maps could be “stayed,” or placed on hold, pending the November election.

(CMA Alert, January 23, 2012 issue)

Medi-Cal program successfully closes out transition In October 2011, the California Department of Health Care Services (DHCS) transitioned to Affiliated Computer Services (ACS) as the new fiscal intermediary for the Medi-Cal program. This transition, which will be completed on January 31, 2012, was the largest and one of the most complex in the nation.

The focus was to move operations from the previous contractor to ACS with minimal impact to physicians and patients. One of the greatest challenges was the amount and volume of inherited suspended claims.

Over the last few months, ACS, with DHCS oversight, has continued to make significant progress toward resolving this issue. After starting with a volume of 1.8 million suspense claims in October 2011, ACS has lowered that volume by more than 30% with the implementation of an aggressive and effective mitigation strategy.

ACS anticipates the claims suspense volume to be lowered by another nearly-30% by mid-February 2012, achieving optimal operating status.

The California Medical Association (CMA) worked closely with DHCS and ACS to reduce negative effects of the transition, and appreciates DHCS’s recognition of the impacts to Medi-Cal physicians during this transition period, and for its pursuit of every possible remediation of suspended claims.

CMA looks forward to a continued partnership between DHCS and ACS to ensure the perspective and concerns of physicians are considered as we seek to improve the Medi-Cal program. CMA members are encouraged to call the reimbursement helpline with any issues.

(CMA Alert, January 23, 2012 issue) JANUARY / FEBRUARY 2012 | THE BULLETIN | 33

medico news

Highlights from AMA’s 2011 House of Delegates The California delegation to the American Medical Association’s (AMA) House of Delegates presented a number of important resolutions at the AMA interim meeting in New Orleans. The following are summaries of some of the resolutions that the AMA House adopted as policy.

Truth and transparency in pregnancy counseling centers: Adopted a substitute resolution that asks the AMA to support that any entity offering crisis pregnancy services disclose information onsite, in advertising, and before any services are provided about the medical services, contraception, termination of pregnancy, or referral for services or adoption options. Advocate that any entity providing medical services to pregnant women that markets medical or any clinical services abide by licensing requirements, have the appropriate qualified licensed personnel and abide by federal health information privacy laws.

Addressing substance use and misuse in the United States: Adopted a substitute resolution that asks the AMA to promote physician training and competence on the proper use of controlled substances; encourage physicians to use screening tools; and provide references and resources for physicians so they identify and promote treatment.

Censorship of physician discussion of firearm risk: Adopted a California resolution that asks the AMA to oppose any restrictions on physicians being able to inquire and talk about firearm safety issues and

risks with their patients, and oppose any law restricting physicians’ discussions with patients and their families about guns as an intrusion into medical privacy.

Generic vs. brand medications: Adopted a California resolution that asks the AMA to advocate to the Food and Drug Administration against removal of generic medications from the market in favor of more expensive brand name products based solely on a lack of studies of the efficacy of the generic drug.

Federal liability protection for EMTALA mandated care: Adopted as amended a California resolution that asks the AMA to support the extension of the Federal Tort Claims Act (FTCA) to all Emergency Medical Treatment and Labor Act (EMTALA) mandated care if an evaluation of a demonstration program, as called for in AMA Policy D-130.971(6), shows evidence that physicians would benefit by such extension. And, if an evaluation of a demonstration program shows evidence that physicians would benefit by extension of the FTCA, that the AMA conduct a legislative campaign, coordinated with national specialty societies, targeted toward extending FTCA protections to all EMTALA-mandated care. And that the AMA assign a high priority to this effort.

(CMA Alert, November 28, 2011 issue)

CMS names six “pioneer” ACOs from California for team-based care The Centers for Medicare & Medicaid Services (CMS) announced December 19 that its program to promote team-based care for Medicare and private payors will launch with 32 “pioneer” accountable care organizations (ACOs) in 18 states, serving up to 860,000 beneficiaries.

Of those 32 medical groups, CMS chose six from California, including Brown and Toland Physicians, San Francisco Bay Area; Heritage California ACO Southern, Central and Coastal California; Healthcare Partners Medical Group, Los Angeles and Orange counties; Monarch Healthcare Orange County; Primec-

are Medical Network, San Bernardino and Riverside counties; and Sharp Healthcare System, San Diego County.

“The pioneer ACO initiative will encourage primary care doctors, specialists, hospitals, and other caregivers to provide better, more coordinated care for patients and could save up to $1.1 billion over five years,” the U.S. Department of Health and Human Services said in a news release.

The pioneer group has agreed to take on more financial risk for a greater reward. According to CMS, if pioneer ACOs deliver sav-

34 | THE BULLETIN | JANUARY / FEBRUARY 2012

ings in their first two years, they will qualify in their third year for a capitated payment. That is a per-beneficiary, per-month payment amount intended to replace some or all of the ACO’s fee-for-service payments with a prospective monthly payment, CMS said. Pioneer ACOs will have to develop contracts with other payors for team-based care that lowers spending and boosts quality. The intent is to spur organizations sponsoring ACOs to more fully commit to team-based care.

(CMA Alert, January 9, 2012 issue)

medico news

Grim cancer statistics prompt CMA to call on physicians to talk with patients about free screenings The American Cancer Society projects that in 2012, over 25,000 new cases of breast cancer and roughly 1,450 new cases of cervical cancer will be diagnosed in California alone. In light of these grim statistics, the California Medical Association (CMA) encourages physicians to help eligible patients take advantage of screening services offered by the state’s Every Woman Counts program.

This free program offers clinical breast exams, mammograms, pelvic exams, and Pap tests to underserved women throughout California.

Despite its obvious value, this program has struggled for funding in recent years and was even closed to new enrollment for six months in 2010. Governor Brown’s recently released

2012-13 state budget also assumes a $14 million reduction for the programs, due to projections of lower patient enrollment.

These lower caseload projections are a major reason for the proposed reduction, as fewer women have joined the program since it re-opened in 2011, largely because they are unaware that it is available and actively enrolling new participants.

CMA urges all physicians to talk to their patients about Every Woman Counts, so that we can help to reverse this unfortunate trend.

If more women are made aware of EWC and acquire services through the program, the proposed cut may be retracted and more lives can be saved.

In order to be eligible for the screening

services offered by the Every Woman Counts program, patients must meet a variety of income and eligibility requirements, including a lack of coverage from their insurance provider for screening services.

A complete list of the program’s requirements is available at http://www.cdph.ca.gov/ programs/cancerdetection/pages/cancerdetectionprogramseverywomancounts.aspx.

Those who qualify are encouraged to call the California Department of Public Health at 800/511-2300 to be referred to a participating physician in their area. Program representatives may also be able to refer women to other low-cost screening options, should they not qualify for the Every Woman Counts program.

(CMA Alert, January 23, 2012 issue)

HIPAA privacy and security training resource now available HIPAA mandates that all medical office staff (including physicians) be trained on the HIPAA privacy rules, security policies, and procedures.

The HIPAA Privacy and Security Rule Training Manual is now available to nonmembers. This manual provides a general training and overview and can be used as a part of your HIPAA training program. The manual contains: • HIPAA Privacy and Security Rule Quiz • Customizable checklist detailing the specific privacy and security rule responsibilities of the employee • Employee certification form The HIPAA Privacy and Security Rule Training Manual is a joint effort by the California Medical Association (CMA) and PrivaPlan® Associates, Inc. For members, the manual is free. The cost for nonmembers is $15. The manual is available in CMA’s resource library at http://www.cmanet.org/ resource-library/detail?item=our-commitment-to-privacy-and-security.

Another resource for HIPAA compliance is the CMA/PrivaPlan HIPAA Privacy and Security Compliance Toolkit, available at http://www. cmanet.org/resource-library/detail/?item=hipaa-compliance-toolkit-cdrom. The toolkit is customized for California law and contains customized forms, policies, and procedures to ensure HIPAA compliance.

(CMA Alert, January 23, 2012 issue)

CMS eases 5010 claim submission deadline The Centers for Medicare & Medicaid Services (CMS) released Technical Direction Letter 12148 in December 2011, which updated instructions for the ASC X12 version 5010 transition. According to the letter, Palmetto GBA will not reject compliant ASC X12 version 4010A1 transactions before April 1, 2012. The exact date 4010A1 transactions will be rejected by CMS will be published at a later date.

Trading partners that have tested and been approved for 5010, but

that are still submitting 4010A1 transactions, have 30 days to complete their changeover to submitting version 5010 production transactions.

All submitters must have tested and been moved into production for submitting 5010 transactions prior to April 1, 2012.

Please contact the Palmetto Technology Support Center at 866/7494301, if you have any questions regarding the 5010 transition.

(CMA Alert, January 9, 2012 issue) JANUARY / FEBRUARY 2012 | THE BULLETIN | 35

medico news

Minor consent: What physicians need to know when treating children California law authorizes parents or guardians of minor children (anyone under the age of 18) to give informed consent for most medical decisions. However, there are some exceptions to this. Minors can consent to certain types of medical treatment under two types of statutes: status-based and treatment-based.

The California Medical Association’s (CMA) medical-legal document #0425, “Minor Consent,” summarizes these statutes and other pertinent issues that physicians should be aware of prior to treating a minor. For instance, minors who are authorized to give legal consent to most medical treatment under the status-based statutes include married (or divorced) minors, minors on active duty with the

U.S. Armed Forces, minors emancipated by a court order, and self-sufficient minors (minors 15 years or older living away from home and managing their own financial affairs).

This member resource also includes information on what to do if the minor has adoptive, unmarried, or divorced parents; parents who disagree about medical treatment; or legal guardians or caregivers. Medical record confidentiality is also discussed. It also includes sample forms that cover an individual authorized to consent to a minor’s medical treatment and an affidavit for a minor caregiver’s authorization.

An example of treatment-based consent for minors includes a new law that went into ef-

fect on January 1, 2012. Minors 12 years of age and older are now able to consent to preventive care, in addition to diagnosis or treatment of sexually transmitted diseases without the consent of a parent or legal guardian. This would include hepatitis B and human papillomavirus (HPV) vaccines.

Medical-legal document #0425, “Minor Consent,” as well as the rest of CMA’s medicallegal library, is free to members in CMA’s online resource library at http://www.cmanet.org/ resource-library. Nonmembers can purchase medical-legal documents for $2 per page.

(CMA Alert, January 23, 2012 issue)

Stage 2 of Meaningful Use for Medicare EHR incentive program pushed back to 2014 On November 30, U.S. Health and Human Services (HHS) Secretary Kathleen Sebelius announced that HHS intends to delay implementation of Stage 2 of Meaningful Use of electronic health records (EHR) until 2014. Under previous rules, physicians who achieved meaningful use in 2011 would have had to move to the higher Stage 2 standard in 2013.

Meaningful use is the set of criteria on which physicians must report in order to receive federal incentive payments for EHR adoption.

What is currently published as meaningful use is known as Stage 1. Later stages will include more reporting measures and higher standards.

The California Medical Association (CMA) Information Technology Council filed comments earlier this year with the Office of the National Coordinator for Health IT asking for just such a delay. CMA believes that many physicians will have a difficult time achieving Stage 1, and the delay will give them more time to adjust their practices to the new elec-

36 | THE BULLETIN | JANUARY / FEBRUARY 2012

tronic environment. According to Sebelius, these policy changes will be accompanied by greater outreach efforts by HHS that will provide more information to doctors about best practices. In communities across the country, HHS will target outreach, education, and training to Medicareeligible professionals who have registered in the EHR Incentive Program, but have not yet met the requirements for meaningful use.

Under the Medicare EHR Incentive Program, physicians can receive incentive payments as high as $44,000. Meaningful use is the necessary foundation for all impending payment changes involving patientcentered medical homes, accountable care organizations, bundled payments, and value-based purchasing. For more information, go to http:// www.hhs.gov/news/press/2011pres/11/20111130a.html.

(CMA Alert, December 12, 2011 issue)

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When someone in your family gets sick, it feels like you are going walking by yourself. But when hospice comes, you feel like somebody is guiding you and you are not alone. Thank God there’s a program like this that picks you up and helps prepare you for the journey you and your loved ones are going to take. Hospice of the Valley helps everyone prepare for that.

— Carmen V. Gary Bertuccelli, social worker Pam Nates, chaplain

When patients and families are coping with serious, life-limiting 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.

• The hallmark of hospice care is that it serves patients wherever they live—be it in their home, nursing home, hospital or assisted-living facility • Hospice of the Valley team members consist of physicians, nurses, social workers, chaplains, hospice aides, volunteers, and grief counselors who are experts in palliative and hospice care and are available to assist in the management of your patient’s needs Margarita Vizcaya, hospice aide

Jeanne Fabricius, RN, case manager

• For those dealing with grief and loss, the Community Grief and Counseling Center at Hospice of the Valley provides families and individuals with one-on-one counseling and loss-specific support groups to adults, teens and children • Since 1979, Hospice of the Valley‘s legacy of compassionate palliative and hospice care, community education, advocacy and outreach has set the standard for quality hospice care state wide and nationally, and our organization is a locally-based, operated, and supported non-profit organization Monique Kuo, MD, medical director

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

JANUARY / FEBRUARY 2012 | THE BULLETIN | 37

membership

Welcome 376 New Members...

And More to Come!

Santa Clara County Medical Association Ryan Abbott San Jose Natalia Abrikosova San Jose Jarrad Aguirre Stanford Samina Ahmed Santa Clara Marcus Alexander Stanford Leila Alpers Palo Alto Jennifer Alyono Stanford Josiah Ambrose Santa Clara Nicholas Anast Redwood City Manish Asaravala Santa Clara Tamerou Asrat Santa Clara Cheryl Bader Mtn View James Badger Palo Alto Hilary Bagshaw Stanford Andrea Baker Stanford Preethi Balakrishnan Santa Clara Philip Barbosa Stanford Nena Barnhart Santa Clara Daksha Barot Santa Clara Janos Barrera Stanford Marita Bautista Santa Clara Monica Berletti San Jose Danielle Bertoni Stanford Punam Bhullar San Jose Sarah Bishop Stanford Kevin Blaine San Jose Laura Bloomfield Stanford Diana Blum Palo Alto Mark Bomann Los Gatos Anthony Bommarito Los Gatos Liana Bonanno Stanford Anita Breckenridge Los Gatos Zachary Brewer Stanford Ioana Brisc Stanford Christie Brown Munoz Stanford Derek Browne Santa Clara Matthew Brucks San Jose Diem Bui San Jose James Byrne Saratoga Lauren Cao San Jose Marc Carmichael Stanford Kent Carson San Jose Dora Castaneda Rodriguez Stanford Rostislav Castillo Stanford Tiffany Castillo Palo Alto Annie Chan Santa Clara Keith Chan Santa Clara Christine Chang Cupertino

SCVMC Resident FP Med Student US Med Student IM GS Resident US AN Resident US OBG OBG GS GS Resident AN Resident Resident GS Resident OBG OBG Med Student Resident SCVMC Resident GS Resident SCVMC Resident GS Resident SCVMC Resident Med Student N AN AN Med Student OPH GS Resident GS Resident AN Resident FP SCVMC Resident SCVMC Resident MFM SCVMC Resident Med Student D AN Resident Med Student US Resident OPH Resident P

38 | THE BULLETIN | JANUARY / FEBRUARY 2012

Pauline Chang Santa Clara Christine Chang-Halpenny San Jose Stephanie Chao Stanford Joan Chapman San Jose Jeff Chen San Jose Jerry Chen Stanford John Chen Santa Clara Marianne Chen Stanford Samuel Chen Stanford Yijun Chen Stanford Jamie Cheung Santa Clara Bonnie Chien Stanford Christine Ching Palo Alto Grace Chlou Stanford Edward Cho San Jose Michelle Choi Santa Clara Nichole Choi Santa Clara Jacqueline Chu Stanford F. Landon Clark Mtn View Sarah Clark San Jose Jennifer Conwell Los Gatos Emily Corrigan Santa Clara Nick Costouros Palo Alto Alexis Crawley San Jose Danielle Cronin Santa Clara Christopher Crowe Stanford Carl Dambkowski Stanford Adam Daond Stanford Daniel daSilva San Jose Smita De Stanford Kelly Derbin Mtn View Dennis Diokno Santa Clara Adam Djurdjulov Stanford Marc Dobrow San Jose Darren Don Palo Alto Morgan Dooley Stanford Chelsea Dorsey Stanford Nathan Douglass Stanford Laura Downey Stanford Monica Dua Stanford Melissa Dunagan Santa Clara Joshua Edwards Stanford Eric Ehman San Jose Jennifer Erdrich Stanford Cordelia Erickson-Davis Stanford Roy Esaki Menlo Park Oloruntoyin Falola San Jose Farshad Fani Marvasti Stanford

OBG SCVMC Resident GS Resident SCVMC Resident EM GS Resident OPH AN Resident AN Resident GS Resident AN Med Student ONS GS Resident EM HBS EM Med Student D SCVMC Resident OBG OBG NM SCVMC Resident PTH Med Student Med Student Med Student SCVMC Resident GS Resident FM IM AN Resident SCVMC Resident OM, PMR AN Resident GS Resident GS Resident AN Resident GS Resident PD AN Resident SCVMC Resident GS Resident Med Student AN Resident SCVMC Resident FP

Angela Feng Lauren Fischer Patrick Flanagan Joseph Forrester Matthew Forrester Carla Fowler William Frederick Teresa Fu Kingsuk Ganguly Esther Garazi Brice Gaudilliere Christine Gebert-Parikh Jon Gerry Sepideh Gholami Melanie Gipp Kathryn Gopez Matthew Gorman Pradipta Gosh Lindsey Grace Jennifer Grady Emily Greenberg Noam Greenman Greg Groetsema Robert Groff Emmanuel Guerrero Anjali Gulati Katheryn Gunnison David Guo Elsie Gyang Janie Ha Leslie Hale Reed Harvey Joseph Hastings Kathryn Hawrylyshyn Claudia Haynes Sarah Hebl Allison Helms Michael Henderson Kelsey Hills-Evans Laura Holmes Kristine Hoque Mary Horner Lukuang Hsu Becky Huang Lyen Huang Cedric Hunter Daniel Hurwit Harry Hwang Loleh Jalilian Chrystina Jeter Grady Jeter Christine Jette Frank Joerke Ronald Jou Stephanie Jun Irene Kang Aarthy Kannappan Lynda Kay

Santa Clara Stanford San Jose Stanford Stanford Stanford San Jose San Jose San Jose Stanford Stanford Santa Clara Stanford Stanford Stanford Santa Clara Santa Clara Santa Clara San Jose San Jose Santa Clara Santa Clara Los Altos San Jose Santa Clara San Jose Santa Clara Stanford Stanford San Jose San Jose San Jose Santa Clara Stanford Santa Clara Santa Clara San Jose Stanford Stanford Palo Alto San Jose San Jose Palo Alto San Jose Palo Alto Stanford Stanford Santa Clara Stanford San Jose San Jose Stanford San Jose Stanford Mtn View San Jose Stanford Santa Clara

AN GS Resident SCVMC Resident GS Resident CS GS Resident SCVMC Resident SCVMC Resident SCVMC Resident AN Resident AN Resident US GS Resident US Resident AN Resident PD US IM SCVMC Resident OTO, OT Resident Resident EM SCVMC Resident AN CD OBG Resident GS Resident GS Resident SCVMC Resident SCVMC Resident SCVMC Resident RO AN Resident US OBG Resident US Med Student Med Student IM SCVMC Resident SCVMC Resident P SCVMC Resident US Resident GS Resident Med Student US GS Resident SCVMC Resident ORS SM AN Resident US GS Resident DR SCVMC Resident GS Resident FP

Marian Kim Marian Kim Rebecca Kim Dhiruj Kirpalani James Ko Winson Koo Steven Kramer Geoffrey Krampitz Palak Kundu Joseph Kwok James La Roy Samuel Lada Elene Lam Remy Lamberts Barrett Larson Mary Laughlin Nathaniel Law Justin Ledesma Lori Lee Roger Lee Yauk Lee Jody Leng Kenneth Leong Calvin Lew Cara Liebert Anna Marie Liess John Liggins Emily Liu Quanjing Liu Vincent Liu Yen Liu Yun-Sheen Liu Michael Llewellyn Jong-Ping Lu Sara Ludlow Kate Luenprakansit Esther Luo Gregory Magee Pantea Mahtosh Michael Marques Juan Marquez Namrata Mastey Marzie McHenry Ethan McKenzie Tracy McMahan David Medina Lindsey Merrihew Cindy Mi Brett Miller Kai Miller Noah Minskoff Sonya Misra Vanessa Moll Michelle Monnie Ellen Morrow Megan Motosue Marta Murawski David Myung

Santa Clara Santa Clara Stanford Santa Clara Santa Clara Santa Clara Santa Clara Redwood City Stanford Stanford Mtn View Palo Alto Santa Clara Stanford San Jose Stanford Los Gatos Stanford Stanford Palo Alto San Jose Stanford Santa Clara Stanford Holmes Beach Mtn View Stanford San Jose Sunnyvale Santa Clara Santa Clara Stanford San Jose Santa Clara Santa Clara San Jose Santa Clara Stanford Santa Clara Stanford Stanford Stanford San Jose Stanford Mtn View Stanford Palo Alto San Jose Stanford Stanford Stanford San Jose Stanford Santa Clara Stanford San Jose San Jose Santa Clara

OBG PD GS Resident PMR US IM FP GS Resident Med Student AN Resident FP IM IM GER GS Resident SCVMC Resident AN Resident AN GS Resident Med Student D SCVMC Resident AN Resident IM Resident AN Resident US Resident IM Med Student SCVMC Resident IM CCM Resident AN Resident SCVMC Resident GS OBG SCVMC Resident IM GS Resident IM AN Resident Med Student Med Student SCVMC Resident AN Resident PD AN Resident Med Student SCVMC Resident AN Resident GS Resident GS Resident NPM AN Resident OBG Resident GS Resident SCVMC Resident *IM Resident

* - Board Certified | US - Unspecified JANUARY / FEBRUARY 2012 | THE BULLETIN | 39

New Members, from page 39 Tejinder Nahal Santa Clara Kazim Narsinh Stanford Dustin Newell San Jose Annie Nguyen San Jose Karl Nguyen San Jose Molina Niedle Santa Clara Mina Nikanjam Santa Clara Jennifer Nissley Santa Clara Sean Novak San Jose Matthew Nowlis San Jose Rafee Obaidi San Jose Mika Ohno San Jose Tomomi Oka Palo Alto Michaella Okihara Mtn View Megan Olejniczak Stanford Lailey Oliva Los Altos Joyce Omdorff Santa Clara Osita Onugha Stanford Iris Otani San Jose Michael Paige Los Gatos Christopher Painter San Jose Erin Palm Stanford Owen Palmer Stanford John Pan Santa Clara Richard Parent Palo Alto Neesheet Parikh San Jose Julia Park Stanford Dipa Patel Los Gatos Siddhartha Patel Cupertino Richa Pathak Santa Clara Carter Peatross Stanford Shelly Pecorella San Jose John Peterson Stanford James Petros San Jose Kim Pham Santa Clara Danielle Pickman Stanford Carlos Pineda Stanford Andre Pinesett Stanford Rohith Piyaratna Stanford Timothy Plerhoples Stanford Andrew Powers Stanford Andrew Price Stanford Xiang Qian Stanford Alexander Quick San Jose Jennifer Ragazzo Santa Clara Lindsay Raleigh San Jose Bhargav Raman San Jose Raghav Raman San Jose Anais Rameau Stanford John Rashkis Los Gatos Sarah Razzak Chaudhary San Jose Balvinder Rehel San Jose Catherine Reid Stanford Eugene Reinersman San Jose Tanya Rinderknecht Stanford Benjamin Robinson Stanford Graham Rodwell Palo Alto Maribeth Ruiz Santa Clara Stephen Ryu Palo Alto

IM GS Resident SCVMC Resident SCVMC Resident DR OBG Resident Resident Resident SCVMC Resident *EM SCVMC Resident SCVMC Resident CS PD AN Resident IM Resident GS Resident SCVMC Resident *AN SCVMC Resident GS Resident GS Resident PMR GS Resident FM GS Resident *R US P AN Resident SCVMC Resident AN Resident PMR PM IM OBG GS Resident GS Resident Med Student AN Resident GS Resident AN Resident Med Student AN Resident SCVMC Resident GYN SCVMC Resident SCVMC Resident R GS Resident FP EM SCVMC Resident SCVMC Resident AN Resident US GS Resident Med Student NEP Resident NS

40 | THE BULLETIN | JANUARY / FEBRUARY 2012

David Saito Ramin Saket Louis Salamone Arghavan Salles Hussein Samji Diane Sanchez Amanda Sandford Manpreet Sanghjari Arbella Sarkis Laura Saucier Amit Saxena Lindsay Sceats Justin Schaffer Aatman Shah Melissa Shah Samee Shahzada Lauren Shapiro Hubert Shih Vijay Singh Roopam Sirohji Daniel Skully Jan Sliwa Brian Smith Jane Snyder Tara Sood Derek Southwell Christopher Starr Jason Steinberg Sara Stern-Nezer Kimberly Stone Christianne Strickland Patrick Sullivan Kevin Sun Trenna Sutcliffe Timothy Sweeney Sultana Tabaraee Al Taira Candice Tam James Tan Vivianne Tawfik Tust Techasith Natacha Telusca Mediget Teshome Peter Than Hariharan Thangarajah Maung Tin Andrew Tran Khoi Tran Tiffany Tran Tatyana Travkina Allison Truong John Truong Halley Tsai Janet Tsui Sanjeev Tummala Ankeet Udani John Van Arnam Srimathi Venkatarman Norma Villabon

Mtn View Santa Clara Stanford Stanford San Jose Gilroy Palo Alto Mtn View San Jose Stanford Santa Clara Stanford Stanford Stanford San Jose Santa Clara Phoenix Stanford Sewell Santa Clara Santa Clara San Jose Campbell Mtn View San Jose Stanford San Jose San Jose San Jose Stanford Los Gatos Stanford San Jose Palo Alto Stanford San Jose Campbell Santa Clara Stanford Stanford San Jose San Jose Stanford Stanford Stanford Santa Clara Stanford Mtn View Santa Clara Stanford Stanford San Jose San Jose Santa Clara Cupertino Stanford Santa Clara Santa Clara Stanford

OTO DR NER GS Resident GS Resident *OTO OBG PD US FP GER Med Student Resident Med Student GS Resident Med Student SCVMC Resident US Med Student GS Resident RHU Resident Resident SCVMC Resident *AN D EM GS Resident SCVMC Resident SCVMC Resident SCVMC Resident GS Resident *PD Med Student SCVMC Resident PD GS Resident SCVMC Resident RO AN AN Resident AN Resident SCVMC Resident SCVMC Resident GS Resident GS Resident GS Resident IM Med Student GS Resident AN Resident Med Student SCVMC Resident SCVMC Resident OPH GE AN Resident Resident US Med Student

In Memoriam Jesus R. Camara, MD

Harold N. Lynge, MD

General Practice 9/25/22 – 2/20/11 SCCMA member since 1972

Neurological Surgery 1/1/22 – 8/26/11 SCCMA member since 1959

William Clark, MD

Cornelio D. Mariano, Jr, MD

*Internal Medicine 10/27/18 – 7/30/11 SCCMA member since 1948

General Practice 7/27/38 – 9/30/11 SCCMA member since 1984

Robert W. Danielson, MD

George Perlstein, MD

*Obstetrics & Gynecology 4/20/21 – 11/26/11 SCCMA member since 1961

Administrative Medicine *Neurology 2/12/36 – 10/13/11 SCCMA member since 1970

Tadashi Kadonaga, MD

Francis H. Schipfer, MD Internal Medicine 11/26/13 – 2011 SCCMA member since 1950

Bryan M. Shieman, MD *Orthopaedic Surgery 3/21/25 – 8/17/11 SCCMA member since 1960

George M. Rugtiv, MD

*Obstetrics & Gynecology 8/26/28 – 8/25/11 SCCMA member since 1963

*General Surgery 6/21/21 – 11/20/11 SCCMA member since 1955

Nicholas R. Trueblood, MD *Obstetrics & Gynecology Infertility 11/28/34 – 8/16/11 SCCMA member since 1968

New Members, from page 40 John Vorhles Ann Vosti Matthew Wagaman Andrew Wall Ange Wang Lora Wang Tammy Wang Tianyl Wang Elizabeth Ward Laura Webb Allison Webb-Perez Ann Weinacker Mark Welton Nicole Wilcox Bradley Williams Ryan Williams William Williams Becky Wong Lauren Wood Linda Xu Lily Yan

Stanford Mtn View Stanford Stanford Stanford San Jose San Jose Stanford Palo Alto Santa Clara Santa Clara Stanford Stanford Mtn View Santa Clara Stanford Santa Clara Stanford Stanford Stanford Stanford

GS Resident OBG AN Resident AN Resident Med Student SCVMC Resident SCVMC Resident GS Resident P PD OBG PUD CCM CRS OBG ADM US Resident ORL AN Resident Med Student GS Resident Med Student

Dominique Yang-Kim Inna Yaskin Celia Yau Emily Yen Victoria Yin Michael Yokell Lauren Yokomizo Mackensie Yore Li Yu Yulia Zak Ali Zaki Elizabeth Zambricki Kamakshi Zeidler Sanford Zeigler Jeanie Zhang Navid Ziran Dimitar Zlatev

Santa Clara Mtn View Santa Clara Santa Clara San Jose Stanford Stanford Stanford Santa Clara Stanford San Jose Stanford Campbell Stanford San Jose San Jose Stanford

US *IM *GER HPM US Resident IM Resident Med Student Med Student Med Student IM GS Resident OBG INF GS Resident PS GS Resident SCVMC Resident ORS GS Resident

* - Board Certified | US - Unspecified

Monterey County Medical Society Aytac Apaydin Jose Chibras Leslie Foote Richard Garza

Salinas Salinas Salinas Monterey

U IM FP GS

Jeffrey Keating David Perrott Wayne Shen Neelima Vegesna

Monterey Salinas Salinas Salinas

PTH ORL N OBG

JANUARY / FEBRUARY 2012 | THE BULLETIN | 41

Classifieds office space for rent/ lease FOR LEASE-FULLY IMPROVED MEDICAL CLINIC • SOUTH MONTEREY COUNTY 5,858 sq. ft. medical facility includes 10 exam rooms, four doctor office spaces, x-ray room/ viewing area – fully leaded, surgical procedure room, gym/physical therapy area, laboratory, break room/kitchen, two individual men’s and women’s restrooms (staff and public) – ADA accessible, day care area, nurses station, storage/closet areas. Tenant improvements totaled $950,000! Have all construction drawings on hand. If you have any questions, or would like to schedule a tour, please call 831/320-5051. Currently, the clinic is vacant.

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.

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 408/9968717. Brokers welcome if you have a client. $2.00 per sq. ft. plus 3N. Located at 1196 South De Anza at Rainbow.

MEDICAL/DENTAL OFFICE SPACE FOR LEASE • MTN VIEW Medical/dental office space located at 2500 Hospital Dr, Bldg I, Mountain View. Call 831/375-6105.

DOWNTOWN MONTEREY OFFICE FOR SUBLEASE Spacious, recently remodeled, excellent parking, flexible terms. Call Molly at 831/6449800.

NEWLY UPDATED 1,508 SQ. FT. MEDICAL SUITE Available now, in all-medical building next to Regional Medical Center. Four exam rooms, two offices, reception, ADA restroom, galley kitchen, storage, sound speakers in all rooms. Some furniture, exam tables included.

Great space, available now. $3,770 gross.

Call or email Liz Walker at 408/436-8386 or lizwalker@reliablepropertymanagement.net.

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.

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.

PRIME MEDICAL OFFICE FOR LEASE • SAN JOSE Excellent location. Westgate area. 1,584 sq. ft. West Valley Professional Center, 5150 Graves Ave. Suite 2/stand-alone unit. Private office, reception area, exam rooms with sinks. Available 2/1/11. Call owner at 408/8671815 or 408/221-7821.

42 | THE BULLETIN | JANUARY / FEBRUARY 2012

METRO MEDICAL BILLING, INC. • • • • • •

Full Service Billing 25 years in business Book Keeping ClinixMIS web based software Training and Consulting Client References

Contact Lynn (408) 448-9210 lynn@metromedicalbilling.com Visit our Website www.metromedicalbilling.com

Pajaro Dunes

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.

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. Timeshare also available. Call Betty at 408/8482525.

PRIME SALINAS MEDICAL OFFICE FOR LEASE 2,150 sq. ft. available, across from Salinas Valley Memorial Hospital. 1045 Los Palos; five examination rooms, laboratory, sterilization, two private offices. Call or email Dr. Hirasuna at 831/484-9439, hi2jtsumo@gmail. com.

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

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

MEDICAL/OFFICE SPACE FOR LEASE • SALINAS Immediately available for lease in modern office building. The office is fully plumbed, wired, and contains approximately 1,235 sq. ft. The office includes a balcony area and use of a large parking lot. Located at 224 San Jose St. Suite 4, across from Salinas Valley Memorial Hospital in Salinas. For more information, call Harold Gordon at 831/594-8920.

SANTA CLARA OFFICE • HOMESTEAD AND JACKSON Plumbed for Dental/Medical, or other use.

1,200 sq. ft. Downtown across from post office and weekly farmers market. Excellent location! Dentist on site, please do not disturb.

Don’t miss! Come see! Call 408/838-8191 or 408/741-1956.

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.

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

HAPPY NEW YEAR WE CAN HELP • Transition from ICD-9 • Work with your office to set up your EMR • Recreate forms • Over 20 years of Medical Practice Experience • Billing/Coding • Marketing Call for complimentary consultation

831-324-0441

Integrated Physician Services ipsmonterey.com

physiatrist) interested in joining our team of professionals in providing high quality occupational medical services to Silicon Valley firms and their injured employees. We can provide either an employment relationship including full benefits or an independent contractor relationship. Please contact Rick Flovin, CEO, at 408/228-0454 or e-mail riflovin@allianceoccmed.com for additional information.

INTERNIST WANTED San Jose Medical Group has an immediate opening for a Board Certified, experienced Internist. One of our busy Internists relocated to Southern California recently, creating an opportunity for the right candidate to step into a successful growing practice. Must have excellent communication, clinical, and interpersonal skills. Excellent salary and benefits with bonus opportunities. Please fax CV to 408/278-3181 or email Tania_mcadams@ sanjosemed.com.

San Jose State University CAREER OPPORTUNITY

Psychiatrist Anticipated Hiring Salary: $8,731 - $10,107/month (prorated for a 10/12 Pay Plan) Please note: Applicants interested in PART-TIME or FULL YEAR employment are encouraged to apply.

The Student Health Center provides a variety of medical services, which are similar to the outpatient care provided in a physician group practice. These services for students include primary and urgent/acute care, evaluation, treatment, and guidance for individual health problems, family planning services, public health prevention programs, and health education. In addition, the SHC provides limited initial care for work-related injuries of employees, and if necessary, assists in referring such persons for ongoing care. The SHC may also provide first aid to campus visitors. SHC employees are expected to work cooperatively, with the entire SHC team, to help determine the most effective delivery of the above services.

Education and Experience • Possession of a valid license to practice medicine in California.

• Possession of a Drug Enforcement Agency license for writing controlled pharmaceutical prescriptions.

• Possession of Medical Board certification in the specialty of psychiatry. If boardeligible, the physician must become board-certified as soon as possible, but not later than two years after the date of hire.

• Completion of a one-year internship, or the equivalent postgraduate year of training • Completion of three additional years of specialized training in the field of psychiatry.

• Minimum of one year of experience in the practice of psychiatry after completion of a psychiatry residency program.

• Completion of annual continuing medical education requirement.

• Possession of a cardiopulmonary resuscitation certificate is preferred.

First Screening Date December 5, 2011 This position is open until filled; however, applications received after the first screening date will be considered at the discretion of the university.

Required Application Materials • Resume • Letter of Interest • Completed SJSU Online Employment Application: To apply, please visit our website at: http://apptrkr.com/216110 EOE Contact Information One Washington Square, San Jose, CA 95192-0046 Phone: 408/924-2250 Fax: 408/924-1784 Email: hrsg@sjsu.edu JANUARY / FEBRUARY 2012 | THE BULLETIN | 43

Classifieds, from page 43

CAREER OPPORTUNITY

Make San Jose State University Your University of Choice Psychiatric/Mental Health Nurse Practitioner Anticipated Hiring Salary: $4,679/month - $6,939/month (prorated for a 10/12 Pay Plan) The Student Health Center provides a variety of medical services, which are similar to the outpatient care provided in a physicians’ group practice. These services for students include primary and urgent/acute care, evaluation, treatment, and guidance for individual health problems, family planning services, public health prevention programs, and health education. In addition, the SHC provides limited initial care for work injuries of employees, and if necessary, assists in referring such persons for ongoing care. The SHC may also provide first aid to campus visitors.

Education and Experience • California Registered Nurse License • Nurse Practitioner Furnishing License • Certification through the California Board of Registered Nursing as a Nurse Practitioner • Successful completion of a Nurse Practitioner program that conforms to the standards of the Board of Registered Nursing or possess equivalent training and experience as outlined by the California Board of Registered Nursing (BRN).

• Willingness to train for job responsibilities equivalent to a PMHNP. • Completion of the Continuing Education requirements First Screening Date December 5, 2011 This position is open until filled; however, applications received after the first screening date will be considered at the discretion of the university.

Required Application Materials • Resume • Letter of Interest • Completed SJSU Online Employment Application: To apply, please visit our website at: http://apptrkr.com/216127 EOE Contact Information One Washington Square, San Jose, CA 95192-0046 Phone: 408/924-2250 Fax: 408/924-1784 Email: hrsg@sjsu.edu

44 | THE BULLETIN | JANUARY / FEBRUARY 2012

EMPLOYMENT OPPORTUNITY Physician/Locum tenens for Family/Internal Medicine. Office based practice only. Coverage mostly needed during vacation. Parttime, must have excellent communication, interpersonal and clinical skills. Please fax CV to 408/356-6676.

FOR SALE SL65 MERCEDES BENZ V12 Twin Bi Turbo 604 HP. Silver metallic, light grey interior at $13,000 original down.

Contact 408/621-4350. $80,000.

OFFICE EQUIPMENT New, unused infant papoose board and rolling metal shelving system – four shelves, 35 in. long, 18 in. deep, 3-6 feet high (adjustable). Call Lauren at 408/358-0223 (9-12 and 2-4 pm, Monday – Thursday).

FOR THE OUTDOORS MAN OR WOMAN • GET A JUMP ON SUMMER ACTIVITY Multiple knapsacks, backpacks, fanny packs.

Ridgeway sleeping bag, never opened, never used. Coleman sleeping bags, like new. Polaron alum. ice chest with water jug. Call/ voicemail Lee at 408/510-9669.

Tracy Zweig Associates A

REGISTRY

&

PLACEMENT

FIRM

Physicians

Nurse Practitioners ~ Physician Assistants

Locum Tenens ~ Permanent Placement 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

tzweig@tracyzweig.com w w w. t r a c y z w e i g . c o m JANUARY / FEBRUARY 2012 | THE BULLETIN | 45

Learn more at www.infocaredr.com or call 1(800)647-3678

RECORD MANAGEMENT SOLUTIONS Electronic Document Management • Application Services • Business Process Automation Solutions • Scanning & Conversion Services Record Retention Management & Confidential Destruction Secure Offsite Storage 1.800.957.5051 x137 www.srcpdeliverex.com

San Jose | San Francisco | Hayward | Sacramento 46 | THE BULLETIN | JANUARY / FEBRUARY 2012

We Celebrate Excellence – Corey S. Maas, MD, FACS CAP member and founder of “Books for Botox®” community outreach program, benefitting the libraries of underfunded public schools

800-252-7706 www.CAPphysicians.com

San Diego orange LoS angeLeS PaLo aLTo SacramenTo

For over 30 years, the Cooperative of American Physicians, Inc. (CAP) has provided California’s finest physicians, like San Francisco facial plastic surgeon Corey Maas, MD, with superior medical professional liability protection through its Mutual Protection Trust (MPT).

Physician owned and physician governed, CAP rewards excellence with remarkably low rates on medical professional liability coverage – up to 40 percent less than our competitors.

CAP members also enjoy a number of other valuable benefits, including comprehensive risk management programs, best-in-class legal defense, and a 24-hour CAP Cares physician hotline. And MPT is the nation’s only physician-owned medical professional liability provider rated A+ (Superior) by A.M. Best.

We invite you to join the more than 11,000 preferred California physicians already enjoying the benefits of CAP membership.

Superior Physicians. Superior Protection.

JANUARY / FEBRUARY 2012 | THE BULLETIN | 47

BULLETIN THE

PRSRT STD U.S. Postage PAID San Jose, CA Permit No. 503

Address service requested

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

years

or very satisfied

93%

in a row of a.M. Best “A” (ExcEllEnt) RAting

of last

total years deClared dividend

28

32 34

Customers satisfied

700 Empey Way, San Jose, CA 95128-4705

$425M totAl DiviDEnDs DEclARED

95

renewal rate

To make a calculated decision on medical liability insurance, you need to see how the numbers stack up—and there’s nothing average about NORCAL Mutual’s recent numbers above. We could go on: NORCAL Mutual won 86% of its trials in 2010, compared to an industry average of about 80%; and we paid settlements or jury awards on only 12% of the claims we closed, compared to an industry average of about 30%.* Bottom line? You can count on us. *Source: Physician Insurers Association of America Claim Trend Analysis: 2010 Edition.

strenghten your Practice at norcalMutual.coM Proud to be endorsed by the Monterey County Medical Society and the Santa Clara County Medical Association.

Our passion protects your practice