ACCMA September/October 2019 Bulletin

BULLETIN ALAMEDA-CONTRA COSTA MEDICAL ASSOCIATION

Serving East Bay physicians since 1860

ISSUE FOCUS:

September/October 2019

Telemedicine/Telehealth

Helping People in Our Community Since 1996

A L A M E D A

C O U N T Y

www.alamedaalliance.org

ACCMA EXECUTIVE COMMITTEE Lubna Hasanain, MD, President Katrina Peters, MD, President-Elect Suparna Dutta, MD, SecretaryTreasurer Thomas Sugarman, MD, Immediate Past President COUNCILORS & CMA DELEGATES Eric Chen, MD Robert Edelman, MD Rollington Ferguson, MD Harshkumar Gohil, MD Russ Granich, MD James Hanson, MD Shakir Hyder, MD Alexander Kao, MD Irina Kolomey, MD Terence Lin, MD Lilia Lizano, MD Abbas Mahdavi, MD Joshua Perlroth, MD Jeffrey Poage, MD Stephen Post, MD Thomas Powers, MD Richard Rabens, MD Steven Rosenthal, MD Katrina Saba, MD Suresh Sachdeva, MD Ahmed Sadiq, MD Jonathan Savell, MD Edmon Soliman, MD Judith Stanton, MD Michael Stein, MD CMA & AMA REPRESENTATIVES Patricia L. Austin, MD, AMA Delegate Mark Kogan, MD, CMA Trustee, AMA Alternate-Delegate Suparna Dutta, MD, AMA Alternate Delegate (at Large) Ronald Wyatt, Jr., MD, CMA Trustee MEMBERSHIP & COMMUNICATIONS COMMITTEE Mark Kogan, MD, Chair Patricia Austin, MD Sharon Drager, MD Robert Edelman, MD James Hanson, MD Jeffrey Klingman, MD Stephen Larmore, MD Terence Lin, MD Irene Lo, MD Lamont Paxton, MD Katrina Peters, MD Frank Staggers, Jr., MD Ronald Wyatt, MD

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NEWS & COMMENTS

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PRESIDENT’S PAGE What We’ve Accomplished Together

By Lubna Hasanain, MD, ACCMA President

TELEHEALTH/ DIGITAL HEALTH 9 CMA 2019 House of Delegates Major Issue: Digital Health By the California Medical Association

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How Telehealth is Affecting the Health Care Landscape Summarized from a White Paper by FAIR Health

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September/October 2019 | Vol. LXXV, No. 5

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The Disenfranchised Physician and the Digital Health Revolution

By Gary A. Goldman, DDS, MD

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Increasing Accessibility: Combining Telehealth with Mental Health Services

By Scott Coffin, CEO, Alameda Alliance for Health

CLINICAL NEWS 18

Don’t Drop Your Patient By the California Department of Public Health

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ACCMA AT WORK 17

Join Us for the ACCMA 2019 Annual Meeting

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East Bay Times Letter to the Editor

By Lubna Hasanain, MD, ACCMA President

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Surviving the Stress of Being Sued

By Frank Staggers, Jr., MD, Chair, ACCMA Litigation Stress Committee

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COUNCIL REPORT

Ketamine: The Next Breakthrough for Depression?

By the Medical Insurance Exchange of California

Where Federal Health Data Policy Meets Privacy By the American Medical Association

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Serving East Bay physicians since 1860

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ACCMA STAFF Joseph Greaves, Executive Director Mae Lum, Deputy Director Jan Jackovic, Director of Operations Griffin Rogers, Director, Napa & Solano County Medical Societies David Lopez, Assoc. Dir. of Advocacy & Policy Essence Hickman, Operations Coordinator Jennifer Mullins, Education and Events Coordinator Hannah Robbins, Communications Coordinator Aimee Robinson, Physician Engagement Coordinator

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NEW MEMBERS

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IN MEMORIAM

ALAMEDA-CONTRA COSTA MEDICAL ASSOCIATION 6230 Claremont Avenue, Oakland, CA 94618 Tel: 510/654-5383 Fax: 510/654-8959 www.accma.org

REDUCE – REUSE – RECYCLE Printed in the U.S.A. with soy inks on paper stock certified by the Forest Stewardship Council.

ACCMA BULLETIN | SEPTEMBER/OCTOBER 2019

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NEWS & COMMENTS

CA’S NEW CONTRACTOR LAW WILL NOT DIRECTLY IMPACT PHYSICIANS

In early September, Gov. Gavin Newsom signed AB 5 – a bill that will reclassify hundreds of thousands of workers as employees instead of independent contractors. The bill may have impacts in healthcare, but the California Medical Association (CMA) fought hard to ensure that the interests of physicians were protected under the bill. CMA successfully secured an exemption for physicians from the legislation. The exemption made explicit in AB 5 as it pertains to physicians is comprehensive, ensuring that physicians are not unduly influenced by a corporate entity when practicing medicine. Dentists, podiatrists, psychologists, and veterniarians were also covered under the exemption, however other health care workers, including physician assistants, nurses, and behavioral health providers will be impacted by the bill. CMA will continue to monitor the implementation of AB 5 and its impact on physicians, patients, and the health care industry. Read more: https://bit. ly/2mmzplW

GOVERNOR GAVIN NEWSOM SIGNS CALIFORNIA VACCINE LAW SB 276

On Monday, September 9, Gov. Gavin Newsom signed a California vaccine oversight bill, SB 276, into law after revising the bill to clarify which medical exemptions will remain valid.

The law will allow the California Department of Public Health to develop a standard medical exemption form that doctors must use, which would go in a statewide database once completed.

CMA President, David Aizuss, M.D., commented, “The physicians of the California Medical Association want to thank the leadership, and particularly Dr. Pan, for showing the leadership to protect public health and ensure physicians are doing their part to protect community immunity and offering highquality, ethical care to their patients.” Read more: https://bit. ly/2lTsAb7

CMA AND ALEDADE, INC. TEAM UP WITH ALTAIS

Altais, a new healthcare services company, has announced a new initiative to help physicians optimize their practice workflows and support value-based care by entering into a collaboration with Washington D.C. area-based Aledade, Inc., and the California Medical Association (CMA). The initiative promises to bring innovative workflow technology and services to physician practices, as well as work with payers to offer value-based arrangements that reward physicians for improved patient care and outcomes. The collaboration targets independent physicians in California, and has been under development

by CMA, Aledad, and Altais for some time. In May, Aledade and CMA together announced a collaboration that aimed to create physician-led accountable care organizations (ACOs)

throughout California to participate in the government-sponsored Pathways to Success Medicare Shared Savings Proogram (MSSP); the first of these Medicare ACOs will be launched in January 2020. With the broader partnership that now includes Altais, physicians will have an opportunity over time to positively impact many more of their patients with the addition of value-based care arrangements for their commercially insured population. Blue Shield has agreed to support the value-based agreement by working with Altais and Aledade in 2020. Read more: https://bit.ly/2kftxKa

LEGISLATURE PASSES BILL REQUIRING PAYMENT FOR TELEHEALTH SERVICES

On Friday, September 13, the California Legislature approved a CMA-sponsored bill, AB 744, aimed at increasing patient access through telehealth. The bill will require health insurers to cover services provided via telehealth in the same way that they would an in-person encounter after January 2, 2021. The bill now awaits Gov. Gavin Newsom’s signature.

Patient access to providers and health care services is an ongoing concern throughout the state. Telehealth overcomes access and cost barriers by utilizing technology to better harness physician time and expertise, and connects patients to their care providers more quickly, efficiently, and conveniently.

Read more: https://bit.ly/2krfGAM

STATE FY 19-20 BUDGET CONTINUES MEDICAL SUPPLEMENTAL PAYMENTS

In June 2019, Gov. Gavin Newsom signed the state budget, which included significant new funding for health care programs, including the increased payment on 23 CPT codes in both the fee-for-service and Medi-Cal managed care delivery systems. DHCS and the Governor’s administration have committed to continuing these supplemental payments for 2.5 years. The budget also includes new funding from Prop 56, including: funding for Medi-Cal Value-Based Payments Program, with specific funding delegated towards behavioral health integration; funding for supplemental payments for developmental and trauma screening, as well as funding over three years to train providers to conduct the screenings; and an additional $120 million in funding for the physician and dentist loan repayment program (CalHealthCares). Read more: https:// bit.ly/2kPIsv1

CMS ACCEPTING HARDSHIP EXCEPTIONS FOR 2019 REPORTING YEAR

The Centers for Medicare and Medicaid Services (CMS) is now accepting hardship exceptions from the Medicare Quality Payment Program (QPP) for the 2019 reporting year.

Physicians and groups who qualify for QPP’s Merit-Based Incentive Payment System (MIPS) can submit a hardship

FOR THE LATEST NEWS, GO TO THE ACCMA WEBSITE AT WWW.ACCMA.ORG/NEWS.

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ALAMEDA-CONTRA COSTA MEDICAL ASSOCIATION BULLETIN

NEWS & COMMENTS

exception application if they meet criteria for the Promoting Interoperability Hardship Exception, or for the Extreme and Uncontrollable Circumstances Exception. The application window will close December 31, 2019. Read more: https://bit. ly/2kjtgWD

CIGNA DISCONTINUES PAYMENT FOR CONSULTATION SERVICES

Cigna recently announced that it will no longer reimburse consultation services, effective for claims processed on or after October 19, 2019. Consultation services previously represented

by CPT codes 99241-99245 and 99251-99255 will need to be billed utilizing the appropriate evaluation and management (E/M) procedure code that describes the office visit, hospital care, nursing facility care, home service or domiciliary/rest home care. Earlier this year, UnitedHealthcare announced that it would no longer reimburse consultation services. Read more: https://bit.ly/2kft76y

UHC EXPANDING LIST OF PROCEDURES REQUIRING PA

United Healthcare (UHC) recently announced in their September 2019 Network Bulletin that they will be expanding the list of surgical procedures that will require prior authorization when performed in the hospital outpatient setting, effective December 1, 2019. UHC plans on adding additional procedures and CPT codes to the current list of services that are subject to review to determine whether the outpatient hospital site of service is medically necessary. This update will not affect procedures performed in an in-network ambulatory surgery center. Read more: https://bit.ly/2kjvIMP

Practice & Liability CONSULTANTS Health Care Practice Management In a special arrangement with Practice & Liability Consultants, ACCMA members may purchase the following practice management kit at a reduced price: • Office StaffPersonnel Policies an d Procedures Manual

Practice consulting services available.

Debra Phairas 461 Second Street, Suite 229 San Francisco, CA 94107 (415) 764-4800 Fax (415) 764-4802 www.practiceconsultants.net

UPCOMING EVENTS

THE PHYSICIAN LEADERSHIP PROGRAM Kick-off Session: Saturday, October 19, 2019 Five Evening Sessions: October 2019 – January 2020 Register online at learning.accma.org/ Leadership ACCMA Offices, 6230 Claremont Ave., Oakland

TELEHEALTH/ TELEMEDICINE 101

Tuesday, October 22, 2019 | 6:00 – 9:00 PM Register online at learning.accma.org Dinner Included | CME Available | Free for Members; $99 for Non-members ACCMA Offices, 6230 Claremont Ave., Oakland

ACCMA ANNUAL MEETING

Friday, November 8, 2019 | Reception begins at 6:00 PM Register online at www.accma.org/events.

For more information, please see the flyer on page 16

EMPLOYMENT LAW: BEST PRACTICES FOR MEDICAL OFFICES Thursday, November 14, 2019 | 6:30 – 8:30 PM Register online at learning.accma.org Dinner Included | Free for Members; $49 for Non-members ACCMA Offices, 6230 Claremont Ave., Oakland

SURVIVING THE STRESS OF BEING SUED AND MINIMIZING THE RISK THAT IT WILL HAPPEN AGAIN Thursday, November 21, 2019 | 6:00 – 9:00 PM Register online at learning.accma.org Dinner Included | CME Available | Free for Members; $99 for Non-members ACCMA Offices, 6230 Claremont Ave., Oakland

TO VIEW A FULL LIST OF UPCOMING EVENTS AND TO REGISTER ONLINE, VISIT LEARNING.ACCMA.ORG!

ACCMA BULLETIN | SEPTEMBER/OCTOBER 2019

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PRESIDENT’S PAGE

What We’ve Accomplished Together

By Lubna Hasanain, MD, ACCMA President

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t has been an honor to serve as your ACCMA President over the past year. The ACCMA is a unique organization that is deeply committed to supporting its members and advancing the medical profession, and to giving voice to the patients we serve.

It has been a wonderful experience to help lead our collective efforts over the past year, and I am very proud of what we have accomplished: • Preserving access to pediatric services – ACCMA advocated to preserve access to pediatric services at UCSF Benioff Children’s Hospital of Oakland in response to efforts

by UCSF to consolidate and integrate services with its Mission Bay campus. One outcome of our efforts was the development of a multi-stakeholder process that includes ACCMA members, which will enable community physicians to collaborate with UCSF leadership to ensure appropriate access to pediatric services in our community.

• Protecting youth at risk for opioid misuse – Under the auspices of ACCMA’s East Bay Safe Prescribing Coalition, we have launched a collaboration with the Alameda County Probation Department to explore the opioid epidemic’s effect on justice-impacted youth and explore preventions and interventions that could help reduce harm to this vulnerable patient population.

• Improving vaccination rates – Under CMA’s leadership, we advocated in favor of SB 276, navigating a nasty political fight with anti-vaccine campaigners to pass a law that will make it harder to issue medical exemptions without having a valid medical exemption.

• Maintaining access to health care services for immigrants – Last month, I wrote a letter to the editor in the East Bay Times opposing the Trump Administration’s changes to the “public charge” rule rule (see page 21). The rule allows US immigration officials to deny citizenship and green cards to legal immigrants based on past and potential future use of public benefits, including Medicaid. This will cause legal immigrants to refrain from using health-care benefits for which they are eligible, even preventative care such as vaccines for children.

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Fair contracting with health plans – Over the summer, we met with our congressional representatives to advocate for a sensible approach to eliminating surprise medical bills, one that will hold health plans accountable for contracting fairly with physicians. We also supported CMA’s efforts to pass AB 744, which is a critical step toward improving access to quality health care across California by ensuring that health care providers are adequately reimbursed for telehealth services.

• Launching a clinician wellness consortium – I am proud to be co-chairing a new initiative to bring together health systems, medical groups, hospitals, clinics, and other provider organizations to identify and disseminate best practices; identify and/or develop programs, services, and resources that can help support clinician wellness; and identify drivers of clinician burnout that can inform local, state, and national advocacy priorities.

• Expanding leadership development – We have been working to expand our Physician Leadership Program, which offers manageable, high quality, affordable leadership skills training. ACCMA received two rounds of grant funding from The Physicians Foundation to support program development, and we are expanding the program to include an intermediate level course in Spring 2020. It will be a deeper dive into the principles and practices of physician leadership.

• Fighting against AB 1404 – Over the past year, the ACCMA has partnered with physicians all over California to oppose AB 1404, a bill that would require nonprofit health care entities to disclose a contracted physician’s personal compensation information to the California Secretary of State for public inspection. Since our opposition, the bill has been made inactive.

These are just a handful of the many accomplishments that we have achieved in the past year. Overall, the ACCMA remains a vibrant, strong, and healthy organization with more members than ever; passionate, dedicated and engaged physician leaders; and a wide range of activities, programs, and services for our members. And, most importantly, the ACCMA continues to give continued on page 13 ACCMA BULLETIN | SEPTEMBER/OCTOBER 2019

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PRESIDENT’S PAGE

ALAMEDA-CONTRA COSTA MEDICAL ASSOCIATION PRESENTS...

Telehealth/Telemedicine 101 Tuesday, October 22, 2019 | 6:00 - 9:00 PM ACCMA Offices, 6230 Claremont Ave., Oakland CME Available | Dinner Provided An educational opportunity for physicians and community members to develop an understanding of technology within telehealth/ telemedicine, how to practice telehealth/telemedicine, and what can & cannot be done when practicing telehealth/telemedicine.

LEARNING OBJECTIVES At the completion of this activity, the learner will be able to: •

Learn how to practice telehealth/telemedicine by understanding the different techniques that are being used when practicing telehealth/telemedicine

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Will be able to understand the ground rules for what can and cannot be done when practicing telehealth/ telemedicine

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Effectively be able to understand the different forms of technology that are associated with telehealth/ telemedicine

REGISTRATION FEES ACCMA members: FREE Non-members: $99

SPEAKERS Dr. Milton Chen is cofounder and CEO of VSee - the telehealth company behind NASA Space Station, Walgreens, Trinity, DaVita, MDLIVE, and 1200 others.

Dr. Geoffrey Rutledge is Cofounder and Chief Medical Officer at HealthTap, where he developed HealthTap’s network of 100,000+ US-licensed doctors in 147 specialties Michael D. Anderson is a Risk Specialist and Supervisor of Patient Safety & Risk Management with Medical Insurance Exchange of California (MIEC) in Oakland, CA. Accreditation Statement: The Alameda-Contra Costa Medical Association is accredited by the Institute for Medical Quality/ California Medical Association (IMQ/CMA) to provide continuing medical education for physicians.

Credit Designation Statement: The Alameda-Contra Costa Medical Association designates this live activity for a maximum of 2.5 AMA PRA Category 1 Credits(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Registration Information Please register online - Go to learning.ACCMA.org and select the program from the calendar. You may also fax this form to 510-654-8959, send it by mail to the ACCMA at 6230 Claremont Avenue, Oakland, CA 94618, or call the ACCMA at 510-654-5383.

Practice Name / Med Group: _________________________________________________________________________ Attendee:___________________________________________ Email: __________________________________________ Attendee:___________________________________________ Email: __________________________________________ Fax: ____________________________________________ Phone:______________________________________________ FOR NON-MEMBERS: Credit Card Number:___________________________________________ Security code:__________ Exp.:_______ Name as it appears on card: _________________________________________________________________________ Billing Address: ______________________________________________________________________________________

CMA MAJOR ISSUE

CMA 2019 House of Delegates Major Issue: Digital Health By the California Medical Association

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ew developments in the digital health field are appearing at a rapid pace. These technologies impact multiple areas of medicine, including diagnosis and treatment, medical records and data, and patient access to care. The selection of digital health as a major issue would focus on educating the House of Delegates and seeking input on the following four topics as they relate to digital health. The House of Delegates meeting is a yearly meeting in which over 500 CA physicians convene to debate on the most critical issues affecting members, the CMA and county medical societies, and the practice of medicine.

ARTIFICIAL INTELLIGENCE Artificial intelligence (AI) and machine learning have the potential to transform the way physicians practice medicine. AI is able to analyze large and complex data sets and could be used to draw data directly from EHR for use in prognostic algorithms that are more accurate than current prognostic models. Artificial Intelligence is already being used to analyze medical images in fields such as radiology and ophthalmology. AI is being used for administrative tasks in hospitals, such as optimizing schedules and reading faxes. AI may also be used to relieve some of the administrative burdens on physicians, saving both time and money and improving physician wellness.

BLOCKCHAIN Though blockchain is most widely known for its use in digital occurrence, it has extensive applications in other fields, including medicine. Blockchain is a secure database, or ledger, spread across multiple computers. Since all users have the same record of all transactions, it is not possible to tamper with the record.

Blockchain has the potential to be used for medical records, where privacy and trust are of paramount importance. It will enable users to move their records across systems in a secure fashion, thus enabling greater interoperability without compromising data security. Blockchain is also being used for “smart contracts” that contain automatic payment provisions upon delivery or rules about how they can be modified or transferred.

DATA MANAGEMENT AND MOBILE HEALTH APPLICATIONS There is currently a trend towards enabling patients to manage

and track their own data. Fitness monitors and watches collect an ever-increasing amount of data on individuals, including activity level, heartrate measurements, and sleep patterns. Apple has plans to ask organizations to let patients use their smartphones to download their own medical records. New prescription apps are being developed to help patients manage their own conditions on a daily basis between their appointments with their physicians. These new technologies raise concerns, including the lack of transparency on how companies are using consumer data.

Patients may also be accessing large amounts of health information without a physician to interpret and explain the data to them.

TELEHEALTH In recent years, the telehealth industry has developed technologies that aim to increase access to care and improve health outcomes for beneficiaries. The rise of direct-to-consumer telehealth companies like Teladoc, American Well, and Doctor on Demand offer patients with minor illnesses around-the-clock access to a physician via telephone or videoconferencing and are indicators that consumer and providers want to use technology in an effort to increase access. Reportedly, there were 1.25 million direct-to-consumer telehealth visits in 2015, with Teladoc providing approximately 600,000 visits – double their visits of the previous year. A survey of large employers indicated that 90 percent of them plan to offer a direct-to-consumer telehealth option to their employees in 2017. For physicians, the adoption of telehealth technologies in order to increase access, the ability to receive reimbursement for telehealth treatment and concerns around liability have dominated the discussion on how to implement telehealth in one’s practice.

“At the end of the day, success must be defined by a patient’s ability to access quality care in an affordable and timely manner,” said David Aizuss, MD, President of the California Medical Association. “CMA remains committed to working with stakeholders and policymakers to develop targeted, pragmatic and workable solutions that reduce health care costs for our patients.”

The full CMA Digital Health Report will be approved at the House of Delegates on October 26–27, 2019. A summarized report of the major issues will be published in a later issue of the ACCMA Bulletin. For questions, please contact David Lopez, ACCMA Associate Director of Advocacy and Policy, at (510) 654-5383 or dlopez@accma.org.

ACCMA BULLETIN | SEPTEMBER/OCTOBER 2019

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PHYSICIAN WELLNESS

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NATIONAL TRENDS IN TELEHEALTH

How Telehealth is Affecting the Health Care Landscape Summarized from a White Paper by FAIR Health

To read the entire report, go to fairhealth.org/publications/whitepapers

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elehealth or telemedicine, the remote provision of clinical services through telecommunications technology, has been growing rapidly in recent years.1 State and federal legislation and regulation have been increasingly broadening access to telehealth.2 A 2019 survey found that physician adoption of telehealth increased 340 percent in three years, from 5 percent reporting having used video visits to see patients in 2015 to 22 percent in 2018.3 Another 2019 survey found that just over half (51 percent) of internal medicine physicians and subspecialists who are members of the American College of Physicians work in a practice that has implemented at least one of five telehealth services.4 In a recent white paper, FAIR Health drew on their repository of over 29 billion private healthcare claim records—the largest in the nation—to analyze telehealth and other alternative venues of care, as well as emergency rooms (ERs).5 The study found that national utilization of telehealth grew 53 percent in the single year from 2016 to 2017, more than any other place of service studied for that variable—urgent care centers, retail clinics, ambulatory surgery centers or ERs. The study shed light on different aspects of telehealth, including geography, age, gender and diagnoses.

Telehealth can be divided into four broad types.6 • Provider-to-provider telehealth involves consultation between healthcare professionals.

• Provider-to-patient–non-hospital-based telehealth. The provider and the patient communicate via telehealth without relation to a hospital. For example, a patient who is home and has not had a recent hospitalization has a video chat with a provider to show his or her rash.

• Provider-to-patient–discharge telehealth. The telehealth visit is a follow-up after the patient is discharged from an inpatient stay in the hospital.

• Physician-to-patient–ED/inpatient telehealth. The patient is in the hospital, whether in the ED or as an inpatient, communicating via telehealth with a physician.

NATIONAL TRENDS OVER TIME From 2014 to 2018, use of non-hospital-based provider-to-patient telehealth increased at a rate greater than other types of telehealth,

growing 1,393 percent. By comparison, usage of all telehealth grew 624 percent.

The telehealth type with the next greatest increase from 2014 to 2018 was physician to patient–ED/inpatient. Usage of that type grew 397 percent. Discharge-related provider-to-patient telehealth followed at 240 percent growth, and the lowest rate of growth was in the provider-to-provider category, which had an increase in usage of 131 percent. In 2018, non-hospital-based provider-to-patient telehealth accounted for 84 percent of all telehealth claim lines, compared with 52 percent in 2014.

RURAL AND URBAN AREAS Claim lines for telehealth overall have recently been growing more rapidly in urban than rural areas, with an increase of 1,289 percent in urban areas compared to 482 percent in rural areas from 2012 to 2017.7 At the level of types of telehealth, however, the picture is more complex.

Usage of non-hospital-based provider-to-patient telehealth from 2014 to 2018 reflects the recent rural/urban pattern of telehealth overall. In urban areas, claim lines for non-hospital-based provider-to-patient telehealth increased 1,227 percent. In rural areas, the increase from 2014 to 2018 was smaller: 897 percent.

However, for discharge-related provider-to-patient telehealth claim lines, this type of telehealth increased more in rural than urban areas from 2014 to 2018. In rural areas, the increase was 407 percent, while in urban areas, the increase was 157 percent.

For provider-to-provider telehealth, the rural/urban pattern from 2014 to 2018 differs again, with an increase in rural areas (68 percent) but a decline in urban areas (minus 24 percent).

AGE AND GENDER DISTRIBUTION In the period 2014–2018, the age group most associated with telehealth overall was that of individuals aged 31–40. Claim lines for that age group made up 21 percent of the distribution of all telehealth claim lines. The age group 41–50 followed closely with 20 percent of the distribution, then the 51–60 age group with 19 percent and those over 60 with 18 percent. In total, the age range 31 and older accounted for 78 percent of the distribution, individuals 30 and younger for 22 percent. continued on page 13 ACCMA BULLETIN | SEPTEMBER/OCTOBER 2019

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CMA ADVOCACY

ALAMEDA-CONTRA COSTA MEDICAL ASSOCIATION PRESENTS...

Employment Law:

Best Practices for Medical Offices Thursday, Nov. 14, 2019 | 6:30 - 8:30 PM ACCMA Offices, 6230 Claremont Ave., Oakland Dinner will be provided Make sure your practice is reviewing its policies to ensure ongoing compliance.

SPEAKER Pamela Tahim Thakur is the managing attorney of Thakur Law

TOPICS

Firm, APC. Pamela Tahim Thakur is

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Independent Contractor vs. Employee

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Exempt vs. Non-Exempt Employees

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Tracking Attendance, Breaks & Lunch

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Preventing Harassment & New Required Training

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Understanding Legal Oblications

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Avoiding Common Mistakes

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Best HR Practices

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Lowering Exposure to Risk/ Liability

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New Employment Laws for 2019/2020

REGISTRATION FEES ACCMA members: FREE

a member of the Los Angeles Bar Association - Healthcare Section, as well as the Orange County Bar Association-Healthcare Section. She is also the Secretary/Treasurer of the Orange County Bar Association, Health Care Division. She represents clients in several different aspects of healthcare law, including federal and state laws and regulations, Medical Board representation, HIPAA compliance, creations, mergers, sales and acquisition of healthcare practices, and more.

Non-members: $49

Registration Information Please register online - Go to www.accma.org/events and select the program from the calendar.

You may also fax this form to 510-654-8959, send it by mail to the ACCMA at 6230 Claremont Avenue, Oakland, CA 94618, or call the ACCMA at 510-654-5383.

Practice Name / Med Group: _________________________________________________________________________ Attendee:___________________________________________ Email: __________________________________________ Attendee:___________________________________________ Email: __________________________________________ Fax: ____________________________________________ Phone:______________________________________________ FOR NON-MEMBERS: Credit Card Number:___________________________________________ Security code:__________ Exp.:________ Name as it appears on card: _________________________________________________________________________ Billing Address: ______________________________________________________________________________________

NATIONAL TRENDS IN TELEHEALTH

In the period 2014–2018, the age group 31–40 accounted for 24 percent of the distribution of non-hospital-based providerto-patient telehealth claim lines. For discharge-related providerto-patient telehealth, which occurs after discharge from an inpatient hospital stay, the data showed that 82 percent of the claim lines for this type of telehealth from 2014 to 2018 were associated with individuals 51 and older.

Sixty-five percent of all telehealth claim lines in the period 2014-2018 were associated with females. For non-hospital-based provider-to-patient telehealth, the proportion of claim lines submitted for females from 2014 to 2018 was 67 percent. But for telehealth visits associated with a hospital discharge, 53 percent of claim lines were submitted for females in the same period.

This result may be related to the older age range associated with discharge-related provider-to-patient telehealth. Other researchers have found that gender differences in healthcare spending are smaller in older adults than in younger adults.8 CONDITIONS & DIAGNOSES Acute upper respiratory infections were the number one reason individuals sought treatment from a provider for non-hospitalbased telehealth in 2018. In second and third place were mental diagnoses—respectively, mood (affective) disorders, and anxiety and other nonpsychotic mental disorders. All three are among the most common reasons patients seek primary care generally.

In 2018, heart failure was the telehealth diagnosis associated with the highest rate of in-person visits within 15 days of a nonhospital-based provider-to-patient telehealth visit for the same or a very similar diagnosis. The diagnosis with the lowest rate was encounters for contraceptive management.

The typical age of patients who had follow-up in-person visits within 15 days of a non-hospital-based provider-to-patient telehealth visit in 2018 varied with the diagnosis. Individuals over age 80 constituted the largest share of the age distribution for heart failure, those ages 23–30 for alcohol-related disorders.

(continued from page 11)

CONCLUSION Telehealth has been growing rapidly, and shows that the category fueling most of that growth is the type in which a provider renders services to a patient without relation to a hospital. From 2014 to 2018, this type of telehealth increased in usage at a rate greater than that of any other type of telehealth and of telehealth overall, and its share of the distribution of telehealth claim lines increased significantly.

FAIR Health is a national, independent nonprofit organization dedicated to bringing transparency to healthcare costs and health insurance information through data products, consumer resources and health systems research support. This summary is provided with permission from FAIR Health. To read the entire report, go to fairhealth.org/publications/whitepapers.

Sources 1 Telehealth is sometimes defined as including not only telemedicine (the remote provision of clinical services via telecommunications technology), but also the provision of certain nonclinical services, such as provider training and continuing medical education. In this paper, telehealth refers only to the former, and is interchangeable with telemedicine.

2 Center for Connected Health Policy, “2018 in Review: State & Federal Telehealth Policy—Legislative Roundup,” December 18, 2018, https:// mailchi.mp/cchpca/2018-in-review-state-federal-telehealth-policy-legislativeroundup.

3 American Well, Telehealth Index: 2019 Physician Survey, https://www.americanwell.com/resources/telehealthindex-2019-physician-survey/.

4 ACP Internist, “ACP Releases Survey Results about Telehealth Technology Availability, Use among Internists,” Internal Medicine Meeting 2019 News, April 12, 2019, https://www.acpinternist.org/immeeting/ archives/2019/04/12/6.htm 5 FAIR Health, FH Healthcare Indicators® and FH Medical Price Index® 2019: An Annual View of Place of Service Trends and Medical Pricing, A FAIR Health White Paper, April 2019, https://s3.amazonaws.com/media2.fairhealth. org/whitepaper/asset/FH%20Healthcare%20Indicators%20and%20FH %20Medical%20Price%20Index%202019%20-%20A%20FAIR%20Health%20 White%20Paper.pdf.

6 The procedure codes included in each type are listed in the table in the Methodology section above.

7 FAIR Health, FH Healthcare Indicators® and FH Medical Price Index® 2019, 25 8 Bradley Sawyer and Gary Claxton, “How Do Health Expenditures Vary across the Population?,” Peterson-Kaiser Health System Tracker, January 16, 2019, https://www.healthsystemtracker.org/chart-collection/health-expendituresvary-across-population/#item-start.

PRESIDENT’S PAGE (continued from page 7)

voice and fight for our patients and our profession. Although we may not win every battle, the ACCMA will always fight for what is right.

Thank you for giving me the opportunity to serve as your ACCMA President. Thank you also to my fellow ACCMA Officers and the members of the Council for their service and support over the past year, to my husband Syed, and to my family.

I wish Doctor Katrina Peters a very successful term as ACCMA President. I have no doubt that Doctor Peters will follow in the fine tradition of outstanding leaders that have served this organization since 1860. I hope you will join us on November 8, 2019, at the Claremont Hotel for the ACCMA Annual Meeting to celebrate Doctor Peters’ installation (please see the Annual Meeting flyer on page 16 for more information).

ACCMA BULLETIN | SEPTEMBER/OCTOBER 2019

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TELEHEALTH & PATIENT PRIVACY

Where Federal Health Data Policy Meets Privacy Reprinted from the American Medical Association, www.ama-assn.org

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ost personal health information exchanged between health care providers is governed by federal regulation. The Health Insurance Portability and Accountability Act (HIPAA) establishes guardrails for the sharing and use of patient health information. Generally, physicians and hospitals may share patient information without explicit patient consent for treatment, payment, and business operations reasons. HIPAA regulations are mainly “permissive” in that they allow but don’t require the sharing of health information. This helps balance the need to share health information while holding HIPAA Covered Entities (CEs) accountable for the privacy and security of that information.

Two recently proposed federal rules pertaining to health information technology and patient information are poised to impact the exchange, access, and use of all electronic medical records. While there are elements in both rules that deserve support, there are also several problems—particularly when it comes to patient privacy. As proposed, the rules would shift the paradigm from permitting data sharing to requiring that data be shared— including with third parties and non-HIPAA CEs who would be under no obligation to keep the information private.

The American Medical Association (AMA) wholeheartedly supports the right of patients to receive their medical information using smartphone applications, but is concerned about the lack of safeguards to ensure that patients understand what they are consenting to when they grant permission to an app to access their information. These apps share sensitive health information with third parties, often without an individual’s knowledge. Much of this information can end up in the hands of data brokers and be used or sold for advertising and marketing. Data being used in this way may ultimately erode patients’ privacy and their willingness to disclose information to their physicians.

As a first step to address this issue, the AMA is calling for controls to be instituted that establish transparency as to how health information is being used, who is using it, and how to prevent the profiteering of patients’ data. To help provide a minimal amount of transparency to patients about how a health app will use their health information, the federal movement should implement a basic privacy framework requiring certified EHR vendor APIs to check an app’s “yes/no” attestations to:

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• • •

Industry-recognized development guidance Transparency statements and best practices A clear privacy notice to patients The AMA also has identified how the rules conflate a payer’s desire for data with a clinician’s need to access, exchange, and use health information. The rules will empower payers to demand more information than is needed, whether for regulatory compliance or other purposes. Physicians who deny a payer’s request for this information may be accused of information blocking— regardless of whether the request is fully warranted.

“Historically, payers have only had access to clinical information when necessary for payment,” Dr. James Madara, AMA’s CEO and Executive Vice President stated in a letter to Department of Health and Human Services (HHS). Physicians take data stewardship very seriously. Removing physicians’ ability to safeguard patient data could have “negative downstream consequences for patients and physicians” that would delay needed care, Dr. Madara writes. Payers could use the information blocking proposals to demand patients’ medical information and circumvent a physician’s clinical decision-making.

Further, payers could use the proposals to request direct access into a physician’s EHR. This raises significant concerns about payer overreach, increased prior authorization, and patient profiling—potentially limiting coverage and access to care, and causing an intrusion on physician medical decision-making. The AMA is requesting that the federal government prohibit payers from using these proposals to place additional contractual demands on physicians and impose meaningful penalties for payer noncompliance with this new prohibition. The AMA is also requesting that the federal government restrict payers from conditioning physician participation in a plan based on whether a doctor will grant the payer electronic access to the practice’s EHR. The AMA has provided several recommendations to strengthen medical data privacy and improve federal health information technology policy.

Reprinted with permission from the American Medical Association.

To read more, go to https://www.ama-assn.org/delivering-care/ patient-support-advocacy/ama-health-data-privacy-framework.

ALAMEDA-CONTRA COSTA MEDICAL ASSOCIATION BULLETIN

GLOBAL HEALTH IMPACT NETWORK

The Disenfranchised Physician and the Digital Health Revolution:

Will We Take an Active Role?

By Gary A. Goldman, DDS, MD

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or the first five years of my career, I practiced dentistry and dental anesthesiology. I then returned to medical school for my MD and completed my anesthesia residency and fellowships at Harvard’s Brigham and Women’s Hospital. I practiced anesthesia for over 30 years in Berkeley while holding various administrative and medical staff positions. Over these years, I also had the opportunity to participate as a serial entrepreneur in the digital health space as a founder, co-founder, investor, advisor, and enterprise physician informatics lead for a 27-hospital system based in Northern California. This wide variety of activities has afforded me a unique window into the world of health care entrepreneurship and investing. It has provided me an up-close opportunity to meet with, interact with, and provide support at the elbows of hundreds of clinician and executive colleagues, both domestically and internationally. Having worn so many “operator” hats has, in addition, afforded me the opportunity to develop a way to bridge the gap between physicians and digital health entrepreneurs, healthcare investors, and healthcare C-suite executives.

Doctors in general are highly intelligent, generate great ideas, and are motivated to help people. What I have experienced is these same professionals are not savvy in their understanding of the business and investing side of the equation. In fact, the meshing of those two cultures is an enigma to most of us, because we are neither classically educated nor wired that way. That said, physicians can be trained and taught the perspective of the business and investing world, given the proper tools and collaborative environment.

The burnout rate for physicians is rising exponentially, approaching 70% in the southeastern US. Private practice incomes are dropping, expenses are rising, and work demands are increasing. The average educational debt for young physicians is becoming unmanageable. The initial wave of digital health has forced on our profession the implementation of electronic healthcare records introduced with the promises of improved documentation and efficiency. Instead, we see clinicians spending increasing amounts of their time looking at a computer screen instead of caring for patients. Practitioners are now expected to spend less time with each patient, and in some cases, they are on

a timer. The ability to practice individualized private medicine is increasingly limited, and standardized medicine is becoming the norm, resulting in loss of power and authority where it matters the most – clinical decision making.

The amount of educational information a practitioner has to assimilate is overwhelming, and without the assistance of digital technology, it is almost impossible. The feedback I frequently hear as our colleagues look at medicine, and at the changes in the patient/provider relationship over the last 20 years, is the overall sentiment of, “This is not what I want to do.” They don’t want to be an employed physician, which is what most physicians who come out of medical school now become. It doesn’t take an oracle to recognize that there is a pandemic of dissatisfaction sweeping over our profession. The symptoms described above are manifold, and the root issue is the disenfranchisement of the practicing physician in the US. In the midst of exponential technological growth, we are at what I believe is the second wave of the digital healthcare revolution. Electronic health records were the opening salvo, and now we are seeing a tsunami of clinical platforms, noninvasive digital sensors, telemedicine and telehealth platforms, virtual reality, artificial intelligence applications and data companies sweeping over every aspect of medicine. Technology tracks how and when we wash our hands, where we access patient and clinical data and information, and how we communicate and collaborate. Online meetings have replaced physical meetings and just-in-time access to information impacts clinical decision making at the point of care.

I firmly believe that health care professionals need to reassert our influence and judgment in the process of technology development and its influence on care delivery. We need to be active participants in the process as investors, advisors, entrepreneurs, and beta testers. How and where do we start, you may ask? My team and I have been working on a solution. We have been building a strategic health professional–driven, digital innovation collaborative network where clinicians have the opportunity to actively participate in the digital healthcare revolution. We can participate continued on page 23 ACCMA BULLETIN | SEPTEMBER/OCTOBER 2019

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DIABETES PREVENTION PROGRAM The Alameda-Contra Costa Medical Association ‌. requests the pleasure of your company

Friday, November 8, 2019 | Reception begins at 6:00 pm The Claremont Club & Spa 41 Tunnel Road, Berkeley, CA Join the East Bay medical community as we celebrate the 151st ACCMA Annual Meeting this year, featuring the installation of 2020 ACCMA President Katrina Peters, MD, and other incoming officers, as well as guest speaker Elizabeth Sherwood-Randall. Elizabeth Sherwood-Randall has spent 35 years addressing the world’s most pressing global and domestic challenges while serving in top public service positions.

Guests are invited to enjoy a lively reception, followed by a formal dinner and presentation. The ACCMA hopes you will join us as we celebrate our new 2020 ACCMA President, our officers, our members, and their extensive contributions to the local medical community.

Katrina Peters, MD

Elizabeth Sherwood-Randall

REGISTRATION

Individual tickets are $150 per person, which includes hosted reception, dinner, and program. $75 of this amount is tax deductible. Tickets may be ordered online at www.accma.org/events, by calling 510-654-5383, or by completing and returning this registration form. Please pay by credit card, or send a check payable to the ACCMA Community Health Foundation, 6230 Claremont Avenue, 3rd Floor, Oakland, CA 94618.

Name: __________________________________________________________________________________________ Name of Guest: _________________________________________________________________________________ Credit Card Number: ______________________________ Exp. Date: _________ Security Code: __________ Billing Address: __________________________________________________________________________________ Billing Zip: ___________________ Phone: __________________________ Email: ____________________________

For more information, or to purchase tickets, visit www.ACCMA.org/Events, or contact the ACCMA at (510) 654-5383. Checks can be made payable to the ACCMA Community Health Foundation, 6230 Claremont Ave., Oakland, CA 94618

ACCMA ANNUAL MEETING

Join Us for the 2019 ACCMA Annual Meeting

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CCMA will be celebrating its history, the achievements of East Bay physicians, and the installation of its 2020 officers— while also raising funds for medical student scholarships—during our 2019 Annual Meeting, to be held November 8 from 6 to 9 p.m. at the Claremont Club & Spa in Berkeley. Sponsorships and single tickets are now available for purchase.

Over the decades, the Annual Meeting has served as a fun and entertaining evening through which the East Bay health care community can connect with one another, enjoy dinner and a program together, recognize outgoing and incoming ACCMA officers, and help raise funds for the ACCMA Medical Student Scholarship Program. This year’s program is packed with engaging speakers, highlights of local physician accomplishments, and poster presentations from previous student scholarship winners.

There will also be a raffle for chances to win a variety of exciting prizes. About 250 people are expected to attend.

All proceeds from the Annual Meeting go to the ACCMA’s scholarship fund, which support students doing local health care research in the UC Berkeley–UCSF Joint Medical Program (JMP). The JMP Program, which began in the mid-1960s with the support of the ACCMA, is the East Bay’s only medical school training program and one of the few in California with a focus on primary care in underserved communities. Research projects supported by our scholarship fund are aimed at reducing health disparities, expanding access to care, and improving community health outcomes. Selected projects must improve care for underserved populations in a lasting way, and have relevance for practicing physicians in our community.

Help us meet our goal of raising $150,000 to endow our scholarship program by buying an individual ticket or becoming a sponsor to support the future of medicine in our community.

We are excited that this year’s keynote speaker is Elizabeth Sherwood-Randall, who has first-hand experience as a defense

and energy policy leader, global crisis manager, and female executive. Ms. Sherwood-Randall has spent 35 years addressing the world’s most pressing global and domestic challenges. Serving in top public sector positions, including as Deputy Secretary of the United States Department of Energy (2014–2017), White House Coordinator for Defense Policy, Countering Weapons of Mass Destruction, and Arms Control (2013–2014), Special Assistant to the President and Senior Director for European Affairs (2009–2013), and at the Pentagon as Deputy Assistant Secretary of Defense for Russia, Ukraine and Eurasia (1994– 1996), Ms. Sherwood-Randall has chosen to engage in the most complex and consequential global challenges, participating in the highest levels of international decision-making. Offering unique insights and unparalleled expertise across a spectrum of issues from energy security to national security, Ms. Sherwood-Randall presents the threats and opportunities that lie ahead through a compelling insider’s lens.

ACCMA is now accepting sponsorships from medical staffs, practice groups, hospitals, and health care advocates who would like to support or attend this year’s event. Starting at $1,500, the Sponsor level includes a table for 10 and acknowledgement in the ACCMA Bulletin, a bi-monthly publication sent to nearly 4,000 physicians. Higher sponsorships at the $3,000 (Supporter), $5,000 (Champion) and $10,000 (Sustainer) levels also include prominent recognition at the event and in promotional materials.

A substantial portion of your sponsorship is tax deductible.

Please contact Jennifer Mullins, ACCMA Education and Events Coordinator, at jmullins@accma.org or (510) 654-5383 for a complete breakdown of sponsor benefits and to reserve your table today. You can also contact her for individual tickets or purchase tickets online by going to www.accma.org/events. We look forward to seeing you on November 8!

Put Your ACCMA Membership to Work! Go to www.accma.org > Membership, or call ACCMA at (510) 654-5383 for help.

ACCMA BULLETIN | SEPTEMBER/OCTOBER 2019

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OPIOID PRESCRIBER RESOURCES

Don’t Drop Your Patient

OPIOID PRESCRIBER RESOURCES FROM THE CALIFORNIA DEPARTMENT OF PUBLIC HEALTH

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s the opioid epidemic continues to affect the country, health care providers stand out as essential partners in helping to end the opioid epidemic in their home states. In order to be successful in the fight against the opioid epidemic, health care providers must have access to resources and support in order to improve patient pain management, while helping their patients avoid opioid overdose and dependence.

One of the most challenging situations reported by prescribers is how to respond to patients already on high doses of opioids (>90 MMEs) or with possible addiction symptoms. These patients are at higher risk and may need your assistance more than ever. Recent concerns about over-prescribing of opioids has led to some misinterpretation resulting in abruptly terminating the use of opioids, which can cause health risks for patients. Some pain management situations may involve the use of opioid medications if alternative approaches are not available or effective. The California Department of Public Health is offering resources to support you as you continue your clinical relationships with your patients to ensure their overall well-being.

On behalf of the Statewide Opioid Safety (SOS) Workgroup and partners, resources are available to assist health care providers in addressing these critical treatment issues with patients: CONSIDER ALL PAIN MANAGEMENT OPTIONS BEFORE STARTING PATIENTS ON OPIOIDS. The Center for Disease Control and Prevention (CDC) recommends exploring multiple treatment options (including nonpharmaceutical alternatives) to address chronic pain management before starting patients on opioids. Speak with your patients’ health plans to find out what alternatives are available.

RECOGNIZE WHEN AND UNDERSTAND HOW TO TAPER PATIENTS AT RISK. Health care professionals should not abruptly discontinue opioids in a patient who is physically dependent on opioids, nor should they implement rapid tapers in patients with long-term dependence. Safe tapers may take months to years to accomplish. Ensure patients understand the risks and benefits of dose maintenance versus dose tapering and develop an individualized plan in collaboration with patients.

The CDC recently clarified that its 2016 guidelines only

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recommended dose limits for new patients. The CDC does not recommend applying arbitrary dose limits to patients dependent on long-term opioids, as there is insufficient data supporting this practice. In a recent study in the Journal of Substance Abuse Treatment, after an abrupt taper, almost half (49%) of people had an opioid-related hospitalization or emergency department visit.

OFFER MEDICATION ASSISTED TREATMENT (MAT) TO YOUR PATIENTS. For patients experiencing opioid use disorder, the use of some MAT, such as buprenorphine, has been shown to be highly safe and effective in lowering overdose risk, decreasing HIV and hepatitis C occurrences, and increasing retention in treatment.

Health care providers who are not yet certified to prescribe buprenorphine should consider obtaining X-waiver certification.

The Alameda-Contra Costa Medical Association periodically offers MAT Waiver Eligibility Training to provide 4 of the 8 hours required to obtain an X-waiver certification. Visit learning.accma. org for a list of upcoming ACCMA educational programs, many of which offer free CME for ACCMA members.

Additional support on MAT and other substance use disorder questions for clinicians is available through the California Substance Use Line, which is staffed 24/7 in collaboration with addiction experts at the UCSF Clinicians Consultation Center and California Poison Control: (844) 326-2626.

PROVIDE PATIENT REFERRALS TO MAT AND ADDICTION RECOVERY PROGRAMS. If you are unable to provide MAT, refer patients to a drug or recovery program within your community. Visit choosemat.org and use the treatment locator tool at the bottom of the Resources webpage to find local MAT and addiction recovery services.

For patients who use opioids or other drugs non-medically, harm reduction programs provide a range of supportive, nonjudgmental services to prevent disease transmission and overdose, offer substance use counseling, and help people connect to and stay engaged with health care. A directory of harm reduction programs in California is available on the Resources for Opioid Prescribers list, located at https://bit.ly/2kMaw2v.

Visit https://bit.ly/2kMaw2v for a complete list of resources available for opioid prescribers.

ALAMEDA-CONTRA COSTA MEDICAL ASSOCIATION BULLETIN

continued on page 23

OFF-LABEL USE OF KETAMINE

Ketamine: The Next Breakthrough for Depression?

By the Medical Insurance Exchange of California

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ANESTHETIC TURNED CLUB DRUG Ketamine was first synthesized in 1962 and approved by the FDA in 1970 for use as a short-acting general anesthetic. Since then, it has gained popularity as an anesthetic in the military and in acute care settings due to its rapid onset, short duration, and safety profile. However, ketamine has also gained popularity as a drug of abuse, due in large part to its dissociative and hallucinogenic effects, and it is listed as a Schedule III controlled substance.

In the 1990s, the psychiatric community began to investigate the role of glutamate in depression, and a growing body of evidence pointed to disruptions in the glutamate system as a possible mechanism of depression. Ketamine, an NMDA receptor antagonist, was further studied under this mechanism, and in 2000 a placebo-controlled, double-blinded study demonstrated that patients receiving intravenous ketamine in subanesthetic doses experienced significant improvement in symptoms of depression within 72 hours of infusion.

patients tended to experience antidepressant effects that lasted for days after their treatment sessions.

Our research revealed that ketamine infusion clinics were quickly being established across the country. Some of these facilities were affiliated with pain clinics and staffed by physicians experienced in the administration of ketamine in acute care settings, such as anesthesiologists and emergency medicine physicians; others were extensions of mental health centers and/or staffed by psychiatrists and psychologists.

Ketamine is typically administered in subanesthetic dosages through either IV infusion or intramuscular injection. More recently, ketamine has been available in sublingual lozenges produced by compounding pharmacies; this has become a popular route of off-label administration due to its ease of use and slower onset, as well as the ability to discontinue administration if the effect is not well-tolerated by the patient.

Based on discussions with MIEC members, there is some provider-to-provider variability in how these patients are managed. Patients receive IV or IM ketamine in a medical office or clinic, under the supervision of a licensed health care provider, with monitoring of vital signs and mental status. The patient may undergo psychotherapy with a psychiatrist or clinical psychologist while under the effect of the medication, or they may simply be monitored while under the effects, which can last for several hours. With patients who self-administer ketamine in lozenge form, some physicians supervise those patients in the office with or without concurrent psychotherapy, which could be provided by a psychiatrist or clinical psychologist. After patients have demonstrated tolerance to ketamine, some providers have elected to provide them with lozenges to use at home for ongoing maintenance therapy.

A NEW TOOL FOR PSYCHIATRISTS Starting in 2016, the Medical Insurance Exchange of California (MIEC), a physician-owned medical malpractice insurer, began receiving inquiries from their members about the off-label use of ketamine either as an adjunctive treatment to facilitate psychotherapy sessions, or as a stand-alone antidepressant. Anecdotally, members reported that the dissociative effects of ketamine seemed to facilitate patients in making breakthroughs in therapy, and those

SOME DIRECTION FOR PROVIDERS In March 2017, the American Psychiatric Association (APA) issued a consensus statement on the use of ketamine in treating mood disorders. The statement, based on research conducted to date on IV ketamine, made note of the relatively small sample sizes, lack of long-term efficacy data, and limited safety data associated with those earlier studies; based on this, the APA urged that continued on next page

ajor Depressive Disorder (MDD) affects an estimated 320 million individuals worldwide (16 million in the U.S. alone), and the incidence of this condition has increased substantially in the last decade. Further challenging psychiatrists, current pharmacologic therapies (MAO inhibitors, tricyclic antidepressants, and SSRIs) are limited by therapeutic lag times of up to weeks or months, and high refractory rates of approximately 30%.

Patients with treatment-resistant depression face limited options, such as transcranial magnetic stimulation (r-TMS) or electroconvulsive therapy (ECT), and patients with suicidal ideation may remain at risk while they wait for a newly-prescribed antidepressant to take effect. In treating acute and treatment-resistant MDD, there is an unmet need for a rapidly acting antidepressant.

ACCMA BULLETIN | SEPTEMBER/OCTOBER 2019

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OFF-LABEL USE OF KETAMINE

(continued from page 19)

providers remain cautious while exploring the possible benefits of ketamine in treating MDD. The APA recommended the following: • Careful patient selection in terms of diagnosis and risks/benefits, noting that ketamine is most effective in the treatment of major depressive episodes without psychotic features associated with MDD. • Full Informed consent for patients including discussion of the risks/benefits and alternatives.

• Managing clinician should be able to administer a Schedule III medication, manage potential blood pressure changes, and treat cardiovascular events requiring ACLS certification.

• Managing clinician should be able to manage changes in mental status and emergency behavioral situations.

• Mental health provider available on-site to evaluate patients for behavioral risks, including suicidality, before discharge.

• Monitoring of patients during administration for basic cardiovascular (BP, ECG) and respiratory (O2, end-tidal CO2) function and ability to stabilize/treat any events (supplemental O2, medications, restraints).

• “At this point of early clinical development, we strongly advise against the prescription of at-home self-administration of ketamine; it remains prudent to have all doses administered with medical supervision until more safety information obtained under controlled situations can be collected.”

REGULATORY APPROVAL, WITH CONDITIONS… On March 5, 2019 the U.S. Food and Drug Administration (FDA) announced approval of Spravato (esketamine) nasal spray, which is the first ketamine-derived medication approved for the treatment of depression. Esketamine, which is the s-enantiomer of racemic ketamine, has been shown to exhibit greater affinity for the NMDA receptor and therefore a greater potential antidepressant effect.

Importantly, the FDA approved Spravato for use under the following conditions: • Eligible patients must have treatment-resistant MDD, defined as having failed at least two prior antidepressants.

• Patients must be concurrently taking an oral antidepressant while undergoing treatment with esketamine.

• Esketamine must be self-administered in a medical office, and the medication cannot be taken home.

• Patients must be monitored by a health care provider for two hours following administration.

• Esketamine will be controlled through a restricted distribution system, under a Risk Evaluation and Mitigation Strategy (REMS).

OPTIMISTIC CAUTION While there has been much optimism around both the off-label

MIEC RECOMMENDS MIEC recommends that esketamine, or ketamine when used off-label for the treatment of depression, should ideally be administered under the supervision of a psychiatrist. Advanced practice providers or physicians from non-mental health specialties who administer ketamine/esketamine for MDD should be working closely with a psychiatrist to manage patients’ underlying depression, the behavioral aspects of ketamine/esketamine administration, and transitioning patients off treatment when appropriate.

Until more research is completed, physicians administering ketamine or esketamine should consider doing the following to increase patient safety and minimize liability risk: • Screen patients carefully to ensure that they are appropriate candidates for treatment, and that

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ALAMEDA-CONTRA COSTA MEDICAL ASSOCIATION BULLETIN

they are not at increased risk for adverse events.

Conduct a full informed consent discussion including risks, benefits, and alternatives, and have patients sign a detailed patient information/ consent form.

Depending on route of administration, monitor patients’ vital signs and/or mental status during sessions.

Develop a plan for responding to patients who poorly tolerate treatment.

Monitor patients for an appropriate amount of time (2 hours or so) following administration.

Store ketamine/esketamine in a safe, secure location.

Avoid providing ketamine/esketamine directly to patients for self-administration at home.

ACCMA LETTER TO THE EDITOR

ACCMA LETTER TO THE EDITOR

Public Charge Rule Will Increase High Health-Care Costs and Cause a Public Health Crisis

By Lubna Hasanain, MD, ACCMA President

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ecently, the Trump administration finalized changes to the “public charge” rule. The rule allows U.S. immigration officials to deny citizenship and green cards to legal immigrants based on past or potential future use of public benefits, including Medicaid.

This will cause legal immigrants to refrain from using healthcare benefits for which they are eligible, even preventative care such as vaccines for children.

We already know that when patients delay getting care, they will end up in the emergency room. At a time when we are already

grappling with high health-care costs, the new rule will increase these costs and cause a public health crisis.

The Alameda-Contra Costa Medical Association, which has 4,600 physician members in the East Bay, opposes efforts to take health care away from California residents and will work with state leaders to ensure that the health of California families is not harmed by public policies.

Originally published in the East Bay Times on August 29, 2019 at https://bayareane.ws/2nD867i

Off-Label Use of Ketamine (continued from page 20)

use of ketamine and FDA-approved esketamine for treatmentresistant depression, there remain some concerns about the longterm effects and risks surrounding this treatment.

First, the FDA approved Spravato on a fast-track application, and the underlying Phase 3 study on which the FDA based its approval included some concerning findings. Out of three clinical trials included in the FDA study, only one study demonstrated a statistically significant effect compared to placebo. The most significant effect was noted at 24–48 hours, compared with lesser changes over the 4-week course of treatment. This evidence, when also considering the study included a concurrent oral antidepressant, potentially raises the question of whether ketamine has any utility beyond a bridging treatment when starting a new oral antidepressant.

Potentially more worrisome is the 40% relapse rate after discontinuing esketamine, and the three suicides that occurred in esketamine recipients following discontinuation of the study.

While the FDA did not attribute the suicides to esketamine, this raises questions about appropriate length of therapy and the risks patients may face after discontinuation of treatment, potentially due to withdrawal syndrome.

There is also some evidence that ketamine’s antidepressant

effects are mediated through opioid receptor activity. A study published in August 2018 found that patients receiving the opioid antagonist naltrexone experienced significantly less antidepressant effects (but undiminished dissociative effects) with subsequent IV ketamine infusion. This study adds to the concern around potential abuse and/or addiction issues around ketamine and esketamine.

To date, the APA has not issued any revised statements or guidelines since the 2017 consensus statement regarding IV ketamine.

On the other hand, there is an acknowledgement that limiting ketamine/esketamine treatment to formal medical settings might present a barrier to those that otherwise would benefit from treatment but cannot travel repeatedly to a physician’s office, due to logistical or other reasons. Currently, there are several efforts underway to seek FDA approval of similar medications; these include a sublingual ketamine lozenge for at-home use, and an oral NMDA antagonist that can be taken as a pill.

Read more at https://bit.ly/2kLe6tK. Reprinted with permission by the Medical Insurance Exchange of California.

ACCMA BULLETIN | SEPTEMBER/OCTOBER 2019

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COUNCIL REPORT

JUNE 13, 2019

The meeting was called to order by Doctor Lubna Hasanain, President.

Aimee Robinson, ACCMA Physician Engagement Coordinator, presented an overview of the membership benefits to discuss when recruiting new members.

Jack Chou, MD, a member of the Los Angeles County Medical Association and a candidate for CMA Vice-Speaker, spoke to the Council to present his platform for his candidacy. He shared his background and accomplishments in the community.

Doctor Hasanain encouraged the Councilors in Districts 3 and 12 to speak to members in their districts to encourage participation on the Council in the Alternate Councilor role.

Mr. Greaves discussed the recommended appointments to the BCHO Access to Care Collaborative. The purpose of the collaborative effort is to identify opportunities to improve access to pediatric services in the East Bay and to advise BCHO on community needs. The Council approved all seven physicians who were nominated, of which three to four will be selected.

Mr. Greaves discussed physician wellness programs at the local and state levels. There will be continued collaboration among the many organizations that attended a roundtable discussion hosted by the ACCMA on June 6 regarding clinician wellness, retention, and burnout. The CMA is looking for nominees for their Well Physician California Advisory Council.

Doctor Calvin Wheeler was nominated to serve on this Council.

The Council approved the nomination.

Doctor Hasanain reminded the Council that the deadline for the Annual CMA Awards for Community Service, Membership, and Wellbeing is June 13. Doctor Hasanain nominated Doctor Frank Staggers, Jr. for the Wellbeing Award. The Council approved the nomination.

Mr. Greaves announced that the ACCMA Finance Committee recommended that there be no dues increase for the 2020 membership year. The Council approved the recommendation for no dues increase.

Mr. Lopez discussed the recommendations from the Medical Services and Quality of Care Committee. The first recommendation was to provide information to members regarding the First Mile Diabetes Prevention Program, which Doctor Hill noted was a great initiative and free of cost to patients and doctors. The second recommendation was to submit a resolution to the CMA Board of Trustees to extend the Physician Payments Sunshine Provision of the Affordable Care Act to include patient advocacy organizations. The Council approved both recommendations.

Doctor Edelman summarized his draft resolution to oppose the DHHS proposed changes to transgender protections against discrimination. The Council held a lengthy discussion regarding the resolution and to include language to protect all classifications of people against discrimination in health care. The Council approved submitting the resolution to the year-round resolution process.

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Doctor Austin provided the AMA delegates report.

Medicare was a major topic of discussion at the AMA Annual Meeting of the House of Delegates. Many resolutions were discussed, and the AMA code of ethics was passed. Doctor Kogan reported that the AMA is against Medicare for all and did not change their position. Doctor Austin encouraged Councilors to donate to the AMA Foundation to support their charitable grants. Doctor Sugarman moved that the ACCCMA should recognize Doctor Austin’s representation of the ACCMA as an AMA delegate and donate $2,500 to the AMA Foundation. The Council approved this recommended donation.

Doctor Kogan reported that the CMA Board of Trustees has not met since the last Council meeting and there was no report from the Trustees. Doctor Klingman added that the Major Issues Report would be approved soon.

Mr. Lopez discussed the upcoming preparation for the House of Delegates meeting in October. He announced that there would be a meeting on October 3rd to discuss the major issues, and asked that Councilors who have not yet provided an RSVP to do so.

A flyer on the 2019 NEPO Summit was provided for information.

Mr. Greaves discussed new state legislation that impacts health care, and what the ACCMA/CMA are doing to advocate for physicians.

A letter from Delvecchio Finley, CEO of the Alameda Health System (AHS) about the organization’s budgetary challenges for the upcoming fiscal year was discussed. The Council directed ACCMA staff to reach out to AHS to obtain more information.

Doctor Hasanain discussed the confirmed case of measles in Berkeley.

The 2019 ACCMA Annual Meeting will be held at the Claremont Hotel on Friday, November 8.

A summary was given of the roundtable discussion on clinician wellness, burnout, and retention held by the East Bay Clinician Wellness Consortium, sponsored by the East Bay Health Workforce Partnership and the ACCMA, on June 6 in the ACCMA offices.

Doctor Hasanain announced that Operation Access was seeking new board members and asked Councilors to contact the organization if they are interested.

Ms. Lum provided an update on ACCMA membership numbers. She stated that our membership numbers are at 98.3% of 2018 year-end. Ms Lum asked the Council to reach out to non-members on the Hot Prospects report and encourage them to join the ACCMA.

Ms. Lum reviewed upcoming educational programs: Social Media and Health Care (June 18), How to Hire Excellent Medical Office Staff (June 26), A Workshop on Advanced Care Planning (July 19), and Managing Pain Safely: Alternatives to Opioids in Primary Care (September 12).

There being no further business, the meeting was adjourned.

ALAMEDA-CONTRA COSTA MEDICAL ASSOCIATION BULLETIN

LITIGATION STRESS

Surviving the Stress of Being Sued

By Frank Staggers, Jr., MD, Chair, ACCMA Litigation Stress Committee

M

ost physicians are sued or face the threat of being sued at least once in their career. Physicians have described the experience of being sued and the litigation process as one of the most stressful periods physicians will encounter during their career. Physicians should be aware of their emotional and physical reactions to being sued. They should utilize coping strategies such as educating themselves about the legal process and reaching out for social support to try to alleviate the severity of their reactions.

If symptoms such as physical illness, depression, or substance misuse persist, physicians should not ignore the symptoms but seek help from their personal physician.

The Alameda-Contra Costa Medical Association (ACCMA) Litigation Stress Program assists physicians threatened with or actually sued for medical malpractice, or those who are under investigation by the Medical Board of California or other governmental agencies. The ACCMA is presenting a free seminar, “Surviving the Stress of Being Sued—and Minimizing the Risk that It Will Happen Again,” on Thursday, November 21 from 6 to 8:30 pm (see inside back cover). The seminar features a physician telling their personal story of coping with a malpractice lawsuit, a defense attorney explaining how a lawsuit proceeds and how to maximize your defense, a physician leader describing the litigation stress support that a major health system provides, and a risk management specialist offering guidance on minimizing liability exposure. Two CME credits are available, free of charge to ACCMA members.

In addition to the support physicians receive from their

personal legal counsel and professional liability insurance company, ACCMA’s Litigation Stress Program also offers moral and emotional support. Under the program, an ACCMA member who is threatened with or sued for malpractice, or who is a subject of a governmental or any other type of investigatory or disciplinary proceeding, may request a confidential visit or telephone consultation with a member of the ACCMA Litigation Stress Committee (LSC). The LSC is a confidential peer review committee of the ACCMA. It was established to promote quality of care by assisting physicians in understanding the various phases of litigation or regulatory hearings; provide information about the non-legal aspects of these processes; advise the colleague about ways to cope with the litigation investigative experience and continue to function effectively, professionally, and personally; and offer suggestions for reducing liability.

To access the confidential services of the ACCMA Litigation Stress Program, call the ACCMA at (510) 654-5383. The ACCMA makes this program available to members and nonmembers, as a public service and professional courtesy. To register for the litigation stress seminar, go online to learning.accma. org/upcoming or call the ACCMA at (510) 654-5383.

This program is another example of the ACCMA’s commitment to addressing issues of concern to the medical profession and improving quality of care in our community. The Medical Insurance Exchange of California (MIEC) is a cosponsor of the ACCMA Litigation Stress Program.

Global Health Impact Network (continued from page 15)

as advisors, investors, and users, helping to mold our future of a health care system that improves access, efficiency, safety, and care – and at the same time, decreases the cost of care. Best of all, this can and will ultimately be a global impact solution, improving health care available everywhere. If you are interested in joining the evolution/revolution, contact me at Gary@globalhealthimpactnetwork.net.

Gary A. Goldman, DDS, MD, is a physician in the East Bay Anesthesiology Medical Group and in the Department of Anesthesiology at Alta Bates Summit Medical Center. He is a Sutter Healthcare Physician Informatics Lead. Dr. Goldman is a member of the ACCMA Council.

ACCMA BULLETIN | SEPTEMBER/OCTOBER 2019

23

ALAMEDA ALLIANCE

Increasing Accessibility:

Combining Telehealth with Mental Health Services

By Scott Coffin, CEO, Alameda Alliance for Health

A

lameda Alliance for Health (the Alliance) is honored to serve nearly 260,000 children and adults in Alameda County. In this article, you will learn about how the Alliance is working with community partners to develop a system of care that will allow our members to access tele-mental health services. You will also learn about Governor Newsom’s focus on early screening services for the state’s youngest residents and how the Alliance is working to prepare for these changes.

TELEHEALTH AT THE ALLIANCE In 1996, the California legislature passed the Telemedicine Development Act – making it one of the first telehealth laws in the country. Since then, California has attempted to lead the way with innovative telehealth legislation, but today’s state laws have not kept up with changing technology. The Alliance has been exploring the efficacy of telepsychiatry through our contracted provider Beacon Health Options (Beacon). Beacon has contracted with a vendor to provide Alliance members with telehealth counseling and telepsychiatry services through video conferencing. Our goal with this partnership is to improve patient access to certain mental health services through the use of their computer, tablet, or mobile phone with a camera.

Through these telepsychiatry services, Alliance members will be able to access psychiatrists, psychiatric nurse practitioners, psychologists, therapists, and counselors. This network of mental health professionals provides services related to anxiety and depression, bipolar disorder, eating disorders, personality disorders, obsessive-compulsive disorders, autism spectrum disorder, substance use, and trauma and abuse. Additionally, they can assist with topics related to parenting, marriage, and relationships; life coaching and career guidance; LGBT+ issues; and grief.

Nearly 1 in 6 California adults experience a mental illness of some kind, and 1 in 13 children has an emotional disturbance that limits participation in daily activities. The Alliance hopes that through these services, we will be able to provide our members with better access to tele-mental health services, including timely treatment by a behavioral health specialist, increased treatment 24

adherence, reduced missed appointments, and decreased hospital readmissions and emergency room visits. Moving forward, we anticipate reviewing the effectiveness and impact that they have on our members and how it will play a larger role in the long-term strategy of the delivery of the Alliance’s system of care.

EARLY SCREENING AND TREATMENT SERVICES FOR CALIFORNIA’S YOUNGEST RESIDENTS On June 27, Governor Newsom signed his 2019–2020 “California For All” state budget with a large focus on the state’s youngest residents. Much of the Governor’s inaugural budget focuses on support and services for California’s low-income children, including improving the early and periodic screening, diagnostic and treatment services (EPSDT) benefit. The EPSDT benefit is designed to ensure that eligible Medi-Cal members receive early detection and preventative care in addition to medically necessary treatment services so that health problems are averted or diagnosed and treated as early as possible.

The Budget includes $30.8 million ongoing federal funds and $23.1 million ongoing Proposition 56 funds for developmental screenings for children in the Medi-Cal program. It also includes $27.2 million ongoing federal funds and $13.6 million ongoing Proposition 56 funds for trauma screenings for children and adults in the Medi-Cal program. In addition, the Budget includes $25 million of federal funds and $25 million of Proposition 56 funds to train providers on delivering trauma screenings.

Along with increased funding for screenings, the Department of Health Care Services (DHCS) is increasing oversight on the EPSDT benefit to ensure that required services are being performed and that we are strengthening our coordination with local entities that provide EPSDT services to our youngest members.

The Alliance is currently working on our pediatric strategy as well as our internal processes to ensure that we are properly overseeing EPSDT services that local health entities provide to our members. continued on next page

ALAMEDA-CONTRA COSTA MEDICAL ASSOCIATION BULLETIN

ALAMEDA ALLIANCE

ABOUT ALAMEDA ALLIANCE FOR HEALTH Alameda Alliance for Health (the Alliance) is a local, public, not-for-profit managed care health plan committed to making high-quality health care services accessible and affordable to Alameda County residents. Established in 1996, the Alliance was created by and for Alameda County residents. The Alliance Board

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of Governors, leadership, staff, and provider network reflect the county’s cultural and linguistic diversity. The Alliance provides health care coverage to nearly 260,000 low-income children and adults through the National Committee for Quality Assurance (NCQA) accredited Medi-Cal and Alliance Group Care programs.

NEW & RETURNING MEMBERS Satya Allaparthi, MD

Aaron Cutshaw, MD

Abid Mogannam, MD

Gastroenterology Gastro Specialists Med Group 19845 Lake Chabot Rd., Castro Valley, CA Melissa Burroughs Pena, MD Cardiovascular Disease Cardiovascular Consult Med Group 365 Hawthorne Ave #201, Oakland, CA

Vascular Surgery General Vascular Surgery Med Group 13851 E 14th St., San Leandro, CA Esther Molnar, MD Infectious Disease Infectious Disease Doctors Med Group 365 Lennon Ln #200, Walnut Creek, CA Kenneth Saffier, MD

Teera Chentanez, MD Infectious Disease Epic Care – Partners in Comprehensive Care 400 Taylor Blvd #201, Pleasant Hill, CA Neha Desouza, MD Hematology Oncology Epic Care – Partners in Comprehensive Care 20400 Lake Chabot Rd #102, Castro Valley, CA Justin Lee, MD Cardiovascular Disease Cardiovascular Consult Med Group 365 Hawthorne Ave #201, Oakland, CA Paul Mead, MD Orthopedic Surgery Muir Ortho Specialists 2625 Shadelands Dr., Walnut Creek, CA

Family Medicine Antioch Health Clinic 2335 Country Hills Dr., Antioch, CA Darrell Tran, MD Anesthesiology East Bay Anesthesiology Medical Group, Inc 3000 Colby St #205, Berkeley, CA Rani Upadhyay, MD Cardiovascular Disease Cardiovascular Consult Med Group 365 Hawthorne Ave #201, Oakland, CA

Emergency Medicine 1425 S Main St., Walnut Creek, CA Maria Pia Platia, MD Obstetrics and Gynecology 3779 Piedmont Ave., Oakland, CA Jacqueline Sergie, MD Psychiatry 3454 Hillcrest Ave., Antioch, CA Shila Shafii Noori, MD Family Medicine 2300 Camino Ramon, San Ramon, CA Geraldine Slean, MD Ophthalmology 3553 Whipple Rd., Union City, CA Erin Smith, MD Emergency Medicine 1425 S Main St., Walnut Creek, CA Michelle Villarta, MD Pediatrics 39400 Paseo Padre Parkway, Fremont, CA

The Permanente Med Group

Feng Zhang, MD

Brittany Ashlock, MD, MPH, PhD Internal Medicine 1425 S Main St., Walnut Creek, CA

Radiology 3600 Broadway, Oakland, CA

Judy Chang-Witt, MD Internal Medicine 2500 Merced St., San Leandro, CA

To place a classified ad, go to www.accma.org > About Us > Advertise with ACCMA, or call our office at (510) 654-5383.

ACCMA members can place a classified ad for four months online and in two issues of the ACCMA Bulletin at NO CHARGE.

ACCMA BULLETIN | SEPTEMBER/OCTOBER 2019

25

IN MEMORIAM

Eugene Taylor, MD

D

octor Eugene Taylor, who served as ACCMA President from 198586, passed away on August 18, 2019 in his home in Pleasanton. Doctor Taylor was born and raised in Berkeley, attended UC Berkeley, was drafted into the U.S. Army, and subsequently received his medical degree from George Washington University specializing in Obstetrics and Gynecology. In addition to being a highly regarded physician in the community and an active ACCMA leader, Doctor Taylor spent time in Pakistan delivering babies at a mission hospital, and was an active member of First Presbyterian Church of Oakland where he served as an ordained Elder.

Doctor Taylor oversaw a number of key achievements during his tenure as ACCMA President, including: ACCMA engaged in a

successful statewide campaign by organized medicine and a large statewide coalition that resulted in the passage in June, 1986, of Proposition 51, the first enhancement of tort reforms in California since the passage of MICRA in 1975 that limited a defendant’s liability for non-economic (pain and suffering) damages; ACCMA participated in negotiations over the establishment of a trauma center in Contra Costa County; ACCMA negotiated the sale of its subsidiary, the Bureau of Medical Economics, a medical collection agency created in 1945, as medical collections was becoming increasingly limited due to the expansion of managed care plans.

Doctor Taylor is survived by his wife Penny and his sons Jim (Berkeley), Jon (Salem, Oregon), his grandchildren: Leah, Jesse, Kate and Laura and his dear brother Glenn and sister in law Virginia, his sister Sue Mooney and husband John, as well as many nieces and nephews.

FIDELIS THOMAS AKAGBOSU, MD, passed away on July 26, 2019. Dr. Akagbosu was born in Nigeria, where he graduated high school, later obtaining his Bachelor of Science and medical degree from Obafemi Awolowo University (University of Ife) in 1979. He met his wife, Dr. Lilian Chizomam Akagbosu, during his residency at the University of Benin Teaching Hospital. In addition to his MD, Dr. Akagbosu also attained a Master of Medical Science in Assisted Reproduction Technology from the University of Nottingham in 1994. As an in vitro fertilization (IVF) expert, Dr. Akagbosu worked with the team that pioneered IVF at Bourn Hall Clinic in Cambridge, England, published numerous articles on fertility, and helped bring IVF technology to Nigeria. Dr. Akagbosu recently worked as Attending Physician and Sub-Chief at the Kaiser Center for Reproductive Health in Fremont, California. He is survived by his daughter, Dr. Cynthia Omoge Akagbosu, his son, Mr. Emmanual Osigbemhe Akagbosu and his son-in-law, Mr. Nathan Putney Swire. Dr. Akagbosu was a member of the ACCMA for 7 years.

became a partner in the Webster Orthopedic Medical Group.

Over the years, he served as Chief of Pediatric Orthopedic Surgery at Oakland Children’s Hospital, and as an orthopedist for the Golden State Warriors, Health Volunteers Overseas, the California School for the Deaf, and at the Paralympic Games. Dr. Barer was a member of the ACCMA for 51 years.

MALVIN BARER, MD, passed away on May 8, 2019. Dr.

Barer was born in New York, where he attended high school before moving to Indiana to attend Purdue University. In 1961, Dr. Barer obtained his medical degree from the University of Amsterdam in Holland. Dr. Barer married his wife, Barbara, in 1962 in Vancouver, Canada, before completing his internship at Cook County Hospital in Chicago. He then trained as a Fellow in Orthopedic Surgery at the Mayo Clinic in Rochester, Minnesota, where their three daughters were born. The family then moved and settled in Oakland, CA, where Dr. Barer

26

DAVID LOUIS ESTRICH, MD, passed away on August 17,

2019. Dr. Estrich was born in Fort Wayne, Indiana, before moving to Oakland to manage a practice specializing in Diabetes.

Dr. Estrich saved countless lives with his long and respected practice. He is survived by his children, Anna Wendorf, Chris Estrich, Mary Jansen, and his sister Judy Fredine, as well as four grandchildren. Dr. Estrich was a member of the ACCMA for 55 years.

PLATO GRIVAS, MD, passed away on July 1, 2019. Dr. Grivas grew up in Los Angeles, CA, before joining the Marine Corps in 1946. After receiving an honorable discharge, Dr. Grivas began medical school at UCLA before transferring to the University of Southern California. He married his wife, Pat, in 1955, before accepting an internship in San Francisco at UCSF, specializing in ophthalmology. Soon after, Dr. Grivas opened his own practice in Walnut Creek, CA. While operating his own practice, Dr. Grivas and his wife Pat were able to travel the globe and explore their love of photography. Dr. Grivas is survived by his three children, Diana, John, and Susan, and his two grandchildren, Connor and Keaton. Dr. Grivas was a member of the ACCMA for 62 years.

ALAMEDA-CONTRA COSTA MEDICAL ASSOCIATION BULLETIN

COUNCIL REPORTS

Put Your ACCMA Membership to Work!

Go to www.accma.org > Membership, or call ACCMA at

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Alameda-Contra Costa Medical Association 6230 Claremont Avenue P.O. Box 22895 Oakland, California 94609-5895

PRSRT STD US POSTAGE PAID 85719 PERMIT NO 271

ADDRESS SERVICE REQUESTED

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