California Family Physician (Winter 2013)

California

FAMILY PHYSICIAN VOL . 64 NO.1 Wint er 2013

MEASLES: NOT IMMUNIZING CHILDREN IS NOT AN ANSWER

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HERE’S THE SCOOP … 2013’S NEW LAWS AND WHAT THEY MEAN TO YOUR PRACTICE

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GET READY FOR ICD-10: COMPLETE AN INTERNAL CODING SELF-AUDIT NOW!

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HEALTH CARE REFORM IN 2013: MEDI-CAL PAYMENT INCREASED FOR PRIMARY CARE

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The Physicians Are in the House: Three Physicians Elected to Serve California Ami Bera, MD, CA District 7 Richard Pan, MD, California State Assembly, 9th Assembly District Raul Ruiz, MD, MPH, California District 36

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Seeking Highly Qualified Faculty

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estern University of Health Sciences’ mission is to produce, in a humanistic tradition, health care professionals and biomedical knowledge that will enhance and extend the quality of life in our communities.

Composed of nine colleges and multiple research centers, WesternU is now one of the most comprehensive academic health centers in the country.

professional and communication skills, an interprofessional education program that promotes a team approach to improve patient care, and excellent residency placements in a variety of medical and surgery specialities. COMP graduates have a record of consistently high first-time pass rates for the Comprehensive Osteopathic Medical Licensing Examination (COMLEX).

WesternU’s College of Osteopathic Medicine of the Pacific (COMP) offers early and extensive clinical training to develop

COMP-Northwest, the Pacific Northwest campus of WesternU’s College of Osteopathic Medicine of the Pacific,

welcomed its inaugural class of 107 students July 2011, at the newly constructed campus in Lebanon, Oregon. As Oregon’s first new medical school in more than 100 years, COMP-Northwest was established to address primary care physician shortages, specifically in rural and small towns in the Northwest.

COMP-Northwest’s mission is “to educate competent, caring and compassionate lifelong learners with the distinctive osteopathic philosophy, from the Northwest, in the Northwest, for the Northwest.”

For further information about COMP and its faculty openings contact: David Connett, DO, FACOFP, Interim-Vice Dean, College of Osteopathic Medicine of the Pacific Associate Dean, Clinical Services; Medical Director, University Medical Centers; Associate Professor, Family Medicine Phone 909-469-5264 • Fax 909-469-5535 • dconnett@westernu.edu 309 E. Second St. • Pomona, California 91766 • www.westernu.edu • (909) 623-6116 2

California Family Physician Winter 2013

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To improve patient safety, you need to stay on top of best practices. That’s why, as shown by the 2011 numbers above, we provide you the risk management advice you need, when and how you want it. It’s why we provide industry-leading CME online and through Claims Rx, our monthly publication based on closed claims. And why we tailor solutions to help with your specific risk issues. The results include 98% policyholder retention, the highest-level CME accreditation and reduced risk for you.

Call 877-453-4486 or visit norCalmutual.Com Proud to support the California Academy of Family Physicians Our passion protects your practice

California Family Physician Winter 2013 3

1520 Pacific Avenue • San Francisco, California 94109 • www.familydocs.org Phone (415) 345-8667 • Fax (415) 345-8668 • E-mail: cafp@familydocs.org

Officers and Board

Staff

President Steven Green, MD

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Heather Hayes

ckear@familydocs.org

Shelly Rodrigues, CAE, FACEHP

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Vice-Speaker Jay Lee, MD, MPH

Foundation President Jimmy H. Hara, MD AAFP Delegates Jack Chou, MD Carla Kakutani, MD AAFP Alternates Jeffrey Luther, MD Eric Ramos, MD CMA Delegation Ashby Wolfe, MD, MPP, MPH Nathan Hitzeman, MD Michelle Quiogue, MD Suman Reddy, MD Kevin Rossi, MD Patricia Samuleson, MD

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California FAMILY PHYSICIAN Quarterly p publication of the California Academy of Family Physicians

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The California Family Physician (CFP) is published quarterly by the California Academy of Family Physicians (CAFP). Opinions are those of the authors and not necessarily those of the members and staff of the CAFP. Non-member subscriptions are $35 per year.

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California Family Physician Winter 2013

o v E r v I E W o F H E A LT H C A r E r E F o r M

17 What’s in Store for 2013?

Adam Francis

18 Get Ready for ICD-10: Complete an Internal Coding Self-Audit Now!

Mary Jean Sage

20 Health Care Reform in 2013: Medi-Cal Payment Increases for Primary Care

Leah Newkirk

21 The Physicians Are in the House: Three Physicians Elected to Serve California 26 New Year’s Resolutions

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Editorial

Our Obligation is Simple: SLP

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President’s Message

Resolutions are a process … rather like life, patient care and professional involvement

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Michelle Quiogue, MD Steven Green, MD

CAFP’s Nominating Committee Submits 2013 Slate

In The News

10 Resident News

It’s a New Year, with New Opportunities and Activities for Students and Residents

11 Public Health and You

Measles: Not Immunizing Children Is Not an Answer

Glennah Trochet, MD

12 PCMH Corner

Making the Business Case for a Patient Centered Medical Home

14 Political Pulse

2012 Election Yields Big Wins for Family Physicians and Patients Ashby Wolfe, MD, MPP, MPH

16 Foundation News

Introducing the CAFP Scholars Program

30 Executive Vice Presidents Forum

Work with Your Public Health Officers to Increase Immunization Rates in Your Counties

David Ehrenberger, MD

Jimmy H. Hara, MD Susan Hogeland, CAE

For the upcoming CME calendar go to www.familydocs.org California Family Physician Winter 2013 5

EdITorIAL

Michelle Quiogue, MD

Our Obligation is Simple: SLP

Part of our daily work as family physicians is to inspire change and to support transitions through sickness and health in our patients’ lives. At this time of year, many of us turn

With resolve, I look forward to a year of genuine, determined action in the maintenance phase of my professional goals. I resolve to promote our specialty through service to the CAFP to the best of my ability in my next term as your Editor. This month, the CAFP Commuour focus inward and seek to change some aspect of our own lives nications Committee launched the enhanced familydocs.org website as well. This issue of CFP invites us to think about resolutions for the new year. Perhaps many of you find yourself, like me, idling at various (visit us today), and we have plans in action to transform and improve membership interaction via an electronic magazine product. I points along the now well-worn Stages of Change model. continue to work toward improved health outcomes through better relationships with my patients and The Stages of Change model shows practice improvement processes. I that, for most persons, a change in collaborate with my practice partners behavior occurs gradually, with the to build a Patient Centered Medical patient moving from being uninterHome (PCMH). Finally, my mainteested, unaware or unwilling to make nance of certification culminates this a change (precontemplation), to year in the ABFM Board Exam (wish considering a change (contemplation), During the past decade, me luck!). to deciding and preparing to make a change. Genuine, determined action is then taken and, over time, attempts to maintain the new behavior occur.

Relapses are almost inevitable and become part of the process of working toward lifelong change.

behavior change has come to be understood as a process of identifiable stages through which patients pass. Physicians can enhance those stages by taking specific action.

Back in 2000, American Family Physician advised, “Physicians should remember that behavior change is rarely a discrete, single event. Physicians sometimes see patients who, after experiencing a medical crisis and being advised to change the contributing behavior, readily comply. More often, physicians encounter patients who seem unable or unwilling to change. During the past decade, behavior change has come to be understood as a process of identifiable stages through which patients pass. Physicians can enhance those stages by taking specific action. Understanding this process provides physicians with additional tools to assist patients, who are often as discouraged as their physicians with their lack of change.”

In terms of my own physical fitness and healthy lifestyle goals, I find myself once again in the relapse phase. Holidays and celebrations have always been prime time for me to put these goals to the side. In recognition of this phase as inevitable, I resolve to pick myself up and get back on the program for the umpteenth time. This time, according to the Stages of Change Model, I should ask myself, “What have I learned from this relapse that will prepare me for the year ahead?”

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California Family Physician Winter 2013

As I contemplate potential opportunities for change, I reflect on all of the experiences of the past year to see a theme emerge: community engagement and family medicine leadership in directing attention to the social determinants of health. I now serve on the AAFP Commission on Health of the Public and Science and Subcommittee on Health Equity (SHE), I began work on Kaiser Permanente’s national Equitable Care and Health Outcomes (ECHO) project; I represented CAFP on the public health subcommittee of the CMA Specialty Delegation; and I recently volunteered for the Kern County Call to Action (the Public Health Department’s initiative to build Kern County’s capacity to effectively promote healthy living). I find myself assessing barriers to change and preparing to take concrete steps to synchronize these divergent experiences into a focused agenda.

Certainly, I have work to do in many other areas of my life, but I am still in denial about those. As you know, during the precontemplation stage, people do not even consider changing. Wherever you find yourself along the Stages of Change model, I hope you seek and find the support you need to move forward in the process. Contact the CAFP to connect yourself to the people and resources you need to lead by example and to continue your daily work of inspiring others toward healthy change.

PrESIdENT’S MESSAgE

Steven Green, MD

Resolutions are a process … rather like life, patient care and professional involvement New Year’s resolutions are not “all or none” for me. I look at them as more of a process. Balance is the resolution that comes to mind for me most years. Balance between home life and work life, rest and exercise, family and friends and patients, sleep and waking. Sometimes things are balanced for me each day, sometimes not so much.

about it. At the same time, we as physicians have our own agendas. We may need to focus on symptom-free metabolic concerns such as blood pressure and blood sugar and cholesterol. Both types of issues are important. If we fail to adequately address blood pressure, the patient could have a real life increase in risk of devastating complications such as stroke or heart attack. Nonetheless the patient may be more concerned with a sore toe, or fear his or her Vitamin D level is not at some arbitrary level. Again, balance plays a role. If, as physicians, we do not balance patient agendas with our own well-meaning medical agendas, the visits can decay into power struggles, which accomplishes nothing.

For me the trick is being flexible with this. Some days I may choose to exercise more than most people, while other days I may have to skip exercise entirely. Skipping exercise doesn’t come easily for me, but at times the gravity in my bed is so Patients come in to see us with their When I look around the room at strong, I give in and rest.

CAFP Board meetings, I see people It can also be the result of concerns. They may be afraid of willing to give their time and energy unfortunate occurrences something real, or of something very to improving the work lives of family such as project deadlines physicians and dedicated to improvfor my practice or CAFP, unlikely to be occurring, yet they ing the health of Californians. These or for even better reasons are worried about it. At the same are not easy things to do. It means such as spending time with giving up time preparing for meetmy family. There are days I time, we as physicians have our own ings and traveling to them regularly. may leave the house before agendas.

Our board members often need to my kids are awake and reparticipate in media activities with turn when they are already short notice or testify at the state asleep (although now that capital regarding pending legislathey are teenagers, it gets tion. They choose to take on this easier to get home before time commitment because it is what they finally go to bed). I do they believe they should do. Again, my best to balance things the challenge is balancing the time commitment with that of famover time. If there are days I miss out on seeing my family as ily and their own work and personal goals. much as I’d like, I balance them with family vacations or activities where we spend more time together.

More than most people, physicians should get training in this sort of balance in their education. I have medical students work This June, I will attempt to swim around Manhattan Island. It will with me in my practice as part of their continuity clerkship. I do take many hours of training in the water, and on land. Fortunately my best to share some of those ideas with them. It is funny how I enjoy the training. I like the hours of swimming with no particutalking with many of them, they believe in the future they will lar need to think, other than when the next feeding will be, or have more free time and less need to worry about balance in their where I’m aiming. It’s a nice balance from the overly structured various priorities. I don’t want to scare them, but I try to let them day of my work life. Maybe doing things in an extreme form is know their lives will most likely keep getting busier and balancing what I consider balance, as long as I juggle them appropriately. their competing demands will become a lifelong job.

Balance also applies within patient visits. Patients come in to see So will I achieve balance in the new year? I’ll keep working toward us with their concerns. They may be afraid of something real, or of something very unlikely to be occurring, yet they are worried it in my own way as best I can…

California Family Physician Winter 2013 7

IN THE NEWS

IN THE NEWS

CAFP’s Nominating Committee Submits 2013 Slate The CAFP Nominating Committee is pleased to submit the following slate for 2013 officers and directors. The election will take place at the Congress of Delegates meeting March 2-3, in Sacramento. All CAFP members are welcome to attend the meeting.

Office

Incumbent

Nominee

President-Elect

Mark Dressner, MD

Del Morris, MD

Speaker

Del Morris, MD (eligible) Jay Lee, MD, MPH (eligible)

Jay Lee, MD, MPH

AAFP Delegate (2013-2014)

Jack Chou, MD (eligible)

Jack Chou, MD

AAFP Alternate (2013-2014)

Jeffrey Luther, MD (eligible)

Jeffrey Luther, MD

Nominating Committee

Maria Greaves, MD (eligible)

Maria Greaves, MD

Elected by the Congress

Vice-Speaker

Lee Ralph, MD

concepts of practice redesign and the elements of a Patient Centered Medical Home. CAFP staff led a training session with each chapter’s representatives about the collaborative process to prepare them for returning and recruiting three small-to-medium sized practices to participate in the collaboratory. The participating chapters are working on recruitment and coaching each team through the pre-work process before all 15 practices from the five states gather on January 12-13, 2013 in Georgia to launch our newest QI endeavor.

New Lobbying Firm Representing Family Physicians in California CAFP has selected the firm of DiMare, Van Vleck and Brown to provide legislative advocacy services. Jodi Hicks, former Vice President for Government Relations for the California Medical Association will be lead advocate for CAFP, with Alice Kessler and others providing services as well. Beginning in January of 2013, the Academy anticipates a very active legislative session and concurrent special session to consider health reform implementation.

Elected by and of the Board SecretaryTreasurer

Lee Ralph, MD (eligible)

Lisa Ward, MD

Editor (20132016)

Michelle Quiogue, MD (eligible)

Michelle Quiogue, MD

CAFP Hosts Meeting in Chicago to Prepare for National Anticoagulation Management Initiative CAFP convened a meeting in Chicago November 1617,2012 with four AAFP state chapters to discuss its newest quality improvement (QI) collaboratory, TEAM-A: The Evolution of Anticoagulation Management. CAFP invited the four chapters: Florida, Georgia, Tennessee and North Carolina to participate in a year-long project designed to improve the health care team’s management of anticoagulation and stroke risk and incorporate

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California Family Physician Winter 2013

Caption: From left to right, the CAFP policy staff with staff from CAFP’s new lobbying firm, DiMare, Van Vleck and Brown (DVB): Adam Francis, CAFP Associate Director, Government Relations; Jodi Hicks, Amy Brown and Alice Kessler, DVB; Callie Langton, PhD, CAFP Director of Workforce Policy and Leah Newkirk, CAFP Director of Health Policy.

NEW ICD-10 DEADLINE:

OCT 1, 2014

2014 COMPLIANCE DEADLINE FOR ICD-10 The ICD-10 transition is coming October 1, 2014. The ICD-10 transition will change every part of how you provide care, from software upgrades, to patient registration and referrals, to clinical documentation, and billing. Work with your software vendor, clearinghouse, and billing service now to ensure you are ready when the time comes. ICD-10 is closer than it seems.

CMS can help. Visit the CMS website at www.cms.gov/ICD10 for resources to get your practice ready.

Official CMS Industry Resources for the ICD-10 Transition

www.cms.gov/ICD10

California Family Physician Winter 2013 9

rESIdENT NEWS

It’s a New Year, with New Opportunities and Activities for Students and Residents Re-Launch and Re-Imagining of the CAFP Foundation’s Preceptorship Program The CAFP Foundation’s Preceptorship Program has long been one of our most popular activities. On its 20th anniversary, we are taking the opportunity to re-imagine the preceptorship program and build on how it can best serve the participating students and preceptors. The CAFP Foundation Board of Trustees is thrilled to announce the CAFP Scholars – a marriage of the Year 1 summer experience, longitudinal activities, and cohort class support. Stay tuned for more details!

New CAFP Website The CAFP website has been in full renovation mode and the newly designed site launches with this edition of California Family Physician. The Student and Resident Department took YOUR suggestions into account and is confident the new website will be more user-friendly by making simplicity and organization the highest priorities.

The new student and resident section of the website has been slimmed down to create the best experience for users. Content is reorganized and updated, making it both easier and quicker for you to find what you need. We are most excited about a brand new section that will make researching California’s family medicine residency programs much easier for students.

The more than 40 family medicine residency programs in California, each with its very distinct personality, offer unique opportunities. But these opportunities, coupled with the vast number of programs, can make the task of deciding where to apply difficult.

CAFP’s student and resident affairs department has been busy formulating its New Year’s Resolutions. We

are always on the lookout for ways to improve and enhance services and resources for all members. And for 2013, the student and resident department has come up with several ways to expand the resources we offer to you as you continue your educational journey.

Updated New Family Physician Toolkit The New Family Physician Toolkit (updated for 2013) is a “must read” for any family medicine resident. Inside you’ll find articles addressing questions to ask a potential employer, how to balance work and family, and basic financial guidance, and more. Download your copy of the Toolkit at http://issuu.com/ cafamilydocs/docs/2013nfptoolkit.

We want to make this process much more enjoyable. We will be launching a Family Medicine Residency Program Directory.

In addition to basic information about each program, the directory will include photos, unique curriculum components, program emphases, meticulous descriptions of the patient populations served and opportunities in the community for spouses and family members.

We hope the resolutions we’ve made to serve you better will make YOUR lives just a little easier in 2013. Many of the modifications discussed above come from member feedback and the Student and Resident Councils, so please stay engaged and don’t hesitate to reach out to us with suggestions or comments. Contact CAFP’s Student, Resident and Social Media Manager, Cody Mitcheltree, at cmitcheltree@familydocs.org or call 415-345-8667.

Happy New Year!

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California Family Physician Winter 2013

PUBLIC HEALTH ANd YoU

Measles: Not Immunizing Children Is Not an Answer

By Glennah Trochet, MD

I was the Public Health Officer for Sacramento County, and one day the nurse epidemiologist asked me to call an angry parent. The nurse had told this working mother that her child, who was well, could not go to school for the next three weeks.

Why? Because a little girl in his classroom had recently returned from a trip overseas with measles. Before it was diagnosed, this child had exposed her entire first grade class to the disease.

The nurse’s investigation revealed that one child in that classroom was under treatment for leukemia, and another was severely immune compromised because of the use of steroids. Following accepted protocol, all children who were not fully immunized against measles were required to stay home from school for the three-week incubation period. They would be allowed back into class when the incubation period was over and if they had not developed measles by then.

This quarantine strategy is an old and effective method for containing the spread of a communicable disease. It was extensively used in pre-vaccine days and has returned now that so many parents refuse vaccination for their children.

This parent had signed a religious belief exemption and her son was not immunized against measles. On the telephone, the mother said that she and her husband worked outside the home and there was no one to take care of her son during the three weeks he had to stay home. I acknowledged that this was a hardship, but explained that her child could get the measles and this presented a risk to his classmates. She was offended, stating that her child was well and did not have to stay home. She told me she would call her lawyer and sue the health department and the school if her child was not allowed to attend class. The conversation ended abruptly with the parent hanging up the telephone.

Many parents currently refuse to have their children immunized for a variety of reasons. Most do so under the misapprehension that the risks of immunizations are worse than the risk of the disease. This is not so.

Childhood immunizations prevent diseases that in the past caused disability and death in a significant proportion of the population who got illnesses such mumps, measles, chicken pox and diphtheria.

We acknowledge a small risk of complications from getting an immunization. The Centers for Disease Control (CDC) states that the risk of encephalopathy from the MMR vaccine is less than one in one million doses given. Other transient reactions are more frequent, with fever occurring in five to 15 percent of children

who get the MMR vaccine and a rash occurring in five percent of children who receive the MMR vaccine. There is no credible evidence linking immunizations to autism, one of the main reasons parents are reluctant to allow their children to be immunized.

Compare this to the risks of the disease of measles, which almost 100 percent of children suffered through prior to the advent of the vaccine. According to the CDC’s “Pink Book,” measles is still a common and often fatal disease in developing countries. The World Health Organization estimated there were 164,000 deaths from measles world-wide in 2008. Approximately 30 percent of reported measles cases have one or more complications. These include diarrhea, otitis media and pneumonia. Pneumonia, the most common cause of death from measles, occurs in six percent of cases and can be viral or superimposed bacterial. Encephalitis occurs in 0.1 percent of cases of measles with one quarter of the cases suffering residual damage. In the USA, death from measles occurs in 0.2 percent of cases, with deaths occurring primarily in young children and adults. Sixty percent of the deaths were caused by pneumonia, and the rest from other complications including encephalitis.

So here is the rationale for immunizing children in the United States against measles: 1. It is still present in the world and is imported to the US (and to California) regularly, exposing those who are not immunized to the complications of the illness.

2. A growing number of children cannot be immunized with live vaccine because of medical conditions such as cancer and immune suppression.

3. The risks of contracting the disease and getting complications from measles far outweigh the risks of receiving the immunization.

4. In addition to the health risks, there are also adverse fiscal consequences for families whose children come down with the disease or are exposed and must be quarantined.

5. We all owe it to society to have our children immunized if they can be, as this not only protects them from illness, but through herd immunity, also protects those children who cannot be immunized for medical reasons.

Fortunately there were no further cases of measles in the classroom of the child with measles, and the mother who hung up on me called our office two days later to find out where she could have her son immunized. We were happy to oblige.

Bibliography: Epidemiology and Prevention of Vaccine-Preventable Diseases. The Pink Book, 12th Edition, Chapter 12: Measles CDC Measles Investigation Quicksheet, California Department of Public Health, January, 2011 California Family Physician Winter 2013 11

PCMH CorNEr

David Ehrenberger, MD

Making the Business Case for a Patient Centered Medical Home News flash: The Patient Centered Medical Home delivers superior health, health care and cost savings… but, can physicians afford it? This article dissects the

business case for a Patient Centered Medical Home (PCMH) from the perspective of the practicing primary care physician.

The business case is about more than “doing the right thing.”

Let us begin with the data that overwhelmingly show that the medical home, an advanced model of primary care as typified by the National Committee for Quality Assurance (NCQA) PCMH 2011 Recognition Program, will transform health care.

In a recent report that evaluated 34 medical home initiatives over the past several years, the medical home model affects health care costs by reducing emergency department (ED) visits by 10 to 50 percent, hospitalizations by 15 to 53 percent and overall health care costs by 11 to 20 percent or $17 to $89 per member per month (PMPM)1. More importantly, these health care savings were accomplished while dramatically improving the care of medical home patients across the spectrum of primary care delivery: improvements included diabetes care (with a 49 percent reduction in Hemoglobin A1c), heart disease (“optimal care” improved by 48 percent), influenza vaccinations (increased by 112 percent), mammography screening (increased by 25 percent), colorectal cancer screening (increased by 39 percent), cholesterol levels (decreased by 27 percent) and patient engagement (selfmanagement) goals( increased by 56 percent).1,2 My twelveprovider family practice participated in the Colorado MultiPayer Multi-Stakeholder Medical Home pilot and at the end of

the three-year initiative, analysis of these outcomes and cost savings performance data confirmed the national experience above. The jury is in; the medical home works.

But what does it cost to build and maintain a medical home?

The data here are much less robust. With the emerging standards defined by NCQA and others, it is clear that “walking the talk” is not cheap. In 2004, the Future of Family Medicine Task Force predicted that the cost of transitioning to a medical home model would range from $23,000 to $90,000 per physician.3 A recent study of federally-funded health centers documented the association between PCMH rating and operating costs, with key medical home attributes—such as access, care management, test/referral tracking—evaluated and scored on a scale of zero to 100; a 10-point higher score was associated with a $2.26 higher operating cost PMPM.4 Preliminary findings from an analysis from the Colorado PCMH pilot are consistent with these findings: the incremental cost, above that required of a traditional though electronic health record-powered primary care practice, of maintaining the systems unique to a mature Level III NCQA 2011 PCMH is at least $4 PMPM.5 This is sobering if you do the math. For a primary care provider with a patient panel of 1800, this amounts to added operational costs of $90,000 per provider per year.

Impossible, you say? Peanuts, I say! Remember the proven downstream health care system payoff of $17 to $89 PMPM savings, or for added punch, $367,200 to $1,922,400 savings per full-time employee (FTE) physician per year.1 The trick is

The business case is about more than “doing the right thing.”

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California Family Physician Winter 2013

PCMH CorNEr in the PCMH payment modeling that connects the dots between those who benefit (patients, employers, government and payers) and those who do the heavy, patient-centered lifting (physicians and their teams).

The good news is that payment reform is an unstoppable force with PMPM “medical home management fees,” pay-for-performance and shared savings programs spreading across the nation. The federal government is on board with the Center for Medicare & Medicaid Comprehensive Primary Care Initiative, which pays an average $20 PMPM fee, in addition to a shared savings program. Payers are in it, too.

Multiple payers that have realized the impact of the medical home on their bottom lines are rolling out both PMPM and shared savings programs nationally. The Patient-Centered Primary Care Collaborative published a study of 26 medical home initiatives showing PCMH-powering PMPMs as high as $11 with the Colorado Pilot rate for a Level III medical home at $7.25.6 The ultimate business case for PCMH rests on the return on investment (ROI). Interestingly, this has been studied in two exemplary accountable care organizations. The Group Health Cooperative showed total savings PMPM of $10.3 and an ROI of 1.52 and the Geisinger Health System studied its PCMH cost savings from 2006 to 2010 to show an ROI of 1.7.1 Although many primary care physicians do not work in large integrated health care systems, these data define the medical home rallying cry to ensure progressive payment modeling becomes standard operating procedure. It makes sense.

Finally, the notion of a business case for PCMH is not limited to the clinical outcomes and cost dimensions that compel physician investment. There is also the urgency for primary care to reinvent itself. Perhaps this

Coastal Southwest Florida needs FP's- outpatient only! reinvention is the most important part of the business case: primary care practices must become datadriven learning organizations that make “meaningful use” of EHRs and data and effective systems of teambased care creating value for both our patients and the primary care teams themselves. This is the “Triple Aim” primary care, the defining calculus of market-relevant value and what ultimately makes our business case.

FP needs in the beautiful SW Florida, located along the gulf coast of Florida. This will be en employed position with one of the largest and most stable health systems in the state. It will be outpatient medicine due to a stable hospitalist program. This is an employee model. The system has EMR and focus is more on quality medicine not quantity. You will receive a very competitive salary $170,000 to $190,000 (depending upon experience), full and extensive benefit package, this location has been in money magazine year after year and is a great place to raise a family. Close to Naples, South Florida and Tampa.

Dr. David Ehrenberger is Chief Medical Officer of Avista Adventist Hospital and Integrated Physician Network, an Accountable Care Organization north of Denver. He practices medicine parttime in a Level III NCQA recognized medical home. He may be reached at davidehrenberger@centura.org

Ray Thomas NHR Director of Recruitment 5521 University Dr. #202 Coral Springs, Fl 33067 1-800-647-2232 ext 204 Fax 1-866-328-1019 Ray@nhrnationwide.com

References: 1. Nielsen, Marci, et al. “Benefits of Implementing the PCMH: a Review of Cost and Quality Results.” Patient-Centered Primary Care Collaborative (2012) 2. Reid, Robert J., et al. The Group Health Medical Home at Year Two: Cost Savings, Higher Patient Satisfaction, and Less Burnout for Providers, Health Affairs 5 (2010): 835-843.

3. Spann, Stephen J., et al. “Report on Financing the New Model of Family Medicine. Annals of FM.” Task Force Report 6 2.3 (2004): 1-21.

4. Nocon, Robert S. “Association between Patient-Centered Medical Home Rating and Operating Cost at Federally Funded Health Centers.”

JAMA308.1 (2014): 60-66.

5. Ehrenberger, David. “Personal Communication. Cost Modeling of the PCMH (preliminary).” Health Team Works (July 2012) 6. Bailit, Michael, et al. “Payment Rate Brief.” Patient-Centered Primary Care Collaborative (March 2011): 1-8.

www.nhrna t i onw ide.com PS - Please look at our latest jobs on the website!

For Advertising CONTACT

Michelle Gilbert mgilbert@pcipublishing.com

1-800-561-4686 ext. 120

California Family Physician Winter 2013 13

PoLITICAL PULSE

Ashby Wolfe, MD, MPP, MPH

2012 Election Yields Big Wins for Family Physicians and Patients Family physicians and their patients scored key wins in the November 2012 election. Family physicians and their

patients scored key wins in the November 2012 election.

Both CAFP recommended positions on ballot measures were validated by voters; important health care reform provisions, including increased pay for primary care services and the Medi-Cal expansion, will now move full steam ahead as well. Family physicians are glad that we can put the election behind us and focus on ensuring that millions of uninsured Californians gain health care coverage and all Californians have access to a family physician and a Patient Centered Medical Home (PCMH).

Proposition 30: 54 percent in favor/46 percent opposed CAFP-supported Proposition 30 passed, ensuring needed fiscal relief for the state’s General Fund. The changes won through Proposition 30 will help address the state’s ongoing budget crisis. The increased funds will help us protect health and human services programs, as well as education programs. This is a win for physicians and patients. State health programs should not undergo further cuts after consecutive years of already devastating reductions.

Proposition 31: 40 percent in favor/60 percent opposed CAFP-opposed Proposition 31 was defeated handily, avoiding what could have been significant unintended consequences of a complicated new law. The measure was an effort to improve state government processes, but some of its provisions, including one that would give the governor significant new powers to unilaterally cut state programs,

... Family physicians and their patients scored key wins in the November 2012 election. Both CAFP recommended positions on ballot measures were validated by voters; important health care reform provisions, including increased pay for primary care services and the Medi-Cal expansion, will now move full steam ahead as well.

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could have led to harmful cuts in health care programs without a vote of the legislature. Proposition 31 also would have amended the state constitution, making it difficult to change law in the future.

State Legislative and Congressional Races Several of CAFP key allies won in state and federal contests, including physicians and other health professionals, three of whom are featured in this magazine: • Raul Ruiz, MD, an emergency room physician from Riverside County, will be the new congressman from District 36. Dr. Ruiz has met numerous times with CAFP and AAFP representatives and will be a champion for many of our priorities in Washington, DC. • Pediatrician Richard Pan, MD won reelection handily in Assembly District 9 in Sacramento. Assemblymember Pan’s experience as a primary care physician gives him unique insight into the everyday lives of family physicians. We look forward to his continued chairmanship of the Assembly Health Committee.

• In a very close and contentious contest, primary care internist Ami Bera, MD, beat incumbent Congressman Dan Lungren in District 7 in Contra Costa County. Dr. Bera has expressed support for health care reform and has a great relationship with AAFP. • Bill Emmerson, DDS won reelection in State Senate District 57 in the Redlands region. Senator Emmerson has been a champion of the Patient Centered Medical Home, primary care payment and other issues that concern family physicians and their patients.

• Congressman John Garamendi secured the seat to represent District 3 in Sacramento and Solano Counties.

Representative Garamendi has been a longtime champion of family medicine and, with a daughter who has chosen to practice family medicine, is keenly aware of the issues family physicians face.

To see all California election results go to: http://vote.sos.ca.gov.

State Legislative Wins The final days of the 2011-2012 Legislative Session were mostly positive for CAFP’s priority bills, with one notable exception: CAFP’s co-sponsored Patient Centered Medical Home definition bill, SB 393 (Hernández), was vetoed by Governor Brown. CAFP remains committed to advancing the PCMH model in California and will consider our advocacy options as we head into the 2013-2014 legislative session.

PoLITICAL PULSE

Thanks to all who reached out to the Governor and his staff asking for a signature on this important bill.

CAFP was pleased that six of our supported bills were signed by the Governor in 2012. We would like to highlight four that will help family physicians and their patients.

• AB 589 (Perea) – This new law creates the Steven M. Thompson Medical School Scholarship Program (not to be confused with the Steven M. Thompson Loan Repayment Program) to provide up to $105,000 in scholarship funds if a student agrees in writing, prior to graduating from an accredited US allopathic or osteopathic medical school, to practice in an underserved area for at least three years. A student can also qualify by agreeing to practice in a clinic that serves county indigent patients. Funding for this program must come from voluntary private contributions.

• AB 1533 (Mitchell) – This new law will help prepare international medical graduates (IMGs) for residency in family medicine by authorizing a five-year UCLA IMG pilot program allowing participants to engage

•

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in supervised patient care activities for 16 to 24 weeks as part of an approved and supervised clinical clerkship/rotation at UCLA health care facilities or with other approved UCLA affiliates. The goal of this law is to train more primary care doctors in underserved communities.

AB 1640 (Mitchell) – This new law requires that aid from the California Work Opportunity and Responsibility to Kids program (CalWORKs) be paid to eligible pregnant women who are 18 years of age or younger at any time after verification of pregnancy.

Benefits previously were limited to the third trimester.

AB 2009 (Galgiani) – This new law ensures that flu vaccine availability for children is a priority. The law will update the priority populations for stateadministered influenza vaccines to mirror the recommendations from the federal Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices.

Dr. Wolfe is Chair, CAFP Legislative Affairs Committee

California Family Physician Winter 2013 15

FoUNdATIoN NEWS

Jimmy H. Hara, MD, CAFP Foundation President

Introducing the CAFP Scholars Program Every change brings opportunity. Our Student Preceptorship

Program has had a wonderful 20 years, and as a mature program is now ready for its next adventure. In the past, medical students spent four weeks in a family physician’s office learning about what life is really like for a family doctor. This program has been extremely popular, and each year we lament that it’s too bad the experience is so short. At its November 2012 Board of Trustees meeting, CAFP Foundation’s trustees unanimously voted to create a new program that will expand students’ experiences beyond the summer.

We’re thrilled to announce the birth of the CAFP Scholars Program.

This program launches in 2013 and combines a longitudinal experience for medical students with the students’ opportunity to spend time in a physician’s practice after Year 1 of medical school. It also adds new learning opportunities and the development of a yearly cohort system so each Scholar has a cohort for support.

Want to get involved with this new program or the Foundation?

We welcome your support as we shape our new program into the premiere learning experience for students interested in family

medicine. Your generosity makes it possible for students and residents to access the CAFP Foundation’s programs and resources as they explore or begin careers in family medicine. It underwrites our research and publications used by many across the state to inform decisions on physician workforce issues. And it powers our consistent push toward the next innovation in family medicine education. Join us on this journey and consider making a tax-deductible contribution to the CAFP Foundation today. Your support is what makes possible the work we do with students and residents.

Need some examples of what your donation can do?

• $25 sponsors a student’s attendance at our Family Medicine Summit in September • $200 sponsors a high school student for an entire semester of our Future Faces of Family Medicine Program • $1,000 sends a medical student to our brand new CAFP Scholars program and will help develop that student into a future family physician We welcome your contribution at any level. Our best wishes to you for 2013!

Receive the California Family Physician Journal Printed or Electronically.

In an effort to be more ecologically responsible we are offering you the opportunity to receive your copy of the California Family Physician journal as an emailed link to an electronic version of the journal. Your name will be removed from the list for the printed and mailed hardcopy of the journal if you choose the electronic option. To see the electronic “ePub” version of the journal visit our webpage familydocs.org and click on the turning page icon.

Two easy ways to subscribe to the new E-CFP: 1. Email srodrigues@familydocs.org, and say “I want to go E” followed by your email address, or 2. Go to: http://bit.ly/RwqgQs and complete the online subscription form.

You’ll be automatically subscribed to the “ePub” and your address will be removed from the mailing list for the hardcopy version. You will be emailed a link to an “ePub

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California Family Physician Winter 2013

Here’s the Scoop … 2013’s New Laws and What They Mean to Your Practice

By Adam Francis CAFP’s Associate Director, Legislative Affairs

dispensing the prescription in an initial amount followed by periodic refills is medically necessary.

The pharmacist exercises professional judgment and dispenses no more than the total amount prescribed, including refills.

With the start of a new year, we want to alert our members to laws passed in 2012 that may affect their practices and patients.

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AB 2109 (Pan) – This new law, sponsored by the California Medical Association (CMA), the Health Officers Association of California and the California chapters of the American Academy of Pediatrics, takes effect in 2014 and requires documentation that health care practitioners have informed parents about vaccines and diseases before parents can obtain exemptions to student immunization requirements based on personal beliefs.

The law prohibits a pharmacist from dispensing a dangerous drug if the prescriber indicates “dispense as written” or words of similar meaning. It also requires a pharmacist to notify the prescriber of the increase in the quantity dispensed. When implemented, this may reduce the paperwork associated with multiple refill requests for long-term prescriptions when treating chronic conditions such as high blood pressure.

In signing the bill, the Governor stated that he will direct the California Department of Public Health to allow for a separate religious exemption. Parents or guardians seeking an exemption to an immunization required for California students will need to document 1. Receipt of information about immunizations and communicable diseases from an authorized health care practitioner, who is also required to document the provision of such information.

• This documentation may not be signed more than six months prior to when the immunization is required (typically, the start of the school year).

• Authorized health care practitioners include licensed physicians, nurse practitioners, physician assistants, naturopathic doctors and credentialed school nurses.

2. Required immunizations the student has received and not received.

SB 1524 (Hernandez) – This new law removes the requirement that newly graduated nurse practitioners (NPs) and certified nurse midwives (CNMs) have at least six months of physician-supervised experience in the furnishing or ordering of drugs or devices. This provision can still be required if the supervising physician includes it in the protocol agreement. CAFP would appreciate feedback from physicians working with newly graduated NPs and CNMs in order to track the effect of this bill on team care.

Many hope that the added counseling opportunities between physicians and parents of school-age children to discuss the benefits of immunizations will improve immunization rates in California.

SB 1301 (Hernandez) – This new law allows a pharmacist to dispense a 90-day supply of medication, excluding psychotropics, if an initial 30-day supply has been completed, periodic refills are allowed and all of the following requirements are satisfied: • The total quantity of dosage units dispensed does not exceed the total quantity of dosage units authorized by the prescriber on the prescription, including refills.

• The prescriber has not specified on the prescription that

SB 1538 (Simitian) – This new law has the laudable goal of giving women more control over their health by alerting them to their level of breast density, through mandating the exact language included in the mammography results report to the patient, specifically for women with dense breasts. CAFP was part of a coalition that that succeeded in removing language from the original bill that encouraged additional, non-evidence-based screening. The coalition also succeeded in amending the bill with language that protects against liability. The amendments the coalition secured are a huge victory for providers and patients.

The dense breast mammography notice sent by the radiologist will now include this statement: “Your mammogram shows that your breast tissue is dense. Dense breast tissue is common and is not abnormal. However, dense breast tissue can make it harder to evaluate the results of your mammogram and may also be associated with an increased risk of breast cancer. This information about the results of your mammogram is given to you to raise your awareness and to inform your conversations with your doctor.

Together, you can decide which screening options are right for you.

A report of your results was sent to your physician.”

California Family Physician Winter 2013 17

CodINg CorNEr

Get Ready for ICD-10: Complete an Internal Coding Self-Audit Now!

By Mary Jean Sage CAFP’s Coding and Billing Consultant

The new compliance date for use of new codes that classify diseases and health problems, International Classification of Diseases (ICD-10) is October 1, 2014.

the confidence to fully code the more intense encounters you conduct. A self-audit can also help you identify incorrect billing patterns before claims are denied by outside auditors.

While it seems like a long time away, now is the time to begin considering what needs to be done in your practice to get ready for this very challenging change in reporting diagnoses.

A prospective or retrospective physician practice coding audit is commonly performed to ensure the physician is submitting appropriately coded claims according to Current Procedural Terminology (CPT) codes, guidelines and conventions and payor payment policies. You, the physician are ultimately responsible for claims submissions to payors, even if a billing service or clearinghouse is submitting claims for you/your practice.

In a recent Practice Management News article, we addressed how to properly respond to a request for medical records and claims payment from Medicare and private health plans. In this article, we cover how to perform an internal coding audit to determine whether your coding is appropriate. The only way to make this determination is to compare the coding on claims against the actual clinical documentation recorded in your patient’s chart. An internal coding audit can reveal whether any variation from national averages is caused by inappropriate coding or by atypical levels of intensity among your patients. A self-audit can help you make corrections before a payor challenges any inappropriate coding and give you

You, the physician are ultimately responsible for claims submissions to payors, even if a billing service or clearinghouse is submitting claims for you/your practice.

In a prospective billing audit, a designated staff person, internal compliance officer or outside consultant reviews the claims before they are submitted to the payer to ensure the appropriateness of the coding, documentation and adherence to health plan medical payment policies. In a retrospective audit, a designated person reviews claims for appropriateness after they are paid. All overpayments and billing errors identified during a retrospective audit should be handled according to the payor’s repayment guidelines.

If the audit reveals a pattern of repeated errors, the physician should obtain legal advice from a health law attorney to determine possible responsibilities. The practice must take the necessary steps to ensure the errors do not recur. It is recommended that a practice perform a prospective audit annually, or when new physicians or billing staff personnel are hired, to identify and address potential errors promptly.

These five rules should guide you through the process of a self-audit: Rule #1: Select charts randomly Do not taint your sample by selecting the charts that are to be audited. Ask a staff member to pull a patient list for a week and pull every tenth chart until you reach a sample

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CodINg CorNEr of 10 charts. It makes sense to concentrate on visits that took place at a certain time so that you can observe trends.

Merely pulling charts at random out of the racks will not accomplish this goal. Avoid selecting specific charts from a specified time period.

Rule #2: Do not review your own charts It is nearly impossible for a physician to complete an unbiased review of his/her own charts. You can read your own handwriting perfectly; you can fill in gaps based on your memory; and you might give credit for things that are not well documented. If you do get audited by an external payer, the person reviewing your charts will be unfamiliar with your handwriting, your work style and your overall practice pattern. The person you choose in your practice to perform the internal audit should certainly have knowledge of the coding rules, be able to complete an auditing worksheet and have a strong understanding of medical terminology. That person may be another physician, a nurse, a qualified coding specialist or a consultant Rule #3: Use the same rules as the auditors Medicare and private insurer auditors may interpret guidelines in different ways but they do stick to a few simple rules. First, auditors are supposed to use whichever Evaluation and Management (E/M) documentation guidelines – either the 1995 or 1997 guidelines – are more beneficial to the physician. For a comparison of the 1995 and 1997 guidelines, please click here.

Rule #4: Keep coding audit results professional and educational Physicians should be given the opportunity to review and study the results of their coding audits and openly discuss what can be improved. Improved coding is encouraged when everyone on staff is committed to the goal of complying with documentation guidelines to avoid a potential adverse impact on the practice. Avoid a heavyhanded response to the chart audit results. Making coding audits punitive for the parties involved does not benefit the practice and can lead to defensive behaviors that are even more harmful than simple miscoding.

Rule #5: Work at correcting errors Completing a coding audit accomplishes very little unless a

serious effort is undertaken to fix any identified problems.

Establishing an on-going reporting and feedback system to physicians is essential to the process. Error rates should be recorded and so should trends in documentation. If one physician is not thoroughly documenting patients’ histories, that should be noted. If another physician or staff person is not recording patients’ chief complaints, which should be noted as well. These should be seen as opportunities for improvement. If the practice or the physician can show improvement from one audit to the next, it is an excellent sign of commitment to fixing errors. Correcting any systematic undercoding that was uncovered in an audit will enable you to collect the revenue to which you are entitled.

Addressing overcoding will minimize the likelihood that you will have to pay money back to Medicare or any other payor if audited.

Auditing physician charges and billing practices is burdensome, but it will typically yield improved claims management processes, cash flow and compliance with applicable laws and regulations. An annual audit allows physicians and practice staff to identify specific coding issues that may recur in similar claims submissions. Careful pre-submission monitoring and review of these similar claims may safeguard against errors that could result in a claim denial. An internal audit allows the physician and practice staff to identify incorrect billing patterns before claims are denied or outside auditors assess penalties.

Get Ready for ICD-10!

CAFP has two programs designed to help you through this process. We developed a 2013 Coding Webinar so you and your staff will know all the ins and outs of new CPT codes for 2013 and can prepare your practice for ICD-10 implementation. The webinar is scheduled for Wednesday, January 30 from 12:15 – 1:45 and registration is available at http://bit.ly/2013cpt.

For those of you who cannot make that date, an ICD10 implementation workshop will be available at our annual meeting http://www.familydocs.org/professionaldevelopment/annual-scientific-assembly.php on May 3-5.

The workshop will be run by our coding specialist and will help practices implement and report ICD-10 codes in all transactions for encounters or discharges on and after the compliance date. Register for these two activities today and prepare your practice for ICD-10.

California Family Physician Winter 2013 19

Leah Newkirk

o v E r v I E W o F H E A LT H C A r E r E F o r M

Health Care Reform in 2013: Medi-Cal Payment Increases for Primary Care The Affordable Care Act (ACA) is a complex law with a lengthy implementation period; it stipulates that between 2010 and 2018, the Health and Human Services Secretary promulgate more than 1,000 sets of regulations and that various federal and state agencies enact these regulations to make real change in health care. The process gives stakeholders, such as the California Academy of Family Physicians, an opportunity to shape the regulations and systems for our constituents, and it gives health care providers and consumers some time to adjust to the new health care landscape.

2013 is an active year for ACA implementation, but in many ways it is a “ramping up” period for the major programmatic provisions that come into effect in 2014: the majority of insurance regulations, the launch of state insurance exchanges, the requirement that individuals have insurance coverage or face a penalty, the Medicaid expansion, the availability of premium and cost-sharing tax credits for individuals and small businesses and more. California’s family physicians must get ready, in 2013, for an onslaught of newly-insured patients, many of whom may have language and cultural proficiency needs. Conservative estimates project that around four million previously uninsured Californians will gain coverage under the ACA. Enrollment in Medi-Cal, the state’s Medicaid program, is expected to increase by 1.7 million people, and four million people are expected to enroll in the state’s health insurance exchange, Covered California.

Anticipating that the entry into the health care market of millions of newly-insured Americans sets the stage for a primary care physician shortage, the ACA boosts payment for primary care providers. The Medicare Primary Care Incentive Payments, a 10 percent bonus for primary care services furnished between 2011 and 2016, is one example. The Medicaid-Medicare payment parity rule, newly effective in 2013, is another example. This rule increases Medicaid (i.e., Medi-Cal) payment for primary care services to Medicare levels for family physicians and other specified providers in 2013 and 2014. As California’s Medicaid payment rates are the second lowest in the country, this is a significant increase. In addition to the increases in Medi-Cal payments, the regulations also update vaccine administration fee maximums that had not been updated since the Vaccines for Children program was established in 1994.

The rule provides higher payment in both the fee-for-service and managed care settings for specific primary care services furnished by:

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California Family Physician Winter 2013

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Practicing physicians who self-attest that they are board certified with a specialty designation of family medicine, general internal medicine and pediatric medicine; Subspecialists related to those specialty categories as recognized by the American Board of Medical Specialties, American Osteopathic Association or the American Board of Physician Specialties who also self-attest that they are board certified; Physicians related to the specialty categories of family medicine, internal medicine and pediatrics who self-attest that at least 60 percent of all Medicaid services they bill or provide in a managed care environment are for the specified Evaluation & Management (E/M) and vaccine administration codes; or Advanced practice clinicians when the services are furnished under a physician’s personal supervision.

Higher payment is not available for physicians who are paid through a Federally Qualified Health Center or Rural Health Center.

The specified primary care services include Evaluation and Management codes 99201 through 99499 and vaccine administration codes 90460, 90461, 90471, 90472, 90473 and 90474. Inclusion of a code in this list does not require a state to pay for the service if it is not already covered under the state’s Medicaid program; it only requires the state to pay for the service at the Medicare rate if covered. All other state coverage and payment policy rules related to the service remain in effect.

CAFP will be in close contact with the Department of Health Care Services regarding the roll-out of this rule. CAFP staff, together with a newly formed Medi-Cal Task Force, will advocate for immediate implementation, administrative simplicity, timely payments and assurance that Medi-Cal managed care plans pay family physicians at the applicable Medicare rates.

California family physicians must decide whether the new rule allows them to care for new Medi-Cal beneficiaries or participate in Medi-Cal at all. To support this decision making process, AAFP has created a dedicated webpage to help members better understand how the rule affects payment for primary care and preventive health care services. California family physicians can also contact CAFP’s Director of Health Policy, Leah Newkirk, at cafp@familydocs.org or 415.345.8667 with any questions.

oN THE CovEr

The Physicians Are in the House: Three Physicians Elected to Serve California Three physicians were elected in November 2012 to serve the people of California … Drs. Raul Ruiz and Ami Bera are heading to Washington, DC for freshman terms in Congress and Dr. Richard Pan returns to Sacramento’s Assembly for a second term.

Thanks to Drs. Jay Lee and Carla Kakutani and Susan Hogeland, Adam Francis and Jodi Hicks for coordinating interviews with these newly-elected physicians. A great way to meet our new California physician congressmen would be to attend the AAFP’s Family Medicine Congressional Conference May 14-15, 2013 in Washington DC. It will be #FMRevolution from the inside!

Raul Ruiz, MD, MPH California District 36, US House of Representatives Congratulations! CAFP is very much looking forward to working with you in your new role. We know that running for office is a difficult process, but what has been the highlight for you as you’ve undertaken this endeavor?

The highlight for me has been the opportunity it’s presented to get to know the concerns and issues of so many people in my district and throughout the country.

I’ve been so moved by the breadth of support I’ve earned for my campaign – from the students who have volunteered their time in between school and jobs, to business owners who have never gotten involved in political campaigns before.

What are your priorities heading into your first legislative session?

My priorities in my first legislative session are to work with members of both parties to solve the problems we face in my district and in our nation. In the Coachella Valley, we face one of the most severe healthcare crises in the nation. There are far too many homes in foreclosure, too many of my neighbors losing their jobs, and too many seniors trying to make ends meet on Medicare and Social Security. In the ER, it doesn’t matter if you are a Democrat or a Republican. A good idea is a good idea, and we work together to find solutions.

As a physician, what led you to seek public office?

From a young age, it has always been my mission to serve the community. It is that mission that led me to become a physician in the first place. When I was 17, and I asked my neighbors to help put me through college, I promised them I would use their

investment in my education by returning home to work as a physician. Since then, I’ve created a program to help more young people who want to become physicians realize their dream, worked with others to create a free clinic for the uninsured, and created a regional initiative to analyze and address the healthcare crisis in this area. I decided to run for Congress because I wanted to implement change on a larger level, and saw that our current representative was voting contrary to the wellness of the community.

What do you see as the role of physicians in terms of political advocacy?

I think it is very important for physicians to be active in political advocacy. As physicians, we work hard to help our patients, and we have a unique view of what is and isn’t working in our current healthcare system. We have a responsibility to make our voices heard politically so we can create more positive outcomes beyond caring for the patients in front of us.

Have you had a chance to work with family physicians in your medical career and what was that experience like?

As an emergency medicine doctor, I know the importance of prevention and primary care. Family physicians are critically important in addressing the long-term health of their patients and vital for the successful implementation of the Affordable Care Act. I see this on a regular basis when consulting with family physicians about their patients who come into the emergency department.

What do you think is the ideal role for primary care in our medical system?

I think that primary care plays a vital role in creating a high quality, affordable health care system that focuses on prevention and improves the health of our population.

What advice would you offer other physicians consdiering seeking political office in California?

First, I would encourage them to do it! We need many more physicians in public office, both in California and nationwide.

I would also encourage physicians running for office not to overlook support from fellow health care providers. I have received support from doctors, nurses and hospital administrators throughout the state. This victory would not have been possible without them.

Thank you for the opportunity to be featured in your magazine. I hope that your members will stay in touch, and can reach me at: info@drraulruiz.com.

California Family Physician Winter 2013 21

oN THE CovEr Dr. Ruiz: At a Glance • Graduated magna cum laude, UCLA • First Latino to receive three graduate degrees from Harvard University – a Medical Doctorate, a Masters in Public Policy and a Masters in Public Health • Returned to the Coachella Valley in 2007 to work as an emergency physician at Eisenhower Medical Center • Senior Associate Dean, University of California, Riverside School of Medicine • Founder and director of the Coachella Valley Healthcare Initiative • Founded a pre-med mentorship program, the Future Physician Leaders program, for students from underserved communities who, as he did in 1990, want to become doctors and return to their community to serve • Helped open clinics giving free care and health education to underserved communities throughout the Coachella Valley

of that will be hard and will play out differently in each state. Of course, continuing to build our economic recovery is key as well as improving schools and education.

Ami Bera, MD CA District 7, US House of Representatives

Are you planning to try to keep up your clinical skills while serving in Congress?

I hope to. It will probably be through volunteering at free clinics, I already do this at UC Davis’ student run clinics and plan to continue when I’m home in the district. Once we get settled in DC, I’ll check into similar opportunities there.

The second time around was the charm for Dr. Ami Bera, who defeated incumbent Dan Lungren to represent California’s 7th Congressional District. The district encompasses Elk Grove and eastern Sacramento County. The tight race attracted attention and money from across the country and was not officially called until almost two weeks after election day.

Dr. Bera is a primary care internist with considerable background in the issues family physicians care about, especially public health and the primary care training pipeline. He served as Sacramento County’s Chief Medical Officer, overseeing all the county primary care clinics, and as University of California, Davis (UCD) School of Medicine’s Dean of Admissions before deciding to run for Congress.

Running for office is a difficult process … what was the highlight for you?

The highlight was seeing our grassroots and volunteer efforts come together and make the difference in the race. We had so many enthusiastic people come out and help, including high school and college students. I hope this will be a lasting benefit of the campaign – -getting young people engaged in the political process.

What are your priorities heading into the 113th Congress?

I see implementing the Affordable Care Act (ACA) such that the patient-doctor relationship and prevention remain. The politics 22

California Family Physician Winter 2013

What do you see as the role of physicians in political advocacy?

Physician involvement is critical. They see the effects of policy every day. Physicians need to talk about that and be a voice for their patients. We talk about being at the table-in times of change; as we take on rebuilding health care we need to be at the head of the table!

What do you think is the ideal role for primary care in our medical system?

Obviously we need more primary care and we’re going to have shortages in some other specialties, too, as we move more people into coverage and as the population ages. Our workforce is not ready; how do we ramp up? I want to work with multiple physician groups to make smart policy to address this.

When asked if he had any advice for other physicians considering a run for political office, Dr. Bera declined, but did say he hoped his success will inspire physicians to get involved at all levels.

Dr. Bera: At a Glance • Son of immigrants from India, was raised in La Palma, California • Bachelor’s degree in biological sciences and medical degree, University of California at Irvine • Served as Associate Dean for Admissions at the UC Davis School of Medicine and as the Chief Medical Officer for the County of Sacramento • Helped UCD student-run clinics find innovative ways to engage with the community and deliver care to those who needed it the most

Richard Pan, MD California State Assembly, 9th Assembly District We know that running for office is a difficult process, but what has been the highlight for you as you’ve undertaken this endeavor?

While my family and I have had to make many sacrifices so I can serve Continued on page 24

The Family Medicine Residency at KDHCD, affiliated with the University of California at Irvine School of Medicine, is seeking an

ASSOCIATE PROGRAM DIRECTOR to assist in leading a dynamic and progressive group of faculty and educators in its inaugural years of training the Family Physicians of the future in the great Central Valley of California. In addition to an active part-time clinical practice, the Associate Program Director will be responsible for leading the educational, scholarly and clinical missions of the residency program along with the Program Director.

We offer an attractive compensation package as well as an academic appointment commensurate with education and experience. Additional details regarding the department and the District can be viewed at the department website. www.kdgme.org

Interested applicants should submit a CV to:

Robert D. Allen, M.D. Program Director, KDHCD Family Medicine Residency 400 W Mineral King • Visalia, CA 93291 Email: rallen@kdhcd.org Phone: 559.624.5213 Fax: 559.625.7559

The California Hospital Medical Center/University of Southern California amily Medicine Residency Program affiliated with Faculty from the USC Keck School of Medicine of USC is seeking an ABFM Board Certified physician to join the Program as USC Faculty. The CHMC FMRP, an unopposed 8-8-8 Program, was established in 1984, and has been fully accredited since its inception. This exciting and challenging full time opportunity includes responsibilities in the areas of in-patient care, ambulatory (continuity clinic) care, obstetrics, and private practice. Your role(s) will include direct patient care, administrative/scholarly time, teaching, and supervision of the Program's Residents You will also be involved with the various paraprofessional educational Programs. California Hospital Medical Center, a major teaching hospital, is a 316-bed, not-forprofit, acute care, safety-net, research and teaching facility which is a part of Dignity Health, a health care organization which provides full service compassionate care at their more than 40 urban and rural hospitals in California, Arizona and Nevada.

California Hospital Medical Center is committed to serving its underserved community. California Hospital Medical Center provides a myriad of tertiary care services, and has specialties in areas such as comprehensive women's (Los Angeles Center for Women's Health) and children's services (including nurse-midwifery services and a teen-parent clinic), 24 hour emergency services (including a sexual assault and domestic violence response team and a Level II Trauma Center), family health services (including the USCEisner Family Medicine Center), Hope Street Family Center and the Donald P. Loker Cancer Center. In our urban community, residents of all ages and backgrounds have access to primary care, preventive treatment, clinical support, chronic disease management, trauma services, and a host of medical and therapeutic specializations. Our residents' primary training site is the FMC. The USC-Eisner Family Medicine Center is staffed by Eisner employees and USC faculty; it is a federally qualified nonprofit community health center dedicated to improving the physical, social, and emotional wellbeing of people in the communities we serve, regardless of income. As an FQHC, we are able to see patients of all ages, regardless of immigration status. The selected candidates will have completed an ACGME approved Family Medicine Residency Program, have a CA license, a current DEA, and be Board Certified We value your experience as an active Faculty in an ACGME FMRP; we will look at both new and experienced physician candidates. Our position provides an academic appointment, research opportunities, and a very competitive compensation and benefit program.

Thank you in advance for your interest.

Please submit your curriculum vitae to: fmrp@usc.edu

PRIMARY CARE PHYSICIANS CAN SUCCEED IN THE “NEW NORMAL” WORLD OF HEALTH CARE! We at SIMED offer Primary Care Physicians the balance of patient centered care, supported by a large physician owned group and professional management team allowing them to reach high levels of personal and financial satisfaction.

Our Primary Care Physicians have established the balance of family, personal and professional lives, allowing them the opportunity to enjoy the wonderful climate, events and attractions of our region.

To learn more about the good things happening at SIMED, visit us at www.simedpl.com or contact Gary Reilly, Vice President of Operations at greilly@simedpl.com or (352) 224-2404.

No recruiters, please California Family Physician Winter 2013 23

oN THE CovEr Continued from page 22 in elected office, it is a privilege to be elected by the people to represent and serve them in the state legislature. Running and serving in elected office has given me the opportunity to meet with even more people and organizations than I did as a physician in the community. The highlight for me is the opportunity to apply my experiences and perspective as a practicing physician, educator, and small business owner to making state policy.

What are your priorities heading into this legislative session?

As Chair of the Assembly Health Committee, I believe this is a particularly exciting legislative session. Most pressing is implementation of the next phase of the Affordable Care Act, particularly the Health Benefits Exchange and Medi-Cal expansion.

However, the start of these programs on January 1, 2014, is not an end but the beginning of a new era for health care in California and the country. I will seek policies to promote prevention and to improve management of chronic disease. I intend to hold informational hearings on addressing adverse selection and the PatientCentered Medical Home at the beginning of the session.

Legislative oversight of Medi-Cal is also a priority. Many of the most vulnerable Californians are being transitioned into MediCal managed care in 2013. While managed care can potentially benefit patients, there needs to be input and cooperation from patients and their caretakers and physicians, with the priority on sufficient access and quality of care. With the addition of Medi-Cal expansion in the ACA, Medi-Cal reform is needed that transparently demonstrates quality and assures equal access to providers and services as required in federal law.

As a physician, what led you to seek public office?

As a pediatrician and residency program director at UC Davis, I taught residents and medical students the importance of community in promoting health. I modeled these principles in my own practice by being involved in community and professional organizations. In addition, I co-founded efforts to provide children health care coverage and strengthen the safety net in my county.

My community involvement led people to urge me to consider running for elected office so I could use my experience to make better policy. While I enjoyed practice and teaching (and I still practice pediatrics), I decided that I needed to offer my background and values to the voters as a choice for public office.

What do you see as the role of physicians in terms of political advocacy?

Physicians have a very important role in political advocacy.

Physicians are usually at the front lines of our communities, witnessing firsthand the problems affecting people’s health.

Physicians can be highly respected community leaders because of our desire to help people and solve problems using good science.

However, successful advocacy requires physicians to reach out beyond the clinic and hospital and to be actively engaged in our professional associations, to build community partnerships, and to support political candidates who value our experience.

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California Family Physician Winter 2013

Have you had a chance to work with family physicians in your medical career and what was that experience like?

I am privileged to work with many family physicians in my career.

At UC Davis, I partnered with the Family and Community Medicine Residency Program on Communities and Physicians Together, the program I founded to teach residents about community health.

I also taught family medicine residents who rotated through pediatrics as part of their residency. Nationally, in response to a 2006 article from the AAFP’s Robert Graham Center, I authored a commentary urging cooperation between family medicine and pediatrics. I also partnered with AAFP leaders in successfully advocating for AMA policy supporting the PCMH. Finally, I deeply appreciate the strong support from family physicians and the CAFP for my candidacy for the legislature.

What do you think is the ideal role for primary care in our medical system?

Our medical system needs to change from one that prioritizes episodic, acute care and encounters and procedures to a system that values prevention and on-going management of chronic conditions with incentives for improving outcomes. Providing patients access to PatientCentered Medical Homes is an important step in this change. Research has shown that the PCMH improves quality and patient satisfaction and reduces cost and health disparities. However, policymakers need to understand that these outcomes come from a strong physician-patient relationship that is at the foundation of the PCMH. Trust in the personal physician promotes patient and family engagement with the health care team. Primary care physicians are critical to advocating for and establishing Patient Centered Medical Homes.

What advice would you offer other physicians considering seeking political office in California?

I would strongly encourage other physicians to consider seeking public office. However, government and politics can be very different from medicine. Process is very important in government and politics. I would encourage physicians to participate in meetings of government bodies and seek appointment to a local commission or board. I would also recommend involvement in your professional association, particularly the legislative committee or PAC board. I would also urge involvement in community organizations to acquire a broader understanding of issues facing your local community.

Dr. Pan: At a Glance • Pediatrician and professor at the UC Davis Children’s Hospital, where he led the pediatric residency program • Founded Communities and Health Professionals Together (formerly Communities and Physicians Together), a nationally recognized program that partners resident physicians with community associations to improve community health • Harvard University, University of Pittsburgh, Johns Hopkins University

Thanks to Drs. Jay Lee and Carla Kakutani, and Ms. Jodi Hicks for their assistance with these interviews.

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New Year’s Resolutions California Family Physician magazine asked several members to share their New Year’s Resolutions with us … Here they are … Did you make a resolution? Want to share? We’d love to hear it.

Nathan Hitzeman, MD: The publicly correct part of me says I should put forth something altruistic for my resolution such as adopt a cat from the animal shelter, or cut down on emissions by unicycling into work. As a fairly busy parent and doctor, the non-PC side of me considers drinking more heavily, but fortunately, I get hung over too easily and that would not agree with me.

Somewhere in the middle, and perhaps leaning toward the more selfish side, is to rediscover my “man card.” I have two young daughters and a household of fairy wings, My Little Ponies, and hair bands everywhere. My relatives live out in the Midwest and shovel snow, chop wood, drive tractors. (We moved away from them because we can’t stand country music and cold weather.) By contrast, I sort items for my recycle bins on Sunday nights and read nutrition labels in the supermarket.

My man goals this year are as follows: master some kind of weapon (or at least manage not to injure myself), buy and drive a motorcycle, follow a sports team and go to a live game and be obnoxious, grow more facial hair (stash or chops, not sure), bathe less, and dare to leave the toilet seat up sometimes. I’ve also asked my wife to buy me the book “Man Made” by Time magazine columnist/humorist Joel Stein to get more ideas (http://www.thejoelstein.com/ ). Wish me luck!

Tom Bent, MD: We all talk about stressing less, exercising more, finding more time for those we love and tracking down that elusive “balance” in our lives. Forget about balance! At age 60, I resolve to pack the most fun into my life I possibly can.

Fun at work? Yes! I love my practice, my patients and my colleagues. At this stage in my career, I am content with what I’ve accomplished and don’t have anything left to prove. Fun at home? 30 years of marriage and we still laugh every day. A beautiful daughter that melts my heart. Lifelong friends who are a joy and a hoot. For 2013 I resolve to burn the candle at both ends and party like it’s 1999!

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California Family Physician Winter 2013

Del Morris, MD: I’m getting in practice for my role at the 2013 Congress: Whereas: Our current health care system does not provide “The Best Health Care in the World” for all Americans; and Whereas: We spend 25-50 percent more per person than the next closest nation in the world and we get worse results, be it Resolved: Commit to make things better.

Whereas: ObamaCare has started us on the journey to reform our health care system; and Whereas: Initial reform has been modest payment reform; and Whereas: This is only groundwork for practice reform that will be needed; and Whereas: Ballooning eligibility for health care insurance coverage in 2014 along with our aging population and increasing chronic disease prevalence will need more primary care capacity than we currently have; and Whereas: Current practice structure with current workforce in the forseeable future cannot meet the need for safe, efficient, quality health care and parity, now, therefore, be it Resolved: Don’t become discouraged and give up, and be it further Resolved: Look for opportunity that will support change, and be it further Resolved: Begin little (Save One Starfish at a time if necessary), and be it further Resolved: Ask for help and advice, and be it further Resolved: Take some risks.

Whereas: I have a granddaughter and another grandchild due in July, now, therefore, be it Resolved: Bright futures!

Julia Blank, MD: Over the last few decades, I’ve fallen into the habit of recycling New Year’s resolutions.

Mostly because, like 70 percent of Americans, my good intentions and willpower fall by the wayside by mid-March.

Sometimes sooner. This year, I’m scrapping the old list. Forget losing weight, reading the classics, and learning a new language.

This year, I’m going to become EFFICIENT. Aging patients, declining reimbursements and the prospect of millions of newly insured patients requiring care. I can’t add hours to my day, but I can work smarter and faster. So, here’s my new list: • Start each visit with the patient’s agenda.

• Ask each patient what he is most concerned about (Well, doc, I think it might be cancer…) and be sure to address that concern before the patient leaves.

• Finish charting (or at least the subjective/assessment/plan) IN THE EXAM ROOM, and print out a copy of this for the patient.

• Touch each paper (lab result, email, phone message) only once. Do it and move on.

• Go home and enjoy my family.

Jack Chou, MD: As health care reform kicks into high gear in 2013, our academy needs to step up as the change leader in shaping the future health care landscape and tipping

the balance toward primary care.

Some of you may already know that I’m running for the AAFP Board of Directors this year. My New Year’s resolution is to remain committed to leading our academy and assisting our members through critical transformative challenges facing all of our practices. With continued advocacy for our specialty and our patients, I seek to inspire the next generation of family physician leaders and stoke the flame of the family medicine revolution for generations to come. (www. jackchou-aafp2013.org)

University of California • Irvine Faculty Position

in Orange County, CA The University of California, Irvine Department of Family Medicine, has openings for board-certified/eligible family physicians to join the UC Irvine faculty in the Health Sciences Clinical Series at the Assistant, Associate, or Professor level. We are seeking qualified individuals with a strong commitment to teaching of Medical Students and Residents.

DUTIES: Ambulatory practice which includes direct patient care, residency teaching, medical student teaching and inpatient service coverage. Obstetrical and procedure skills desirable.

REQUIREMENTS: American Board of Family Medicine certified or eligible, excellent clinical skills, interest in clinical teaching, eligible for UC Irvine Medical Center medical staff privileges, and proven leadership skills. Bilingual in either Vietnamese or Spanish desirable. Academic rank and salary are commensurate with experience. Applications will be considered until the positions are filled.

TO APPLY: Please log onto UC Irvine’s RECRUIT located at https://recruit.ap.uci.edu/apply/ or email tarslani@uci.edu Contact Details Taleen Arslanian • tarslani@uci.edu (714) 456-7081 UC, Irvine is an equal opportunity employer committed to excellence through diversity.

MedSpring Urgent Care, Houston: Seeking BC FP Physicians for new Urgent Care locations in Sugarland, River Oaks, Memorial Area and Katy.

We offer gorgeous centers featuring 12 hour shifts, no nights, no call, no overhead and a great payor mix.

MedSpring is dedicated to getting patients ‘back to better,’ and we are looking for doctors who seek to provide outstanding service to every patient. MedSpring is poised to become an industry leader in Urgent Care and we are looking for doctors to grow with our company. Excellent compensation, annual bonus, benefit package, licensure and CME reimbursement, paid medmal insurance, and excellent opportunities for leadership.

Contact Julianne Sherrod at 512-861-6362 or send your CV to julianne.sherrod@medspring.com California Family Physician Winter 2013 27

CHIEF MEDICAL OFFICER AND FAMILY MEDICINE PHYSICIAN

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UIHS: Howonquet Clinic is a premier healthcare clinic located in beautiful Northern California along the Pacific Coast near the majestic Redwoods. UIHS is a unique nonprofit made up of a consortium of nine tribes, with a mission “To work together with our clients and community to achieve wellness through health services that reflect the traditional values of our American Indian Community”.

UIHS provides wrap-around services which include: Medical, Dental, Behavioral Health, and Community Services. Our focus is to empower our clients to become active participants in their care. If you value outdoor adventures, such as: backpacking, kayaking, biking, fishing, and surfing, and you envision yourself providing services to an underserved but deserving community in a caring and holistic manner, come join our team!

Please visit our website at www.uihs.org or call (707)825-4036 for more information.

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Michelle Gilbert mgilbert@pcipublishing.com

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PHYSICIAN – FAMILY MEDICINE Vista Community Clinic located in North San Diego County Seeking: Full-time, part-time and per diem Family Medicine Physicians.

Requirements: California license, DEA license, CPR certification and board certified in family medicine.

Bilingual English/Spanish preferred.

Bright Health Physician of PIH is Presbyterian Intercommunity Hospital’s not for profit 1206(I) Foundation Model multispecialty medical group that is rapidly growing to meet its community needs. In response to this growth, and due to physician retirements and succession planning, many immediate openings are available for full-time Family Practice Professionals. We have openings for both experienced and new graduates.

Bright Health Physicians and Presbyterian Intercommunity Hospital provide patients personalized attention and specialized care using the most advanced medical technology for patients. Our team approach utilizes outpatient physicians, mid-level professionals, 24/7 adult and pediatric hospitalists and chronic care specialists to provide the best possible healthcare for patients. PIH is located in Whittier a large metropolitan suburb of Southern California 30 miles east of Los Angeles. It’s a great place to raise a family with an excellent selection of schools, an average of 310 days of sunshine per year, and access to snow skiing or surfing just 30 minutes away.

Career Opportunity

We are looking for full-time Family Practice Professionals; new graduates and experienced positions are available. We are interested in enthusiastic motivated and committed individuals who work well in a group environment. Our staff enjoys a work-life balance as well as opportunity to work with a team of well-trained trusted professionals who value each and every team member within the group.

Come learn more about why physicians and advanced practice professionals commit to work at Bright Health Physicians.

www.pih.net www.brighthealth.com Ad.Family Practice Physician.5.12.12.indd 1

California Family Physician Winter 2013

• Competitive compensation and benefits • Unique work-life balance organizational benefit program • Continuing education time off with stipend • Mentorship programs • Paid holidays • Support for building a successful practice, including turnkey operations and qualified staff • Shareholder opportunities

Contact: Physician Recruitment Presbyterian Intercommunity Hospital & Bright Health Physicians of PIH 562. 698.0811 EXT 81843 or 81125 Submit CVs to MDjobs@pih.net

Contact Us: Visit our website at www.vistacommunityclinic.org Forward resume to hr@vistacommunityclinic.org or fax resume to 760-414-3702

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Susan Hogeland, CAE

EXECUTIvE vICE PrESIdENT’S ForUM

Family Physicians: Work with Your Public Health Directors to Increase Immunizations Rates in Your Counties The low rates of immunization for infectious diseases among school children in some counties in California are cause for concern. In the New Year,

family physicians can resolve to increase those rates by continuing to be trusted sources of valid information for parents about the benefits of immunization, and by countering misinformation some parents may have about negative effects of vaccination. Scientifically unsupported notions about the relationship between vaccinations and increased incidence of autism spectrum disorders, now thoroughly debunked by exhaustive analysis but still alive and well among many, along with the movement for “naturalism,” i.e., intentional exposure of children to infectious diseases, are at least partly to blame for areas in California with low rates. Access to care likely also plays a role.

Are there risks with childhood immunizations? There are, although they are small. Would anyone want his or her child to be the one-in-a-million kid with a potentially fatal or debilitating adverse reaction to a vaccine? No, of course not. It would be horrible. But do we all have some responsibility to our fellow humans to do what we can to mitigate outbreaks of thoroughly preventable diseases? We do (another good reason for all of us adults, especially health care professionals, to get our seasonal flu shots – I did, did you?).

Some years ago on my way to work, I listened to an interview on National Public Radio with a mother in Sebastopol, California talking about taking her son to a “chickenpox party” so he could intentionally be exposed and develop the disease “naturally.” Clearly she had given no thought to who her son might unintentionally expose to the disease in her household, or in her neighborhood: the neighbor with a compromised immune system, the elderly, the pregnant or infants too young to be immunized. It’s that lack of concern for or awareness of others that is so alarming.

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California Family Physician Winter 2013

The outbreak of pertussis leading to multiple infant deaths in our state last year is a perfect example. This thoroughly preventable disease took the lives of those too young to be immunized. Some parent somewhere failed to immunize his or her children, leading to the exposure of these infants. And when celebrities get involved in the advocacy efforts against vaccination, as recently occurred in the California Legislature, things get even worse.

CAFP member and former director of public health for Sacramento County Glennah Trochet, MD, found a potential solution to this situation. Invoking her authority as then director of Public Health, she required that unvaccinated children remain at home, out of school, for 21 days if an outbreak of a preventable infectious disease occurred in their schools. It was amazing how quickly principle crumbled in the face of child care demands – in 2011-12, 91.73 percent of children entering school in Sacramento County had all required immunizations; 2.49 percent claimed Personal Belief Exemptions (PBEs). Many of the counties with the lowest rates of entrants with all required immunizations also have the highest rates of PBEs – for example, Humboldt County has a 63.64 percent rate of entrants with all required immunizations, and a 19.87 percent rate of entrants with PBEs. Sierra County has the highest rate of PBEs at 22.73 percent.

Dr. Trochet’s is a fabulous solution to this public health concern, along with the strong recommendations of trusted family physicians to parents to have their children fully immunized. I would love to see family physicians in each county in California encourage public health directors to implement similar policies. Dr. Trochet was visionary and strategic – and who knows how many lives she saved as a result.

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California Family Physician Winter 2012 2013 31

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