SEPTEMBER / OCTOBER 2016
ALSO INSIDE:
VOLUME 22 | NUMBER 5
CMA INSIGHT ON CALIFORNIA POLITICS
• Physicians Must Post Nondiscrimination Statements by October 19 • Well-Being • MACRA • Telemedicine
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2 | THE BULLETIN | SEPTEMBER / OCTOBER 2016
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
5 Physicians Must Post Nondiscrimination Statements by October 19
CME Tracking
8 CMA Insight on California Politics
Discounted Insurance
10 MACRA Update
Financial Services
12 MACRA: What Should I Do Now to Prepare? A Checklist for Physician Practices
Health Information Technology
14 Well Now: What Humans Need to Flourish
Resources House of Delegates
18 Liability Risks of Telemedicine: State Standards Among Considerations
Representation
20 3 Steps to Responding to Negative Online Comments
Human Resources Services
38 The Team Approach to Successful Breastfeeding and Tongue/Lip: Tie Release
Legal Services/On-Call Library Legislative Advocacy/MICRA Membership Directory APP for the iPhone Physicians’ Confidential Line Practice Management Resources and Education
Departments 6 Message From the SCCMA President 7 Message From the MCMS President 26 Frequently Asked Questions About CURES 27 Physicians Encouraged to Use Care When Advertising
Professional Development
28 CDPH Update Requirements For Reporting Listed Conditions
Publications
29 News 2 Use
Referral Services With
30 MEDICO News
Membership Directory/Website
37 New Member Benefit: PNN/eNews Bulletin
Reimbursement Advocacy/
41 In Memoriam
Coding Services Verizon Discount
45 Classified Ads 46 Welcome New Members SEPTEMBER / OCTOBER 2016 | THE BULLETIN | 3
THE SANTA CLARA COUNTY MEDICAL ASSOCIATION OFFICERS President Scott Benninghoven, MD President-Elect Seham El-Diwany, MD Past President Eleanor Martinez, MD VP-Community Health Cindy Russell, MD VP-External Affairs Kenneth Blumenfeld, MD VP-Member Services Ryan Basham, MD VP-Professional Conduct Vanila Singh, MD Secretary Seema Sidhu, MD Treasurer Anh Nguyen, MD
CHIEF EXECUTIVE OFFICER
COUNCILORS
William C. Parrish, Jr.
El Camino Hospital of Los Gatos: Lewis Osofsky, MD El Camino Hospital: Vacant Good Samaritan Hospital: Vinit Madhvani, 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: Faith Protsman, MD Stanford Health Care / Children's Hospital: John Brock-Utne, MD Santa Clara Valley Medical Center: Clifford Wang, MD
CMA TRUSTEES - SCCMA Thomas M. Dailey, MD (District VII) Tanya Spirtos, MD (District VII)
BULLETIN THE
Official magazine of the Santa Clara County Medical Association and the Monterey County Medical Society
THE MONTEREY COUNTY MEDICAL SOCIETY
Printed in U.S.A.
OFFICERS
Managing Editor Pam Jensen
Opinions expressed by authors are their own, and not necessarily those of The Bulletin, SCCMA, or MCMS. The Bulletin reserves the right to edit all contributions for clarity and length, as well as to reject any material submitted in whole or in part. Acceptance of advertising in The Bulletin in no way constitutes approval or endorsement by SCCMA/ MCMS of products or services advertised. The Bulletin and SCCMA/MCMS reserve the right to reject any advertising. Address all editorial communication, reprint requests, and advertising to: Pam Jensen, Managing Editor 700 Empey Way San Jose, CA 95128 408/998-8850, ext. 3012 Fax: 408/289-1064 pjensen@sccma.org © Copyright 2016 by the Santa Clara County Medical Association.
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President Craig Walls, MD PhD President-Elect Maximiliano Cuevas, MD Past-President James Hlavacek, MD Secretary Alfred Sadler, MD Treasurer Steven Harrison, MD
CHIEF EXECUTIVE OFFICER William C. Parrish, Jr.
DIRECTORS Valerie Barnes, MD David Holley, MD John Jameson, MD William Khieu, MD Eliot Light, MD
Phillip Miller, MD David Ramos, MD James Ramseur, MD Marc Tunzi, MD Raymond Villalobos, MD
Physicians Must Post Nondiscrimination Statements by October 19
The U.S. Department of Health and Human Services (HHS) Office of Civil Rights (OCR) recently finalized new nondiscrimination rules intended to advance health equity and reduce health care disparities. Under the rule, which implements section 1557 of the Affordable Care Act, individuals are protected from discrimination in health care on the basis of race, color, national origin, age, disability and sex, including discrimination based on pregnancy, gender identity and sex stereotyping. This new rule is the first federal civil rights law to broadly prohibit discrimination on the basis of sex in federally funded health programs. It also includes important protections for individuals with disabilities and enhances language assistance for people with limited English proficiency. This rule applies to those who provide or administer health-related services or insurance coverage and receive “federal financial assistance.” Federal financial assistance includes Medicare, Children’s Health Insurance Program, Medicaid, meaningful use payments, HHS grants, Centers for Medicare and Medicaid Services gain-sharing demonstration projects, federal premium and cost-sharing subsidies, etc. The rule does not apply to physicians who participate only in Medicare Part B, unless they are also receiving meaningful use incentive payments. Covered physicians must comply with the following requirements: • Post a notice of nondiscrimination and taglines in the top 15 languages spoken by individuals with limited English proficiency • Develop and implement a language access plan • Designate a compliance coordinator and adopt grievance procedures (applicable to group practices with 15 or more employees) • Submit an assurance of compliance form to OCR Physicians should note that in addition to administrative enforcement mechanisms, such as loss of federal financial assistance, individuals are permitted to bring individual or class action violation claims directly against physicians in federal court. To assist with implementation, OCR has translated into 64 languages a sample notice and taglines for use by covered entities. In addition, OCR has published a summary of the rule, factsheets on key provisions and a list of frequently asked questions, all available at http://www.hhs.gov/civil-rights/for-individuals/ section-1557. The California Medical Association (CMA) has sought guidance from the California Department of Health Care Services to determine what languages California physicians must post for the nondiscrimination notice. As additional information becomes available, CMA will provide more detailed instructions about how physicians may comply with this rule. SEPTEMBER / OCTOBER 2016 | THE BULLETIN | 5
President, Santa Clara County Medical Association
SCOTT BENNINGHOVEN, MD
MESSAGE FROM THE
SCCMA PRESIDENT
Become an “Active” Member of the SCCMA
Scott Benninghoven, MD is the 2016-2017 president of the Santa Clara County Medical Association. He has a general surgery practice in the South County and practices at Saint Louise Regional Hospital, Regional Medical Center of San Jose, as well as O’Connor and Good Samaritan Hospitals.
Physicians have a well-deserved reputation for providing care for our patients to improve their lives. This is done on many levels and in many venues. The obvious is in direct patient “face-to-face” contact as Medicare defines it. This is how our patients see it and remember us. This is the simplest, and before I became involved in SCCMA, the only way I was aware we helped our patients. Yes, I was aware of epidemiology and population-based healthcare, but that is done in far-off offices and certainly not related to my patients. Those beliefs were naive and short sighted, but my previous beliefs are not the subject of this article. Physicians who treat patients on a daily basis can, and I believe should, make a difference in our patient’s lives far beyond just that ‘’simple” encounter. There are a multitude of ways that are within the time and energy of almost every physician in the SCCMA. Our CEO, Bill Parrish, along with many key physicians, have done a remarkable job in bringing our county’s active membership to over 4,000 physicians. But what does “active” mean? I would ask you to use the organization and resources of SCCMA, and by extension the CMA, to improve the health of your patients and community in a way that they will never know, but may be the most important “care” you provide. The changes that we make now affect how our children’s physicians may care for them decades from now. I challenge you to go to the next step and make healthcare a better place for our patients. You can do this in several small ways that can have a big impact. 1. Become involved in Proposition 56. The CMA has a webinar that is free and available on how to be an advocate for the Yes on 56 campaign. This proposition is to increase the cigarette tax by $2 and, proportionately, other tobacco containing products. The purpose is to decrease cigarette and electronic cigarette use, especially by our children. Nearly 17,000 children under 18 will get hooked on tobacco products, first as e-cigarettes, and one-third of them will die due to a tobaccorelated illness. This Prop 56 intends to
6 | THE BULLETIN | SEPTEMBER / OCTOBER 2016
change that by taxing tobacco, which has been shown to reduce the number of current and new cigarette smokers. The revenue from this tax, which is only paid by smokers, will help offset some of the $3.5 billion spent for treatment of tobacco related illnesses and work toward smoking cessation. Physicians across this state showed, in 2014, that we could stop Proposition 46 by becoming involved and talking to our patients one on one. We can do it again by becoming involved, educated, and spending one minute with each patient explaining Prop 56 and asking for their yes vote. 2. Taking a day and traveling to Sacramento on Legislative Day, usually the third Tuesday in April (on April 18, 2017 this next year) is one of the best ways to become involved in regulatory and the political process. The decisions made this year by the legislature will impact our state healthcare for decades to come. This day is set aside to allow Santa Clara County physicians to join with physicians from across the state to meet in Sacramento. We get a chance to hear about upcoming bills and, my favorite, to meet with our local state legislators to discuss those bills that are important to us. The personal relationships with our legislators built over the years are incredibly important when it comes to influencing health care policy. 3. Becoming a member of the House of Delegates (HOD), which is the policycreating arm of the CMA, is the best way to meet fellow physicians from around the state. There are represenatives (delegates) from each designated area of the state (districts). Policy created at the HOD determines how the CMA will represent us in the legislature until the HOD changes that policy. Some policy is very specific and affects a small number of physicians
Continued on page 44
President, Monterey County Medical Society
CRAIG A. WALLS, MD
meetings with administrators, C-suite types, community leaders, politicians and Quality Department staff. Yesterday, one of my residents sat with two of my credentialing experts and walked through every step of the exhaustive process to confirm the credentials and the facts of a medical staff application. What an eye-opener! Have you performed a criminal background check recently? Our residents attend board meetings. Do you think board meetings are boring? Try sitting in a board meeting where you are the topic of discussion – then get back to me. Let me ask you seasoned and salty old docs this: Do you know how much work is generated by a physician’s brief lapse in professionalism such as a rude comment to a staffer? Have you ever thought about how much your administrators get paid to discuss, document, counsel, action-plan, review, and report such a lapse? Hopefully the residents who see this process learn to steer away from that particular whirlpool. Empowering residents (and faculty) to bring meaningful change to their work environment now and into the future is one of the expressed goals of the rotation. There are multiple objectives to this rotation and there is a lot of work expected. But most of that work, I would imagine, comes as a refreshing break from the clinical duties of a resident. They liaise with preceptors, observe committees (seeing how the sausage is made), identify and connect with a mentor, keep a journal, and write an essay. This all in addition to selected readings regarding the history of health insurance in America, care for the underserved, professionalism, the patient-centered medical home and healthcare management. Come to think of it, I wonder if they would let me take the rotation?
MESSAGE FROM THE
Where I work I have the great pleasure of working with resident physicians. Residents are terrific reminders of what we wanted to be and who we are. I hope those things are the same for you and for me. Emergency physicians did not choose their specialty with a dream of aspiring to practice management and hospital/clinic administration. While sweating in the trauma bay in the wee hours of the morning, we were not hoping to go to a utilization review meeting. Neither did surgeons or pulmonologists or any clinicians that I know of aspire to practice management. We imagined ourselves taking care of patients to the exclusion of all other duties. How adorably naïve we were. No physician provides care in a vacuum. We are all subject to the clinical and operational environment that swirls around us and constitutes the sea we swim in. Your slit lamp is broken and your next patient was grinding a metal pipe fitting with his Dremel when he had a sudden eye pain. The nearby correctional facility sent you a suicidal patient who cannot be placed on a psychiatric hold while legally in custody. You send your beloved patients to an Emergency Department expecting them to be admitted and instead they are transferred. While providing care for underserved patients, you cannot generate the revenue you need to pay the rent on your office space. I could go on. You could go on. Physicians bemoan the unfunded mandates and the hypertrophy of compliance and the bullying of risk. We can do more than moan. It almost seems that our society would prefer we care for our patients with one hand tied behind our back. Our culture knows you are a cardiologist and hands you half a stethoscope. We let the family doctor take the x-ray, but we do not let her look at it. It is enough to make us think of retirement or career change or worse. Our brilliant residency faculty has embraced these contradictions, and they are inoculating our young physicians against the ravages of careershortening sociomedical dissonance. Our residents now take a Practice Management rotation where they get exposed to the many streams that make up the rapids of a medical career. Our residents spend time shadowing leaders in their hospital administration. They take part in
MCMS PRESIDENT
Practice Management Resident Rotation
Craig A. Walls, MD, is the 2016-2017 president of the Monterey County Medical Society. He is an Emergency Medicine doctor with the California Emergency Physicians Medical Group and is currently practicing with Natividad Medical Center in Monterey.
SEPTEMBER / OCTOBER 2016 | THE BULLETIN | 7
CMA CAPITOL INSIGHT An insider’s report on California politics
November Ballot Rundown
California’s ballot has evolved into an impressive – and daunting – laundry list of policy proposals, running the gamut of fiscal and social policy. While the 17 measures on the ballot are not a statewide record, many of the state’s hotbutton political issues – including health care, guns, criminal justice and environmental protection – will all be decided by voters this fall.
By Anthony York Veteran Journalist
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Tax measures loom large this year, with Propositions 55 and 56. Prop. 55 would extend the state’s income tax rates on top earners, which were initially instituted in 2012 when voters approved Prop. 30. Prop. 56 would implement a new $2-per-pack increase of the levy on tobacco products to help raise money for Medi-Cal and other important health-related services. The tax is supported by the California Medical Association (CMA), Democratic mega-donor Tom Steyer, and the state council of the Service Employee International Union (SEIU). This ballot has a little something for everyone – from taxes to transparency to new regulations for the porn industry. We’ve got price caps and bag bans, guns and cannabis, and that’s all before you get to any of the candidates for federal, state and local office. Here is a rundown of the ballot proposals, broken down by subject matter:
HEALTH CARE
Prop. 52 (CMA supports) would lock in hospital fees to allow the state to draw down federal health care funds. While that is a non-controversial measure, another health-related proposal could be the most costly of the election fights this year. And that’s saying something. Prop. 61 (CMA opposes) would cap prices the state could pay on prescription drugs. The pharmaceutical industry has already raised more than $60 million to fight the proposal. While the proponents will be massively outspent, the idea of price caps has polled well among California voters. CMA maintains that Prop. 61 would likely increase – not lower – state prescription drug costs. Legislative vehicles, like SB 1010, provide real reforms to protect consumers and lower drug costs. Prop. 56 (CMA supports) falls into both the health care and tax categories. The measure would raise per-pack taxes on cigarettes and other tobacco products by $2 to $2.87. The money would be used to shore up Medi-Cal and provide other health care services.
TAXES
The larger tax measure is Prop. 55 (CMA supports), which extends the state’s higher income taxes for those earning more than $500,000 per year. Billed as a way to fund schools, projections from the governor’s office show the state running future budget deficits if the measure is not approved.
EDUCATION
Despite opposition from Gov. Brown, who has indicated that school bonds should be left to local governments, Prop. 51 would authorize $9 billion in state borrowing to dedicate to school construction projects. The proposal has bipartisan support, with major funding coming from developers, as well as backing from education groups. Prop. 58 (CMA supports) would overturn Proposition 227, the “English Only” initiative passed by state voters in 1998. The fact that this is not a hot-button issue this cycle is a sign of just how much has changed in California politics over the last two decades.
ENVIRONMENT
The two environmental proposals on the ballot are tied to the legislature’s passage of a ban on single-use plastic bags in 2014. Many local governments have already passed similar bans, and more than half of all Californians live in places that have local bag bans in effect. Prop. 67 would overturn the statewide ban, while Prop. 65 would
require grocery stores to direct paper bag sale proceeds toward environmental fund instead of allowing stores to pocket the money. Grocers were a major backer of the 2014 legislation, and Prop. 65 is seen largely as political retribution from the plastic-bag industry.
PUBLIC SAFETY
Prop. 57 is the criminal justice reform package backed by Gov. Jerry Brown. The measure would allow for earlier parole for non-violent offenders and give judges more latitude in deciding whether or not to try juvenile offenders as adults. Prop. 60 would require adult film actors to wear condoms during sex while filming. Prop. 63 (CMA supports) is the gun-control measure backed by Lt. Gov. Gavin Newsom. Newsom, who is a candidate for governor in 2018, has been heavily engaged on the guns issue and is a staunch supporter of the cannabis legalization initiative. Backed by the California Academy of Preventive Medicine and others, Prop. 64 (CMA supports) would regulate and control the cultivation and use of non-medical cannabis. The proposal would raise up to $1 billion in taxes for state and local governments, according to a fiscal analysis of the proposal.
DEATH PENALTY fall.
Californians will have two chances to vote on the death penalty this
Prop. 62 ends the death penalty in California, making life imprisonment with no parole the strongest possible sentence. This would be a smidge of poetic justice for students of California history, since the death penalty issue was among the most controversial in Jerry Brown’s first stint as governor. The issue led to the electoral defeat of three of Brown’s state’s Supreme Court justices, including Rose Bird. Prop. 66 would preserve capital punishment and attempt to speed up judicial review of death penalty cases.
GENERAL GOVERNMENT
Prop. 53 (CMA opposes) would change the law to require voter approval for state revenue bonds of $2 billion or more. The measure, backed by wealthy Central Valley agribusiness executive Dean Cortopassi, is seen as an effort to stifle Gov. Brown’s plan to build two massive new tunnels to divert water from the Sacramento-San Joaquin River Delta to Southern California. The water project is one of the major legacy infrastructure projects being pushed by the governor. Prop. 54: Backed by wealthy Republican donor Charles Munger Jr., this measure would change the way the state legislature does businesses. The proposal is an effort to end the last-minute writing of legislation, requiring any bill to be in print for 72 hours before it is approved by state lawmakers.
CAMPAIGN FINANCE
Prop. 59 holds no legally binding authority. The measure is simply a way for Californians to voice their displeasure about Citizens United, the Supreme Court decision that paved the way for increased corporate participation in electoral politics. This measure urges the court to reconsider that decision, and change our nation’s campaign finance laws. CMA Capitol Insight is a biweekly publication for members of the California Medical Association.
SEPTEMBER / OCTOBER 2016 | THE BULLETIN | 9
CMS Eliminates Penalties for First Year of MACRA and Offers “Pick Your Pace” Options The Centers for Medicare and Medicaid Services (CMS) announced on September 8 that it will allow physicians to choose the level and pace at which they comply with the new MACRA Medicare payment reforms. Participating at any level in 2017 will ensure that you will not be hit with payment penalties in 2019. The welcome announcement comes after the California Medical Association (CMA), American Medical Association (AMA) and other physician stakeholders urged CMS to ease the burdens and delay the first MACRA reporting period to give physicians more time to prepare. MACRA (the Medicare Access and CHIP Reauthorization Act of 2015) repealed the flawed sustainable growth rate payment system, and established two payment paths: 1) A fee-for-service path that consolidates the current reporting programs under the Merit-Based Incentive Payment System (MIPS) and 2) an Alternative Payment Model (APM) path. CMS will begin measuring performance for eligible clinicians in 2017, with payments based on those results beginning in 2019. Under the MIPS fee-for-service program,
the most lenient participation option would allow physicians to simply “test” the program to ensure that their systems are working and that they are prepared for broader implementation in 2018 and beyond. While physicians who choose this option will not receive bonus payments, they will avoid a negative penalty. Under the second option, physicians can opt to submit data for less than the full reporting year. While CMS has not yet specified the timeline, CMA believes the 2017 reporting period could be only 90-180 days. Physicians who choose this option would not only avoid a negative payment adjustment, but could receive a small bonus. Physicians can still choose, if they are ready, to report a full year of data under MIPS in 2017 and be eligible to receive a modest bonus, depending on their performance. The APM program is largely exempt from the MIPS criteria. Details about the participation options will be described fully in the final rule that will be published November 1. CMA will provide additional information when available.
10 | THE BULLETIN | SEPTEMBER / OCTOBER 2016
MACRA Education and Assistance for Physicians
CMA has created a MACRA Resource Center on the CMA website www. cmanet.org/MACRA . In addition to providing CMA information, it contains links to the CMS information, extensive AMA resources, including the STEPS Forward program, and additional resources provided by the national specialty societies, with information about their clinical data registries. CMA will continue to provide webinars, education, information, tools and resources, and assistance to help practices prepare for MACRA. CMA will continue our extensive regulatory and legislative advocacy to continue to improve MACRA for the practicing physician.
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MACRA: What Should I Do Now to Prepare? A Checklist for Physician Practices Prepared by CMA’s Center for Economic Services Wondering where to start? There are some critical first steps that physicians should take to prepare for MACRA implementation. The most important step is to get educated about MACRA. Some specific actions to consider include: LEARN THE BASICS OF MACRA Under the MACRA proposed rule, there will be two main, pathways for physician reimbursement, the Merit-Based Incentive Payment System (MIPS) and Alternative Payment Models (APMs). For an overview on the two pathways, download AMA’s MACRA Action Kit (see page 5), which also includes a checklist (see page 2). Also, watch the California Medical Association (CMA) webinar titled, “What Is MACRA? What Is CMA Doing to Improve It? What Steps Can You Take to Prepare Now?” and the Centers for Medicare & Medicaid Services (CMS) webinar, “MACRA and the Quality Payment Program: An Update on the Recent Proposed Rule.” The webinars will allow you to view at your own pace and will give you the basics of MACRA. Both webinars can be found in the MACRA resources section of the CMA website (www.cmanet. org/macra). AMA’s MACRA Action Kit: https://download.ama-assn.org/ resources/doc/washington/16-0384-advocacy-macra-action-kit. pdf
REMEMBER THAT THIS IS A PROPOSED RULE AND IS NOT FINAL CMS issued its proposed rule on April 27, 2016, and received many comments from interested stakeholders, including CMA. The final rule is expected on November 1. CMA encourages practices to get ready, but to remember that the details are subject to change. To read CMA’s comprehensive comments to CMS outlining constructive improvements to MACRA, visit the MACRA resource section of the CMA website (www.cmanet.org/macra). There you will also find a link to AMA’s extensive comments.
DETERMINE WHETHER YOU ARE EXEMPT FROM MIPS PARTICIPATION The proposed rule exempts practices from MIPS if they have a low volume of Medicare patients. This threshold is defined as $10,000 or less in Medicare billed charges and 100 or fewer Medicare patients annually. Physicians in their first year of Medicare participation are also exempt.
DETERMINE WHETHER YOUR PRACTICE MEETS THE REQUIREMENTS FOR SMALL, HPSA, OR NON-PATIENT FACING PHYSICIAN ACCOMMODATIONS AND EXCEPTIONS The proposed rule provides accommodations and additional flexibility for various practice sizes and configurations. See the 12 | THE BULLETIN | SEPTEMBER / OCTOBER 2016
CMS Small Practices Fact Sheet for more information. CMS Small Practices Fact Sheet: https://www.cms.gov/Medicare/Quality-lnitiatives-Patient-Assessment-lnstrumentslValueBased-ProgramsIMACRA-MIPS-and-APMs/Small-PracticesFact-Sheet.pdf
PARTICIPATE IN PQRS IN 2016 Whether your practice ends up participating in MIPS or APMs, there will be a quality reporting component. If you haven’t yet successfully participated in CMS’s Physician Quality Reporting System (PQRS), try again in 2016. CMS has created a 2016 PQRS Implementation Guide that includes a beginner reporter toolkit to help get you started. You’ll gain familiarity with the reporting process and will have access to view your PQRS feedback reports, which can help to guide practice improvements under MACRA. CMS 2016 PQRS Implementation Guide: https://www.cms. gov/Medicare/Quality-lnitiatives-Patient-Assessment-lnstruments/PQRS/How_to_Get Started.html
REVIEW QRUR REPORTS TO IDENTIFY WHERE IMPROVEMENTS CAN BE MADE CMS publishes a mid-year and annual Quality and Resource Use Report (QRUR) to help practices understand their cost and quality assessments under the Value Modifier and quality under PQRS. To access your practice’s QRUR report, visit the CMS Enterprise Portal. One person from the practice will need to obtain an Enterprise Identity Management System (EIDM) account. For more information on setting up an EIDM account, visit the CMS website. CMS Enterprise Portal: https://portal.cms.gov/wps/portal/ unauthportal/home/ CMS Website: https://www.cms.gov/Medicare/MedicareFee-for-Service-Payment/PhysicianFeedbackProgram/Obtain2013-QRUR.html
REVIEW PROPOSED MEASURES AND DETERMINE HOW YOU WILL REPORT Decide which measures will work for your practice and how you will report the data to CMS. For more information on the proposed individual quality measures for MIPS, see Tables A – G on pages 28,399 – 28,569 of the proposed rule. Proposed Rule: https://www.gpo.gov/fdsys/pkg/FR-2016-0509/pdf/2016-10032.pdf
Under MIPS there are four reporting categories that allow for different reporting mechanisms: through claims, electronic health records, clinical registry, qualified clinical data registry or the group practice (25+ physicians) reporting option web interface. For more information on reporting mechanisms, see CMS’s “The Merit-Based Incentive Payment System (MIPS)” slide deck (begins on slide 43). CMS’s “The Merit-Based Incentive Payment System (MIPS): https://www.cms.gov/Medicare/Quality-lnitiatives-Patient-Assessment-Instrumentsl/Value-Based-Programs/MACRA-MIPSand-APMs/Quality-Payment-Program-MIPS-NPRM-Slides.pdf
patients in 2017. • For a complete list of the proposed ACI categories, see Table 6 on pages 28,222 – 28,226 of the proposed rule (with additional information in Section II.E.5.g.7). Proposed Rule: https://www.gpo.gov/fdsys/pkg/FR-2016-0509/pdf/2016-10032.pdf
CONDUCT A SECURITY RISK ANALYSIS IN EARLY 2017
If you are not already participating in a qualified clinical data registry, contact your specialty society about participating in theirs. Data registries are a method of reporting that can assist reporting in three of the four MIPS categories. Qualified Clinical Data Registry: https://www.cms.gov/Medicare/Quality-lnitiatives-Patient-Assessment-lnstruments/PQRS/ Downloads/2016QCDRPosting.pdf
Failure to do so will result in a score of zero for the ACI category. The risk analysis should comply with the HIPAA Security Rule requirements. For more information on conducting a HIPAA security risk analysis CMA members have free access to our ondemand webinar, “HIPAA Security Risk Analysis: How to Make Sense of this Requirement” available on our website at www.cmanet.org/webinars. Additional information can be found in CMA On-Call Document #4102, “HIPAA Security Rule,” also free to CMA members in the online health law library at www.cmanet. org/cma-on-call. The American Medical Association (AMA) website also has resources to help with this step at www.ama-assn.org/ go/hipaa.
EVALUATE EHR AND VENDOR READINESS – IS YOUR EHR CONSIDERED CERTIFIED EHR TECHNOLOGY (CEHRT)?
VIEW AMA’S STEPS FORWARD PRACTICE TRANSFORMATION SERIES LEARNING MODULE
CONSIDER PARTICIPATING IN A QUALIFIED CLINICAL DATA REGISTRY
Make sure your EHR is certified. To see which EHR systems are CEHRT, see the CMS website. CMS website: https://www.cms.gov/regulations-and-guidance/legislation/ehrincentiveprograms/certification.html
TALK WITH YOUR EHR VENDOR ABOUT HOW ITS PRODUCT SUPPORTS TRANSITION TO MIPS Find out whether your vendor will meet Medicare MIPS quality reporting requirements or new payment model adoption. Are there any costs associated with needed updates? Ask about timelines for MACRA readiness and interoperability. Document the conversations.
REVIEW CMS’S LIST OF CPIA Determine which clinical practice improvement activities (CPIA) your practice is already doing and what adjustments need to be made to complete additional activities by 2017. For a list of high weight CPIA categories, see Table 23 on pages 28,263 - 28,265 of the proposed rule. For a complete list of proposed CPIA, see Table H on pages 28,570 - 28,586 of the proposed rule. Proposed Rule: https://www.gpo.gov/fdsys/pkg/FR-2016-0509/pdf/2016-10032.pdf
CONSIDER WAYS YOUR PRACTICE CAN REPORT AT LEAST ONE UNIQUE PATIENT FOR EACH ADVANCING CARE INFORMATION (ACI) MEASURE ACI will replace the EHR incentive program. Practices should ensure they can report at least one unique patient (or answer “yes”) for each measure of the base score’s six objectives. Ideas (for 2017) include: • Reach out to existing patients to encourage use of the patient portal. • If your EHR allows you to send a secured message through your patient portal to all of your patients at once, you might consider sending an appointment reminder to all of your
To help practices make the shift to value-based care, AMA has created the STEPS Forward learning module. The module includes five steps to prepare a practice for value-based health care, answers to common questions and case vignettes describing how physicians can create value-based practices. AMA Steps Forward Learning Module: https://www.stepsforward.org/modules/value-based-care
CONFIRM WHETHER YOU ARE A PARTICIPANT IN ANY OF THE ADVANCED APMS ALREADY APPROVED BY CMS For a list of the CMS-approved advanced APMs in the proposed rule, see Table 32 on page 28,312. Proposed Rule: https://www.gpo.gov/fdsys/pkg/FR-2016-0509/pdf/2016-10032.pdf
STAY UP-TO-DATE ON MACRA RELATED NEWS • Sign up to receive CMS MACRA email updates (https:// public-dc2.govdelivery.com/accounts/USCMS/subscriber/ new?topic_id=US-CMS_12196) • Sign up to receive Medicare news directly from CMA through content update alerts. By doing so, you will be notified anytime a new story about MACRA is posted to our website. To do so, just activate your web account (if you haven’t already done so) and sign up for custom content alerts on the topics that are of interest to you. You will then be notified any time there is new content posted in one of your interest areas. To do so, 1) Click on “My Account,” 2) In the left sidebar, click on “My Alerts,” 3) Under New Content Alerts, click “Alert Settings,” 4) Type “Medicare” in the search box and hit enter. You can adjust the frequency and format that you receive alerts via the account dashboard. For more information, see www.cmanet.org/custom-content.
CHECK CMA’S MACRA RESOURCE CENTER AT WWW.CMANET.ORG/MACRA FOR UPDATES! For additional information on steps you can take now to prepare, see the AMA MACRA checklist (pages 2-3). SEPTEMBER / OCTOBER 2016 | THE BULLETIN | 13
S TRI V E, THRI V E AN D TAK E FI V E The science of well-being
WELL NOW
WHAT HUMANS NEED TO FLOURISH
Plug “wellness” into a search engine and you’ll get 405 million hits — and a lot of advice. Everyone, from genuine experts to click-bait writers, has an opinion about what’s good for us.
We are told to strengthen our willpower, but indulge ourselves; exercise, but not too much; go vegetarian, but eat more meat; develop our social network, but indulge in more “me time;” have great sex, but not too much; safeguard our financial health, but spend our money on travel that leaves memories; keep our minds active, but empty our minds and meditate; volunteer; forgive; and be grateful. “There’s been a lot of ‘expert speak’ on the concept of what it means to be well,” says associate professor of psychology and of medicine Catherine Heaney, PhD, who is leading a team at Stanford that has been working to define and measure wellness. “What there has been less of,” H eaneysays, “is going to ordinary people and trying to get a sense of what being well means to them.” People long for a sense of well-being. For thousands of years, everyone — from philosophers such as Aristotle, Epictetus and Buddha to the smooth-talkingest snake-oil salesmen — have tugged at the problem of what makes for a good life.
By Jennie Dusheck Republished with the permission of Stanford Medicine magazine, http://stanmed.stanford.edu
14 | THE BULLETIN | SEPTEMBER / OCTOBER 2016
SEPTEMBER / OCTOBER 2016 | THE BULLETIN | 15
Researchers at UC-Berkeley’s Greater Good Science Center, for example, report six major underpinnings of happiness, one component of wellness: compassion, friendship, gratitude, forgiveness, exercise, and mindfulness. Private foundations, including the Charles Koch Foundation, have taken an interest in funding well-being research. Even governments have gotten into the act. In 2008, a commission of economists assembled by Nicolas Sarkozy, the president of France, called for the development of broader measures of national well-being. Two years later, the United Kingdom did the same. But what does it mean to be well? If we want to promote wellness for everyone, we have to, first, be able to say exactly what it is and, second, devise rigorous ways of measuring whether it is increasing or decreasing. Once we can measure it, we can begin to discover which factors promote it or diminish it. In this way, an ambitious Stanford project aims to tackle anew an age-old question.
THE PATH TO WELLNESS In 2014, the Stanford Prevention Research Center launched the WELL program — its ultimate goal, to improve the health and wellness of whole populations. WELL, the Wellness Living Laboratory, emphasizes research on overall health rather than the absence of disease. Funded by an unrestricted $10 million gift from the Amway Nutrilite Health Institute Wellness Fund, WELL proposes to identify what factors help people maintain health and wellness and to develop techniques to help people to change their lifestyles. The center’s WELL for Life program is both an observational study and an interventional study. WELL will observe more than 30,000 people over many years and also test behavioral modification and other interventions to help people make health improvements such as quitting smoking, eating better, or exercising more. The center’s health promotion arm, the Health Improvement Program, will enable the techniques to reach the wider population. “This is an effort to change the world of medicine and health,” says John Ioannidis, MD, DSc, professor of medicine and of health research and policy, who directs the center. “It may sound very ambitious, but I see this as a way to refocus the key priorities of biomedical research. “The vast majority of biomedical research has focused on treating diseases,” he says. “A much smaller part has focused on maintaining health and maybe some prevention efforts. But there’s very, very little research that has tried to look at the big picture — what makes people happy, resilient, creative, fully exploring their potential and living not only healthy, but more-than-healthy lives.” Among the things the WELL team wants to know: Is wellness the same for everyone, or do factors like gender or age influence how we perceive it? For example, among young adults, wellness might revolve around finances, career and athleticism. But as we age, social connectedness and resilience to stress may become more important drivers of our sense of how well we feel. “We want to determine not only what makes people feel that they have a higher level of wellness, but also interventions that would help it,” says Ioannidis. “So we want to ask not only what is the profile of someone who feels good about their life, but how can we make that profile better? “And how can we intervene with simple means — things that we do in everyday life — not with drugs or devices or complex procedures in the hospital?” “We know that a person’s ability to move more, to sit less, and to eat healthfully are influenced by their environment. This includes social relationships, neighborhoods, and public policy,” says Abby King, PhD, professor of medicine and of health research and policy, who studies what’s needed for healthy behavior change. “It’s about helping people make connections between their own pursuit of well-being and their health,” explains Heaney. Maybe for some people, making a better life for their children is more motivating than reducing their risk of a heart attack in the distant future, she says. Once a doctor knows what motivates patients, it may be possible to harness that in the service of patients’ well-being and physical health. During the first five years, the 30,000 participants — 10,000 each in China, Taiwan and the United States — will supply mountains of personal health infor16 | THE BULLETIN | SEPTEMBER / OCTOBER 2016
mation, ranging from general health and lifestyle information to genetic and other biological markers, says Sandra Winter, PhD, director of WELL. And it’s likely WELL will expand to other countries in the future. Each of the thousands of participants will periodically answer scores of questions such as, “During the last two weeks, did your diet, physical activity, and sleep habits influence your well-being?” or “How confident are you that you can bounce back quickly after hard times?”
LISTENING WELL How do you ask people meaningful questions about a concept as fuzzy as wellness? To create an accurate vocabulary of wellness, trained interviewers sat down with more than 100 people from Santa Clara County and listened to their stories. Demographically representative of this diverse area, the 100 included men and women, young and old, and a variety of ethnic groups. Similar efforts took place in China and Taiwan. Tia Rich, PhD, WELL senior research assistant, interviewed half of the Santa Clara County participants. She asked them to talk about a time of peak wellness, a time of low wellness and, finally, their current state. In each case, she also asked them to describe all aspects of their life that they wanted to share regarding each level of wellness. And then Rich listened. The conversations lasted anywhere from 30 minutes to two hours. “The process of listening to 50 people share their life stories was extremely meaningful. It was really an honor to be trusted in that way,” she says.
THE DOMAINS OF WELLNESS After transcribing the Santa Clara County interviews and sorting the responses almost line by line into categories, Heaney’s team identified 10 domains of wellness that people most commonly mentioned: • Social connectedness • Lifestyle behaviors • Stress and resilience • Emotional health • Physical health • Meaning and purpose • Sense of self • Finances • Spirituality or religiosity • Exploration and creativity For these interviewees, having a social network was the single largest driver of wellness. Being integrated into a social network, having opportunities to receive support and companionship, feeling loved and feeling a sense of belonging, and also having others in your social network doing well is what most enhances wellness, said the interviewees. As one put it, “If my family is doing well, I will be doing well.” But having a social network can be as much a burden as a comfort. “When people in your social networks are not doing well or when they act in ways that are socially undermining,” says Heaney, “that detracts from our sense of well-being.” It’s important to manage our social connections so they contribute more than they detract. “It’s like the old saying,” she laughs, “When you’re a parent you can never be happier than your least-happy child.” So, ultimately, we need to find ways to support those we love while remaining somewhat stoic about their problems, so our own well-being doesn’t decline, too. The second major domain was lifestyle behaviors such as eating well and getting plenty of sleep and exercise. People looked back on times when they were engaging in healthy behaviors as times of great well-being, says Heaney. As one interviewee reported, “I’d been outside all summer long just doing labor. I mean, sometimes you dig ditches, and sometimes you’re pruning Mrs. McGillicuddy’s pansies. Whatever it is, you’re outside all day long, which really nourishes the animal, I’m here to say. And I remember my mother, for some reason we were driving along, and I said, ‘I’m at the peak of my physical health.’”
WELLNESS AND RESILIENCE The team also found that stress and resilience to stress were important factors in wellness. Major changes, such as a divorce or moving from another country, were especially likely to induce stress. But participants also spoke with pleasure about how well they had coped during a difficult time. One interviewee said, “Even the worst of times, even the most difficult of times, there’s always been light and strength, and that is because I have a very rich inner life. And in the end, I have hope.” Some people can adapt to the most dire of circumstances. In her book The Pursuit of Happiness, Carol Graham, PhD, an economist and a senior fellow at the Brookings Institution who studies happiness and well-being, reports that even though poor people around the world are less happy than the wealthy, some of the poorest often report high well-being. Even those with serious illness may report a sense of well-being. “I was surprised by the extent to which people did not talk about illness,” Heaney says. People who had cancer might not even mention it in the context of their well-being. “Having an illness or not having illness was not what was important. What was more important was the experience of it and the extent to which a person felt like they were managing or coping. “People would actually say, ‘Yeah, you know, a time of particularly high wellbeing for me was when I was diagnosed with heart disease,’ ” says Heaney. “And you’re like, ‘What?’ ” But they would then go on to say, ‘Yeah, because I learned how resilient I am. I learned how strong I am. I have come out of that a better person and I learned what matters to me.’ ” The last five domains, which came up less often, included having a sense of meaning and purpose, which could encompass accomplishments or, alternatively, a sense of why we are here; a sense of self (a measure of confidence and self-esteem); financial comfort; spirituality; and, finally, exploring (or pioneering) and creativity.
BUILDING THE QUESTIONNAIRE Using the 10 domains, Heaney and her team wrote 72 questions designed to probe people’s experiences of wellness. The questionnaire is already online for a small test group of WELL participants, and ultimately it will be available for all 10,000 U.S. participants. Participants are asked, for example: During the last two weeks, how often did you feel... ... that you were very capable?
... that you were interested in your daily activities? To get at resilience, Heaney and her team included questions such as: How confident are you that you can... ... bounce back quickly after hard times? ... adapt to change? ... deal with whatever comes your way? ... see the humorous side of problems? The 72 questions have been translated for use in the China and Taiwan arms of the WELL study, field tested to make sure they have the same meaning in all three sites and modified to adjust for cultural or language differences. Additional modules may be added in each country to address determinants of wellness that are specific to that culture. While the questions themselves might vary a little from site to site, it remains to be seen how different the answers will be. More broadly, each of the three WELL for Life sites will look a bit different, says Winter. “In the Bay Area, we’ve really been focusing on an online registry. In China, we are using a more traditional study approach in which people are going to come in in person, and we’ll gather physiological data such as BMI, height, weight, grip strength, plus blood samples and a battery of survey questions. And just as in Santa Clara, we’ll be following these people over time.” Meanwhile, the Taiwan arm of the study will add a biobank of tissue samples collected from all 10,000 participants. Ioannidis says these tissues may reveal biological markers for wellness. “Just as we can monitor diabetes by looking at blood sugar levels,” he says, “is there some wellness biomarker that can tell us something about how one feels about one’s life? Are there biomarkers that indicate levels of wellness and that change as people’s levels of wellness increase or decrease? “Of course, this is exploratory,” he says. “I cannot promise that we will have hundreds of biomarkers explaining everything about wellness, but it’s possible that some of them will be of interest.” That would be a huge step forward. How confident are you that you can... ... overcome obstacles? ... stay focused under pressure? ... think of yourself as a strong and resilient person? ... manage any unpleasant feelings that you might have? ... not get disheartened by setbacks? In a few years, the WELL project team may be able to help us answer questions like these with “very confident.”
THINKING BIG: THE STANFORD PREVENTION RESEARCH CENTER How’s this for a goal: Increase human wellness around the world. Doable? It’s a tall order, but the group taking on this challenge, the Stanford Prevention Research Center, has a history of success helping large groups of people overcome large problems. And now it’s the home of the Wellness Living Laboratory project, which aims to build the evidence base of wellness and test ways to support it globally. The center, founded in the 1970s, has its roots in a massive effort to reduce risk factors for cardiovascular disease. The founder, John Farquhar, MD, now professor emeritus of medicine and of health research and policy, led the landmark study that assessed the use of media campaigns to reduce heart disease risk in two California towns, Monterey and Salinas. (They were successful.)
The center’s research now integrates many disciplines, including behavioral science, epidemiology and health education. Its current leader, John Ioannidis, MD, DSc, focuses on evaluating the validity of scientific studies and finding ways to optimize research practices. Ioannidis is the C. F. Rehnborg Professor in Disease Prevention and a professor of medicine and of health research and policy. Among the center’s pioneering efforts: • Establishing the role of exercise, nutrition, and cholesterol levels in heart disease • Testing the effectiveness of nicotine replacement in treating nicotine addiction • Examining the influence of social and
cultural factors on health • Analyzing methods for preventing eating disorders and obesity in adolescents Today, the center’s investigators continue to focus on finding ways to solve problems affecting large populations and to test potential solutions. Their studies include projects on motivating health food choices, preventing sexual assault, ending nicotine addiction, increasing physical activity and reducing such chronic diseases as heart disease, breast cancer, osteoporosis, and dementia. The center also runs an evidence-based health promotion program for Stanford staff and faculty that provides expertise to outside organizations. So, boosting wellness worldwide? It just might be feasible.
SEPTEMBER / OCTOBER 2016 | THE BULLETIN | 17
RISK MANAGEMENT
Liability Risks of Telemedicine: State Standards Among Considerations Dustin Shaver Vice President of Risk Management at NORCAL Mutual Insurance Company Telemedicine utilization growth continues at an impressive rate. According to the FAIR Health database (the largest repository of private healthcare claims), telemedicine use in the U.S. nearly doubled between 2007 and 2015. Over half of all U.S. hospitals now use some form of telemedicine, according to the American Telemedicine Association. Telemedicine is widely credited with improving patient access, cost efficiencies, and quality of care. This and increasingly favorable state and federal telemedicine legislation may explain the rapid increase in its utilization. Despite the advantages, telemedicine has liability risks, such as privacy, security, patient confidentiality, credentialing, and misdiagnosis due to a lack of continuity of care. Additionally, the soft skills that may come naturally in a personal patient encounter may need to be adjusted for electronic encounters. Telemedicine providers should evaluate their “webside” manner. For example, equipment needs to be positioned to simulate direct eye contact; active listening cues may need to be exaggerated; posture and facial expressions may need adjustment and sessions must be started and ended appropriately. Seemingly minor electronic communication strategies can significantly affect the success of a telemedicine encounter. Physicians who adopt telemedicine also have administrative considerations that may pose a challenge and liability risk. For instance, professional licensure portability and individual state mandated practice standards present major challenges. There are significant differences among state telemedicine laws and the laws are constantly changing. In the 2016 legislative session, for example, over 150 telemedicine-related bills were introduced by 44 states. The issues addressed by these bills ranged from informed consent requirements to online prescribing pa-
rameters to Medicaid reimbursement. Physicians should be aware of the telemedicine laws in their own state and in the state of every patient in their telemedicine practice. Understanding the laws is paramount to understanding the medical liability risks that may be involved in the various different stages of providing telemedicine. Medical professionals providing virtual visits must work harder to reduce practice liability exposures. To help enhance patient safety and reduce risk: • Understand that individual state telemedicine practice laws vary from state to state. • Consult with your healthcare business attorney as needed. • Check your professional licensure portability to ensure that you are licensed to practice in the jurisdiction where the patient resides. • Consult with your medical practice liability insurance company to ensure
18 | THE BULLETIN | SEPTEMBER / OCTOBER 2016
that your policy covers all jurisdictions where you plan to provide services. • Be aware of online prescribing regulations that vary across jurisdictions. • Comply with all applicable privacy and security standards for the secure transmission of protected health information between patient, provider, and payers. • Standardize telemedicine patient visits to help minimize the potential for error and to support good communication practices. • Take care to ensure that the primary care physician and patient relationship is not fractured with ongoing use of telemedicine consultation. Telemedicine is an emerging practice and the rising rate of adoption by both physicians and patients is an indication of its value. As with all advancement in the field of medicine, the advantages of adopting a new way of practice should be considered carefully and risks assessed. It is important to consult with your medical professional liability insurance provider on your individual policy to ensure you are adequately covered for the scope of practice, and consult with your business attorney as needed. NORCAL Mutual has a team of risk management specialists available to consult and assist policyholders with the assessment of their practice and to help identify and address risk exposures. To learn more about managing telemedicine risk exposure, NORCAL policyholders can access the September 2016 Claims Rx entitled “Telemedicine Risk Management,” which is available through MyACCOUNT on the new MyNORCAL® mobile app.
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L IA T EC OR SP P RE
3 Steps To Responding To Negative Online Comments The growth of online physician rating sites is causing a lot of physicians to feel like they’re losing control of their reputations. When seeing negative comments online, it’s natural for professionals to want to respond immediately to defend their reputations. But is that always the best course of action? In this special report, NORCAL’s Risk Management experts discuss the pros and cons of responding to negative online comments and lay out three steps to developing a plan of action for responding to online comments.
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Considering Legal Action? Think Twice. When physicians have attempted to use the legal system to stop online harassment, the courts have generally been less than accommodating to them. The following case demonstrates the courts’ attitude toward physicians’ attempts to protect their reputations.
“
She did not listen to my concerns and did not answer my questions. While I was sitting in her office, she took two phone calls and on one, scheduled a presentation for her practice by a drug rep.
”
I am getting my records and getting another doctor.
Responding to the Challenge of Online Ratings Case Study: This case involved a neurologist who filed a lawsuit against the son of a former patient claiming defamation. The judge dismissed the case and stated, “The court does not find defamatory meaning but rather a sometimes emotional discussion of the issues.” The case was widely publicized through newspaper, internet and television media outlets, and it resulted in a negative impact on the physician’s practice.
If you’re considering suing a reviewer, there are many potential issues you need to be aware of to avoid pitfalls and counter-suits. Consult with your attorney as soon as possible before taking any steps in that direction.
With the growth of social media and online marketing outlets, physicians are experiencing a not-so-new phenomenon—bad publicity—but in a new medium. There are many online sites that allow patients to rate their physicians and leave narratives about their experiences, and the number is growing. Today, for example, 80% of Ob/Gyns and 60% of surgeons have more than five online ratings, while just four years ago only one in six had any online ratings.1 New websites allow people to rate, review, or leave comments about their doctors, operating in much the same way as online services that help people find the best hotels or avoid plumbers who overcharge.2 As these websites are increasing in popularity, so is the significance of their ratings. And while the ratings are generally positive, some patients are using these sites to make serious and repetitive attacks on providers’ reputations and competency. As a result, physicians may feel personally under attack, and some have claimed that the comments negatively affect them emotionally and financially. When these attacks occur, physicians may naturally want to go into a defensive mode in order to preserve their reputations, but they must still always maintain compliance with HIPAA and other privacy laws. Furthermore, if physicians respond immediately and impulsively, they may do more harm than good. While this new reality may seem daunting, with a deliberate, reasoned approach, physicians can not only respond to negative online comments appropriately, but also enhance patient satisfaction by identifying and addressing any underlying issues that may have led to them.
SEPTEMBER / OCTOBER 2016 | THE BULLETIN | 21
NORCAL Mutual Risk Management Insight— 3 Steps to Responding to Negative Online Comments Because online reviews can affect your practice—both positively and negatively—the issue certainly warrants a plan of action. Developing one can help prepare you for when you become the target of negative online comments and help you avoid an emotional response in favor of a more measured one. These steps can also help improve your online ratings, mitigate the effects of negative online comments and guide your response to negative ratings before you ever face a crisis. Remember: Always maintain compliance with HIPAA and other privacy laws. Do not reference patient information, the medical record or other protected information in public forums.
01
Be Proactive: Develop a digital and social media plan for your practice. To proactively build your online reputation, consider monitoring online comments and requesting reviews from patients. Also, creating your own practice website and social media presence can help you control your message. Also consider the information and suggestions in this article to develop guidelines for responding to online reviews. Other helpful tools include office surveys and patient complaint processes to help you understand and address the needs and concerns of your patients.
02
Don’t Panic: Objectively assess the situation that led to the comments. Avoid an emotional, off-the-cuff response. Review the medical record for potential issues, but never reference the medical record in your response. If there are significant issues, contact your professional liability insurance carrier and inform a representative about the situation. If the issue directly affects patient care and you therefore have interactions with the patient, document all communication and follow-up in the medical record.
03
Maintain Professionalism: Keep your tone professional and put the patient’s needs first. If you decide to respond, remember your response becomes part of your online reputation. Follow group practice guidelines if you’re part of a group practice. Always maintain compliance with privacy laws and don’t directly or personally attack the individual posting the comment. Attempt to move the discussion to a private forum with a response like, “I’m sorry you had this experience. I’d like to discuss it with you. Please contact my office.”
TH E I M PAC T O F O NLIN E RAT IN G S RATINGS AWARENESS AND ACTIONS
40 37% 35%
%
6%
RATINGS TONE
6%
88% of reviews on physician rating sites were positive3
consider physician rating sites ‘somewhat important’ when choosing a physician4
6% of reviews on physician rating sites were negative3
avoided a physician with bad ratings4 88%
selected a physician based on good ratings4
22 | THE BULLETIN | SEPTEMBER / OCTOBER 2016
6% of reviews on physician rating sites were neutral3
This report is presented as a courtesy by NORCAL Mutual Insurance Company. Our Risk Management Specialists are always ready to help policyholders with risk issues and to support practice changes that lower risk and improve patient safety.
About NORCAL Mutual NORCAL Mutual Insurance Company is a policyholder-owned and physician directed medical professional liability insurance carrier that provides protection to physicians, health care extenders, medical groups, hospitals, community clinics and allied health care facilities across the nation.
NORCALMUTUAL.COM
References 1. Avondet, B. “All online physician ratings are not created equal.” KevinMD.com. October 30, 2014. Available at: http://www.kevinmd.com/ blog/2014/10/online-physician-ratings-created-equal.html (accessed 5/11/15). 2. Roan, S. “The rating room.” L.A. Times. May 19, 2008. 3. Lagu, T; Hannon, NS; Rothberg, MB; Lindenauer, PK. “Patients’ evaluations of health care providers in the era of social networking: an analysis of physician-rating websites.” Journal of General Internal Medicine. 2009;25(9):942-946. 4. Hanauer, DA; Zheng, K; Singer, DC; Gebremariam, A; Davis, MM. “Public Awareness, Perception, and Use of Online Physician Rating Sites.” JAMA. 2014;311(7):734-735. doi:10.1001/jama.2013.283194. Available at: http://jama.jamanetwork.com/article.aspx?articleid=1829975 (accessed 5/12/15).
Copyright ©2015 NORCAL Mutual Insurance Company. All rights reserved. This document may not be reproduced or distributed without express written consent from NORCAL Mutual Insurance Company. SEPTEMBER / OCTOBER 2016 | THE BULLETIN | 23
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Fully plumbed dental suite in Rose Garden area. Flexible terms. Good freeway access. Great satellite office or start up location.
Great location & high traffic area. Ground floor plumbed dental suite and second floor office space available. Elevator served.
2,000 SF AVAILABLE
820 SF AVAILABLE
393 Blossom Hill Rd, San Jose
470 E. Calaveras Blvd, Milpitas
2080 S. Bascom Ave, Campbell
Modern medical suites in a premier Class A medical office building. TI available for qualified tenants. Easy access to Hwys 85, 87, and 101.
Medical/dental space available at Calaveras Park Professional Center. High traffic area with convenient access to Hwys 680 & 880.
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560-1,980 SF AVAILABLE
2100 Forest Ave, San Jose Single-story medical building directly across from O’Connor Hospital. Flexible floor plans and sizes. TI dollars available.
690 Saratoga Ave | Suite 200 | San Jose, CA 95129 408-217-6000 T | 408- 457-8803 F www.HealthMedRealty.com Lic. 01902032
SEPTEMBER / OCTOBER 2016 | THE BULLETIN | 25
FAQ
Frequently Asked Questions About CURES This article is reprinted with the permission of the Medical Board of California, originally printed in their Newsletter, Vol. 139, Summer 2016.
The deadline to register for CURES (Controlled Substance Utilization Review and Evaluation System) has come and gone, but the Medical Board continues to receive numerous questions on the subject. Some of the most frequently asked questions about CURES are answered below.
WHAT IS CURES? CURES (Controlled Substance Utilization Review and Evaluation System) is a database of Schedule II, III and IV controlled substance prescriptions dispensed in California. This database serves the public health by allowing prescribers and dispensers to review a patient’s prescription history, and assists regulatory oversight and law enforcement agencies in their ability to enforce the laws of the state of California. CURES is committed to the reduction of prescription drug abuse and diversion without a legitimate medical practice or patient care.
WHICH PHYSICIANS ARE REQUIRED TO REGISTER IN CURES? Any physician with an active California medical license and a federal DEA registration certificate that authorizes him/her to prescribe, order, administer, furnish or dispense Schedule II, III and IV controlled substances must be registered to access CURES. (California Health and Safety Code section 11165.1). Registration does not mean a physician’s prescribing practices will now be available for review for the first time in the CURES system, as that has been occurring since 1999 (see below); however, registration in CURES allows physicians to review the prescribing history of their patients.
I MISSED THE JULY 1, 2016 REGISTRATION DEADLINE. WHAT SHOULD I DO NOW? Register as soon as possible, using this link: http://oag.ca.gov/curespdmp.
WHAT WILL HAPPEN TO ME IF I DON’T REGISTER IN CURES? There was no specific penalty written into the statutory language. However, if it was brought to the Medical Board of California’s (Board) attention that a physician was not registered, the Board would investigate the matter. The Board would be focusing on bringing the physician into compliance. The Board will be seeking regulatory authority to issue a citation and fine for failing to register as required by law. In the meantime, if 26 | THE BULLETIN | SEPTEMBER / OCTOBER 2016
the Board was investigating a physician and found other violations, the failure to register may be added to an accusation as a cause for discipline. The Board believes CURES is important and that registration is the first step. Physicians are also encouraged to use the system once they are registered.
PRIOR TO JULY 1, 2016, WAS MY PRESCRIBING PATTERN VISIBLE IN CURES? Yes, a physician’s prescribing pattern has been visible since CURES replaced the California Triplicate Prescription Program in 1999. The law requires a controlled substance that has been dispensed by a pharmacist or via a direct dispenser to be entered into the CURES database. This database has been accessible since 1999 to physicians, prescribers, and regulatory/law enforcement agencies. More recently, the request for patient and prescriber information became available via online access.
DO I HAVE TO STOP PRESCRIBING IF I AM NOT REGISTERED? No, failure to register into the CURES system does not impact your ability to prescribe. CURES only allows you to review a patient’s prescription history. Keep in mind, however, that registration is required by law.
HOW DOES CURES BENEFIT ME AS A PHYSICIAN? By accessing CURES, you can learn about a patient’s controlled substance history and identify patients who may be “doctor shopping” or at risk of addiction. In addition, the CURES 2.0 program offers many tools and alerts for physicians that can assist in providing care to their patients. (See MBC’s Summer 2015 Newsletter for more information.)
WHAT INTERNET BROWSERS ARE REQUIRED TO ACCESS CURES 2.0 (THE CURRENT VERSION)? CURES 2.0 users must use Microsoft Internet Explorer version 11.0 or higher, Mozilla Firefox, Google Chrome, or Safari. Earlier versions of Internet Explorer are not supported by CURES 2.0 for security considerations.
WHICH AGENCY ADMINISTERS THE CURES DATABASE? The California Department of Justice administers CURES. For more information, please email the CURES Help Desk at cures@doj.ca.gov or call 916/227-3843.
PRACTICE MANAGEMENT
Physicians Encouraged to Use Care When Advertising This article is reprinted with the permission of the Medical Board of California, originally printed in their Newsletter, Vol. 139, Summer 2016.
By Britt Durham, MD Health Quality Investigation Unit, Tustin Office The research and development of new treatments, medications, and therapeutics is an ongoing perpetual work in progress. Technical breakthroughs have made dynamic improvements in the health and well-being for many. Patients with chronic debilitating diseases and progressive deadly disease look toward new research for cures and represent a vulnerable population for those promising unfounded and unproven solutions. The Medical Board of California (Board) is concerned that some claims may give consumers a wrong impression that could ultimately endanger their health. Laws such as Business and Professions Code section 17508 have been created to make it unlawful for any person doing business in California to make any false or misleading advertising claim, including claims that purport to be based on factual, objective, or clinical evidence. Health and Safety Code section 110395 summarizes the spirit of these laws by stating that it is unlawful for any person to manufacture, sell, deliver, hold, or offer for sale any food, drug, device, or cosmetic that is falsely advertised. Business and Professions Code section 651 states that it is unlawful for any person licensed to disseminate or cause to be disseminated any form of public communication containing a false, fraudulent, misleading or deceptive statement, claim or image for the purpose of or likely to induce the rendering of professional services or furnishing of products in connection with the professional practice or business for which he or she is licensed. Advertisement and marketing under this section includes mail, television, radio, newspaper, list or directory, internet or other electronic communication. Health and Safety Code section 110403 lists specific medical conditions and diseases that have been historically associated with unlawful advertising. They include: bone and joint diseases, cancer, diabetes, heart disease, mental disease, paralysis, epilepsy, sexual impotence, and Acquired Immune Deficiency Syndrome (AIDS). Recent false and misleading advertising investigations have included medical conditions such as: Parkinson’s, cerebral palsy, stroke, multiple sclerosis, spinal injuries, anoxic brain damage, and autism. The Board and the Department of Consumer Affairs have investigated cases involving treatment modalities such as stem cell, hyperbaric oxygen, intravenous insulin infusion, balloon venography, and heavy metal chelating therapies. When violations were found, physicians were disciplined. The marketing of alternative diagnostic procedures that falsely advertise that they are better than present standard of care diagnostics
have also resulted in discipline. One such case promoted a non-standard of care breast cancer testing that replaced mammography and resulted in increased risk of breast cancer detection failure. ... it is unlawful for any person to manufacture, sell, deliver, hold, or offer for sale any food, drug, device, or cosmetic that is falsely advertised. In addition to treatment therapies and diagnostic testing, it is also unlawful to advertise the term “board certified” unless the individual is certified by a board that is an American Board of Medical Specialties (ABMS) member board or a specialty board approved by the Medical Board of California. It is unlawful for any medical professional to make a deceptive advertising claim or representation pertaining to the type of service provided that is beyond their scope of practice or based on their false credentials. Physicians have been disciplined for advertising misleading and deceptive statements regarding their training, such as marketing their credentials from a prestigious hospital when they actually never finished their training. These false and deceptive advertising violations can result in discipline against a medical license. Medical advertising should be created in the context of the following questions: Does the advertisement contain a misrepresentation of fact? Is it intended or likely to create false or unjustified expectations of favorable results? Note that this includes the use of any photograph or other image that does not accurately depict the results of the procedure being advertised or that has been altered in any manner from the image of the actual subject depicted. Does it fail to fully and specifically disclose all variables and other material factors relating to fees? Does it make a claim—either of professional superiority or of performing services in a superior manner? If so, is that claim relevant to the service being performed and can that claim be substantiated with objective scientific evidence? According to the U.S. Food and Drug Administration (FDA), health fraud scams refer to products that claim to prevent, treat, or cure diseases or other health conditions, but are not proven safe and effective for those uses. False and deceptive health care advertising can waste money and can lead to delays in getting proper diagnosis and treatment. They can also cause serious or even fatal injuries. The laws discussed in this article were enacted, in conjunction with the FDA rules, to protect the public from misleading claims and advertising. Medical professionals are encouraged to review their advertising practices to ensure they are in compliance with the law. SEPTEMBER / OCTOBER 2016 | THE BULLETIN | 27
CDPH Update Requirements For Reporting Listed Conditions This article is reprinted with the permission of the Medical Board of California, originally printed in their Newsletter, Vol. 139, Summer 2016. The California Department of Public Health (CDPH), in consultation with the California Conference of Local Health Officers, recently updated Title 17, Section 2500 of the California Code of Regulations (CCR). Section 2500 specifies that health care providers must report all cases of certain conditions to the local health department within a specified timeframe. This notice is to inform you of the changes to this Section and to remind you of the reporting requirements. These changes, effective immediately, are summarized below. The updated Section 2500 condition list is posted on the CDPH Division of Communicable Disease Control website.
CHANGES TO TITLE 17 CCR SEC ON 2500 The following conditions have been removed and are no longer required to be reported to the local health department: • Pelvic Inflammatory Disease (PID) • Severe Acute Respiratory Syndrome (SARS) • Staphylococcus aureus infection • Toxic Shock Syndrome The following conditions have been added and are now required to be reported to the local health department: • Chikungunya Virus Infection – report within one working day • Flavivirus infection of undetermined species – report immediately by telephone • Novel Virus Infection with Pandemic Potential – report immediately by telephone • Respiratory Syncytial Virus (only report a death in a patient less than five years of age) – report within seven calendar days • Zika Virus Infection – report immediately by telephone The following conditions have been reworded for clarity: • Acquired Immune Deficiency Syndrome (AIDS) is reworded to Human Immunodeficiency Virus (HIV) Infection, stage 3 (AIDS) ȧȧ Human Immunodeficiency Virus (HIV), Acute Infection now appears as a separate condition in the list • Anaplasmosis/Ehrlichiosis now appear as two separate conditions in the list • Chickenpox (Varicella) (only hospitalizations and deaths) is reworded to Chickenpox (Varicella) (outbreaks, hospitalizations and deaths) • Dengue is reworded to Dengue Virus Infection • Haemophilus influenzae, invasive disease is reworded to Haemophilus influenzae, invasive disease, all serotypes The following conditions have a change in a reporting requirement: • Haemophilus influenzae, invasive disease, all serotypes, is now required to be reported only in persons less than five years of age (previously was in persons less than 15 years of age) • Hantavirus Infection is now required to be reported within one working day of identification (previously was reportable immediately) Please contact your local health department if you have any questions about communicable disease reporting requirements. 28 | THE BULLETIN | SEPTEMBER / OCTOBER 2016
This article is reprinted with the permission of the Medical Board of California, originally printed in their Newsletter, Vol. 139, Summer 2016.
FDA APPROVES BUPRENORPHINE IMPLANT
The U.S. Food and Drug Administration (FDA) recently approved Probuphine, the first buprenorphine implant for the maintenance treatment of opioid dependence. The implant, consisting of four one-inch-long rods surgically inserted under the skin on the inside of the upper arm, provides a constant, low-level dose of buprenorphine for six months in patients who are already stable on low-to-moderate doses of other forms of buprenorphine. Probuphine (buprenorphine) should be used as part of a complete treatment program that includes counseling and psychosocial support. Providers must complete training and become certified through a restricted program called the Probuphine Risk Evaluation and Mitigation Strategy (REMS) program to insert and remove the implants. Side effects from treatment with Probuphine (buprenorphine) include implant-site pain, itching, and redness, as well as headache, depression, constipation, nausea, vomitng, back pain, toothache, and oropharyngeal pain. The safety and efficacy of Probuphine (buprenorphine) have not been established in adolescents less than 16 years of age. Clinical studies of Probuphine (buprenorphine) did not include participants over the age of 65. Probuphine (buprenorphine) has a boxed warning that includes a warning that the insertion and removal of the implant are associated with the risk of implant migration, protrusion, expulsion and nerve damage resulting from the procedure. For more information, please visit: http://www.fda.gov/ Ne w s Eve nt s / Ne w s r o om / P r e s s A n n ou n c e m e nt s /u c m 5 03719. ht m?s ou rc e =govdel iver y& ut m _ me d iu m= ema i l& ut m _ source=govdelivery.
“DESENSITIZATION” BOOSTS ACCEPTABILITY OF DONOR KIDNEYS
A process altering patients’ immune systems is making it possible for patients in need of donated kidneys to accept organs from incompatible donors, according to an article in The New York Times. The method, called desensitization, filters antibodies out of a patient’s blood to keep them from attacking a transplanted kidney, as they do in about half of the cases. “The patient is then given an infusion of other antibodies to provide some protection while the immune system regener-
ates its own antibodies. For some reason – exactly why is not known – the person’s regenerated antibodies are less likely to attack the new organ,” according to the article. Kidney specialist Dr. Jeffery Berns of the University of Pennsylvania’s Perelman School of Medicine, president of the National Kidney Foundation, said the method “has the potential to save many lives.” About 100,000 people are waiting for a kidney transplant in the U.S. (The New York Times, March 9, 2016)
USING GOOGLE GLASS TECHNOLOGY MAY CUT PHYSICIAN CHARTING TIME
Five health care systems – including Sutter Health and Dignity Health in California – have invested a combined $17 million in Augmedix Inc., a San Francisco startup “... that uses Google Glass technology to maintain electronic health records and free up doctors to spend more time with patients,” according to an April 25, 2016 article in The Sacramento Bee. The article describes Google Glass as “essentially computer-embedded eyewear, giving the user hands-free access to a wide range of data.” Augmedix “claims the technology can reduce a typical physician’s charting time by three hours per day.”
DIGITAL TOOLS HELPED HEART ATTACK SURVIVORS LOSE WEIGHT
A small study at Mayo Clinic found that cardiac patients receiving digital prompts on their smartphones or using a specially designed web portal in addition to the normal cardiac rehabilitation program lost more than four times the weight of those who did not use the additional technology. Mayo cardiologists worked with the clinic’s IT department to create the app and portal. Heart attack survivors enrolled in the 12-week cardiac rehab program at Mayo exercise under supervision and are taught about nutrition, stress management, smoking cessation, and ways to manage cardiac health. The study looked at 80 patients over the 12 weeks. Those receiving digital encouragement were found to be more compliant with exercise and nutrition guidance offered in the rehab program. They lost nine pounds, while those attending the rehab program without the digital tools lost two pounds. (Medical Device and Diagnostic Industry, www.mddionline. com, May 12, 2016) SEPTEMBER / OCTOBER 2016 | THE BULLETIN | 29
CMA Alert, September 19, 2016 issue
CMS practice expense calculations do not reflect California’s higher practice costs As required by law, at least every three years the Centers for Medicare and Medicaid Services (CMS) adjusts payments under the Medicare physician fee schedule to reflect local differences in practice costs. In the proposed 2017 Medicare physician fee schedule, CMS made nationwide updates to the geographic practice cost indices (GPCI) based on new wage, rent and malpractice expense data. Unfortunately, according to CMS, the malpractice and practice expense GPCIs went down in nearly every region of California, which would result in a 0.48 percent GPCI payment reduction in all but a few regions of California. The California Medical Association (CMA) is urging CMS to review the data for accuracy, as physician office expenses in California have increased in recent years relative to the rest of the nation. “California’s real estate market has experienced a remarkable recovery in most regions of the state over the last several years,” CMA wrote in comments submitted to CMS. “We find it unfathomable that California physicians would be taking a pay cut in 2017 because practice expenses decreased relative to the rest of the nation.” CMA also urged CMS to reconsider the inappropriate weighting of the rent expense category, which was given only an 8% weight in the practice expense GPCI. “Office ‘rent’ is one of the largest and most expensive cost components for physicians, and we would argue that it should be given a much larger weight to more accurately reflect its impact on physician practice expenses,” CMA wrote in its comments. The proposed Medicare payment rule also begins to implement the California “GPCI fix,” which will overhaul California’s outdated geographic payment localities. It transitions the payment localities to Metropolitan Statistical Areas, which is consistent with the way Medicare pays hospitals. The localities will be updated annually. This long-overdue fix updating California’s Medicare physician payment regions will raise payment levels for 14 urban California counties misclassified as rural, while holding the remaining rural counties permanently harmless from cuts after 2017. The transition to the new localities starts next year, with the higher locality payments being phased in over a six-year period starting in 2017. Unfortunately, because of the overall GPCI practice expense and malpractice expense reductions, most California physicians will not see pay30 | THE BULLETIN | SEPTEMBER / OCTOBER 2016
ment increases in 2017. However, without the CMA-led locality change, California physicians would be receiving an even larger payment cut. CMA has reviewed all of the implementation calculations and provided some minor corrections to ensure that the GPCI fix is implemented accurately. CMA will continue to work closely with CMS on the transition to the new California payment localities. For more details, including a corrected payment impact chart by locality, see CMA’s comments at http://www.cmanet.org/files/assets/ news/2016/09/cma-gpci-comments-090616.pdf.
CMA Alert, September 19, 2016 issue
United Healthcare fails to provide proper notification on rollout of clinical data submission protocol The California Medical Association (CMA) is concerned that United Healthcare (UHC) failed to properly notify physicians before implementation of its Clinical Data Submission Protocol. Although California law (California Insurance Code §10133.65 and Health & Safety Code §1375.7) requires payors to provide contracted physicians with the 45 business days’ advance notice of any material contracting changes, UHC’s only notification to physicians about this new protocol was in its Network Bulletin. First introduced in 2015, the program originally targeted only Medicare benefit plans and required physicians to submit all laboratory test results for UHC Medicare patients. The expansion of the program will require practices to submit laboratory tests for all UHC Medicaid and commercial benefit plans. UHC has stated, however, that it will help practices establish the transmission method that works best with their current capabilities. At the request of CMA, UHC delayed the expansion of its Clinical Data Submission Protocol in California. Originally scheduled to take ef-
fect July 1, 2016, the expansion was pushed back until September 2. However, CMA believes UHC is not compliant with state law as it has not formally notified all affected physician practices of changes to the protocol. CMA is evaluating its next steps and will update physicians when additional information is available. While UHC lauds the sharing of clinical patient data as an opportunity to support quality and cost-effective patient care, CMA is also concerned about the administrative burden of the protocol and the impact on physician practices. For more information about the protocol and requirements for submitting data to UHC, physicians should refer to the updated Clinical Data Submission Protocol Frequently Asked Questions and Methods of Clinical Data Exchange, or contact either the UHC Provider Call Center at 877/842-3210 or their local UHC Network Account Manager or Provider Advocate.
CMA Alert, August 22, 2016 issue
Chronic pain and opioid treatment guidelines for injured workers now in effect The California State Division of Workers’ Compensation’s (DWC) new guidelines on the treatment of chronic pain and opioid prescribing for injured workers are now in effect. The guidelines include best practices and universal precautions for safe and effective prescribing of opioids for pain due to a work-related injury. According to DWC, the new guidelines encourage safer prescribing of opioid pain relievers with the primary goal of significantly reducing the rate of opioid-related adverse events and substance misuse and abuse. Since 2014, the California Medical Association (CMA) has provided input to the DWC on the complicated issues related to prescription opioid misuse and overdose, based on CMA’s support for a well-balanced approach to opioid prescribing and treatment that considers the unique
needs of individual patients. CMA has published two white papers for physicians on prescribing opioid medications; both are available in CMA’s online resource library at http://www.cmanet.org/resource-library. • Opioid Analgesics in California: Relieving Pain, Preventing Misuse, Finding Balance • Prescribing Opioids: Care and Controversy CMA’s Institute for Medical Quality also frequently hosts continuing medical education in pain management. To find out about available courses, go to https://imq.inreachce.com. For more information on safely and effectively prescribing controlled substances for pain, see CMA’s safe prescribing resource center at www. cmanet.org/safe-prescribing, available to members only. SEPTEMBER / OCTOBER 2016 | THE BULLETIN | 31
CMA Alert, September 19, 2016 issue
CMA Alert, September 19, 2016 issue
CMA Q4 council reports now available for comment
CDPH urges providers to adopt new TB screening recommendations
The California Medical Association (CMA) has posted its fourthquarter council reports online, part of the year-round (quarterly) policymaking process instituted at the close of the 2015 CMA House of Delegates. In August 2016, the fourth-quarter resolutions were opened for online testimony. At the close of the comment period, the testimony received was used to inform CMA’s various councils, which then met and developed recommendations that will go before the Board of Trustees in October. These council reports are now available online and open for further comment and discussion through October 10, just prior to the board meeting. If you have any feedback that you think would be critical for the board to consider, now is your opportunity to make your voice heard. To view the reports and/or to make a comment, go to https://www. cmanet.org/account/groups/hod-year-round/resolutions. You will need to log-in with your CMA web account. Submit a resolution for consideration If you have a resolution you would like to submit for future consideration, please e-mail it to resolutions@cmanet.org. The resolution submission deadline for the first quarter (Q1) of 2017 is October 19, 2016, but we encourage you to submit well in advance of the deadline to ensure that it is considered promptly. Please read the guidelines at https://www.cmanet. org/hod before submitting a resolution. Resolutions that do not follow the guidelines will be rejected.
The California Department of Public Health (CDPH) urges providers to adopt new tuberculosis (TB) screening recommendations, recently announced by the U.S. Preventive Services Task Force, calling for adults 18 years of age or older who are at increased risk of TB to be screened for the disease. CDPH has developed a California Risk Assessment Screening Tool to help providers quickly identify people at risk for developing the disease, as well as a fact sheet that offers suggested courses of treatment. Those considered to be at increased risk of TB include individuals born in countries with elevated rates of the disease and individuals who live in settings with a large number of people, like group homes or homeless shelters. Evidence shows that screening of individuals at increased risk for TB is an effective method for preventing the development of the disease. In California, an estimated 2.4 million people have latent TB infection. In 2015, 2,137 people in the state were diagnosed with TB. For more information on TB, please visit the CDPH Tuberculosis Control Branch web page at http://www.cdph.ca.gov/programs/tb.
CMA Alert, August 8, 2016 issue
CDC urges aggressive Zika screening of pregnant women The Centers for Disease Control and Prevention (CDC) is urging physicians to be more aggressive in screening pregnant women for the Zika virus. The new guidance comes amid growing concerns about Zika, which, if contracted by pregnant women, can result in severe birth defects — including microcephaly, which stunts children’s brain development. It has also been implicated in miscarriages and diseases like Guillain-Barre, a neurological disorder that causes temporary paralysis. The CDC update recommends that all pregnant women in the United States and its territories should be “assessed for possible Zika virus exposure” whenever they get a prenatal care visit. Physicians are also being urged to test for the virus if a pregnant woman or her sexual partner have traveled to an area where the virus was actively spreading. Previously, Zika testing was only recommended if they were also showing symptoms — CDC is now recommending testing even in the absence of symptoms. Zika has been spreading in many Latin American and South American countries, along with Puerto Rico. Public health experts warn it could 32 | THE BULLETIN | SEPTEMBER / OCTOBER 2016
reach the continental United States by summer’s end. Epidemiologists are investigating two cases in Florida in which local mosquitoes may have transmitted the virus. Another key part of the new CDC guidelines emphasizes that both symptomatic and asymptomatic pregnant women should be screened within two weeks of the date of possible Zika exposure with PCR, a DNAbased test. If the PCR test is negative, or an at-risk pregnant woman misses that initial two-week window, the CDC calls for screening with a test that searches for antibodies to the virus. That test, which is effective for as long as 12 weeks after exposure, is considered a less reliable indicator and has drawn some criticism because it can generate false positives. To read the CDC guidelines, see this article at http://www.cmanet. org/news.
CMA Alert, September 6, 2016 issue
Subject matter experts needed for primary care residency grant program The Office of Statewide Health Planning and Development (OSHPD), is seeking subject matter experts to join application review panels for the Song Brown Primary Care Residency Program. The program, which provides grant funding for primary care residency programs, is looking for variety of health care professionals, including physicians, residents and students. The California Medical Association (CMA), as part of a coalition of health care stakeholders, was able to secure $100 million in the FY 2016-
17 California State Budget to support and expand primary care residency training and programs in medically underserved areas through the Song-Brown Workforce Training Program and targeted investment in teaching health centers. The funding will be appropriated over six years to create a reliable and continuous funding stream that primary care residency programs in California so desperately need. Advocating for additional funding for this program was a CMA priority and now that the
funding has been appropriated, it is critical that physicians remain engaged in the process for awarding the funding. Each review panel is comprised of up to five individuals and panelists may be asked to review up to 15 applications. Applications to serve as a reviewer are accepted on an ongoing basis. For more information, go to http://www. oshpd.ca.gov/HWDD/Song _Brown_Prog. html.
CMA Alert, September 19, 2016 issue
IMQ offers FREE CME for online course on child abuse and neglect In an effort to prevent more childhood trauma, the Institute for Medical Quality (IMQ), a subsidiary of the California Medical Association, is offering a free online course to help physicians, nurses and mental health providers recognize and report child abuse and neglect. This interactive course, approved for 1.25 continuing medical education (CME) credits, was produced by the Child Abuse Prevention
center in Sacramento, an international training, education, research and resource center dedicated to protecting children and building healthy families. The course is especially helpful for learning how to handle questionable situations. Nurses, social workers and other health care professionals also are encouraged to take the training, as they often have more extensive contact with patients or families. IMQ has received a grant from the Califor-
nia Governor’s Office on Emergency Services to provide this training at no charge. The course is approved for physician CME credits, nursing continuing education units or a completion certificate for other health care professionals. Pre-registration is required. To initiate the training, go to http://www. imq.org/education/caprrc.aspx.
CMA Alert, September 19, 2016 issue
UC Davis & CDPH conduct physician survey on CURES The opioid overdose epidemic in California has brought with it heightened interest in California’s Controlled Substance Utilization Review and Evaluation System (CURES). Now, a new effort to understand CURES usage and controlled substance prescribing in California has begun under two multi-year grants to improve CURES and prevent prescription drug overdoses. As part of the grant project, the University of California, Davis, and the California Department of Public Health – in collaboration with the Medical Board of California – are conducting a physician survey to provide insight and information regarding the prescribing of controlled substances in California. The information will also be used to help guide efforts to make CURES more user-friendly and to improve patient care and safety.
Physician participation is voluntary. The information will be analyzed only by the research team at UC Davis, and the findings will be presented only in aggregate. No personal or identifying information will be shared with payors or other parties, and individual responses will not be shared with the medical board. Individual responses will NOT be reported to the medical board or to any other state agency. The survey has been approved by the UC Davis Institutional Review Board. If you have any questions about this survey, you can contact the project leader, Stephen Henry, MD, at 916/734-2177. Physicians whose licenses expire November 30, 2016, are eligible to participate in the survey. To take the survey, go to http://cal.md/CURESsurvey. SEPTEMBER / OCTOBER 2016 | THE BULLETIN | 33
CMA Alert, September 6, 2016 issue
FDA warns of risks from mixing opioids with antianxiety drugs The Food and Drug Administration (FDA) announced last month that it will require tough new warning labels that spell out the increased risks of combining anti-anxiety (benzodiazepines) with prescription opioids. Nearly 400 opioid products will now be required to carry “boxed warnings” – the FDA’s strongest warning – that highlight the risks from combined use, which include extreme sleepiness, respiratory depression, coma and death. The new warning labels are one of a number of steps the FDA is taking as part of the agency’s Opioids Action Plan, which focuses on policies aimed at reducing prescription opioid misuse, abuse and overdose, while still providing patients in pain access to effective and appropriate pain management. The FDA is also urging physicians to be extra careful when prescribing medication regimens that mix the two classes of drugs, and prescribe opioid pain medicines with benzodiazepines or other central nervous system depressants only to patients for whom alternative treatment options have been ineffective. “We implore health care professionals to heed these new warnings and more carefully and thoroughly evaluate, on a patient-by-patient basis, whether the benefits of using opioids and benzodiazepines – or [central nervous system] depressants more generally – together outweigh these serious risks,” said FDA Commissioner Robert Califf, MD. According to the FDA, if these medicines are prescribed together,
physicians should limit the dosages and duration of each drug to the minimum possible while achieving the desired clinical effect. Physicians should also warn patients and caregivers about the risks of slowed or difficult breathing and/or sedation, and the associated signs and symptoms. Go to http://www.fda.gov to see the drug and safety communication from the FDA.
CMA Alert, August 8, 2016 issue
California to get federal funds to help identify and treat babies born with microcephaly The Centers for Disease Control and Prevention (CDC) announced that it has awarded more than $16 million to 40 states and territories, including California, to establish, enhance and maintain information-gathering systems to rapidly detect microcephaly – a serious birth defect of the brain – and other adverse outcomes caused by Zika virus infection. According to the announcement, the California Department of Public Health will receive $720,000. These awards are a stopgap diverted from other public health resources until Zika funds are provided by Congress. The funding will help states and territories ensure that infants and their families are referred to appropriate health and social services. The awards will also enable states and territories
to monitor the health and developmental outcomes of children affected by Zika. To date, 21 pregnant Californians have tested positive for Zika; all of them acquired the disease from travel to a Zika-affected area or through sexual contact with a traveler. “It is critical to identify infants with birth defects related to Zika virus so we can support them and their families,” said CDC Director Tom Frieden, M.D., M.P.H. “This CDC funding provides real-time data about the Zika epidemic as it unfolds in the United States and territories and will help those most devastated by this virus.” Zika is mainly transmitted by the aedes mosquito. While this mosquito isn’t common in the far northern parts of California, it can be
34 | THE BULLETIN | JULY SEPTEMBER / AUGUST / OCTOBER 2016 2016
found in larger numbers in Southern California and as far north as the Bay Area and Madera County. Zika can also be sexually transmitted. There is no vaccine or treatment for Zika, and many people infected with Zika have no symptoms. In those who do have symptoms, the most common complaints are fever, rash, joint pain and conjunctivitis (red eyes). Zika infection during pregnancy can cause microcephaly and other severe defects in the developing fetus. CDC encourages everyone, especially pregnant women and women planning to become pregnant, to protect themselves from mosquito bites to avoid possible Zika virus infection. For more information on the Zika virus in California, visit the CDPH website, www.cdph. ca.gov.
CMA Alert, August 22, 2016 issue
Big Tobacco launches dishonest ad campaign about Prop. 56 Tom Torlakson, California’s state superintendent of public instruction, has demanded that broadcasters immediately stop airing false and deceptive ads from tobacco companies about the Proposition 56 tobacco tax initiative. Big Tobacco, which has put $36 million into the opposition campaign so far, continues to assert that Prop. 56 would take money away from education — a statement Torlakson called “preposterous” and “insulting to those of us committed to the education and well being of California’s children.” “It is absolutely untrue to claim that no money from the proposed tobacco tax would go to schools,” Torlakson wrote in a legal declaration that is part of a demand to stations to cease and desist broadcasting the ads. “Make no mistake, Proposition 56 will not divert a dime away from schools,” Torlakson said. “Rather, it will raise revenues for school-based tobacco prevention and intervention programs.” The Legislative Analyst’s Office estimates that Prop. 56 would add tens of millions in new funding for comprehensive anti-tobacco instruction and cessation efforts in California classrooms. Sales taxes are imposed on top of any excise taxes, including Prop. 56’s tobacco tax, so an increase in the tobacco tax would also increase sales tax revenues, which are largely allocated toward schools.
Supporters of Prop. 56 said they expect this is the beginning of a barrage of lies from tobacco companies, who will spend tens of millions peppering the airwaves with deceptive advertising. The California State PTA, representing more than 800,000 school advocates, has joined the many education and children’s advocacy groups that are part of the broad coalition supporting Prop. 56, which also includes the California Medical Association, American Cancer Society Cancer Action Network, American Lung Association in California and American Heart Association. Prop. 56 will protect children by increasing California’s cigarette tax by $2 per pack, with an equivalent increase on products containing nicotine derived from tobacco, including electronic cigarettes. It will keep kids from ever starting to use deadly, addictive tobacco products, and it will save lives. “We know that increasing tobacco taxes reduces youth smoking. Tobacco companies know this too. That is why they are spending millions to obfuscate the provisions of Prop. 56 and mislead voters about its impact on schools,” Torlakson wrote. “As educators, neighbors, parents and grandparents, we aren’t fooled. Tobacco companies do not care about our children, they want to create a new generation of consumers.”
CMA Alert, September 6, 2016 issue
CMA-sponsored bills head to Governor Brown for his signature The California State Legislature has passed two California Medical Association (CMA)sponsored bills: AB 2121, a life-saving measure requiring alcohol servers and managers to complete a training course on responsible beverage service; and SB 1177, to establish a Physician Health and Wellness Program for California physicians. Another CMA-sponsored bill, SB 563, was incorporated into SB 1160 to increase transparency and accountability in the workers’ compensation utilization review process. These bills are now on the Governor’s desk awaiting his signature. AB 2121 would make Department of Alcoholic Beverage Control responsible beverage training mandatory statewide for anyone serving alcoholic beverages. Educating beverage servers in bars and restaurants is a key compo-
nent to reducing drunk-driving fatalities. The bill was spurred by a tragic drunk-driving accident that took the lives of two medical students from the University of California, San Diego. In 2013, alcohol-involved collisions resulted in nearly 1,100 deaths in California and more than 16,000 injuries, according to the California Highway Patrol. “Many of these tragedies can be avoided by giving alcohol servers the tools needed to effectively and safely intervene with an intoxicated patron,” said CMA President Steve Larson, MD, MPH. “AB 2121 will make our streets safer and reduce the death toll caused by drunk driving, and we urge the governor’s support of this measure.” SB 1177 would authorize the Medical Board of California to establish a Physician
and Surgeon Health and Wellness Program for California physicians suffering from substance abuse disorders. CMA-sponsored SB 563, which was absorbed into SB 1160, would expressly prohibit financial incentives for workers’ compensation utilization review physicians and companies, ensuring focus accurately remains on the question of medical necessity and that injured workers get timely access to the care they need. The bill also includes a number of other reforms to the utilization review process. For more information on these or any other bills of interest to physicians, CMA members can sign up for CMA’s Legislative Hot List at www.cmanet.org/newsletters.
SEPTEMBER / OCTOBER 2016 | THE BULLETIN | 35
CMA Alert, August 22, 2016 issue
CMA Alert, August 22, 2016 issue
Pilot planned to develop DEA denies petition to electronic POLST registry in CA reschedule cannabis but relaxes restriction on research
A $3 million pilot project to build an electronic database for Physician Orders for Life-Sustaining Treatment (POLST) has been approved by the board of directors of the California Health Care Foundation (CHCF). Participating in the project will be the Alameda-Contra Costa Medical Association (ACCMA). POLST 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. Currently, in California most POLST information is maintained only as a pink piece of paper that stays with the patient or the medical record. “The POLST form is a powerful tool for helping patients specify the treatments they do and don’t want,” said Kate O’Malley, CHCF senior program officer. “But when the paper form is not immediately available, it can result in unwanted care for the patient. Building and testing an electronic database for POLST forms can improve access to this critical information.” The Coalition for Compassionate Care of California (CCCC) will serve as the operations center for the registry. Pilot partners will design, develop and test a secure, cloud-based web portal for electronic submission, storage and retrieval of POLST data. The registry pilot project was spurred by passage of SB 19 (Wolk) in 2015, which authorized an electronic POLST registry pilot and identified the California Emergency Medical Services Authority (EMSA) as lead agency for the pilot. CCCC and EMSA will work together to create a cloud-based registry where completed POLST forms can be securely submitted and retrieved. The pilot registry will be tested and evaluated in two locations: San Diego and Contra Costa counties. ACCMA, one of the California Medical Association’s county medical societies, will coordinate the Contra Costa pilot. It is hoped that the pilot will help guide the expansion of the electronic registry statewide. For more information about the project, go to http://coalitionccc. org/2016/08/chcf-funds-pilot-project-develop-electronic-polst-registry-in-california.
The U.S. Drug Enforcement Agency (DEA) denied a request to remove cannabis from its schedule 1 classification, despite the fact that 25 states, including California, have approved the medical use of cannabis for a growing list of health conditions. According to the DEA, cannabis remains a schedule I controlled substance because it does not meet the criteria for currently accepted medical use in treatment in the United States, there is a lack of accepted safety for its use under medical supervision, and it has a high potential for abuse. However, recognizing that there is growing public interest in expanding research into the potential medical utility of cannabis and its chemical constituents, DEA also announced a policy change that could spur broad scientific study of cannabis. The DEA policy change is designed to foster research by expanding the number of DEA-registered cannabis manufacturers. Since 1968, the University of Mississippi has been the only institution in the United States authorized to grow the drug for use in medical studies, limiting the supply and variation of strains for federally approved research purposes. DEA’s new policy will allow additional entities to apply to become registered with DEA so that they may grow and distribute cannabis for federally funded or other academic researchers, as well as for strictly commercial endeavors funded by the private sector and aimed at drug product development. This new policy creates a legal pathway for commercial enterprises to produce cannabis for product development. The California Medical Association (CMA) in 2011 published a white paper on cannabis that found that physicians need access to better research on the drug, which has not been possible under current drug policy. The paper, available at http://www.cmanet.org/files/pdf/news/cmacannabis-tac-white-paper-101411.pdf, is a thoughtful study and response to an important issue, continuing CMA’s tradition of providing guidance on public health.
CMA Alert, August 8, 2016 issue
Covered California announces plan offerings for 2017 Covered California, the state marketplace for health insurance under the Affordable Care Act, recently announced the qualified health plans that were approved to offer coverage in the exchange market for 2017. All of the plans that offered coverage in 2016 will continue to do so in 2017. Three of the plans will also be expanding into new regions this year. • Molina is expanding its HMO coverage into Orange County (region 18)
through delegated relationships with Monarch and Heritage Network. • Oscar is expanding its EPO coverage into San Francisco (region 4), Santa Clara (region 7), and San Benito, Santa Cruz and Monterey (region 8). • Kaiser is expanding into Santa Cruz and Monterey through collaboration with Watsonville Community Hospital and Dominican Hospital for inpatient
36 | THE BULLETIN | SEPTEMBER / OCTOBER 2016
and ambulatory specialty care. Kaiser plans a phased expansion to include the opening of three medical offices in January 2017 and a specialty hub for enrollees to be added by 2020. For a complete listing of plans and product types offered by region, see the Covered California 2017 Plans Booklet (see page 31) at www. coveredca.com.
NEW MEMBER BENEFIT
Physicians News Network (PNN) Great News! The Santa Clara County Medical Association (SCCMA) and Monterey County Medical Society (MCMS) have teamed with Physicians News Network (PNN) to deliver weekly eNews Bulletins edited specifically for the interests of Santa Clara and Monterey County Physicians. The PNN | SCCMA-MCMS eNews Bulletin, delivered to your email every Tuesday, will focus on the business of local healthcare delivery, reporting on topics specific to SCCMA, MCMS and Northern California physicians along with timely news on hot button issues that directly impact your practice in these challenging times. In addition to up-to-the-minute news, look for these sections in your PNN eNews Bulletin: • KUDOS | A favorite among our readers, the Kudos section highlights the achievements of your local colleagues and institutions. • I & I | The Infrastructure and Investment section focuses on healthcare-related financial, real estate, and infrastructure news at the local level. • ICYMI | We don’t want you to miss a thing! The New ICYMI (In Case You Missed It) section will feature important stories from other PNN publications around the state, including our connected care and technology news bulletin, PNN CONNECTED. • R&D | While PNN strives to deliver local and state business news that is most important to your practice, the new Research & Development section will briefly summarize local clinical research, studies, reports and achievements, keeping
you in the loop with everything that’s happening in your medical community. In addition, every Thursday PNN CONNECTED will deliver to you news on all aspects of connected care, including data sharing and provider connectivity; EHRs; monitors and devices; software, apps, phones and tablets; reports, studies and surveys; as well as innovations, success stories, business and legislation. While focusing on California facilities, companies, innovations and transactions, we will also explore stories about what’s working at hospitals and practices throughout the country in an effort to empower our physician readers to continue to lead the charge in the world of connected care.
edited by professional healthcare journalists, and will serve as a valuable resource by helping you stay informed, track emerging trends, and take advantage of new opportunities. Look for the issues of the PNN | SCCMAMCMS eNews Bulletin on Tuesdays, followed by PNN CONNECTED on Thursdays. If SCCMA-MCMS does not have your current email address and you would like to receive these, please call SCCMA-MCMS and request to be added to the distribution list.
PNN eNews Bulletins are written and SEPTEMBER / OCTOBER 2016 | THE BULLETIN | 37
TO SUCCESSFUL BREASTFEEDING AND TONGUE/LIP TIE RELEASE Randy Ligh, DDS; James Ochi, MD; Rosanne Tedesco, MD, IBCLC
As a greater number of mothers are now breastfeeding, they are looking for support and solutions to achieve successful breastfeeding. The cause and effect solution is not a simple “yes or no.” As we explore the different disciplines involved with this “dyad” relationship, we will demonstrate that support may come from many disciplines simultaneously and solutions are not always the most obvious. A landmark ultrasound study from 2008 by Geddes and Associates has shown that the tongue movements used by tongue-tied babies are qualitatively different from those used by babies whose tongues are not tethered and limited in movement range. Significant pain and nipple damage for the mother was caused by these ineffective movements. Compared to babies who were not tongue-tied, the tongue-tied babies were not able to draw the nipple as deeply into the mouth.
38 | THE BULLETIN | SEPTEMBER / OCTOBER 2016
The American Academy of Breastfeeding Medicine develops clinical protocols that serve as guidelines for the care of breastfeeding mothers and infants. “All newborn infants, whether healthy or ill, should have a thorough examination of the oral cavity that assesses function as well as anatomy.” A semi-quantifiable scoring system, such as that designed by Hazelbaker, provides such an assessment tool. The Hazelbaker scoring system has been validated in a sample of term neonates and tested for interrater reliability. Hazelbaker scores indicative of significant ankyglossia (tongue-tie) have been shown to be highly correlated with maternal sore nipples and difficulty latching the infant onto the breast. Given that a tongue or lip tie is present and the release is successful there are other issues that need to be addressed for successful breastfeeding to occur and continue. This discussion
will not go over the surgical options or techniques for the release, but rather address important peripheral issues that may actually play a more dominant role. The “release” only provides the anatomical potential for a normal latch and successful breastfeeding. There is a spectrum of recommendations regarding post-surgical stretching and exercises to prevent readhesion of the surgical site. Recently, the International Affiliation of Tongue-tie Professionals mentioned elevating the tongue 5-8 times daily in the week after surgery to prevent readhesion and the need for revision.
INTERNATIONAL BREAST CERTIFIED LACTATION CONSULTANTS
and early handling of the baby may contribute to alterations in cranial structure that affect normal function. Due to the compression of the skull, sometimes the cranium doesn’t expand evenly, is asymmetrical, and cranial work may be necessary.
PSYCHOLOGIST Postpartum depression can magnify any discomfort at the breast. In this study, rates of maternal postpartum depression were measured in relation to breastfeeding success. Mothers with the lowest rate of postpartum depression were the ones who intended to breastfeed and successfully did so. Mothers with the highest rate of postpartum depression were the ones who intended to breastfeed, but didn’t or couldn’t. It is also important for the new mother to feel competent in her ability to feed her child. This can impact her feeling about motherhood and her relationship to her newborn.
Tongue-tied individuals have developed a pattern or coordinated muscle habit that establishes a muscle memory that has to be changed after the “release.” It is possible that new mothers have no idea what normal breastfeeding is like and need professional guidance to help optimize posiPEDIATRICIAN/FAMILY PRACTITIONER tion and latch. Adjunctive aids like nipple shield, breast pumps, and suck The physician will have timely input on the infant’s genetic predispotraining may be of help. sition for ankyglossia. Syndromes Most babies achieve successsuch as Smith-Lemli-Opitz ful breastfeeding after release. (x-linked), Orodigitalfacial, XThe amount of time is variable; it linked Cleft Palate (TBX gene M.D. seems to take longer for the posmutation), and Van Der Woude D.D.S. terior ties. I.e. type III – IV: this is Lactation Syndrome all have a higher incipossibly due to the delay in diag(IBCLC) dence of ankyglossia. nosis. It is of primary importance The presence of a midline that mothers maintain their supdefect constellation should also R.N. ply by pumping, especially if the be considered if there are other infant is limited in their ability to Chiro. issues. Mother remove breastmilk. Nipple pain NUTRITIONIST for the mother or ability to trans& Suppressed lactation may fer milk should be of primary Child cause decreased milk supply in concern in the decision to treat. S.L.P. the mother. Generally adequate Each dyad should be assessed Family hydration, nutrition, and stimuindividually, most likely by an lation are recommended. IBCLC (International Board CerA galactagogue is a medicatified Lactation Consultant) who O.T./ E.N.T. tion or an herb suspected to help is trained to assess the function of initiate, maintain, or increase the the tongue. P.T. Psych. mother’s milk production. HerbOTOLARYNGOLOGIST al extracts such as fenugreek, (EAR, NOSE AND blessed thistle, and nettle have THROAT) been mentioned. There is insuffiAn Otolaryngologist consulcient evidence in the literature to tation is important in order to establish the diagnosis of ankyglossia and support their safety and efficacy, but success has been reported anecdotrule out concurrent conditions such as submucous cleft and laryngomaally. lacia. Newborns are obligate nasal breathers, which mean they are comA modest increase in expressed breast milk was reported in the Copletely dependent upon breathing through the nose, and cannot breathe chrane Review (Donovan 2012) when the drug domperidone was prethrough the mouth. It is therefore important to address anything which scribed to mothers of preterm infants. might interfere with nasal respiration as this will interfere with feeding whether or not ankyglossia is present. PEDIATRIC DENTIST/ORTHODONTIST Family history is also important as many times parents or siblings The maxillary and mandibular frenums (lip frenums) have often will have had feeding difficulties early on. been implicated for persistent dental diastemas even after orthodontic Dr. James Ochi, a pediatric ENT , showed objective improvement treatment has closed the space. in breastfeeding symptoms after lingual frenotomy for ankyglossia. Dr. Complications in the area involve the insertion of the frenum into Bobby Ghaheri, another pediatric ENT, maintains that “babies who have a notch in the alveolar bone, so that a heavy band of fibrous tissue lies difficulty with breastfeeding are actively in distress, similar to the aban- between the teeth. doned baby – cortisol levels can rise. High cortisol levels and its effects are Recession of the marginal tissue below the cementoenamel junction very complex, needing further research. and loss of attached gingiva can also result from a strong frenum pull. The inability to toilet or clear food particles from the lateral comCHIROPRACTORS/CRANIOSACRAL THERAPISTS missures of the mouth due to a lack of lateral tongue mobility can cause a The birth process, interventions at delivery (forceps), birth trauma
SEPTEMBER / OCTOBER 2016 | THE BULLETIN | 39
chronic erythema and cracking of the tissues there. The pooling of saliva and the buildup of food particles and bacteria creates this chronic condition. A meta analysis involving 41 studies showed that the likelihood of developing a malocclusion was 3 times greater if no breastfeeding occurred; or 1.85 times greater if nonexclusive breastfeeding occurred; or 2.5 times greater if there was a shorter duration of breastfeeding.
OCCUPATIONAL THERAPIST/PHYSICAL THERAPIST Suck/swallow/breath synchrony is an action pattern that coordinates sucking, swallowing, and breathing which allows us to eat and breathe without choking. This synchronized pattern of activity develops even before birth allowing newborns to begin eating right after birth. Atypical development of this pattern can result in many indications for concern and problems. The pharynx is involved with a dual role of feeding and breathing. This dual role can contribute to difficulties if the processes are not coordinated. When differences are noted between nutritive and non-nutritive sucking quality there is concern for some problem in the suck-swallowbreath coordination. Compromised respiratory function in infants often make them unable to adequately accommodate the work of feeding.
SPEECH THERAPIST Speech production and acquisition can be affected by an individual’s personal structural issues (tongue tie), sensory issues, motor issues, and auditory issues. Nicole Archambault, CCC-SLP has presented information making a connection between tongue-tie and ear infections. The lingual frenum restriction can result in swallowing patterns that do not adequately ventilate the eustacian tubes to support optimal middle ear function. There appears to be a relationship between tongue position, tongue thrust, and breathing (sleep apnea).
FAMILY Certainly, the family, both nuclear and extended, are part of the team constellation that will and should contribute towards the success of the breastfeeding process. Physical support in terms of task delegation, activity reorganization, and prioritization are critical. Planning, time management, and flexibility are paramount. Psychological support and encouragement, as well as reasonable expectations, are necessary. Adherence to professional recommendations and open continuous communication insures success.
Thesis, Pacific Oaks College, 1993 4. Ballard, JL; Auer, CE; Khoury, JC: Ankyglossia assessment, incidence, and effect of frenuloplasty on the breastfeeding dyad PEDIATRICS 110:e63 5. Mobi Motherhood International “Massage For Releasing Tension In Muscles Before and After The Release” www. mobimotherhood.org/tongue-and-lip-tie.htm 6. Chang, Christopher: “Posterior Tongue Tie and Its Treatment” www.fauquierent.net 7. Kotlow, L: Academy of Laser Dentistry Presentation “Breastfeeding, Lasers, and Tethered Oral Tissues” Orlando, Florida, April 16,2016 8. Genna, CW SUPPORTING SUCKING SKILLS IN BREASTFEEDING INFANTS (Second Edition) (Jones and Bartlett Learning, Massachusetts, 2013) p.250 9. Ochi, J “Treating Tongue-Tie” CLINICAL LACTATION 2014 5(1) pp. 20-25 10. Ghaheri, Bobby blog post “Breastfeeding Problems Can Affect the Emotional Health of Mom and Baby” www.drghaheri.com 11. Moss, M: “Cranial Work for Infants” www.drmarilynmoss.com 12. Ghaheri, B: Academy of Pediatric Dentistry Presentation “Treatment of Infant Tongue Tie and Lip Tie” San Antonio, Texas May 28, 2016 13. Hazelbaker, AK: TONGUE TIE MORPHOGENESIS< IMPACT ASSESSMENT AND TREATMNT (Aidan and Eva Press, Ohio, 2010) pp.64-65 14. Wilson-Clay, B; Hoover, K: THE BREASTFEEDING ATLAS (FIFTH EDITION) (LactNews Press, Manchaca, Texas, 2013) p.33 15. Proffitt, WR, et. al CONTEMPORARY ORTHODONTICS (FOURTH EDITION) (Mosby, St. Louis, Missouri, 2007) p.569 16. Kotlow, L: The Influence of the Maxillary Frenum on the Development and Pattern of Dental Caries on Anterior Teeth ion Breastfeeding Infants; Prevention, Diagnosis and Treatment JOURNAL OF HUMAN LACTATION 26 (3) pp. 304-308 17. Effect of Breastfeeding on Malocclusions: a systematic review and meta-analysis Acta Paediatrica: 2015:104, pp.54-61 18. Children’s Therapeutics of Austin “Oral Motor Intervention” www.childrenstherapeutics.com 19. Glass, R “Nutrition Assessment:Feeding” www.depts. washington.edu/growing/Assess/Feeding 20. Chang, Christopher “Tongue Tie” www.fauquierent.net 21. Bacon, C “ASHA Article” christiebacon@gmail.com
SUMMARY
ABOUT THE AUTHORS
Our ultimate goal is to provide the proper professional support, guidance, and advice for the mother and child to continue their lives in a healthy manner. If their respective conditions can be improved, it is our responsibility to lead them in this direction. We must be cognizant of allied professional fields that can have a positive impact on the life of the mother and child. We must also not be myopic and realize that certain conditions at birth evolve into causing other conditions later in life.
James W. Ochi, MD Pediatric Otolaryngologist Sharp Rees-Stealy Medical Group San Diego, California
BIBLIOGRAPHY
1. Geddes, D et. al Frenulotomy for Breastfeeding Infants With Ankyglossia: Effect on Milk Removal and Sucking Mechanisms Imaged by Ultrasound PEDIATRICS 122:1; e188-e194 2. Academy of Breastfeeding Medicine “ABM ProtocolsAssessment of Ankyglossia” www.bfmed.org 3. Hazelbaker, AK: The assessment tool for lingual frenum function (ATLFF): Use in a lactation consultant private practice. Masters
40 | THE BULLETIN | SEPTEMBER / OCTOBER 2016
Randy Q. Ligh, DDS, MA Diplomate, American Board of Pediatric Dentistry Private practice, San Jose, California
Rosanne Tedesco, MD, IBCLC Non-practicing Pediatrician and Board Certified Lactation Consultant Parenting and Breastfeeding Services San Jose, California
In Memoriam Richard F. Cain, MD
Wallace Sampson, MD
Allan Vishoot, MD
Family Medicine 7/15/24 – 6/24/16 SCCMA member since 1962
*Internal Medicine Hematology/Oncology 3/29/30 – 5/25/15 SCCMA member since 1963
*Orthopaedic Surgery 4/1/26 – 6/16/04 SCCMA member since 1958
Harry S. Chong, MD *Otolaryngology 7/30/12 – 9/4/14 MCMS member since 1949
Emma O. Dong, MD *Ophthalmology 9/10/13 – 12/11/15 MCMS member since 1941
William E. Goodrow, Jr, MD Pediatrics 7/12/29 – 7/2/15 SCCMA member since 1961
Lawrence B. Hooper, MD *Family Medicine 12/11/28 – 7/15/16 SCCMA member since 1962
J. Ian McNeill, MD Internal Medicine 1/20/20 – 1/11/15 SCCMA member since 1954
Therese Michelson, MD *Anesthesiology 1/1/20 – 6/19/13 SCCMA member since 1966
Harry Oberhelman, MD *General Surgery 1/1/23 – 2/10/16 SCCMA member since 1961
Donald Rawson, MD Pediatrics 1/1/30 – 11/19/15 SCCMA member since 1964
J. Robert Schauwecker, MD *Radiology *Nuclear Medicine 4/26/31 – 12/9/15 SCCMA member since 1966
Frederick Schwertley, MD General Practice 1/1/35 – 3/6/16 SCCMA member since 1966
Boyd Seaman, MD Internal Medicine 10/22/30 – 3/15/15 SCCMA member since 1961
Robert Shelby, MD *Psychiatry 11/29/20 – 6/27/04 SCCMA member since 1955
Virgil Voss, MD *Radiology 1/1/29 – 5/20/16 SCCMA member since 1967
James Weatherholt, MD *Obstetrics and Gynecology 8/27/20 – 9/20/13 SCCMA member since 1953
Theresa Wells, MD *Orthopaedic Surgery 6/24/16 – 4/9/07 SCCMA member since 1955
Frank Wheeler, MD *Internal Medicine 7/8/22 – 12/21/12 SCCMA member since 1955
Gilbert Smith, MD *Urology 9/4/23 – 11/5/14 SCCMA member since 1951
Mansfield Smith, MD Otology *Otolaryngology 1/1/29 – 12/18/14 SCCMA member since 1965
Lewis Sullivan, MD *Obstetrics and Gynecology 1/1/30 – 9/24/05 SCCMA member since 1963
SEPTEMBER / OCTOBER 2016 | THE BULLETIN | 41
King of the Charlatans John R. Brinkley By Michael Shea, MD Leon P. Fox Medical History Committee John R. Brinkley was born July 8, 1885 in North Carolina. His father was John Richard Brinkley, a poor mountain man, who practiced medicine in North Carolina, and served as a medic for the Confederate States Army during the Civil War. John R. Jr. began his career in medical fakery shortly after marrying his first wife, Sally Wike, in 1907. They traveled across the country, posing as quaker doctors. Their show started as a vaudeville act and ended with John R. selling an alcoholic laden drink or a bottle of cathartic pills, either of which would be good for what ailed you. Showing some sign of integrity, they moved to Chicago, where he enrolled in an eclectic medical school (Bennet Medical College). Unable to afford tuition, he withdrew after his third year. He eventually purchased a medical certificate from a diploma mill, the Kansas City Eclectic Medical University. In 1913, the road to success became a bit bumpy. His wife and three children left him and moved to North Carolina. Brinkley then met a man named Crawford and together 42 | THE BULLETIN | SEPTEMBER / OCTOBER 2016
John R. Brinkley, circa 1921
they established a men’s virility clinic in Greenville, South Carolina. They injected their patients with colored water, and charged them $25.00 each. They called the treatment “Electric Medicine from Germany.” In spite of some success, they hastily left town due to 30 or 40 bad checks passed to many of the local merchants. The next stop was Memphis, Tennessee. Here, Brinkley met Minnie Jones, a physician’s daughter, who would remain by his side for a lifetime. They had one child, which they named John Richard Brinkley III. After serving two months in jail for passing the bogus checks in Greenville, he was called into active duty by the army during WWI. Suffering from a nervous breakdown, he lasted only two months in the service. Next, the couple answered a physician wanted ad in Milford, Kansas. They set up a 16 room clinic, which would become famous across the country. At the heart of their success was one of the most infamous surgical procedures in medical history. The origin of this operation is thought to have begun when a local farmer sought treatment for being sexually weak. Brinkley had learned
about the concept of transplanting glands from animals to humans, probably when he was at the Bennet Medical School, but this is not known for certain. At any rate, he transplanted two goat testicles into the farmer’s scrotum. The farmer survived and responded with glowing reports on his sexual health. His wife further confirmed this by delivering a healthy child one year later. Thus began a series of similar operations that would propel the “doctor” to fame and fortune. It also propelled him into the spotlight of the AMA’s Morris Fishbein, MD, who made a career out of exposing medical charlatans. This would prove to be the ultimate downfall of John Brinkley. Taking his famous surgery out of Kansas, he began to have trouble with his medical license as other states failed to recognize the Kansas permit. He decided to explore other avenues for his talents by establishing a radio call-in show named the Medical Question Box. Callers would voice their symptoms and be prescribed medicines of dubious worth through the Brinkley Pharmaceutical Association. This program generated $14,000 per week (or $10,277,600.00 per year in current value). This medical chica-
Continued on page 44
Leon P. Fox Medical History Committee The Leon P. Fox Medical History Committee meets bi-monthly, the first Monday at noon (lunch provided). The purpose of the committee is to identify, collect, and preserve archival material, memorabilia, and artifacts representing the medical history of Santa Clara County. A guest speaker gives a historical presentation at each of the meetings, which is then transcribed for SCCMA’s Medical History archives. If you are interested in joining this committee, please contact Pam Jensen at SCCMA at (408) 998-8850 or pjensen@sccma.org. SEPTEMBER / OCTOBER 2016 | THE BULLETIN | 43
King of the Charlatans, from page 43 nery eventually lost him his medical license in Kansas. Turning to politics in order to change his fortune, he ran for governor of Kansas in 1930. In spite of being a write-in candidate, he finished with 29% of the vote. Though this did not win the election, it did show his popularity in Kansas. Time began to run out for the goat gland doctor. He had lost his medical license, his bid for governor, and his medical radio program (even his private radio station was closed down). In 1938, Morris Fishbein published a two-part series called “Modern Medical Charlatans.” This exposed his questionable credentials, and repudiated his entire medical career. Brinkley sued Fishbein for libel and $250,000 in damages. He lost. The verdict unleashed a barrage of lawsuits (at least 42 patients had died due to complications of his gland surgery) resulting in awards totaling three million dollars. He declared bankruptcy in 1941. The IRS was after him for tax fraud and the U. S. Post Office was investigating him for mail fraud. After suffering three heart attacks, he died at age 57, penniless, in San Antonio on May 26, 1942. He was buried at Forest Hill in Memphis, Tennessee. His house, commonly called the Brinkley Mansion still stands today in Del Rio and has been designated Texas Historic Landmark number 13015.
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Locum Tenens ~ Permanent Placement V oi ce: 8 0 0 - 9 1 9 - 9 1 4 1 or 8 0 5-641-9141 FA X : 8 0 5 - 6 4 1 - 9 1 43
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Become an “Active” Member of the SCCMA, from page 6 or patients, while other policy created years ago affects every patient and physician in California. (Translation— very important stuff happens here.) The delegates to HOD “meet” virtually quarterly and decide how they view various policy proposals. All the delegates then meet once a year for a weekend to discuss 5-8 major topics of interest to HOD. This year, some of the topics will be MACRA, Physician Burnout, Opioids, Recertification and Maintenance of Certification, and ACA changes as it relates to section 1332 waiver. 4. The SCCMA has many committees that meet on a regular basis. There are councilors from each hospital which form the Council, and along with the Executive Committee, meet 7-8 times a year to discuss topics of importance, but probably more beneficial, to be educated from experts regarding topics of interest. Council meetings are open to all members of SCCMA and meet the first Tuesday of the scheduled month. In addition, there are many committees that meet less frequent. They vary from the Bioethics Committee, to the Medical History Committee, to the Environmental Health Committee. The best part of these activities that take place at the SCCMA offices on Empey Way is meeting like-minded and enthusiastic local physicians. Each one of these four ways to improve health care in our county and state are very important and worth the time and energy expended. As you have noticed, each activity requires an increasing commitment, but in return I find also produced a bigger return for me. I am asking you to take that first step like I did and become an “active” member of the SCCMA. I have gotten much more out of it than I have given. I would be thrilled to talk to anyone who is interested in any of these options and help guide you to more information.
Classifieds OFFICE SPACE FOR RENT/LEASE OFFICE FOR LEASE/SUBLEASE O’Connor Hospital area with office lease/ sublease. Please contact Dr. Maggie Chau at 408/799-7842 for details.
MEDICAL OFFICE SPACE FOR LEASE • SANTA CLARA Medical space available in medical building. Most rooms have water and waste. Reception, exam rooms, office, and lab. X-ray available in building. Billing available. 2,500–4,000 sq. ft. Call Rick at 408/228-0454.
MEDICAL SUITES • GILROY First class medical suites available next to Saint Louise Hospital in Gilroy, CA. Sizes available from 1,000 to 2,500+ sq. ft. Time-share also available. Call Betty at 408/848-2525.
MEDICAL OFFICE SPACE TO SHARE • SUNNYVALE Convenient location. One large private office plus one exam room, shared waiting room and front office. Newly built, total 1,280 sq. ft. Available now. Please call 408/438-1593.
MEDICAL OFFICE SPACE TO SHARE • CAMPBELL Convenient location. 5+ exam rooms M-F. In-office digital x-ray. Two large private offices, shared waiting room and front office. Total office size 3,000 sq. ft.
smile.amazon.com A great way to support your Alliance When you shop at AmazonSmile, Amazon donates 0.5% of the purchase price to Santa Clara Medical Association Alliance Foundation Inc. Bookmark the link http://smile.amazon.com/ ch/27-1977428 and support us every time you shop.
Available now. Call 408/376-3305 or marlene@svspine.com.
MEDICAL OFFICE SPACE TO SUBLET • MTN VIEW Mountain View Medical Office space to sublet. 1,100 sq. ft. Available three days a week. In large medical complex, behind El Camino Hospital. Basement storage, utilities included. Large treatment rooms, small lab space, bathroom, private office, etc. Call Dr. Klein. Cell 650/269-1030.
FOR LEASE/SALE • LOS GATOS 2,946 sq. ft. well designated office near Good Samaritan Hospital. Upstairs from Los Gatos Surgery Center. Six large exam rooms, two small exam rooms, two consultation rooms, one large lab, one large billing office, three bathrooms, and lunch room. Call 408/356-5027.
FOR RENT • LOS GATOS 1,600 sq. ft. space, with two exam rooms and one office with bathroom for rent. Shared waiting room, kitchen and lab. Private window check-in for shared condo in Los Gatos, in the Los Gatos Surgical building. Call 925/337-4583. Available immediately. Will renovate with new carpet and paint prior to move in.
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.
FOR SALE FOR LEASE/SALE • LOS GATOS 2,946 sq. ft. well designated office near Good Samaritan Hospital. Upstairs from Los Gatos Surgery Center. Six large exam rooms, two small exam rooms, two consultation rooms, one large lab, one large billing office, three bathrooms, and lunch room. Call 408/356-5027.
MEDICAL WEIGHT LOSS PRACTICE / RETIREMENT SALE Proven, highly recognized, and profitable established weight loss practice in beautiful Marin County. Current six figures, room for expansion. Work-life balance, time freedom, financial security, relationship-driven practice. I am 100% committed in assisting the new owner with all the support necessary to ensure a smooth transition. Please contact me for more information or to schedule a visit. Gail Altschuler, MD at 415/309-6258 or drgail@marinweightloss.com.
METRO MEDICAL BILLING, INC.
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SEPTEMBER / OCTOBER 2016 | THE BULLETIN | 45
MEMBERSHIP
Welcome 122 New Members Santa Clara County Medical Association Name Natasha Abadilla Mary Abusief Bahar Aghighi Alvaro Amorin Estela Ayala Amee Azad Denise Babin Pete Baumeister Andrew Bellino Elena Brandford Ryan Brewster Susan Butler John Chan Allen Chang Jerome Chelliah Calvin Chen Erica Chimelski Matthew Chin Namisha Chotai Anthony Cordova Saroja Dandamudi Monique Debruin Bart Dolmatch Ritika Dutta Bonnie Dwyer Emily Earl-Royce Victor Eng Jamie Everett Julia Fridland Jaclyn Gadbaw Marianne Ghobrial Anitha Gundupalli
City Specialty Stanford US San Jose REI Los Gatos END Stanford US Mountain View US Stanford US San Jose FP Palo Alto EM Mountain View EM Stanford US Menlo Park US Los Gatos D San Francisco OBG Mountain View EM Palo Alto OBG Mountain View US Mountain View EM Los Altos IM Sunnyvale FP Stanford US Santa Clara IM Sunnyvale US Mountain View R Irvine US Mountain View MFM Stanford EM Stanford US Mountain View EM Sunnyvale OBG Mountain View FP Mountain View IM Sunnyvale IM
Name Audrey Hall Alvin Haynes, CMO Helene Hoi Elizabeth Huffman Yves Jodesty Natalia Johnson Timothy Keyes David Kim Fabio Komlos Savitha Krishnan Andrew Lai Erin Lally Steve Lee Shelley Leong Kevin Li Ross Liebman Hanna Linstadt Paloma Marin-Nevarez Daniel Martinez Jung Gi Min Jennifer Minor Melissa Nguyen Adebukola Onibokun Mark Owolabi Lisa Packard Neda Pasyar Courtney Pedersen Judith Pelpola Bradford Perkins Nhung Pham Kwan Pun Katherine Putz
City Specialty San Jose PD San Jose IM Mountain View PD Mountain View PD Santa Clara IM Los Gatos IM Menlo Park US Atherton EM Mountain View R Mountain View OBG Los Altos EM San Jose OPH Mtn View CD Campbell IM Stanford US Sunnyvale SM Sunnyvale EM Stanford US Milpitas GP Walnut Creek US Santa Clara IM Santa Clara FP Campbell NS San Jose US Mountain View OBG Mtn View PEM Palo Alto US Stanford US Los Gatos FP Sacramento IM Mountain View IM Mountain View UC
Name City Specialty Zhen Qian Stanford ORH Robert Quint San Jose CD Kerisimasi Reynolds Campbell OSM Nina Rezai San Jose PD Marisa Rivera Santa Clara IM Joseph Romero Sunnyvale EM Siegfried Rotmensch Mountain View MFM Naghmeh Rowhani Santa Clara PD Gurpreet Sarao Los Gatos FP Sachin Shah San Francisco CTS Wen Shen Mountain View PD Katerina Shetler Mountain View GE Yekaterina Shpanskaya Menlo Park US Meena Song Sunnyvale IM Matt Stevenson Mountain View EM Kristen Strength Santa Clara OBG Shoba Subramanian Mountain View END Dina Sukharev Los Gatos FP Joseph Ta Palo Alto OTO Pei Tsau Palo Alto US Vipul Vachharajani Stanford US Shivam Verma Palo Alto US Keir Warner Stanford EM Cynthia Weller Mountain View AN Kathryn Wheeler Sunnyvale PD Chris Winstead-Derlege Menlo Park EM Thomas Wolfe Mountain View N Amy Wong Mountain View MFM Thee Wong San Jose IM Akira Yamamoto Mountain View OSM Soo-Hyun Yoon Mountain View PEDUC Sohail Yousufi San Jose IM
Monterey County Medical Society Name Isabelle Barnard Christopher Carver Gary Chang Jonathan Choi Dragan Dimitrov Anthony Filly Jeffrey Fiorenza Joan Frisoli Lloyd Garren
City Specialty Monterey GE Salinas NS Monterey AN Monterey N Monterey NS Carmel R Monterey IM Carmel R Monterey GE
Name Richard Garza Sohrab Gollogly Gus Halamandaris Ernst Hansch Richard Hell Jan Kamler Samera Kasim Toby Katz Jennifer Keir-Garza
City Specialty Monterey GS Monterey OSM Salinas NS Monterey R Monterey GE Monterey GE Monterey ORS Monterey GE Monterey OTO
US - Unspecified 46 | THE BULLETIN | SEPTEMBER / OCTOBER 2016
Name Michael Le James Lin Michael Mendoza Walter Mills Susan Roux Kalle Varav Gerald Wahl Patrick Wong
City Specialty Monterey GE Monterey OSM Monterey GE Salinas FP Carmel Valley DR Monterey AN Salinas N Monterey PMM
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