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SEPTEMBER / OCTOBER 2015  |  VOLUME 21  |  NUMBER 5

YOU ASKED FOR IT Answers to Common Questions Received by the MBC


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2 | THE BULLETIN | SEPTEMBER / OCTOBER 2015

OR SCAN TO LEARN MORE!


BULLETIN THE

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

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

MEMBER BENEFITS

Feature Articles

Billing/Collections

10 You Asked For It: Common Questions Received by the

CME Tracking

Medical Board of California

Discounted Insurance

16 CURES Update

Financial Services

18 Reporting Lapses of Consciousness – What is Your

Health Information Technology Resources

Legal Responsibility? 19 Practice Check-Up: Marketing Your Practice

House of Delegates Representation Human Resources Services

Departments

Legal Services/On-Call Library

5 From the Editor’s Desk

Legislative Advocacy/MICRA

6 Message From the SCCMA President

Membership Directory iAPP for

8 Message From the MCMS President

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

20 Medical Times From the Past 24 Surviving ICD-10: An FAQ for physician practices 28 Guidelines For Physician Well-Being Committees to Assist Impaired Physicians 32 MEDICO News

Membership Directory/Website

38 Welcome New Members

Reimbursement Advocacy/

40 Classified Ads

Coding Services Verizon Discount

42 Reflections From the Past: Archives of Medical Antiquities SEPTEMBER / OCTOBER 2015 | THE BULLETIN | 3


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

CHIEF EXECUTIVE OFFICER

COUNCILORS

William C. Parrish, Jr.

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

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

BULLETIN

THE MONTEREY COUNTY MEDICAL SOCIETY

Editor

OFFICERS

THE

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

Printed in U.S.A.

Joseph S. Andresen, MD

Managing Editor Pam Jensen

Opinions expressed by authors are their own, and not necessarily those of The Bulletin, SCCMA, or MCMS. The Bulletin reserves the right to edit all contributions for clarity and length, as well as to reject any material submitted in whole or in part. Acceptance of advertising in The Bulletin in no way constitutes approval or endorsement by SCCMA/ MCMS of products or services advertised. The Bulletin and SCCMA/MCMS reserve the right to reject any advertising. Address all editorial communication, reprint requests, and advertising to: Pam Jensen, Managing Editor 700 Empey Way San Jose, CA 95128 408/998-8850, ext. 3012 Fax: 408/289-1064 pjensen@sccma.org © Copyright 2015 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


As Summer into Autumn Slips By Joseph Andresen, MD

And almost count it an Affront The presence to concede Of one however lovely, not The one that we have loved -So we evade the charge of Years On one attempting shy The Circumvention of the Shaft Of Life’s Declivity.

Editor, The Bulletin

As Summer into Autumn slips And yet we sooner say “The Summer” than “the Autumn,” lest We turn the sun away,

JOSEPH S. ANDRESEN, MD

Time marches on as marked by another summer passing by so eloquently stated in Emily Dickinson’s, “As Summer into Autumn Slips:”

FROM THE

Warm ocean breeze, lobster rolls, fireworks, and sweet fresh picked corn. Our child’s engagement announcement, another parent milestone. So begins a cross-country road trip from Woods Hole, Massachusetts. Stopping to admire the majesty of Niagara Falls, thunderous and never ending. Traveling through Ontario, Canada, our neighbor to the north. Mt. Rushmore with its unforgettable silhouettes. The dramatic and jagged peaks in Teton National Park stretching across the horizon. More stars than one can count in the Wyoming night sky. Twin Falls, Idaho and on to Winnemucca, Nevada. Not in time for the dust storms at Burning Man. And still hours of desolate high desert on the home stretch to California. Many moments of silence with few words but more meaning.

EDITOR'S DESK

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.

Perhaps a bit melancholy, but a reminder that our clocks never stop. As physicians, we do what we can to slow our patient’s life’s declivity. Cherishing our own memories as fathers, mothers, sons, and daughters gives us the energy, wisdom, and compassion to continue our important work.

SEPTEMBER / OCTOBER 2015 | THE BULLETIN | 5


End-of-Life Care By Eleanor Martinez, MD

President, Santa Clara County Medical Association

ELEANOR MARTINEZ, MD

MESSAGE FROM THE

SCCMA PRESIDENT

President, Santa Clara County Medical Association

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.

Medicine has rapidly changed. The various influx of new advances in technology, and the discovery of newer drugs and interventions have made new strides in how medical care has impacted all of us. The goals were to eradicate diseases, cure or alleviate their serious, usually debilitating consequences, and hopefully to improve quality of life and prolong it. Ironically, it has been written “it is not easy to die well in modem times” - quoted from Ira Byock, MD’s book The Best Care Possible. It is less than a half century ago that we could not envision patients surviving diseases like leukemia, diabetic nephropathy, or severe heart and vessel diseases. Nowadays, we read and learn about stem cell transplantation, new chemo-therapeutic drugs for cancers which we thought meant imminent death, liver transplantation, and heart replacement. With these come the difficult challenges that both the medical community and the patients and their families confront. The question then arises, when do we come to a point of realization that these “high intensity treatment and interventions” are more a burden rather than a benefit? There was an article written by Ken Murray, MD, narrating his experience with the deaths of his physician mentor and his cousin. When they were given a terminal diagnosis, both chose to take matters into their own hands and control their care on dying. They took charge of their end-of-life care. He came to the conclusion, (and several studies have agreed), that when faced with a terminal diagnosis, the majority of doctors choose not to have interventions and most elect to die at home or outside the hospital. Their wishes were no different than those of a patient with a terminal or chronic illness. Their wants and needs were similar: freedom from pain and suffering, avoidance of multiple hospitalizations and expensive high intensity medical care, and a death with dignity surrounded by their loved ones in an environment that is familiar to them. Yet most patients do not receive these. Part of the failure is also due to their unrealistic expectation for cure. It has been addressed multiple times that the failure in end-of-life management and palliative care lies in several areas - namely the system, the doctors, and the patients. Our American culture has not yet accepted that

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we are mortals. Death is inevitable. Some doctors have the view that death is a defeat - a failure. We find it very difficult to have a conversation with our patients regarding the futility of the disease. We are afraid that in having these talks we give no hope to our patients. As a whole, we are not prepared to do so. How many of us have taken classes on palliative care in medical school? As a matter of fact, it is only recently that some medical schools have included this in their curriculum. A study published in PLOS ONE (Stanford) surveyed 1,000 medical students and found that almost all refrained from talking to patients about end-of-life care because they felt ill equipped to do so. 99.99% reported having encountered barriers about talking about the subject. And these are the future doctors! Research has shown that most Americans would prefer to have a say in the matter. A 2013 survey showed that 9 out of 10 Americans think it is important to discuss their end-of-life wishes, but only a quarter had done so. Several articles have been published showing that when patients are shown videos to facilitate end-of-life decisions (e.g. CPR, intubation decisions, end-of-life discussions with cancer), these patients were more knowledgeable and more certain about their choices, compared to those given verbal information. Most patients have expressed that they prefer their physicians initiate the discussion. It is becoming evident that more training, of doctors and the medical community, as well as the patient, is needed — and, that time can no longer be delayed. The discussion on the issues regarding endof-life care and advance directives, hospice care, and palliative care needs to happen now. The toll of the failure to do so is a price too high to pay – emotionally, physically, and economically. I mentioned the failure of the system. As previously stated, both doctors and patients need the education and training to be able to address this sensitive and life changing topic. As physicians, the dictum “first, do no harm” has been deeply ingrained in our being. Yet, I do believe that we have not provided enough when we care for our patients at the end of their lives, or when they are given a terminal diagnosis. In the end, we have done harm to our patients with our failure to educate. But how can we? Not only do we lack the training, but we have no time to address these long con-


versations. Our current reimbursement systems incentivize us to treat disease — to do things. This current system is not set up to plan or counsel for such medical care. Medicare, Medicaid, and insurance companies would pay for services in diagnosing and treating patients. The RVUs are based on the intensity and sophistication of services that doctors provide. The RVUs for doing procedures have more RVUs assigned than the RVUs for visits to provide counseling for patients and their families – especially during the difficult times of decisions on end-of-life care. There is a Medicare payment proposal to address this. Hopefully, in January 2016, this proposal to address reimbursements for such discussion by the physician will come to fruition. The system has also let down our patients with the failure to institute the wishes of the patients, due to a lack of effective communication. The system is not yet fully integrated to coordinate such care. For example, how many DNR statuses have been ignored because it was not communicated well, or not available in the chart? Changes in the hospitals and medical records need to be addressed. We, the physicians, need to be the voice, for ourselves, and our patients, so that proposals fully address what is at stake. It should not be allowed to be crafted by people who are not in the know. The medical community needs to take a lead. This is already happening in some states. If this is successful, then it is anticipated that new educational training on compassionate end-of-life care and palliative care will follow. So what is the SCCMA doing? The Bioethics Committee is now deliberating on what program to employ to best address compassionate palliative care and advance care programs within the Santa Clara County. There are some programs already employed within the Kaiser Medical System, as well as in Southern California. Once a decision is made, we will then initiate training beginning with medical students (which, by the way, is now occurring in various medical schools). Training will also be provided so we have knowledgeable consultants who would act as facilitators to begin these conversations. Of course, this would be a coordinated endeavor that will include the doctors, hospice care providers, social workers, and

the hospital staff. I am inviting those who are interested to attend the Bioethics Committee meeting and voice your concerns. Or, even write the chair of that committee your input – Dr. Faith Protsman at doctorprotsman@aol.com. As physicians, we have the position to engage our patients and the public in this discussion. The consolidation of this activism would be, in my mind, the necessary tool to effect change in this arena. Take the example of the public outcry to change laws against drunk drivers. It began with the loud outcry of angry mothers. It was the consensus of the public that led to change. Perhaps this is what we need to fix our broken medical system. We can start with addressing the importance of advance directives, compassionate end-of-life issues, and the benefits of hospice care, to cite a few. We, as physicians, need to engage our patients by being honest with them and guide them to take a very proactive role in making decisions regarding this matter. Medicine is both a science and art. The art of medicine is embodied in ethics, and decision-making. That art of decision-making invokes making the best possible decision. We, as physicians, should lead the way at providing what we want as we approach the end of our lives – freedom from pain and suffering, and a gentle death, with dignity, surrounded by our loved ones, with minimal medical interventions and impact on finances. We should do the same for our patients. I end this article by asking ourselves this: How many of us, physicians, have an executed Advance Directive Document? How many of us have had a discussion with our loved ones on how we would like to be cared for in the event we are dying from an incurable disease or can no longer speak for ourselves? Have we had those discussions? The right time to have this conversation is while we are still able to live our lives the way we want it, and that is NOW! Then, we can share our own experiences in doing so with our patients, and help them do likewise. SEPTEMBER / OCTOBER 2015 | THE BULLETIN | 7


Natividad Medical Center By James M. Hlavacek, MD

President, Monterey County Medical Society

JAMES M. HLAVACEK, MD

MESSAGE FROM THE

MCMS PRESIDENT

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.

On this last day of August I am slowly moving into fall. The drought and the heat have done a number on my lawn (brown), my roses (small and few), and my fruit trees (no fruit). The predictions are for an el Nino winter, so we may be dealing with floods and mudslides. Much like the unpredictable weather, medicine continues to move in unknown and chaotic directions. It is my hope that working with the Monterey County Medical Society and California Medical Association, we will be able to continue to practice medicine in a way that takes care of our patients and ourselves. We need to be engaged or we will be taken over. The new Trauma Center at Natividad Medical Center has been a wonderful success story. Trauma is the leading cause of death for patients, ages 1-45. Since NMC opened the Trauma Center on January 1st through May, it has taken care of 1,349 cases, with 4,756 in-patient days. The Trauma statistics are very intriguing. The majority of trauma patients are motor vehicle accidents 42%, add motorcycle accidents 10%, and bicycle accidents 2%, for a total of 54% (I can’t wait for the self-driving car!). Gunshot wounds and stab wounds account for 7.3% and 6.5% of all trauma cases, far fewer than I would have expected. The financial aspect of trauma is worth a detailed look. The breakdown of payor mix is as follows: Medicare 22%, Medi-Cal 39%, Commercial Insurance 38%, and Self pay 1%. That last percentage is not an error. Very few trauma patients have no coverage, this surprised me and it may surprise you. Natividad ended its fiscal year almost $3 million in the black, when it was budgeted to lose $3.7 million. As an anesthesiologist, I see the impact of the Trauma Center everyday. No longer are injured patients sent out of the County. The benefit to the patients and their families, many of whom are financially disadvantaged, is remarkable. I have personally gotten to know several trauma patients well, especially a retired sheriff from Fresno who rolled his Harley in South County and spent 11 days in the ICU. The other news out of Natividad is the expansion of the Family Practice Residency Program. MCMS Board member Dr. Steve Harrison heads

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up this amazing program. The residency now has 10 residents per year, up from 8 per year. There is a brand new spacious and modern clinic for the residents and staff. This is a joint effort between Natividad and the Monterey County Health Department. I recently took care of a patient from Livingston, California. He needed to have a plate removed from his wrist from a previous accident. I asked him why he was here at Natividad (two hours away), and his response was that the doctor who did his initial operation would not see him again because the patient was covered by Medi-Cal. This story is not unique to Monterey County; there are countless stories of patients forced to travel enormous distances for medical treatment. Who is to blame? The answer is complicated and not easily solved. Payments for physician services continue to be under pressure. I have recently used the example above in meetings with Assembly members Luis Alejo, and Mark Stone. They are very aware that Medi-Cal payments are too low for most doctors to accept. The legislature is working to increase payments to doctors. In the meantime, the big insurance companies are merging: Anthem with Cigna, and Aetna with Humana. How this will impact our practices will be the next challenge. I don’t see this consolidation as a good thing for doctors. More than ever, it is time to be part of organized medicine. My own insurance through Anthem is changing; we are being “grand-mothered” (the policy is through my wife’s dental practice) into a new plan, which, no surprise, will have higher deductible and less coverage for more money! CMA President Dustin Corcoran is coming to Monterey on November 9th. Mark your calendars, and we will have a series of meetings with him and you. On a personal note, my father passed away on August 29th. He suffered a stroke in January of this year. It has been quite a journey to bring him out to Salinas and become the primary overseer of his care. I would like to thank Dr. Tony Galicia and the staff of the Sam Karas Acute Rehab Unit, Villa Serra Memory Care Unit, and VNA-hospice for the excellent care my father received. He led a full life and is now gone at 97.


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You Asked For It Common Questions Received by the Medical Board of California By Christine Valine, Public Information Analyst, MBC

These questions are reprinted with the permission of the Medical Board of California, originally printed in their Newsletters from 2012 through 2015. The following are common questions that the Medical Board of California receives. Read on and see if you know the answers too.

Recently, I heard that a physician who owes back taxes will have his/ her medical license suspended by the Medical Board of California.

You are referring to a law (Business and Professions Code section 494.5) that went into effect in July 2012. The Medical Board of California (and other licensing entities) is required to suspend the license of any licensee or refuse to issue a license to any applicant who has outstanding tax obligations due to the Franchise Tax Board (FTB) or the State Board of Equalization (BOE) that appear on their list of top 500 tax delinquencies over $100,000 (Revenue and Taxation Code section 7063).

What is the Physician Sunshine Act?

This is a provision of the Patient Protection and Affordable Care Act; requiring any payments made to doctors by the manufacturers of drugs, devices, biological, or medical supplies that are reimbursed by Medicare, MediCal, or the Children’s Health Insurance Program to be publicly reported under the Physician Payments Sunshine Act.

Is it legal for me to establish a physician-patient relationship through telehealth?

The physician-patient relationship may be established via telehealth, provided that the use of a telehealth exam to establish the relationship is within the standard of care for the particular situation, and provided the telehealth exam complies fully with

10 | THE BULLETIN | SEPTEMBER / OCTOBER 2015


Business and Professions Code section 2290.5. Some situations and patient presentations are appropriate for the utilization of telehealth as a component of, or in lieu of, in-person provision of medical care, while others are not. Ultimately, if the Board investigates a complaint about how a physician is using telehealth, the physician’s actions will be reviewed by his or her peers to determine whether the standard of care is met.

Is my medical assistant required to have a phlebotomy certificate from the California Department of Public Health to draw blood in my office?

No. Medical assistants are permitted to draw blood in a physician’s office as long as they have received the proper training and are deemed by the supervising physician to be proficient in performing the procedure.

I understand a medical assistant is not permitted to administer an injection that contains an anesthetic, but is the medical assistant permitted to apply a topical anesthetic, such as lidocaine?

The regulations state a medical assistant is prohibited from administering any type of anesthetic agent; this includes the application of topical anesthetic agents.

I heard medical assistants are now permitted to administer vaccinations at a private, governmental, or nonprofit clinic.

This is true. The previous law stated vaccinations could only be administered by a physician, registered nurse, or vocational nurse. This law was repealed in 2012.

Am I allowed to withhold medical records for a patient who has not paid my bill?

California law states you may not withhold a patient’s medical records for an unpaid bill (Health & Safety Code section 123110(j)).

The law states drugs dispensed from my office must be kept in an area that is secure. What is considered a secure area?

The regulation defines a secure area as a storage area within the physician’s office that is locked, secure at all times, and with the keys to the locked storage available only to staff authorized by the physician.

I passed the American Board of Addiction Medicine Certification in December, 2012. Does the Board recognize the ABAM Certification in this respect as being authorized to advertise that I am board certified by the American Board of Addiction Medicine?

Physicians are prohibited from advertising that they are board certified, unless they are certified by: An American Board of Medical Specialties member board; A specialty board with an ACGME ac-

credited postgraduate training program, or; A specialty board with “equivalent” requirements approved by the Medical Board of California. Addiction medicine is not a recognized board certification by any of the above entities. The law does not, however, prohibit the advertising of specialization, regardless of board certification status.

I am a physician and about to open a cosmetic spa where laser treatments will be performed. Who is authorized to use lasers?

Physicians may use lasers. In addition, physician assistants and registered nurses (not licensed vocational nurses) may perform laser treatments under a physician’s supervision. Unlicensed medical assistants, cosmetologists, electrologists, or estheticians may not legally perform any type of laser treatment under any circumstance, nor may registered nurses, or physician assistants perform them independently, without supervision.

I have heard that physicians who are responding to an emergency call are permitted to exceed speed limits. Is this true?

It is true that a physician traveling to an emergency is exempt from many of the speeding laws, if the vehicle displays the CHP-approved emblem, indicating that the vehicle is owned by a licensed physician. The exemption is not for use on freeways and does not allow the physician to exceed the state maximum speed limit (65-70 mph). The exemption also does not apply to other traffic laws, such as stop lights, stop signs, yield signs, etc. (MVC 21058).

I have a small laboratory as part of my medical office. Am I required to register as a clinical laboratory?

A. Yes. A physician office laboratory (POL) is considered a clinical laboratory if any patient testing is done, such as urine dipstick tests, fingerstick blood tests, or Pap smear review and reporting. Your POL must either be licensed or registered. For more information, please call the Department of Public Health-Laboratory Field Services at (510) 620-3796.

How many Physician Assistants and/or Nurse Practitioners is a physician allowed to supervise?

Current law allows a physician to supervise no more than four physician assistants or four nurse practitioners at any moment in time. A physician may supervise a combination of nurse practitioners and physician assistants as long as the stated limits are not exceeded.

I am having a difficult time finding opportunities to earn CME hours. Can you provide me with some suggestions?

There are many educational activities, which can qualify for CME credit. You can contact any of the following accrediting organizations for specific information about qualifying programs and activities: California Medical Association--Institute for Medical QualContinued on page 12

SEPTEMBER / OCTOBER 2015 | THE BULLETIN | 11


You Asked For It, continued from page 11 ity (CMA/IMQ) (415) 882-5151; the American Medical Association (AMA) (800) 621-8335; the Accreditation Council for Continuing Medical Education (ACCME) (312) 527-9200; or the American Academy of Family Physicians (AAFP) (800) 906-6000.

I believe a patient stole a prescription pad from my office. Am I required to report this and to whom?

If your tamper-resistant prescription forms are lost or stolen, you must first report the theft to your local law enforcement agency to obtain the report number that must be included in your report to the State Department of Justice, Bureau of Narcotic Enforcement, CURES Program. You must also report the theft to the Drug Enforcement Administration’s regional office in your area, and a written narrative should be provided to the Medical Board’s Central Complaint Unit.

I just began practicing and was told I need to display a sign in my office regarding my education.

There are actually two signs you are mandated by law to display in a prominent area in your medical office: (1) a Notice to Consumers which states that medical doctors are licensed and regulated by the Medical Board of California, and (2) a sign stating your name, highest level of academic degree, and your board certification, if any. These signs may be placed individually or as one sign. The following link provides complete information regarding the exact wording and examples http://www.mbc.ca.gov/licensee/notices.html.

I am a physician in solo practice. Am I required to have back-up coverage whenever I go on vacation or just want a day off?

There is no law mandating you to provide back-up coverage for your medical practice. However, you should provide instructions to your patients on what to do if they have an emergency, such as directing them to a hospital’s emergency department or an urgent care facility.

The nurse practitioner I supervise has a furnishing license. Is she allowed to recommend medical marijuana?

No. Only physicians and osteopaths can recommend medical marijuana.

Am I required to have a chaperone in the room when examining a patient?

If the patient requests a chaperone in order to feel more comfortable, you should accommodate the patient. However, there is no law in California that requires you to do so.

Am I required to have a DEA number if I am not prescribing any controlled substances?

No. A physician who administers, prescribes, or dispenses any controlled substance must be registered with the Drug Enforcement Administration.

12 | THE BULLETIN | SEPTEMBER / OCTOBER 2015

I have a nurse practitioner in my office who recently received her doctorate degree. She is insisting that patients address her as “doctor.” Is this permitted?

If a person has received a doctorate degree then, for the purpose of introduction, use of the term “Doctor” would not be in violation of Business and Professions Code section 2054. However, if that introduction is in a setting that would lead a reasonable person to conclude that this person is licensed to practice medicine in the State of California, without being licensed by the Medical Board of California, they would be in violation of this section.

Is it okay to delegate informed consent to my nurse?

Obtaining informed consent is the responsibility of the physician performing the procedure and should not be delegated to another person. Additionally, a physician can be charged with negligence if informed consent has not been obtained from the patient.

I am confused about the new laws regarding med spas. I am a nurse working at a med spa, and I was told the doctor now needs to be on site during every cosmetic procedure.

The Medical Board is in the process of adopting regulations regarding the appropriate level of physician availability needed within clinics or other settings using laser or intense pulse light devices for elective cosmetic procedures. The proposed regulation states, in part, that whenever an elective cosmetic medical procedure, involving the use of a laser or intense pulse light device, is performed by a licensed health care provider, a physician with relevant training and expertise shall be immediately available to the provider. “Immediately available” means contactable by electronic or telephonic means without delay, interruptible, able to furnish appropriate assistance and direction throughout the performance of the procedure, and able to inform the patient of provisions for post procedure care. Such provisions shall be contained in the licensed health care provider’s standardized procedures or protocols.

I am a physician in private practice and need to renew my fluoroscopy certificate, but am not sure who to contact.

Your fluoroscopy certificate and renewal are issued from the California Department of Public Health, Radiologic Branch. This agency also issues the initial permit for authorization to use any x-ray equipment or act as a supervisor. You can contact staff at (916) 327-5106 or visit the Web site at http://www.cdph.ca.gov/programs/pages/ radiologichealthbranch.aspx

I employ an esthetician in my practice and was recently told I need to contact the Board of Barbering and Cosmetology to register my practice.

Your medical office must have an establishment license issued by the Board of Barbering and Cosmetology in order to employ a cosmetologist, esthetician, or manicurist. You can contact that board at (916) 574-7570 or visit its Web site at http://www.barbercosmo.ca.gov/


I would like to know how to place my license in inactive status. I will likely not be practicing medicine in California for the next few years, due to training, and I am considering changing my status to inactive for a temporary time period, so I will not have to pay renewal fees.

Inactivating a license does not change the expiration date, and the renewal fee is the same as the fee for an active license. The advantage to holding an inactive license is that you will be allowed to renew your license without completing the Continuing Medical Education (CME) requirements. There are two options for you to avoid paying renewal fees, which I will describe briefly. There is additional information and application forms on the Medical Board’s Web site under the “A to Z Index.” Retired License: A retired physician may not practice medicine or write prescriptions in California; a retired physician does not pay renewal fees, except for the mandatory $25 Physician Loan Repayment Program (PLRP) fee; and a retired physician does not need to comply with CME requirements. Voluntary Status: A physician may provide voluntary, unpaid service; a physician does not pay renewal fees, except for the mandatory $25 PLRP fee; and the physician must comply with CME requirements.

I have just completed the 300-hour training and certification program in Medical Acupuncture for Physicians and wanted to inquire as to whether there is any additional registration I need to do with the Medical Board to be able to include medical acupuncture in my practice.

Physicians licensed by the Medical Board of California are authorized to practice acupuncture within their scope of licensed medical practices. While a physician may perform this function, he/she may not supervise a nurse not licensed by the Acupuncture Board of California as an acupuncturist.

I am a physician who was recently sued by one of my patients. In settling this case, my attorney is telling me the settlement information will include a “gag clause” that will prevent the patient from filing a complaint with the Medical Board. Another physician told me this is illegal.

Business and Professions Code §2220.7 prohibits physicians from including, or permitting to be included, a provision (also referred to as a “gag clause”) within a civil settlement, that prohibits another party in the lawsuit from contacting, cooperating with, or filing a complaint with the Medical Board, or that requires the party to withdraw a complaint filed with the Medical Board. A physician who violates this law is subject to disciplinary action by the Board.

How long should a medical doctor keep a record of continuing medical education credits?

A physician should keep proof of CME credits for four years in case he or she is audited by the Medical Board.

As a physician in solo practice, am I required to be

certified in Cardiopulmonary Resuscitation (CPR) in order to renew my license?

There is no statutory requirement for a physician to be certified in CPR for the renewal of the license with the Medical Board.

What is a physician’s obligation regarding a death certificate?

A death certificate is a legal document, and disposition of the remains cannot occur until the death certificate is filed with the Office of Vital Records and Statistics. The attending physician is required to complete and sign a death certificate within 15 hours of the natural death of his or her patient (unless the case is subject to coroner’s inquiry). The physician is responsible for either providing the certificate to the hospital, delivering it to the funeral director, or arranging with the funeral director to pick it up at his or her office. If the attending physician is unavailable, a physician may designate another physician who has access to the physician’s records and who is in consultation with the physician.

I am a family physician and would like to know if I am allowed to prescribe antibiotics to myself and other family members.

There is no law that prohibits physicians from treating themselves or family members; however, this practice is discouraged. When treating a family member, the physician’s judgment may be compromised because of personal feelings that could influence his or her professional medical judgment. If a physician does treat a family member, the physician must follow the same protocol as for any other patient. There must be an appropriate prior examination and medical indication, and a medical record for the patient. (Note: By law, a physician is not permitted to prescribe or administer any controlled substances to himself or herself - B&P Code §2239).

I have been in practice for more than 30 years and have been storing my patient’s medical records in a storage facility. How long must I keep these medical records?

The Medical Practice Act does not require a physician to keep medical records for a specific period of time. However, there are provisions in contracts a physician may have signed with medical malpractice carriers, insurance companies, HMOs, and government health plans that require a provider/physician to maintain the records for a certain period of time. In general, medical records should be retained indefinitely for those patients under active treatment. For inactive patients, a 10-year retention period is advised. It is recommended that records of minors be kept at least until the patient reaches the age of majority (18) plus one year.

I am a physician and run a medical spa. I have a medical assistant who was educated in a local career college and is experienced. She currently assists with dressings, cleanup, and other minor tasks. I was wondering if it is permitted to have her do some minor treatments under my direction, such

Continued on page 14

SEPTEMBER / OCTOBER 2015 | THE BULLETIN | 13


You Asked For It, continued from page 13 as use of the Velashape or Velasmooth device by Syneron, which treat cellulite?

A medical assistant is permitted to perform simple and routine medical tasks. The devices used to treat cellulite manipulate the tissue and, therefore, are considered invasive. The use of these devices is not within the scope of practice for a medical assistant.

I would like to open a medical spa and partner with an esthetician. What is required by the Medical Board?

Any facility where medical procedures are being performed must be owned at least 51% by one or more physician(s). The remaining 49% can be owned by other licensed medical professionals, as listed in California Corporations Code §13401.5. No lay person or entity may own any part of a medical facility. If the facility has a name other than the physician’s own name, then the physician must obtain a fictitious name permit from the Medical Board. If you plan to hire an esthetician for your medical cosmetic practice, you must have an establishment license issued by the Board of Barbering and Cosmetology (BBC). For information on this license, please visit the BBC’s website at www.barbercosmo.ca.gov.

I am a retired physician. Can I still write prescriptions?

No. If your license is in retired status, you cannot practice medicine and you cannot write prescriptions. Physicians who maintain their license in active status by paying the full renewal fee of $820, and physicians who maintain their license in voluntary status and work as authorized by this status and pay the required renewal fee of $37, are permitted to write prescriptions.

What is the new law regarding medical assistants now being allowed to hand medications to a patient?

As of January 1, 2015, a medical assistant is permitted to hand to a patient a properly labeled and pre-packaged non-controlled prescription drug. The properly labeled and pre-packaged non-controlled prescription drug must have the patient’s name affixed to the package, and the supervising physician, physician assistant, nurse practitioner, or nurse-midwife must verify that it is the correct medication and dosage for the specific patient and provide the appropriate patient consultation prior to the medical assistant handing the medication to the patient.

Does the physician always need to be on the premises when a medical assistant is performing medical tasks?

The supervising physician may, at his or her discretion, provide written instructions to be followed by the medical assistant, and those written instructions may provide that a physician assistant, nurse practitioner, or nurse midwife may supervise the medical assistant while the physician is off the premises.

14 | THE BULLETIN | SEPTEMBER / OCTOBER 2015

I am writing in regard to your question and answer in the Fall 2014 issue that service dogs in a physician’s office must have service animal tags. It is my understanding that service animal tags are not required by law.

California Civil Code Section 54.2 states that a service dog must be on a leash and tagged by an identification tag issued by the county clerk, animal control department, or other agency. However, the American Disabilities Act (ADA Title II, 28 CFR Part 35) states that there is no requirement for documentation that the service dog has been certified, trained, or licensed as a service dog or that the service dog wear an identifying vest. The ADA further states that if the need for a service dog is not obvious, such as a mental disability, the physician or staff member is permitted to ask two questions regarding the legitimacy of the service dog: (1) Is this animal required because of a disability, and (2) What work or task has this animal been trained to perform. Specific training means the dog has been trained to perform a specific response every time a person has, for example, an anxiety attack or panic attack (ADA Title II, 28 CFR Part 35). If this is the case, the service dog must be accommodated. A comfort companion (pet) that has not been trained to provide a specific response for a certain action does not need to be accommodated, even if the individual has a physician’s note. For more information, visit http://www.ada.gov/service_ animals_2010.htm.

I am in the process of closing my practice. How many days’ notice am I required to give my patients?

The law does not specify the exact number of days required to notice patients prior to closing. The sooner you can notify your patients, the better, as you want to allow your patients enough time to find another physician, so you do not risk liability for “patient abandonment.” The California Medical Association suggests you send each patient notice by certified mail, return receipt requested, and maintain those documents in the patient’s medical record. You should also inform inactive patients, or those who may have moved, by placing an advertisement in a local newspaper, through your answering service, and posting a notice in your reception area. You will want to provide your patients with information on how to obtain a copy of their medical records. You should check with your professional liability carrier as to how long you should maintain patient records so as not to jeopardize your malpractice tail coverage (the extended coverage after the cancellation or termination of a policy).


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This article is reprinted with the permission of the Medical Board of California, originally printed in their Newsletter, Vol. 135, Summer 2015.

pharmacies during the prior twelve months. These alerts will be viewable on the physicians’ dashboard when they sign on to the CURES 2.0 system.

WHAT IS THE CURES SYSTEM?

SB 809: REQUIREMENT TO REGISTER BY JANUARY 1, 2016

California’s Prescription Drug Monitoring Program (PDMP), Controlled Substance Utilization Review and Evaluation System (CURES), allows authorized physicians, law enforcement, and regulatory agencies to view information on Schedule II – IV controlled substances dispensed to patients in California. Pharmacists and direct dispensers are required to report information on all Schedule II – IV controlled substances dispensed, and must do so within seven days of dispensing. The information is then uploaded into CURES. The CURES system has provided prescribers and dispensers with Schedule II – IV prescription data via an online web portal since 2009. The system, as currently configured, provides authorized prescribers and dispensers who have registered on the system with prescription detail for an individual patient’s prescription records (Patient Activity Report, or PAR), which includes the patient’s name, date of birth, and address; drug name, form, strength, quantity, dispensing pharmacy name and license number; prescriber DEA Certificate number; prescriber name, prescription number; refill number; and date of dispense. A physician can use this information for multiple purposes, including identifying a patient who may be a “doctor shopper,” viewing medications dispensed to the patient that were prescribed by other physicians, and providing a complete picture of Scheduled drugs dispensed to a patient. The CURES system can be an extremely helpful tool for physicians who are prescribing controlled substances. The Medical Board’s newly revised Guidelines for Prescribing Controlled Substances for Pain emphasizes that physicians should use the CURES PDMP to identify patients who obtain drugs from multiple sources as part of the Patient Evaluation and Risk Stratification process. The Guidelines also recommend that physicians document, in their medical records, that they requested a Patient Activity Report (PAR) from CURES and the outcome of such report.

UPGRADING CURES: CURES 2.0

The CURES system is in the process of being upgraded. Over the last two years, the Department of Justice (DOJ) selected a vendor, identified what stakeholders thought an upgraded CURES system should include, and designed “CURES 2.0.” CURES 2.0 is going to enhance the information that a physician can obtain from the system. In addition to the functionality of the current system, CURES 2.0 will provide an improved user interface and an analytics engine that will provide physicians with critical information regarding atrisk patients. An example of a new feature with the upgraded CURES 2.0 is that prescribers will be able to specify patients with whom they have pain management agreements to signal to other providers that additional prescribing of controlled substances to these patients could be potentially counter-productive or harmful. The new CURES 2.0 will also provide alerts to physicians if a patient meets certain criteria, such as a patient who has obtained prescriptions from four or more prescribers and four or more 16 | THE BULLETIN | SEPTEMBER / OCTOBER 2015

CURES 2.0 is expected to provide faster, more reliable service to a much larger medical practitioner base, sufficient to accommodate the hundreds of thousands prescribers and dispensers in the state who are required by Senate Bill (SB) 809 (DeSaulnier, Chapter 400, Statutes of 2014) to register with the system by January 1, 2016. This new system was finalized on July 1, 2015. In order to ensure a smooth transition from the current system, CURES 2.0 will be rolled out to users in phases over the next several months, beginning with early adoption by a select group of users who currently use CURES and meet the CURES 2.0 security standards, including minimum browser specifications. With the new CURES 2.0, users will be required to use Microsoft Internet Explorer Version 11.0 or greater, Mozilla FireFox, Google Chrome, or Safari when accessing the system. The DOJ is currently identifying prescribers and dispensers who meet these criteria and will contact them and coordinate their enrollment into CURES 2.0. For all other current users, access to CURES 1.0 will not change and no action is needed at this time.

PHYSICIANS NOT CURRENTLY ENROLLED IN CURES HAVE TWO OPTIONS:

1. Submit an application form electronically (https://pmp. doj.ca.gov/pmpreg/Signup _input. action?at=12) and then mail a notarized copy of the printed and signed Application Confirmation, along with copies of the following supporting documents to the California Department of Justice, PDMP/ CURES, P.O. Box 160447, Sacramento, CA 95816 or email it to pmp@doj.ca.gov: ȧȧ Drug Enforcement Administration registration certificate, ȧȧ Medical license, and ȧȧ a government-issued photo identification 2. Or, wait until a streamlined application and approval process for access to the CURES 2.0 becomes available within the next two months. This streamlined process will be online and will eliminate the need for a notary. Pursuant to SB 809, passed by the legislature and signed by the Governor in 2014, a physician authorized to prescribe, order, administer, furnish, or dispense Schedule II, Schedule III, or Schedule IV controlled substances must have submitted an application to the DOJ for registration into the CURES system by January 1, 2016. Physicians not currently enrolled in CURES should follow the instructions above to ensure they are registered by the deadline. The Medical Board will be posting frequently asked questions about CURES 2.0 and the registration process on its website once the streamlined process has been completed and more information on the upgraded system is available.


SEPTEMBER / OCTOBER 2015 | THE BULLETIN | 17


Reporting Lapses of Consciousness: What is Your Legal Responsibility? By Linda Hill, MD, MPH This article is reprinted with the permission of the Medical Board of California, originally printed in their Newsletter, Vol. 135, Summer 2015. Your 34-year-old diabetic patient reports a hypoglycemic episode resulting in temporary disorientation and near loss of consciousness. If the patient drives, are you required to notify the health department of the diagnosis? Based on California Health and Safety Code section 103900, the answer is yes. The code states that every physician and surgeon shall notify the local health officer when they have diagnosed a patient with a disorder characterized by lapses of consciousness. Lapses of consciousness pose a particular threat to motorists and others who share the road. Such conditions are characterized by: • marked reduction of alertness or responsiveness to external stimuli; • inability to perform one or more activities of daily living; or • impaired sensory motor functions used to operate a motor vehicle. Examples of conditions that may, but do not always, cause the functional impairment included in the definition of lapses of consciousness are syncope, hyper- and hypoglycemia, seizures, dementia (including Alzheimer’s disease), brain neoplasms, post-CVA status, narcolepsy, and sleep apnea. Making the decision to report a patient depends on whether the lapse of consciousness is related to an ongoing condition or a one-time event. For example, a one-time loss of consciousness due to a single event, 18 | THE BULLETIN | SEPTEMBER / OCTOBER 2015

such as a sport-related concussion, is likely not reportable, unless there is residual impairment. Physicians are protected from liability for making good-faith reports. Indeed, failing to report may have consequences if a patient with a qualifying condition subsequently experiences a motor vehicle crash. The California Department of Public Health has a specific form for reporting lapses of consciousness; it is the Confidential Morbidity Report Form 110C. The form requests information that pertains to driving and will be forwarded to the California Department of Motor Vehicles. The Training, Research and Education for Driving Safety (TREDS) program at the University of California, San Diego (UCSD), has resources to assist physicians in the identification and management of patients with age-related driving impairments. A short video, Physician Mandated Reporting of Drivers in California, reviews medical conditions that require reporting and provides case examples. An easy reference pocket guide with screening and reporting guidelines is available at no charge. While discussions about driving may be difficult to initiate, compliance with these requirements protects patients, their families, and our communities from harm. For additional information, visit the TREDS website or call 858/534-9330. Dr. Hill, the director of TREDS, is a professor at UCSD and chairs the Graduate Medical Education Committee, American College of Preventive Medicine.)


PRACTICE CHECK-UP

Marketing Your Practice? Prepared by CMA Center for Economic Services (CES) A physician’s reputation for providing accessible quality of care can go a long way in assuring a stable patient base. But, physicians may also wish to consider a marketing strategy. While there are many consultants who can help physicians with the creation and implementation of a marketing plan, adopting just a few steps may help physicians build and/or maintain a viable practice. Understand your environment – It’s important to understand the types of patients cared for and the environment in which the practice is located. For example, is there a particular “culture,” i.e., do patients prefer alternative, complementary practices versus traditional medical care? If so, your marketing goals may need to be tailored to meet the needs of the patients and culture of the area in which the practice is located. Brand your practice – It’s critical to brand your practice by delineating what distinguishes your practice from others and assures your patients that they have made the right decision to remain with you. Branding requires much more as a reputation of quality, a consistency of message, and is developed over a period of time from the provision of quality care, communications, relationships, and trust. As a result, the ability of a practice to “brand” itself as a reputable medical practice that is dedicated to patient care is to ensure that it maintains that ability through all of its services, communications and relationships with patients, other colleagues, hospitals, and managed care payors. This requires commitment of not only the physicians, but also the staff, to ensure that all services provided are professional. Identify and strengthen ties with your target audience – A practice’s “target audience” is the entities to which the practice’s marketing efforts should be directed. This includes not only current and prospective patients, but also hospitals, third-party payors, and even patient practices who represent the medical conditions that fall within your specialty, i.e., the American Diabetes Association would be a great target audience for an endocrinologist. Referrals from existing patients are a great way to attract new patients. These referrals can be obtained through the following: • An office sign reminding patients that you welcome their referrals, such as, “We appreciate you as our patient and want you to know that the highest compliment from you is for you to refer your friends and family to our practice.” • Create a brochure that patients can provide to their family and friends. • Send thank you notes or emails to patients who do refer to your practice. • Send patients birthday messages. If appropriate, remind them of their annual check-up. • Make the office a welcoming experience. Ensure exam rooms are

clean and welcoming after each use. Keep the waiting room clean and make sure there are current magazines for patients to peruse while they wait. Consider providing water with lemon slices and/ or coffee in the waiting room. • Be visible in your community by donating medical services for a local charity auction. • Have a practice presence at health fairs, sporting events, etc. Just as patients are important to boost referrals, so are other physicians in the community. Techniques with physician colleagues are similar to those for patients, including: • Maintain a collegial relationship with other physicians, such as having lunch or engaging in other social events with them. • Have a visible presence – physicians who give public lectures or provide a strong presence in the medical community raise their profiles as experts in the area. • Join and participate in your local and state medical societies. Many medical societies have patient referral programs. You may also want to consider creating a website, brochure, or newsletter for your practice that includes photos of the physicians, staff, and office. It’s also helpful to include testimonials, office hours and appointments, patient forms, etc. Evaluate and adjust your marketing plan as necessary – A practice can compare its progress with its marketing plan by looking at patient survey scores, referral sources, increased income, increased new patients, and decreased complaints. If the practice’s progress does not measure up, then there needs to be an evaluation as to why. Depending upon what the answers are, new approaches within the practice itself, as well as the marketing plan, may be needed. For more information on marketing your practice, please visit www. cmanet.org to download free CMA Prepared On-Call Documents: “Accessing Patients: Marketing and Other Steps Physicians Can Take,” “Advertising by Physicians,” and “Practice Promotion through Third Party Coupons.”

SEPTEMBER / OCTOBER 2015 | THE BULLETIN | 19


OHLONE INDIAN HERBAL MEDICINES By Michael A. Shea, MD Leon P. Fox Medical History Committee The Ohlone Indians lived in the Bay Area for thousands of years. At the time of the California Missions (late 1700’s), there were approximately 10,000 of them living in separate communities called tribelets. A tribelet contained about 250 people. Each tribelet had its own medicine man, the shaman, who was available for serious illnesses. Lesser maladies could be treated by almost anyone in the tribelet as most Ohlones were very knowledgeable about herbal medicine. The following is a discussion of some of those herbs and the conditions they were used to treat. Black Sage (Artemisia douglasiana) is found in chaparral and grassland areas where it can grow to over six feet in height. The Ohlone would gather the small seeds, grind them into a meal, and soak them in water to produce a tea to drink. The leaves would be chewed without any preparation for their benefit. The tea was used to treat asthma, earache, arthritis, and urinary tract ailments. The leaves were used for cuts and sores, espe20 | THE BULLETIN | SEPTEMBER / OCTOBER 2015

cially involving the mouth and throat. Black Sage contains diterpenoids, aethiopinone, and ursolic acid. These compounds have been found to have anti-inflammatory properties. Chia (Salvia columbariae) was one of the most widely used plants by the Indians on the West Coast. The seeds, because of their gelatinous property, were mixed with water and applied to the eyes to treat irritation and inflammation. They were also taken internally to reduce fever. Chia contains omega-3 fatty acids and dietary fiber, which in modern medicine has been recommended for correcting unhealthy lipid patterns. Another commonly used grassland plant was Milkweed, (Asclepias eriocarpa), also known as Immortal. This was an important remedy for asthma and colds. This was accomplished by burning the leaves and inhaling the smoke. The plant could also be used as a decoction (a decoction is produced by boiling the plant in water and using the liquid either externally as a poultice or taken internally as a liquid). Milkweed also has a high dextrose content and was used as a sweetener by the Indians. Interestingly, it also contains the cardiac glycoside, digitalis, and thus could be toxic if taken in large amounts.


Several other important plant species of the dry grassland-mesa environment of the inner Santa Clara Valley include: Jimsonweed, Amole, and Tobacco. Jimsonweed (spanish name Toloache) grows in the dry parts of Southern California and up into the lower Sacramento Valley. Toloache does contain atropine and scopolamine, and the latter can produce hallucinations, which the Indians used to guide them in their lives. Pain, boils, and respiratory problems were also indications for Jimsonweed. The seeds of this plant, smoked with tobacco, were reportedly used as an aphrodisiac. Amole (Soap Root) grows in abundance on rocky banks and hills throughout the San Francisco Bay Area. The root contains Sapotoxin, which has spermicidal, antibiotic, expectorant, and analgesic properties. It is also toxic to fish, and when mixed with water produces a foam, which if spread over a small stream will cause the fish to float to the surface, where the Ohlones would gather their catch. Other uses of Soaproot include: antisepsis, soap, and as a glue to attach their feathers to arrows. The leaves, because of their flexibility and succulent nature would be wrapped around acorn dough and baked on heated rocks. The abundant tough external fibers sheathing the bulbs were used to craft brushes and combs. Lastly, the soap lather was beneficial for dandruff treatment. Yerba Santa (Eriodictyon californicum), a dark green, resinous shrub, five to seven feet high, grows profusely on dry bushy hillsides. It contains 12 flavinoids, which do have antibiotic and anti-inflammatory properties. The herb was boiled to make a bitter tea and used to treat coughs, colds, sore throat, asthma, tuberculosis, and rheumatism. A linament was also used as a wash to reduce fever. The fresh leaves were pounded into a poultice, and were bound on the skin sores of men and animals. The tender leaves and stems were used as hot compresses to treat sore joints.

The California Bay Tree, often called the Laurel, grows on shady hillsides and is common in the San Francisco Bay Area and in Monterey. The leaves were moistened and applied to the forehead for relief of headaches and a decoction used for poison oak. The Bay tree also has anti-insecticide properties and was used to protect acorns in granaries. Manzanita (Little Apple) berries and leaves were used in a decoction for poison oak due to its astringent properties. It was also taken orally for bronchitis, bladder symptoms, and headaches. Blood Root (Eriogonum latifolium) grows on hillsides and along open streams. The Indians would prepare the root, stem, and leaves as a decoction to be taken internally for colds and coughs. Trillium Chloropetalum grew profusely in the wetlands. The Ohlone used this plant for chest pain, applying various parts of the plant as hot compresses to the area of chest discomfort. The use of Trillium as an external remedy is consistent with its intensely bitter taste as an oral agent. Some authors describe Indian food and medicine as spiritually and mythologically linked. Plant parts for food were not always the same as those used for medicine. It seems that if the Indians held that the spiritual power resided in the whole plant, it was only reasonable that the edible parts be used for food and for internal remedies and that the inedible parts be used for external remedies, or for charms and ceremonial purposes.

ADDENDUM

In some of the herbal plants used by the Ohlone for treatment of ailments, scientific research has verified chemicals with medicinal active properties. These have been mentioned in this article (e.g. flavinoids). In others, no identifiable active agent could be documented.


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SEPTEMBER / OCTOBER 2015 | THE BULLETIN | 23


FAQ SURVIVING ICD-10: An FAQ for physician practices After much debate and years of delay, the October 1 implementation date for ICD-10 has finally arrived. As the implementation unfolds, there likely will be unanticipated hurdles that need to be overcome. The California Medical Association (CMA) has a number of resources to help members prepare and we have created the following FAQs to help practices survive ICD-10 implementation:

1. Can I continue to submit claims to health plans using ICD-9 codes for dates of service on or after October 1, 2015? No. The federally mandated conversion date, which is based on date of service, is October 1, 2015. For dates of service on or after October 1, 2015, ICD-10 codes will be required on all claim transactions. Failure to submit claims using ICD-10 codes will result in denials. The claims will then have to be re-coded and re-submitted with ICD-10 codes.

2. I had read that CMS was allowing a “grace period.” What does that mean to physician practices? In early July, the Centers for Medicare & Medicaid Services (CMS) announced that for a period of one year, it will allow for flexibility in the claims payment, auditing and quality reporting processes as the medical community gains experience using the new ICD-10 code set. CMS subsequently issued updated guidance that clarified the flexibilities it is offering. So what does the CMS flexibility mean to practices? •

Claim denials: According to the CMS guidance, as long as the code submitted is from the right family of codes, is coded to the maximum level of specificity, and as long as there isn’t an LCD or NCD that requires a specific code, the Medicare claim will be processed and will not be audited. If, for example, you submit a valid five-character code, you wouldn’t be audited simply because you selected the wrong fifth character. This flexibility will continue for a period of 12 months.

Quality reporting: Physicians will not be penalized under the quality reporting programs for errors related to the additional specificity of the ICD-10 diagnosis code, again as long as a code from the correct family of codes is used.

Advance payments: If Medicare contractors are unable to process claims within established time limits because of administrative problems, such as contractor system malfunction or implementation problems, advance payment may be available to keep resources flowing to physician practices. Rev. 09/30/15

Questions: Call CMA’s reimbursement help line, (888) 401-5911 or economicservices@cmanet.org 24 | THE BULLETIN | SEPTEMBER / OCTOBER 2015

Page 1 of 4


ICD-10 ombudsman: CMS has set up an ombudsman, Dr. William Rogers, to monitor the implementation of ICD-10 and to help triage physician and provider issues related to the transition. Inquiries can be submitted via email to ICD10_Ombudman@cms.hhs.gov. Individual claim issues should be directed to Noridian, the Medicare Administrative Contractor (MAC) or the individual payor rather than the CMS ombudsman, as individual claim information is not available to the ombudsman office staff. MACs have received increased funding from CMS to staff for ICD-10 implementation and field provider inquiries.

To be clear, the ICD-10 implementation date of October 1, 2015 has not changed. Claims submitted to Medicare with ICD-9 codes on or after that date will be rejected. Additionally, the CMS flexibility only applies to fee-for-service Medicare claims and does not necessarily extend to commercial, Medi-Cal, Medicare Advantage or workers’ compensation claims.

3. I heard that workers’ compensation carriers weren’t required to transition to ICD-10. Is that true? The final rule requires HIPAA covered entities to adopt ICD-10 by October 1, 2015. While adoption of ICD-10 is not required for non-covered entities, such as workers’ compensation programs, the Division of Industrial Relations and the Division of Workers’ Compensation adopted regulations on September 22, 2015, requiring use of ICD-10 for workers’ compensation claims effective October 1, 2015. The regulations also include updates to the following forms: •

Doctor’s First Report of Injury (Form 5021)

Primary Treating Physician’s Progress Report (Form PR-2)

Primary Treating Physician’s Permanent and Stationary Report (Forms PR-3, Pr-4).

The only changes to the forms are related to use of ICD-10 rather than ICD-9. The regulations provide a “grace period” for use of the revised workers’ compensation forms. Either the old or new versions can be used until December 31, 2015. For services rendered on or after January 1, 2016, the new forms are required. Again, ICD-10 codes are required for services rendered on or after October 1, 2015. You can, however, use the old forms through the end of the year.

4. How do I handle billing of claims that span the ICD-10 implementation date? For example, a patient is seen from September 28, through October 2, 2015, can I submit one claim for all of these services? Only one version of ICD codes can be submitted on a claim. In the above example, if the claim was for an outpatient visit, the claim would be split into two claims, also known as split billing, with the services performed on September 28-30 on one claim using ICD-9 diagnosis codes, and the ICD-9 code indicator in box 21 marked. Services performed on October 1 and October 2, 2015, would be billed on another claim using ICD-10 diagnosis codes with the ICD-10 indicator in box 21 marked. Failure to split bill will result in denials. For inpatient services, claims for patients who are admitted prior to October 1 and discharged after October 1 should be billed using ICD-10 codes. If billing professional claims for global OB services with dates of service that span October 1, please check with the payor. CMA has received differring instructions from some payors. For more information on billing claims that span the ICD-10 implementation date, visit the Medicare Learning Network SE1408. Rev. 09/30/15

Questions: Call CMA’s reimbursement help line, (888) 401-5911 or economicservices@cmanet.org

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SEPTEMBER / OCTOBER 2015 | THE BULLETIN | 25


5. Since ICD-10 codes include specification of laterality for some conditions, do we need to continue to use CPT modifiers for laterality? Yes. ICD-10 will not change the reporting of CPT codes, including modifiers for physician services. Failure to continue to code laterality modifiers on CPT codes may result in denials. For more information, click here.

6. If we obtained a prior authorization with an ICD-9 code, but the service wasn’t performed until on or after October 1, will it still be valid or do we have to get a new authorization? Practices are encouraged inquire with their local payors. CMA did, however, survey the major payors about how they will handle situations where the authorization was obtained with an ICD-9 code, but the service occurs after the ICD-10 transition date. All of the major payors responded that they will honor prior authorizations obtained prior to the ICD-10 transition date using an ICD-9 code as long as the service provided corresponds to the authorization. However, ICD-10 codes must be billed if the service is performed on or after October 1 and it is recommended that the authorization number be included on the claim form in box 23.

7. Prepare a vendor contact list. In the event your practice experiences problems, it’s helpful to have the contact information for your vendors, including billing services, clearinghouses, practice management systems, EHRs, etc., readily available to staff. Contact information for the large payors in California can be found below.

8. What resources does CMA have available for physician practices? As the implementation unfolds, there will likely be hurdles that need to be overcome. CMA has a number of resources to help members prepare: •

ICD-10 Transition Guide: This guide will help practices of all sizes successfully make the switch to the new ICD-10 coding system. It answers frequently asked questions and includes CMA’s “ICD-10 Transition Preparation Checklist” to help ensure the transition is a smooth one. The guide is FREE to members-only.

CMA ICD-10 Overview Webinar: CMA has an on demand webinar available on its website. Access to the previously recorded webinar is free to CMA members and their staff ($99 for non-members) and is intended as a final review for those who have a base knowledge of ICD-10. For more information click here click here.

Discounted ICD-10 Education and Training: CMA has partnered with AAPC to offer discounted specialty-specific documentation training for physicians (three-hour, online courses). For more information on the 21 different specialty-specific documentation courses offered, visit www.cmanet.org/aapc (be sure to login to the CMA website to access member pricing).

ICD-10 News Alerts: The CMA website allows registered users to create custom content alerts on the topics that are of interest to you. Once signed up, you will be notified any time there is new content posted in one of your areas, including ICD-10 issues. To sign up, go to www.cmanet.org and visit your account dashboard, click on “My Alerts,” then select “ICD-10.”

One-on-One Assistance: If you are having trouble with claims being denied or delayed—whether it’s related to ICD-10 or not—CMA is here to help. Members can call on our practice management experts for one-on-one help with payment, billing and contracting problems. This is a FREE service to CMA members only. Rev. 09/30/15

Questions: Call CMA’s reimbursement help line, (888) 401-5911 or economicservices@cmanet.org 26 | THE BULLETIN | SEPTEMBER / OCTOBER 2015

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Contact information for ICD-10 related issues for the major health plans is below: Plan Name

ICD-10 Contact Information

Aetna

(888) 632-3862

Anthem Blue Cross

(855) 854-1438

Blue Shield of California

(800) 541-6652

Cigna

(800) 88Cigna (882-4462)

Health Net

(800) 641- 7761 or provider_services@healthnet.com

Medi-Cal

For claims related issues, call the telephone service center at (800) 5415555. For global, systemic issues email ICD-10Medi-Cal@xerox.com

Noridian (Medicare MAC)

(855) 609-9960

United Healthcare

Call your provider advocate or (877) 842-3210 or ICD10questions@uhc.com

Still have questions? Visit CMA’s ICD-10 resource center at www.cmanet.org/icd10. In the resource center, you can access CMA’s ICD-10 implementation guide, CMA’s ICD-10 on-demand webinar, and the most recent ICD-10 related news among other resources. CMA members and their staff also have FREE access to our reimbursement helpline at (888) 401-5911 or economicservices@cmanet.org.

Rev. 09/30/15

Questions: Call CMA’s reimbursement help line, (888) 401-5911 or economicservices@cmanet.org

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SEPTEMBER / OCTOBER 2015 | THE BULLETIN | 27


GUIDELINES FOR PHYSICIAN WELL-BEING COMMITTEES TO ASSIST IMPAIRED PHYSICIANS Norman T. Reynolds, MD Distinguished Life Fellow of the American Psychiatric Association The following outline is intended to inform medical staff committees, especially physician well-being committees (PWBC), of their important role in identifying and assisting physicians who are impaired or suspected of impairment. The outline provides guidelines for conducting preliminary or “screening evaluations” in simple cases and guidelines for “comprehensive evaluations” in more complex cases. In accordance with Joint Commission Standards, medical staffs and their well-being committees should be aware of “red flags” that suggest impairment and offer assistance to such physicians that is separate from a disciplinary process. Assisting impaired physicians can promote personal well-being and restore them to good professional functioning thereby protecting patient care.

GENERAL GUIDELINES

• Medical staff committees can screen for problem behaviors that suggest psychiatric problems, substance abuse, or behavioral/ interpersonal problems. • Medical staff committees should not engage in diagnosing or treating physicians. • Instead, they should refer to experienced professionals for evaluation, treatment, and monitoring. • PWBCs can conduct complaint “verification,” but should not conduct medical executive committee (MEC) “formal investigations.” • Collect records in advance of referring for evaluation. • Committee approach toward the physician being screened:

28 | THE BULLETIN | SEPTEMBER / OCTOBER 2015

• • • • • • •

ȧȧ Act with respect and compassion. ȧȧ Do not automatically assume that the physician is guilty of all complaints. ȧȧ Give the physician an opportunity to express his or her viewpoint. ȧȧ Be prepared to set limits when indicated. ȧȧ Be honest and do not bluff. ȧȧ Be encouraging, offering realistic options. (Involving a physician who is openly in recovery can be reassuring that success is possible.) ȧȧ While offering assistance, ensure that patient safety comes first. Comply with relevant policies, bylaws, and state/federal laws. Avoid short-cuts; do things right the first time. PWBCs should not discipline (e.g., 805 reports to MBC); instead refer to the MEC if discipline is indicated. Encourage early intervention so as not to enable problems. Choose a case manager on the committee to act as a point person for communications with the physician and professional resource evaluators. Obtain informed and signed consent from the physician in communicating with others. Periodically, educate the medical staff membership about issues of wellness, burnout, and assistance to physicians who suffer impairment or a potentially impairing illness.

Resources: Accreditation Council on Graduate Medical Education (ACGME), Americans with Disabilities Act (ADA), American Medical Association (AMA), ASAM, California Medical Association (CMA), Cali-


fornia’s Confidentiality of Medical Information Act (CMIA), Federation of State Medical Boards (FSMB), Federation of State Physician Health Programs (FSPHP), Medical Board of California (MBC), The Joint Commission (TJC).

LEVELS OF PROFESSIONAL EVALUATION

Preliminary or “screening evaluation” and “comprehensive evaluation” are two levels of evaluations that can be conducted by professional evaluators. As noted below, there are some cases in which a preliminary or screening evaluation may be acceptable. Always, the professional evaluator should be mindful of the possibility of more serious underlying problems which may result in a recommendation for a comprehensive evaluation. The risk in conducting a Screening Evaluation is that it may miss important underlying conditions. It is in the nature of impairment that psychological dynamics of shame and denial can result in the physician obscuring problems in order to avoid consequences. Lack of accurate self-assessment and insight can be a part of physician impairment. The impaired physician genuinely may not recognize the nature and extent of the impairment and plead for return to practice. Allowing a physician who manifests impairment to return to work does not benefit that physician. It risks poor patient care, the shame and guilt associated with preventable adverse outcomes, lawsuits, discipline, and even permanent loss of licensure. The Comprehensive Evaluation is intended to be comprehensive and in-depth; it is the equivalent of psychological surgery. Because addressing psychological issues can be challenging, considerable time is spent extensively covering history, and the physician under evaluation is encouraged to freely present his/her viewpoints. When evaluating impaired physicians, the evaluator can be confronted with the physician’s deeply embedded defenses of minimization and denial. Too easily, inexperienced evaluators ally with the physician’s defenses, often well articulated. The impaired physician may invite a cursory evaluation by trying to impress the evaluator with his/her prestige and status. Brief evaluations often miss the mark resulting in protracted impairment. It is important to do the evaluation right the first time for the benefit of the physician, significant others in the physician’s life, and patients. A comprehensive evaluation can be life saving to the physician’s professional career and personal life.

Screening Evaluation: • MD has positive attitude toward PWBC and acceptance of referral for evaluation • Cooperates in providing information and background records • Open to feedback and recommendations • Presents with “minor problems:” ȧȧ Stress or burnout without diagnosable mental illness ȧȧ Recent or occasional occurrence of problems; not part of a long-standing pattern ȧȧ No actual impairment in work performance • Agrees to subsequent, periodic evaluation before final evaluation and determination regarding FFD • Agrees to a preventive approach, especially in cases of “potentially impairing illness” (ASAM) • Presents with a low risk of litigation • No need for an extensive written report • The preliminary or Screening Evaluation may result in a recommendation for a Comprehensive Evaluation. Comprehensive Evaluation: • Problem is part of a longstanding recurrent pattern.

• MD is contentious, oppositional, and resistant to intervention and assistance. • Complex diagnostic case involving potentially many cooccurring conditions, e.g., substance abuse, mental illness, personality problems, physical conditions, and/or external stressors. • Impaired work performance or disruption of coworkers. • Failure to respond to prior discussions, redirection, or discipline. • Unreasonably blames others and circumstances for problems. • Wants retribution. • Little or no prior treatment or inadequate treatment. • Significant denial, lack of self-awareness, and lack of insight. • Litigious. • Placed on administrative leave because of seriousness of problems. • Need to ensure protection of the public while pursuing a goal to alleviate the symptoms, return to work, manage problems, and prevent recurrences. • Need for an extensive written report with data and analysis to support recommendations; report serves as case management plan for treatment and monitoring. Failure of the physician to accept or comply with remediation could result in a recommendation to pursue disciplinary action through the MEC, especially if there is risk of danger to the public.

ELEMENTS OF COMPREHENSIVE EVALUATION

Modified from Reynolds NT, A model comprehensive fitness-forduty evaluation. Occupational Medicine: State of the Art Reviews, 2002.

Review of Records: • Incident reports prompting the referral for evaluation • Job description • Job performance evaluations • Police reports • Department of Motor Vehicle records • Prior psychological evaluations (e.g., pre-employment) • Medical and mental health treatment records • Pharmacy records of medications obtained by the individual being evaluated • National Practitioner Data Bank entries Face-to-Face Interviews for Comprehensive History: • Basic identifying data • History and perspective of the physician • Habits: nicotine, caffeine, alcohol, and substances • Background history: medical, financial, legal, education, employment, family, and social Mental Status Examination: • General appearance • Alertness and orientation • Symptoms (physical, psychological, psychosomatic) • Mood and affect • Cognitive screening • Personality dynamics and relationship skills (pathological, defenses, positive coping skills) • Reality testing Laboratory: • Alcohol and drug urine screening via chain-of-custody • Hair sample analysis for drugs Continued on page 30 SEPTEMBER / OCTOBER 2015 | THE BULLETIN | 29


Guidelines for Physician Well-Being, continued from page 29

Polygraph Examination for select cases

• Indicators of violence or suicidality • Interpersonal problems with patients, coworkers, or administrators • Failure to follow rules or expected behaviors Refer, especially if there are many problem behaviors. Consider referral if there is only one or two problem behaviors that are of considerable significance especially if there are indications that the behaviors represent the beginning of an ongoing pattern. Word of caution: Do not refer physicians simply because they have expressed criticism of the system of care or because they have engaged in whistle blowing even if such actions create discomfort in others. In some cases, these physicians may benefit from medical staff support in furthering a legitimate cause or agenda.

RED FLAGS / INDICATIONS FOR REFERRAL

SUMMARY

• Complete blood count including red blood cell indices • Chemistry panel including liver function tests

Questionnaires and Psychological Testing: • CAGE • Michigan Alcohol Screening Test (MAST) • Alcohol Use Identification Test (AUDIT) • Minnesota Multiphasic Personality Inventory (MMPI) and Personnel Evaluation • Millon Clinical Multiaxial Inventory (MCMI) • Specialized tests when indicated (e.g., neuropsychological tests to evaluate cognition)

Significant changes compared to usual or baseline functioning: • Poor work performance • Absenteeism • Tardiness • Odor of alcohol • Poor grooming and hygiene • Inappropriate mood and affect • Sleeping on the job • Slurred speech • Gait disturbance • Bizarre or unprofessional thought processes, communications, or behaviors

Medical staffs and their well-being committees play a vital role in assisting physicians who manifest or are suspected of impairment. The Joint Commission created standards that require medical staffs to provide assistance to such physicians that is separate from a disciplinary process. In this article, guidelines are offered for medical staffs to provide such assistance that are consistent with best practices and maximize opportunities for physicians to be restored to healthy functioning and safe practice.

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SEPTEMBER / OCTOBER 2015 | THE BULLETIN | 31


CMA Alert, September 8, 2015 issue

CMS clarifies ICD-10 “grace period” guidance In early July, the Centers for Medicare & Medicaid Services (CMS) announced that for a period of one year, it will allow for flexibility in the claims payment, auditing and quality reporting processes as the medical community gains experience using the new ICD-10 code set. CMS specifically clarified its statement that during the 12 months after ICD-10 implementation, contractors would not deny claims based solely on the specificity of the ICD-10 diagnosis code. However, according to the latest FAQ, claims will be rejected if they do not contain a valid ICD-10 code. CMS further defined a “valid code” as one that is coded to the maximum level of specificity. Claims will not, however, be rejected or audited simply because they contain the wrong code—as long as it is a valid code from the right family. ICD-10 codes contain at least three characters, but sometimes as many as seven characters. The three-character “coding family” may then be further subdivided with more characters to provide additional specificity. If, for example, you submit a valid five-character code, you wouldn’t be audited simply because you selected the wrong fifth character. So, what does the CMS flexibility really mean? While coding to the

correct level of specificity is the goal for all claims, claims will be processed and will not be audited as long as the first three characters are from the correct “coding family.” This does not mean that you can submit claims that do not at least attempt to provide additional specificity, when required. If a submitted code is not recognized by the system as a valid ICD-10 code, it will be rejected. The physician can, in such an instance, resubmit the claims with a valid code. To clarify, the ICD-10 implementation date of October 1, 2015, has not changed. To help physicians prepare for the transition, the California Medical Association (CMA) has updated its ICD-10 Transition Guide, which includes an ICD-10 transition preparation checklist. The guide also includes, among other things, information on how payors will handle prior authorizations around the transition date; listing and links to CMA’s live ICD-10 training courses; more information on CMS’ “grace period;” and a visual of the anatomy of ICD-10 code structure. For the latest news and information on the ICD-10 transition, including the ICD-10 Transition Guide, see www.cmanet.org/icd10.

CMA Alert, September 8, 2015 issue

NPs and PAs can sign POLST forms beginning in 2016 A new law (Assembly Bill 637) recently signed by Governor Jerry Brown will allow nurse practitioners (NP) and physician assistants (PA), under the direction of a physician and within their scope of practice, to sign Physician Orders for Life-Sustaining Treatment (POLST) forms and make them actionable medical orders. The law goes into effect on January 1, 2016. The POLST form is a legally recognized document that outlines a plan of care reflecting patients’ wishes concerning medical treatment and interventions toward the end of their lives. The California Medical Association (CMA) co-sponsored AB 637, citing the importance of POLST as a tool for honoring end-of-life care preferences. The new law will result in increased use of POLST orders by allowing nurse practitioners and physician assistants the ability to sign the document so that it legally goes into effect immediately. Therefore, patients can exercise more control over the medical treatment they receive. End-of-life conversations are never simple, but POLST is a powerful 32 | THE BULLETIN | SEPTEMBER / OCTOBER 2015

tool for physicians to use to help patients consider the level of care they want and need at the end of life. Thoughtful end-of-life planning can make a patient’s last few weeks, months, or even years far more satisfying. CMA publishes a POLST Kit, which includes legal forms and wallet identification cards, and answers frequently asked questions about endof-life issues. Physicians are encouraged to keep a supply of forms in their offices for use when having end-of-life discussions with patients. For more information on POLST, see CMA On-Call document #3451, “Decisions Regarding Life-Sustaining Treatment: Advance Directives and POLST,” and visit CMA’s website for more resources on end-of-life decisions at www.cmanet.org/endoflife. POLST Kits can be purchased from CMA’s online resource library. Single copies are $5 for members ($6 for nonmembers). Significant discounts are available on bulk purchases. For bulk purchase inquiries, please call CMA Publications at 800/882-1262.


CMA Alert, September 8, 2015 issue

Study finds that majority of Covered California plans have narrow physician networks A study by University of Pennsylvania researchers shows that 75% of health plans sold in California under the Affordable Care Act (ACA)—through Covered California—have significantly limited networks. More than 90% of California’s HMO networks for individual coverage were narrow, compared to a third of PPO plans in the state. Nationwide, 41% of provider networks were labeled narrow, meaning they included 25% or less of the physicians in a rating area. Big insurers like Anthem Blue Cross and Blue Shield of California have cut the number of physicians and hospitals available to consumers in what they describe as an attempt to reduce costs. While this may be another way of controlling health care costs for plans, consumers unfortunately have no easy way to tell if the plan they chose is adequate for their needs before enrolling. Researchers said better data on exchange networks is essential so regulators can ensure patients have sufficient access to doctors and consumers can determine whether a lowerpriced plan with a narrow network is a good deal. The California Medical Association (CMA) has urged state regulators to require insurers to provide additional instructions necessary for patients to successfully locate and navigate the specific network in which he or she has enrolled. This may also help to ensure that any cost savings the plans see from narrow networks are not partially the result of patients being unable to get needed care. More information also needs to be available to patients so they can make in-

formed decisions when selecting a plan. CMA has further asserted that California’s ability and standards for monitoring network adequacy and directory accuracy must continue to evolve to meet the challenges of this new health insurance environment, where minor fluctuations in a network can have major ramifications on access. Last year’s Senate Bill 964, which standardized much of the timely access reporting process and required annual provider network reviews, was a step in the right direction toward ensuring network adequacy, but inaccuracy in provider directories still remains an issue. Inaccurate provider directories in particular make it hard for the state to regulate and monitor network adequacy standards. Provider and patient frustration with poor network information has grown significantly in recent years as a number of plans’ networks have continued to shrink. Indeed, the potential impact to a consumer of an erroneous physician listing is much higher when only a fraction of the physicians in an area are in-network for a health plan. Last November, the California Department

of Managed Health Care (DMHC) released the results of an audit of the Anthem and Blue Shield Covered California networks. Among other things, the audit found that 12.8% of the physicians listed on Anthem’s network were not accepting Covered California patients, while 12.5% were not in practice at the location listed in Anthem’s directory. In the case of Blue Shield, only 56.7% of the physicians listed in Blue Shield’s Covered California directory could be verified as accepting Covered California patients. These inaccuracy rates were consistent with CMA’s own verification efforts and analyses. DMHC will be conducting a follow-up of its audit this fall to determine whether the health plans have resolved their inaccurate network directories. Physicians who are misidentified as participating in a network by Anthem or Blue Shield when in fact they are not, or whose information in a network directory is inaccurate, are urged to contact CMA’s Center for Economic Services at 888/401-5911 or economicservices@ cmanet.org.

SEPTEMBER / OCTOBER 2015 | THE BULLETIN | 33


CMA Alert, August 24, 2015 issue

CMA urges Congress to immediately pass EHR meaningful use reform With physicians potentially facing large penalties for meaningful use and other Medicare reporting programs, the California Medical Association (CMA) is urging the California members of Congress to cosponsor the American Medical Association’s meaningful use (MU) reform legislation, H.R. 3309, “The Further Flexibility in HIT Reporting and Advancing Interoperability Act” (FLEX IT 2 Act) and to immediately move the bill. “Physicians are facing a tsunami of Medicare regulations that threaten the viability of our practices,” said CMA President Luther F. Cobb, MD. “H.R. 3309 would provide some important flexibility and sanity in the meaningful use program while advancing interoperability. Medicare could see a significant decline in physician participation and access to care if these bureaucratic programs are not reformed.” Recently, the Medicare program made a stunning announcement that while 78% of physicians are using an electronic health record (EHR) – particularly in California, where physicians have been early adopters – more than 50% of eligible physicians will face meaningful use penalties under the EHR Incentive Program in 2015. The Medicare EHR Incentive program

was intended to increase physician use of technology to improve care and efficiency. Unfortunately, the program’s unrealistic and unnecessary requirements are hindering participation in the program, forcing physicians to purchase expensive EHRs with poor usability that disrupt workflow, interfering with patient care, and imposing administrative burdens. H.R. 3309 addresses the following problems in the meaningful use program: Eliminates the all-or-nothing approach. Under the current system, physicians who meet anything less than 100% of the measures are hit with a financial penalty. It imposes the same penalty on a physician who has met 99% of the requirements as a physician who does not attempt to participate in the program at all. H.R. 3309 will recognize the differences in specialty measures and provide credit on a sliding scale that incentivizes physicians to participate and continue improving. Aligns quality reporting requirements across Medicare programs. H.R. 3309 streamlines the reporting requirements across Medicare’s various quality reporting programs and deems physicians who have successfully met physician quality reporting system (PQRS)

In Your Medical Staff or Medical Group A new service, launched in June, makes consultants from California Public Protection & Physician Health (CPPPH) available to assist individual medical staffs and medical groups in their own settings as they address physician health and behavioral issues. Consultants with experience and expertise can work with you in your hospital or your group, assisting you to implement your policies and procedures and giving specific, individualized recommendations. For more information, see www.CPPPH.org and contact CPPPHInc@gmail.com or call Ashley Burke at 415/764-4822.

34 | THE BULLETIN | SEPTEMBER / OCTOBER 2015

goals to have satisfied the MU quality requirements. Delays stage 3 requirements. To improve physician participation, stage 2 needs to be reformed and successfully completed by physicians before stage 3 begins. Expands the hardship exemption. The bill provides exemptions for physicians subject to disruptive technology problems, including physicians who change EHR products. It also provides exemptions for certain physicians who are close to retirement and recognizes specialties that do not directly interact with patients. Shortens the reporting timeline. The bill institutes a 90-day reporting period to remove barriers to interoperability and promote usability. The current 365-day reporting period limits innovation, leaving physicians with no downtime to upgrade products, improve usability and test innovative solutions. Advances interoperability. The bill ensures that EHRs are interoperable—capable of sending, receiving, and incorporating data through repeated testing and evaluation by end users. It also provides flexibility so that physicians are not liable for EHR products that are not interoperable.

Medical Board of California Newsletter, Summer 2015 issue

Free CME Activities on FSMB Opioid Prescribing Policies In collaboration with the Substance Abuse and Mental Health Services Adminisration (SAMHSA), the Federation of State Medical Boards (FSMB) has created learning activities to educate state medical boards and the physicians and other health care providers they license on the FSMB’s updated responsible opioid prescribing and office-based opioid treatment policies. These free CME activities are a valuable resource for physicians seeking education related to opioid addiction as well as the appropriate use of opioid analgesics in the treatment of pain. For more information, contact Kelly Alfred at kalfred@fsmb.org.


CMA Alert, September 21, 2015 issue

California has the most exchange enrollees in the U.S. California has enrolled more people through its Affordable Care Act (ACA) health insurance exchange of any state, with about 1.4 million enrollees as of June 30, according to new federal data. California surpassed Florida – with 1.3 million exchange enrollees as of the end of June – to have the highest exchange enrollment. Nationwide, 9.9 million U.S. residents signed up for the ACA. About 7.2 million consumers purchased coverage through the federal exchange and 2.7 million purchased coverage through state-based exchanges. Of those who purchased coverage in California, 9,302 people who just purchased catastrophic coverage; 350,225 bought a bronze plan; 895,657 bought a silver plan; 74,067 purchased a gold plan; and 64,316 bought a platinum plan. Covered California open enrollment for 2016 begins November 1, 2015, and ends January 31, 2016. For more information on the exchange’s 2016 offerings, go to http://www.coveredca.com/PDFs/7-27-CoveredCA2016PlanRates-prelim.pdf. With so many patients relying on exchange plans for their health care, it is even more critical that physician practices understand their participation status. For help verifying your participation status, see the California Medical Association’s (CMA) “Surviving Covered California” tip sheets.

These documents are available free to members in CMA’s online resource library at www.cmanet.org/resource-library. CMA also continues to monitor the problem of health plan network directory accuracy. Last November, the California Department of Managed Health Care (DMHC) released the results of an audit of the Anthem Blue Cross and Blue Shield Covered California networks. Among other things, the audit found that 12.8% of the physicians listed on Anthem’s network were not accepting Covered California patients, while 12.5% were not in practice at the location listed in Anthem’s directory. In the case of Blue Shield, only 56.7% of the physicians listed in its Covered California directory could be verified as accepting Covered California patients. These inaccuracy rates were consistent with CMA’s and some county medical societies’ own verification efforts and analyses. DMHC will be conducting a follow-up of its audit this fall to determine whether the health plans have resolved their inaccurate network directories. Physicians who are misidentified as participating in a Covered California network when in fact they are not, or whose information in a network directory is inaccurate, are urged to contact CMA’s Center for Economic Services at (888) 401-5911 or economicservices@cmanet.org.

Medical Board of California Newsletter, Summer 2015 issue

Hormonal Contraception Available Without M.D. Prescription As early as October 1, 2015, pharmacists will be able to furnish self-administered hormonal contraception to women without a physician’s prescription in accordance with a protocol approved by the California State Board of Pharmacy and the Medical Board of California. This authority was established by Senate Bill 493 (Hernandez, Chapter 469), which passed in 2013, amending sections of the state’s Business and Professions Code relating to pharmacy. The protocol requires women to fill out a brief health questionnaire to be reviewed by the pharmacist; answers are clarified if necessary. The pharmacist is required to measure and record the patient’s seated blood pressure. If it is determined that a self-administered hormonal contraceptive is not appropriate for the patient, the pharmacist will refer the woman to her primary care provider or a nearby clinic for further evaluation. If the woman is a suitable candidate for

birth control, the pharmacist shall review use of the product with the patient, including dosage, effectiveness, potential side effects, and safety, as well as the importance of receiving recommended preventative health screenings and the fact that self-administered hormonal contraception does not protect against sexually transmitted infections. The pharmacist is required to answer patient questions and provide the patient with informational materials. The new law applies to all hormonal contraceptives approved by the Food and Drug Administration, including oral, transdermal, vaginal, and injection. The pharmacist shall notify the patient’s primary care provider of any drug(s) or device(s) furnished to the patient, or enter the appropriate information in a patient record system shared with the primary care provider, as permitted by that primary care provider. If the patient does not

have a primary care provider, or is u n able to provide contact information for his or her primary care provider, the pharmacist shall provide the patient with a written record of the drug(s) or device(s) furnished and advise the patient to consult an appropriate health care professional of the patient’s choice. For more information, visit the Board of Pharmacy’s website at http:// www.pharmacy. ca.gov.

SEPTEMBER / OCTOBER 2015 | THE BULLETIN | 35


CMA Alert, August 24, 2015 issue

Legislators turn to health community for Medi-Cal solutions Last month, a panel of California legislators listened to health care providers, health advocates, and frustrated recipients of an underfunded health insurance program to get a better idea of how to improve the state’s widely used Medicaid program, Medi-Cal. And, by the end of the hearing, the health community’s solution to the problem was clear: fully fund Medi-Cal. A lack of funding has resulted in decreased access to health care for many Medi-Cal beneficiaries, which has often led to long wait times for appointments or having to travel long distances to receive treatment. “Our state’s abysmally low provider reimbursement rates are having a direct impact on children and families throughout California,” Ruth Haskins, MD, a Sacramento OB-GYN and member of the California Medical Association (CMA), told the legislators. “Hospitals, clinics, dentists, pharmacists, physicians, and even health insurers all agree that the chronic underfunding of the Medi-Cal program remains one of the biggest challenges in health care. And sadly, the evidence of this underfunding is manifesting itself in several ways.” The panel was part of a Governor-ordered special session on health care, which was called to find new solutions to improving the Medi-Cal program, among other things. Currently, physicians are reimbursed roughly $16 for a typical office visit under Medi-Cal, which is far below the cost of providing care. California’s low reimbursement rates rank the state as the third lowest in the country.

“Doctors’ offices simply can’t stay open without setting low limits on the number of Medi-Cal patients that we can serve,” Dr. Haskins said. By fully funding Medi-Cal, the state would increase access to physicians and their practices, while decreasing the amount of crowding in more costly hospital emergency rooms. Fully funding the program would also save money by preventing diseases and conditions that are expensive to treat. One way to provide this funding would be to raise the tobacco tax in the state, which would have multiple benefits. A tobacco tax increase would not only decrease tobacco use, which is the No. 1 cause of preventable death in the country, but generate revenue for Medi-Cal. The tax would also help strengthen California’s legislative efforts to curb cancer, which are currently falling short, according to a new report from the American Cancer Society Cancer Action Network. CMA is part of a broad coalition of health and labor organizations that is committed to raising the state’s tobacco tax. While no action was taken by legislators at the informational hearing, Assemblyman Rob Bonta, chairman of the Assembly Public Health and Developmental Services Health Committee, noted that he will continue to solicit input from experts to find “the most creative, most effective” solutions. “There’s much to be done, as we’ve discussed,” Bonta said, “and very little time to do it.”

CMA Alert, September 8, 2015 issue

Report: high levels of cancer-causing chemicals found during e-cigarette tests The Center for Environmental Health (CEH), a consumer safety organization based in Oakland, has announced it will take “legal action” against electronic cigarette manufacturers after finding cancer-causing chemicals in a number of “vaping” products. CEH said that it is initiating legal action against the companies for failing to warn consumers of the presence of these cancer causing chemicals, as required under California’s strong consumer protection law known as Proposition 65. CEH’s report, “A Smoking Gun: Cancer Causing Chemicals in E-cigarettes,” outlines the first-ever large sampling of actual e-cigarettes and vaping products tested simulating realworld use of the products. The report found that the majority of e-cigarettes tested pose a serious cancer risk—with most of the 97 e-cigarettes

and “vaping” products it tested containing levels of formaldehyde and acetaldehyde that were higher than the state’s safety standards. According to the report, 21 out of 24 companies tested had at least one product that produced “hazardous amounts” of those chemicals. Tests showed that 21 products contained a level of one of the chemicals at more than 10 times California’s standards and seven products contained one of the chemicals at more than 100 times the safety level. “For decades, the tobacco industry mounted a campaign of lies about cigarettes, and now these same companies claim that their e-cigarettes are harmless,” CEH Executive Director Michael Green said in a statement. “Anyone who thinks that vaping is harmless needs to know that our testing unequivocally shows that it’s

36 | THE BULLETIN | SEPTEMBER / OCTOBER 2015

not safe to vape.” Tests results also found “high levels” of formaldehyde and acetaldehyde in nicotine-free e-cigarettes, with one product producing acetaldehyde at more than 13 times the legal safety limit. E-cigarettes — products of an industry that is largely uncontrolled — could face stiffer regulations in California, if legislators decide to pass a current proposal that would regulate the products similar to that of traditional cigarettes. That proposal (SBX2 5), which is strongly supported by the California Medical Association, is currently being mulled over in a legislative special session on health. It passed the Senate on August 27 with a 25-13 vote.


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Pre-register at: http://www.imq.org/education/caprrc.aspx SEPTEMBER / OCTOBER 2015 | THE BULLETIN | 37


MEMBERSHIP

Welcome 126 SCCMA Members Santa Clara County Medical Association Name Sanjay Agarwal Roxanne Almas Carlie Arbaugh Megan Baker Jacqueline Botros John Brock-Utne Mustafa Bseikri Debra Bunger Robert Burns Philip Buss Amanpreet Buttar Lakshmi Bythadka Nataliya Carlson Therese Chan Tack Aditi Chandra Jayaram Chandrasekar Alice Chao Ann Chen Kathleen Chin Jeyling Chou Stephanie Chow Austin Cook Henry Curtis Casey Dart Jacqueline Delyaei Michelle Dinh William Dixon Patrick Do Jeffrey Dorr Sofia Essayan-Perez Kristina Evans Yi-Jen Fong Mollie Friedlander Indira Fulara Thomas Gildea Alexandra Gordon Daniel Greenberg Christopher Gunasekera Tiffany Hackett Anshul Haldipur Michelle Han Jessica Hawkins

City Specialty San Jose US San Jose US Palo Alto US Palo Alto P San Jose US Stanford AN Santa Clara PD Aptos P San Jose IM Mountain View EM San Jose ON San Jose US San Jose OBG San Jose US San Jose US San Jose IM Santa Clara EM San Jose US Santa Clara OBG San Jose OBG Cupertino OBG Stanford US San Francisco EM Sunnyvale EM Santa Clara IM San Jose US Atherton EM San Jose R San Jose R Stanford US San Jose EM Campbell IM Stanford US San Jose US San Carlos EM Palo Alto EM Palo Alto US San Jose IM Danville EM San Jose R Stanford US San Francisco US

Name City Specialty John Horn Pleasant Hill R Kirsten Hornbeak La Jolla US George Hsieh San Jose D Jose Huerta-ibarra Watsonville IM Michael Hwa San Jose US Calvin Hwang Santa Clara EM Brian Ichwan Santa Clara EM Rashad Jabarkheel Jacksonville US Meenakshi Jain San Jose IM Dustin Johnson Santa Clara R Kelly Johnson San Francisco IM Ronald Jou San Jose GS Rajalakshmi Kalimuthu San Jose FP Sean Kanakaraj San Jose US Amina Kim San Jose IM Janet Kim San Jose US Ping-ru Ko Santa Clara NSP Ari Kriegsman San Jose US Padmapriya Krishnamurthy San Jose US Priya Krishnarao San Jose R Kevin Ku San Jose IM Christina Lalani Scottsdale US Randy Liang San Jose IM Jennifer Lin San Jose US Michael Lin Santa Clara FP Colin Little Mountain View EM George Liu Stanford US Jeffrey Liu Mountain View OPH Katie Lorentz San Francisco FP Mingming Ma San Jose R Mark Mamlouk San Francisco R Holly M Thompson Santa Clara NM Shanique Martin Stanford US Robert Miller Sunnyvale R Faisal Mirza San Jose ORS Trupti Nangare San Jose US Supriya Narasimhan San Jose US Carter Neugarten Mountain View EM Jo Ann Nguyen San Jose FP Polina Niedle Santa Clara OBG Sheila Nouchian San Jose US Daniel Orjuela Walnut Creek EM US - Unspecified

38 | THE BULLETIN | SEPTEMBER / OCTOBER 2015

Name Alex Penn Adela Perez Renuka Perla Duyen Pham Maryann Pitts Shawn Quinlan Andrea Quintana Jessica Rainey Whitney Rassbach Navdeesh Reiners Matthew Roosevelt Harleen Sahni Patricia Salmon Rebecca Schneyer Sean Sha Melisa Shah Carolyn Sinow Roopam Sirohi Megan Stephenson Megan Storm Meena Swaminathan Mika Tabata Christopher Takehana Nikola Teslovich Jonathan Tijerina Robin Tittle Stephanie Tjho Bernette Tsai Hwa-te Tsai Aruna Venkatesan Luis Verduzco Christopher Viale Joseph Walsh Carson Welty Stacy Yadava Azita Yavari Elizabeth Yu Eishaa Zaid Susan Zhao Joanne Zhou Alexander Zozula

City Specialty San Jose R Reseda US San Jose US San Jose US San Jose US San Jose OBG San Jose OBG Mountain View EM San Jose AI Santa Clara OBG San Jose FP San Jose FP San Jose END Stanford US Santa Clara IM San Jose IM Palo Alto US Santa Clara HOS Santa Clara FPMRS Palo Alto EM San Jose IM Stanford US San Jose R Stanford US Menlo Park US San Jose FP San Jose OBG San Jose IM San Jose IM San Jose D San Jose AN Monte Sereno AN Campbell IC San Jose PD San Jose OBG Sunnyvale IM San Jose CD Santa Clara OBG San Jose CD Stanford US Santa Clara EM


MEMBERSHIP

Welcome 25 MCMS Members Monterey County Medical Society Name Natalie Aratow-Gallardo Angela Brennan Kristin Burstedt Rohit Chetty Blair Cushing Leah Dahlfred Kanta Dhanda Navneet Kaur Katy Kemeze

City Specialty Salinas US Salinas US Salinas US Salinas US Salinas FP Salinas US Salinas US Salinas US Salinas US

Name Anna Kong Nathaniel Leep Jeffrey Lehr Alexis Lima Sebastian Marchevsky Jennifer Mitchell Megan Moran Mary Pennington Scott Prysi

City Specialty Salinas US Salinas US Monterey A Salinas US Salinas US Salinas US Salinas US Salinas US Monterey GP

Name Ivette Ramos Whitney Rassbach Peter Ro Jacqueline Romero Steven Schumann Bani Singh Judi Wong

City Specialty Salinas US San Jose AI Salinas US Salinas US Salinas FP Salinas US Salinas US

US - Unspecified

Holiday Discount Program For Monterey County Medical Society And Santa Clara County Medical Association Members When it comes to holiday giving, Harry & David offers the finest gourmet delights and handcrafted indulgences. Our baskets, boxes and towers overflow with an impressive array of hand-picked fruit and sweet and savory treats. Each gift is shipped with the strongest guarantee in the business.

Enjoy a 15% discount on gifts priced at $30 and above from October through December, 2015. To take advantage of this offer: • Visit www.harryanddavid.com to select your gifts. • Then call 1-877-456-9900 to place your order. • Let the agent know you are calling for your “Unions and Associations” discount. • Provide this reference code: MH89 For large orders (20 gifts or more), please contact:

Michael Holway, Harry & David Corporate Sales T 877.322.5600 ext. 2 O 541.864.4501 | F 800.523.2290 mholway@harryanddavid.com Please note: Discount does not apply to wine gifts, Cheesecake Factory, Stock Yards, Wolferman’s, or club gifts. Offer cannot be combined with other offers or discounts.

SEPTEMBER / OCTOBER 2015 | THE BULLETIN | 39


Classifieds OFFICE SPACE FOR RENT/LEASE OFFICE SPACE TO SHARE • LOS 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 408/2280454.

MEDICAL SUITES • GILROY First class medical suites available next to Saint Louise Hospital in Gilroy, CA. Sizes available from 1,000 to 2,500+ sq. ft. Timeshare also available. Call Betty at 408/8482525.

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/DENTAL/PROFESSIONAL OFFICE SUITE • SALINAS Second story of professional building across from Salinas Valley Memorial Hospital. Private balcony. Freshly painted and carpeted, ready for occupancy. 1,235 sq. ft. at $0.729/ sq. ft. Rent is $900/month. Contact Steven Gordon at 831/757-5246.

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 marlene@svspine. com.

GATOS

Located adjacent to El Camino Hospital Los Gatos. Beautiful large office. In-house x-ray, 3 exam rooms available on a daily basis and 7 available 2 days/week. Procedure room. Large open reception area with lovely waiting room. One physician consultation office available. Patient and staff restrooms. Lovely break area with refrigerator, dishwasher, microwave, and adjacent patio. Hi-speed internet, outside and inside storage areas. Ample parking. Cost of sublease proportionate to usage. Call 408/378-7240.

OWN YOUR OWN MEDICAL BUILDING • 1,368 SF Plus income from additional multi-tenants. Professional office building (+/- 3,008 SF). Great freeway access to Hwy 17/880, 85 & 280. Pride of ownership building / well maintained. Call Derik for additional information at 408/436-3670.

MONTEREY OFFICE FOR LEASE 2,236 sq. ft., five exam rooms, lab, physician office, two bathrooms, basement storage. Travertine floors and granite counters in waiting room. Overlooks redwoods and stream. Contact owner at 831/277-5645.

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Contact: 408-673-0936 email: binta.patel@zenservices.net www.zenservices.net

40 | THE BULLETIN | SEPTEMBER / OCTOBER 2015

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

INTERNAL MEDICINE PHYSICIAN NEEDED We are looking for an internal medicine physician for our multi-specialty group. Please email your CV to kaajhealthcare@gmail. com.

WANT AN UNHURRIED, SATISFYING RELATIONSHIP WITH PATIENTS? Well-established concierge medicine practice in Santa Cruz, CA seeks Board Certified Family Medicine or Internal Medicine physician to provide periodic/weekend, outpatient, and inpatient coverage. This flexible, part-time position can expand into a position in the practice with own panel of patients. For more information, please contact: Grace Laurencin, MD (mgl@laurencinpp.com).

PRIMARY CARE PHYSICIAN FOR NONPROFIT CLINIC Catholic Charities of Santa Clara County is looking for a Primary Care Physician as a Supervising Physician for a Physician As-


sistant, Nurse Practitioner, and medical interns on Thursdays. Clients include homeless, mental health, and seniors. Contact jobs@catholiccharitiesscc.org.

URGENT CARE PHYSICIANS Are you an ideal Urgent Care doctor? Do you like a fast-paced, diverse work day? Do you prefer a dynamic team approach to care delivery? Are you more inspired by immediate patient care versus building a panel and managing a standard in-basket? Urgent Care medicine may be for you. Some of the current Urgent Care doctors have come to PAMF from emergency room careers, where the all-night shifts impinged on their personal lives. Others prefer the pace and variety of cases each day brings. Palo Alto Medical Foundation (PAMF) has full-time opportunities for Board Certified / Board Eligible Internal, Family, or Emergency Medicine Physicians to join our medical group at the following locations: San Mateo, Santa Cruz, and Los Gatos, CA. Per Diem opportunities are available at our Fremont and Mountain View locations. PAMF physicians are dedicated to excellence and patient-centered care. PAMF seeks UCC doctors who demonstrate the ability to assess and diagnose quickly, exhibit patience and compassion, and possess a commitment to achieving superior clinical outcomes in a friendly, patient-focused setting. Palo Alto Medical Foundation for Health Care, Research and Education is a not-forprofit health care organization dedicated to enhancing the health of nearly one million people in the Bay Area. Our two physician groups consist of 1,300 physicians practicing in primary care and more than 40 medical and surgical specialties. Please contact: Palo Alto Medical Foundation Physician Recruitment Department Phone: 650-934-3582 Fax: 650-691-6193 MDCareers@pamf.org No placement agencies, please EEO - Equal Employment Opportunity

INTERNAL MEDICINE PHYSICIANS Palo Alto Medical Foundation (PAMF) has full-time opportunities for Board Certified / Board Eligible Internal Medicine Physicians to join our medical group at the following locations: Santa Cruz, Fremont, San Jose, Sunnyvale, San Carlos, and Dublin, CA. PAMF physicians are dedicated to excellence and patient-centered care. As a PAMF Primary Care doctor, you will collaborate with a talented team of hundreds of

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

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Contact Lynn (408) 448-9210 lynn@metromedicalbilling.com Visit our Website: metromedicalbilling.com medical specialists in tackling complicated diagnoses, from cancer to cardiovascular care. PAMF offers doctors a resource-rich working environment replete with comprehensive ancillary services including onsite laboratories, digital imaging departments in nearly all of our medical centers, infusion centers, health resource libraries and more. These are shareholder track positions, which offer a very competitive salary guarantee, plus incentive and a generous benefit package leading toward full shareholdership following 24 months of employment. Palo Alto Medical Foundation for Health Care, Research and Education is a not-forprofit health care organization dedicated to enhancing the health of nearly one million people in the Bay Area. Our two physician groups consist of 1,300 physicians practicing in primary care and more than 40 medical and surgical specialties. Please contact: Palo Alto Medical Foundation Physician Recruitment Department Phone: 650·934·3582 Fax: 650-691·6193 MDCareers@pamf.org No placement agencies, please. EEO - Equal Employment Opportunity

FAMILY MEDICINE PHYSICIAN • STANFORD PRIMARY CARE CLINICS Part-time and full-time position for experienced family medicine doctor. Stanford University has nine academic primary care clinics in Santa Clara County and we are looking for experienced physicians interested in teaching or research, and providing high quality care in an academic environment. We have new outpatient facilities with a progressive team approach to patientcentered care. We are offering benefitted, as well as per-diem positions. Contact: Kirsti Weng, MD/MPH at email: kiweng@ stanford.edu.

PRIMARY CARE PHYSICIAN • FAMILY MEDICINE • INTERNAL MEDICINE Asian American for Community Involvement (AACI), a federally qualified health center, is looking for a full-time, bi-lingual (Cantonese, Mandarin, or Vietnamese) Primary Care Physician for our East/West San Jose locations. For consideration, please apply at http://aaci.org/contact/career-opportunities/.

FOR SALE FAMILY PRACTICE FOR SALE Family Practice for Sale. East San Francisco Bay, CA.  Multi-location, multi-discipline practice for the Asian community’s established residents and newcomers. Revenue $1.4 million. Seller works only half-time. The languages spoken by physicians and staff include Cantonese, Mandarin, Punjabi, and Spanish; buyer doctor must be fluent in at least one Chinese dialect. The office also performs sleep studies. EMR in place. High profit margin, and seller will stay to train buyer in proprietary systems. Independent appraisal available. Offered at only $682,000. Excellent seller financing terms available with reasonable down payment. Real estate also available.  Contact info@ MedicalPracticesUSA.com or 800/5766935.  www.MedicalPracticesUSA.com.

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SEPTEMBER / OCTOBER 2015 | THE BULLETIN | 41


REFLECTIONS FROM THE PAST

Archives of Medical Antiquities By Richard Mahrer, MD SCCMA Member since 1955 The pages are somewhat jaundiced with age, but I have kept my 1956 log book from my first year in practice starting July 1, 1956. I was an import from Cleveland with a two year stop at Ft. Hood, Texas, at the kind request of my government, and a final year of internal medicine residency at Santa Clara Valley County Hospital (VMC to more youthful physicians), which was then a rural white stucco cluster of buildings surrounded by large and green lawns studded with palm trees and across the street from orchards of blossoming fruit filling the valley, which then was appropriately named “Blossom Valley.” I started solo practice without help (except for employing an alcoholic nurse with cirrhosis who I “rescued” during my residency, and who said tearfully, she would be delighted to work for me since she had given up all hope of ever being employed again), in the very same office where I still practice after 59 years. Admittedly the old adage, “practice makes perfect,” certainly doesn’t apply to every practitioner, and certainly not to me at age 90, but it has been a long and wonderful ride, but there may not be too many more miles left to go.

Glancing at July, 1956, I saw a total of 135 patients, which included those seen during 38 house calls, and 28 for insurance exams. Not included were patients I saw as a volunteer at the old downtown “emergency clinic.” One and one half hour complete exams in the office were $20.00, and lab (CBC, differential count, urinalysis, and sedimentation rate) was $5.00. House calls were $7.50 – unless I received a cash payment – in which case the charge was $6.00. Routine 30 minute office visits were $5.00, short visits $4.00, sigmoidoscopy, $10.00, hospital visits, $5.00, insurance exams, $7.50 and chest fluoroscopy, $5.00. I worked seven days each week, which included many night calls as well. I paid my nurse $55.00 every two weeks and bought her a car – neither of which kept her from starting to drink again – but that’s another story. My total business for the month was $1,095.00 for which I received $396.00 in payment (No wonder I’m still working!). One elderly gentleman had rectal bleeding and was very dehydrated. I did a sigmoidoscopy at his home and found colon cancer, which despite later surgery ultimately proved fatal a short time later. I even took a small microscope on house calls if I suspected there was a urinary tract infection and was able to see white blood cells on several occasions, which confirmed the diagnosis.

42 | THE BULLETIN | SEPTEMBER / OCTOBER 2015

Most of my patients were from patient referrals or from the “Physicians Exchange” downtown in San Jose, which I visited many times and made friends with the operators – one of whom became my patient. It was the only answering service in town and new patients would frequently call and I received my share of referrals. For example, on Saturday August 4th, I was called by the exchange and asked if I would volunteer to go on board in a National Guard helicopter to rescue an injured hunter who had been accidentally shot in the chest near Mt. Hamilton! Since I like to fly, I accepted the offer, but won’t detail the hazardous five hour trip, successfully landing finally in the O’Connor Hospital parking lot with a wounded patient who miraculously survived. I charged $50.00 for the ordeal since it obviously wasn’t an ordinary house call. Incidentally, the surgical team and hospital were reimbursed. I am still waiting for my $50.00! But the practice finally grew, and although solo practice is now an endangered species, (perhaps I should change the name on the office door to “Jurassic Park Clinic”) it’s been a most rewarding lifetime endeavor!


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