MAY / JUNE 2016 VOLUME 22 | NUMBER 3
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Mercer Health & Beneﬁts Insurance Services LLC • CA Insurance License #0G39709 777 S. Figueroa Street, Los Angeles, CA 90017 • 800-842-3761 • CMACounty.firstname.lastname@example.org • www.CountyCMAMemberInsurance.com * The initial premium will not change for the ﬁrst 10 or 20 years unless the insurance company exercises its right to change premium rates for all insureds covered under the group policy with 60 days’ advance written notice. The County Medical Associations & Societies receive sponsorship fees for insurance programs that offset the cost of program oversight and support member beneﬁts and services.
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Official magazine of the Santa Clara County Medical Association and the Monterey County Medical Society
700 Empey Way • San Jose, CA 95128 • 408/998-8850 • www.sccma-mcms.org
MEMBER BENEFITS Billing/Collections CME Tracking Discounted Insurance
Feature Articles 14 Through Your Patient’s Eyes 17 The New CDC Opioid-Prescribing Guidelines 18 Chronic Pain Management 26 Saving Your Landline May Save Your Life!
Financial Services Health Information Technology Resources House of Delegates Representation Human Resources Services Legal Services/On-Call Library Legislative Advocacy/MICRA Membership Directory iAPP for the iPhone Physicians’ Confidential Line Practice Management
Departments 6 From the Editor’s Desk 7 Book Review 8 Message From the SCCMA President 10 Hippocratic Oaths 12 Message From the MCMS President 22 Discount Ticket Program 23 2016-2017 SCCMA Committee Response Form 32 CMA Benefits of Being A Member 34 New Member Benefit: Medical Practice Purchasing Group
Resources and Education
36 Medical Times From the Past
38 CMA Leaders Advocate Physician Priorities in Washington, D.C.
Publications Referral Services With
40 The Lifecycle of Legislation: From Idea Into Law
42 Classified Ads
44 CURES Registration Deadline
46 Are You Leaving Money on the Table?
Verizon Discount MAY / JUNE 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
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)
THE MONTEREY COUNTY MEDICAL SOCIETY
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 email@example.com © Copyright 2016 by the Santa Clara County Medical Association.
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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
1820 Ogden Dr. | Burlingame, CA 94010 650-375-1644 815 Pollard Dr. | Los Gatos, CA 95032 408-370-9098 bapelvicsurgery.com
Thank You Presidents By Joseph Andresen, MD
Editor, The Bulletin
JOSEPH S. ANDRESEN, MD
Physician Editor, The Bulletin
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.
Twelve months has quickly passed since Drs. Eleanor Martinez and James Hlavacek took over the reins as presidents of the Santa Clara County and Monterey County Medical Societies respectively. Humbled by the responsibility, yet excited by the upcoming challenges, Dr. Martinez likened her involvement as 80th President of SCCMA as a team member in a ball game where the center of focus is always on the ball, or in our profession, the paJames M. Hlavacek, MD tient. Most importantly, Dr. Martinez Eleanor Martinez, MD recognized that we could no longer emphasize these points over this past year in writallow outside forces dictate how we care for our paing more extensively regarding the value of membertients. Our strength in meeting these challenges is ship, events unfolding in 2016 including MACRA best when we act as a strong and formidable team. A (Medicare Access and Children’s Health Insurance strong and vibrant CMA is the mechanism best able Reauthorization Act) and perhaps most urgently, the to accomplish this. Over this past year Dr. Martinez importance of being at the table in shaping our proshared her interest in end-of-life care and the unique fession going forward. insight and privilege that physicians have in improving this aspect of our patient’s lives. We also received With busy medical practices, family responsian update and highlights from the CMA House of bilities and the need to stay abreast of new knowlDelegates that included support of Dr. Joaquin Aredge, we all march along at a frenetic pace. Perhaps ambulo’s run for State Assembly, medical student it is the internal thermostat that develops from resiinvolvement, and concerns over debt among many dency training. Add the responsibilities of leaderimportant topics. The California End-of-Life Opship to one’s shoulders and the personal sacrifice is tion Act was signed into law on October 5, 2015 by significant. Yet the rewards and accomplishments in Governor Brown. Dr. Martinez enlightened us all both small and large ways leave a memorable mark on this important legislation and urged us to read in a lifetime. Please join me in congratulating Drs. the California Physicians Legal Handbook (CPLH). Martinez and Hlavacek for their contribution and service over this past year. And I encourage each of Dr. Hlavacek came into office as Monterey you that may be tempted to step forward in a leadCounty Medical Society President a year ago with ership position in the future, to ask whether they leadership experience as Chief of Staff of Natividad would do it again. I’m sure the answer would be a Medical Center. He enlightened us all to the many resounding “yes”! challenges of serving a diverse population with high quality care, including a level two-trauma center in Salinas, California. Dr. Hlavacek called on all of us to get involved and participate in educating our patients, our community, and our legislators. Citing the success of defeating Proposition 46 and the passage of SB 277 vaccination bill, Dr. Hlavacek encouraged those physicians who are not members in their local medical societies and the CMA to join us in recognizing that the benefits are numerous and far outweigh the cost of joining. He has continued to
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A Surgeon’s War; My Year in Vietnam By Henry Ward Trueblood, MD TWO DIFFERENT PATHS ONLY FIVE YEARS APART: In 1968, the Tet Offensive failed to overthrow the South Vietnamese government but marked a turning point in the war with disillusionment and public support at home diminishing. A large antiVietnam War movement had developed as part of a larger counter culture. In 1970, the Vietnam War was still raging when I graduated from high school and first registered for the draft as an 18-year-old. Membership at the Berkeley (Quaker) Friends Church, and letters from family supported my opposition to becoming a combatant. I was fortunate to receive a 1-O or conscientious objector classification. Five years earlier, the Vietnam War was our undisputed national priority. Dr. Ward Trueblood received his draft notice immediately after internship at the University of Pennsylvania. As did his father who served as a physician during WWII, Ward made the decision to serve in the U.S. Navy as a surgeon, and was sent directly to Vietnam to treat the wounded. In 1989, I first met Ward Trueblood when entering private practice as an anesthesiologist. We worked together over the next 17 years at El Camino Hospital. He was well respected and a skilled surgeon who kept up on current affairs and the bigger picture of world events. As a member of Physicians for Social Responsibility, Ward had deep convictions and a strong moral compass. Twenty-six years later, I have in my hands, “A Surgeon’s War; My Year in Vietnam”, a personal account of Dr. Trueblood’s year of service in Vietnam. As another Memorial Day passes us, the significance of Dr. Trueblood’s observations of war cannot be ignored.
HORRORS THAT NEVER LEAVE YOU: “October 30, 1965: Bad night. Sixteen dead and thirty-three wounded. Very close to us. Had to keep helmets and flak jackets close by while in triage.” With limited supplies, 18-hour days working to exhaustion and heroics beyond belief, the inevitable would happen. A sutured wound would stop bleeding. The EKG suddenly became flat and realization that an 18 year-old precious son had just lost his life.
One of the hardest duties was the unzipping of body bags to fill out the official death report for each dead Marine. For Dr. Trueblood, each body bag was a reminder that he had to make his life add up to something; “to alleviate the suffering that surrounded us.” “Nearly every day we cared for people on the verge of death. At times it was overwhelming, and I would close my eyes for a few seconds, hoping to make the right decisions for the Marine in front of me. I was painfully aware of my limits. No doubt colleagues were going through a similar kind of agony, although we never talked about it. Our patients simply died or lived. None of us kept a tally.” A colonel was brought into the triage area with nothing recognizable below his navel. The wish to die, surrounded by family in a dignified fashion, was not possible. Given morphine, he died quietly. It is a horror that awoke Dr. Trueblood many, many nights and a memory that has never left him.
PERSONAL LESSONS AND INTROSPECTION: Yet in this sea of human destruction, somehow the tightly knit comradery of the healers tried to make light of their limitations. Many times, short of supplies, when a needed instrument wasn’t there, a corpsman would respond, “It’s on back order, Doc”. “Three joys: letters, showers, cold beer.” “Never take your eyes off the field. Never. Never”, yelled the senior surgeon. “To this day, I judge a surgeon by the same standard.” Recognition of extraordinary qualities in others: Walderon’s dry wit and talents as an anesthesiologist, Dr. Escajeda’s guidance in performing Dr. Trueblood’s first splenectomy. The prayer of St. Francis: “Make me an instrument of thy peace.” “I couldn’t save every Marine. I could only do my best. That’s all I could do.” Thirty-five years later, recognition of the stoicism and sadness, like his father before him, that resulted in a groundswell of unprocessed emotion.
SILVER LINING? If there is any silver lining in wartime medicine, it must be the accumulated knowledge learned. Frozen blood storage, early hydration
saline replacement to protect the kidneys and lungs, and more sophisticated measurements and understanding of acid-base balance, cardiac output and vascular resistance all came about during this time. A generation of more skilled surgeons in trauma medicine returned to civilian life but at a tremendous price in blood and treasure.
A FULL AND DISTINGUISHED CAREER: Dr. Trueblood finished his tour of duty, came home, married Nancy, the love of his life and completed his surgical training at Stanford University. Continuing a full and distinguished career, he currently serves as Trauma Attending at Santa Clara Valley Medical Center and teaches medical students bedside skills. This is in addition to being the recipient of many awards including Kaiser Family Foundation Award for Excellence in Clinical Teaching, Stanford University School of Medicine, 2010 Alumnus of the Year for Earlham College among others. “Long after war, whether in private practice, engaged in university teaching or operating on strangers or friends, I continue to follow the spiritual path that I discovered in Vietnam and that I remained determined to follow.” - Ward Trueblood, MD On this Memorial Day, let us remember and honor those who have served and continue to serve. And through Dr. Trueblood’s writings, never forget the heavy price and burden that those who witness war carry forward which ultimately touches all of our lives. Respectfully Submitted, Joseph Andresen, MD MAY / JUNE 2016 | THE BULLETIN | 7
The Noble Oath By Eleanor Martinez, MD
President, Santa Clara County Medical Association
ELEANOR MARTINEZ, MD
MESSAGE FROM THE
President, Santa Clara County Medical Association This is the time of the year where medical schools and allied health schools all across the country are holding their graduations. I was fortunate enough to be invited to attend the graduation of a student (whom I mentored) from the Stanford Physician Assistant School, as well as the graduation of my niece from the Indiana University School of Medicine. Another woman that I mentored is going to graduate from SUNY Downstate Medical School this month. In both events, the culmination was taking the Hippocratic Oath. It was then that I decided to revisit this Oath that I had taken many ages ago. Much to my surprise, I realized that the original Oath of Hippocrates written in Iconic Greek was written by him, or his students, in the late fifth century BC. This was followed by various revisions. There was the Declaration of Geneva, drafted in 1948, by the World
Eleanor Martinez, MD is the 2015-2016 president of the Santa Clara County Medical Association. She has a solo obstetrics and gynecology practice in Los Gatos.
Medical Association – concerned over the state of affairs of medical ethics and the world. In 1964, Dr. Louis Lasagna, Academic Dean of the School of Medicine at Tufts University, rewrote the Oath and it is this version that is used by the majority of U.S. Medical Schools. Graduates of Osteopathic Medical Schools have their own version, which has been in use since 1954. In reviewing the original Oath and the abovementioned revisions, the theme is Primum non nocere (First do no harm). Although the original Hippocratic Oath did not mention this statement per se, it states “I will carry out, according to my ability and judgement, this oath…”. All of the Oaths echo the same deep spiritual invocation. The original Hippocratic Oath served as the foundation that defined ethical medical practices and morals. Subsequent revisions were made to embody these guidelines for us Physicians, Doctors of Medicine, and Healers. President Kennedy once said, “Change is the law of life. And those who look only to the past or present are certain to miss the future.” During the time of Hippocrates, disease was deemed a product of nature, not punishments by gods or due to superstition. It was a product of environmental factors, diet, and living habits. Medicine, during his time, knew nothing about anatomy and physiology. The Hippocratic school was focused on patient care and prognosis incorporating passive treatment. Hippocratic medicine was passive and humble. In general, such approach is “kind to the patient, treatment was gentle and emphasized keeping the patient clean and sterile.” There was reluctance to use drugs. Such passive treatment was successful in treating simple ailments and the reliance on the healing power of nature was advocated. Hippocratic medicine was lauded for its strict adherence to professionalism, discipline, and the rigorous practice of medicine. It advocated detailed documentation of observation and findings so that such records can be passed to other physicians.
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Modern medicine has brought the practice of medicine to be more focused on specific diagnosis and specific treatment. Frequently, the treatment is a specialized one. The advances in medicine made it necessary to draft revisions in the Hippocratic Oath. Changes to the Hippocratic Oath were necessary to gain relevance. This issue of the SCCMA Bulletin Magazine (on page 10 and 11) contains both the original Hippocratic Oath written in the fifth century BC and the current Declaration of Geneva, drafted by the World Medical Association in 1948. The latter is further revised in 1964 when the prayer was omitted, thus making it a more secular version. It is interesting to note that the original version begins by taking a sworn oath to Apollo Physician and to the gods and goddesses, and so on. The newer version immediately defines the expectations of a Doctor of Medicine, imploring us to respect our peers, as well as our patients. The Oath calls us to remember that there is an art in the practice of medicine and science. It addresses that we, doctors, are given the responsibility to prevent diseases, as prevention is preferable to cure. Note, these documents were written in 1948 and revised in 1964. Who would have thought that “I will apply, for the benefit of the sick, all measures which are required, avoiding those twin traps of overtreatment and therapeutic nihilism…Most especially must I tread with care in matters of life and death. Above all, I must not play at God,” would be called into attention in issues that face our profession today. End of life, compassionate care of the dying, duty to patient care, not to an insurance entity or government requirement – Who would have thought that as early as the fifth
century, rigorous and detailed documentation of observation and findings would be vital in the care of the individual. Now we have the EHR. The issues that surround abortion and lethal injection calls into question whether we are violating the Hippocratic Oath. Debate on these two issues is only the beginning. In times like today, we are reminded to be centered in the Oath that we took as Doctors of Medicine. Finally, I would like to believe that if we do not violate that Oath, I “may enjoy life and art, respected while I live and remembered with affection there-after. May I always act so as to preserve the finest tradition of my calling and long experience the joy of healing those who seek my help.” On most days, I do believe it. I am passionate about being a doctor. It was a gift I was given, which I hold with high regard. Perhaps in some way I have lived sharing the knowledge of medicine to those who have crossed my path, like those who have graduated this year in medical school, or allied medical professional schools. We all work together to care for our fellow human beings. First do no harm. Do unto others as you would have them do unto you.
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The Hippocratic Oath Classic Version The full text from the "Harvard Classics" Translation.
I SWEAR by Apollo the physician and AEsculapius, and Health, and All-heal, and all the gods and goddesses, that, according to my ability and judgment, I will keep this Oath and this stipulation -- to reckon him who taught me this Art equally dear to me as my parents, to share my substance with him, and relieve his necessities if required; to look upon his offspring in the same footing as my own brothers, and to teach them this art, if they shall wish to learn it, without fee or stipulation; and that by precept, lecture, and every other mode of instruction, I will impart a knowledge of the Art to my own sons, and those of my teachers, and to disciples bound by a stipulation and oath according to the law of medicine, but to none others. I will follow that system of regimen which, according to my ability and judgement, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous. I will give no deadly medicine to any one if asked, nor suggest any such counsel; and in like manner I will not give to a woman a pessary to produce abortion. With purity and with holiness I will pass my life and practice my Art. I will not cut persons labouring under the stone, but will leave this to be done by men who are practitioners of this work. Into whatever houses I enter, I will go into them for the benefit of the sick, and will abstain from every voluntary act of mischief and corruption; and, further, from the seduction of females or males, of freemen and slaves. Whatever, in connection with my professional service, or not in connection with it, I see or hear, in the life of men, which ought not to be spoken of abroad, I will not divulge, as reckoning that all such should be kept secret. While I continue to keep this Oath unviolated, may it be granted to me to enjoy life and the practice of the art, respected by all men, in all times. But should I trespass and violate this Oath, may the reverse be my lot. Source: "Harvard Classics Volume 38" Copyright 1910 by P.F. Collier and Son. The bold print is added by http://euthanasia.com/oathtext.html
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The Hippocratic Oath, Modern Version I swear to fulfill, to the best of my ability and judgment, this covenant: I will respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share such knowledge as is mine with those who are to follow. I will apply, for the benefit of the sick, all measures which are required, avoiding those twin traps of overtreatment and therapeutic nihilism. I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon's knife or the chemist's drug. I will not be ashamed to say "I know not," nor will I fail to call in my colleagues when the skills of another are needed for a patient's recovery. I will respect the privacy of my patients, for their problems are not disclosed to me that the world may know. Most especially must I tread with care in matters of life and death. If it is given me to save a life, all thanks. But it may also be within my power to take a life; this awesome responsibility must be faced with great humbleness and awareness of my own frailty. Above all, I must not play at God. I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person's family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick. I will prevent disease whenever I can, for prevention is preferable to cure. I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm. If I do not violate this oath, may I enjoy life and art, respected while I live and remembered with affection thereafter. May I always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help. Written in 1964 by Louis Lasagna, Academic Dean of the School of Medicine at Tufts University, and used in many medical schools today.
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Election Year 2016 By James M. Hlavacek, MD
President, Monterey County Medical Society
JAMES M. HLAVACEK, MD
MESSAGE FROM THE
President, Monterey County Medical Society
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.
The 2016 election year is in full swing. At the national level we will see a battle between Hillary and Donald. All indications point to the most expensive presidential race costing well over a billion dollars, that is billion with a B! The following are the official tallied results for the MCMS 2016 elections of MCMS Officers, Directors, and “Physician of the Year”: Craig Walls, MD, PhD – President; Max Cuevas, MD – President-Elect; Alfred Sadler, MD – Secretary; Steven Harrison, MD –Treasurer; Philip L. Miller, MD – Director; Raymond Villalobos, MD – Director; and David Ramos, MD – Director. The “Physician of the Year” is Richard Dauphiné, MD. Richard Dauphiné, MD, FACS, is the medical director of the Monterey Sports Medicine Center and a board-certified orthopedic surgeon with 30 years of active surgical experience on the Monterey Peninsula. He has been an MCMS member since 1974. Locally, we have three County Supervisors up for re-election. The MCMS Board has interviewed candidates for Supervisor, as well as those for State Assembly. The Board has had a lively discussion about if we should endorse candidates, and if we do, which candidates should receive donations through our MD-PAC. The majority of the Board members voted to endorse candidates and to send contributions. I am pleased that we have had these discussions and many excellent points of view. The Board is still deciding on its endorsement for Supervisor for the 4th district, so this will not be listed. Here are the endorsed candidates: • Congress: Jimmy Panetta • State Senate: Bill Monning • State Assembly: Anna Caballero • State Assembly: Mark Stone • County Supervisor 1st District: Luis Alejo • County Supervisor 5th District: Dave Potter The Board also sent its endorsement and a contribution to Joaquin Arambula, MD, who is a candidate for the 31st Assembly District. Dr. Arambula is an emergency room physician. I met him at the CMA House of Delegates convention. The Wall Street Journal, weekend edition of May 14-15, ran a front page story about one family’s ordeal with fentanyl. In my anesthesiology practice I administer this medication almost every
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day. I remember when fentanyl was a breakthrough new drug for cardiac anesthesia in the late 1970’s and early 1980’s. Now fentanyl is the latest addiction due to its ease of manufacture in illegal labs in Mexico and China. Deaths from narcotic overdose in 2014 were 18,893! The death of rock star Prince is thought to be from a narcotic overdose. This epidemic is proving to be very difficult to treat. The Zika virus is also threatening to become an epidemic. The Senate has passed legislation to provide emergency funding of $ 1.1 billion for both international and domestic control and prevention efforts to fight the outbreak of the Zika cases. Also in the Wall Street Journal, the number of uninsured people in the USA is now below 10% of the population. Approximately 28.6 million people were uninsured in 2015. The Obama administration celebrated this accomplishment citing the Affordable Care Act, which has driven the number of uninsured people down from 16%, in 2010, when the health law was enacted. On the ballot, this November, will be the California Tobacco Tax for Healthcare, Research and Prevention Act. This ballot initiative would increase the tax on a pack of cigarettes by $2. California’s tax on cigarettes ranks 33rd in the country. It has been proven elsewhere that increasing the tax on cigarettes decreases smoking and prevents young people from starting to smoke. The CMA, American Heart Association, California Hospital Association, and other organizations are proponents of this act. As I wind up my time as your President, I want to thank all the members of the MCMS for their support and guidance. I also want to thank our leadership team headed by Bill Parrish, Jean Cassetta, Leslie Sorensen, Pam Jensen, and Sandie Moore. The year has gone by very quickly. The Medical Society and CMA do so much for all physicians. Let’s try and bring more members into the fold. I hope you will all join me at the annual meeting and dinner. We are honored that Ruth Haskins, MD, President-Elect of the CMA will be our keynote speaker. The dinner is at Corral de Tierra Country Club on Thursday, June 16th. Hope to see you there!
MCMS MEMBER SPOTLIGHT
Looking Back at 50 Years of Medicine in Monterey Convinced to come to the Peninsula in 1967, Dr. Hisashi Kajikuri never left Reprinted with permission of the Monterey County Herald (http://www.montereyherald. com)
By Mariana Barrera email@example.com, @MontereyHerald on Twitter If there is someone who has seen the evolution of medicine, it’s 90-year-old Dr. Hisashi Kajikuri, who has been on the Monterey medical scene for nearly 50 years. When World War II ended, he was in premed in Japan. It was in medical school he decided he wanted to study in the U.S. The Americantrained professors were the most dynamic and impressed him the most versus the Germantrained. Kajikuri was awarded a Fulbright Scholarship to study at the University of Indiana as a cardiovascular research fellow from 1960-1963. After that he returned to Japan to teach at the Kurume University School of Medicine to fulfill his Fulbright commitment. Kajikuri returned to the U.S. to continue his studies and further his training in thoracic and cardiovascular surgery at the University of Minnesota and the University of Michigan. “A lot of changes took place and they were all for the good,” said Kajikuri about the field since he started studying. His interest and capability caught the attention of his fellow resident and mentor at Chapel Hill, who convinced Kajikuri to head to the Monterey Peninsula in 1967. He hasn’t left since. Kajikuri opened his surgical practice in Monterey and it wasn’t until last year that he closed it. “I have worked hard at that for nearly 50 years,” said Kajikuri, who performed his last surgery at the age of 89. Now, at the age when most people are done working, Kajikuri wakes up each morning and heads to the hospital. For the last few years Kajikuri has been invited to assist and witness the
Dr. Hisashi Kajikuri, 90, stands beside Japanese calligraphy meaning “virtue” that a patient made him at his office in Monterey. (David Royal Monterey Herald) cardio-thoracic surgery at Community Hospital of the Monterey Peninsula. “I must say I like it,” said Kajikuri. Kajikuri’s passion for his work and dedication has not gone unnoticed. Kajikuri was the first recipient of the Physician Recognition Award, an award that honors members of the medical staff in appreciation of their services and contributions to Community Hospital. His office is adorned with multiple awards that he has earned throughout his lifetime as a surgeon. Kajikuri was recognized by Rep. Sam Farr, D-Carmel, in 2003 as an exceptional physician. He also received a letter of recognition from George W. Bush. Once again in 2003 he was awarded the “Physician of the Year” award. Kajikuri has witnessed firsthand how much surgeries have evolved from the time he started training.
“Sometimes people talk about how many complications and how many people die and so on, but tremendous systematic work is done in a hospital,” said Kajikuri. “It’s unbelievable from 50 years ago how things moved on.” Kajikuri has helped a multitude of people throughout the years, but even after all the good he has done, he considers himself the lucky one. “I was fortunate enough to come to this country and to witness the pioneering of medicine,” said Kajikuri. “It’s been a massive amount of development and that was such an exciting time and I feel privileged to have practiced medicine.” Kajikuri today still sees a few patients in his office in Monterey, and is happy. “I worked hard, and that was fun,” said Kajikuri. “It was really fun, and with all of this I was lucky.” MAY / JUNE 2016 | THE BULLETIN | 13
Note from the MBCâ€™s Executive Director: For the past three years, the Medical Board of California (Board) has made it a priority to address the epidemic of deaths related to overprescribing and misuse of controlled substances. The Board held a Joint Forum with the State Board of Pharmacy, initiated a Prescribing Task Force that was instrumental in revision of the Boardâ€™s Guidelines for Prescribing Controlled Substances for Pain (Guidelines) released in November 2014, produced public service announcements (PSAs) for both the public and physicians about the importance of safe prescribing and opioid use, and took enforcement actions against physicians who departed from the standard of care when prescribing opioids to patients. The Legislature also believes this issue is important and passed legislation that requires any physician who is authorized to prescribe, order, administer, furnish, or dispense Schedules II, III, or IV controlled substances to be registered with CURES (Controlled Substance Utilization Review and Evaluation System) by July 1, 2016.
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However, despite all the outreach and education regarding this issue, the Board continues to receive complaints and file accusations against physicians for inappropriate prescribing to patients. A recent letter to the Board providing a different perspective on this issue is printed here in an effort to further educate physicians on the importance of appropriately prescribing controlled substances. The letter has been edited for length and is being published anonymously at the request of its author.
A PATIENT’S STORY “Over the last 12 years, eight physicians have prescribed or attempted to prescribe Vicodin to me or my children. (As) the wife of a retired internist (and) daughter of an adult and child psychiatrist, ... I am certainly a fan of western medicine and physicians. But every physician, staff, and surgical facility I have dealt with as a patient or mother of a patient has been very pushy about our taking Vicodin for the following procedures.” The letter lists a child’s tonsillectomy, broken growth plate of a teen’s thumb, a teen’s bruised jaw with possible concussion, an adult’s finger surgery, and a young adult’s wisdom teeth removal. “Most of these physicians do not know each other; they span three (wealthy) counties within the state. I have had concerns over this information since our first son’s tonsillectomy – the first time a physician tried to convince me to fill a prescription for Vicodin. The recent attention to the role of physicians in heavy narcotic prescriptions for this particular patient base (wealthy, white, educated suburban families), prompted me to think that perhaps I should finally share my concerns. “If I had filled a prescription for each of these visits, which average one every two years, we would have a dangerously ample supply of the drug in our house, and our children’s brains would have had a disturbing level of repeated exposure to a highly addictive narcotic. It causes me to wonder how many Vicodin pills are on my street or in my children’s dormitories. “When the physicians each attempted to prescribe Vicodin to us, not one of them or their staff asked if there were any issues of addiction in our family history, ... nor were risks and the impact of addictive substances on the adolescent brain discussed, even when I inquired about them and
asked specific questions about risks. Neither were general risks to adults discussed. With each query, the physician or staff response was that we did not have to use the drug if we did not want to but that we should have it on hand in case the pain was bad. “In fact, the response I received from the surgery center and all support staff who dealt with me regarding my finger was quite unpleasant. They heavily pressured me to fill a prescription before going home. While I was lying on my back, ... the staff literally laughed at my suggestion that I would rather not take Vicodin and told me I would need it. It is the only time I can recall actually feeling bullied, and this by people who had in every other manner been absolutely wonderfully kind to me, providing excellent care. I conceded to taking a written prescription solely because of their tactics, but did not fill it, and most certainly did not need it, though they convinced me as best they could that I should take it. “The good news is that each physician’s skill and handiwork was quite fine and no such narcotics were needed or desired by any of us. The procedures performed ... were all superbly executed with little pain, speedy recoveries, and zero Vicodin. “I share this because physicians need to remember that they are part of a larger medical community, which has great power over patients, and that there is often a cumulative effect on families you might not consider when wanting patients to avoid pain. It is understandable that physicians not want us to suffer pain after a procedure. After all, I fully understand patients would come whining to the physician first, likely at unpleasant hours, and will post positive reviews on websites if a procedure is painfree. But, at a minimum, deeper discussion of what physicians are prescribing is warranted. “My experience with three different obstetricians at three different California hospitals, delivering babies (each weighing over nine pounds) vaginally was entirely different, with every detailed and respectful discussion (not monologues from the obstetricians of the risks, but two-way discussions about risks and benefits), resulting in very positive experiences for all three births. None of those physicians are on this list and yet wom-
…the staff literally laughed at my suggestion that I would rather not take Vicodin…
This article is reprinted with the permission of the Medical Board of California, originally printed in their Newsletter, Vol. 138, Spring 2016 issue MAY / JUNE 2016 | THE BULLETIN | 15
…at a minimum, deeper discussion of what physicians are prescribing is warranted en will often tell you there is little more painful than childbirth. (Yet) the ONLY physicians who have NOT pressured me to take Vicodin are obstetricians. In other words, this method of pushing the drug is endemic and pervades all other areas of practice, whether for adults or children. Perhaps the medical community as a whole could learn from obstetricians’ methods of discussing pain management with patients. “Last, please know that as the wife of a physician, I am often asked why physicians ‘push’ addictive narcotics. Patients (and mothers) ask me if physicians get kickbacks from pharmaceuticals. I tell them no, but you can see the perception people are developing of the medical community. It is very sad.” Note: While the Board’s Guidelines are intended to provide physicians with guidance on prescribing controlled substances in the long- term treatment of chronic pain, they also address acute pain. Specifically, they state, “[o] pioid medications should only be used for treatment of acute pain when the severity of the pain warrants that choice and after determining that other non-opioid pain medications or therapies likely will not provide adequate pain relief. When opioid medications are prescribed for treatment of acute pain, the number dispensed should be for a short duration and no more than the number of doses needed based on the usual duration of pain severe enough to require opioids for that condition.” The Board encourages physicians to use these Guidelines when prescribing controlled substances and to follow the standard of practice when prescribing controlled substances that are highly addictive and have a tendency for abuse.
For information about free CMEs that tackle opioid prescribing, SAMHSA offers the following online: http://www.opioidprescribing. com/overview https://www.scopeofpain.com/ 16 | THE BULLETIN | MAY / JUNE 2016
Opioid Pain Medicines FDA Warning The U.S. Food and Drug Administration (FDA) is warning about several safety issues with the entire class of opioid pain medicines. These safety risks are potentially harmful interactions with numerous other medications, problems with the adrenal glands, and decreased sex hormone levels. The FDA is requiring changes to the labels of all opioid drugs to warn about these risks. • Opioids can interact with antidepressants and migraine medicines to cause a serious central nervous system reaction called serotonin syndrome, in which high levels of the chemical serotonin build up in the brain and cause toxicity (see list of Serotonergic Medicines) http://www.fda.gov/drugs/drugsafety/ucm489676.htm. • Taking opioids may lead to a rare but serious condition in which the adrenal glands do not produce adequate amounts of the hormone cortisol. Cortisol helps the body respond to stress. • Long-term use of opioids may be associated with decreased sex hormone levels and symptoms such as reduced interest in sex, impotence, or infertility. Patients and health care professionals are urged to report side effects involving opioids or other medicines to the FDA MedWatch program: www. fda.gov/medwatch, using the information in the “Contact FDA” box at the bottom of the page. (from the FDA website)
The New CDC OpioidPrescribing Guidelines Reprinted with the permission of San Francisco Medicine, a publication of the San Francisco Medical Society The Centers for Disease Control and Prevention (CDC) issued guidelines in March that recommend primary care providers avoid prescribing opioid painkillers for patients with chronic pain. The risks from opioids greatly outweigh the benefits for most people, the CDC says. The summary points of the guidelines are: 1. Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate. 2. Before starting opioid therapy for chronic pain, clinicians should establish treatment goals with all patients, including realistic goals for pain and function, and should consider how therapy will be discontinued if benefits do not outweigh risks. Clinicians should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety. 3. Before starting and periodically during opioid therapy, clinicians should discuss with patients known risks and realistic benefits of opioid therapy and patient and provider responsibilities for managing therapy. 4. When starting opioid therapy for chronic pain, clinicians should prescribe immediate-release opioids instead of extended-release/longacting (ER/LA) opioids. 5. When opioids are started, clinicians should prescribe the lowest effective dosage. Clinicians should use caution when prescribing opioids at any dosage, should carefully reassess evidence of individual benefits and risks when increasing dosage to ≥50 morphine milligram equivalents (MME) per day, and should avoid increasing dosage to ≥90 MME per day or carefully justify a decision to titrate dosage to ≥90 MME per day. 6. Long-term opioid use often begins with treatment of acute pain. When opioids are used for acute pain, clinicians should prescribe the lowest effective dose of immediate-release opioids and should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids. Three days or less will often be sufficient; more than seven days will rarely be needed. 7. Clinicians should evaluate benefits and harms with patients within 1–4 weeks of starting opioid therapy for chronic pain or of dose escalation. Clinicians should evaluate benefits and harms of continued therapy with patients every 3 months or more frequently. If benefits do not outweigh harms of continued opioid therapy, clinicians should optimize other therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids. 8. Before starting and periodically during continuation of opioid therapy, clinicians should evaluate risk factors for opioidrelated harms. Clinicians should incorporate into the management plan strategies to mitigate risk, including considering offering naloxone when factors that increase risk for opioid overdose, such as history of overdose, history of substance use disorder,
higher opioid dosages (≥50 MME/day), or concurrent benzodiazepine use are present. 9. Clinicians should review the patient’s history of controlled substance prescriptions using state prescription drug monitoring program (PDMP) data to determine whether the patient is receiving opioid dosages or dangerous combinations that put him or her at high risk for overdose. Clinicians should review PDMP data when starting opioid therapy for chronic pain and periodically during opioid therapy for chronic pain, ranging from every prescription to every three months. 10. When prescribing opioids for chronic pain, clinicians should use urine drug testing before starting opioid therapy and consider urine drug testing at least annually to assess for prescribed medications as well as other controlled prescription drugs and illicit drugs. 11. Clinicians should avoid prescribing opioid pain medication and benzodiazepines concurrently whenever possible. 12. Clinicians should offer or arrange evidence-based treatment (usually medication-assisted treatment with buprenorphine or methadone in combination with behavioral therapies) for patients with opioid-use disorder. Issued March 2016; full 52-page document at: http://www.cdc.gov/drugoverdose/prescribing/resources.html
• Checklist for prescribing opioids for chronic pain: http://stacks.cdc. gov/view/cdc/38025 • JAMA Patient Information page: Opioids for Chronic Pain http:// jama.jamanetwork.com/article.aspx?articleid=2503507 • CDC Fact Sheet/Checklist/Non-Opiate Tools: http://www.cdc.gov/ drugoverdose/prescribing/resources.html
MAY / JUNE 2016 | THE BULLETIN | 17
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From 1999-2014, more than 165,000 people have died from prescription opioid overdose in the U.S.—outstripping deaths from illicit substance use. This trend mirrors the increased prescribing of opioid medications at high doses over long periods of time to treat chronic, non-cancer pain (CNCP). Contributing factors include concerted efforts to answer concerns about the undertreatment of pain; aggressive marketing by pharmaceutical companies attesting to the safety of prescription opioids for long term use; escalating drug doses to address perceived tolerance to the drugs’ analgesic effect; lack of awareness of effective, non-opioid based pharmacologic treatments (e.g., select anticonvulsants and antidepressants); and lack of access to effective non-pharmacologic treatments (e.g., cognitive-behavioral therapy (CBT)). In March of this year, the Centers for Disease Control (CDC) responded to this crisis with a set of Guidelines for Prescribing Opioids for Chronic Pain. The document assesses the evidence regarding the risks and benefits of using opioids in the treatment of CNCP in the primary care setting (outside of the setting of end of life). The authors acknowledge that there is insufficient evidence in many areas to guide practice, and, where there is evidence, it is often only of fair quality. Yet the sense of urgency to reverse the trend in prescription opioid related deaths, the authors believe, outweighs the desire for higher quality data to guide practice at this time. So what does the CDC conclude from the available science when it comes to the use of opioids in treating CNCP (defined as pain lasting greater than three months or past the time of normal tissue healing)? The document assesses the clinical evidence in five areas: 1. Effectiveness: There is no evidence to support the effectiveness of opioids for long-term therapy (≥ 1 year) of CNCP when it comes to impact on pain level, function or quality of life. 2. Risk: Long-term opioid therapy is associated with a dosedependent risk of abuse and overdose. Overdose risk seems to increase dramatically at doses as low as 50 mg morphine equivalents (MME)/day with a hazard ratio as high as 3.73 in some studies compared to doses less than 20 MME/day. Additionally, there is some evidence pointing to increased risk of cardiovascular events when using opioids. 3. Dosing: There is inconsistent evidence about the risk of using extended release/long acting (ER/LA) formulations compared with immediate release (IR) dosing. When compared to extended release morphine, this uncertainty extends to the use of methadone for CNCP therapy with evidence pointing to increased overdose risk, lower overall risk of mortality and no risk difference.
4. Risk Prediction and Mitigation: Available tools to assess opioid abuse and misuse tools at the initiation of therapy (e.g., Opioid Risk Tool and Screener and Opioid Assessment for Patients with Pain-Revised) have low specificity and sensitivity. No evidence exists to guide the use of Prescription Drug Monitoring Programs (PDMP), opiate management plans, urine drug testing (UDT), pill counts, or abuse-deterrent formulations in mitigating the risk of misuse, abuse, or overdose. 5. Acute Pain: There is evidence to suggest that the use of opioids in treating acute surgical pain or pain related to trauma increases the likelihood of ongoing use at one year.
ULTIMATELY, THE DOCUMENT’S FINAL RECOMMENDATIONS ARE BASED ON “CONTEXTUAL EVIDENCE” IN THE FOLLOWING AREAS: Nonpharmacologic and Nonopioid Pharmacologic Treatments: In studies lasting up to six months, CBT, exercise, and combined movement and behavioral treatments (compared to single modality therapy) reduced pain and improved function. In addition, the document refers to several other guidelines that indicate non-opioid analgesics (acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), COX-2 inhibitors); select anticonvulsants (gabapentin and pregabalin); and select antidepressants (tricyclics and serotonin norepinephrine reuptake inhibitors) as first or second line treatments. The potential harm of these medications (specifically, acetaminophen and NSAIDs) is considered to be substantially less than the risk of opioids. Additional Data On Opioid Risk and Risk Mitigation: Based on the review of additional studies not included in the clinical review, the authors take a firmer position on the disproportionate association of methadone in up to one third of opioid related deaths despite representing <2% of opioid prescriptions outside of opioid treatment programs. They also point to time-scheduled as opposed to as needed dosing of opioids leading to higher daily doses over time. Some additional risk factors for harm or overdose highlighted include: co-prescription of benzodiazepines, sleep apnea, renal or hepatic insufficiency, age ≥ 65, depression, and substance abuse/dependence. When it comes to risk stratification, the authors suggest that PDMP and UDT, while not supported by clinical evidence, may help identify situations that are high risk for harm or overdose. They do, however; acknowledge the limitations of these tools including the cumbersome nature of using PDMPs and the potential for misinterpretation of UDT results potentially leading to inappropriate clinical decisions. When it comes to risk mitigation, the authors extrapolate from the successes of naloxone distribution in community-based over-dose prevention programs targeted to substance users in lowering overdose deaths as a potential strategy for decreasing overdose from prescription opioids. Finally, the authors found little to no evidence at this point to subMAY / JUNE 2016 | THE BULLETIN | 19
stantiate the concern that changes in opioid prescribing practices may lead to unintended increases in the use of heroin or illicitly obtained opioids. Provider and Patient Perspective: Faced with the dilemma of trying to address the increase in prescription opioid related deaths in a setting of little to no high quality data, the authors review provider and patient perceptions about opioid therapy for CNCP. Providers are worried, frustrated, and lack confidence in addressing concerns about opioid risk with their patients. In turn, patients are concerned about “addiction,” report high levels of side effects, and are unsure about the overall benefit of opioid therapy when there is little else available to treat their symptoms. Cost: The authors point to the high direct and indirect costs of prescription opioids including prescription expenses; costs of opioid-related overdose; and costs related to abuse, dependence, and misuse compared with costs of non-pharmacologic and non-opioid based pharmacologic therapies.
RECOMMENDATIONS When it comes to distilling the evidence into recommendations for clinical practice, here, too, the authors feel that the crisis regarding prescription opioid related deaths outweighs the lack of compelling, gold-standard level evidence.
HERE IS MY TAKE ON THE EXTENSIVE RECOMMENDATIONS: Providers should have a systematic approach to opioid prescribing: proceeding with caution; identifying a clear and compelling indication to prescribe opioids; and being frank with patients about what we know about the risks and benefits of these treatments. After all, they are worried about the risks of opioids as well. When providers choose opioids, they should be used at the lowest effective dose. While the guidelines stop short of naming a dose ceiling, the increase in overdose risk at ≥ 50 MME/day is repeatedly mentioned. Furthermore, the recommendation is to avoid increasing dosage ≥ 90 MME/day without clear and compelling justification. IR opioids are favored over ER/LA formulations at the start of therapy. Methadone and transdermal fentanyl should not be first line choices. The guidelines raise questions about the use of both ER/LA formulations along with as-needed IR dosing for so called “breakthrough pain.” For those patients already at high doses, the recommendation is to review the evidence of increased risk and discuss tapering to a safer dose. When tapering, go slow, about 10% per week, and allow for pauses in the taper if patients are experiencing withdrawal symptoms. Tapers may be accelerated if there is very high risk for overdose. Tapers are not necessary if there is compelling evidence of total diversion. Opioids should be used as part of a multimodal treatment strategy that includes evidence-based non-pharmacologic and nonopioid medications. Clear goals should be established at the outset for assessing risk and benefit of ongoing treatment, along with an “exit strategy” if risk outweighs benefit or if there is no benefit. As risk of opioid misuse or overdose is hard to predict, providers should take a “universal precautions” approach to monitoring and mitigation strategies that involve frequent and regular followup. Here the guidelines recommend follow-up within the first four weeks of start of therapy and at least every three months thereafter. In addition, the guidelines recommend checking the PDMP before the start of therapy and at least every three months thereafter. UDT 20 | THE BULLETIN | MAY / JUNE 2016
should be obtained before the initiation of therapy and at least annually thereafter. One final mitigation approach is the risk based co-prescribing of naloxone (e.g., history of overdose, history of substance use disorder, high opioid dosage (≥50 MME/day), concurrent benzodiazepine use, which should be avoided whenever possible). When treating acute pain, the recommendation is limit opioids to three days or less, and not more than seven days in rare circumstances. If during the course of therapy, opioid use disorder is diagnosed, providers should offer or arrange for patients to access medication-assisted treatment with buprenorphine or methadone.
COMMENTARY Depending on one’s clinical setting, these guidelines may align to varying degrees with already established standards. More likely, though, is that current clinician practice varies greatly from these guidelines. As such, greater provider and patient education, awareness, and technical assistance may be needed to successfully transform the use of opioid therapy in CNCP treatment. As overwhelming as continuing to treat CNCP has been as a medical community, changing practice may feel more overwhelming. This will take time. After all, it took us almost 20 years to come to this point. Whatever you may think of the strength of the arguments for change in opioid prescribing practice, it is clear that change is here. In closing, I offer these thoughts and calls to action as a way to guide our way forward in a process that will overhaul the way we treat CNCP in the years to come—hopefully to the benefit of our patients and communities: • We want to advocate for payors and other stakeholders to support the creation of payment models to support evidence-based non-pharmacologic therapies. • When we make a change in our practice, we want to be transparent with our patients about why we are making the recommendations we’re making. • We want to reach out to our colleagues within our practices; acute, specialty and tertiary care settings; and other community stakeholders to craft a consistent, compassionate, and comprehensive approach to pain management that focuses on safety and well-being. • We don’t want to refuse to write another opioid prescription. Despite the risks, there are still compelling indications for the use of opioids in treating CNCP. • We don’t want to make sudden changes in the treatment plan that leave patients feeling judged, blamed, abandoned, or mistrusted. After all, they didn’t create this problem. We need their trust and they need to know our commitment is steadfast in order for us to back out of this crisis together with the least harm possible.
REFERENCE Dowell, D.; Haegerich, T.; Chou, R “CDC Guideline for Prescribing Opioids for Chronic Pain –United States, 2016:” MMWR 65(1):1-49
Joseph Pace, MD, is San Francisco Health Network Director of Primary Care Homeless Services and Medical Director, Tom Waddell Urban Health. He is co-chair of the San Francisco Safety Net Pain Management Work Group. He also co-hosts City Visions, a “thinking person’s talk show” on KALW-FM public radio.
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700 Empey Way, San Jose, CA 95128 (408) 998-‐8850 FAX (408) 289-‐1064
2016-2017 SCCMA COMMITTEE RESPONSE FORM
Listed below are the current SCCMA committees—all meet at the Medical Association building. Omitted are those where membership is by election (e.g., Council and Executive Committee), bylaw consideration, and/or existing protocol (e.g., Awards, Membership, Physicians’ Well-Being, and Professional Standards/Conduct). SCCMA committees help recommend policies for the Association, standards for practice in Santa Clara County, and aid in the development of important relationships with governmental and public service organizations. Committee service commences on July 1, 2016. The majority of the committees will not meet during July and August, however. In accordance with SCCMA bylaws, committee appointments are made each year by the President and state that, “The terms of office of the chairs and members of all committees shall be at the discretion of the President, and, in any event, shall end with the term of office of the President by whom they were appointed…” Therefore, the terms of fiscal 15-16 committee members and chairs, having been appointed by Eleanor Martinez, MD, will officially end with her term of office — June 30, 2016. Name:
Members interested in serving on any of the following Committees are asked to return this form.
Bioethics (Bi-monthly, dinner) To educate its
members regarding bioethical decision making, discuss bioethical issues and develop guidelines, and advise government and industry leaders regarding the ethical aspects of health care policy.
Leon P. Fox Medical History (Bi-monthly, first Monday, lunch) To identify, collect, and preserve archival material, memorabilia, and artifacts representing the medical history of Santa Clara County.
Environmental Health (Bi-monthly, dinner) To study and address environmental and occupational health concerns.
High School Outreach Program (Yearly) To speak about your specialty before local high school students at the annual program, which is designed to pique the students’ interest in becoming a physician in our community.
Medical Student Mentor Program (Yearly) To volunteer as a mentor to a Stanford medical student. Students can “shadow” practicing physicians to learn about their specialties and modes of practice.
FAX form to 408/289-1064 or mail to SCCMA by 7/15/16. 06/12 MAY / JUNE 2016 | THE BULLETIN | 23
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o landlines seem obsolete? Do you even have a landline? As it turns out most people do have one and depend on it for many or most of their home phone calls, requesting emergency response or when their electric power goes out. Although more people are using cell phones and Voice Over Internet Protocols (VOIP) to communicate via the Internet, the latest CDC study from 2014 shows that in most states, including California, the majority still have landlines. According to the CDC, 57% of Californians indeed still have a traditional landline and 7% have only a landline for communication, especially in rural areas. (4) Plain old telephone service through copper wires (POTS as the industry calls it) has been and continues to be the safest, most private, most reliable, and cheapest way to keep us all connected at home, internationally, and in emergencies. While Americans have enjoyed universal access to traditional telephone service at an affordable rate for almost a century, this may not be the case for much longer if AB 2395 were to pass. This incredible sophisticated system of communication, which was developed from the early 1900’s and has served all of us well in emergencies and daily life is now in jeopardy of demise. AT&T is leading the charge here and in other states. (6)
By Cindy Russell, MD VP of Community Health, SCCMA AB 2395 – TELECOMMUNICATIONS: REPLACEMENT OF PUBLIC SWITCHED TELEPHONE NETWORK A new California bill AB 2395 backed by AT&T and introduced February 2016 is poised to remove regulated landlines (switched telephone 28 | THE BULLETIN | MAY / JUNE 2016
network services) to deregulated Internet Protocol (IP) enabled services and networks by 2020. IP or VOIP uses a phone service over the Internet for communications. AT&T state that only 6% of Californians have only a landline for telephone service, and each year there are more people who give up their landline as they use their cell phone as their primary number. The bill states energy will also be saved using fiberoptics. “Rather than modernizing phone service, this bill would take us back to the dark days
when consumers were totally at the mercy of AT&T,” said The Utility Reform Network (TURN) executive director Mark Toney. “It will eliminate the most basic consumer protections, regardless of the enormous impact abandoning copper could have on emergency services and vital communications.”
DON’T CUT THE CORD: LANDLINE AS A LIFELINE Those opposing the bill note that landlines are important as a backup for emergencies and power outages, to transmit faxes, and for businesses using landlines. Moreover, the voice quality of landlines is superior compared to the Internet phone service. If the bill were to pass, then the options include VOIP, which require a computer with Internet access or a router/modem that provides phone, internet, cable access….or a cell phone. All of these services, of course, are provided by AT&T, Comcast, and several others. If people have only Internet or cell tower phone service and lose power, then they will need to have back-up generators or batteries in order to communicate. The cell towers also need back up generators or batteries in case of a power outage or other cause of failure. Other concerns specific to AB2395 include compromised service and cost to rural populations, and lack of affordability to disabled and low-income people. Those opposing the bill, so far, include the California Public Utilities Commission, Communications Workers of America, AARP, California Labor Federation, California Alliance of Retired Americans, and Mendocino County Board of Supervisors. TURN also opposes this and states “AT&T’s bill degrades 911, puts public safety, small businesses, and rural customers at risk.”
division analysis states the bill would undermine the California and federal commitment to universal service, negatively impact public safety, and undermines the CPUC authority over safe and reliable services as it would essentially deregulate phone lines. A CPUC memorandum dated March 17, 2016 states “The adoption of this bill would leave thousands of Californians, predominantly rural customers, without access to landline telephone service, and hence access to 9-1-1 and other necessary communications.” In addition, the CPUC states the bill is not necessary to promote IP services as infrastructure is already being upgraded. (29)
DIGITAL DEVICES USE A SURPRISING AMOUNT OF ENERGY With regards to energy costs some studies suggest that the electrical needs of digital devices towers over traditional devices. Energy consumption has risen dramatically as digital data is created, used, and transmitted. A study by Digital Power Group in 2013 found that the average iPhone used more electricity than a medium sized energy star rated refrigerator. (7,8) Although criticized for its overestimation, there is still a significant and growing energy demand from digital devices and cell tower transmitters that are always powered on. Although the fiberoptic transmission, perhaps, may reduce energy costs, this is not the whole story. Is the use of digital phones themselves taken into account, as well as the servers and cell towers required to power them and transmit a tidal wave of data? Energy costs may be much more if the total system costs are taken into account. According to TURN, “Masked as an environmental bill, the real intent and effect of the legislation would be to allow telephone companies to abandon basic landline telephone service and force customers to subscribe to services that may not be affordable, offer reliable service, or function during power outages. The bill would leave millions of residential and small business customers without the safety net – for essential telecommunications services and jeopardize the public health and safety of Californians.”
“Some fiber-based and VoIP systems won’t work with medical alert devices, fax machines or home alarms” (27)
911 WASN’T BUILT FOR CELL PHONES First responders are also concerned as the call-tracing software used by firefighters, ambulance services, and police, works only on landlines. This accuracy insures the most rapid response for medical or other emergencies. In order to locate someone with a cell phone in an emergency cell tower, triangulation is required and it doesn’t give you exact location. “If you don’t quite get the right information for where the pizza shop is [to pick up a pizza], no one dies. For 911, people die,” says Roger Hixson, technical director of the National Emergency Number Association (NENA) (21). After a major Alaskan power outage in March 2016, the Anchorage police advised residents “Don’t cut the cord.” (22)
RURAL RESIDENTS DEPEND ON LANDLINE SERVICE Those from rural communities who are largely dependent on landlines for regular phone service and emergency services are very worried. Although AT&T states they will make sure everyone has phone service, there are no assurances as to service or quality in the current state of the bill. The bill gives residents one year to get VOIP after 2020 if they do not already have it by 2020. The cord will then be cut. The Rural County Representatives of California wrote a letter to the author of the bill, on April 11, 2016 stating “Unfortunately, modern communications systems are either non-existent, unreliable, or cost-prohibitive in many of our member counties. Subsequently, traditional landline phone service remains the backbone and only reliable two-way communication mode. (3)
CALIFORNIA PUBLIC UTILITIES COMMISSION (CPUC) OPPOSES AB 2395 The CPUC, who has a fundamental duty to provide safe and reliable utility service embodied in PU Code § 451, opposes this bill. The CPUC
SECURITY AND PRIVACY CONCERNS WITH FIBER OPTIC TECHNOLOGIES At first, fiber optic networks were believed to be one of the most secure infrastructure options. Industry experts now believe that fiber is almost as easy to tap as copper and is virtually undetectable with today’s technology. “And, tapping into fiber no longer MAY / JUNE 2016 | THE BULLETIN | 29
requires a submarine or a multimillion-dollar project funded by government agencies. The required equipment has become relatively inexpensive and commonplace, and an experienced hacker can easily pull off a successful attack.” (11)
PRIVACY AND HACKABILITY OF WIRELESS DEVICES Removing landlines pushes us further into the wireless era, which is certainly convenient, but has its downsides. These are becoming more and more apparent with time. Not everyone is enthusiastic about the switch. In a “60 Minutes Overtime” episode from April 16, 2016 mobile security experts showed how strangers can hack the phone in your pocket, not to mention computers. (24) Security issues have not been addressed with current wireless technology. According to tech experts, cordless phones, iPhones, smart meters, and a host of other wireless devices face hacking risks. Encryption can help, but is expensive and not foolproof. Wireless routers in your home are susceptible to phish attacks and unwanted ads via the Internet. Large service providers may not be able to easily find or fix the problem, and home visits may be difficult to schedule. Ted Harrington, marketing head of Independent Security Evaluators of Baltimore explains why router hacking could turn into a big problem based on a new study of wireless routers and hacking risks. “What’s notable about this is that if you compromise the router, then you’re inside the firewall. You can pick credit card numbers out of emails, confidential documents, passwords, photos, just about anything,” he said. (13)
WIRELESS COMMUNICATIONS AND PUBLIC HEALTH
“Everyday we receive calls where we get a (cell) tower address, and that’s all.” Carl Hall, chief of technology, Alpharetta Public Safety Department. (20)
There has been exponential worldwide expansion and dependence on wireless communication networks and infrastructure including cell phones, cell towers, wireless routers, medical devices, and utility smart meters throughout our homes and communities. Scientists, physicians, and the public are increasingly concerned about the long term impact on public health due to this relentless rising exposure of the population to wireless radiation. More cell phone towers will be built to provide wireless service. AB57 (2105) passed the California legislature clearing the way for fast tracking cell towers. This is problematic from a public health standpoint as the Telecommunications Act of 1996 states that environmental or human health concerns cannot be taken into consideration in placement of cell towers 30 | THE BULLETIN | MAY / JUNE 2016
despite the fact that many studies demonstrate adverse effects of cell tower radiation on humans and birds. In May 2015, an International Scientist Appeal signed by more than 200 published scientists who study electromagnetic frequency (EMF) was sent to the World Health Organization to ask that they “initiate an assessment of alternatives to current exposure standards and practices that could substantially lower human exposures to non-ionizing radiation.” (82) The scientific community has unexpectedly demonstrated adverse biological and clinical effects from wireless EMF at or below our current approved exposure standards, including single and double stranded DNA breaks, creation of reactive oxygen species, immune dysfunction, cognitive processing effects, stress protein synthesis in the brain, altered brain development, sleep and memory disturbances, ADHD, sperm dysfunction, brain tumors, abnormal animal behavior, and bee colony collapse. (31-94) A major problem is the long latency period of years to decades to study and identify adverse health effects such as brain cancer and neurodegenerative damage. Another important consideration is that children’s brains are developmentally immature until adolescence, their skulls are thinner, and the brain is considerably more vulnerable to toxin exposure. (23,24)
INCREASING WIRELESS COMMUNICATIONS AND ELECTROHYPERSENSITIVITY
A new category of medical illness is now being discussed in the medical literature called electrohypersensitivity (EHS). An increasing number of people in all walks of life report suffering from exposure to electromagnetic fields. Non-specific neurological and dermatologic symptoms, including headaches, occur at levels below current safety guidelines. Even students have reported symptoms once Wi-Fi was installed in schools. (103) In Sweden, electrohypersensitivity is a fully recognized functional impairment. (101) Some people develop similar symptoms of sleeplessness, fatigue, and headache symptoms after a nearby cell tower or home smart meter is installed. So far, studies have been mixed and no pathophysiologic mechanism has been identified. Researchers, however, at Louisiana State University, in 2011, studied a self reported EMF sensitive physician and found “In a double-blinded EMF provocation procedure specifically designed to minimize unintentional sensory cues, the subject developed temporal pain, headache, muscle twitching, and skipped heartbeats within 100 s af-
ter initiation of EMF exposure (p < .05).” They concluded, “EMF hypersensitivity can occur as a bona fide environmentally inducible neurological syndrome.” (102)
ORGANIZATIONS CONCERNED ABOUT WIRELESS TECHNOLOGY AND PUBLIC HEALTH WHO – The World Health Organization, in 2011, designated radiofrequency electromagnetic fields used in wireless communications, including cell phones, to be a Group 2B carcinogen. (95) European Parliament – Resolution 1815 – In a 2011 report “Potential Dangers of Electromagnetic Fields and Their Effect on the Environment.” The Council of Europe issued a call to European governments to “take all reasonable measures” to reduce exposure to electromagnetic fields “particularly the exposure to children and young people who seem to be most at risk. (26) AAP – The American Academy of Pediatrics, in 2013, in a letter to the FCC has asked for reassessment of exposure to radiofrequency electromagnetic fields limits and policies that protect children’s health and well-being throughout their lifetimes and reflect current use patterns. (96) Insurance Companies – In a 2013 Emerging Risk Report, Zurich based insurance company called Swiss Re, the second-largest reinsurer in the world and the insurer of the World Trade Center, listed electromagnetic fields in the highest category of casualty risk due to “unforeseen consequences” beyond 10 years. (97) U.S. Department of Interior – On February 7, 2014, the U.S. Department of Interior stated in a letter to the National Telecommunications and Information Administration that “The second significant issue associated with communication towers involves impacts from non-ionizing electromagnetic radiation emitted by these structures. Radiation studies – have documented nest and site abandonment, plumage deterioration, locomotion problems, reduced survivorship, and death – from cellular phone towers in the 900 and 1800 MHz frequency ranges – However, the electromagnetic radiation standards used by the Federal Communications Commission (FCC) continue to be based on thermal heating, a criterion now nearly 30 years out of date and inapplicable today.” (98) California Medical Association – In 2014, the CMA adopted Resolution 107-14, which stated that the CMA supports efforts to reevaluate microwave safety exposure levels associated with wireless communication devices and that the CMA supports efforts to implement new safety exposure limits for wireless devices to levels that do not cause human or environmental harm based on scientific research.
Canada – Parliament Standing Committee on Health recommended practical advice on how to reduce exposure to EMF radiation after holding extensive public hearings, in June 2015, and called for more research. (16) Spain – Several municipalities have passed resolutions to urge removal of Wi-Fi in schools and public places (16) Italy – Parliament voted to enact the precautionary principle and reduce wireless exposures whenever possible.(16) Germany – The German Federal Office for Radiation Protection advises reducing exposure to EMF as much as possible, and in Frankfurt all wireless networks are banned in schools. (16) Austria – The Public Health Department of Salzburg recommends not using WLAN or DECT in schools. In 2016, the Vienna Medical Association updated new cell phone safety guidelines. (15) Taiwan – In 2015, the government updated their Protection of Children and Youths Welfare and Rights Act to include a complete ban on children under the age of two from using electronic devices such as iPads, televisions, and smartphones. (16) Several states in the U.S. have already started the landline shut down (Michigan, Kentucky, Wisconsin, Ohio), but their residents are not happy and are fighting back. There remain several attributes of landlines that cannot be served by internet providers. Landlines work even when the power goes out; they are compatible with medical monitoring devices, such as pacemakers, that transmit the data to medical centers. They can also reliably pinpoint your exact location when you call 911. These are not optional services that we should abandon. Valid health and safety reasons argue for preservation of the landline for all of us, regardless of age. It will be important to follow AB 2395 as it goes through the various committees.
“The adoption of this bill would leave thousands of Californians, predominantly rural customers, without access to landline telephone service, and hence access to 9-1-1 and other necessary communications.” CPUC
INTERNATIONAL POLICY ACTIONS ON WIRELESS EMF France – In 2015, France passed a broad policy on wireless technology that includes a ban on Wi-Fi in nurseries and kindergarten, requires that Wi-Fi be turned off when not in use in schools, requires cell antennae location information to be readily available and includes antennae EMF monitoring and compliance. (99) Israel – In 2013, Israeli Ministry Of Education issued guidelines to limit Wi-Fi in schools. In 2016, the City of Haifa, Israel ordered all schools to disconnect wireless and install wired internet instead. (100)
REFERENCES For a full report of all references, visit www.sccma-mcms.org, and click on the “Committees/Environmental Health” tab.
The Story of Ma Bell http://money.cnn.com/2001/07/09/deals/att_ history/ ) The Telecom History Group, Inc. http://www.telcomhistory.org/vm/ scienceLongDistance.shtml Rural County Representatives of California. Letter. April 11, 2016. http://www.rcrcnet.org/sites/default/files/useruploads/County_ Operations/Telecommunications/2015_16_Letters/AB_2395_Ltr_to_ Auth_04112016.pdf Landline statistics CDC- 2014-http://www.cdc.gov/nchs/data/nhis/ earlyrelease/wireless_state_201602.pdf Vandalism blamed for massive phone, Internet outage on North Coast. Sept. 3, 2015 http://www.pressdemocrat.com/news/4429875-181/ internet-phone-and-wireless-service?artslide=0
MAY / JUNE 2016 | THE BULLETIN | 31
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34 | THE BULLETIN | MAY / JUNE 2016
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The History of San Jose Hospital By Michael Shea, MD Leon P. Fox Medical History Committee On May 25, 1921, 43 physicians signed a statement of intent to found a new hospital in San Jose. This was done in response to the merger of Columbia and East Columbia Hospitals, effectively reducing the number of hospital beds in San Jose. The cost was $450,000, raised by community subscription. The location was known as the Joseph Lee home site, on the north side of east Santa Clara Street between 14th and 15th Streets. The main item of landscaping was a giant redwood tree that Lee brought down from the Santa Cruz mountains and planted in front of his house in 1860. The grand opening was June 4, 1923. This was the third major hospital in San Jose (the first was Santa Clara County Hospital and the second, O’Connor Hospital). The three-story 36 | THE BULLETIN | MAY / JUNE 2016
structure sat on a spacious lawn with a basement and a penthouse, which housed the surgical suite. The construction material was reinforced concrete in order to resist earthquakes and fire. There were 44 private rooms and nine four-bed wards, plus a nursery. The private rooms were plush with carpet and drapes, color schemes, telephone, and a silent signal system connected to the nurse’s station. There also was a lavatory in each room. The penthouse surgical suite had five operating rooms and two solariums, landscaped with gardens. The basement housed the x-ray and fluoroscopy unit, lab, emergency room, pharmacy, morgue, linens, bake shop, kitchen, and two cafeterias (one for the doctors and one for the nurses). It was described as the first truly modern hospital in the country. The hospital had a board of directors, a medical staff, and an administration. The first president of the medical staff was
Thomas L. Blanchard. Doctors paid a membership fee of $100 and annual dues were six dollars. There was no departmentalization at that time. Two thirds of admissions were for surgery – mainly T&A’s, hysterectomies, and appendectomies. One third of admissions were for medical indications such as nonsurgical orthopedic problems and childbirth. Quality assurance was accomplished by monthly staff meetings. Surgical mortality was very good. Obstetrical maternal mortality was not so good. The rate was 1.5% and newborn mortality was 4%. These both changed for the better after Dr. Alson Shufelt (the first obstetrician in San Jose) began his practice at this time. In 1925, 40% of deliveries were done in the hospital. By 1929, that figure had changed to 75% and most of these were done at San Jose Hospital. The first administrator was Henry J. Bost-
wick. He was succeeded by Wm. P. Butler in 1932. Mr. Butler guided the hospital through the depression years and succeeded in making it a nonprofit institution. This encouraged endowments and donations. During World War II, the population of service people increased in San Jose. This increased the need for hospital beds. Mr. Butler responded by decreasing hospital stays, turning private rooms into semiprivate rooms, and creating more four-bed wards. He also started a new industrial accident ward called the Derby Ward. Post war, hospital census increased again, with deliveries at ten per day, and this with only two delivery rooms. In 1946, four barracks were purchased and moved across the street yielding an additional 34 beds. Using Hill-Burton funds (Federal Government loans), the hospital added beds by extending the east wing northward and adding a story in front of the west wing. Capacity now was 240 beds. David Olsson became the next administrator when Butler died from a heart attack in 1951. He set his sights on increasing the number of beds by not only adding a four story 120-bed addition to the west wing, but also purchased Alum Rock Hospital (67 beds). However, most doctors did not use the new acquisition, and it
became an extended care facility. In 1968, a 2.7 million, 252-bed building was constructed as a separate unit at San Jose Hospital and used for extended care and inpatient psychiatry. 1970 marked the merger of Doctors Hospital on the Alameda with San Jose Hospital. The medical staff was not happy. They were not told of the merger and did not approve of the quality of care that Doctors Hospital was known for. Renamed Park Alameda Hospital, it continuously bled money from San Jose Hospital and was finally sold to the city and was used as an alcohol rehab unit. 1974 saw the arrival of John Aird. He came with a masters degree in health administration. He was in his thirties and was one of the youngest hospital administrators in the country. Some of his positive measures were: (1) the closure of Park-Alameda Hospital, (2) closure of the nursing school, (3) the CAPI Unit (adolescent psychiatric inpatient center), and (4) remodeling of the Emergency Room. Also, in 1974, Stanley Skillicorn, MD became the director of medical education. His quality of care program won national acclaim. The 1970’s also saw increased government regulations and decreased reimbursement to hospitals (e.g. PSRO’S, HSA– Health System Agencies).
In 1976, Robert Brueckner was appointed day-to-day administrator and John Aird took charge of planning and development. The name of the hospital also changed to San Jose Health Center, reflecting a broader role in dealing with the health care system. The first surgicare center in the Valley opened in 1976. It was founded by Dr. James Dickson, an anesthesiologist, and later sold to San Jose Hospital. A Family Practice Residency Program was founded at the hospital by Dr. Lee Blanchard and was very successful. An Alternative Birth Center was started at San Jose Hospital in the same time frame. This allowed mothers to labor and deliver in the same room. It had a home-like atmosphere. It proved to be very popular with patients, and soon spread to other hospitals. Time, however, was starting to run out for San Jose’s third hospital. The downtown area was starting to be adversely affected by suburban growth in homes and shopping malls. New hospitals were being built in the outlying areas of San Jose. All of these factors led to the financial instability of San Jose Hospital. The doors finally closed in 2006. A vacant lot is all that is left of the hospital that for 83 years served the heart of the city and its people. MAY / JUNE 2016 | THE BULLETIN | 37
CMA Leaders Advocate Physician Issues in Washington, DC By Elizabeth McNeil CMA VP, Federal Government Relations Nearly 30 physician leaders of the California Medical Association (CMA) traveled to Capitol Hill in February for the American Medical Association (AMA) National Advocacy Conference to lobby Congress about the associations’ top health care priorities. CMA physicians also met with the leadership of the Centers for Medicare and Medicaid Services (CMS), who are responsible for implementing the Medicare payment reform legislation (the Medicare Access and CHIP Reauthorization Act of 2015, or MACRA) and the California geographic practice cost index (GPCI) “fix” that will overhaul California’s outdated geographic payment localities. The group met with 25 members of Congress and 40 staff members, lobbying for meaningful use simplification, Medicare recovery audit contractor audit reform, prescription drug cost reduction for patients, rational ways to curb the opioid epidemic, and the need to reverse the U.S. Department of Education’s regulation that excludes California physicians from the public service loan forgive38 | THE BULLETIN | MAY / JUNE 2016
ness program. CMA representatives also met with several CMS leaders, including Patrick Conway, MD, MSc, CMS chief medical officer and deputy administrator of the CMS Innovation Center. Dr. Conway is overseeing the implementation of MACRA’s alternative payment models. The group also met with the CMS staff responsible for implementing MACRA’s Merit-Based Incentive Payment System (MIPS). The meeting with CMS was productive and encouraging. CMA leaders emphasized the need for CMS to simplify and reduce the administrative burdens in the meaningful use program and the Physician Quality Reporting System. Dr. Conway expressed a clear understanding of the problems physicians are experiencing with the current reporting programs. He told the group that he believes CMS will significantly improve those programs under the new MIPS regulations due out this spring. CMA also urged CMS to open the pathway for multiple physician-led alternative payment models (APM). Dr. Conway noted that CMS is looking for a broad range of APMs to be submitted by physicians. The conversation led CMA to believe that
APMs would not be limited to proven accountable care organizations that are accepting significant financial risk, as previously thought. On the APMs, CMA urged CMS to provide physicians participating in APMs with total cost of care data for attributable patients to help them better manage their costs. Most importantly, CMA asked that any APM start-up costs and ongoing administrative costs be part of the downside financial risk calculations. Otherwise, only hospital-led systems would have the capital to participate. Dr. Conway clearly understood that individual physicians and small physician groups would not be able to accept the same level of risk, and encouraged CMA to continue to weigh in on these important issues. CMA also reported that many national specialty organizations are aggressively developing APMs for submission to CMS. However, CMA told Dr. Conway that several specialties had reported that they could not meet the statutory requirements for APMs for various reasons, and the group pressed CMS to explore these barriers. CMA will remain vigilant and actively involved in MACRA implementation on behalf of California physicians.
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ALL healthcare providers (MD, DO, RN, PhD, LCSW, MSW) are encouraged to take this valuable course!
Course available 24/7 Pre-register NOW at: http://www.imq.org/education/caprrc.aspx MAY / JUNE 2016 | THE BULLETIN | 39
By The California Medical Association The California Medical Association (CMA) is the largest, most influential medical organization in California, and an aggressive advocate for doctors and patients. CMA relies on the involvement of its members to communicate the physician vision of medical care to the public, to lawmakers and to the regulators who determine how medicine is practiced. An idea is born: Ideas for new health policy are born in a number of places. One of them is in the hearts and minds of the physicians of California. CMA members can directly influence the association’s health care advocacy agenda by submitting a resolution for consideration to the CMA House of Delegates. CMA policy is established: Resolutions are assigned to councils and subcommittees for study and development, then opened up for discussion by your physician colleagues before recommendations are developed for 40 | THE BULLETIN | MAY / JUNE 2016
action by the CMA Board of Trustees. Many of CMA’s sponsored bills have their genesis in an idea submitted by our physician members. While not all CMA policies result in direct legislative action, they are used to guide CMA’s positions on the hundreds of health care bills that are introduced into the State Legislature each year. Bills are introduced: The California Legislature operates on a two‐ year session. Each year, primarily in January and February, bills are introduced by lawmakers for consideration. The governor may also call a special session of the Legislature to deal with specific subjects. CMA takes a position: Each year, with physician input, CMA monitors more than 500 bills and takes a public position on around 200 bills. Those positions include watch, support, oppose, support if amended and oppose unless amended. CMA also may choose to sponsor or co-sponsor legislation that is of critical importance to the physicians of California. Bills move through the process: If a bill is to become law, it must be
HOW A BILL BECOMES A LAW BILL IS INTRODUCED
COMMITTEE HEARINGS COMMITTEE HEARINGS IF PASSED (SENT TO OTHER HOUSE)
FLOOR ACTION RETURNED TO ORIGINAL HOUSE
IF PASSED WITH AMMENDMENTS IF PASSED WITHOUT AMMENDMENTS
BILL GOES TO GOVERNOR IF ORIGINAL HOUSE CONCURRS
passed out of one or more committees, approved by a simple majority of both houses, and signed by the governor. Laws ordinarily take effect on January 1 of the following year. Briefly, a bill progresses through the following steps: 1. A bill is introduced. 2. The bill is heard in one or more committees in its house of origin (either Senate or Assembly), including public testimony. 3. If the bill passes out of committee(s), it goes to the house floor for a vote. If it passes out of the house, it is sent to the other house for consideration following the same process described above. 4. If approved by both houses, the bill goes to the governor for signing. 5. The governor has three choices: sign the bill into law, allow it to become law without his or her signature, or veto it. A governor’s veto can be overridden by a twothirds vote in both houses. CMA monitors and protects physician interests: CMA’s powerful government relations team works tirelessly with legislators to educate
IF NOT VETOED
MOST BILLS BECOME LAW JAN. 1 OF THE NEXT YEAR
them on how legislation could enhance or threaten patients’ health or physicians’ ability to practice medicine. Their activities include reading and tracking bills and amendments, shaping bill language, meeting with legislators, testifying in committee, conducting research, and preparing policy papers and position letters. Every year, CMA not only supports and shapes the development of valuable health care policy, but the association also stops a number of harmful legislative proposals. For more information on CMA’s legislative advocacy, and how you can get involved, visit www.cmanet.org. CMA also publishes a “Legislative Hot List” during the legislative session, which provides a summary and the current status of CMA-sponsored bills, as well as the progress of other significant legislation. To subscribe, visit www.cmanet.org/newsletters.
MAY / JUNE 2016 | THE BULLETIN | 41
Classifieds OFFICE SPACE FOR RENT/LEASE MEDICAL OFFICE SPACE TO SUBLET • 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.
MEDICAL OFFICE SPACE TO SHARE • 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 email@example.com. 42 | THE BULLETIN | MAY / JUNE 2016
allianceoccmed.com for additional information.
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.
INTERNAL MEDICINE PHYSICIAN NEEDED
MEDICAL/DENTAL/PROFESSIONAL OFFICE • PALO ALTO
INTERNIST AVAILABLE FOR LOCUM TENENS
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.
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@
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. 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 firstname.lastname@example.org.
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 email@example.com Visit our Website: metromedicalbilling.com
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.
Tracy Zweig Associates INC.
Nurse Practitioners ~ Physician Assistants
Locum Tenens ~ Permanent Placement V oi ce: 800-919-9141 or 805-641-914 1 FA X : 805-641-9143
tzw ei g@ tracyzw ei g. com w w w. tracyzw ei g. com
EXCLUSIVE MEDICAL COLLECTIONS ACCURATE CONSISTENT
ATTORNEY ON STAFF
THE BUREAU OF MEDICAL ECONOMICS Competitive pricing with a rate of recovery over twice the national average. Providing exclusive medical revenue recoveries since 1947. Knowledgeable collectors and certified medical coders all working to provide maximum recovery while maintaining the physician/patient relationship. SCCMA BME is a not-for-profit owned by physicians for physicians founded by SCCMA. No risk as there is No fee unless there is 09-03-15 a recovery. As an SCCMA-MCMS member benefit, you are entitled to a discount of no less than 5%!
Call (408) 998-5811 x 3034 Email firstname.lastname@example.org
1(888) 543-7497 www.bmesc.org MAY / JUNE 2016 | THE BULLETIN | 43
To SCCMA-MCMS Members: REMINDER: Deadline to register for CURES is July 1, 2016 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 submit an application to register for the Controlled Substance Utilization Review and Evaluation System (CURES) by July 1, 2016. The California Medical Association (CMA) has compiled a list of educational materials to familiarize physicians with the registration process and key features of the newly upgraded system, CURES 2.0. These resources include tips on how to register for CURES 2.0 and an on-demand webinar that walks users through that process. These resources are available at www. cmanet.org/cures. To register with the new automated system, visit http://oag. ca.gov/cures. Physicians who experience problems with the new system should contact the DOJ CURES Help Desk at (916) 2273843 or email@example.com. Providers are also encouraged to report these technical issues to CMA's member service center at (800) 786-4262 or firstname.lastname@example.org.
44 | THE BULLETIN | MAY / JUNE 2016
Physicians’ and Dentists’ Confidential Line Substance Abuse Depression Career Burnout Stress
About the hotline: We are a confidential service dedicated to assisting physicians and dentists who may feel overwhelmed by aspects of their personal or professional lives. Our goal is to help our colleagues before their lives and practices are in jeopardy. How it works: All calls are completely confidential. Callers are quickly connected to a physician or dentist with extensive experience in helping health professionals having problems with stress, substance abuse or mental health issues. Callers receive the support and referrals needed to better manage whatever issues with which they may be struggling. Who should call: If you’re a physician or dentist looking for help with substance abuse or a psychological or emotional problem, we’re here to help. If you’re a colleague, family member or friend of a physician or dentist in need of assistance, please don’t hesitate to call.
While you’ll be there for your patients, we’ll be here for you. Northern California: 650.756.7787 • Southern California: 213.383.2691
The Physicians’ and Dentists’ Confidential Line is a project of the California Medical Association and the CMA Alliance, with additional support from the California Dental Association. MAY / JUNE 2016 | THE BULLETIN | 45
Small and large practices alike must decide whether it is better for them to do their medical billing in-house or to outsource their billing to a medical billing service, such as Promedico, the preferred Billing Partner of the Santa Clara and Monterey County Medical Associations. There are many factors to consider before making this choice, but ask yourself: would you perform your own hip replacement? Medical billing requires an ever changing set of skills and at times can be quite complex. Often, a local medical billing company can provide the best revenue management cycle for your practice. Let’s start with the billing staff. Medical billing companies hire individuals who have a desire to work in the billing field. They hire trained and skilled workers who have already achieved a level of competence. Many billers also possess either a certificate of achievement in billing or have become certified professional coders. This takes the guess-work out of billing and ensures correct coding at all levels. In fact, one of the most common denials is for codes not being medically necessary. Experienced billers know how to code and are aware of potential denials before the bill is ever sent out. A billing company has multiple billers, and those individuals often collaborate to ensure clean bills are sent right the first time. Secondly, as you are aware, the industry is ever changing. Each year there are new codes, both procedurally and diagnostically. Did you know that ICD-10 changes take effect every year in October, for the upcoming year? Or that the CCI edits are updated quarterly? The software that most billing companies use is equipped to handle the required changes. Most billing companies provide ongoing education for the billing staff. In addition, billing companies use the top of the line billing software such as Ingenix Encoder pro or Code X, to assist them in insurance appeals and to avoid unnecessary bundling. Billing companies are always aware of the reimbursement trends. They can often offer advice on whether or not to consider certain PPO or HMO networks or even if you should accept the Covered California Plans or Medi-Cal. 46 | THE BULLETIN | MAY / JUNE 2016
Medical billing companies have “economies of scale” and can help keep your costs down. You do not need to hire additional staff and pay worker compensation benefits or additional payroll taxes, not to mention health benefits and 401K contributions. You do not have to spend additional costs for updating software or because there is an increase in the postal rates. You will not have to purchase additional hardware or provide more desk space in your office. A billing company can operate at a lower rate and pass those savings on to you. Perhaps the most important reason for choosing outsourced billing is for cash management. With the rising costs of running a medical practice, cash flow becomes a major factor. Most billing companies will have clean claims going out faster and with fewer errors. Electronic submission and receipt posting means faster turnaround time for your payments. Your goal should be to get the highest payment in the shortest time. If an in-house biller is on vacation for a week or two, no bills are being sent out, and no payments are coming in. Most billing companies have support to handle this very issue so your cash flow is never interrupted. Finally, physicians should focus on what they do best. If you can spend your time treating patients and not worrying about writing appeals or wondering if the clearing house got your bill, you will be less stressed and more focused on patient outcomes. Let your medical billing company handle the insurance problems and the patient billing questions. Let them handle your contracting and credentialing issues. Medical billing companies can advise you on many aspects of your practice, not just billing. Remember, you set out to be a doctor, not a medical biller. So let the professional medical billers do what they have been trained to do. This will allow you the time with your patients to be the best physician you can be. Promedico offers a free Billing Audit and Consultation, in addition to a fee discount, to all Santa Clara and Monterey County Medical Association members. The Non-Member cost is $495.00. Promedico can be reached at 408/680-0000.
Success. It’s what California’s finest physicians strive for... and what CAP can help you achieve. Since 1977, the Cooperative of American Physicians (CAP) has provided superior medical professional liability coverage and valuable risk and practice management programs to California’s finest physicians through its Mutual Protection Trust (MPT). 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
MAY / JUNE 2016 | THE BULLETIN | 47
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