New CCMA President Physicians of the Year To Test or Not to Test The Doctor’s Dilemma
WINTER 2017
Dr. Edward N. Li
Leaders In Progressive Vascular Treatment To refer a patient please call 805-643-3330 or fax us at 805-643-3331 We have 2 convenient locations in Santa Barbara County to serve your patients: Santa Barbara Office 2323 Oak Park Lane, Suite 102 Santa Barbara, CA 93105 Lompoc Office 136 North Third Street Lompoc, CA 93436 www.WestCoastVascular.com
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Board Certified Vascular Surgeon
Dr. Kevin M. Casey Board Certified Vascular Surgeon
Our physicians are experts in the treatment of: • Abdominal Aortic Aneurysm • Limb Preservation • Peripheral Artery Disease • Varicose Veins • Carotid Stenosis • Dialysis Access • Wound Healing Dr. Li and Dr. Casey are contracted with most major insurance plans including: • SANSUM HMO • Health Net • Aetna • Medicare • Blue Shield Covered CA • Santa Barbara Select IPA • Blue Shield PPO • TriCare • CenCal Health • United Healthcare Winter 2017
VOLUME 2, NUMBER 1 • WINTER 2017
{FEATURES}
6 8 10 14 16 18 20 26 Winter 2017
NEW CCMA PRESIDENT PHYSICIANS OF THE YEAR
{DEPARTMENTS}
ANNUAL MEMBERSHIP MEETING
32 MEN’S HEALTH: TO TEST OR NOT TO TEST
VISITING PROFESSOR
34 RISK TIP: THE DOCTOR’S DILEMMA
TELEMEDICINE FOR EVERYONE
36 PUBLIC HEALTH: COMMUNITY HEALTH
ARE MEDICATIONS FROM INDIA SAFE?
38 NEW MEMBERS
NEW LAWS
39 IN MEMORIAM
IMPROVEMENT PLAN
EXPANDING CARDIOVASCULAR CARE
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Letter from the CEO
A SEAT AT THE TABLE
Now more than ever it is important to be a part of organized medicine. With the changing political landscape, we need your support to ensure we are able to protect your practice and your patients.
PRESIDENT David Dodson, MD PRESIDENT ELECT Jennifer Hone, MD SECRETARY Daniel Berger, MD TREASURER Joseph Schwartz, MD IMMEDIATE PAST PRESIDENT Charity Dean, MD, MPH DIRECTORS Jonathan Berkowitz, MD, PhD; Philip Delio, MD; Lisa Ercolini-Bhatia, MD; Douglas Jacobson, MD; Bindu Kamal, MD; Samira Kayumi-Rashti, MD;
DANA GOBA
We will keep you up to date regarding potential and passed legislation. There are many new laws going into effect in 2017, and our feature story in this issue will discuss some that affect our medical community.
Douglas Murphy, MD; and Juan Reynoso, MD CHIEF EXECUTIVE OFFICER Dana Goba CMA HOUSE OF DELEGATES Representatives Sam Ahmad, MD; Sharon Basham, MD; Ned Bentley, MD; Charity Dean, MD, MPH; David Dodson, MD; Jennifer Hone, MD; Chris Lumsdaine, MD;
Some of these laws were due to measures on the ballot this past November. With our members’ support, the California Medical Association was 100% successful with all eight statewide ballot measure endorsements. This includes investing in Medi-Cal, increasing funding for anti-smoking programs, and preventing an increase in state prescription drug costs.
Doug Murphy, MD; Jenni Nix, MD; John Sawyer, MD; Joe Schwartz, MD; Steven Yao, MD CENTRAL COAST PHYSICIANS MAGAZINE EDITOR David Dodson, MD MANAGING EDITOR Dana Goba LAYOUT EDITOR Sherry Lavone Design CONTRIBUTING WRITERS David Dodson, MD;
If you are not a member of CCMA/CMA, join us at www.cmanet.org/join or by calling 800.786.4262. If you want to support candidates and legislators that understand health care, make a donation to CALPAC, which is the California Medical Association Political Action Committee. As the saying goes, if you are not at the table, you are on the menu. With your support, we will be working to ensure you have a seat at the table.
Lisa Ercolini-Bhatia, MD ; Dana Goba, MBA; Jill Fonte, MBA; Susan Klein-Rothschild, MSW; Howard Marcus, MD, FACP; Christopher Schmidt, MD; Maria Zate CONTRIBUTING PHOTOGRAPHERS Cottage Health; Sansum Clinic SUGGESTIONS, story ideas, or completed stories written by current Central Coast Medical Society members are welcome. Opinions expressed by authors are their own and not necessarily those of the CCMA. CCMA reserves the
Best,
right to edit all contributions for clarity and length as well as to reject any material submitted. PLEASE DIRECT EDITORIAL INQUIRIES AND SUBMISSIONS TO: Central Coast Physicians 5350 Hollister Ave, Ste A4
Dana Goba Chief Executive Officer Central Coast Medical Association
Santa Barbara, CA 93111 T 805.683.5333 F 805.687.2871 E magazine@sbmed.org ADVERTISING rates and information sent upon request. Acceptance of advertising in Central Coast Physicians in no way constitutes approval or endorsement by CCMA of products or services advertised. CCMA reserves the right to reject any advertising. All advertising inquiries can be sent to magazine@sbmed.org.
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Winter 2017
CALIFORNIA MEDICAL ASSOCIATION
PROTECTING YOUR PROFESSION standards and oversight puts the safety and health of patients at risk.
WHAT CMA DOES FOR OPHTHALMOLOGISTS Medicare Payment Reform: CMA was integral in the passage of federal legislation to reform the badly broken Medicare physician payment system. This legislation will stabilize the physician payment system and is worth hundreds of millions of dollars to physicians nationwide over the coming decade. CMA was also key to the passage of the long overdue “California GPCI fix,” which will The Recognized Voice ofpayments California Physicians update the Medicare localities and increase to physicians in many counties by more than $400 million in the next 10 years.
MICRA: and its county societies led the successful fight against the trial lawyers’ Proposition 46,physicians in one of the most CMA and CMA its county medical societies have represented California’s forconten160 tious and high-stakes ballot fights in California history. Had it passed, the ballot measure would have decimated the landmark Medical years the recognized voicewhich of the house medicine. CMA alsofor partners with Injuryas Compensation Reform Act (MICRA), has kept access of to affordable health care a reality patients acrossregularly the state. CMA defends this landmarkof lawCalifornia, year after year. The of Californiawe ultimately rejected Prop. our 46 by combined one of the widestvoices margins in thestalwartly specialty societies andvoters together stand taller, state history (67 percent to 33 percent). stronger, fighting for the future of medicine and our noble profession. Taking on Big Tobacco: CMA helped launch the new “Save Lives California” coalition, committed to raising the state’s tax
Working tocoalition Protect Your Specialty on tobacco. The is working to strengthen the state’s anti-tobacco policies to prevent death from tobacco-related diseases and reduce the costs of smoking on California’s health system. In 2016, we successfully passed a sweeping series of tobacco control
Over the past several years, optomotrists have launched an unprecedented number of bills—including raising the legal age to purchase tobacco from 18 to 21—an action that will undoubtedly save countless California children attacks to expand their scope of practice. CMA and our specialty society partners have from a deadly, lifetime addiction to nicotine. vigilently defended these and other attempts to irresponsibly expand the scope of practice Physician practitioners. Workforce:CMA We are committed to expanding funding for GME to ensure that there are enough residency slots to train of non-physician strongly believes that allowing practitioners to perform physicians in regions where health services are needed most.and CMA to secure procedures they aren’t trained to do care can threaten patient safety leadwas to able higher costs $100 million in the 2016-2017 state budget to expand the Song-Brown Program to create more residency slots in California. and greater fragmentation of care.
Key Victories and Priorities
There are 821 ophthalmologist members of CMA.
Scope of Practice: Every year, CMA dedicates a vast amount of resources to the successful defeat of several scope-of-practice expansion attempts before the State Legislature. Each of the bills claims to be a solution to California’s access to care crisis, but, in reality, they each posed a very real danger to patients.
WON’T YOU JOIN US?
SB 492 (2013 and 2014) and SB 622 (2015) would have both allowed optomotrists to an array of supplementary procedures with little additional training, including scalpel surgeries, laser surgeries and WE intraocular injections. Through diligent lobbying and with the ARE HERE FOR YOU engagement of our physician members calling and writing to their • CMA and its county medical societies – representing 41,000 physicians, residents and medical students – influence public policy at legislators, CMA convinced lawmakers that lowering certification the state and federal levels.
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Members have free access to valuable professional resources, including nearly 5,000 pages of legal information related to the practice of medicine in CMA’s online health law library.
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Our extensive network of benefit partners makes it so that your membership can easily pay for itself.
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As an ophthalmologist, I’m proud to be a CMA member because CMA advocates CMA only apatients’ phone call away! Our live-person centerbest is available Mon-Frimedical during business at (800) 786-4262. foris my rights to havecall the quality andhours surgical care.”
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Join today to activate your personal webDouglas account at www.cmanet.org. Jacobson, M.D., Ophthalmologist, Member Since 2012
FOR MORE ABOUT CMA AND ITS PROGRAMS, VISIT WWW.CMANET.ORG. Rev. 07/11/16
President of Central Coast > David Dodson, MD
2017 President of Central Coast Medical Association: David Dodson, MD The Central Coast Medical Association is pleased to announce David Dodson, MD, as president of the 2017 Board of Directors. Dr. Dodson has served on the Board of Directors since 2013. He has also been active with CCMA’s state affiliate, the California Medical Association, where he has worked on policies and legislation that affects physicians and patients. In addition, in 2017 Dr. Dodson will serve on the delegation to the American Medical Association. Prior to CCMA, Dr. Dodson was involved with organized medicine in Massachusetts, where he served as president of the Charles River Medical Society, which is a component society of the Massachusetts Medical Society. In addition, he was chairman of the men’s health committee with the Massachusetts Medical Society. He has a special interest in Men’s Health, and he was the keynote speaker at the 5th International Conference on Men’s Health in Vienna, Austria. Dr. Dodson received his Doctor of Medicine at the University of Ottawa where he graduated with honors, and he did his residency at Harvard’s Brigham and Women’s Hospital. He was in private practice in Boston until 2010 when we relocated to Santa Barbara to work at Sansum Clinic as a primary care internist. Dr. Dodson lives in Santa Barbara with his wife, Leslie, and their two dogs, Zeke and Molly. He enjoys staying fit, reading the New York Times, and traveling, especially to visit his daughter in Boston.
Central Coast Medical Association’s 2017 Board of Directors President: David Dodson, MD President-Elect: Jennifer Hone, MD Secretary: Daniel Berger, MD Treasurer: Joseph Schwartz, MD Immediate Past President: Charity Dean, MD, MPH
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Directors: Jonathan Berkowitz, MD, PhD; Philip Delio, MD; Lisa Ercolini-Bhatia, MD; Douglas Jacobson, MD; Bindu Kamal, MD; Samira Kayumi-Rashti, MD; Douglas Murphy, MD; and Juan Reynoso, MD.
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was the Chief of Staff at French Hospital Medical Center in addition to serving on their Board of Directors. He is also currently the Intensive Care Unit director. Besides being a member of the Central Coast Medical Association, Dr. Soll belongs to the American College of Chest Physicians, American Thoracic Society, Society of Critical Care Medicine, California Thoracic Society, and American Academy of Sleep Medicine. Dr. Soll is married to Angela, and they are the proud parents of two daughters, Katherine and Elizabeth. When not practicing medicine, Dr. Soll can be found on the golf course and has shot a holein-one at Dairy Creek.
2016
physicians Of The Year Award The Central Coast Medical Association honors physicians who have worked to improve the quality of health care, contributed to the education of other physicians, and engaged in community service and other activities outside of medicine. San Luis Obispo County: Dr. Mark Soll Dr. Joe Schwartz (left) and Dr. Mark Soll (right) During his presentation of the award, Dr. Joe Schwartz, a psychiatrist with Central Coast Psychiatric Consultants, shared stories of patients who had written notes to Dr. Soll expressing their appreciation of his care. Of the hundreds of notes, common themes were kindness, compassion, respect, confidence, and honesty. In addition, Dr. Soll is an advocate for physicians and other health professionals. “Dr. Soll stands for the values that have always been the guiding principles for physicians.” stated Dr. Schwartz, “He brings his skills to those in need with grace, generosity, and tireless compassion. He leads by example and prods us all to try harder and never give up the fight for the good and right.” Dr. Soll received his undergraduate degree in microbiology from University of California, Los Angeles, where he graduated Magna Cum Laude and Phi Beta Kappa. He went on to study at the University of California, San Diego School of Medicine where he also did his internship and residency in internal medicine and his fellowship in pulmonary and critical care medicine. Dr. Soll receive d his board certifications in internal medicine, pulmonary medicine, and critical care medicine. Dr. Soll has been with Central Coast Chest Consultants since 1992. He has served as the Chief of Medicine at Sierra Vista Regional Medical Center. He
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Santa Barbara County: Dr. Ayesha Shaikh Dr. Lynn Rudman (left) and Dr. Ayesha Shaikh (right) Dr. Lynn Rudman presented the award and shared stories of Dr. Shaikh, who has traveled the world helping women. Dr. Shaikh has been on medical humanitarian trips to South Sudan and El Salvador where she taught best practices in obstetrics to local physicians at small rural hospitals, and she is planning another trip in the near future as well. Dr. Shaikh received her Bachelor of Medicine and Surgery from Stanley Medical College at Madras University and then went on to receive her medical degree in obstetrics and gynecology from Seth G.S. Medical College at Bombay University in India. She completed her second residency at Mount Sinai Medical Center in Chicago where she received the Abby Norman Prince Award. Dr. Shaikh moved to Santa Barbara in 1984, and she currently practices medicine at the Santa Barbara Medical Center. She is on staff at Santa Barbara Cottage Hospital where she has served as Chief of Staff and as Chair of the OB/GYN Department. Dr. Shaikh is a past president of the Central Coast Medical Association, and she has served as a trustee with Santa Barbara Middle School, Direct Relief International, William Sansum Diabetes Center, and Planned Parenthood. She is a fellow of the American College of OB/GYN and is a member of the American Medical Women’s Association. Dr. Shaikh is married to Mohammed Shaikh, PhD, a materials engineer and business executive, and they have a daughter, Sarah. When not practicing medicine or volunteering, Dr. Shaikh enjoys golfing, reading, and traveling.
Winter 2017
Winter 2017
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The 2016 Annual Membership Meetings were a rousing success with keynote speakers from California Medical Association leadership: president, Ruth E. Haskins, MD, and speaker of the house, Lee T. Snook, Jr, MD. We thanked outgoing president, Charity Dean, MD, MPH, and welcomed incoming president David Dodson, MD.
THANK YOU
TO OUR PLATINUM SPONSOR, THE DOCTORS COMPANY
Winter 2017
CENTRAL COAST PHYSICIANS
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THANK YOU
TO OUR PLATINUM SPONSOR, THE DOCTORS COMPANY
Visiting Professor > Barbara Lee Bass, MD
Visiting Professor of Surgery By Jill Fonte, MBA, Director of Marketing, Sansum Clinic
Barbara Lee Bass, MD, John F. and Carolyn Bookout Presidential Endowed Chair of the Department of Surgery, Professor of Surgery, Houston Methodist Hospital (Houston, Texas) has been selected as the Visiting Professor of Surgery for 2017. The Visiting Professor of Surgery program provides expert educational seminars for practicing Santa Barbara surgeons and physicians. More importantly, it allows surgical residents in training at Santa Barbara Cottage Hospital the chance to interact daily for one week with the icons, leaders, and outstanding teachers of the art of surgery. Surgical Academic Week with Dr. Bass is scheduled for March 1317. This unique educational program advances the level of surgical care available in our community, and is made possible by generous support from our title sponsor, Cottage Health, and grateful patients, medical groups, individual community surgeons and physicians, and corporate donors. Dr. Bass is an international thought leader in surgical education, over the last 10 years at Houston Methodist Dr. Bass has created innovative surgical training pathways to develop surgeons to lead diverse roles in our evolving health care systems; as skilled providers of state of the art surgical care, as surgeon scientists in basic and translational research, and as skilled administrative leaders prepared to develop systems to improve delivery of quality surgical care. Exemplifying her passion to transform education, Dr. Bass is the founder and executive director of the Methodist Institute of Technology, Innovation and Education (MITIE), a unique 35,000 sq. ft. simulation, education and research facility committed to lifelong retraining and retooling of surgeons in practice. Since 2007, MITIE has hosted hands on courses for over 35,000 surgeons and health care providers. Coupled to research in surgical technologies and innovative educational platforms, MITIE is a unique education and research institution. Dr. Bass is widely recognized as a visible and effective leader in American surgery. Leadership positions she has held include terms as Chair of the American Board of Surgery and the Board of Governors of the American College of Surgeons, Regent of the American College of Surgeons, and President of the Society for Surgery of the Alimentary Tract and the Society of Surgical Chairs and other officer positions in numerous professional organizations. Recently Dr. Bass was nominated as President Elect of the American College of Surgeons. Honors include the Distinguished Service Award of the American College of Surgeons, the highest honor bestowed for contributions to improve the surgical profession, and the Nina Starr Braunwald Award given for her contributions to advance the careers of women in surgery, and the US Army Commendation medal for her work at Walter Reed Army Institute of Research. Over 29 continuous years, Dr. Bass’ research program has been funded by many agencies including the NIH, NSF, the VA, and industry. She has published over 170 peer reviewed manuscripts, monographs, and chapters and served as co-editor of 3 books and holds two patents for surgical technology devices. She has served on the editorial boards or as associate editor for the leading surgical academic scholarly journals including the Annals of Surgery, Surgery, World Journal of Surgery and others.
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Do you know What, When and How to Report Child Abuse?
FREE ONLINE COURSE! Course developed by the Child Abuse Prevention Center
Approved for 1.25 AMA PRA Category 1 Credits™ Approved for 1.25 CE credits
ALL healthcare providers (MD, DO, RN, PhD, LCSW, MSW) are encouraged to take this valuable course!
Course available 24/7
Course can be offered in a group training using a single log-in. Contact Leslie Iacopi at (415) 882-5167 for more details. Register NOW at: Winter 2017
http://www.imq.org/education/caprrc.aspx CENTRAL COAST PHYSICIANS
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Telemedicine FOR EVERYONE
By Christopher P Schmidt, MD • Originally published in the November/December 2016 issue of The Bulletin.
As a dermatologist, the possibilities of telemedicine were evident early in my career. You did not need a patient to make a diagnosis. You just needed a good picture. Telemedicine was initially promoted as a benefit to patients. It would increase their access to specialty care and surmount geographic barriers. Unfortunately, the only reimbursed format at the time was live interactive video, which was too impractical for widespread use. Patients also had limited access to the technology. Telemedicine languished. During this dark time, I was involved with a few unsuccessful start-up telemedicine platforms that focused on direct patient access to specialists. There was a lot learned from the experience but there were no compelling reasons for physicians to adopt the practice. That changed 2012 when California’s own telehealth law (AB 415) went into effect. Now physicians of all specialties would be beneficiaries of telemedicine. The new law authorized physicians
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to collect for all forms of electronic interaction. This means you could now be reimbursed for all the free care that you normally give out via the phone or email by using store and forward telemedicine. The largest benefit however is the savings that will occur when physicians no longer have to shoulder the burden of rent, staff, and other expenses when providing care that can be done outside the boundaries of an office. As a result, physicians should explore what aspects of patient care can be responsibly provided online and then try to move patients in that direction. Any progress physicians make in moving portions of their practice online will be protected by the parity law. It requires that online visits be reimbursed at the same full level as an office visit. Telemedicine is now very practical. Physicians should be wary of many of the telemedicine sites that are out there. Most of the ones you read about in the headlines do not meet the California Medical Association’s (CMA)
Winter 2017
Principles of Telemedicine. These are the anonymous doctor banks, prescription mills, and sites that use physicians in foreign countries. Fortunately, there are telemedicine sites that closely adhere to the CMA’s telemedicine standards. Store and forward platforms like HealthLens (Author is a founder), Azova, and SkyMD enable physicians to practice online in a medically sound and ethical manner. The primary standard is allowing patients to receive online care from their established physician. This enables follow up with that particular physician and a physical location if an office visit is necessary. Another CMA principle is that the patient’s medical insurance should be used to cover the visit. The CMA adherent platforms also provide secure messaging between patient and physician so the visits can be interactive. Most commercial insurance companies including Blue Cross, Blue Shield, Cigna, and United Healthcare cover store and forward telemedicine. Medicare only covers it in Alaska and Hawaii but there is legislation in progress to expand to all 50 states. To be reimbursed for store-and-forward telemedicine visits, just attach the GQ modifier to your CPT code; e.g. 99203 GQ. In my practice, I see about 60 online patients per month. Acne, eczema, and seborrheic keratoses make up the majority of the
conditions I diagnose online. Time sensitive conditions like shingles are not an uncommon online diagnoses and it is much easier to get patients on antivirals within that 72-hour window of opportunity when they don’t have to wait for an office visit. I even see new patients on the internet. According to the Medical Board of California, you can evaluate a new patient online and establish a physician-patient relationship as long as the photo(s) submitted by the patient allows the physician to perform a physical examination that is adequate enough to reasonably make a diagnosis. Established patients, who make up the majority of my online visits, can be evaluated and treated without a photograph. This works out well for prescription renewals. Medical research will also benefit from the shift to online care because of the data that telemedicine provides. In the short time HealthLens has been in operation, we have amassed a large library of clinical images, corresponding diagnoses, treatments and, most importantly, outcomes. The granularity of the data will allow for unprecedented levels of analysis. Veering from long practiced norms is a troubling process for the medical community. However, the opportunity to eliminate so much of the expense involved in patient care cannot be ignored. Physicians should be leading the charge in shifting patient care online. We will be among the beneficiaries.
2016
Presentation & Reception Barbara Lee Bass MD, FACS
Thursday, March 16, 2017 5:30 pm to 7:00 pm
John F. and Carolyn Bookout Presidential Endowed Chair of the Department of Surgery
Professor of Surgery Houston Methodist Hospital, Houston, TX
Sansum Clinic Julie and Jack Nadel Lobby 317 West Pueblo Street
Presentation 5:30 pm Reception 6:15 pm
Free parking at Sansum Clinic Space is limited. Reservations required. Please RSVP to Juli Askew
(805) 681-7762 or jaskew@sansumclinic.org Title Sponsor
Speaking on
The Passion of Surgery: Breaking the Surgical Glass Ceiling Contributor
Winter 2017
Do changing gender demographics challenge and/or influence surgical patient care?
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are
M E D I C AT I O N S FROM INDIA safe for patients? By Lisa Ercolini-Bhatia, MD
Prior authorizing medication is a daily battle for doctors/health care providers as well as for our patients. It is no longer a question of which medication is the best for our patient, but rather which medication the insurance will cover to help treat the problem. Even when we know the right medication for the patient, our heart sinks to think of the battle to authorize a higher tier medication. Recently, I traveled to New Delhi, India, with my husband and children to visit my husband’s family. As usual, I was asked to answer health questions for a family member’s health condition. I gave betamethasone ointment to treat some eczema and found out the 30 gram tube cost $0.80. That is not a typo. Under a $1 for a 30 gram tube of the medication. Then my niece needed some liquid Benadryl, nasal saline for congestion, and bulb suction, which were a total of less than $3. I was shocked. Levaquin is also less than $3 for the 10-day supply. My mother in law takes Crestor, which is available in India generically, as they do not recognize the patents, for $3-4 per month. A thousand questions filled my head as well as debating how many containers of Levaquin I can legally take back in my suitcase. There are several concerns about pharmacies in India. Just like many countries outside the United States, there is no prescription required for medication. The minute my father in law feels a tickle in his throat, he goes to the chemist to grab some amoxicillin. I am frightened for the growing antibiotic resistance I am sure will surge from the free access to medications in India and many other countries with open access. Self-prescribing is a dangerous practice that can lead to resistance and subjecting the body to medication that may be unwarranted. Secondly, India and many developing countries manage
to manufacture several medications generically as they do not recognize the patents enforced by the US FDA. On April 1, 2014, the FDA banned the US imports of some generic drugs associated with Canadian drug Apotex, which has a presence in India to keep costs low. In addition, Ranbaxy, Sun Pharmaceutical, and Wockhardt were companies situated in India subject to these inquiries from the FDA. In 2012, the US Congress passed the FDA Safety and Innovation Act, which requires inspections at foreign facilities to ensure standards were met. However, the FDA inspectors were spread too thin and could not keep up with the volume1. In contrast, the US FDA issued an import warning to Ranbaxy pharmaceuticals in Mohali in Punjab province, India. The inspectors reported violations at the factory including failure to investigate manufacturing problems and failure to follow quality standards. Two other Ranbaxy factories had similar alerts in 20092 . At the end of the day, the main question is present. Should patients take drugs made outside of the US? I usually advise patients what I would do myself or advise my family member. Forty percent of medications are manufactured outside of the US. In addition, 80% of all raw drug ingredients come from other countries outside of the US. In short, it depends. If the medication is a non-emergent medication used to reduce risk factors such as cholesterol lowering agents, then I might consider it. However, antibiotics, antivirals, or other more emergent medications, I would try to obtain the medication from more domestic means. What would you advise? What would you take? Definitely more scrutiny and investigation is required regarding this very important concerns for our patients.
Footnotes: 1. Are generic drugs like Apotex medication made in India safe?. Consumer Reports April 25, 2014. 2. FDA stops 11 Indian made drugs from entering US. CBS news. Sept 16, 2013.
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2017
NEW HEALTH LAWS
Significant new California laws of interest to physicians The California Legislature had an active year, passing many new laws affecting health care. In particular, there was a strong focus on health care coverage, drug prescribing, public health, and workers’ compensation issues. On the following pages you will find highlights of the most significant health laws of interest to physicians.
ADVERTISING
CLINICAL TRIALS
AB 2744 (Gordon) – Healing arts: referrals
AB 1823 (Bonilla) – California Cancer Clinical Trials Program
Provides that the payment or receipt of consideration for advertising, wherein a licensed healing arts practitioner offers or sells services through a third-party advertiser, does not constitute a referral of patients when the third-party advertiser does not itself recommend, endorse, or otherwise select a licensee. Requires that a licensee disclose in the advertisement that a consultation is required and that the purchaser will receive a refund if not eligible to receive the service. Specifies that these provisions do not apply to basic health care services or essential health benefits, as defined.
Establishes the California Cancer Clinical Trials Program to increase patient access to eligible cancer clinical trials in underserved or disadvantaged communities and populations. Requests the University of California (UC) to establish and designate an institute or office with the authority to solicit and receive funds from business, industry, foundations, and other private and federal sources for the purpose of administering the program. Establishes a five member board to administer the program. Authorizes the UC to use its own state source funds for oversight and administration of the program relating to the initial start-up costs of the program only, provided the UC is reimbursed from federal and private sources funds. Requires
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the program, on receipt of funds totaling $500,000, to establish the Cancer Clinical Trials Grant Program to increase patient access to cancer clinical trials in underserved or disadvantaged communities and populations.
Authorizes records-based biomedical research involving inmates that uses existing information, but which does not include prospective interaction with human subjects.
CONFIDENTIAL INFORMATION
AB 2024 (Wood) – Critical access hospitals: employment
AB 1671 (Gomez) – Confidential communications: disclosure
CMA Position: Support Makes it a crime for a person who unlawfully eavesdrops upon or records a confidential communication with a health care provider, to intentionally disclose or distribute the contents of the confidential communication in any manner, in any forum, including on Internet websites and social media, or for any purpose without the consent of all parties to the confidential communication unless specified conditions are met. AB 2828 (Chau) – Personal information: privacy: breach
Requires any agency, person, or business that owns or licenses computerized data that includes personal information to disclose a breach of the security of the system to any California resident whose encrypted personal information was, or is reasonably believed to have been, acquired by an unauthorized person, if the encryption key or security credential was, or is reasonably believed to have been, acquired by an unauthorized person, and the entity that owns or licenses the encrypted information has a reasonable belief that the encryption key or security credential could render that personal information readable or useable. SB 514 (Anderson) – California Health Benefit Exchange
Prohibits the California Health Benefit Exchange (Covered California) from disclosing personal information obtained from an application for health care coverage to a certified insurance agent or certified enrollment counselor without the consent of the applicant, unless the agent or counselor is assisting the applicant. Does not preclude Covered California from sharing information of current enrollees or applicants with the same counselor or insurance agent of record, as specified. SB 1238 (Pan) – Inmates: biomedical data
CMA Position: Support Specifies that biomedical research does not include the accumulation of statistical data in the assessment of the effectiveness of non-experimental public health programs or treatment programs in which inmates routinely participate.
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CORPORATE BAR Until January 1, 2024, authorizes a federally certified critical access hospital to employ physicians and surgeon or doctors of podiatric medicine and charge for professional services rendered by those medical professionals if the medical staff concur by an affirmative vote that the professional’s employment is in the best interest of the communities served by the hospital and the hospital does not direct or interfere with the professional judgment of a physician and surgeon, as specified. Requires the office, on or before July 1, 2023, to provide a report to the Legislature containing data on the impact of this authorization on federally certified critical access hospitals and their ability to recruit and retain physicians and surgeons, as specified.
DRUG PRESCRIBING AND DISPENSING AB 1668 (Calderon) – Investigational drugs, biological products, and devices
Enacts the Right to Try Act authorizing the manufacturer of an investigational drug, biological product, or device that is not yet approved by the United States Food and Drug Administration (FDA) to make the investigational product available to an eligible patient with a serious or immediately life-threatening disease or condition, as specified, when that patient has considered all other treatment options currently approved by the FDA, has been unable to participate in a relevant clinical trial, and for whom the investigational drug has been recommended by the patient’s primary physician and a consulting physician. Authorizes, but does not require, a health plan to provide coverage for any investigational product made available pursuant to this law. Specifies other criteria and requirements for the use of investigational drugs. AB 1748 (Mayes) – Pupils: pupil health: opioid antagonist
CMA Position: Support Authorizes a pharmacy to furnish naloxone hydrochloride or another opioid antagonist to a school district, county office of education, or charter school if certain conditions are met. Requires the school district, county office of education, or charter school to maintain records regarding the acquisition and disposition of naloxone hydrochloride or another opioid antagonist furnished by the pharmacy for a period of 3 years from the date the records were created. Authorizes the
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New Health Laws > 2017
provision of emergency naloxone hydrochloride or another opioid antagonist to school nurses and trained personnel. Immunizes physicians for issuing a prescription or order for such purposes. This bill contains other related provisions and other existing laws. SB 482 (Lara) – Controlled substances: CURES database
Requires a health care provider authorized to prescribe, order, administer, or furnish a controlled substance to consult the Controlled Substances Utilization Review and Evaluation System (CURES) prior to prescribing a Schedule II, III or IV drug to a patient for the first and at least once every four months thereafter if the substance remains part of the treatment of the patient. Provides exemptions under specified conditions. Authorizes a health care practitioner to provide a patient with a copy of the patient’s CURES patient activity report. SJR 29 (Hernandez) – EpiPen: pricing.
Senate joint resolution measure to urge the U.S. Food and Drug Administration to reconsider its denial of approval for generic alternatives to the epinephrine auto-injector EpiPen and urge the U.S. Congress to investigate the impact that Mylan’s monopoly has had on the price hikes for EpiPen, and urges the Congress and President to take action to limit the unrestrained ability of drug manufacturers to increase prices based only on what the market can bear.
HEALTH CARE COVERAGE AB 72 (Bonta) – Health care coverage: out-of-network coverage
Requires a health care service plan, for contracts and health policies issued, amended, or renewed on or after July 1, 2017, to provide that if an enrollee or insured receives covered nonemergency services in a contracting health facility provided by a non-contracting individual health professional, that enrollee or insured would be required only to pay the “in-network cost-sharing amount” unless the enrollee or insured provides written consent that satisfies specified criteria. Establishes a payment rate which is the greater of the health care service plan or health insurer’s average contracted rate for commercial products, as specified, or 125 percent of the amount Medicare reimburses for the same or similar services. Requires the establishment of an independent dispute resolution process for claims and claim disputes related to covered nonemergency services provided at a contracted health facility by a noncontracting individual health care professional. Requires the development of a standardized methodology for plans and
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insurers to use in determining the average contracted rate. Limits enrollee and insured cost sharing for these covered services to costs no than those incurred had the services been provided by a contracting health professional unless the enrollee provides advance written consent to use out-ofnetwork benefits. SB 10 (Lara) – Health care coverage: immigration status
CMA Position: Support Requires Covered California to apply to the United States Department of Health and Human Services for a Section 1332 waiver to allow persons who are not otherwise eligible to obtain coverage through the Exchange because of their immigration status to obtain coverage from Covered California. Requires Covered California, after the waiver is granted, to require an issuer that offers a qualified health plan in the individual market through the Exchange to concurrently offer a California qualified health benefit plan to these individuals. SB 923 (Hernandez) – Health care coverage: cost-sharing changes
CMA Position: Support Prohibits a health care service plan contract or health insurance policy from changing the cost sharing design, as defined, during the plan or policy year, except when required by state or federal law. Applies to grandfathered health care service plan contracts and health insurance policies and non-grandfathered health plan contracts and health insurance policies in the individual and small group markets that are issued, amended, or renewed on or after January 1, 2017.
HEALTH CARE FACILITIES AND FINANCING SB 867 (Roth) – Emergency medical services
CMA Position: Co-sponsor Extends until January 1, 2027, provisions of the Maddy Emergency Medical Services (EMS) Fund, which authorizes each county to establish an emergency medical services fund for reimbursement of costs related to emergency medical services. Extends provision that authorize each county to elect to levy an additional $2 penalty for deposit into the EMS Fund for every $10 of fines, penalties, and forfeitures collected for criminal offenses and requires 15 percent of those funds collected to be used as funding for pediatric trauma centers. SB 1365 (Hernandez) – Hospitals
Requires a general acute care hospital, except as specified,
Winter 2017
to notify patients scheduled for a service in a hospital-based outpatient clinic, as defined, when that service is available in a nonhospital-based location that may cost less. Defines “hospital-based outpatient clinic,” for purposes of this bill, as a department of a provider, as defined in specified provisions of federal regulations, that is not located on the campus of that provider.
MEDI-CAL AB 635 (Atkins) – Medical interpretation services
CMA Position: Support Requires the Department of Health Care Services (DHCS) to work with stakeholders to conduct a study to identify current requirements for medical interpretation services as well as education, training, and licensure requirements, analyze other state Medicaid programs, and make recommendations on strategies that may be employed regarding the provision of medical interpretation services for Medi-Cal beneficiaries who are limited English proficient (LEP), in compliance with applicable state and federal requirements. Establishes a pilot project to improve medical interpretation services. AB 1696 (Holden) – Medi-Cal: tobacco cessation services
CMA Position: Support Requires Medi-Cal to cover tobacco cessation services only to the extent that federal financial participation is available and not otherwise jeopardized. Requires that the tobacco cessation services covered under Medi-Cal be subject to utilization controls and include all intervention recommendations assigned a grade A or B by the United States Preventive Services Task Force. Specifies that beneficiaries who are covered under this bill shall not be required to receive a particular form of tobacco cessation service as a condition of receiving any form or tobacco cessation service. Requires the Department of Health Care Services to seek any federal approvals necessary to implement the provisions of this bill. SB 586 (Hernandez) – Children’s services
CMA Position: Support Authorizes the Department of Health Care Services to establish a Whole Child Model program under which managed care plans served by county organized health system or Regional Health Authority in designated counties would provide California Children’s Services (CCS) to Medi-Cal eligible CCS children and youth. Limits number of managed care plans that are eligible to participate in the program.
PROFESSIONAL LICENSING AND DISCIPLINE AB 2745 (Holden) – Healing arts: licensing and certification
Specifies that a physician or surgeon licensee who is otherwise eligible for a license but is unable to practice some aspects of medicine safely due to a disability is authorized to receive the limited license if specified described conditions are met, including payment of the appropriate fee. Clarifies the Medical Board of California’s authority to: revoke, suspend, or deny a license for licensees and applicants who are guilty of unprofessional conduct, expands the Board’s authority to request medical records of deceased patients, authorizes specified disciplinary actions for licensed midwives, research psychoanalysts, and certified polysomnographic technologists. SB 1177 (Galgiani) – Physician and Surgeon Health and Wellness Program
CMA Position: Sponsor Authorizes the Medical Board of California (MBC) to establish a Physician and Surgeon Health and Wellness Program for the early identification and appropriate interventions to support a licensee in his or her rehabilitation from substance abuse and authorizes MBC to contract with an independent entity to administer the program. Requires
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New Health Laws > 2017
program participants to enter into an individual agreement with the program that includes, among other things, a requirement to pay expenses related to treatment, monitoring, and laboratory tests, as provided.
®
SB 1261 (Stone) – Physicians and surgeons: residency fee exemption
Removes the requirement that a physician and surgeon reside in California in order to receive a license fee waiver, when the license is for the sole purpose of providing voluntary and unpaid services.
PUBLIC HEALTH AB 1639 (Maienschein) – Pupil health: The Eric Paredes Sudden Cardiac Arrest Prevention Act
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AB 1719 (Rodriguez) – Pupil instruction: cardiopulmonary resuscitation
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CMA Position: Support Establishes the Eric Paredes Sudden Cardiac Arrest Prevention Act that would require the California Department of Education to make available specified guidelines and materials on sudden cardiac arrest and warning signs. Requires pupils and parents to sign an acknowledgment of receipt of an information sheet on sudden cardiac arrest symptoms and warning signs before athletic participation. Requires training of coaches, athletic trainers, or authorized persons. Requires coaches to remove from participation a pupil who passes out or faints while participating in or immediately following an athletic activity and sets other requirements for action in the event a pupil experiences specified symptoms.
CENTRAL COAST PHYSICIANS
Creates a pilot project to be administered by the California Department of Public Health (CDPH) to assess and make recommendations regarding the effectiveness of the routine offering of a human immunodeficiency virus (HIV) test in the emergency department of a hospital. Requires participating hospitals to offer an HIV test to any patient in the hospital
Winter 2017
emergency department, collect specified information, and to report the information to CDPH.
TOBACCO
AB 2640 (Gipson) – Public health: HIV
CMA Position: Co-sponsor Defines the term “smoking” for purposes of the Stop Tobacco Access to Kids Enforcement Act. Changes the definition under the law of “tobacco products” to include electronic devices, such as electronic cigarettes, that deliver nicotine or other vaporized liquids, and makes the furnishing of tobacco product to a minor a misdemeanor.
Requires a medical care provider or person administering a test for human immunodeficiency virus (HIV) to provide patients who test negative for HIV infection, and are determined to be at high risk for HIV infection by the medical provider or person administering the test, with specified information and information about methods that prevent or reduce the risk of contracting HIV, including, but not limited to, pre-exposure prophylaxis and post-exposure prophylaxis, consistent federal guidelines. SB 1095 (Pan) – Newborn screening program
CMA Position: Support Requires the California Department of Public Health to expand statewide screening of newborns to include screening for any disease that is detectable in blood samples as soon as practicable, but no later than two years after the disease is adopted by the federal Recommended Uniform Screening Panel (RUSP) or enactment of this bill, whichever is later. SB 1408 (Allen) – Tissue donation Deletes the prohibition in existing law on the transplantation of tissue from a donor with HIV and instead permits such transplantation if the physician and surgeon performing the transplantation has ensured that the organ from an individual who has been found reactive to HIV may be transplanted only into an individual who has been found reactive for HIV before receiving the organ and is either participating in clinical research approved by an institutional review board pursuant to federal requirements, or if the U.S. Secretary of Health and Human Services determines that participation in this clinical research is no longer warranted as a requirement for transplants, as specified.
REPRODUCTIVE ISSUES SB 999 (Pavley) – Health care coverage: contraceptives: annual supply
CMA Position: Support Requires a health care service plan or a health insurance policy to cover, and authorizes a pharmacist to dispense, up to a 12-month supply of FDA-approved, self-administered hormonal contraceptives when dispensed at one time for an enrollee or insured at one time by a provider, pharmacist, or at a location licensed or authorized to dispense drugs or supplies. Incorporates chaptering amendments for SB 253 (Monning).
Winter 2017
SBX2 5 (Leno) – Electronic cigarettes
SBX2 7 (Hernandez) – Tobacco products: minimum legal age
CMA Position: Co-sponsor Extends the applicability of specified provisions of the Stop Tobacco Access to Kids Enforcement Act, including but not limited to provisions prohibiting the furnishing of tobacco products to, and the purchase of tobacco products by minors to persons under 21 years of age. Authorizes the California Department of Public Health to conduct random, onsite sting inspections of tobacco product retailers. Exempts active military personnel who is 18 years of age or older as confirmed by a military identification card.
WORKERS’ COMPENSATION AB 2503 (Obernolte) – Workers’ compensation: utilization review
CMA Position: Support Requires a physician providing treatment to an injured worker to send any requests for authorization for medical treatment, with supporting documentation, to the claims administrator for the employer, insurer, or other entity, according to rules adopted by the Administrative Director of the Division of Workers’ Compensation. SB 1160 (Mendoza) – Workers’ compensation
CMA Position: Co-sponsor Requires the Administrative Director of the Division of Workers’ Compensation to adopt regulations to provide employees with notice regarding access to medical treatment following the denial of a claim. Increases the penalty assessments and require the posting of a list of claims administrators who are in violation of data reporting requirements. Revises and recasts provisions related to utilization review with regard to injuries occurring on or after January 1, 2018. Modernizes data collection in the workers’ compensation system and implements anti-fraud measures in the filing and collection of liens.
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E x p a n din g t h e D e p t h o f
CARDIOVASCULAR
Care on the Central Coast
Specialists at the Cottage Heart and Vascular Center at Santa Barbara Cottage Hospital offer unmatched expertise that expands treatment options for the care of patients. By Maria Zate • Manager of Public Relations • Cottage Health
Cardiovascular disease is the leading cause of mortality worldwide, contributing to more than 17 million - or one in three - deaths per year, according to the American Heart Association. By 2030, deaths caused by cardiovascular issues are expected to exceed 23 million. Physicians on the Central Coast have a tremendous resource to reduce heart and vascular disease by partnering with specialists at the Cottage Heart and Vascular Center at Santa Barbara Cottage Hospital. From the early 1970s when Cottage was the first in the region to offer open heart surgery, to the most recent debut of Transcatheter Aortic Valve Replacement (TAVR) and new procedures for arrhythmias, Santa Barbara Cottage Hospital has been the region’s leader for offering advanced treatments for heart and vascular disease. “Our program at Cottage offers the most comprehensive structural heart program on the Central Coast, and the highest volumes for the most complex procedures,” said Dr. Joseph Aragon, Director of the Structural Heart Program at Cottage and Chair of Cardiology at Sansum Clinic. “We offer a breadth of services equal to that of tertiary referral centers,” explained Dr. Brett Gidney, Electrophysiologist. “We have a high volume of Afib ablations and an experienced team of nurses and technicians. It all contributes to our excellent success rate and very low rate of complications.” Advances in minimally invasive techniques used in the cath lab and EP lab have reduced the need for heart surgery while contributing to improved outcomes, said Dr. Phillip West, Medical Director of Cardiovascular Surgery at Santa Barbara Cottage Hospital. >>
DR. WATSON
DR. ARAGON
“Bet ter management of hyperlipidemia through the use of drugs a n d s t e n t i n g h a s r e d u c e d c o r o n a r y a r t e r y d i s e a s e .” - D r . W e s t
“Better management of hyperlipidemia through the use of drugs and stenting has reduced coronary artery disease,” said Dr. West. “However, in the last 20 years, due to improved longevity and other factors, there has been an increase in aortic valve disease. TAVR now offers a way to replace an aortic valve without open heart surgery.” While aortic valve replacement is a standard procedure for aortic stenosis, open heart surgery often poses a high risk for elderly patients. The first non-surgical replacement of the aortic valve, TAVR involves a collapsible aortic heart valve that is inserted through the femoral artery and threaded up to the heart. In September 2015, Dr. Aragon and Dr. Michael Shenoda, Interventional Cardiologist, were the first to do
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the TAVR procedure at Cottage, supported by a team of cardiothoracic surgeons and a dedicated team of nurses and technicians. Cottage expects to complete 100 TAVR procedures by the end of February, according to Dr. Aragon, who has watched the structural heart program at Cottage blossom since he arrived in 2005 and established the region’s only percutaneous atrial septal defect closure program. For the treatment of arrhythmias, the services found at Cottage are also unparalleled on the Central Coast, especially for atrial fibrillation (Afib), which affects roughly one in four people over the age of 40. Services include a variety of advanced ablation procedures as well as implants. Santa Barbara Cottage Hospital is the only location
Winter 2017
DR. GIDNEY
“We’ve developed a group of physicians and administrators to work together to improve qualit y and outcomes, cre ate new p r o g r a m s , a n d i n c r e a s e p a t i e n t s a t i s f a c t i o n .” - D r . W a t s o n
on the Central Coast and one of just a select number of locations nationwide to offer Watchman, a minimally invasive procedure that seals off the left atrial appendage so it no longer hosts blood clots that can cause strokes. An estimated 20 percent of all strokes occur in patients with Afib. Watchman is designed for patients who have Afib that is not related to heart valve disease and who need an alternative to blood thinners due to bleeding risks. Within 45 days of a successful Watchman placement, most patients can stop taking blood thinners. Dr. Gidney and Dr. Aragon were the first to perform Watchman at Cottage in 2016 and since then more than 75 patients have had the procedure.
Winter 2017
Developing new programs that are successful rely heavily on teamwork between physicians and hospital administration, explained Dr. Thomas Watson, Interventional Cardiologist, and Cottage’s Chair of the Cardiology Department and Physician Director of Cardiovascular Services. “We’ve developed a group of physicians and administrators to work together to improve quality and outcomes, create new programs, and increase patient satisfaction,” Dr. Watson said. “The growth of TAVR and Watchman at Cottage has exceeded our expectations, and there are more new programs coming soon.”
CENTRAL COAST PHYSICIANS
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CENTRAL COAST PHYSICIANS
Winter 2017
In The News
IN THE
NEWS
Providing physicians, office staff, and healthcare executives with relevant and up-to-date information
Congratulations to the following CCMA members serving on Boards at local hospitals and medical centers in 2017. Cottage Health Board of Directors Edward Bentley, MD Richard Ponce, MD Elliot Prager, MD Anne O’Meara Rodriguez, MD
French Hospital Medical Center Community Board Michael DeWitt Clayton, MD
Lompoc Valley Medical Center Board of Directors David McAninch, MD Lisa Ercolini-Bhatia, MD
Sierra Vista Regional Medical Center Governing Board Scott Bisheff, MD Phillip Kissel, MD
Twin Cities Community Hospital Governing Board Andrew Anthony, MD Kevin Colton, MD Thomas Hale, MD Randolph Lawrence, MD Jonathan Riegler, MD
Follow the Central Coast Medical Association online Facebook @CentralCoastMed
Twitter @CentralCoastMed
HAVE SOMETHING TO SHARE? We welcome submissions to our In-the-News Section from our community healthcare partners. We prefer Word files and .jpg images and may edit for space restrictions. Send your files to magazine@sbmed.org one month prior to publication (January 1st for the Spring issue, April 1st for the Summer issue, July 1st for the Fall issue and October 1st for the Winter issue).
Winter 2017
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31
TO TEST OR NOT TO TEST By David Dodson, MD
Speaking as a man, a primary care internist, and former chairman of the Men’s Health Committee of the Massachusetts Medical Society, PSA is perhaps the test I love to hate, and have done for many long years. That said, this was a favorite topic at the annual Men’s Health Symposium, which I had the honor to chair at Massachusetts Medical Society. At a symposium I attended a few years ago, one of our distinguished speakers remarked that since its introduction about 25 years ago, we have been saying we need a better test, we are still saying that, and we still don’t have it. Alas, that remains the case.>>
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Winter 2017
Men’s Health > Prostate Cancer
With prostate cancer being the commonest internal malignancy - one in six men will get it at some point in their life - a good screening test would be extremely valuable. A good screening test should be 1) inexpensive, 2) non-invasive, and 3) lead to decreased morbidity and mortality for the disease being screened. PSA certainly fulfills the first two criteria, but whether it does the third is the crux of the debate, and if PSA screening does not reduce morbidity and/or mortality, clearly it is useless at best. According to the US Preventive Services Task Force (USPSTF), PSA screening is worse than useless because such screening over diagnoses prostate cancer, leading to over treatment, and needless morbidity and mortality. This judgment is based primarily on the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial (PLCO) trial, published almost 10 years ago. This multicenter, ten year study compared PSA screening vs “usual care” to see if screening lowered prostate cancer mortality. Published in the New England Journal of Medicine along with the European Randomized study of Screening for Prostate Cancer (ERSPC), the PLCO trial failed to show a survival advantage to being screened. In contrast, the ERSPC study did, albeit a small one. What accounts for the difference? For one thing, it helps to be Swedish, because the positive results in the European trial derived mainly from the Swedish site; most of the other sites did not have positive results. More importantly, the PLCO trial has been faulted because during the nearly ten years the trial ran, PSA screening was widely adopted, with the result that the usual care group had a lot of PSA screening, so it wasn’t a good comparison of screening versus not screening. So where does this leave us? How do I deal with the dilemma? One thing advocated by all professional bodies who have weighed in on the matter, and that I believe is key, is that the decision to screen with PSA or not to screen should be a decision shared by the screener and the screenee. I understand that many docs will feel that the conversation required is just one more time consuming burden in an already long day. While there is certainly truth to that, who ever said ours is an easy job? As a surgeon I once cared for put it, “if you don’t have time to do the job right in the first place, where will you find time to fix the mistakes you’ll make? My conversation with patients begins with informing men they have a one in six chance of getting prostate cancer at some point in their life but that they are far more
Winter 2017
likely to die with it than to die from it. I quote Dr. Richard Ablin, who discovered PSA: imagine a box with a turtle and a box with a rabbit. The rabbit can jump out and run around, the turtle cannot. Most prostate cancers are turtles, not rabbits. In fact, about five out of six are turtles. The problem is that with one in six men getting prostate cancer, those one in six prostate cancers that are rabbits mean that 3% of men will die of prostate cancer, making it the #2 cancer killer of men, behind lung cancer and just ahead of colon cancer. Finally, I inform men that both prostate biopsies and prostatectomies for confirmed cancer carry a significant risk of morbidity and mortality. In particular, the risk of sexual impotence and urinary incontinence are high. These facts need to be conveyed before patients can make an informed consent. Depending on the patient, it can take anywhere from one to five minutes. Having had the conversation, I tell men I am happy to run the test should they wish, but fully respect their opinion should they prefer not to have it. I encourage African Americans, who have both a higher incidence and a higher mortality from prostate cancer than men of other races, to be screened. Likewise, men who have a first-degree relative with prostate cancer are a higher risk and are encouraged to be screened. Finally, although it is not screening at this point, I run PSAs to follow up on any abnormalities on digital rectal exams. And that is how I deal with the PSA screening dilemma. How do you do it? It’s a major problem, one no one has the last word on. Your thoughts will be appreciated and valued.
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Dilem 34
CENTRAL COAST PHYSICIANS
Winter 2017
Dilemma THE DOCTOR’S
By Howard Marcus, MD, FACP
The Doctors Company Internal Medicine Closed Claims Study analyzed 1,180 claims that closed from 2007–2014. The study found that the top allegation, representing 39 percent of claims against internists, was diagnosis related and resulted from a delay or failure to diagnose. Physicians fail to diagnose accurately for many reasons. The dilemma can be understood best in the context of the complexity of clinical medicine. Illnesses present with an infinite number of variations, illustrated by the 68,000 ICD-10 diagnostic codes and 8,000 recognized diseases and syndromes—many of which are uncommon. It is in this context that failure to diagnose may be viewed as an error or lapse in reasoning rather than just a failure of clinical skill. Therefore, diagnostic accuracy can be improved with a better understanding of how to avoid pitfalls in medical decision making. The monograph Improving Diagnosis in Health Care characterizes failure to diagnose in terms of two types of thinking processes—rapid and slow—and the effects of psychological biases on medical decision making. Type I, or rapid decision making, involves pattern recognition (heuristics) that allows the clinician to successfully diagnose and treat most patients efficiently. Type II, or slow decision making, requires recognition by the clinician of the possibility of a complex medical problem and the need for careful thought, a differential diagnosis, lab and imaging studies, reference resources, and/or consultation with a specialist. Recognition of risk factors is essential. Psychological biases may undermine accurate diagnosis and treatment. Some common examples include the following: Anchoring bias: The tendency to rely too heavily
on, or “anchor” to, one trait or piece of information when making decisions—usually the first piece of information or diagnosis that is acquired. Premature closure: The tendency to apply premature closure to the decision-making process by accepting a diagnosis or treatment before it has been fully verified. Overconfidence bias: A universal tendency to believe we know more than we do. Optimism bias: The tendency to be overly optimistic by overestimating favorable and pleasing outcomes. This can also be considered a form of denial. The following illustration is taken from The Doctors Company Internal Medicine Closed Claims Study. A 65-year-old female presented with nausea, fever, and a dark area in the visual field of the right eye. She was diagnosed with a viral infection. Four days later, she presented to an ophthalmologist with the loss of central vision in the right eye and was diagnosed with a retinal detachment, resulting in permanent loss of vision. Primary care physicians see many patients with nonspecific symptoms of nausea and fever. Most of these patients have an acute and self-limited viral illness. However, complaints of acute visual loss are relatively uncommon in a general practice, and most primary care physicians do not have the training or equipment to properly evaluate those patients. This case illustrates overconfidence bias in which the physician appears to have failed to recognize the potential significance of an unusual visual complaint, concentrating instead on the more common viral illness. Read the full study, including expanded case examples and risk mitigation strategies, at www.thedoctors.com/internalmedicinestudy.
mma Contributed by The Doctors Company. For more patient safety articles and practice tips, visit www.thedoctors.com/patientsafety.
Public Health
Update
Community Health Improvement Plan for Santa Barbara County 2017
By Susan Klein-Rothschild, MSW • Deputy Director, Community Health • Santa Barbara County Public Health Department
In the summer of 2016, the Public Health Department completed a Community Health Assessment for Santa Barbara County. Through the assessment, which included surveys from more than 3,000 county residents, data from a variety of sources, and meetings with more than 50 community partners and coalitions, we gained a better understanding of the current health status of our residents. This process revealed priorities to improve the health of our community, priorities that were consistent across ethnicities and throughout all communities within the County. These priorities have been translated to a Community Health Improvement Plan.
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Winter 2017
The Community Health Improvement Plan identifies priority health goals for our community with activities and strategies for action, and activities that ensure measurable improvement in Santa Barbara County. We strive for a Community Health Improvement Plan (CHIP) that is realistic yet still stretches us a bit without reaching beyond our capacity. The CHIP is a collaborative plan that is dependent on collaborative work by many community partners to improve health in Santa Barbara County. Community Health Improvement Plan Goals & Objectives GOAL #1: Obesity Prevention – Increase the number of county residents who maintain a healthy weight and decrease the number of county residents in the obese category leading to better health outcomes and a healthier community.
a) B y December 31, 2020, increase the percentage of adult residents with a healthy BMI (between 18.5 & 24.9) by 5% over 2016 rates. b) B y December 31, 2020, reduce the number of children in the WIC program in the obese BMI range to the Healthy People 2020 goal of 9.4%.
c) B y December 31, 2020, increase the number of miles of connected bike paths from baseline by 20%.
d) B y December 31, 2020, increase the number of classes available in Santa Barbara County on healthy eating by 25%.
e) B y December 31, 2020, 100 health care providers will have written prescriptions for outdoor activity.
GOAL #2: Access to Healthcare – Increase the number of low-income residents who see a Primary Care Provider annually.
GOAL #3: Integration of Healthcare – Strengthen the integration of behavioral and physical healthcare.
a) I ncrease the number of county Medi-Cal residents who have had basic healthcare screening by 10% annually.
b) B y December 31, 2017, provide education to 500 county residents about how to access the appropriate level of medical care.
a) B y December 31, 2020, train at least 50% of the county’s primary care and behavioral health providers on the importance of practice integration.
c) D ecember 31, 2020, provide education to 2000 additional county residents about how to access the appropriate level of medical care.
b) B y December 31, 2020, increase the number of consumers by 50% who sign release of information forms for all Public Health Department and Behavioral Wellness patients to share information.
c) B y December 31, 2020, increase the number of residents who receive care through FQHCs screened for behavioral health services.
d) B y 2020, have mutual access to the Public Health Department and Behavioral Wellness Electronic Health Records for shared patients.
To view the entire plan, go to www.sbcphd.org.
Winter 2017
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New Members
8 NEW
THE CENTRAL COAST MEDICAL ASSOCIATION WELCOMES THE FOLLOWING PHYSICIANS AS MEMBERS
...and even more on the way.
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George Cheng, MD Radiation Oncology Cancer Center of Santa Barbara Santa Barbara 682.7300
Helen John-Kelly, MD Gastroenterology Pacific Children’s Gastroenterology Santa Barbara 879.4242
Gregory Cogert, MD Clinical Cardiac Electrophysiology Sansum Clinic Santa Barbara 898.3138
Jamil Muasher, MD Diagnostic Radiology Pueblo Radiology Medical Group Santa Barbara 682.7744
Cary Fitchmun, MD Family Medicine Arroyo Medical Group Pismo Beach 474.2600
Virginia Siegfried, MD Gynecology Planned Parenthood California Central Coast Santa Barbara 963.2445
Corey Frucht, MD Dermatology Santa Barbara Skin Care Santa Barbara 569.1164
Michelle Withee, MD, MBA Internal Medicine Santa Barbara 252.1229
CENTRAL COAST PHYSICIANS
Winter 2017
In Memoriam
In Memoriam Dan Secord, MD Dan Secord, MD died this past October at age 80 from bladder cancer. Dr. Secord was born in Kansas City, Missouri. He joined the United States Army Medical Corps in 1955, and went on to study medicine at the University of California College of Medicine in Los Angeles where he graduated in 1965. He completed his internship and residency in obstetrics and gynecology at Los Angeles County Hospital, and was Chief Resident at San Bernardino County Hospital. Dr. Secord began his private practice in Santa Barbara in 1969, and he joined the Santa Barbara County Medical Society that same year. On his Medical Society application, he included his hobbies as sailboat racing, amateur radio operator, private pilot, astronomy, and weather forecasting. Dr. Secord was active with the Medical Society and served on many committees along with the Board of Directors. Dr. Secord became active in politics, and was endorsed by the Medical Society who wrote a letter to Mayor Sheila Lodge in 1986 regarding his appointment to the Santa Barbara City Council, which touted his leadership skills and ability work with a variety of people. Dr. Secord is survived by his wife, Mary, his children Cindy Tomkinson, Richard Secord, Stephanie Curtis, Lara Mislang, Jennifer Secord, and 10 grandchildren.
Winter 2017
Russell Tyler, MD Russell Tyler, MD dies this past November at the age of 90. Dr. Tyler was born in Minneapolis, Minnesota in 1926 and moved to Los Angeles at the age of 16. After serving in the Army, Dr. Tyler went to school at the University of Southern California, where he met his future wife, Charlotte Speer, and they both attended the USC School of Medicine. After studying Internal Medicine, Dr. Tyler opened a practice in Whittier, CA. In 1975, Dr. Tyler and his family moved to Santa Barbara where he became the Medical Director of Clinical Services at the County Hospital. In 1981, he became the first Medical Director of the Tri-Counties Veterans Administration Outpatient Clinic. In addition, he and his wife, Dr. Charlotte Tyler, started the Internal Medicine Residency Program at Cottage Hospital. Dr. Tyler was active with the Santa Barbara County Medical Society and served as president in 1983. He also founded the Retired Physicians Group. Dr. Tyler enjoyed adventure, and was especially passionate about sailing his Cal 40, “Cipango�. During his retirement, he traveled throughout the world including Morocco, Italy, France, Antarctica, Mexico, South America, Egypt, Norway, Japan, and China. Dr. Tyler is survived by his wife, Charlotte, their two children, Kit and Terry, and two grandchildren.
CENTRAL COAST PHYSICIANS
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