2016 March/April

MARCH / APRIL 2016 VOLUME 22 | NUMBER 2

RETHINKING MENTAL ILLNESS

WILL NEUROSCIENCE LEAD THE WAY?

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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

Feature Articles

Billing/Collections

10 Brain Waves: How Neuroscience Could Determine

CME Tracking Discounted Insurance Financial Services Health Information Technology

Your Mental Health Treatment 16 mHealth Best Practices & Top Apps For Doctors & Patients 24 What Does the CCI Mean for Physicians?

Resources House of Delegates Representation Human Resources Services

Departments 5 From the Editor’s Desk

Legal Services/On-Call Library

7 Message From the MCMS President

Legislative Advocacy/MICRA

27 Retirement – A Report and A Request for Help

Membership Directory iAPP for

28 Medical Times From the Past

the iPhone Physicians’ Confidential Line Practice Management Resources and Education Professional Development Publications Referral Services With

30 Welcome New Members 33 In Memoriam: Edward A. Hinshaw 34 MEDICO News 40 Classified Ads 42 Practice Management: Tip of the Month

Membership Directory/Website Reimbursement Advocacy/ Coding Services Verizon Discount MARCH / APRIL 2016 | THE BULLETIN | 3

THE SANTA CLARA COUNTY MEDICAL ASSOCIATION OFFICERS President Eleanor Martinez, MD President-Elect Scott Benninghoven, MD Past President James Crotty, MD VP-Community Health Cindy Russell, MD VP-External Affairs Kenneth Blumenfeld, MD VP-Member Services Anh Nguyen, MD VP-Professional Conduct Vanila Singh, MD Secretary Seema Sidhu, MD Treasurer Seham El-Diwany, MD

CHIEF EXECUTIVE OFFICER

COUNCILORS

William C. Parrish, Jr.

El Camino Hospital of Los Gatos: Ryan Basham, MD El Camino Hospital: Vacant Good Samaritan Hospital: David Feldman, MD Kaiser Foundation Hospital - San Jose: Hemali Sudhalkar, MD Kaiser Permanente Hospital: Martin Wong, MD O’Connor Hospital: Michael Charney, MD Regional Medical Center: Erica McEnery, MD Saint Louise Regional Hospital: Diane Sanchez, MD Stanford Health Care / Children's Hospital: John Brock-Utne, MD Santa Clara Valley Medical Center: Clifford Wang, MD

CMA TRUSTEES - SCCMA Thomas M. Dailey, MD (District VII) Tanya Spirtos, MD (District VII)

BULLETIN

THE MONTEREY COUNTY MEDICAL SOCIETY

Editor

OFFICERS

THE

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

Printed in U.S.A.

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. The Bulletin and SCCMA/MCMS reserve the right to reject any advertising.

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 2016 by the Santa Clara County Medical Association.

4 | THE BULLETIN | MARCH / APRIL 2016

President James Hlavacek, MD President-Elect Vacant Past-President Jeffrey Keating, MD Secretary Edward Moreno, MD Treasurer Cary Yeh, MD

CHIEF EXECUTIVE OFFICER William C. Parrish, Jr.

DIRECTORS Paul Anderson, MD Valerie Barnes, MD Ronald Fuerstner, MD Gary Gray, DO Steven Harrison, MD David Holley, MD

John Jameson, MD William Khieu, MD Eliot Light, MD James Ramseur, MD Marc Tunzi, MD Craig Walls, MD

Dr. Quentin D. Young, Public Health and Civil Rights Advocate

Dr. Young’s medical training and career was intimately connected to Cook County Hospital. As chairman of the department of medicine, he worked tirelessly to improve the county public health system. He was fired twice from his position and rehired by the hospital’s governing body, involving his support of young interns and resident physicians who went on strike for improved conditions.

Dr. Margaret Flowers, a U.S. Senate candidate in Maryland recalls, “I think it was Quentin who coined the phrase — ‘everybody in, nobody out.’”

May this be an opportunity for reflection, inspiration and a reminder of how our life’s work can be much more far reaching than we realize.

Editor, The Bulletin

His parents were Eastern European immigrants who met in North Carolina. Growing up in the South, a young Quentin was affected by witnessing the difficulties faced by African-American sharecroppers in North Carolina. His father earned a pharmacy degree from Fordham University and the family later moved north, finally settling in Hyde Park. Dr. Young graduated form Hyde Park High, the University of Chicago and completed his MD degree at Northwestern University in 1947.

Consumer advocate Ralph Nader said “Dr. Young was a physician for all seasons — for his patients, for public health facilities, for workplace safety and for full Medicare for all people with free choice of doctors and hospitals.”

JOSEPH S. ANDRESEN, MD

On March 7th, we lost a remarkable physician and individual. Dr. Quentin D. Young, age 92, died at his daughter Polly Young’s home in Berkeley, California. Dr. Young was a personal physician to Martin Luther King, Jr. and a life long advocate for universal health care. His medical practice spanned 60 years finally retiring in his mid 80’s.

Located in Hyde Park, he took care of patients from all backgrounds, notably including then Chicago Mayor Harold Washington, the Beatles, and Barack Obama.

And at age 77, Dr. Young participated in a 15 day, 167-mile walk across Illinois to promote universal health care. His strong belief in a single payor health care system available to everyone left him at odds with President Obama’s Affordable Care Act. In Dr. Young’s 2013 autobiography — “Everybody In, Nobody Out: Memoirs of a Rebel Without a Pause,” Young writes that “had I been in Congress, I would have unequivocally voted against Obamacare.”

EDITOR'S DESK

Physician Editor, The Bulletin

a rock to the head and had to be sewn up.”

FROM THE

By Joseph Andresen, MD

Joseph S. Andresen, MD, is the editor of The Bulletin.

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

Advocating for social justice dovetailed with medicine in the arc of Dr. Young’s life. He was a volunteer registering black voters during Mississippi’s Freedom Summer in 1964. He marched from Selma to Montgomery, Alabama in 1965 during the Civil Rights movement. “I received the honor of looking after King during the march,” Young said. “He took MARCH / APRIL 2016 | THE BULLETIN | 5

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President, Monterey County Medical Society

I recently attended the Center for Healthcare Governance Conference. The quote above is, “Be at the table, or be on the menu!” Medicine continues to be under attack from all sides, and the only way we are going to succeed in this difficult environment is to be actively engaged, and yes, be at the table! Your membership in MCMS and CMA is your seat at the table!

The conference highlighted many shifts in the direction of health care systems (no longer hospitals) to be more consumer focused. The rise of Yelp, Healthgrades, and other websites to rate physicians is a trend that will determine more and more how patients make decisions on where they will receive health care. Word of mouth referrals are being used less and less as patients search the internet for the highest ranking doctor. The University of Utah Health Center is one organization that has been very successful at using social media to connect with patients and improve their performance and grow.

Their presentation about how they have focused on patient comments to improve their services was most impressive.

The other trend is big business’s joint ventures with health care systems to open clinics in retail stores. The example was putting urgent care centers in Walmart and Target. The opinion data from patients treated in these centers showed very high patient satisfaction.

The elections are now getting more and more coverage at the local level. I’m not talking about Hilary, Bernie, The Donald, or Ted, but about Jane and Dennis, Mary and Dave, Fernando, Luis, and Tony, Karina and Anna, Casey and Jimmy, all of whom are running for public office. Your Board of Directors has had one round of interviews with the candidates and will have two more sessions to get to know the candidates and their positions. The Board may then decide to endorse certain candidates. Stay tuned!

At a CSUMB reception for diversity in health care, I met Dr. Donna Christian-Christensen, MD. She is the first female physician elected to the House of Representatives. Donna was a long serving member of Congress from the U.S. Virgin Islands. I didn’t realize that we had Representatives from The Virgin Islands. They can do everything the other 435 can, except vote! She was very active in the legislation to get the Affordable Care Act passed. She told me she was heading to South Carolina to campaign for Hil-

JAMES M. HLAVACEK, MD

President, Monterey County Medical Society

ary Clinton!

Our Board met with Arthur Lurvey, MD, the physician contractor medical director of Noridian Healthcare solutions, which is the organization that pays the bills we send to CMS. Arthur, an endocrinologist, was very entertaining and presented an informative and funny slide show. He is on the side of physicians. The main point of his talk was that we need to properly document everything we send for payment. Dr. Lurvey also gave a presentation for doctor’s offices earlier that day, with about 50 people in attendance.

The Natividad Family Medicine residency recently matched all 10 positions. Steve Harrison, MD, Board Member and Residency Director told me there were over 700 applicants, and 140 interviews for the 10 slots. The new interns come from all over the USA, and there will be seven men and three women. Great work Steve and your staff!

March 30th is Doctor’s Day. This national day of recognition was commissioned by President George H.W. Bush. The fact that the day is the anniversary of the first public demonstration of ether general anesthesia is something I am most proud of. At Natividad, my main hospital, I have organized a reception and dinner to honor our doctors and medical students. This will be our 1st annual Doctor’s Day celebration.

The End of Life legislation (Right-to-die) will become law on June 9th. Senator Bill Monning, one of the bill’s authors has been holding meetings to inform the public about how the implementation of the law will work. There will be a public forum in Monterey on April 29th. If any members are interested in representing the Medical Society at this meeting, please let me know. I can give you the contact information.

Our annual Monterey County Medical Society dinner is June 16th at Corral de Tierra Country Club. You will soon be receiving your ballots for our Physician of the Year. We are also recruiting for new Board Members. Board members are advocates and information sources for our members, and the general public. If interested, please contact me, or Jean Cassetta at 831/455-1008.

My term as your President is almost up. I want to thank all of you for your support and encouragement. I would also like to thank Bill Parrish our Executive Director, Jean Cassetta, Leslie Sorensen, Pam Jensen, Sandie Moore and the support staff for all their hard work.

MESSAGE FROM THE

By James M. Hlavacek, MD

MCMS PRESIDENT

Be at the Table

James Hlavacek, MD, is the 2015-2016 president of the Monterey County Medical Society. He is an Anesthesiologist and is currently practicing Chief-of-Staff with Natividad Medical Center, in Monterey, and also practices at George L. Mee Memorial Hospital.

MARCH / APRIL 2016 | THE BULLETIN | 7

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Brain Waves How neuroscience could determine your mental health treatment

T

he elderly gentleman’s screams echoed down the halls of the transitional home for the mentally ill, the voices in his head torturing him. His only relief came when he held a transistor radio, tuned into static, tightly clamped to his ear.

“The voices were not quieted by medication,” says Leanne Williams, PhD, a Stanford neuroscientist who vividly remembers her patient from nearly three decades ago, when she was training to become a therapist in Australia. Many of the patients she cared for during those three years in her 20s had been institutionalized for years — some for decades. An older woman who believed she was constantly about to give birth, tortured daily by labor pains. A severely depressed young man whom Williams and her co-worker found one morning hanging lifeless from the back of a bathroom door, the depression finally too much for him to bear.

The experience was frustrating, Williams says. As a therapist, she believed that by understanding the psychology of human behavior she could treat these severely mentally ill patients. But she soon realized she simply didn’t have enough tools to understand what was going on inside their brains. Instead, she began to learn from her patients.

“It struck me that the man who heard voices was using the sound frequencies on his radio to modulate his brain activity, yet we were bereft of treatments to do anything similar,” she says. “I finished up these work experiences with 100 percent clarity that I needed next to go into research. I wanted to understand brain dynamics and how this understanding could be connected to the real-world experience of mental disorder. From then on, I was on a mission.”

By Tracie White This article was originally published in the winter 2016 issue of Stanford Medicine magazine. It is republished with permission from the Stanford School of Medicine’s Office of Communication & Public Affairs.

10 | THE BULLETIN | MARCH / APRIL 2016

SPECIAL TO THE BULLETIN

MARCH / APRIL 2016 | THE BULLETIN | 11

‘MINDLESS NEUROSCIENCE, BRAINLESS PSYCHIATRY’

The past quarter-century has seen a wealth of advances in neuroscience, from neuroimaging techniques that make it possible to see inside the live human brain to noninvasive electrical brain stimulation to selective activation of neurons using laser light for research in animals. The popularity of the field has exploded, with membership of the Society for Neuroscientists steadily climbing from its founding in 1969 to 40,000 members today. Yet little if any of this activity has resulted in improvements in clinical care for the mentally ill.

“We haven’t yet seen the progress toward improved clinical care that we would have hoped,” says Sarah Morris, PhD, acting director of the National Institute of Mental Health’s Research Domain Criteria Initiative, a program begun five years ago to accelerate the translation of basic neuroscience research into new models for mental disorder and treatment. This gap, often caricatured as “mindless neuroscience versus brainless psychiatry,” must be bridged if modern neuroscience is to bring help to the mentally ill, wrote Thomas Insel, MD, in May 2015 in Director’s Blog, the blog he produced as director of NIMH. The disconnect can, in part, be explained by the lack of a working biomedical model of mental illness, many in the field say. The current model of mental health treatment, in use since the days of Freud, is based solely on observation by clinicians and the reporting of symptoms by patients.

The new model combines these traditional methods of diagnosis and treatment with the biological concept of the brain as a network of circuits.

The circuit, or network, approach focuses on how the billions of neurons in the brain communicate with one another via electrical signals. It cuts across the current broad diagnostic categories like anxiety or depression, with the hope of creating a new understanding of exactly what mental illness is.

The circuit approach, Williams says, provides a scientific path toward more accurate disease diagnosis and treatment while helping eliminate the stigma associated with mental illness as a personal failing or weakness.

“You boil it down to the superhighways of the brain, which are the routes where most of the neuronal traffic is going for the primary functions of the brain,” Williams explains. “Imagine the road system. There are all these little hiking trails, then you’ve got the big superhighways where most of the traffic occurs. These brain circuits are explaining those main routes.” Almost daily, new studies are published mapping these circuits and explaining what they do. Or what they don’t, when altered or destroyed.

It’s been nearly 30 years since Williams moved on from her career as a therapist and entered the world of brain research. And she’s getting restless. Personalized neuroscience, a form of precision health that provides the best treatment for each individual patient, has the potential to change lives now, she maintains.

“I’m shocked so little of this research has bridged this gap,” says Williams. She is running a clinical neuroscience study called the Research on Anxiety and Depression, or RAD, project. Funded by NIMH to develop the Research Domain Criteria Initiative approach, hers is one of the first studies to test a step-by-step process that combines neurobiological tests, such as brain scans, with measures of real-world function, such as occupational and social well being, to diagnose and treat patients. She describes it as a “pragmatic” research design that mirrors what would happen in an actual mental health clinic using this approach. By making it comfortable 12 | THE BULLETIN | MARCH / APRIL 2016

and practical for participants, she has designed a prototype for use in the real world.

The trial is an attempt to find an array of biological markers to classify anxiety and depression in new ways. It draws on the new model emerging from neuroscientists and psychiatrists — one that incorporates an examination of the brain as an organ much like a cardiologist examines the heart.

“We take it for granted in other areas of medicine that the organ is relevant,” Williams says. “When you go to see the heart doctor with a heart problem, you would expect them to run tests. Right now in psychiatry we don’t think about the brain at all when we are making a diagnosis or planning a treatment.”

It’s time we did, she says.

CHECKING THE CIRCUITS

Noreen Ford, a 59-year-old middle school teacher who lives in Belmont, California, is lying on her back inside a brain scanner — a functional magnetic resonance imaging machine — located in a lab in the university’s Main Quad. A mechanical chunk-chunk-chunking noise startles her at irregular intervals. She’s suffered mild depression on and off and had panic-like symptoms, but primarily she signed up for the RAD trial because, like many of the other participants, she was interested in “seeing inside my brain.”

On a screen in front of her face flashes a series of photographs of smiling and terrified faces. She is supposed to push one of two buttons — one to indicate happy, the other to indicate fearful. This is one of several tests she will take during the hour or so spent inside the machine, each triggering a different brain circuit associated with depression and anxiety.

Williams sometimes seems as much a clinician as a brain scientist: Dressed more formally than the typical researcher, she drops by the lab regularly to check in and offers her lab assistants quiet encouragement.

Williams describes the multiple fMRI tests that participants take as akin to “exercise for the brain.”

Over the past two years, Ford and about 160 other participants with either anxiety or depression or a combination of the two have participated in RAD. They each spend a day on the Stanford campus for testing. They donate a swab of saliva for a genetic test that can help pinpoint antidepressant effectiveness and the influences of genetic variations on brain circuits, and they take a battery of “brain tests” while inside the fMRI machine for about an hour. After a walk across campus from the lab to the psychiatry building, meant to provide a relaxing break, participants eat lunch and then undergo a traditional symptom-based psychiatric evaluation.

Williams reads and interprets the resulting brain scans, searching for any abnormalities in those circuits. In an optional feedback session, Williams, the patient and the patient’s therapist meet together in a comfortable therapy room to discuss how the patient’s brain is functioning and possible treatment options, such as drugs, psychotherapy or brain stimulation. All participants also take a follow-up survey 12 weeks after the initial testing. The researchers plan to continue the trial through 2017.

“The results provide a lot more detailed information about what is going on with our clients,” says clinical psychologist Nancy Haug, PhD, the research director at the Gronowski Center, a community mental health clinic and a collaborator with the RAD study. “A lot of times, the information confirms what our therapists already know and are already doing;

SPECIAL TO THE BULLETIN

“There is no objective way of saying which treatment will work best for which patient. …It can take a few years of trial and error."

MARCH / APRIL 2016 | THE BULLETIN | 13

other times it might suggest different treatment alternatives. Often the feedback sessions are very helpful.”

INTO THE CLINIC

Globally, 405 million people experience depression and 274 million experience anxiety disorder. These disorders are the main causes of disability and lost productivity, with an economic cost of about $50 billion per year, according to a study published in a 2013 issue of The Lancet.

The current treatment model relies on finding a treatment through a process of elimination.

“There is no objective way of saying which treatment will work best for which patient,” Williams says. “Thirty percent of the time it will work.

The other 70 percent of the time it fails. It can take a few years of trial and error. What is happening to your brain in the meantime is that it is becoming more and more unwell.”

Patients grapple with new side effects each time they try a new drug, or withdrawals each time they change drugs. They jump from drugs to talk therapy to combined treatments and back again, searching for what works for them. Sometimes they never find it.

To get people better faster, or to get a higher percentage of people better, new drugs are crucial, says Amit Etkin, MD, PhD, assistant professor of psychiatry and behavioral sciences at Stanford Medicine. But the psychiatric drug pipeline has virtually dried up. “There is a huge concern about a lack of new drugs,” says Etkin, who is also turning to neuroscience for improvements in mental health care.

RDoC, the NIMH project, has succeeded in increasing the pace of research bridging neuroscience and new clinical models, funding about 30 grants that each average $400,000 per year over four to five years. All of these are still in process, so they have not yet resulted in changes to clinical care.

Some neuroscience-based methods of treatment are close to cracking the clinical door, Etkin says. Brain stimulation methods such as transcranial magnetic stimulation or deep brain stimulation, which activate various brain circuits, have shown promising results as treatment for emotional disorders.

“It’s a very active area of research right now,” he says. He’s also optimistic about the prospect of using brain scans for the early detection of mental illness and getting patients into treatment prior to the onset of symptoms.

“Think of it like a cancer screening test,” he says. A routine fMRI scan would be part of a preventive-care treatment plan. “If you wait for symptoms, you’ve waited too long.”

An ongoing national clinical trial called EMBARC is another effort to use the personalized approach. Launched three years ago by psychiatrists at the University of Texas Southwestern Medical Center, the trial — much like RAD and Williams’ previous trial, iSPOT-D — is attempting to find biological markers that can better predict how people with depression will respond to medication. Helen Mayberg, MD, a professor of psychiatry at Emory University, made headlines recently with a study that identified a biomarker in the brain that predicts whether a depressed patient will respond better to psychotherapy or antidepressant medication.

Clinical trials are urgently needed to evaluate the efficacy of neuroscience-based treatments in clinical care, Mayberg says. She, like Williams, is an advocate for moving neuroscience research into the clinic now.

14 | THE BULLETIN | MARCH / APRIL 2016

“Patients just can’t wait for all the scientists to solve all the riddles of the brain,” Mayberg says. “Every few months, there’s another discovery of another tool to get at another aspect of how the brain is working. The hard part now becomes, how much do you need to know before you can do something practical with it?”

SEEING INSIDE THE BRAIN

The trajectory of Williams’ career has mirrored these developments in neuroscience. After studying behavioral psychology as an undergraduate and working as a clinical therapist for those three years in her 20s, she received a British Council scholarship to study for her PhD in cognitive neuroscience at Oxford University, which she earned in 1996, and began a career as a research scientist.

“I wanted to go to Oxford because of their history of innovative work linking clinical symptoms of mental illness to underlying physiology,” Williams says. “This was before the days of brain imaging, and the measures we used included performance on behavioral tasks, physiological recordings and eye-movement recordings.”

Understanding the brain as an organ became her new focus, and as technology advanced, functional magnetic resonance imaging became her new research tool.

“The more I wanted to understand what was really going on in the human brain, the more I knew I’d have to understand the neurobiology of the brain,” she says. The advent of new imaging tools like positron emission tomography and functional magnetic resonance imaging has been key to advances in modern neuroscience. A PET scan uses radioactive tracers to look for disease in the body. An fMRI measures changes in blood oxygen levels, which can indicate brain activity. In 1999, Williams was recruited to the University of Sydney’s psychology school and in 2004 to its medical school, where for 12 years she was the director of the Brain Dynamics Center, which aimed to help create a new neurobiological model of the brain for understanding mental illnesses.

For Williams, the RAD study is a benchmark in her career. Finally, findings from her years of brain research are being tested in clinical care.

To design the study, she has drawn on data from the iSPOT-D trial, which included more than 1,000 people with depression and revealed biomarkers — brain circuit patterns and genetic profiles — that appear to predict treatment response. Williams was the lead academic researcher of the industry-sponsored trial from 2008 to 2013.

For example, her report, published in the journal Neuropsychopharmacology, indicated that participants whose fMRIs showed low reactivity in the amygdala — a small structure in the brain that plays a key role in processing emotions — would respond better to the SSRI class of antidepressants like Prozac and Zoloft than to SNRIs like Cymbalta or Effexor.

It was this trial that initially brought Williams to Palo Alto. She came to Stanford, which was one of the study’s 12 sites, in 2011 as a visiting professor. In early 2013 she joined the faculty as a professor of psychiatry and behavioral sciences with a joint appointment at the Palo Alto Veterans Affairs Health Care System. Shortly thereafter, she was awarded the RDoC grant and began recruiting for the RAD trial.

TAILORING THE TREATMENT

The RAD study envisions a future in which a physician with an anxious or depressed patient would order various neurobiological tests,

SPECIAL TO THE BULLETIN

such as an fMRI brain scan, to help make a more precise diagnosis and to “I always think, how can we translate this back to the patient?” she guide treatment choice. Currently, the diagnostic categories are extreme- says. ly broad, Williams says. Patients with anxiety or depression could have “I talked to one software engineer who was finding it hard to concenwidely varying symptoms, and the cause could be very different, yet the trate at work,” she says. “He was needing to take a nap in the afternoon.” first-line treatment is often the same. The model she is developing breaks Using mappings of the engineer’s brain circuits, Williams explained down these broad diagnostic categories into “types” based on brain circuit how his “default mode” circuit was in overdrive even when he was at rest, dysfunctions. Matching each type of depression or anxiety with the best which put him into a state of rumination about his negative thoughts. This evidence-based treatment is the ultimate goal. disruption meant the man, who was depressed, had problems engaging his In the study, researchers scan six of the large-scale neural circuits “cognitive control” circuit and dampening down the ruminative thoughts that most neuroscientists agree are associated with anxiety and depres- in order to focus. Instead, his brain was stuck in overdrive, making it difsion. These circuits are evoked during different ficult to concentrate at work. tasks like the one Ford underwent in the fMRI When she talks to participants stuck in this machine. The intrinsic architecture of these cirstate of rumination and dysregulated circuits, she cuits is also scanned when the patient is at rest asks: inside the machine.

“When you wake up in the morning is your The six brain circuits are mapped out for brain immediately overwhelmed? Are you like “THINKING OF MENTAL each of the participants, then compared with how ‘Oh my God, I’ve got this to do, that to do, and I the circuits should look in a healthy brain. Any can’t see a way through’?

ILLNESS IN THESE TYPES deviations — faulty connections that are gener“When I give the feedback, I tell them to try ating too little or too much communication bethings that will help shift them out of that state of tween brain regions — are used to diagnose a speoverdrive. I think of analogies from heart health OF BRAIN TERMS SEEMED cific brain-based type of anxiety or depression. where the best current evidence suggests combinFor example, the “threat” circuit, which foling new interventions, drugs and lifestyle changlows a circular path of neuronal activity from the es. As a lifestyle change, try really fast walking, or MORE REASONABLE THAN amygdala to several other parts of the brain and listening to music, something that will get your back to the amygdala, is involved with how we rebrain into a different kind of rhythm because you act to threat or loss. Terrifying facial expressions, can’t ruminate while walking really fast or while THE CONCEPT OF MENTAL like those in Ford’s fMRI brain test, trigger this dancing, for example.” circuit. A breakdown in the “threat” circuit can The software engineer told her that he enresult in a type of depression Williams refers to as joyed Latin dancing, so she recommended he ILLNESS BEING SOMEONE’S the “negativity bias.” try that as a way to break out of rumination and “In depression, you will see some people get over-firing of his default mode circuit. A complestuck in one of those circuits for negative emomentary option was transcranial magnetic simuFAULT OR A LACK OF TRYING tion,” she says. “They’ll say they feel bad, that lation, which can help regulate the default mode everything feels bad. Trying to concentrate and circuit and the way it interacts with the cognitive switch to a different mode — a different circuit control circuit.

HARD ENOUGH.” — can be really hard, almost impossible.” In this “So that’s the concept of the personalized case, a clinician should pick a treatment that will approach,” she says. “Thinking of mental illness help get the patient unstuck. There is evidence in these types of brain terms seemed more reacertain antidepressants work well for this because sonable than the concept of mental illness being the action of the medication matches the funcsomeone’s fault or a lack of trying hard enough.” tion of the circuit, she says.

While it’s not yet clear how to deploy these “We are trying to link all this science to the real world,” Williams individualized treatments on a broad scale, Williams says, she believes it’s says. “We talk to participants about their symptoms, their work experi- time to try. ences, their quality of life, how they cope, how they regulate their emo“I don’t understand why we can’t do it now. It’s not unsafe. We are still tions. All the things that could be pertinent to how your brain functioning giving the same treatments. It’s hard to see a bad outcome. Why not try it?” relates to your experiencing the world.”

Tracie White is a science writer for Stanford School of Medicine’s Office of Communication & Public Affairs. Email her at traciew@stanford.edu.

PERSONALIZED PSYCHIATRY

As a neuroscientist conducting clinical research, Williams says it has been important to build strong partnerships with clinicians. Since she is no longer a therapist, she needs this pipeline for study recruitment, but she also believes communication with patients and therapists is essential if she wants to know how best to translate her research into clinical care.

MARCH / APRIL 2016 | THE BULLETIN | 15

mHEALTH / is an abbreviation for mobile health, a term used for the practice of medicine and public health supported by mobile devices. mHealth applications include the use of mobile devices in collecting community and clinical health data, delivery of healthcare information to practitioners, researchers, and patients, real-time monitoring of patient vital signs, and direct provision of care via mobile telemedicine.

By Marion Webb

With more and more Americans expressing interest in monitoring their health using mobile devices, and with doctors’ acceptance and usage of these technologies on the rise, the way to incorporate them into physician practices raises many questions and concerns. In this issue of The Bulletin, we will help clarify some of these issues, starting with the current regulatory framework and mHealth best practices. We’ll also take a look at the promise of using Apple software to help researchers track and study major diseases as well as how this information will ultimately benefit doctors. You’ll find a top 10 list of medical apps you can use in your practice today and the top 10 health apps to prescribe to your patients.

16 | THE BULLETIN | MARCH / APRIL 2016

REGULATORY FRAMEWORK There is no denying that the world of mobile health, or mHealth, is continually changing, due in large part to rapid advances made by the innovative industry. This, in turn, has brought challenges to regulating the industry in terms of ensuring proper consumer access and patient safety.

FDA Recent moves by the U.S. Food and Drug Administration (FDA) to provide more transparency regarding compliance with governing laws have been welcome news to the mHealth industry, which requested the transparency.

As it stands today, consumer apps such as those that track fitness or provide reminders for doctors’ visits and/or drug dosing schedules or save and display particular medical records are not regulated by the FDA, according to an article written by attorneys at Wiley Rein LLP. The agency also does not regulate mobile apps sold in the Apple iTunes Store or Google Play.

Remaining under FDA oversight, as stated in the FDA’s final guidance, are “mobile apps that are medical devices and whose functionality could pose a risk to patient’s safety if the mobile app were to not function as intended.”

Apps that clearly fall under FDA oversight and require clearance, the attorneys noted, comprise those that connect to a medical device to control it or are used for active patient monitoring or medical data analysis; transform mobile platforms into regulated devices by using attachments or functionalities similar to those found in regulated devices; or perform patient-specific analysis, diagnosis, or treatment recommendations.

The attorneys pointed out that confusion still exists for those inventing apps that include both characteristics of a “medical device” and an app that doesn’t fall under the FDA’s regulatory framework.

FCC Ambiguity also still exists when it comes to questions pertaining to privacy protection such as who monitors sensitive health data and where it gets stored, which are issues regulated by the Federal Communications Commission (FCC).

The FCC and FDA entered into a Memorandum of Understanding to collaborate with each other within the areas of their respective agencies.

The attorneys further noted that the FCC’s recent action to change the regulatory classification of broadband to be more highly regulated — in the same manner as safeguarding consumer data by telephone companies — by directing broadband providers to employ “effective privacy protections in line with their privacy policies,” may “unintentionally be muddying the waters.”

Although the new rules imposed through broadband reclassification apply only to broadband providers, a petition has already been filed by Consumer Watchdog to apply the new rules to edge providers like Google and Facebook to give the FCC authority to force those companies to honor consumers’ “do not track” preferences, the attorneys wrote.

While it remains to be seen what action the FCC will take, the request would extend new privacy rules to all edge providers, including mHealth apps.

FTC Finally, the Federal Trade Commission (FTC) also collaborates with the FDA and FCC to protect consumers from unfair and deceptive acts or practices as well as false or misleading claims, the attorneys wrote.

When it comes to mHealth, they said, the FTC has already been active in enforcing against mobile health app marketers that have not met those requirements.

The attorneys noted that while all three agencies seem to have adopted the idea of fostering regulatory flexibility, they also have reserved discretion given that mHealth appears highly innovative and complex.

MARCH / APRIL 2016 | THE BULLETIN | 17

According to an online study of 2,024 Americans

by Research Now, 56% of Americans want their doctors to monitor their health using connected health devices and both consumers and doctors believe that mobile health apps are beneficial to quality of life. Of 1,000 mobile health users surveyed, 60% said they use apps to monitor workouts and activity, and 53% use apps to get motivated to exercise. Using apps to monitor calorie intake and weight loss ranked third and fourth. Among the 500 surveyed healthcare professionals, the majority, or 86%, believed that using mobile health apps will increase their knowledge of their patients’ medical conditions, and 76% said it will help them manage patients with chronic diseases. Sixtyone percent said they believed they could use apps to help those at high risk for developing health issues, and 55% believed they could use them to help healthy people stay healthy.

This article is reprinted with the permission of Physician Magazine, a publication of PNN, www.PhysiciansNewsNetwork.com

FEATURE | mHEALTH & APPS

BEST PRACTICES FOR PHYSICIANS With the technology rapidly evolving, it may be difficult to figure out which mobile health solutions are right for you and your practice.

Here are some ways that doctors have successfully implemented mobile and portal technologies into their practices as well as what things to consider when doing so, according to Physicians Practice, a practice management website, and other experts.

1. Patient portals | Patient portals are a great way to streamline patient visits and help patients come to appointments more informed. A good way to approach this is to send patients a message prior to their visit to fill out paperwork and bring it to the visit.

2. Mobile apps | Mobile apps can be a great way to monitor patients’ health, and more doctors are open to prescribing them. According to Manhattan Research data, the conversation is more likely to take place if a doctor is part of an ACO. Some 90% of doctors who own a wearable device or use health apps themselves had discussions with patients about wearable devices. For the top consumer apps, see the sidebar of this story.

3. Text messages | More doctors also find that text messages are a great, effective and cost-effective way to remind patients of appointments. According to a Cochrane Collaboration review, “Text message reminders improved the rate of attendance at healthcare appointments compared with no reminders . . . and postal reminders.”

4. Activity trackers | When it comes to tracking activity and health information that can be shared by providers, the question is, do doctors want and need all that information to help them make a better diagnosis or provide better care?

Fast Growth Expected in Medical Apps Market | The medical apps market is estimated at $489 million in 2015. While that’s not huge compared to the total app market, the mhealth apps market was a mere $85 million five years ago. And medical apps are expected to be a fast growing area and one with loyal customers. The finding was made in Kalorama Information’s recent report “mHealth Markets Worldwide.” The report indicates that estimated ownership trends among healthcare workers are a driver in mHealth sales. Over five years ago, around 25% of practicing physicians in the U.S. used a PDA or smartphone for professional and other uses. This increased to approximately 35% to 40% in 2008. By 2010, more than 50% of physicians used smartphones or PDAs on a regular basis for everyday treatment activity. Today upwards of 70% of physicians and medical workers use mobile medical apps on a regular basis. And when they use apps, they tend to pay more, with medical apps averaging $9. The report indicates growth for medical apps is estimated at 41.9% compounded annually over the past five years, while the growth for all apps combined is at 38.1%. Apple’s iOS platform is the highest performing among its competitors with about 55% of the medial app market in terms of dollars for 2015. Sales for medical apps for Apple smartphones, tablets and similar equipment can be estimated at $268.8 million for the year. Apple has experienced increasing competition from its main competitor Android (Google) and newer competition from the Windows platform in recent years. The result has been a slowly eroding market share. However, the growing use of the iPad in health functions is keeping Apple at the top of the list.

18 | THE BULLETIN | MARCH / APRIL 2016

APPLE RESEARCHKIT SOFTWARE

TOP 10 MEDICAL APPS FOR DOCTORS

TOP 10 HEALTH APPS FOR CONSUMERS

Epocrates | remains the gold standard for medical apps to look up drug information and interactions, find providers for consults and referrals and quickly calculate measurements such as BMI.

The following health apps, rated by thousands of physicians in a HealthTap survey based on ease of use, effectiveness, medical accuracy, validity and soundness for patient prescriptions, as well as other physician recommendations, made the top 10 list:

Up To Date | chock-full of medical info that gives answers to clinical questions when needed. App is free. Subscription is $499 a year per physician.

Doximity | social network for doctors. App and membership in the network are free.

Read by QxMD | centralizes medical literature and journals in magazine format. App is free. Some PubMed and other journals require subscription or credentials.

NEJM This Week | access articles, images of medical conditions, listen to video and audio of articles. Free.

Skyscape | decision-support tool with drug information, a medical calculator, evidence-based clinical information and summaries of journal articles.

Isabel | database of more than 6,000 disease presentations and symptoms with the ability to refine by age, gender and travel history.

App requires online access. Monthly subscription is $10.99, or annually $119.99.

Medscape | a unit of WebMD that offers prescribing and safety information for drugs, procedure videos, a medical calculator and continuing medical education (CME) information.

KidSpeak | free app geared toward pediatricians, family physicians and emergency medicine physicians; explains disease pathology to parents and kids in an easy-tounderstand manner.

Prognosis Psychiatry | a collection of case-based presentations on patients with psychiatric complaints.

1. Weight Watchers Mobile 2. My Fitness Pal and Run Keeper 3. White Noise Lite 4. Instant Heart Rate and Glucose Buddy 5. Pocket First Aid & CPR (Jive Media) 6. Calorie Counter and Diet Tracker (MyFitnesPal.com) 7. Spot a Stroke Fast by the American Heart Association 8. Drugs.com 9. Health Tap 10. The American Red Cross

REPORT / Smartphone users now have more than 165,000 apps available to help them stay healthy or monitor a medical condition, but just three dozen account for nearly half of all downloads, the IMS Institute for Healthcare informatics reports.

Among the most recent technological advances that research scientists are considering in mobile technology is the ResearchKit software introduced by Apple last year with five apps to investigate Parkinson’s disease, asthma, heart disease, diabetes and breast cancer.

A sixth app was reportedly released in June to collect information for a long-term study on gays and lesbians by the University of California, San Francisco.

This is how it works: Any iPhone user who wants to participate in a study can simply download the app and fill out a questionnaire to determine eligibility and establish a baseline for comparisons. Users learn about the study before giving consent. The idea is that scientists at research institutions can use the preliminary data from participants to gain a better understanding of major diseases.

To protect privacy, Apple will not see any data.

To date, more than 75,000 people have enrolled in the health studies, which use specialized iPhone apps built with software Apple created to turn the smartphone into a research tool.

Once enrolled, iPhone users use the app to submit data on a daily basis by answering survey questions or using the iPhone builtin sensors to measure their symptoms.

MARCH / APRIL 2016 | THE BULLETIN | 19

FEATURE | mHEALTH & APPS

THE INTERNET OF THINGS (IoT) / refers to any object or device that connects to the Internet to automatically send and/or receive data, including medical devices, such as wireless heart monitors or insulin dispensers; wearables, such as fitness devices; and office equipment, such as printers. IoT devices connect through computer networks to exchange data with the operator, businesses, manufacturers and other connected devices, mainly without requiring human interaction.

For instance, the Parkinson’s mPower app uses the iPhone sensors to measure and track patients’ symptoms from tremor, balance and gait, and also asks participants to provide information before and after they take medications every day. The goals are to cull insights into the variables of Parkinson’s, find better ways to track the progression of the disease and improve the quality of life for those living with the disease.

Another app, the MyHeart Counts app, collects data about physical activity and cardiac risk factors for Stanford scientists studying the prevention and treatment of heart disease.

“There are two major elements to the study,” said Michael McConnell, MD, professor of cardiovascular medicine and principal investigator for the MyHeart Counts study, in a press release. “One is collecting data as broadly as possible on physical activity, fitness and cardiovascular risk factors, which provides important feedback to the participants and helpful research data for our study. The second is studying ways to help people enhance activity and fitness, and decrease their chance of heart disease.”

Dr. McConnell also said that while there has been an explosion in the marketing of wearable devices to record and report information about behaviors, physical activity or sleep patterns to improve health, there is limited scientific data to show they’re effective. Stanford wants to study which types of behavior-modification methods actually succeed. The scientists hope that the results will ultimately also help physicians.

“Preventive medicine hasn’t worked by having doctors make to-do lists for their patients, then seeing them every six months later and hoping they did everything on the list,” he said.”

FBI ISSUES CYBER ALERT FOR IoT AND MEDICAL DEVICES As more businesses and homeowners use web-connected devices to enhance company efficiency or lifestyle conveniences, their connection to the Internet also increases the target space for malicious cyber actors. Similar to other computing devices, like computers or smartphones, IoT devices also pose security risks to consumers. The FBI is warning companies and the general public to be aware of IoT vulnerabilities cybercriminals could exploit, and offers some tips on mitigating those cyber threats.

The FBI specifically calls out the potential vulnerabilities of IoT devices that can lead to the theft of personal information and intentional tampering with devices to cause harm, according to a Health Data Management article on the subject. In particular, the agency warns that unprotected medical devices used in home healthcare, such as those used to collect and transmit personal monitoring data or time-dispense medicines, are a ripe target for cybercriminals, especially devices capable of long-range connectivity.

The FBI provided a list of recommendations to better safeguard IoT devices: • Isolate IoT devices on their own protected networks.

• Disable UPnP on routers.

• Consider whether IoT devices are ideal for their intended purpose.

• Purchase IoT devices from manufacturers with a track record of providing secure devices.

• When available, update IoT devices with security patches.

• Consumers should be aware of the capabilities of the devices and appliances installed in their homes and businesses. If a device comes with a default password or an open Wi-Fi connection, consumers should change the password and allow it to operate only on a home network with a secured Wi-Fi router.

• Use current best practices when connecting IoT devices to wireless networks, and when connecting remotely to an IoT device.

• Patients should be informed about the capabilities of any medical devices prescribed for at-home use. If the device is capable of remote operation or transmission of data, it could be a target for a malicious actor.

• Ensure all default passwords are changed to strong passwords. Do not use the default password determined by the device manufacturer. Many default passwords can be easily located on the Internet. Do not use common words and simple phrases or passwords containing easily obtainable personal information, such as important dates or names of children or pets. If the device does not allow the capability to change the access password, ensure the device providing wireless Internet service has a strong password and uses strong encryption.

20 | THE BULLETIN | MARCH / APRIL 2016

! s e t a D e s e h T e v Sa

SCCMA Annual Awards Banquet and Installation Tuesday, June 7, 2016 6:15 pm Social | 7:00 pm Dinner & Program The Fairmont Hotel, San Jose

Installation: Scott Benninghoven, MD, SCCMA President 2016-17 Honoring: Eleanor Martinez, MD, SCCMA President 2015-16 Award Honorees: Richard Slavin, MD – Robert D. Burnett, MD Legacy Award Raj Bhandari, MD – Benjamin Cory, MD Award Daniel Jacobs, MD – Outstanding Achievement in Medicine Danny Sam, DO – Contribution in Medical Education Lynn Rosenstock, MD – Contribution to the Medical Association Paul Jackson, MD – Contribution to the Community Janice Bremis – Citizen’s Award Robin Riddle – Citizen’s Award

Formal invitations will be mailed by the end of April

•

MCMS Annual Physician of the Year Banquet & Installation

Thursday, June 16, 2016 6:30 pm Social | 7:00 pm Dinner & Program Corral De Tierra Country Club Installation: Craig Walls, MD, MCMS President 2016-17 Honoring: James Hlavacek, MD, MCMS President 2015-16 Physician of the Year: To Be Announced

Formal invitations will be mailed end of April MARCH / APRIL 2016 | THE BULLETIN | 21

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IN SANTA CLARA COUNTY, COVERAGE FOR PATIENTS DUALLY ELIGIBLE FOR MEDICARE AND MEDI-CAL HAS CHANGED.

24 | THE BULLETIN | MARCH / APRIL 2016

WHAT DOES THE CCI MEAN FOR PHYSICIANS? This article discusses California’s Coordinated Care Initiative (CCI), including an overview and information about topics such as care coordination, how physicians can keep seeing patients who join Cal MediConnect, and how physicians can work with CCI health plans.

Joining a Cal MediConnect plan is voluntary. Physicians can continue to see patients who join a Cal MediConnect plan for a period of time through continuity of care or can join a plan network (see below for more information).

OVERVIEW

MEDI-CAL MANAGED CARE PLANS

California launched the CCI to help support dual eligible—people with both Medicare and Medi-Cal. The initiative grew out of research and pilots conducted in California and other states showing that dual eligibles can benefit from better coordination of care and of their Medicare and Medi-Cal benefits. The initiative includes Cal MediConnect, a new health plan option that covers and coordinates Medicare and Medi-Cal benefits, and mandatory Medi-Cal managed care for dual eligibles who remain in fee-for-service Medicare or Medicare Advantage.

Cal MediConnect health plans can help support physicians by making it easier for their patients to access all the services and supports they need, including transportation and long-term services and supports (LTSS) such as in-home care or adult day services. Cal MediConnect care coordinators can make sure physicians have timely information about changes in a patient’s health status or care they are receiving from other providers. Physicians can participate in interdisciplinary care teams to direct patients care and ensure patients are getting needed services from their plan.

Whether a physician is in a Cal MediConnect plan network or seeing patients in fee-for-service Medicare or Medicare Advantage, the following is important information about these changes and the new choices patients have for their health care coverage.

CAL MEDICONNECT PLANS People with both Medicare and Medi-Cal can now enroll in Cal MediConnect plans in Santa Clara County. Anthem Blue Cross and Santa Clara Family Health Plan are the two Cal MediConnect plans in Santa Clara and will provide all Medicare and Medi-Cal benefits for patients who enroll. This includes prescription drugs, care coordination, coordination with behavioral health services, and new transportation and vision benefits.

Most dual eligibles who do not join a Cal MediConnect plan will continue to receive Medicare services as they always have and are required to select a Medi-Cal managed care plan. In Santa Clara, the Medi-Cal managed care plans are Anthem Blue Cross, Santa Clara Family Health Plan, and Kaiser Permanente. Medi-Cal plans are responsible for MediCal benefits, including LTSS, such as nursing facility stays and adult day services, and Medicare co-pays. Joining a Medi-Cal plan does not change a dual eligible’s relationship with their Medicare providers or Medicare, and doctors can continue to see these patients and bill Medicare for their services. Medicare providers do not need to be in the Medi-Cal plan network and patients will not be assigned a Medi-Cal primary care physician.

Physicians will only need to work with the plan if they provide or refer for Medi-Cal services. If physicians have patients in Medi-Cal plans, they should bill that plan for any Medicare cost sharing owed under state law.

For more information about billing, see below.

CARE COORDINATION

Dual eligible patients often have both higher needs for health care and other services as well as challenges in accessing the care they need due to financial, cultural, or linguistic barriers. While many individual physicians do an excellent job coordinating care for their dual eligible patients, many dual eligibles do not get the help and support they need.

HOW CAL MEDICONNECT SUPPORTS PHYSICIANS AND CARE COORDINATION A major focus of Cal MediConnect is supporting physicians in the management of complex patients. Cal MediConnect plans are responsible for conducting a comprehensive Health Risk Assessment (HRA) for all enrollees to assess medical, behavioral health, LTSS, functional, and social needs. The HRA is the basis for assigning a health plan care coordinator to high-need patients, as well as establishing an interdisciplinary care MARCH / APRIL 2016 | THE BULLETIN | 25

What Does The CCI Mean For Physicians? continued from page 25 team and an individualized care plan. Physicians can access the HRA results, which can help them understand their patients’ histories and broad spectrum of needs.

Physicians can participate on the interdisciplinary care teams, which provide patients with care coordination support, such as ensuring patients are managing their appointments and prescriptions, facilitating transitions out of hospitals or institutional care, and are receiving the in-home and community support they need to live independently. Plans will help coordinate LTSS services such as in-home care (In-Home Supportive Services or IHSS) and adult day services (Community-Based Adult Services or CBAS), as well as short- and long-term nursing care. This coordination can help relieve the administrative burden some practices experience when helping patients access care and in-home and community-based services.

WORKING WITH CAL MEDICONNECT PLANS CONTINUITY OF CARE How to Keep Seeing Patients if They Join a Cal MediConnect Plan Cal MediConnect enrollees are eventually required to receive all covered services from physicians and other providers who are part of the plan’s network. Through continuity of care, enrollees have the right to temporarily continue seeing an existing physician outside of their Cal MediConnect network for a specified period following enrollment. This is in addition to a patient’s right to request completion of covered services for certain conditions. Under continuity of care, enrollees may be able to continue to receive Medicare covered services from an existing primary or specialty care physician with whom they have an existing relationship for up to six months and Medi-Cal covered services for up to 12 months.

Steps for Continuity of Care Requests Cal MediConnect plans must attempt to determine if there are continuity of care needs during the HRA process. Patients, their providers, or their authorized representatives can also request continuity of care. Plans must allow continuity of care requests by phone and it’s the plan’s responsibility to first attempt to validate the pre-existing relationship through Medicare claims data before requesting evidence from the enrollee or provider.

The Cal MediConnect plan then works with the physician and makes a good faith effort to determine whether the physician will accept the higher of the Medicare or plan rate for services, and whether there are quality issues that would prevent the physician from being eligible to participate with the plan for that enrollee.

If agreement is reached between the Cal MediConnect plan and the physician, the enrollee can continue receiving Medicare services from the physician for up to six months. At the discretion of the Cal MediConnect plan, this six-month period may be extended.

BILLING AND THE CCI Billing for Patients in Cal MediConnect Health Plans Patients enrolled in Cal MediConnect health plans generally need to receive all physician services from providers in the Cal MediConnect plan network. Physicians who are part of a Cal MediConnect plan’s network no longer need to bill Medicare and Medi-Cal for Cal MediConnect enrollees’ care. They should bill and receive all payments directly from the Cal MediConnect health plan or the plan’s delegate (IPA or medical group).

This is intended to simplify the billing processes for physicians.

Some physicians may receive monthly capitation payments and some may bill fee-for-service, depending on the arrangement they have with the Cal MediConnect plan or its delegate.

Billing for Patients with Original Medicare/Medicare Advantage and Medi-Cal Managed Care Plans For patients in a Medi-Cal plan, physicians should continue billing Medicare as they have in the past. Medi-Cal plans are now responsible for Medi-Cal benefits including Medicare cost sharing and some long-term care, durable medical equipment, and other services and supports. The only role Medi-Cal plans will have with respect to physician services for dual eligibles who remain in fee-for-service Medicare will be to adjudicate the payment of crossover claims for any Medicare cost sharing owed under California state law. Usually, because of state law, the Medi-Cal plan will not be required to pay anything. The dual eligible patient can not be billed for Medicare or Medi-Cal services.

Balance billing If a patient has Medi-Cal coverage, a physician cannot charge them for their health care costs. This is called “balance billing” and is prohibited by state and federal law for Medi-Cal patients, including dual eligible patients. A physician may not bill a patient for any charges that are not reimbursed by Medicare or Medi-Cal (or the Medicare Advantage or Medi-Cal plan), if the service is covered by Medicare or Medi-Cal. In other words, a physician must accept as payment in full whatever amount the physician receives from Medicare or Medi-Cal (or the health plan) for a Medicare or Medi-Cal covered service. The only exception is that physicians may bill Medi-Cal patients who have a monthly share of cost obligation, but only until that obligation is met for the applicable month.

Physicians who violate these protections are subject to sanctions.

CONTRACTING WITH CAL MEDICONNECT HEALTH PLANS Physicians interested in contracting with a Cal MediConnect plan should contact the plan’s provider services department. Most health plans contract with IPAs and medical groups, so physicians should be aware that they may have to contract with those groups in order to join the health plan network. Each plan can provide a list of its Cal MediConnect contracted IPAs and medical groups upon request.

QUESTIONS? NEED MORE INFO?

More information is available at www.CalDuals.org/providers or www.dhcs.ca.gov. Please email info@calduals.org with any questions or requests for training for your staff or other resources.

Cal MediConnect Plan

Provider Services

Provider Website

Santa Clara Family Health Plan

408-376-2000

http://bit.ly/scfhp-prov

Anthem Blue Cross

1-855-817-5786

http://bit.ly/anthem_prov

26 | THE BULLETIN | MARCH / APRIL 2016

RETIREMENT

A Report And A Request For Help

By Joseph Mason, Jr., MD

Since my retirement from active clinical practice four years ago, I have continued to experience joy and fulfillment at prior levels, despite occasionally still being in bed at 7am.

I pursue with increased vigor my non-medical pursuits such as cooking, wine exploration, woodworking, and travel. But it is not of those activities that I write.

I started volunteering at thesecondopinion almost immediately after retirement. A 501(c)3 non-profit based in San Francisco, thesecondopinion provides free second opinions in cancer treatment for patients who apply. Not only are the opinions free, they are convenient, since the staff does all the work of gathering medical records, images, and pathology slides. Additionally, the comprehensive opinions, provided by volunteer physicians, are independent, and free of any commercial or institutional biases. Everything is HIPAA compliant, and malpractice insurance is provided for the physicians.

Patients are evaluated in a tumor board format. The consultative panel comprises a chair (usually a medical oncologist), a medical oncologist, a radiation oncologist, a diagnostic radiologist, a pathologist, and any surgical specialists who would be appropriate for the patient’s situation. The panelists have appropriate materials for review before the panel actually convenes. The panel meets at the office with

the patient and any family members or friends whom the patient wishes to accompany them. The evaluation does not include a physical examination. A consultation letter is sent expeditiously to all physicians to whom the patient wishes it to go, with a copy going to the patient. The patient also receives an audio recording of the panel discussion.

Patients report great satisfaction with the experience we provide, and the physician panelists feel enormously gratified to be providing such an important service. As one might expect, given the sophistication of the medical community, it is unusual for us to opine that treatment has been inappropriate. It is common, however, to discover that patients have mistaken, or incomplete notions of their disease and its treatment.

As far as I can determine, no other organization in the country is doing something like what we do.

We are always looking for a few good folks. To learn more, please check out the website: www.thesecondopinion. org. If you have questions, feel free to contact me by e-mail: joemason48@sbcglobal.net. If I have spurred your interest in volunteering for this unique and valuable work, you can do so on the website, or by contacting me.

By the way, one need not be retired to participate!

I look forward to hearing from you.

MARCH / APRIL 2016 | THE BULLETIN | 27

Great Moments in Medicine

Lister Introduces Antisepsis

By Gerald E. Trobough, MD Leon P. Fox Medical History Committee In the early nineteenth century, surgery was like asking a patient to sign their own death certificate. The risks of a postoperative infection were high, especially in hospitals. Surgery on the surface of the body resulted in a 35% infection rate. Amputations had a mortality rate of 50% from infection. To open the abdomen, chest, or skull was unthinkable.

Surgeons were not required to wash their hands before surgery or between patients. This procedure was not considered necessary to avoid infections. Most hospitals and surgical facilities did not have soap or water that was readily available.

Joseph Lister, a Scottish surgeon, born in England in 1867, was aware of the microbiology work of Pasteur and the germ theory. Lister introduced antisepsis in the mid 1860’s in an attempt to reduce postoperative infections. He had become interested in medicine at an early age. His father’s favorite hobby was studying microscopy and as a result, Joseph became very skilled in using the microscope. Being raised a Quaker, he was not allowed to go to Cambridge or Oxford Universities even though he was an excellent student. Only members of the Church of England were able to attend such prestigious institutions. He attended London’s Univer28 | THE BULLETIN | MARCH / APRIL 2016

sity College obtaining a Bachelor of Arts and a Bachelor of Medicine degree in 1852.

In 1853, Lister was introduced to Dr. James Syme, the Professor of Clinical Surgery at the University of Edinburgh Medical School in Scotland and was accepted as a resident surgeon. Within one year, Lister was promoted to teaching surgery and given a private office for surgical consultations. He invented some ingenious surgical instruments while at Joseph Lister Edinburgh including: a needle for silver wire sutures, a hook for removing foreign bodies from the ear, forceps for use in the sinuses, blunt pointed bandage scissors, and a screw tourniquet for compressing the abdominal aorta.

In 1860, Dr. Lister was named Professor of Surgery at the University of Glasgow. It was here that Lister made his most noted studies. The first change he made as a professor was to have everyone wash their hands with soap and water. At first, this procedure was met with resistance from other staff members but the soft spoken Quaker got his way. In his efforts to reduce postoperative infections, Lister studied various methods of wound treatment. He left the wound open or he closed the wound. He used water

Leon P. Fox Medical History Committee The Leon P. Fox Medical History Committee meets bi-monthly, the first Monday at noon (lunch provided). The purpose of the committee is to identify, collect, and preserve archival material, memorabilia, and artifacts representing the medical history of Santa Clara County. A guest speaker gives a historical presentation at each of the meetings, which is then transcribed for SCCMA’s Medical History archives.

If you are interested in joining this committee, please contact Pam Jensen at SCCMA at (408) 998-8850 or pjensen@sccma.org.

dressings, irrigations, and collodion in his studies, all to no avail. His final conclusion was it was necessary to kill germs without killing the tissue to lower the infection rates.

In 1865, Lister treated an 11-year-old boy with a compound leg fracture. Most surgeons treated this condition with amputation due to the high postoperative infection and death rates. Lister treated the boy with carbolic acid and after four days he removed the dressing and found there was no infection. He continued to treat the wound for six weeks and the boy made a complete recovery. By 1867, Lister reported on 11 cases of compound fractures and all but two had a successful outcome. He then treated abscesses with carbolic acid getting similar great results. He reported his findings in a series of articles published in Lancet Medical Journal.

Despite the obvious successes, the British surgeons were apathetic, indifferent, or antagonistic towards the concepts of antisepsis. Surgeons felt the more blood and gore displayed on the surgery gowns after surgery indicated their expert surgical skills. Undiscouraged, Lister persisted. He required surgeons and assistants to scrub their hands with soap and water and to dip their hands frequently during the surgery in a carbolic acid solution. Instruments

were soaked for 20 minutes prior to surgery and sutures were washed with the antiseptic before use. The skin in the field of operation was washed with soap and water. Towels soaked in carbolic acid were draped around the incision site. In addition, Lister devised a 1:100 dilution spray of carbolic acid that he sprayed around the operating room, nearly suffocating the operating room staff.

Lister’s techniques were finally accepted worldwide in 1879. It is noted that it took another 10 years to convince his London colleagues of the benefits of antisepsis. He was showered with honors, including his elevation to a peer as Baron Lister by Queen Victoria in 1897. Joseph Lister became the first medical person to receive this honor in Britain.

Lister will be remembered in history as the man that raised the profession of surgery from a “game of chance” to a safer, scientific art and science.

MARCH / APRIL 2016 | THE BULLETIN | 29

MEMBERSHIP

Welcome 313 SCCMA Members Santa Clara County Medical Association Name City Specialty Tinuola Ademola Los Altos IM Nia Adeniji Hayward US Maryam Afshar San Jose PD Ishita Aggarwal San Jose OBG Narges Alipanah Jahroudi San Jose IM Jessica Allan Palo Alto HOS Kumiko Aman San Jose FP Esther Amuyunzu San Jose IM Angela Anagnos San Jose N Kunal Angra San Jose US David Anzaldua San Jose FP Elizabeth Arias Palo Alto HOS Rohini Arramreddy San Jose IM Raheel Ata Menlo Park US Rachel Aviv Santa Clara IM Khamidulla Bakhadirov Santa Clara N Jharna Barwani Mtn View IM Karen Bauer Palo Alto HOS Victoria Bawel Stanford US Cecil Benitez E Palo Alto US Rebecca Benton Palo Alto PD Melody Besharati San Jose OBG Poorti Bhandarkar San Jose IM Michael Bogatch San Jose ORS Adam Bolour San Jose FP Rajshree Bongale San Jose P Rhea Boyd Palo Alto PD Richard Briones Los Gatos AN Linh Bui Santa Clara US Margaret Carter San Jose OTO Raymond Chan San Jose IM Tyrone Chan San Jose US Alice Chang Santa Clara HNS Jennifer Chang Santa Clara GE Johnny Chang Palo Alto PS Ryan Chao San Jose R Faisal Cheema Santa Clara HEM Timmy Cheng San Jose IM Walter Cheng Palo Alto HOS Gregg Chesney San Jose EM Andrew Chiu San Jose R Thomas Chou San Jose PTH

Name Pandora Swee-Kee Chua Alice Tung Chuang Nkiruka Chuba Rose Chumo Linda Chung Lydia Chung Melody Chung Jennifer Cohen Michael Cohn Theresa Colosi Carlos Cruz Dana Cruz Michael Cruz Courtney Cunningham Christina Danial Phawanjit Demos Joseph Doan Sahar Doctorvaladan Elizabeth Dorwart Shannon Dralla Erica Drazan Brian Dula Duy Duong Mrinal Dutia Laura Dyner Stephanie Feldstein Andrew Fischer Vanessa Flores Keith Follmar Julia Fong Todd Fong Eric Fuh Andrea Gallardo Elisha Garg Shally Garg Alexandra Garnett Maria Kristina Gestuvo Nataly Ghanem Aradhana Ghosh Priyanka Ghosh Simarjeet Gill Marina Glibicky

City Specialty San Jose US San Jose IM San Jose OBG Santa Clara IM Los Altos AN Santa Clara IM Santa Clara IM San Jose GM Palo Alto PLM Los Gatos ORS Palo Alto UC San Jose IM San Jose IM San Jose IM San Jose IM San Jose EM Santa Clara IM San Jose OBG San Jose US San Jose OBG Palo Alto PD Palo Alto AN San Jose IM Santa Clara HEM Los Altos PD San Jose US San Jose US Gilroy FP Saratoga PS Los Altos IM San Jose IM San Jose IC Gilroy P Santa Clara IM San Jose IM Santa Clara IM Palo Alto GM San Jose US San Jose IM San Jose US San Jose IM Santa Clara IM

US - Unspecified

30 | THE BULLETIN | MARCH / APRIL 2016

Name City Specialty Eric Goldlust Santa Clara EM Adrian Goldman Gilroy PD Kelly Gonzales San Jose TRS Sergio Gonzalez San Jose FP Nirmala Gopalan San Jose GM Tarini Goyal San Jose IM Kyle Graham San Jose OBG Jonathan Grigsby Gilroy FP Sava Grujic San Jose PTH Janhavi Gudal Los Gatos IM Kathryn Gunnison San Jose OBG Yueyang Guo San Jose R Nidhi Gupta San Jose IM Pooja Gupta Milpitas OBG Bonnie Hall San Jose IM Christina Hamilton Martinez OBG Simrat Hansra Santa Clara IM Catherine Harris San Jose U Kim Hartwig San Jose FP Thomas Hau San Jose EM Sawsawn Hayatdavoudi S San Fran EM Tyler Hensel Santa Clara FP A B Marilyne Hepie San Jose HOS Jessica Hightower San Jose US Shana Hill San Jose PCC Andrew Ho San Jose GE Stephanie Ho San Jose OBG Wendy Ho Santa Clara OM Marie Holzapfel Milpitas OBG Golara Honari San Jose D Denny Hong Loma Linda IM Scott Honowitz San Jose R M Hosseini-Varnamkhasti San Jose PTH Julie Huang Santa Clara PD Laura Huang San Jose IM Rex Huang San Jose P, CHP Christopher Hwang San Jose US David Jacobson San Jose IM Saranya Jayakar San Jose IM Dinah Jeyasingh San Jose FP Duangpom Jitjai San Jose IM Alfred Johnson Morgan Hill GS

MEMBERSHIP

Welcome 313 SCCMA Members Santa Clara County Medical Association Name Payal Karsan Archana Kayastha Nirvair Kelley Victoria Kelly Randi Kestler Changhyun Kim Grace Kim Katrina Kline Neelima Komatineni Nadya Kondrashov Russell Kosik Malgorzata Kozak Saloni Kumar John Kuratani Calvin Kwong Veronica Lagos-Jaramillo Shiau-Yeng Lai Lukas LaSyone Eric Lau Nancy Lau Minh Le Dong Lee Jennifer Lee Kevin Lee Philip Lee Rachel Lee Stephen Lee Joseph Li Kefu Li Ai-ling Lin Gary Lin Lonnie Lin Stephanie Lin Shira Lipton Erin Liu Jessica Liu Rosa Liu Yueyi Liu Melinda Lorenson Jacqueline Lou Nicholas Love Albert Luo

City Specialty San Jose PD Palo Alto PD San Jose IM Palo Alto RHU Cupertino IM San Jose US San Jose IM Palo Alto HOS Sunnyvale IM Sacramento OBG San Jose R San Jose US San Jose IM Santa Clara CHN San Jose IM Fremont IM San Jose FP Santa Clara IM San Jose IM Cupertino IM San Jose IM Santa Clara PDO San Jose RHU San Jose R Palo Alto HOS San Jose IM Monterey D San Jose IM San Jose IM San Jose IM San Jose IM Milpitas OBG San Jose R Palo Alto D Campbell IM San Jose IM San Jose OBG San Jose R Mtn View OBG San Jose OBG Palo Alto US San Jose CD

Name Albert Ma Gregory MacDonell Samineh Madani Vinit Madhvani Elizabeth Mahal Yinchong Mak Fawad Malik Lydia Mandrussow Arek Manugian Benjamin Marsh Marlene Martin Juan Martinez James McAvoy James Mccarrick Sonya Meyers Payvand Milani Maria Miyar Alireza Mofrad Bahar Mojgani Bianca Mosley Elizabeth Moynier Aparna Mukkamala Manasi Nabar Neera Narang Daniel Nelson Jacqueline Newton Lynn Ngai Tin Ngo Alexander Nguyen Andy Nguyen Diana Nguyen Janet Nguyen Maiuyen Nguyen Minh Nguyen Thomas Nguyen Grace Nicksa Dayani Nualles-percy John Oh Veena Panduranga Annie Park Chul-Kyun Park Hemal Patel

City Specialty Santa Clara IM Saratoga AN San Jose END Menlo Park EM San Jose EM Palo Alto IM San Jose P San Jose IM Santa Clara IM San Jose PD San Jose IM La Jolla IM San Jose US San Jose OBG San Jose OM Santa Clara IM San Jose PDD San Jose IM San Jose EM Santa Clara IM Palo Alto OBG Saratoga IM Campbell IM San Jose US Campbell EM San Jose IM San Jose IM San Jose SO San Jose IM Milpitas FP Palo Alto IM San Francisco R San Jose OBG Santa Clara IM San Jose IM Santa Clara PDS San Jose IM San Jose VIR Santa Clara HOS Santa Clara IM Sunnyvale AN Santa Clara IM

Name Leena Patel Clifford Pereira Anthony Pham Madison Pham Teri Pham Jeanine Phan Danielle Pickham Elaine Pico Tanya Podchiyska Katherine Pogrebniak Charles Poon Nutan Poseria Arifa Rahman Neha Rajkanan Menaka Raju Marilyn Ralph Swapna Rao Beth Rasmussen Sreelakshmi Ravula David Reinert Divya Reouk Susie Reyes Michael Richardson Monica Richardson Farhana Rob Christopher Rombaoa Daniel Rosenstein Aaron Rudin David Sandman Sergio Sapetto Tohru Sato Payam Sazegar Ira Schachar Daniel Schiffner Matthew Schoen Kristin Schueler Shristi Shah Shobha Sharma Haleh Sheikholeslami Peter Shen Eric Shi Jennifer Shih

City Specialty San Jose FP San Jose GS San Jose US San Jose IM San Jose IM San Jose FP San Jose GS San Jose PM Redwood City US Stanford US San Jose PCC Milpitas IM Pleasanton P San Jose IM San Jose PTH Santa Clara IM San Jose RHU Santa Clara OBG Los Gatos PTH San Jose IM San Jose FP San Jose IM Palo Alto US San Jose OBG San Jose FP San Jose IM San Jose U San Jose US San Jose DR San Jose IM San Jose GE Santa Clara FP San Jose IM Palo Alto RO Stanford US San Jose R San Jose CHP San Jose IM Los Altos FP Santa Clara R Santa Clara US San Jose R

US - Unspecified

MARCH / APRIL 2016 | THE BULLETIN | 31

MEMBERSHIP

Welcome 313 SCCMA Members Santa Clara County Medical Association Name Rajesh Shinghal Hadas Shiran Shashi Shravana Michael Sighinolfi Meenakshi Sigireddi Peter Smith Crystal Smith-Spangler Jae Sohn Nima Soltanzad Rebecca Soskin Vanessa Starr Kayvahn Steck-bayat Ekaterina Stepina C. Subramanian Brian Sun Melissa Sung Mayura Suryanarayan Kathryn Sutter Zunera Tahir Amy Teng Alexis Teplick

City Specialty Palo Alto U San Jose US Milpitas IM San Mateo IM Santa Clara IM San Jose R Palo Alto IM San Jose US Los Altos IM San Jose PD San Jose PDR San Jose OBG Gilroy FP San Jose IM San Jose IM Palo Alto IM San Jose HOS San Jose PD San Jose IM Mtn View OBG Santa Clara PD

Name Ann Thomas James Thomas Lana Tong Mary Tran Ariel Troncoso Anhdao Truong Justin Tse Amanda Velazquez Hima Venigandla An Vo Hong-ngoc Vo Jason Vuong Shrilakshmi Vyas Thao Wagner Ruta Wakharkar Beilin Wang David Wang Fengdan Wang Jennifer Wang Candice Weaver Emilee Wilhelm-Leen

City Specialty Santa Clara IM Palo Alto HOS San Jose US San Jose IM San Jose P San Jose IM San Jose US Milpitas PD San Jose IM San Jose IM S San Fran R San Jose IM Santa Clara IM San Jose MSR Santa Clara IM San Jose IM San Jose IM Santa Clara IM San Jose IM San Jose FP Sunnyvale IM

Name Nicolette Wolters Margaret Wong Michael Wong Christopher Woo Phil Wu Michael Xiang Adele Xu Guofan Xu Lei Xu Kyle Yang Michael Yen Kellie Young Phillip Young Wesley Yu Fiona Yuen Kevin Yuen Lisa Zaba Pei Zhang Lily Hsiao Zhong

City Specialty San Jose OBG San Jose IM Santa Clara RO Santa Clara CD San Jose US Santa Clara IM Stanford US San Jose R Mtn View US San Jose IM San Jose US San Jose IM Palo Alto HOS San Francisco US San Jose IM San Jose IM Santa Clara D San Jose IM San Jose IM

Welcome 4 MCMS Members Monterey County Medical Society Name Mary Coleman

City Specialty Salinas DBP

Glenn Cooperman Soraya Esteva

Salinas Salinas

US - Unspecified

32 | THE BULLETIN | MARCH / APRIL 2016

OBG OBG

Eric Lee

Gilroy

D

In Memoriam

Edward A. Hinshaw May 5, 1937- March 21, 2016 Physician Champion

By William Parrish and James Hinsdale, MD On March 21, 2016, the physician community suffered a great loss…the passing of Ed Hinshaw Sr. Ed suffered a ruptured aneurysm on February 9, 2016 during his annual family vacation to the Big Island, Hawaii. Ed was the consummate family man. He is survived by his lovely wife of 57 years, Barbara, four children, and ten grandchildren.

Ed Hinshaw was dedicated not only to representing doctors, but helping them in any way he could.

He had a consummate, palpable respect for doctors that could not be duplicated. The adversarial context that physicians are placed in by the malpractice process is very difficult to identify with unless one has experienced it first hand. Mr. Hinshaw went over and above any other attorney’s role in supporting doctors in defending medical malpractice suits.

Ed always took doctors’ calls personally, and was always willing to help. His skill in resolving doctors’ disputes (even among doctors) was legendary. One observer said once that Ed Hinshaw was the one who kept the peace in Santa Clara County. Whenever a doctor was threatened by a plaintiff attorney, and Ed Hinshaw started answering calls for that doctor, much of the puffing and posturing of threatened litigation quickly evaporated. In 2006, SCCMA awarded Ed the Citizen of the Year Award in recognition of his significant contributions.

In addition to being a great litigator, Mr. Hinshaw was an avid sportsman…excelling in swimming and water polo. But more than anything, Ed valued family, was a great friend, and a true gentleman. I can say without reservation, I’ve never met a finer or more respected individual than Ed Hinshaw…R.I.P.

MARCH / APRIL 2016 | THE BULLETIN | 33

(CMA Alert, March 21, 2016 issue)

Largest set of tobacco regulation bills in decades sent to governor’s desk California legislators continued to crack down on smoking when the state Senate approved a landmark series of tobacco regulation bills as a means to reduce tobacco use and save lives, especially among youth. The six bills now head to the desk of Governor Jerry Brown, who has 12 days to sign them.

The bills would raise California’s smoking age to 21; begin classifying e-cigarettes as tobacco products; close loopholes in the state’s smoke-free workplace laws; require all schools to be tobacco-free; allow county governments to put tobacco taxes up for local votes; and update the state’s tobacco licensing fee program.

“We can’t afford to sit on the sidelines any longer,” said Senator Ed Hernandez, speaking on behalf of SB 7 X2, his authored bill that would increase California’s smoking age. “It’s time for California to lead the way in tobacco control once again.”

If the governor signs the package of bills, California would be the second state in the country to increase the age to buy tobacco products to 21, and one of the few to regulate e-cigarettes like other tobacco products.

Following the bill’s passage, the California Medical Association (CMA) released a statement applauding the Senate’s action, calling it the “most sweeping set” of tobacco legislation in decades.

“It’s clear that California is ready to move forward and implement tobacco reform that has a real impact on the future of health care,” said CMA President Steven E. Larson, MD, MPH. “We must now look forward to November and use this momentum

to pass the $2-per-pack tobacco tax ballot measure,” he added.

CMA, as a member of Save Lives California coalition, is currently collecting signatures to qualify the California Healthcare, Research and Prevention Tobacco Tax Act of 2016 for the November ballot. The initiative will increase the state’s tobacco tax from its current $0.87 per pack – a rate that hasn’t been changed since 1998 – to $2.87 per pack. That tax will also apply to other tobacco products containing nicotine, such as e-cigarettes.

The ballot measure will save lives and reduce teen smoking, as well as generate revenue for many of the state’s underfunded health care programs. Ninety percent of people who smoke start as teens, and studies show that for every 10 percent increase in the cost of tobacco products, teen smoking drops by up to 6.5 percent.

Learn more about the Save Lives California ballot initiative by visiting www.savelivesca.com.

(CMA Alert, March 21, 2016 issue)

CURES 2.0 webinar now available on-demand Under California law, all individuals practicing in California who possess both a state regulatory board license authorized to prescribe, dispense, furnish or order controlled substances and a Drug Enforcement Administration Controlled Substance Registration Certificate (DEA Certificate) must register for the Controlled Substance Utilization Review and Evaluation System (CURES) by July 1, 2016.

34 | THE BULLETIN | MARCH / APRIL 2016

The California Medical Association (CMA) recently cohosted a webinar with the Department of Justice to help physicians navigate the CURES 2.0 registration process. The webinar provides an overview of key user features of the updated system and tips on how to avoid technical issues.

This webinar is now available on demand in CMA’s online resource library and is free to all interested parties.

(CMA Alert, March 21, 2016 issue)

CMA joins AMA comments on CMS MACRA Quality Measure Development Plan The Centers for Medicare and Medicaid Services (CMS) recently released a draft strategic framework for future quality measure development, as called for under the Medicare payment reform legislation passed last year (the Medicare Access and CHIP Reauthorization Act, also known as MACRA).

The California Medical Association (CMA), the American Medical Association (AMA) and other health care organizations recently submitted comments on this proposal in a joint letter.

CMS’s proposed Measure Development Plan (MDP) directly supports the implementation of MACRA’s new fee-for-service MeritBased Incentive Payment System (MIPS), which is supposed to consolidate and simplify the existing Medicare quality reporting programs , including the Physician Quality Reporting System (PQRS), meaningful use and the value modifier, as well as the new alternative payment models (APM). The MDP also highlights known measurement and performance gaps and recommends approaches to close those gaps through development, use and refinement of quality measures. According to CMS, the MPD and the comments CMS receives on it will influence the type of funding CMS distributes for measure development over the next five years.

CMA and AMA were deeply engaged in the legislative process that ultimately led to the enactment of MACRA and believe that for this new law to be successful, physicians will need a strategic quality framework that supports innovation, improves care delivery for patients and

leads to more sustainable physician practices.

“We believe a participatory process between physicians and CMS is critical to assuring practicing physicians that quality measures within MIPS and the APMs will be clinically relevant and meaningful for their practice and setting of care, as well as administratively actionable and helpful in providing better care and value for patients,” the AMA comments said.

AMA also criticized the new CMS plan for following the same piecemeal approach to measurement where each Medicare quality program operates in a silo. AMA urged CMS to follow the intent of MACRA, which is to encourage flexibility and provide the chance to redesign and overcome existing problems. Leading quality experts are also calling on CMS to rethink the design of quality programs.

In the letter, AMA asked CMS to improve upon the current quality programs by ensuring that MIPS and APMs take into consideration the various physician specialties and sub-specialties so that all physicians can effectively and successfully participate. AMA also urged CMS to avoid adopting the one-size-fits-all approach as currently constructed under the value-based modifier and meaningful use programs, which have diverted physician efforts and resources away from participating in activities that truly have a positive impact on patient care.

The letter called on CMS to provide more timely and usable data to physicians so that they can improve patient care, instead of narrowly focusing on penalties and rewards. And, it reminded CMS that these goals can only be

achieved if accountability is also assigned to the vendors who control what is being required of physicians.

Organized medicine offered an alternative approach that uses a recent Institute of Medicine report as a roadmap for how health care is measured. The letter urges CMS to “start with a broad problem that needs to be solved (such as diabetes or hypertension), set targets for success, identify key roles for physicians as well as other stakeholders, and use measurement to guide us toward our targets.”

Regarding the Alternative Payment Models, AMA said that quality measures in an APM should demonstrate that the APM is achieving its goals for care improvement. Experience to date with APMs has found that APM measures are more likely to be based on outcomes of care, such as complication, readmission and reoperation rates, instead of typical PQRS check-thebox measures.

AMA also asked CMS to only allow physician-led organizations to develop quality measures to ensure that the measures are more meaningful to users, uphold national standards and harmonize with clinical data registries.

And, finally, the letter urges CMS to expand its risk adjustment methodology to incorporate race, income and community features to avoid inaccurate conclusions about quality and performance that could unfairly penalize physicians who treat socio-disadvantaged patients and hinder access to care.

MARCH / APRIL 2016 | THE BULLETIN | 35

(CMA Alert, March 21, 2016 issue)

National ‘Match Day’ largest on record, but many California students must study elsewhere The National Resident Matching Program announced on March 21 that the 2016 Match Day for graduating medical students was the largest on record, with 42,370 registered applicants and 30,750 positions filled. The number of United States medical school seniors grew by 221 to 18,668, and the number of available first-year positions rose to 27,860, which is 567 more than last year. “Match Day,” an annual rite of passage for future physicians, is the system through which medical school students and graduates obtain residency positions in U.S. accredited training programs.

Despite the high numbers of candidates matching with residency programs this year, hundreds of qualified California students must leave the state to study elsewhere due to a lack of funding for graduate medical training, highlighting the need to pass Senate Bill 22.

“Each year, California is fortunate to have thousands of ambitious medical students apply for residencies across the state, eager to improve the health of their communities,” said Steven E. Larson, MD, MPH, president of the California Medical Association. “Many of these physicians-in-training will one day be the backbone of health care in our state. But sadly, some will be forced to head elsewhere, since current funding levels are not high enough to ensure enough residency spots in California. The data tells us that if a medical student is forced to leave the state to complete his or her training, it is more likely they will stay and practice out of state, despite our desperate need for more physicians, particularly in primary care.”

California has lost tens of millions of dollars in funding for primary care physician training. In 2016 alone, more than $40 million of funding for the training of

California’s primary care physicians is expiring.

To help combat a physician shortage in the state and protect patients’ access to care, the state legislature is currently considering SB 22, which would direct state funds to new and existing graduate medical education primary care physician residency positions and support training medical school faculty.

“Solving California’s dire physician shortage is critical to the health care for all Californians,” said Senator Richard Roth, author of SB 22. “I introduced Senate Bill 22 to fund additional medical residency positions throughout our state’s medically underserved areas, especially in Inland Southern California and the Central Valley. Studies have shown that if we train tomorrow’s doctors in the areas that need them most, they are more likely to continue serving those areas, helping alleviate critical physician shortages and ensuring equal access to health care.”

SB 22 has passed the Senate and is expected to be taken up by the Assembly Health Committee in June.

(CMA Alert, March 21, 2016 issue)

HHS awards $12 million to California not-for-profits to help expand access to medication-assisted treatment for opioid-use disorders On March 11, the U.S. Department of Health and Human Services (HHS) announced $12,593,225 in funding through the Health Resources and Services Administration (HRSA) to improve and expand the delivery of substance abuse services in California health centers, with a specific focus on treatment of opioid use disorders in underserved populations.

Administered by HRSA, these awards will allow California to increase the number of patients screened for substance use disorders and connect them to treatment; increase the number of patients with access to medication-assisted treatment for opioid use and other substance use disorder treatment; and provide training and educational resources to help health profession36 | THE BULLETIN | MARCH / APRIL 2016

als make informed prescribing decisions. HHS Secretary Sylvia Burwell has estimated that this nationwide effort should support substance use treatment for approximately 124,000 new patients and help save lives.

“Health centers treat some of the most atrisk patients in the country,” said HRSA Acting Administrator Jim Macrae. “These awards position health centers to be at the forefront of the fight against opioid abuse in underserved communities.”

Research demonstrates that a whole-patient approach to treatment through a combination of medication, counseling and behavioral therapies is most successful in treating opioid use disorders. In 2014, over 1.3 million people received

behavioral health services at health centers, a 75 percent increase since 2008. This funding builds upon and leverages previous investments by providing support to health centers to improve and expand the delivery of medication assisted treatment substance abuse services in an integrated primary care/behavioral health model with a specific focus on treatment of opioid use disorders in underserved populations.

“HRSA’s innovative investment in the delivery of medication-assisted treatment for substance use disorders affirms the importance of behavioral health to overall health,” said Kana Enomoto, Acting Administrator of the Substance Abuse and Mental Health Services Administration.

(CMA Alert, March 21, 2016 issue)

End of Life Option Act to take effect June 9 in California When the California legislature adjourned a special session on health care in March, it started a 90-day countdown to the implementation of the physician aid-in-dying law (ABX2 15) that was adopted last year. The law will take effect on June 9.

As written, the law requires two physicians to agree, before prescribing the drugs, that a patient has six months or less to live. Patients must be able to swallow the medication themselves and must affirm in writing, 48 hours before taking the medication, that they will do so.

In an effort to help physicians and patients navigate the End of Life Option Act, the California Medical Association (CMA) has published new legal guidance in a question-and-answer format intended to help physicians and patients understand this new complex law. Throughout the 15page document, both straightforward questions as well as those without answers yet are included. CMA acknowledges that the resource will evolve as the law is implemented.

“As physicians, there are a lot of questions about requirements under the new law, required documentation and forms, requests for the drug, consulting physicians and so on,” said CMA President Steven E. Larson, MD, MPH. “There certainly will be areas that evolve as we look to best practices in areas like which drugs to prescribe, but this is a resource to help us all navigate the new landscape.”

CMA’s health law library is the most comprehensive health law and medical practice resource for California physicians, containing On-Call

documents with up-to-date information including current laws, regulations and court decisions related to the practice of medicine. On-Call documents are generally a benefit for CMA members and are available for sale to the public; however, On-Call document #3459, “The California End of Life Option Act,” is free through CMA’s website.

“CMA was fielding calls from not only our members, but the general public about what the End of Life Option Act means and how it will impact care moving forward,” said CMA General Counsel Francisco Silva.

“This is a complicated issue, and both physicians and patients should have access to answers that help further the patient-physician relationship.”

CMA removed longstanding opposition to physician aid-in-dying last May and took a neutral position on the End of Life Option Act, ABX2 15.

CMA encourages Californians to think and talk with loved ones about their wishes for end-of-life medical care before a serious illness or injury occurs. CMA has developed a number of guidelines, forms and other resources to assist providers, patients, and loved ones with making important end-of-life decisions. CMA’s end-of-life resources can be found on CMA’s website at www.cmanet.org/endoflife.

Contact: CMA legal information line, 800/786-4262 or legalinfo@ cmanet.org.

(CMA Alert, March 21, 2016 issue)

Final regulations requiring health insurers to have adequate networks and accurate directories go into effect The California Department of Insurance (CDI), which regulates most PPOs in the state, issued permanent regulations last month that require health insurers to develop and maintain adequate provider networks. This move comes after emergency regulations were issued in January 2015 to help ensure patients can get timely access to care.

While the California Department of Managed Health Care (DMHC), which regulates HMOs and certain PPO products, has had in place network adequacy standards for a number of years, CDI has not. These regulations will thus ensure that Californians, regardless of the model of care they choose to purchase, have access to timely health care.

“The California Medical Association (CMA) strongly agrees that it is necessary to put into place a permanent regulatory framework that equips the department to more effectively monitor insurance products moving forward,” said CMA President Steven E. Larson, MD, MPH. “CMA surveys have identified major inaccuracies within directories over the last several years, but this move today will help make certain that patients are working with accurate lists that result in the ability to get medical care.”

The regulations, which go into effect immediately, provide significant protections for patients who have long faced challenges accessing care as the result of health insurers narrowing their provider networks. Signifi-

cant provisions require health insurers to: • Include adequate numbers and types of providers in networks; • Provide for treatment of mental health and substance use disorders; • Monitor and comply with established appointment wait time standards; • Report changes to networks to CDI for review; • Maintain accurate, publicly-available provider network directories and update them weekly; and • Arrange for out-of-network care for patients at the in-network price when there are insufficient in-network providers.

CMA commented extensively on drafts of the regulations, pushing for comprehensive rules that would address the issue of access in a meaningful way while reducing confusion caused by inaccurate provider directories. Significantly, CMA successfully advocated for provisions requiring health insurers to: • Obtain physicians’ written assent before including and listing them as a participant in a specified network; and • Meet timely access and network adequacy standards at the lowest cost tier, if they are using tiered networks.

MARCH / APRIL 2016 | THE BULLETIN | 37

(CMA Alert, March 21, 2016 issue)

SCCMA-MCMS/CMA members qualify for an additional 5 percent discount on their Workers’ Compensation Rates!

Workers’ Compensation: The California Medical Association (CMA), Preferred Insurance and Mercer have teamed up to create a workers’ compensation insurance program that provides safety, stability, service, and savings to members. See how these features can help control your costs as an employer.

Savings: CMA members qualify for an additional 5 percent discount* on top of Preferred’s already competitive rates. Preferred’s rates are set for long-term consistency and competitiveness. Rates are managed by focusing on workplace safety, fraud prevention, and controlling medical costs for your practice by getting employees back to work as soon as practical.

All physician practices can request a premium indication from Preferred to see what they could be saving.

Service: Mercer’s insurance advisors are knowledgeable about the needs of physicians and are available to walk you through the application process, either by phone or in person. Preferred’s claims examiners are friendly, accessible and experts in helping members with an employee injury or illness claim. Plus, Preferred’s payroll management and flexible payment plans help you manage your premiums in the way that works best for you and your practice’s cash-flow needs.

Safety: In additional to mandatory CalOSHA information and videos on workplace safety, Preferred’s risk advisors are available for consultations when you need them. They also have a strong fraud prevention policy and as a California-based carrier, they know exactly what it takes to do business successfully in this state – all things that help keep your employees and your business safe.

Stability: Preferred Insurance prides itself on its stability, which includes maintaining some of the best and most consistent pricing available for CMA members. And because of PreferredSelectMPN, its medical provider network of credentialed medical professionals, claim costs can be closely monitored and managed while providing quality care to injured employees. Preferred’s unique medical expense management approach helps keep your costs of doing business predictable and stable.

See how CMA’s workers’ compensation team can help you save! Call Mercer today at 800/842-3761 for a premium indication or visit www.

CountyCMAMemberInsurance.com. *Most practices will qualify for group pricing and receive the 5 percent discount; however, some practices will need to be underwritten separately if they do not qualify for the special program terms and conditions. A minimum premium applies to very small payrolls.

(CMA Alert, March 21, 2016 issue)

IMQ seeking physician surveyors for Corrections and Detentions Health Care Program The Institute for Medical Quality (IMQ), a subsidiary of the California Medical Association, is looking for physicians interested in participating in the IMQ Corrections and Detentions Health Care Program. The program currently has a dearth of physician surveyors, and a wealth of opportunity.

Your participation can make a difference in ensuring that jails maintain a high quality of care, including in areas such as infection control, health screenings, medication administration, etc.

The corrections program has many surveys lined up, and has just secured a contract in a major county to provide consultations. Surveys are scheduled throughout the state of California and provide surveyors with a chance to visit counties from Humboldt to San Diego, and everything in between. This program is rapidly growing; your time contributions will 38 | THE BULLETIN | MARCH / APRIL 2016

make a huge difference. Facts: • Because of the disproportionately high health needs of jail inmates and their relatively low access to health services outside of custody, jail systems are important providers of health care in California. In 2012, there were nearly 2.3 million health care visits provided to California’s county jail inmates.

• The prevalence of tuberculosis among inmates is as much as 17 times greater than among the total U.S. population. The prevalence of AIDS among inmates is five times higher than among the total U.S. population IMQ is seeking physicians with some experience in correctional medicine, emergency medicine or urgent care. However, if you are not familiar with corrections, we will prepare you.

Contact: Kevin Reeder, 415/882-5132 or kreeder@imq.org.

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Diabetes Self-Management Program Do your patients struggle with Diabetes? Are they Medicare Part B beneficiaries?

The Health Trust, accredited by the American Association of Diabetes Educators, offers a suite of evidenced based Diabetes management services that can help.

Call 408-961-9858 or email diabetesED@healthtrust.org, to learn more.

SCCMAby Stanford University to deliver these workshops The Health Trust is licensed in multiple languages.

09-03-15 • 1:1 Medical Nutrition Therapy session w/ a Registered Dietitian (Medicare Part B beneficiaries only) • 6 week peer led workshop series covering the AADE 7 Self-Carebehaviors MARCH / APRIL 2016 | THE BULLETIN | 39

Classifieds OFFICE SPACE FOR RENT/LEASE MEDICAL OFFICE SPACE TO SHARE • OFFICE FOR LEASE/SUBLEASE O’Connor Hospital area with office lease/ sublease. Please contact Dr. Maggie Chau at 408/799-7842 for details.

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. Time-share also available. Call Betty at 408/848-2525.

MEDICAL OFFICE SPACE TO SHARE • SUNNYVALE Convenient location. One large private office plus one exam room, shared waiting room and front office. Newly built, total 1,280 sq. ft. Available now. Please call 408/438-1593.

CAMPBELL

Convenient location. 5+ exam rooms M-F. In-office digital x-ray. Two large private offices, shared waiting room and front office. Total office size 3,000 sq. ft.

Available now. Call 408/376-3305 or marlene@svspine.com.

MEDICAL OFFICE SPACE TO SUBLET • MTN VIEW Mountain View Medical Office space to sublet. 1,100 sq. ft. Available three days a week. In large medical complex, behind El Camino Hospital. Basement storage, utilities included. Large treatment rooms, small lab space, bathroom, private office, etc. Call Dr. Klein. Cell 650/269-1030.

MEDICAL/DENTAL/PROFESSIONAL OFFICE • PALO ALTO Downtown Palo Alto, approximately 850 sq. ft. in garden setting, parking lot, three exam rooms, private office, reception area, private, quiet. Call Pete to see, at 650/465-3110.

METRO MEDICAL BILLING, INC.

• • • • • •

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

Contact Lynn (408) 448-9210 lynn@metromedicalbilling.com Visit our Website: metromedicalbilling. com 40 | THE BULLETIN | MARCH / APRIL 2016

EMPLOYMENT OPPORTUNITY OCCUPATIONAL MEDICINE PHYSICIANS • PRIMARY CARE, ORTHOPEDICS, & PHYSIATRY Our occupational medical facilities offer a challenging environment with minimal stress, without weekend, evening, or “on call” coverage. We are currently looking for several knowledgeable and progressive primary care and specialty physicians (orthopedist and physiatrist) interested in joining our team of professionals in providing high quality occupational medical services to Silicon Valley firms and their injured employees. We can provide either an employment relationship including full benefits or an independent contractor relationship. Please contact Rick Flovin, CEO at 408/228-0454 or e-mail riflovin@ allianceoccmed.com for additional information.

INTERNAL MEDICINE PHYSICIAN NEEDED We are looking for an internal medicine physician for our multi-specialty group.

Please email your CV to kaajhealthcare@ gmail.com.

INTERNIST AVAILABLE FOR LOCUM TENENS Internist available for Locum Tenens.

Part-time/full-time/vacation coverage.

Call or text 831/345-9696.

FOR SALE INTERNAL MEDICINE PRACTICE FOR SALE Internal Medicine Practice for sale. Turnkey operation. EMR – electronic billing.

Trained staff willing to stay. Great opportunity to build an excellent practice in lovely community in Monterey Bay. Call 831/345-9696 or email r.s.kochi@att.net.

STEAL MY PRACTICE • I’M RETIRING Fall in love with practicing medicine again.

Proven profitable Weight Loss practice in Marin County. Multiple 6 figures, ready to take it to the next level. Work-life balance, time freedom, financial security, relationship driven practice. I’m 100% committed to all the support necessary to ensure a smooth transition. Call for more information or to schedule a visit – Gail Altschuler, MD at 415/309-6258.

NOW AVAIL ABLE!

2016 Physician Membership Resource Directory ORDER YOUR COPIES TODAY! There are a lot of updates and changes in the new 2016 edition.

Make sure to order enough copies for you and your staff!

Contact Pam Jensen at 408/998-8850 today!

MARCH / APRIL 2016 | THE BULLETIN | 41

PRACTICE MANAGEMENT:

TIP OF THE MONTH Are you using the two new CPT codes to report prolonged services provided by clinical staff? Under the direct supervision of a physician or other

qualified provider (99415, 99416), these time-based services are reported in addition to a primary outpatient evaluation and management (E/M) service, 99201-99215.

For more information, see the Coding Corner article in the March issue of the CMA Practice Resources (CPR) newsletter, available at www.cmanet.org/cpr.

TPO Human Resource Management, one of our many partners, is

offering a COMPLIMENTARY Initial Consulting call for all members. In addition, there will be an interactive, fun, and insightful training session on HR Hot Topics for SCCMA Members on Wednesday, April

13 and for MCMS on Tuesday, April 19 from 12:00-2:00 - Lunch will be served.

The mandatory CURES registration’s deadline is July 1, 2016, for all physicians with an active medical license and Drug Enforcement Agency certificate. CMA has posted a webinar on the CURES 2.0 registration process, which was presented by the DOJ. The webinar is now available on-demand in the CMA Resource

Library at http://www.cmanet.org/resource-library/detail/?item=cures-20-navigating-the-states new0&r_search=&r_page=&return_to=list

TROUBLE GETTING PAID? WE CAN HELP!

SCCMA and MCMS’s Reimbursement Advocacy Program (RAP) is a MEMBER ONLY benefit. Sandie Moore is a Certified Coding and Reimbursement Specialist with 25+ years experience in medical practice operations. Our goal is to empower physician practices by providing billing/coding resources and guidance to improve the success of reimbursement for your practice. Assistance ranges from coaching and education to direct intervention with payors or regulators. Contact Sandie for assistance at (408) 998-8850 or (831) 455-1008 x3007 or email sandie@sccma.org

For Membership Info, call Leslie at 408.998.8850 or ,

831.455.1008 x3008 or email leslie@sccma.org .

42 | THE BULLETIN | MARCH / APRIL 2016

Success.

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As a physician-directed organization, we understand the realities of running a medical practice, and we are committed to supporting you with a range of valuable programs and services. These include a 24-hour adverse outcomes hotline, HR support, EHR consultation, a group purchasing program, and payment and reimbursement education and support, to name a few.

Prepare for Value-Based Compensation with CAP’s Free Guide As payers move toward a more value-focused model of reimbursement, your practice’s revenue stream may soon be tied entirely to clinical outcomes and patient experience.

CAP’s Physician’s Action Guide to Value-Based Compensation is replete with valuable information and tips to help you stay ahead of the VBC curve and attain fair and prompt reimbursement from public and private payers.

Request your free electronic or hard copy today!

800-356-5672 | CAPphysicians.com/Value

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MARCH / APRIL 2016 | THE BULLETIN | 43

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