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March 2016 | Volume 64
5 6 8
By The Round-Up Staff
The Science of Quality
Why It’s Hard to Measure Improved Population Health
By Sandro Galea, MD, MPH, DRPH
Addressing Our Nation’s Physician Shortage: A Scholarship-Winning Essay By Aishan Shi
Measuring Quality of Care for the Sickest People
By Diane E. Meier, MD, FACS
How do you feel about the medical boards being regulated by the state health department?
What is a Homeopath?
By Bruce Shelton
22 24 27
MCMS Board Meeting Minutes In Memoriam Marketplace
ember Profile 15 M The role of data in quality control:
an interview with Dr. Hamed Abbaszadegan
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March 2016 In the last decade, quality has become front and center in our healthcare system. When the Affordable Care Act set out by moving away from quantity and began tying reimbursement to quality of care, it started a paradigm shift that is still taking shape today. With CMS’s Physician Quality Reporting System (PQRS) in full effect, physicians are now incurring penalties rather than the initial PQRS participation incentives. In replacing the SGR formula to assess Medicare Part B payments, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) combines numerous CMS quality reporting systems into one and goes further towards rewarding providers who deliver high-quality care. With MACRA, the Merit-based Incentive Payment System (MIPS) will kick in next year by annually measuring a provider’s performance in four categories and assign them a MIPS score that will have a dramatic impact on Medicare reimbursement. In fact, the federal government has its sights set on 30% of all Medicare reimbursements being tied to quality by the end of 2016, and increasing this to 50% by the end of 2018. This has many providers nervous about getting excluded from networks, as many payers are mandating quality targets and booting out those who fail to meet the mark. Unfortunately, many argue that the mark is constantly moving, and there is much consternation over what we should actually be measuring. In this issue, we dive into some of these concerns over quality. Our profile physician this month is Hamed Abbaszadegan, MD, MBA, Chief Medical Informatics Officer at the Phoenix VA Hospital. Dr. Abbaszadegan spearheads a number of quality initiatives at the VA and spoke
What’s Inside with Round-up about his current role, and how quality is at the forefront of the care they deliver to our veterans. We have an article from Diane Meier, MD on the challenges of measuring the quality of care for the sickest of patients, and Sandro Galea, MD, MPH, DrPH shares with us the difficulty in quantifying populating health. We also have an article penned by the late Bruce Shelton, MD, the only homeopathic members of the Society. Prior to Dr. Shelton’s passing in early February, he shared some thoughts with Round-up on the confusion over what a homeopathic physician actually is.
Jay Conyers, PhD EXECUTIVE DIRECTOR
Also included in this issue is the first of four winning essays submitted by local medical schools. The Society and MICA Foundation have co-sponsored a scholarship program for local medical students to write about emerging topics in healthcare. One $2,500 award will be made to each of the four local medical schools – University of Arizona College of Medicine Phoenix, A.T. Still University, Midwestern University, and Creighton School of Medicine. The winning scholarship essay from the University of Arizona College of Medicine – Phoenix was submitted by first-year medical and MBA student Aishan Sha, and is included in this issue. Congratulations to Aishan! Next month, we shift away from quality and focus our attention on technology. As an expanding resource in the physician toolkit, technology has proven to not only enhance the efficiency of how care is delivered, but aims to contribute to measuring quality and expanding access to care. Technology can be a true Swiss Army knife if used effectively in medicine, and in April, we profile a physician – Dr. Robert Guyette – who has embraced technology in how he practices medicine. Until then, enjoy this issue of Round-up……
The Science of Quality
his month’s topic is the science of quality. Quality is one of those words that has an obvious and easily agreed upon definition, however when used in medicine has become almost nonsensical. We all learned how to care for patients in medical school, residency, and perhaps fellowship; and the medicine we learned was the best medicine available at the time. We all continue learning throughout our careers from our peers, from CME courses, and now from our mandatory MOC curricula. And while I do remember putting some thought into purchasing a “quality” stethoscope, and a “quality” pair of shoes to wear in the cath lab while doing angioplasty, I don’t remember thinking about whether the care I provided my patients should be “quality” or not. Clearly the term “quality” as it applies to modern medicine did not originate with any physician actively practicing medicine. As all of us know, when we hear the term “quality” it means we are being judged by external sources such as the government, insurance companies, or other health care networks, usually in an attempt to save money. In the most idealistic sense, health insurers, including the government, are interested in good patient outcomes, which is what the word quality is supposed to mean. This is to be distinguished from “value,” which is defined as the cost per unit of quality. Insurers have decided that they are interested in paying for quality care. Medically, the closest thing we have to measuring quality is outcomes data. Unfortunately, the science of outcomes is in its infancy. And, it is very difficult and costly to measure. In their rush to achieve “value,” insurers have made up a long list of “quality” metrics on which we physicians are to be judged. And this is where the problem begins. For example, one of the “quality” measures on which I as a cardiologist am being judged is the use of beta blockers after a myocardial infarction. Seriously? Using a beta blocker after a myocardial infarction is not higher level medicine - we learned that in second year medical school. Interestingly, the first year we were scored on this metric our results were quite poor. The second year our results improved dramatically. Data similar to this have been bandied about the medical literature as evidence that incentives for quality metrics in fact does result in improved quality. However, we all know what 6
really happened. We all know that we didn’t improve our beta blocker use after myocardial infarction at all, mainly because we already knew that we were supposed to do that, and were therefore using beta blockers appropriately all along. What we did improve was our ability to adequately document our compliance with that metric. All across the country, physicians have invested billions of dollars into electronic medical records, whose main purpose, I have become convinced, is to collect similar sorts of data. As most of us know, this has not resulted in our actually improving our quality, rather it has resulted simply in the insurers ability to capture data on the way we practice medicine. There is a business axiom which states: you cannot change that which you cannot measure. This axiom is responsible for the proliferation of so-called “dashboards” which insurers and health care network executives use to judge the physicians under their purview. One obvious metric on these dashboards with which we are all familiar is LOS or length of stay. However, there are a myriad of other examples. And while some do represent a genuine improvement in quality, such as a reduction in CAUTIs, or catheter-associated urinary tract infections, others simply
President’s Page represent a way for insurers or networks to improve their bottom line. Take the simple LOS metric, for example. I have a number of patients in my outpatient clinic who, in an attempt to improve LOS, have been discharged on home oxygen. Never mind the fact that they have never actually been diagnosed with any pulmonary ailment that would necessitate supplemental oxygen. It was simply quicker to discharge them with home oxygen rather than actually figuring out why they were hypoxic. And we all know what happens once a patient is “on home O2.” They stay that way forever, because once “on home O2” finds its way into their past medical history, nobody ever asks why, or tries to get them off O2 – that patient is simply on O2, probably from COPD, but who knows? I just need to get them back down to their two or three liters per minute, and I can discharge them again. As it happens, I’ve discovered that some of these patients are simply in heart failure. After some aggressive diuresis, they are able to be weaned off the O2. Some of these patients have been on home O2 for several years without ever having an actual diagnosis. Whatever the reason, the quality metric based system simply wasn’t interested in a diagnosis, it was interested in a timely discharge. Now, I am not blaming any particular physician for this, and I am sure their are other non-cardiac similar examples. However, this clearly illustrates one of the unintended consequences of the so-called quality metrics in common use today. I also have seen a number of patients who come to me asking for advice on whether or not they should take a new medication that their primary care physician prescribed for them. They took the prescription but haven’t filled it yet because they wanted to check with me
first. The primary care physician wasn’t aware of this, I suspect. I also suspect that the primary care physician checked all the appropriate boxes on their EMR to indicate their compliance with prescribing the appropriate medications for the appropriate conditions, thereby receiving a good “quality” score. The health system which employs the primary care physician tallies all the checked EMR boxes from all similar primary care physicians and I suspect there is a lot of jubilant back-slapping by the network administration when the final numbers are calculated, showing compliance with their quality initiative. But the patient isn’t taking the medication. Now, nine-point-nine times out of ten, I would counsel the patient to take the medication that their primary care physician prescribed for them, so in the end, hopefully, the patient takes the medication. But if those are only the patients that were engaged enough to actually remember the medication and specifically ask me in a visit, how many more patients are simply just not taking them at all? When does this get factored in? I bring this up not to simply raise the issue of patient noncompliance because that would simply be too easy, too convenient an excuse which always lurks when a bad outcome occurs. I bring up this example to illustrate that what at its essence is a human-to-human interaction based on mutual trust and understanding is simply very hard to quantify; very hard to convert into an EMR checkbox. This is not to say the endeavor is worth nothing. Perhaps a time will come when the medical science of outcomes research and the health system initiative loosely called “quality” will merge and result in real improvement in the health of our individual patients. But I fear that time is a long way off.
Adam Brodsky, MD, MM MCMS PRESIDENT 2016 email@example.com 602.307.0070
Dr. Brodsky specializes in Interventional Cardiology He joined MCMS in 2005. Contact Information: Heart & Vascular Center of Arizona 1331 N. 7th Street Suite 375 Phoenix, AZ 85006 http://heartcenteraz.com
Why It’s Hard to Measure Improved Population Health SANDRO GALEA, MD, MPH, DRPH
mbitious programs to improve the U.S. health care system typically include improving population health in their objectives. But one of the great challenges in these efforts lies in how to measure success. In general, population health is defined as the health outcomes of a group of individuals and how those outcomes are distributed within the group. But most discussions about measuring outcomes focus on the group as a whole and neglect distribution.
That’s unfortunate because, as every business person knows, what gets measured is what gets managed. If we simply measure overall population health, we can almost certainly improve it by focusing on low-hanging fruit — improving the health of groups that are easily accessible and most amenable to changing their behavior. (Think, for example, of the wellness programs that are common today in the business world.) But these efforts will inevitably widen health gaps, improving the health of some while leaving marginalized communities behind. Closing those gaps should be at the heart of efforts to measure and improve population health, even if 8
it means sacrificing some efficiency. For example, much effort has gone into behavioral intervention apps, like those designed to help people quit smoking. Although the data is still out, it’s plausible that these apps make a difference for people who use them. But those users are almost certainly people who have ready access to the technology and the discipline to apply it. People who can neither afford a smartphone nor lead lives organized enough to be driven by apps are left out, widening the health gap between app users and nonusers. Such approaches probably explain what has happened with the decline in tobacco use in the United States. Only about 1 in 5 adults now smokes, a historic low, but we are stuck there because most smokers are in the lower socioeconomic brackets. An alternative approach would explicitly aim to narrow the gap by doing the harder and more expensive work of targeting smokers with fewer means and enrolling them in smoking-cessation programs. This might divert efforts from the smartphone strategy, perhaps resulting in somewhat higher overall smoking rates, sacrificing some efficiency and cost savings in favor of greater equity.
Why should we be willing to accept such sacrifices, especially at a time when health care costs dominate the headlines? There are three reasons:
ethnicity and income — and tabulate, report and hold themselves accountable to relative achievement in health indicators across these groups.
1. Health equity could bridge social divides, yielding much larger dividends than simple cost savings. Health is a public good that forms part of the social fabric. Health inequities fray that fabric, contributing to broader resentments of social inequities.
Finally, we can establish incentives that promote both efficiency in improving the absolute numbers and equity in closing gaps. The job of stimulating the adoption of such incentives may initially have to fall to government. But over time they could become embedded in provider culture, effecting a shift in system indicators we value and reward.
2. Narrowing health gaps is a value that drives much health care. 3. In an increasingly interconnected world, it is impossible to separate social groups. Poor health in some groups threatens the health of all groups. There are several ways we can change the focus of measurement of health indicators from absolute achievement to measurement that accounts for inter-group differences. First, we can make closing the health gaps between groups one of the prime objectives in health improvement. Second, we can include relative indicators of health along with absolute indicators in metrics. This will require that health systems measure factors around which we may expect difference — like race,
SANDRO GALEA, MD, MPH, DRPH Dr. Sandro Galea is an emergency physician and epidemiologist. He is the Robert A. Knox professor and dean of the Boston University School of Public Health.
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Measuring Quality of Care for the Sickest People BY DIANE E. MEIER, MD, FACP
spend a lot of time thinking about the Affordable Care Act and how it will affect the sickest, most vulnerable and, therefore, most costly patients in the U.S.
I practice in the relatively new interdisciplinary specialty of palliative medicine, which aims to improve the quality of life of people with serious, complex illnesses. So all of my patients are living with profound fatigue, pain, shortness of breath, financial and family stresses and mountains of worry. The ACA’s focus on quality over quantity could increase attention to the needs of such patients. Or, with its twin focus on reducing out-of-control spending, the ACA might prompt a race to the bottom, as necessary – but costly – treatments are summarily avoided. How do we ensure that the neediest patients receive care that is truly valuable to them, instead of the usual merry-go-round of costly emergency room visits and hospitalizations for problems that can – and should – be managed at home? The answer to this question lies in defining how the concept of “value” applies to patients who need palliative care, devising a system for rigorously measuring that value and then implementing it in practice. Working alongside a seriously ill patient’s regular 10
medical team, the palliative care clinician focuses on relieving pain, symptoms and other stresses. Studies of palliative care show that it improves patients’ and their families’ quality of life and reduces hospitalization and use of emergency services. We start by asking patients and their families what matters to them, not focusing on the disease alone. We recognize that for patients with serious, progressive (usually chronic) conditions, as their illness evolves, what matters to them and their families also changes. Most patients value care that helps them stay at home and remain independent for as long as possible; that does not result in financial bankruptcy; and that tries to reduce suffering of all kinds – bodily pain, difficulty breathing, nausea, depression, anxiety and existential and spiritual distress. Palliative care clinicians, working alongside the patient’s regular doctors, provide that support directly to patients and their often exhausted, overwhelmed family caregivers. But for that support to become the standard of practice, it must be bolstered by a system for measuring quality and outcomes, tailored to the unique needs of the palliative-care patient population and consistent with the value-based goals of the ACA.
In addition to following helpful advice from the American Academy of Hospice and Palliative Medicine, I suggest four tactics: 1. Explicitly ask patients and their families what matters most to them, and ensure that this information is recorded, made available in the medical record and actively used by all involved parties in decision making about care.
The challenge we face is obvious. If quality measurement is to achieve its purpose, the health care system must define and measure the outcomes that matter to the people at highest risk of neglect, under-treatment, overtreatment and suffering. Cost containment is urgent and necessary. But so is protection for the patients most in need of care and least able to advocate for themselves.
2. Require that all clinicians (doctors, nurses, social workers and others) receive basic training and certification in pain and symptom management, communication and coordination of care across time and settings.
DIANE E. MEIER, MD Dr. Diane E. Meier is the director of the Center to Advance Palliative Care at the Icahn School of Medicine at Mount Sinai, in New York City
3. Document and analyze the perverse financial incentives that impede delivery of care that is consistent with the priorities and needs of patients and their families. 4. Measure and facilitate access to high-quality palliative care services for all people with serious illness, regardless of age, stage of disease, or care setting.
© 2015 The New York Times News Service From hbr.org c.2015 Harvard Business School Publishing Corp. Distributed by The New York Times Syndicate HEALTH
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What is a Homeopath? BY BRUCE SHELTON
Editor’s Note: Dr. Shelton reached out to Round-up back in January when it was made public that a proposed piece of legislation was wrongly assuming homeopathic physicians do not possess the same level of training as do MD and DO physicians. Prior to his untimely passing in February, he penned the article below to clarify the distinction amongst MDs, DOs, and MD(H)s and describe what led him down the path of homeopathic medicine.
may be wrong, but I believe I’m the only Homeopathic Medical Doctor MD(H) in the Maricopa County Medical Society, and have been of the Society since 1974. I’ve long considered myself a physician first and foremost, and have never really worried about the confusion over what each type of physician can and cannot do. However, I realize that many people, including Arizona lawmakers, don’t quite understand what a homeopathic physician is and does.
I’m a 1971 MD graduate of New York Medical College and moved to Arizona that same year to take the three-year family practice residency at Good Samaritan Hospital. I then practiced as a regular Board Certified Family Physician in Phoenix and took and passed the Family Practice Boards five times until 2001, when I voluntarily changed my style of practice to Homeopathy. I’m no longer board certified in family practice but am a forty-year Fellow of AAFP.
A recent bill made this clear to me, as Rep. Jay Lawrence sponsored a bill this legislative session that would limit the issuance of medical marijuana prescription cards from only MD and DO physicians, and specifically prevent homeopaths and naturopaths from participating in the state’s program. Fortunately, the homeopath community was able to educate Rep. Lawrence on the differences between the two physician types, and thus, the bill was pulled. However, it has made me realize that there lacks a true understanding of what a homeopathic physician is.
The stimulus for the change was my developing a complicated and crippling case of asthma that couldn’t be resolved with seven different strong asthma drugs that left me disabled. My answer came when an otolaryngic allergist put diluted drops of Botrytis mold under my tongue and 20 minutes later my lungs opened up as if I were given a shot of epinephrine, but without the side effects. This led to my taking a course in otolaryngic allergy, which lead me to learn that homeopathy was legal in Arizona. Thus, I enrolled in the 450-hour course from the British Institute of Homeopathy so that I could
become an Arizona MD(H) licensee and a Diplomate and later a Fellow of the British Institute.
left to hospital-based physicians, whom NDs readily agree are another field entirely.
You cannot become an Arizona Homeopathic licensee unless you are a graduate of an MD or DO program from a North American medical school and hold a valid and clean MD or DO license from one of our fifty states. Once you earn the Arizona Homeopathic license you can give up your license from the other state but since my MD license was already from Arizona, I’ve kept and qualified for both of my Arizona licenses. Today, I’m the President of the Arizona Board of Homeopathic and Integrative Examiners plus I work for a Homeopathic manufacturer (Desbio) and have lectured all over the United States and several foreign countries. I used to be the USA Medical Director for the worlds largest manufacturer of combination Homeopathic remedies (HEEL). And recently I testified before the FDA on Homeopathic labeling at a hearing in Washington, D.C. I have an active practice of Homeopathic Family Medicine near Moon Valley in North Phoenix.
This entire discussion was brought to the forefront when it was discovered that 90% of the prescriptions for medical marijuana in Arizona were being written by naturopaths. This is likely what led to the Rep. Lawrence’s now-dead bill, which aimed to exclude NDs and MD(H)s from authorizing medical marijuana cards.
Through the years, I’ve learned how to treat seemingly incurable health problems that traditional medicine calls psychosomatic, which can be cured by Homeopathic and Integrative medicine. I remember when I first had that feeling of confidence that I had mastered allopathic medicine. It was around 2:00 in the morning when I was the Intern on duty at Good Sam – in 1972 – when I was called to the ICU and needed to make a decision on what electrolytes to add to an I.V. on a patient with an arrhythmia after an MI. An hour after adding the right combination of “lytes” to the I.V. (with by then the concurrence of the attending) the EKG normalized and I felt that I had arrived into our hallowed fraternity. In fact, I’ve always believed that my later successes as a Homeopath really depended on my knowledge base of allopathic medicine on-the-job training. However, I’ve always felt there was more I needed to know and after experiencing the failure of traditional asthma therapy found that answer by adding my Homeopathic and Integrative knowledge to my base core of allopathic experience. What then is a naturopathic physician by comparison? Arizona is blessed to have one of the nation’s premier schools of Naturopathic Medicine and has filled our community with some excellent practitioners in outpatient Integrative Medicine. It’s a four-year program that is, in my opinion, very similar to traditional four-year medical training, with the primary exception of not having any of the hospital-based procedures that allopaths use on a daily basis. There aren’t any naturopathic ICUs, nor are there any naturopathic surgical operating rooms. It can be argued that 90% of the medical needs of patients are outpatient and office based with the other 10% being
I can report that I’ve written a total of one prescription for a patient with chronic pain who is today benefiting from medical marijuana. As a rule, medical homeopaths have other answers for chronic pain and utilize the laboratory to find the chronic infections that set up the auto-immune allergic type reactions that cause chronic pain that can be reversed with Homeopathic remedies. Homeopathy is also part of the naturopathic scope of practice but sometimes it’s easier to fall back on the easier way out with a form of practice (i.e., legal medical marijuana) than a long, drawn-out process that can be considered allopathic by a naturally-trained physician.
Through the years, I’ve learned how to treat seemingly incurable health problems that traditional medicine calls psychosomatic, which can be cured by Homeopathic and Integrative medicine. Marijuana, in its diluted form, also happens to be a homeopathic remedy (as Cannabis Sativa), which has many uses including ascites, cataract, cystitis, glaucoma, headache, hysteria, infertility, nosebleeds, palpitations, stammering, and tetanus, among others. It is listed in the HPUS – the FDA’s official compedium of legal Homeopathic remedies – and can be given as a diluted homeopathic drop when indicated. As a homeopathic, it has no narcotic-type effect and does not require a DEA number to prescribe. In fact, most homeopathics can be used under OTC-type indications and rules. I invite any of my fellow physicians to call me for a consultation on hard to treat patients and even to tune into my training webinars that I do for Desbio. I’ll always respond as a medical specialist does and refer patients back to you just as any other specialist does with a letter of findings and instructions of next steps. mcmsonline.com/round-up
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Preferred Partner Program discounts. Patient referral service. Advocacy efforts. Engagement in the medical community. Round-up subscription. Community outreach. MCMS business services. And much more!
The role of data in quality control:
an interview with
Dr. Hamed Abbaszadegan
BY DOMINIQUE PERKINS
r. Hamed Abbaszadegan feels his career path all started with Arizona. His family started here, but moved for a short while to Southern Illinois. When they decided to move back to Phoenix, Abbaszadegan jumped right into school, attending Arizona State University, and graduating with a degree in microbiology from the Barrett Honors College. It was here he met his wife, Mona Amini, MD. They were married after graduation, and he worked for a year in blood banking. He and Amini then attended St. Matthews University School of Medicine, and couples-matched into their residency programs at Banner University Medical Center â€“ Phoenix. After his residency training in Internal Medicine was completed, Abbaszadegan stayed on to complete another year of Chief Residency in Quality and Patient Safety. mcmsonline.com/round-up
“That extra year of training (1 of only 60 in the country), involved numerous informatics initiatives, thus upon completion, I began my current role as the Chief Health Informatics Officer at the Phoenix VA Health Care System,” Abbaszadegan said. This position is the basic equivalent of the chief Medical Informatics Officer at other facilities. Part of his duties includes serving as the site director for the 5th (there are 11 total) ACGME fellowship program in Clinical Informatics. “My Initiatives involve improving quality/safety of health care delivery through improvements within the Computerized Patient Record System, usage of big data analytics for care delivery, and redesigning chronic disease management through population health management,” Abbaszadegan said.
“In order to improve the quality of care we provide, there will need to be less reliance on tasking the provider, and more utilization of the support team” In addition to his current position with the VA, Abbaszadegan also holds university appointments as a Clinical Assistant Professor in Internal Medicine & Biomedical Informatics at the University of Arizona College of Medicine – Phoenix. “Besides the academic and administrative duties, I do see patients in high acuity settings (in-patient hospital and emergency department),” he said Aside from the debates and measures in place to regulate the cost of medicine to patients, the biggest driving force in medicine currently is quality. With so many new regulations in place already consuming physician time and energy, not to mention the notorious physician shortage, some might ask if it is realistic for our current healthcare system to choose to focus more on quality than quantity. Abbaszadegan admits there are difficulties to the approach. “Conceptually, when it comes to direct patient care, it is difficult to grasp this concept of see-less-but-do-more for patients,” he said. 16
The direct patient view may be too narrow. “As we are unlocking the data in our electronic health records, population health management is becoming realized,” he said. “This is how quality will be improved.” As the Chief of Informatics, Abbaszadegan is responsible for the role of the electronic health record and its use in health care delivery to support quality improvement. EHR’s have years of stored clinical data, which is now becoming accessible, and useful, through programming tools such as sequel query language. Most physicians would agree that they are overloaded with ‘quality data’ and there is no clear understanding as to how to utilize it. In his work with the VA, Abbaszadegan said they have numerous pilot projects in place, but that no one has found the “slam-dunk” methodology to implement use of data. “One of my core roles is to ensure that my analytics section remains innovative in quality improvement,” Abbaszadegan said. “It is time to re-create processes of care with data integrated in its use,” he said. “Guidelines of care will still be made by respected societies (such as the American College of Physicians), but the steps to use data will be created on the front line.” While tracking data can lead to the organization and management of chronic disease, as well as appropriate follow-up for age-related screening, this can only be possible with the help of ancillary staff. “In order to improve the quality of care we provide, there will need to be less reliance on tasking the provider, and more utilization of the support team,” he said. “Providers should engage in the business of making care decisions, not in managing lists.” Some physicians may be relieved to hear him say that, as quality initiatives can sometimes feel like yet another demand on time and energy they don’t have to give. Even the Physician Quality Reporting System (PQRS), Abbaszadegan said, is much more about population care management than individual physicians. “In my opinion, most doctors are worried because the name implies grading,” he said. “We are innately competitive, and grading systems probably brings back the education years.” However, Abbaszadegan said he views the PQRS as a health system score, rather than an individual score, since the goal is definitely to improve overall care.
“Why should Doctor X have only 70% of his/ her patients with completed screening, when Doctor Y’s team has 95%?” he said. “Obviously, there is a patient ownership component, but improved population organization can lead to better follow-up compliance. This should light a fire to get the team of Doctor X to get ancillary staff to reach out to their panel.”
When it comes to measuring quality, Abbaszadegan sees three major metric topics: 1. General safety metrics This could include falls, medical errors, wrong-site surgery, etc. 2. Chronic disease metrics This area would focus on improvements in areas such as decreasing the number of CHF readmissions and ER re-visiting rates, improving smoking cessation, etc. 3. Preventative screening metrics Which would cover the percentage of patients who have had colonoscopies, mammography screening, etc. While many medical errors are often associated with hospitals, there is application for controlling them within other settings as well. “The notion that errors are individualistic has been disproven,” Abbaszadegan said. “System processes that are prone to errors are
what lead to them, thus error reporting will improve quality.” With better ways of tracking these errors it is easier to see where improvements can be made. Abbaszadegan went on to explain that the Phoenix VA has a culture of error reporting, with processes in place to improve systems issues and involve the stakeholders in decisions. “Our Chief Residency in Quality and Patient Safety (CRQS) program has played a large role in involving physicians in this process,” he said. “For the upcoming year, we have a CRQS in the ambulatory setting, thus we are excited to expand beyond the hospital setting.” Like many other systems, the Phoenix VA answers to numerous other governing authorities. An increase in media attention throughout the past few years led to an acceleration in quality improvement efforts. “Informatics, population health set-up, and data use for providing smarter health care delivery is at the forefront of what we do at the Phoenix VA,” Abbaszadegan said. “Our projects with the City of Chandler Fire department have been on the news, with goals to expand by using predictive data in providing preventative care. All of the new tools and data will continue to improve the quality of care we provide.”
“Providers should engage in the business of making care decisions, not in manging lists.”
Dr. Hamed Abbaszadegan | On the Personal Side Describe yourself in one word. Energetic
What is your favorite food, and favorite restaurant in the Valley?
Lamb Kabob (Iranian-Style); Persian Room in North Scottsdale
What career would you be doing if you weren’t a physician? Racecar Driver
Favorite activity outside of medicine? Racing
What’s a hidden talent that you have that most wouldn’t know about you? Play the Violin
Best movie you’ve seen in the last ten years? Still…Shawshank Redemption
Favorite Arizona sports team (college or pro)?
Arizona Cardinals (before and after Kurt Warner)
How do you feel about the medical boards being regulated by the state health department? BY ROUND-UP STAFF
egislation is being proposed in the Arizona House of Representatives to centralize the regulation of health practitioners. If HB2501 passes in its current form, all health-related licensing boards will eventually be under the regulatory control of the Arizona Department of Health Services (ADHS). While the regulatory boards would still exist and operate independent of one another, each would essentially relinquish their regulatory, administrative, and licensing operations, with a new ‘single state agency’ entity taking over these functions.
In early 2015, the U.S. Supreme Court ruled that the North Carolina State Board of Dental Examiners wielded too much power in using its regulatory authority to determine who could and could not perform teeth whitening. In its lawsuit, the Federal Trade Commission (FTC) felt that the dental board was pushing out non-dentists engaged in teeth whitening, thereby violating the Sherman Antitrust Act. The Supreme Court agreed, and thus, many states are now evaluating if their health-related boards engage in similar practices. Arizona is now considering an action to prevent any speculation that our own health boards engage in antitrust activities. The bill, sponsored by Arizona Rep. Heather Carter (R- Cave Creek), is widely supported by Governor Ducey’s office. Supporters of the bill contend that such a centralization of regulatory function will improve the efficiency of licensing and minimize the possibility that regulators, in the form of board members within their own health profession, may exercise judgments that could be perceived as conflicts of interests. Those opposed to the bill have expressed concern over whether such efficiencies can be realized and if license processing times and other regulatory functions will be adversely impacted. MCMS surveyed its members recently and asked how they felt about the purpose of HB2501. Survey results discussed below are only reflective of those members who completed the survey. When asked if they support the concept of transferring all health-related licensing boards to ADHS, 70% of physicians indicated their disapproval. Only 14% were in support of board centralization, with another
16% uncertain. Similarly, nearly nine in ten physicians (88%) agreed with the statement that practicing physicians (MDs and DOs) should maintain the current primary regulatory authority over physicians engaged in the practice of medicine. When asked about the processing and issuing of medical licenses, only 14% of those responding to the survey agreed that centralization of the licensing functions of Arizona’s health-related boards will improve the efficiency of licensing physicians. With only 9% unsure, roughly 77% indicated their belief that licensing will be even slower if consolidation occurs. Similarly, 62% felt that board centralization would not have an impact on any antitrust liability that may exist under the current board structure, with 24% unsure. Many who completed the survey expressed their support for the current board structure, whereby physicians regulate physicians. However, several expressed concern over the board selection process, and called for more transparency in how and why certain physicians are appointed to the Arizona Medical Board. Collectively, the majority of respondents felt strongly about physicians maintaining the regulatory authority over the practice of medicine, and did not support the concept of moving this critically important function to a state employee. A number of physicians were also concerned that the ADHS is already functioning beyond its scope and is grossly underfunded, suggesting that additional responsibility being shifted to the state-run organization would further slow things down. Most who responded to the survey agreed that licensing wait times will grow and further discourage out-of-state physicians from applying for an Arizona license. However, several respondents agreed that centralization of licensing staff could streamline the licensing process, but only if the proper organization structure were put in place. So while the Governor’s office has indicated that HB2501 is a high priority this legislative session, there will certainly be plenty of opposition from healthcare practitioners – physicians, nurses, and others, alike – who agree that practitioners should ultimately regulate their craft. mcmsonline.com/round-up
Addressing Our Nation’s Physician Shortage: A Scholarship-Winning Essay BY AISHAN SHI
ince the Affordable Care Act was signed into law, nearly 20 million individuals who were previously insured have better access to healthcare each year. Additionally, 40 million Americans reach retirement annually, and this number is only projected to increase as the Baby Boomer generation leaves the workforce. These two factors – as well as an overall growing population – result in a drastic increase in demand for healthcare services such that physician supply is predicted to be short by approximately 60,000, one-third of which is for primary care fields.1 Although this area of healthcare is crucial for keeping patients healthy and out of hospitals, only one-third of physicians in the U.S. are PCPs, and they make up only 16% of nearly 30,000 U.S. medical graduates.2 The rest of primary care providers are composed of foreign medical graduates, nurse practitioners, and physician’s assistants. In order to help meet demand and reduce healthcare spending (currently 18% of GDP), new healthcare delivery models have evolved that focus on coordinating care stemming from the primary care field.
Two of the most popular acronyms that have been developed in the healthcare world in recent years are ACO and PCMH. Unlike previous models of healthcare delivery, Accountable Care Organizations (ACOs) aim to cut costs and maximize quality care by creating a single network of hospitals, physicians, insurers, and other medical resources that can coordinate and work together to manage patients’ long-term care. Although insurance models such as Health Management Organizations (HMOs) have been established on similar goals, ACOs claim to be more effective because they incentivize and reimburse for the right treatments rather than more treatments. The traditional fee-for-service (FFS) model is thought to 20
be the cause of excessive diagnostics and care plans, resulting in wasted time, administrative work, and reduced quality of care. ACOs will avoid fostering this sort of behavior by implementing per-member-permonth (PMPM) reimbursements with shared-savings rewards such that physicians in the ACO all profit the savings that result from staying below a targeted spending limit. Yet, ACOs are more than just a method to incentivize healthcare spending reductions. As demand increases and healthcare professionals are expected to take care of more patients over the same number of hours in a day, efficiency in communication and operations leads to saved time, and therefore, is one method to accommodate growing demand. The complementary healthcare delivery model to ACOs is the Primary Care Medical Home (PCMH, also known as Patient Centered Medical Home). Whereas ACOs can be managed primarily as an insurance, hospital, or physician group organization, PCMHs are managed by primary care physicians and focus on preventative care. These are the individual practices and networks that can make up an ACO, which provides the financial framework to make coordinated care possible. Shared goals and processes include effectively and efficiently utilizing electronic medical records (EMRs) to communicate information between healthcare providers; analyzing performance data; providing patients with better access to medical information; and most importantly, improving patient outcomes.3 These areas of performance are measured by the National Committee on Quality Assurance that accredits PCMH programs. Ultimately, the desired result is improved quality of care, better health management, and hence, a decrease in volume of patients requiring more complex procedures that
drive up physician demand. Already, studies have shown that 40% of ACOs’ reduction of healthcare-spending increase is attributed to improved healthcare management that decreases physician demand.1 Nonetheless, the physician shortage cannot only be resolved by employing techniques to hopefully curb demand. The supply side is also experiencing a change in culture that affects physician’s time with patients. Overall, the number of U.S. medical graduates is increasing from year to year by about 30 percent. Additionally, with passing of the Resident Physician Shortage Reduction Act of 2015 (also known colloquially as the Graduate Medical Education or GME Bill), residency positions are projected to increase by 3,000 each year from 2015 to 2019 to compensate for 20 years of stagnant spots available to students.4 These new positions will be allocated across specialties to those with the greatest need first. In spite of these efforts to increase physician supply, the AAMC Center for Workforce Studies finds that young physicians (ages 26-35) work an average of four hours less in 2010 compared to 1980, whereas physicians over 35 worked about the same amount as they did in 1980.1 This disparity may be accounted for by a variety of reasons: 1) resident-hours restrictions were capped to 80 hours in 2011; 2) longer and more intensive education leading up to practicing years results in greater burnout in young physicians; or 3) younger physicians also desire more flexibility in their schedules in order to start families or focus on wellness. Furthermore, fewer hours worked does not translate to fewer patients seen. Quite conversely, physicians now have a much heavier patient-load and must work more efficiently than the physicians before the turn of the century. Unfortunately, the reality remains that fewer work hours hurts the growing physician shortage. However, just as technology is a key player for ACOs and PMCHs, it can also be part of the solution to the flexible work hours that young physicians are seeking. Telemedicine is a growing part of not only hospital practice, but also private practice and consultation. Companies like American Well, HealthTap, and 2nd MD connect patients directly to physicians virtually, through phone apps, kiosks, and computers. Although business-oriented with the goal to make healthcare more accessible and less expensive, these telemedicine companies are also well-suited for young physicians who need time away from the workplace in order to accommodate family, and for older physicians who have retired from the workplace. Furthermore, this business model supplements ACOs and PMCHs in their aim to streamline healthcare delivery and emphasize preventative medicine. Because the virtual meetings hosted by these companies have records delivered beforehand and are
directly contracted with insurance or are subscription based, physician’s time with patients is maximized. Of course, these services are no substitute for in-office visits in many situations, but they do function as another gatekeeper in medicine by limiting excess procedures, taking valuable time, and simultaneously reducing in-office volume while increasing supply. For many years now, physicians, politicians, providers, and patients have cried out about the growing physician shortage. Other healthcare professionals such as physician’s assistants and nurse practitioners have already played an important role in filling the gap in primary care. However, the need for physicians in this area and others still remains. Efforts to meet demand have been made by increasing medical school graduation classes, creating more residency positions, and creating technologies that should (in theory) help make administration processes easier. Yet, as supply remains limited, it becomes necessary to turn to changes in healthcare delivery to decrease demand and increase supply while focusing on improving quality of care through better health management and preventative medicine. References: 1. HIS inc. “The Complexities of Physician Supply and Demand: Projections from 2013 to 2025.” March 2015. 2. UnitedHealth Center for Health Reform and Modernization. “Advancing Primary Care delivery: Practical, Proven, and Scalable Approaches.” September 2014. 3. DeVries, Andrea, et al. “Impact of Medical Homes on Quality, Healthcare Utilization, and Cost.” American Journal of Managed Care. 2012; 18(9): 534:544. 4. AMA Wire. “4 Things Students Should Know About the New GME Bill.” May 2015.
AISHAN SHI Aishan Shi is a first year medical and MBA student at the University of Arizona College of Medicine – Phoenix. Prior to medical school, she graduated from the University of Arizona with bachelor’s degrees in biochemistry, molecular and cellular biology, and English literature. Having grown up in Arizona, she considers herself a native to the state and hopes to continue her future training and practice here as well. In her spare time, she enjoys reading Shakespeare and post-modern literature, hiking, playing piano, and volunteering.
MARICOPA COUNTY MEDICAL SOCIETY
MEDICAL SOCIETY BUSINESS SERVICES
MCMS Board of Directors Meeting Minutes February 16, 2016 | 6 pm Board Members
Adam Brodsky, Ross Goldberg, May Mohty, John Couvaras, Ryan Stratford, Jay Crutchfield, Tanja Gunsberger, Kelly Hsu, Lee Ann Kelley, Marc Lato, John Middaugh, Constantine Moschonas, Anita Murcko, Steve Perlmutter, Pamela McCloskey, and Kimberly Weidenbach were present.
Jay Conyers was present. Dr. Brodsky called the meeting to order at 6:07 pm.
Dr. Brodsky asked Jay to review the old business items on the agenda. Jay provided an overview of the February 4th Beers with Peers event, and the Board discussed how to improve the event next time. Jay also provided brief updates on the pension plan lawsuit, the building space plan, and the upcoming presentation for AHCCCS medical records reviews. Lastly, he updated the Board on the progress of the medical board audit project.
A motion was made to approve the consent agenda, comprising January Board minutes. The motion carried.
Dr. Brodsky Dr. Murcko gave a presentation on committee charges and summarized the committee’s recent meeting. She provided legislative updates on SB1473 (nursing scope of practice), SB1283 (pharmacy database mandate), HB2501 (regulatory board consolidation), SB1443 (posting of non-disciplinary actions on the AMB’s website), and HB2310 (prescribing orders for biosimilars). The board discussed the impact of each of these bills, and Dr. Murcko encouraged the board to all register for the ‘Request to Speak’ system offered through the legislature. Dr. Brodsky encouraged those interested in having access 22
to the portal to send Jay an email for him to create an account for them. Dr. Murcko summarized the committee’s discussion about survey topics, and indicated those recommended for upcoming issues of Round-up. The board discussed the possibility of taking positions on some of the more impactful topics, rather than just summarize survey results and concerns responding physicians have expressed. Dr. Murcko also discussed the committee’s recommendation to organize a Policy Forum in the fall. The suggested format was a panel discussion comprising Senate and House representation, preferably someone from each of the respective health committees, and a representative from the Governor’s Office, ideally the health policy advisor. The board discussed the pros and cons of this format, and the concept of having questions around recent legislative issues as well as ones that may be on the legislative agenda in 2017. Jay agreed to engage House and Senate leadership, as well as the Governor’s office, after the legislative session ends and check on interest and availability.
Dr. Kelley gave a presentation on committee charges and summarized the committee’s recent meeting. She outlined the committee’s recommendation to invite Drs. Rick Averitte and Adele O’Sullivan to be our guest speakers for the event, scheduled for April 28th in the Society’s courtyard. The committee recommended a format similar to last year’s, yet suggested less time for the social hour and more time on the back end for Q&A with the speakers, as well as time to mingle after the presentations. Dr. Kelley also discussed the committee’s recommendations for the Annual Event. The committee suggested the Society have a speaker that can address issues facing physicians today, such as physician burnout and resilience. Some speakers were suggested, both local and nationally, and Jay agreed to reach out to those suggested. The committee recommended that the Society not consider making the event a philanthropic fundraiser, but to consider something for next year. It was proposed that we
Board Minutes consider some smaller concepts to incorporate to raise some money for the event, and designate a charity to support. Lastly, Dr. Kelley communicated the committee’s recommendation that any clinic activity first look to expand efforts already developed by other local partners. Jay agreed to compile a list of local community clinics and healthcare non-profits that may be ideal partners.
Dr. Gunsberger gave a presentation on committee charges and summarized the committee’s recent meeting. She summarized the committee’s recommendations for what should be included in new member packets as well as the idea of developing ‘Welcome to Arizona’ packets for recently licensed physicians in Maricopa County. She also discussed the committee’s recommendation to organize quarterly new member welcome events, and possible distribute them throughout the valley. Dr. Gunsberger suggested that the Board reconsider dues for resident members. The Board discussed last year’s decision to implement a new dues structure whereby residents pay nothing the first year, but $25 each subsequent year. It was suggested that active members have the opportunity to sponsor a resident and cover their membership fee. The board supported this concept and agreed to consider it later in the year. The Board agreed that the Society should consider bringing back the directory, which was printed annually until a few years back. To save on cost, it was recommended that the directory be online and searchable.
Jay discussed with the Board the need to designate delegate to ArMA, and detailed the current members serving in those roles, and their term expiration. The Board discussed the expiring terms for Drs. Brodsky (serving as a one-year fill-in), Howard Fleishon, and Dan Lieberman. A motion was made to nominate Drs. Brodsky and Fleishon for another term. The motion carried. A separate motion was made to nominate Dr. Tanja Gunsberger for the vacant position. The motion carried.
The meeting was adjourned at 7:27 pm.
George Alvin Folk, MD
Alvin George Alan Folk, MD, of Sun Lakes, Arizona, entered into rest on Friday, January 15, 2016. He is the beloved husband of Diane K. Folk, PhD. He was a member of the Maricopa County Medical Society from 1978-2009.
Carolyn Frances Gerster, M.D
Dr. Carolyn Frances Gerster, a loving mother to her sons and a devoted wife, passed away quietly in her sleep during the early morning hours of Thursday, January 28, 2016, at her home in Paradise Valley. Dr. Gerster was a long-time resident of Phoenix, who returned to the Valley to raise a family and build a successful medical practice, specializing in internal medicine and cardiology. She was born January 15, 1928 in San Francisco, the only child of Evelyn and Richard Taylor. Upon her parent’s divorce in the early 1930s, Carolyn moved with her mother to Phoenix, hoping to cure Carolyn’s respiratory problems, and find steady work for her mother. Soon, her health was restored, but as the Great Depression ran its course, one of the lessons it taught was that education increased one’s chances for success. Carolyn finished grade school by 1940 and then graduated from high school in just three years, receiving a scholarship to the University of Oregon to study medicine. Seven years later she had completed her undergraduate degree and medical school, graduating in the summer of 1950 at the age of 22. She interned at Queens Hospital in Honolulu. After serving one-year residencies at hospitals in Santa Barbara and Portland, she joined the United States Army as a Medical Service Officer, attaining the rank of Captain. 24
Carolyn and Dr. Josef Gerster, were married in February of 1958, in Portland, Oregon, and moved back to her childhood home of Phoenix in 1959, where they built a life, started a practice, and raised five sons. She excelled as a physician, and became a member of several professional organizations. She cofounded the Arizona Right to Life Committee, serving over the years as its President and Chairman of the Board. She also served as the Arizona Director to the National Right to Life Committee (NRLC), Vice President, Chairman of the Board, and President. In 2011 she was honored as a Delegate Emeritus. To her family, she will be loved for her devotion to her home, her husband, and her sons. She was selected as Arizona’s Mother of the Year in 1987. She will long be remembered and respected by family, friends and foes. She was greatly saddened by the recent death of her husband Josef, with whom she shared a marriage of nearly 58 years. She is survived by her five sons John (Sue), Eric (Darlene), Kurt (Kristine), Mark, and Karl (Joanne) and ten grandchildren.
Charles Ashley Saffell M.D.
Charles Ashley Saffell, a retired Family Practice Physician and Mesa resident for 40 years, passed away on January 23, 2016 after a short illness. Charles was a beloved husband, father and grandfather, and he always had a hug for everyone, including his patients. Dr Saffell was born in Newport, Arkansas, was raised in Batesville and DeValls Bluff, Arkansas and Memphis Tennessee. His Bachelor of Science degree is from Memphis State University, and he received his Doctor of Medicine, (M.D.) in 1962 from the University of Tennessee Medical Units in Memphis. He met and married his wife, Marion Wilson, in Memphis on June 1,1957. After graduating from medical school, Dr Saffell served as a Flight Surgeon in the US Air Force for a few years, then began his practice in Lakeland, Florida. He then moved his family to Oakridge, Oregon, and in 1975 moved to Mesa where he practiced 28 of his 41 years of
In Memoriam practice, An active birder, Dr Saffell led field trips for Audubon Societies in Florida and Oregon before coming to Arizona, where he led many field trips to the Granite Reef Dam area on the Salt and Verde rivers. He is one of the 8 founding members of Desert Rivers Audubon Society which serves the SE valley. Dr Saffell is survived by son Charles A. (Chuck) Saffell, ll, daughter Leigh O’Hara Saffell, MBA, grandchildren Maren Neill Saffell, and Rachel Anne Saffell, and many others.
Kenneth B. Desser, MD
Dr. Kenneth B. Desser, age 75, passed away on February 17, 2016 in Phoenix. He served as a Captain in the Vietnam War and was the recipient of the Purple Heart, Bronze Star with oak leaf cluster, Valor Device for Heroism, Cross of Gallantry with Silver Star
for bravery and Combat Medical Badge for actions while serving with the first infantry division. He was the Director of the Cardiology Fellowship Program at Banner Good Samaritan Medical Center from 1981 until his passing. While Director, more than 200 fellows graduated from the program and most chose to practice in Arizona. Dr. Desser was a Fellow of the American College of Physicians, American College of Chest Physicians, American College of Cardiology and American Heart Association. He was a Clinical Professor of Medicine at the University Of Arizona College of Medicine and was the first member of the Phoenix Medical School faculty to receive teacher of the year and elective of the year simultaneously from the University of Arizona medical students. Dr. Desser was a senior member of the American Federation for Medical Research and served on the editorial board of the Journal of the American College of Cardiology, American Journal of Cardiology
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In Memoriam and Arizona Medicine. He authored over 300 articles and chapters in textbooks including senior author in the New England Journal of Medicine. Dr. Desser felt that he had the best wife in the whole world, Carmen, and loved every pet he owned with a passion. He is also survived by daughters Brett Desser, Lori Desser Holmes, son-in-law Richard Holmes and grandson Cadence Grey Holmes. Upon reflection, he said “I guess I had an interesting life.”
Herbert Johnson Louis M.D.
Herbert Johnson Louis (Tim) was born April 22, 1928, to Henrietta Johnson and John Jeffry Louis in Evanston, Illinois, and passed away at his home in Paradise Valley, February 16, 2016. He was the great-grandson of Samuel Curtis Johnson, founder of the SC Johnson & Son. He studied at Deerfield Academy in Deerfield, Massachusetts, Williams College in Williamstown, Massachusetts and Northwestern University Medical School in Chicago, Illinois. He married Julie deLescaille, his college sweetheart, in 1950, before beginning his medical residency training, which was completed at Hines Veterans Administration in Chicago (interrupted and enhanced by two years of medical service as an Army Captain under Major George Woodard in France, all capped by a fellowship at 12 different medical orthopedic centers in England. Tim and Julie moved to Phoenix, Arizona in 1961 to begin his professional career in private practice. Shortly after beginning his practice, Tim realized that his true calling was in education. He soon created and chaired the Maricopa County hospital’s orthopedic residency program. The countless children he treated and the 50 residents he trained were a source of tremendous pride. Tim was an active member of the American Academy of Orthopedic Surgery, within which he served on many subcommittees. Career honors included: elected member of the Association of Bone and Joint Surgeons, serving for a time as its 26
President, and for many years he acted as an examiner for the national Orthopedic Board of Surgery. He was integrally involved in creating the Phoenix Children’s Hospital and served on its board since its inception. He was a passionate and active member of The Phoenix Thunderbirds. To all, he was known to have a wry sense of humor and a keen sense for traditional values. He is survived by his wife Julie, his six children: Hank Louis, Peggy Moreland, Clif Louis, Carrie Hulburd, Steve Louis, and Tim Louis, and his 22 grandchildren and 8 great-grandchildren. He took enormous pride in his children, grandchildren and great-grandchildren, nurturing their abilities and passions with vigor. His legacy will live on through them. He will be sorely, lovingly, and respectfully missed.
Bruce Howard Shelton, MD
Bruce Howard Shelton died on Friday, February 12 at age 71. He is survived by his wife of 47 years, Audrey, his daughters Terri Hurvitz (Scott), Laurie Shelton, and Jaclyn Wollheim (Bryan) and 6 granddaughters: Rachel, Sophie and Annie Hurvitz and Macey, Hillary, and Whitney Wollheim. Bruce was born in Brooklyn, New York and raised in Suffern, New York. He was a graduate of Franklin & Marshall College and went on to New York Medical College where he earned his MD in Family Medicine. In 1971 he moved to AZ for his residency where he resided until his death. Bruce became a Homeopathic Physician in 1988. He dedicated the following years in serving the community as a distinguished leader in Homeopathy. He served multiple terms as the President of the Homeopathic Board and was the Medical Director for DesBio Pharmaceuticals. He leaves a tremendous legacy of family love, commitment to his patients, and respect and admiration of all those whose lives he touched. Bruce will be remembered as an amazing husband, father, grandfather, uncle, brother-in-law, doctor, teacher, wine connoisseur, storyteller, chocoholic, and a hero to many.
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MICA posts eleventh consecutive year of dividends. MICAâ€™s history of dividend payments extends well beyond the last eleven years. In fact, since our founding in 1976, MICA has distributed over a half a billion dollars in dividends to its members.
Medical Professional Liability Insurance (602) 956-5276 (800) 352-0402 www.mica-insurance.com Dividends declared for a policy year reflect the Companyâ€™s financial performance. Past performance does not guarantee future dividends.