SAN FRANCISCO MEDICINE J O U R NA L O F T H E S A N F R A N C I S C O M E D I CA L S O C I E T Y
PATIENT MOTIVATION BEYOND COMPLIANCE Tips for the Rushed Physician Motivating Weight Loss Helping Smokers Quit
Plus: Legislative Advocacy Day CMA’s “Humane Shift” on End-of-Life Care Making Primary Care Sexy (Again?)
VOL.88 NO.5 June 2015
IN THIS ISSUE
SAN FRANCISCO MEDICINE June 2015 Volume 88, Number 5
PATIENT MOTIVATION: BEYOND COMPLIANCE FEATURE ARTICLES
10 Motivational Interviewing: Tips for the Rushed Physician Tauheed Zaman, MD
President’s Message Roger S. Eng, MD, MPH, FACR
12 Motivating Smokers to Quit: Tips for Clinicians Mai-khanh Bui-Duy, MD, and Eliseo J. Pérez-Stable, MD
14 Perioperative Smoking Cessation: Our Best Chance to Get You to Quit? Paul Preston, MD, and Ray Liu , MD 16 Motivating for Weight Loss: Resources and Tips Erica Goode, MD
19 Multiple Motivators Needed: Education and Nudging Aren’t Enough for Health Behavioral Change Joyce Frieden
21 Bringing Sexy Back: A Recipe for Sexiness Needed to Revitalize Primary Care in the U.S. J. Nwando Olayiwola, MD, MPH, FAAFP 29 CMS Update: CMS Is Transforming the U.S. Health Care System to Focus on Value, Not Volume Ashby Wolfe, MD, MPP, MPH, and David Saÿen, MBA
32 Medical Community News 34 Classified Ad 34 Upcoming Events
ADVOCACY UPDATES 9
24 Legislative Leadership Day: SFMS Physicians Champion Package of Bills to Improve Public Health and Increase Access to Health Care 25 Advocacy: Take Action! Barbara Rotter
26 Legislative Leadership Day: A Resident’s Perspective Katherine Ort, PGY2 27 San Francisco Legislative Update John Maa, MD
Editorial and Advertising Offices: 1003 A O’Reilly Ave. San Francisco, CA 94129 Phone: (415) 561-0850 Web: www.sfms.org
SFMS Advocacy Activities
MEMBERSHIP MATTERS Activities and Actions of Interest to SFMS Members California Medical Association Removes Opposition to Physician Aid in Dying Bill; SFMS Advocacy Initiates New Discussion on PAD The California Medical Association (CMA) has become the first state medical association in the nation to change its position on the long-debated issue of physician-assisted dying (PAD). SFMS has been a longtime advocate on this difficult topic. Our delegation asked CMA to consider neutrality at least three times in the past fifteen years. The latest SFMS effort was a letter submitted to the CMA board in January 2015 urging a more open consideration, and after much debate the CMA Council on Legislation voted overwhelmingly in favor of neutrality. By removing decades-old organizational policy, CMA has eliminated its historic opposition and is now officially neutral on SB 128 (Monning/Wolk), the End of Life Option Act. CMA’s amendments to SB 128 have been accepted by the authoring senators and are partly based on clinical guidelines/safeguards developed at SFMS. Physicians would be explicitly protected from any sanctions for either participating or declining to participate in PAD.
SFMS to Launch PQRS Resource Center
All Medicare Part B physicians, including those participating in Medicare Accountable Care Organizations and other Centers for Medicare & Medicaid Services Innovation Center models, will need to comply with CMS’s value-based payment (VBP) program by January 2017. SFMS cohosted a value-based payment (VBP) seminar in May. Keynote speakers David Saÿen, CMS Region IX administrator, and Ashby Wolfe, chief medical director of the San Francisco Regional Office, discussed Medicare’s efforts to improve the quality and efficiency of medical care and provided actionable information to assist physician practices with VBP adoption. SFMS will continue to collaborate with CMS to develop additional resources and in-person workshops to assist physicians with VBP transition to avoid the mandated penalties. There will be a recurring PQRS/VBP column in San Francisco Medicine, starting with this issue (p. 29). New resources and events will also be announced via the SFMS website.
UnitedHealthcare to Alter Premium Designation Criteria
UnitedHealthcare (UHC) has altered the criteria for meeting the physician cost-efficiency component of its Premium Designation program. UHC will now designate a physician as “cost efficient” when he or she has met the episodic cost benchmark, even if the physician did not achieve the population cost benchmark. The change impacts physicians in family medicine, internal medicine, pediatrics, ob/gyn, allergy, cardiology, endocrinology, nephrology, neurology, pulmonology, and rheumatology. Surgical specialties are all excluded. 4
Physicians who have questions or concerns with their physician assessment reports or their Premium Designation can contact UHC at (866) 270-5588. SFMS member practices that are unable to obtain answers to their questions or resolve the issue with UnitedHealthcare directly should contact CMA at (916) 551-2865.
Steven M. Thompson Physician Corps Loan Repayment Award Offers Special Application Cycle for Eligible Primary Care Physicians
The Health Professions Education Foundation (HPEF), a division of the Office of Statewide Health Planning and Development, has announced a special application cycle for the Steven M. Thompson Loan Repayment Program award. Applicants for this award could receive up to $105,000 for loan repayments in exchange for a service obligation in California’s medically underserved areas or public mental health system. HPEF will accept applications from May 18 through June 26. Primary care physicians specializing in family medicine, internal medicine, obstetrics and gynecology, and pediatrics are eligible to apply. Please visit http://bit.ly/1A53aYH for more information.
Anthem Blue Cross Announces Changes to Reimbursement Policies and Claims Software
Anthem Blue Cross recently notified physicians of upcoming changes to the insurer’s reimbursement policies and claims editing software, ClaimsXten. The changes will go into effect on July 1, 2015. Along with the notice, Anthem provided a comprehensive grid outlining the new, revised, and existing reimbursement policies and claims editing rules as well as copies of its reimbursement policies. The changes include additions to the types of service Anthem will consider bundled with another procedure and thus will be ineligible for separate reimbursement (Policy CA – 0008). Anthem has also added to the list of CPT codes that will have a frequency edit (Policy CA – 0016), thus setting a limit on the number of units or number of times a code is eligible for reimbursement on a single date of service. A new frequency edit of note is a limit on the preparation of allergen immunotherapy of 120 doses per 365 days. Anthem has clarified to CMA that it will consider payment for more than 120 doses per 365 days if there is a medical reason, and if the additional doses are actually received by the patient and not discarded as pharmaceutical waste. The most significant change is a modification to Anthem’s policy on evaluation and management (E/M) services billed on the same day as a preventive exam (Policy CA – 0026). Effective July 1, 2015, when physicians bill a preventive visit on the same day as a problem-oriented E/M visit, Anthem will only reimburse the problem-oriented E/M visit at 50 percent of the physician’s contracted rate. To address this change, practices have the option of advising patients that a separate appointment is required to address
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the problem-focused issue. However, it will be important for practices to manage patient expectations. When the preventive services appointments are scheduled, staff should inquire with patients about whether they wish to discuss any other health issues with the physician and, if so, advise that a separate appointment will be required due to the plan/insurerâ€™s policy. The practice can then schedule the problem-oriented visit first and schedule the preventive service for a later date. Even if the patient indicates that he or she has no other health issues to discuss with the physician, the scheduler should advise the patient that if other health issues arise, another visit may be required. Physicians are encouraged to review all of the claims editing changes as well as the corresponding detailed payment policies to understand how the changes will affect their individual practices.
June 2015 Volume 88, Number 5 Editor Gordon Fung, MD, PhD Managing Editor Amanda Denz, MA Copy Editor Mary VanClay EDITORIAL BOARD Editor Gordon Fung, MD, PhD Obituarist Erica Goode, MD, MPH Michel Accad, MD Erica Goode, MD, MPH Stephen Askin, MD Shieva Khayam-Bashi, MD Payal Bhandari, MD Arthur Lyons, MD Toni Brayer, MD John Maa, MD Chunbo Cai, MD David Pating, MD Linda Hawes Clever, MD SFMS OFFICERS President Roger S. Eng, MD President-Elect Richard A. Podolin, MD Secretary Kimberly L. Newell, MD Treasurer Man-Kit Leung, MD Immediate Past President Lawrence Cheung, MD SFMS STAFF Executive Director and CEO Mary Lou Licwinko, JD, MHSA Associate Executive Director, Public Health and Education Steve Heilig, MPH Associate Executive Director, Membership and Marketing Jessica Kuo, MBA Director of Administration Posi Lyon Membership Coordinator Ariel Young
BOARD OF DIRECTORS Term: Jan 2015-Dec 2017 Steven H. Fugaro, MD Brian Grady, MD John Maa, MD Todd A. May, MD Stephanie Oltmann, MD William T. Prey, MD Michael C. Schrader, MD
Term: Jan 2013-Dec 2015 Charles E. Binkley, MD Gary L. Chan, MD Katherine E. Herz, MD David R. Pating, MD Cynthia A. Point, MD Lisa W. Tang, MD Joseph Woo, MD
Term: Jan 2014-Dec 2016 William J. Black, MD Benjamin C.K. Lau, MD Ingrid T. Lim, MD Keith E. Loring, MD Ryan Padrez, MD Rachel H.C. Shu, MD Paul J. Turek, MD CMA Trustee Shannon Udovic-Constant, MD AMA Delegate Robert J. Margolin, MD AMA Alternate Gordon L. Fung, MD, PhD
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MOTIVATING SMOKERS TO QUIT Tips for Clinicians Mai-khanh Bui-Duy, MD, and Eliseo J. Pérez-Stable, MD Among the many controversies within medicine, recommending smoking cessation to patients seems as though it would be an easy no-brainer. An
estimated 3.6 million Californians continue to smoke despite the fact that tobacco use accounts for approximately 90 percent of all lung cancer and COPD deaths in the U.S.1 Cigarette smoke contains more than 7,000 chemicals, sixty-nine of which are known to cause cancer,2 and tobacco use directly contributes to cardiovascular disease.3 Despite these facts, many of us in our clinical practices are hard pressed to provide routine tobacco cessation counseling for our patients. In one study using primary care office visit data from the National Ambulatory Medical Care Survey of 2001–2009, at least 50 percent of smokers with chronic smoking-sensitive diseases received no counseling whatsoever.4 Considering that more than 70 percent of smokers visit a physician each year,5 there are numerous opportunities to counsel patients in urgent care, or a familiar primary care patient with chronic disease, or an ambulatory patient established in a specialty practice. In addition, there are 6.5 million smokers hospitalized annually whose attention is held captive during hospitalization in their mandatory smoke-free hospital.6 Even for the patient who only interacts with the health care system in the form of intermittent emergency room visits, there remains an opportunity to exert influence as a clinician on why tobacco cessation is so important for patients. So why hasn’t tobacco cessation counseling consistently found its way into our practice, and how can we change this?
As a clinician in practice, you are busy. Tobacco cessation is just one of many issues to address for a full panel of patients. And yet, despite physicians’ fears7 about how long it can take to address tobacco use, there is strong evidence that even minimal interventions of three minutes do increase overall abstinence rates.8 The evidence also shows that the longer and more frequent the counseling, the more effective the response. If you have time to talk with your patient for ten minutes to deliver high-intensity counseling, great! But if not, even as little as three minutes can make a difference to your patient. Checking in, at each visit, about tobacco use and cessation options with your patients who smoke provides ongoing reminders that you consider this an important problem.
Lack of Skill and/or Lack of Confidence
Promoting any behavior change presents a challenge, and while motivational interviewing is frequently cited as a tool with which to engender such change, it has not tradition12
ally been a part of medical school curricula. Motivational interviewing can be particularly helpful for the majority of smoking patients who are not quite ready to quit—with 40 percent not planning on quitting in the next six months and another 40 percent having no plans to quit in the next month. Motivational interviewing includes four general approaches: 1) expressing empathy through open-ended questions regarding the importance of quitting, 2) highlighting discrepancies between patients’ stated goals and values and their current behaviors, 3) backing off and using reflection if the patient is resistant, and 4) supporting self-efficacy by building on past success attempts or soliciting patient-generated next steps. Although motivational interviewing is a distinct skill set that can be taught, practiced, and reinforced, it may take time to train yourself and your staff to the point where you feel comfortable. In the meantime, take advantage of the brief intervention of the 5As, an evidence-based approach to providing tobacco cessation counseling:
Ask. Ask about tobacco use for every patient and every encounter. “How often do you smoke?”
Advise. Use strong and personalized statements to advise tobacco cessation. “As your doctor, I want you to know that quitting is the single most important thing you can do to protect your health as well as your family’s health.” Assess. Assess willingness to quit at this time. “On a scale of 1 to 10, how ready are you to quit smoking?”
Assist. For patients who are willing to quit, offer assistance with medication therapy and/or provide or refer for counseling treatment. For patients who are not willing to quit, use motivational interviewing strategies to harness self-engendered change. “Here is a list of support groups in our area, if you feel you need more support to help you quit.” “Call the California Smokers Helpline at 1-800-NO-BUTTS for assistance to quit smoking.” “On a scale of 1 to 10, how important is it to you to quit smoking?”
Arrange. Arrange for follow-up to check in on the success of any quit attempt or ask permission to arrange follow-up to further discuss tobacco use at a future visit. “Let’s set a follow-up appointment in two weeks to see how you are doing off tobacco.” “Let’s talk more about quitting tobacco at our next visit.” Many smokers do not plan a quit date but instead quit smoking as a result of an epiphany or a qualitative change. This is sup-
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ported by ongoing motivation and steady and supportive information on the benefits of cessation and the risks of smoking.
Addressing Both Behavioral and Biological Aspects of Tobacco Dependence
Tobacco dependence is a chronic disease, and physicians can apply similar perspectives when counseling patients who are on treatment for uncontrolled chronic diseases such as hypertension or diabetes. Given nicotine’s highly addictive nature, patients struggle not only with the behavioral aspects of tobacco cessation but also with the biological dependence. Of the estimated 44 percent of smokers who try to quit each year, about 5 percent are successful; this means that tobacco cessation requires more than just one serious attempt to quit. In a Wisconsin survey, close to 70 percent of smokers reported one to five serious quit attempts, with 8 percent trying between six and ten times and 3 percent attempting more than ten times.9 Although most smokers choose to go “cold turkey” on their own strategy, the evidence shows that patients who use counseling services (self-help materials, a quit line, or individual counseling) are anywhere from 1.2 to 1.7 times more likely to quit smoking compared with those who use no counseling; and patients who use both medication and counseling are 1.7 times more likely to quit compared with those who use counseling alone.9 Nicotine replacement therapy (NRT), recommended as first-line treatment for tobacco dependence, includes the longacting nicotine patch as well as the short-acting nicotine gum, lozenge, nasal spray, or inhaler. Tobacco treatment specialists will provide daily long-acting patch use for patients interested in NRT while simultaneously providing short-term NRT support to address cravings throughout the day. In addition, varenicline and bupropion SR are FDA-approved medications also recommended as first-line treatment options for tobacco dependence. The combination of bupropion SR with the nicotine patch was found to have abstinence rates 2.5 times higher than a placebo.9 In short, cold turkey is good, proactive counseling or medication use are better, and combination therapy is best to maximize the success of a quit attempt. California-based physicians are fortunate to be able to refer their patients to the free, state-funded California Smokers Helpline, operated by Moores U.C. San Diego Cancer Center. In operation now for more than twenty years, the Helpline—home of the 1-800-NO-BUTTS number—offers tobacco counseling services in English, Spanish, Cantonese, Mandarin, Korean, and Vietnamese, which are the six most common languages spoken in California. The University of California system, through the U.C. Tobacco Cessation Network, has now paired with the Helpline in an exciting project to develop a two-way e-referral system among each of the five U.C. medical centers and the Helpline. U.C. clinicians can now order an e-referral through their electronic medical record (EMR) to the Helpline when assisting their patients with cessation services, and the Helpline will proactively call patients in the preferred language within one to two business days. The Helpline will send the ordering clinician a brief update via the EMR when they provide counseling, self-help mateWWW.SFMS.ORG
rials, or nicotine replacement therapy for eligible patients. There are efforts now underway to bring this two-way e-referral to community clinic partners; however, all providers in California may access the Helpline’s website at www.nobutts.org and click on the “Web Based Referral” tab to have the Helpline contact individual patients for counseling. Given that tobacco use remains the leading preventable cause of death in the United States and that our patients’ tobacco use impacts their health through all aspects of the health care system, it is crucial for us to take those three minutes with every smoker, at every encounter, to: ask and advise on tobacco use, assess their willingness to quit with assistance if desired, and arrange for them to follow up on their quit attempt. Mai-khanh Bui-Duy, MD, is assistant professor of medicine and Eliseo J. Pérez-Stable, MD, is professor of medicine. Both are with the Division of General Internal Medicine, Department of Medicine, at the University of California, San Francisco.
References 1. Centers for Disease Control and Prevention. National Center for Chronic Disease Prevention and Health Promotion. Tobacco Information and Prevention Source (TIPS). Tobacco Use in the United States. January 27, 2004. 2. U.S. Department of Health and Human Services. How Tobacco Smoke Causes Disease: The Biology and Behavioral Basis for Smoking-Attributable Disease: A Report of the Surgeon General, 2010. 3. U.S. Department of Health and Human Services. Health Consequences of Smoking: A Report of the Surgeon General, 2004. 4. Nelson KE et al. Primary care physician smoking screening and counseling for patients with chronic disease. Preventive Medicine. 2015. 71; 77-82. 5. Jamal A et al. Tobacco use screening and counseling during physician office visits among adults—National Ambulatory Medical Care Surgery and National Health Interview Survey, United States, 2005–2009. Morbidity and Mortality Weekly Report, 61(02):38-45. Available at www.cdc.gov/mmwr/preview/ mmwrhtml/su6102a7.htm (last accessed 6 May 2015). 6. Rigotti NA et al. The use of nicotine-replacement therapy by hospitalized smokers. Am J Prev Med. 1999 Nov; 17(4);255-9. 7. Champassak SL et al. A qualitative assessment of provider perspective on smoking cessation counseling. Journal of Evaluation in Clinical Practice. 20 (2014);281-287. 8. Agency for Healthcare Research and Quality, Rockville, MD. Treating Tobacco Use and Dependence. April 2013. http:// www.ahrq.gov/professionals/clinicians-providers/guidelinesrecommendations/tobacco/clinicians/update/index.html. 9. Center for Tobacco Research and Intervention, University of Wisconsin Medical School. How smokers are quitting: Action Paper Number 3. January 2003. Available at http://www.ctri. wisc.edu/Publications/publications/HowSmokersQuit.pdf. Accessed May 6, 2015.
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PERIOPERATIVE SMOKING CESSATION Our Best Chance to Get You to Quit? Paul Preston, MD, and Raymond Liu , MD In our daily work as surgeons, anesthesiologists, internists, or anyone who might refer a patient for surgery, it is very common to come across a patient who ad-
mits to smoking cigarettes. At present, 11 percent of adults in San Francisco are smokers.1 If asked, all these folks will admit they know smoking is bad for them, but it’s hard to quit. It is extremely tempting to move on with anesthesia and surgery. We can probably get them through this, we’ve already failed to get them to stop, didn’t I hear somewhere that stopping smoking might make things worse? Besides, this is a lot of extra work and I already am behind with my surgical, anesthesia, or clinic responsibilities. Two major facts should make us reconsider this approach. First, the data are clear that smoking cessation of any duration reduces the cost and complications from surgery, with longer cessation being better. Less well appreciated, the surgical event is perhaps the most powerful nudge we have to get smokers who want to quit (and this is most of them!) to actually stop smoking long term. Recent studies show that even basic perioperative interventions, nicotine replacement plus brief counseling, can result in 25 percent quit rates one year after surgery.2,3 Major cardiac surgery can result in a 55 percent quit rate.4 This is always the single most valuable medical intervention for patients who smoke. To stir the pot, we’ve compiled some common myths about perioperative smoking cessation that need to be addressed. Please read on—how many of these have you heard (or said yourself)?
Patients don’t want to hear more about smoking cessation before a procedure.
Actually, they do. While most know the general hazards of smoking, they do not appreciate the increased risks of surgical complications or failure. Nobody wants a sermon, but the data and options for quitting (long term or just for a bit) are very well received. Of note, patients particularly value hearing this from their surgeon. This is not to discount the importance of referring MD or anesthesia, but is a consistent theme we should be aware of.
We’re already doing everything we can.
We all work hard to get patients to stop smoking in San Francisco. Kaiser Permanente has targeted this for years. Yet when surveyed, fewer than half of our smokers who had surgery remembered any conversation about quitting for surgery, and only 4 to 8 percent had filled a nicotine replacement prescription! Maybe we need to do more? 14
Brief smoking cessation increases complications, and my patient needs surgery soon. This is a persistent myth, so please read the referenced editorial by Drs. Shi and Warner. One study at one time showed an insignificant trend toward increased respiratory complications among people who had just quit smoking. While a large body of later evidence refutes this risk of increased complications, the initial data have been widely misinterpreted, indeed almost used as an excuse, to free providers from perioperative smoking cessation work. Even twelve to twenty-four hours of smoking cessation allow carbon monoxide clearance and better oxygenation. Longer cessation is clearly better, but shorter is never bad.
We’ve already failed; why try again? They just don’t want to quit.
A tiny minority of smokers are happy with their habit. Most smokers are addicted, embarrassed at the fact, and looking for a reason to quit. In one year (2008), 46 percent of Kaiser members who smoke tried to quit. National data show that almost seven of ten smokers want to quit.6 Short of a massive heart attack, nothing seems as powerful as a surgical event in getting folks to quit. The bigger the operation, the more powerful the effect, but even a basic program can reasonably produce a 25 percent one-year quit rate.
The damage is done. They already have CAD, COPD, etc. It’s just too late to quit.
A study of patients from the American College of Surgeons NSQIP database strongly refutes this. With more than 600,000 patients and 125,000 active smokers, continued smoking caused harm over and above the comorbities already caused by smoking.7 Even in patients with cancer directly or indirectly related to smoking, there is a significant increase in survival if the patient can stop smoking at the time of diagnosis and surgery.8 This is notable even in relatively distant tumors such as colorectal cancer.9 This may be a gift of quality time for some patients.
OK, I’m convinced, but where will I find the time and who will own this?
We can’t argue that we’re already overbooked; that is plainly true. The most effective perioperative smoking cessation involves brief but honest advice and referral from all involved physicians, the addition of nicotine replacement and other smoking cessation aids, and follow-up counseling. Key times for physician advice on smoking cessation include the initial referral to a surgeon, the conversation in the surgeon’s office, anesthesia preop processes, and during admission and
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MOTIVATING FOR WEIGHT LOSS Resources and Tips Erica Goode, MD What resources can you use to guide overweight and/or obese patients toward effective, sustained weight loss? Aside from the entrenched (due to serious psy-
chological issues) or those with medical conditions requiring steroids, antipsychotics, or other medications that almost surely promote weight gain, the issue comes down to effective, longterm habit changes. Before you begin efficiently engaging an individual in this seemingly daunting task, especially for those whose weight has begun in childhood, you need to know the following (even if your ultimate solution with that patient may be referral to bariatric surgery). I will include a section on pre- and post-bariatric surgery, criteria for reimbursable referral, and which program and type of surgery to recommend. Even if surgery is the ultimate solution, you should urge that patient to work toward 5 percent weight loss prior to surgery (all good programs will require this) and to begin planning new ways to eat, exercise more effectively, and practice good habits each day. Habits are what this comes down to. Two excellent recent books on the topic can provide you with a questionnaire to help patients determine which type of person they are and how best to make life easier and more comfortable via these changes toward “life, liberty and the pursuit of happiness.” Of note: Few of us are fully satisfied with our own mastery of daily habits, so this may be of use to you as well. (Doctor, heal thyself.) Over the years, with patients who have lost significant weight, I ask at each visit, “What has become easier?” The answers: breathing, moving, making love, walking without knee or foot pain, dancing, gardening, swimming, feeling better about themselves. A few women have resented (transiently) being hit on, noting, “I was there all along! Why didn’t he like me for who I am?” A few others have complained about changes in relationships, since the boyfriend or husband is now jealous of male acquaintances that he formerly felt were not a threat. (But this is a relationship worth examining anyway.) In contrast, it is important to ask people initially what they think will improve once they lose the weight, to underscore the positive improvements. Please, always remember how difficult habit changes can be; applaud people for ongoing losses, and keep learning about newer resources. Better yet, start an online newsletter to send updated messages. (Check Payal Bhandari, MD’s website as an example.) Please also remind them that not only are cardiovascular, diabetic, and lower extremity joint risks increased by doing nothing; pregnancy is more difficult, mobility if raising children is harder, and 25 percent of U.S. adults now are known to have fatty livers unrelated to alcohol (NAFLD). The 2 to 3 percent of these who have nonalcoholic steatohepatitis can progress to advanced fibrosis and hepatoma.2 16
A final concern for those with BMI over 30 and elevated LDL cholesterol, triglycerides, BP, and FBS, is a 22.5 percent faster decline in cognitive skills relative to those of normal weight absent these risk factors.3 The two recent books on habit evaluation and changes, referred to earlier, are: The Power of Habit, Charles Duhigg, Random House, 2014. I found the chapters “The Craving Brain” and “The Neurology of Free Will” (that old topic from philosophy courses), and an addendum under “Afterword” regarding weight loss, to be especially useful. Duhig provides many scientific examples of neurobiology studies regarding cue/behavior/reward habit formation and methods of taking the unproductive behavior out of the loop. He also gives many examples of creepy data gathering by industries to “make” us want to use their products. The second book, Better Than Before: Mastering the Habits of Our Everyday Lives, by Gretchen Rubin, can assist you in providing a list to patients of four ways in which we, as humans, approach “life’s requirements.” Using her categories, these are: Upholders, Questioners, Obligers, and Rebels. Obligers are common; these folks find it easy to meet external obligations but often fail to meet their internal expectations. (I am one of these; everything gets done, except my slowly evolving “cure” for the pack-rat habit). These people often say they learned to eat “that way” as children; or that they can’t (won’t, don’t have time to) cook for themselves. They are prime candidates for using a Fitbit for exercise; challenging a friend to walk with them x times/week; giving themselves small nonfood gifts at week’s end for staying on track.1 Questioners are also very common: They resist outer expectations but respond quickly to inner ones. This is where you, the physician, can convince your patient with facts, incontrovertible truths, and clear information that should be laced with benefits. Example: When patients are struggling to keep on task with taxes, you can state that with a difficult mental task, they burn almost no calories, but both blood sugar and insulin levels fluctuate, which creates a false need for food. Ask him/her to stop for a cup of tea, a coffee, or club soda with bitters and lime, but not to be fooled into thinking food is needed. If necessary, a bowl of raw vegetables may help. Going for a walk partway through or a making quick social call to a friend might also help. Rebels aren’t that common. But they are tough since they are not habituated into responding to either external or internal expectations. (Think two-year-old children.) These folks may respond to the “Do you want to clean up your life now, or later?” argument, or not. (I have seen a batch of these folks in my practice; one was a young woman engineer who continued to argue with me—insisting that foods had more calories than I had told her and
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that I caused her to continue to weigh too much—even knowing that I was running late to give a talk to the residents. I left the room; she left the practice.) Upholders are the rare, delayed-gratification people; they do whatever they must to make life more pleasant, even such boring tasks as income tax management months before the deadline or planning a PowerPoint and doing it well in advance. (My beloved husband is one of these; there are many funny stories about these sterling behaviors that he finds effortless.) Once your patient, and you, decide which category best fits, you can urge the patient to decide what he or she will do to provide the needed changes, with perhaps one new shift per month. I would suggest arming them with this Personal Profile list, with examples. Schedule a second visit in a month; be sure staff notifies you if this is canceled. Also, I would urge at least one individual visit (with spouse or significant other) to a nutritionist with BS, MPH certification, or a registered dietitian; and a visit to some pool, gym, walking path, tennis court, reggae class—again with that person—to develop a plan for activity. In former groups of mine, the patients on their own chose to begin inline skating weekly; another group began a tap dance class. Guidance from you or others is essential. Weight loss, to be sustained, requires that it should proceed at about 1 to 1-1/2 pounds per week (except for the first week or two, with excess fluid losses when sodium and carbohydrate intake is lower). This will avoid cardiac arrhythmias and triggering of excessive YY protein/neuropeptide Y shifts. Stringent dieting almost always translates into major binges after the person has lost significant weight, and almost invariably results in full regaining of weight and then some. Added to this (and confirmed in calorie balance records of patients keeping careful logs) is a newly discovered problem with serious fasting: Brown fat converts to white, energy-storing fat; which triggers calorie conservation and lowers heat loss from this new storage-based fat. Future weight loss is more difficult the longer the severe fast continues.4 And you need to decide whether a screening evaluation referral to a cardiologist or other specialist might be needed. (Initial vital signs and labs, plus questions regarding possible sleep apnea, will guide you.) I have urged many patients into water-walking at the shallow end of a pool, if they have significant knee or foot issues.
For nutrition counseling: The outpatient hospital nutrition department where you admit patients is a good place to start. If your patient is a military veteran, the Nutrition Services at the VAH are excellent. The American Dietetic Association website can steer you to registered dietitians in the Bay Area. IHH (at CPMC and adjacent to Marin General Hospital) telephone listings are available; you can begin by calling the San Francisco Institute for Health and Healing at (415) 600-3503. To motivate patients: A plan with a collaborator is extremely
helpful, whether it’s a spouse, best friend, coworker who also wishes to lose weight, someone to whom he/she is accountable. Urge your patient to make this very specific, including a contract regarding frequency, duration, details. (Two former patients are an example: They decided to walk frequently enough to “burn off” X calories, which they had decided would equal a shared giant pizza, their reward for doing all those weeks of walking, losWWW.SFMS.ORG
ing pounds, and controlling intake. When they reached that point, they liked how they felt and looked and decided instead on a large latte each, as they walked further. Both continued doing well, collaboratively. Before your patient leaves you at that follow-up visit, have him/her commit to the plan, sign it, and state that you will keep a copy in the chart (not necessarily as an EMR document). Upholders will manage without the external supports; many Obligers and Questioners can learn to move toward Upholder status, if they recognize pitfall patterns and become annoyed enough with themselves. Recent studies of group programs for weight loss have confirmed that Weight Watchers and Jenny Craig have the best data for long-term weight management . . . if patients continue to attend groups with some frequency. Other groups can be helpful as well, such as the HOW program; but the latter can become rather draconian and shaming, which fails to motivate, over time. After all, the goal is improved happiness, comfort, and some level of self-satisfaction at achieving one’s goals. A fairly new program in the wider Bay Area, JumpStart, is excellent; it was developed by two physicians, has a good staff of nutritionists and counselors, and includes a good follow-up plan. ShapeDown for children, begun twenty-five years ago by Laurel Mellin at UCSF’s Family and Community Medicine Department, has been excellent. It is now under different management, however, and I am not familiar with numbers of children being helped. Higher-risk children are those in schools with no upgrade to their physical education programs; with less improvement in school lunches than advisable; and those of divorced or singleparent families, due to time constraints regarding cooking and access to after-school programs. For pediatricians, and one’s own children, knowing about school programs is important to be the best parent and physician. Feeding patterns in the home are enormous motivators to future habits in adolescents and adults.5
Erica Goode, MD, MPH, is board-certified in internal medicine. She practices general medicine with an emphasis on nutrition. Dr. Goode is an Associate Clinical Professor at UCSF. Before getting her medical degree, she worked as a public-health nutritionist and wrote a weekly nutrition column for the Washington Post. Dr. Goode is a longtime member of the SFMS and of the San Francisco Medicine editorial board.
References 1. Omisten-Long. Habits, Not Diets. 2. Report of the SEER-Medicare database; Zobair Younossi, MD, 5,748 U.S. Hepatocellular Carcinoma Patients; Surveillance, Epidemiology, and End Results database, as reported to the European Association for the Study of the Liver (EASL) International Liver Congress, April 24, 2015, Vienna. 3. Focus on Healthy Aging, V14 G, p. 6, Icahn School of Medicine, Mt. Sinai, NY, April 2015. 4. Yang, Xiao-yong. Cell. Research conducted at Yale School of Medicine, Dept. of Comparative Medicine and Physiology. October 19, 2014. 5. Journal of Nutrition Education, multiple issues. JUNE 2015 SAN FRANCISCO MEDICINE
PRIMARY CARE PERSPECTIVE J. Nwando Olayiwola, MD, MPH, FAAFP
Bringing Sexy Back A Recipe for Sexiness Needed to Revitalize Primary Care in the U.S. Have you heard the one about the primary care physician hanging up on the cardiologist in fury? Well, it almost happened, very recently, when a cardiologist reminded this primary care physician that primary care is no longer sexy. Follow along and this will all make sense. . . . I hope that this piece will convince you that not only has primary care lost its sex appeal but that we desperately need to “bring sexy back” for the future of the foundation of our health care system. I recently had a great conversation with a young budding cardiologist friend of mine, who called me to get some mentoring on her career path as she pursues her training in a prestigious cardiology fellowship. She is in the first year of her fellowship and has done a few important cardiology rotations, but she found herself a little bit bored during some of them. For example, when she did her cardiac catheterization rotation, she found it fascinating but said, “I cannot imaging focusing on the narrowest arteries all day.” Then she did her “prevention” rotation, which, per her peers, is kind of the “blow-off rotation.” What she experienced surprised her—she found herself very much in love with the prevention cardiology rotation and realized that in this area, she could make a huge difference in improving the health of populations, eliminating disparities in cardiovascular disease and building a culture of wellness. As she spoke, she was illuminating the realm of possibilities in prevention: employee wellness, advocacy, school health, outreach, medical management, partnerships, policy. . . . I was excited and happy to hear the exuberance in her voice until she said this: “When I told my colleagues and mentors, they said, ‘Well, if you are going to focus on prevention, you might as well have been just a primary care doctor.’” My initial reaction was not unexpected, as a primary care physician and the associate director of the prestigious Center for Excellence in Primary Care (CEPC) at the University of California at San Francisco (UCSF), with a focus on transforming primary care delivery and thereby making it a more viable medical field. I was insulted and disappointed. She didn’t even realize how loaded her comments were. I was reminded, in that conversation, once again, that primary care is no longer sexy. But I have heard such comments so many times, even since my days in medical school at Ohio State University, where approximately 60 percent of my classmates went into primary care residencies, which is remarkable: “You are way too smart to go into family medicine,” or “You are going to be so bored in primary care,” or “You are going to be a jack of all trades, master of none,” or “You are going to be poor in primary care.” Over time, I have found that none of these panned out—I am not too smart for primary care and in fact, I often feel that I am not smart enough WWW.SFMS.ORG
to manage some of the very complicated patients I have seen in all of the safety-net settings I have worked in, with a plethora of chronic diseases, behavioral health issues, and socioeconomic challenges that impede their ability to manage their health in the midst of uphill battles against social determinants of health destined to keep them in crisis. I have definitely not been bored in primary care. I am not a jack of all trades. Finally, I am not poor! So why did my friend’s comment irk me? Over the years, we have seen a disturbing trend away from primary care and alarming projections of a physician workforce shortage of 40,000 doctors by 2020. As the demand for primary care increases with an aging patient population, aging physician workforce, projected demands by newly insured patients under the Affordable Care Act, and other factors, the supply of physicians dedicated to the core primary care specialty areas (family medicine, general internal medicine, and pediatrics) is decreasing. I experienced this challenge firsthand as the former chief medical officer of a large federally qualified health center system. The recruitment challenge was untenable. The majority of physicians who turned over did so within the first two years of employment, leading to more frustrated physicians. We were constantly competing with other health care organizations for the “top recruits,” but the pipeline was more like a drop than a gush. It was a vicious cycle. Realities like this one have led to the widely publicized “primary care crisis,” which in itself has spun primary care in a negative light. After all, who wants to go into a field that is in “crisis”? “Crisis” does not resonate with the glory days of primary care. As graduates of primary care residency programs enter a field that they are told is in crisis, it truly becomes a self-fulfilling prophecy. “Crisis,” therefore, is antithetical to “sexy.” What happened to the robust growth in physician capacity that we saw in the 1960s and 1970s that upheld that image of the heroic primary care physician? A 1994 report by the Council on Graduate Medical Education (COGME) predicted a large surplus of specialist physicians of 80,000 by 2000 and 120,000 by 2020. In response to this, increasing numbers of medical students selected careers in primary care specialties as opposed to nonprimary care. I daresay that because it offered balance, marketability, and job security, there was a window in which primary care was indeed sexy. In 2003, COGME issued another report using a slightly different methodology that projected the opposite, an actual shortage of 85,000 physicians, mostly spe-
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Primary Care Perspective Continued from the previous page . . . cialists, by 2020. Numerous changes in federal support and financing of residency training, medical education, and so forth ensued. A subsequent 2005 physician supply analysis by the Health Resources Services Administration reported that approximately one-third of all active physicians under the age of 75 were in the primary care specialties, and two-thirds were in the nonprimary care specialties, and this trend has continued over the years. The 2013 National Residency Matching Program data shows very modest increases in primary care entry, and not nearly enough to move from a physician workforce that is 32 percent primary care physician to the 40 percent that is being called for to meet the current demand. With primary care at the foundation of the health care system, we cannot afford for it to fail, nor can we let it drift into the shadows. To further illustrate that primary care is no longer sexy, it is important to look at perspectives of medical students as they choose careers. A 2010 study by Miriam Shapiro and Alice Fornari at the Albert Einstein School of Medicine, published in in the Einstein Journal of Biology and Medicine, looked at factors influencing primary care residency selection by fourthyear medical students in an urban, private medical school. Of all the factors examined, the one with the strongest positive and negative influence on residency choice was the clerkship experience. Fifty-three percent of the respondents reported that they were either told or directly overheard negative comments about primary care careers at least five times during their clinical clerkships. When questioned more specifically about why family medicine was not pursued, the reasons cited most often were “broad focus, lack of prestige, and stereotype of family medicine as a nonacademic field” . . . aka . . . not sexy . . . at all . . . to the future of our practicing physician workforce. Couple the derogatory comments with the public cry of a field in crisis and it makes perfect sense why medical students are not feeling this career choice initially, or that they defect from it after some time. In fact, the Robert Graham Center for Policy Studies in Primary Care and Family Medicine published a 2013 study showing that “the amount of NIH research funding has a direct and inverse correlation with the number of medical students who choose family medicine and the size of family medicine faculty at a medical school.” Between 2006 and 2010, major family medicine research departments received less than one-half of one percent of the $57.6 billion NIH research grant pool. Additionally, of the more than 7,000 physicians who completed a study done on burnout by Shanafelt et al, published in the Archives of Internal Medicine in 2012, physicians were found to have significantly more symptoms of burnout and more dissatisfaction with work-life balance than other U.S. professionals. Family physicians, general internists, and emergency medicine physicians had the highest rates of burnout and were noted to be at highest risk. The more I think about the doom and gloom that lurks over the primary care conversation, partly by reality, partly by perception, and partly by semantics, the more I think about how pop culture can offer a solution. Now, we don’t historically connect pop and hip-hop music with medicine, but it seems 22
that the situation calls for an infusion. As Justin Timberlake and Timbaland popularized through their catchy worldwide 2006 hit, we need to “Bring Sexy Back” to primary care. How can we reshape the appeal of primary care from a set of specialties that few want to pursue into specialties that many want to pursue? Dictionary.com defines “sexy,” in one of its forms, as “excitingly appealing; glamorous.” Here are some ingredients for a recipe for sexiness that I believe will revitalize and bring glamor to primary care, making it a desirable set of specialty areas for medical students, professionally rewarding for physicians, and ultimately, enjoyable and life-improving for patients.
“Bringing Sexy Back” Recipe
2 cups Crisis Reframing | Reframe the primary care “crisis” as a primary care “opportunity.”
2 cups Burnout Reduction | Restore the joys of practicing in primary care specialties by optimizing physician wellness, performance, and advancement opportunities.
2 cups Energizing the Base | Bolster the energy of the
primary care pipeline through grassroots efforts targeted at medical students, medical school curricula, and resident training, supporting the efforts of organizations like Primary Care Progress. Enhance performance of primary care residency teaching clinics.
2 cups Optimize Delivery | Maximize the outputs and po-
tential of the delivery care team.
2 cups Reimbursement Changes | Reward primary care providers for the unpaid components of their work. Minimize the payment gaps between specialties. 2 cups Research Capacity Building | Develop and ex-
pand academic and other primary care-based research funding and capacity.
2 cups Semantics Caution | Be thoughtful in the use of language and avoid terminology that juxtaposes “primary care” and “specialties.” Use of “primary care specialties” and “subspecialties” is more reflective of investments in training.
2 cups Workforce Investments | Support modifications to GME funding, including expansions of primary care residency financing, incentives, and programs; offset debt burden for physicians entering primary care specialties.
By mixing all of the above and realizing that this will require a Crock-Pot to cook, and not a wok, we can bring sexy back to primary care. So back to my cardiologist friend . . . would my telling her that primary care is special and that her colleagues were wrong to bash it have made a difference on that call? Would hanging up in fury have led her to an epiphany about their misconceptions regarding primary care? Probably not. But would making primary care specialties more glamorous, excitingly appealing, and sexy by showcasing the opportunities in the
SAN FRANCISCO MEDICINE JUNE 2015 WWW.SFMS.ORG
LEGISLATIVE LEADERSHIP DAY SFMS Physicians Champion Package of Bills to Improve Public Health and Increase Access to Health Care
SFMS delegation with Assemblymember David Chiu A dedicated group of SFMS physicians, residents, and practice staff joined more than 300 of their colleagues on April 14 to bring the voice of medicine to legislators. During CMA’s forty-first annual Legislative
Leadership Conference, SFMS members had the opportunity to lobby legislative leaders as champions for medicine and their patients. Among the issues discussed were Medi-Cal reimbursement rates, vaccination, and tobacco-related legislation.
Here is a sampling of SFMS-sponsored bills:
SB 243 (Hernandez) and AB 366 (Bonta) would dramatically improve access to care for Medi-Cal beneficiaries by repealing recent cuts to Medi-Cal provider reimbursement rates; increasing reimbursement rates for most outpatient providers to Medicare levels, for both fee-for-service and Medi-Cal managed care providers; and increasing hospital Medi-Cal rates on a one-time basis, requiring annual increases thereafter. SB 277 (Pan and Allen) would eliminate the personal belief exemption option from school immunization law, except for families who homeschool, and require the governing board of a school district to notify parents or guardians of school immunization rates. The goal is to reduce the incidence of vaccinepreventable diseases, protect those who cannot receive vaccine due to age or medical condition, and protect those at greater 24
risk of severe complications if they do become infected and ill. SFMS applauds Senator Mark Leno and Assemblymember David Chiu for coauthoring this bill and thanks Assemblymember Phil Ting for his support of SB 277. The bill is now being heard in the Assembly. SB 591 (Pan), California Tobacco Tax Act of 2015, would increase California’s tobacco tax by $2 per pack. Funds raised by the tax would be allocated to tobacco prevention and education programs provided by the California Department of Health Care Services (DHCS) and to enforcement of tobacco laws. SB 140 (Leno) would regulate electronic cigarettes and ensure that such products are subject to similar laws as other tobacco products and that they fall under California’s smoke-free laws. This legislation is also supported by both Assemblymembers Chiu and Ting. SB 203 (Monning), coauthored by Senator Leno and Assemblymember Chiu, would require a warning label on sugarsweetened beverages sold in California. California consumers have a right to know about the unique health problems associated with soda and other sugary drinks. SFMS had previously submitted a letter of support for this bill. AB 1086 (Dababneh) would require health plans to authorize and honor assignment of benefit agreements and send payment directly to out-of-network providers. It would ease the administrative and financial burden placed on patients.
SAN FRANCISCO MEDICINE JUNE 2015 WWW.SFMS.ORG
SFMS Partners with AAP-CA to Oppose AB 170 AB170 (Gatto) would create a barrier in the newborn screening program that complicates and delays the process, putting babies at significant risk of disability and death. The bill would convert the newborn screening program from an “opt-out” to an “opt-in” process. At the April Health Committee hearing, Assemblymember Gatto likened the information from the blood spots to credit card data that would put individuals at risk should it be stolen. Currently, blood spots are stored separately from their identifying information, which is itself stored on a server not connected to the Internet. The Federal government passed regulation in December 2014 that would require informed consent for federallyfunded research on newborn blood spots. While there is a need for transparency about what sort of research is done with blood spots and how consent should be obtained, the American Academy of Pediatrics - California recommends waiting for federal regulations to be defined instead of prematurely developing our own in California. Moving the newborn screening program to an opt-in model would jeopardize the screening program in ways that we consider to be grave and dangerous. We do not want to go back to an era in which we delay detection of life-threatening conditions such as PKU or SCID. The bill was tabled in the Assembly Health Committee after SFMS and AAP-CA physicians voiced opposition to the bill during Lobby Day.
Senate President pro Tempore Kevin de León
Governor Jerry Brown WWW.SFMS.ORG
ADVOCACY: TAKE ACTION! Barbara Rotter Too often we become inured to our daily struggles in health care and forget that we have a voice. We get frus-
trated, complain, throw up our hands in despair, and then go back to our routines. There is a cure for this ritual. It’s called advocacy. Wikipedia defines advocacy as “a political process by an individual or group which aims to influence decisions within political, economic, and social systems and institutions.” One of the most important ways to influence positive change is to be an active participant in the advocacy efforts of the CMA and San Francisco Medical Society. As a medical practice executive, I have a point of view that positions me to help elected officials understand the impact of their policies on private practice in a unique way. Lobby Day is about seizing an opportunity and persuading legislators to support our position on health care issues. We focus on issues that matter to our patients, our physicians, and our industry. I partner with the physicians who attend and we deliver a powerful message. Every Lobby Day for the past several years, I wake up very early to catch the train to Sacramento from San Francisco. Once I arrive in our State’s capital, it’s a quick, brisk walk to the Sheraton Grand, where a streamlined program has been organized. Many highly esteemed physicians, CMA representatives, and lobbyists give us the background we need to feel confident when talking to legislators. SFMS staff facilitate the entire process and provide well-written handouts that describe the pending bills. This event is important enough that Governor Brown made a special appearance and addressed the audience. At the appointed times, we walk to the capitol and meet directly with legislators and let them know how their work impacts us. As we walked the long halls of the capitol this year, I heard many staffers say how impressive it was to see so many physicians in their white coats taking time to talk with legislators. It was quite a sight! This year, we advocated on several issues impacting public health and practice management. I took the lead on addressing SB 1086 (Dababneh)—assignment of reimbursement rates for outof-network providers—in each meeting and explained how this bill would ease the administrative burden on the patient and provider while providing crucial cost information. After I was given several minutes to explain the bill, several legislators asked additional questions. With the information I was given on the bill and the research I had done, I felt confident in asking them to support the bill. Each legislator thanked me and said they would examine the bill more closely. They also asked for contact information to reach out to our group if they have additional questions as they are considering their position on the bill. As you can see, we can cause positive change if we speak with one clear voice. Time and time again, legislators and staffers expressed gratitude for our visits. Come and join us in Sacramento next year! Barbara Rotter is vice president of finance for Golden Gate Urology and a California State MGMA Legislative Liaison. JUNE 2015 SAN FRANCISCO MEDICINE
Amy Whittle, Emily Balkin, Katherine Ort, Kimberly Jablon, Daria Thompson
A RESIDENT’S PERSPECTIVE Katherine Ort, PGY2
Advocacy work at the policy level has always seemed out of reach to me. Sure, on a small scale as a pe-
diatrician in training, I am required to be an “advocate” for my patients on a daily basis to ensure that their individual health care needs are met. Taking care of a single child involves innumerable battles fought by the entire health care team. This can, at times, be exhausting. I have always admired my hardworking and passionate colleagues who have taken this fight further and made change in the wider health care arena; however, I have never thought of myself as having a voice in the larger public domain. I did not think it mattered if I spoke up, as I have always felt that there were others—more qualified, more passionate—already doing the work. I do not follow politics closely and have never thought carefully about who is actually making laws and how they come to fruition, despite their impact on my daily practice. I have depended on others to make sure the right laws were put in place. Until now. I am currently in a block in our residency curriculum set aside for training in advocacy work and health policy. As part of this rotation, a group of my colleagues and I were relieved of our usual rigorous clinical duties to attend the CMA Legislative Advocacy Day in Sacramento on April 14. It ended up being one of highlights of my training thus far. We arrived at the event and donned buttons stating “The Kids Sent Me.” We were fortunate enough to travel around with 26
the San Francisco Medical Society to meetings with a number of legislators representing our district. Our leaders helped focus our key talking points regarding upcoming bills affecting our patients. As a team, we set out for the capitol building to meet with the lawmakers. Our meetings were brief but efficient and meaningful. In about ten to fifteen minutes, we were able to share the CliffsNotes version of our stance on a number of bills affecting the children of California, and I believe that our presence alone made an impact. We were able to provide education, based on our clinical experience, on the implications of the proposed laws in our practice. The legislators listened. Following our meetings we were able to sit in on the Assembly Health Committee, where we witnessed heated debates regarding controversial bills that would directly change some of our day-to-day medical practices. Around thirty pediatricians from around the state, armed with our “The Kids Sent Me” buttons, stood to voice our opposition to AB 170, a bill that would change newborn screening from optout to opt-in. Our voices were heard and the bill was tabled. It was powerful and inspiring experience that showed me I had a voice, and I was proud to use it. Katherine Ort, PGY2, is in the UCSF Pediatrics Residency Program and is a member of the SFMS.
SAN FRANCISCO MEDICINE JUNE 2015 WWW.SFMS.ORG
CMS UPDATE CMS Is Transforming the U.S. Health Care System to Focus on Value, Not Volume Ashby Wolfe, MD, MPP, MPH, and David Saÿen, MBA Centers for Medicare and Medicaid Services, Region IX
Thanks to the Affordable Care Act, all Americans have new options for getting health insurance coverage. During our last Open Enrollment, nearly 11.7 million Americans signed up or were reenrolled through the Health Insurance Marketplace. Since several of the Affordable Care Act’s coverage provisions began to take effect in 2010, about 16.4 million uninsured people have gained health coverage. That’s the largest reduction of uninsured adults in four decades. Thanks to the Affordable Care Act, American families across the country have the financial and health security that comes with coverage. They can rest a little easier at night, knowing a sickness or an accident won’t mean a lifetime of insurmountable debt. As physicians, you are well aware that our health care system, for the last fifty years, has under-delivered on access, affordability, and quality. Health care costs grew significantly faster than things like the Gross Domestic Product and middleclass family incomes. It is within our common interest to address these issues and build a health care delivery system that delivers better care, spends health care dollars more wisely, and keeps patients healthy, rather than waiting to care for them when they get sick. This is germane to the trends in practice transformation that we are seeing right now. Information belongs in the hands of physicians and their patients, empowering them to make better choices.
When it comes to improving the way doctors are paid, we want to reward value and care coordination rather than volume and care duplication. To help drive the health care system toward greater value-based purchasing—rather than continuing to reward volume regardless of the quality of care delivered—the Department of Health and Human Services (HHS) has set a goal to have 30 percent of Medicare payments in alternative payment models by the end of 2016, and 50 percent by the end of 2018. This will be achieved through investment in alternative payment models such as Accountable Care Organizations (ACOs), advanced primary care medical home models, new models of bundling payments for episodes of care, and integrated care demonstrations for beneficiaries who are Medicare-Medicaid enrollees. It will also be achieved by a careful focus on providing higher-quality care more efficiently and effectively to the population. The Physician Quality Reporting System (PQRS) has been in place for almost ten years, providing physicians who see Medicare patients under Part B of the Physician Fee Schedule with an opportunity to report on aspects of care they provide, and WWW.SFMS.ORG
the use of feedback reports to drive a cycle of continuous improvement. Through 2014, physicians were eligible to receive incentive payments for their participation. In 2015, however, the program becomes mandatory for all physicians in all modes of practice. In addition, attesting through the EHR Incentive program (commonly known as Meaningful Use) also is now mandatory this year. Negative payment adjustments to reimbursement claims in 2017 will occur for those clinicians who opt not to participate in quality reporting.
CMS has a number of resources, including a specific “How to Get Started” tutorial, online at www.cms.gov. The information available will help inform you as to whether you are eligible for the program, the best way to prepare in order to meet criteria as a physician who reports successfully, and how to choose which measures to report. To further support all physicians who are reporting in 2015, CMS has created guidance to facilitate successful quality reporting through one program (i.e., PQRS), satisfying the requirements for the remaining mandatory reporting programs.
CMS is also working to give new tools to clinicians to help them redesign their practices to support higher-quality care. For example, through the Transforming Clinical Practice Initiative, we will invest up to $800 million in providing hands-on support to 150,000 clinicians and their practices for developing the skills and tools needed to improve care delivery and transition to alternative payment models. For those physicians who continue to serve patients in Medicare or Medicaid Fee-for-Service, quality improvement will continue to occur under the PQRS and EHR Incentive programs. We are in a period of unprecedented transformation in the health system. The recent legislation signed by President Obama in April 2015, known as the Medicare Access and CHIP Reauthorization Act (MACRA) will likely help to further streamline the current quality reporting programs, including PQRS and the EHR Incentive program. However, making operational changes will be attractive only if payment reforms are broadly adopted by a critical mass of payers. When clinicians encounter new payment strategies for one payer but not others, the incentives to change are weak. In fact, a physician who alters her system to prevent admissions and succeed in an alternative payment environment may lose revenue from payers who continue fee-for-services payments. Therefore, we are launching a Learning and Action Network to help accelerate the transition to more advanced payment mod-
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C. Dianna Nicoll, MD, PhD, MPA
At the San Francisco Veterans Affairs Health Care System (SFVAHCS), realizing patient-centered care means empowering patients to be informed, active participants in their own health care. Currently, several innovative education programs are helping us lay the foundations for veteran-centric approaches to provider-patient engagement. One of these is VA’s “Whole Health: Change the Conversation” course for clinical providers. In this three-day program, dozens of SFVAHCS clinicians learned practical skills for providing personalized, proactive, patient-driven care. The course helped familiarize providers with an integrative care approach, teaching them to develop personalized health plans with their patients and to start conversations about what really matters to each patient—including the physical, psychological, social, and spiritual dimensions of well-being. Providers also practiced techniques of self-care and mindfulness to help nurture their own health and well-being. In addition to this clinical course, SFVAHCS hosted a Whole Health Coaching Course for both clinical and nonclinical staff interested in learning about integrative health care and helping patients set and reach their own wellness goals. SFVAHCS has also initiated a partnership with Cal Humanities to host a “Literature & Medicine Program.” Through facilitated discussions of stories, poems, plays, personal narratives, and films, this monthly discussion series invites health care workers to explore new ways to empathize and communicate with patients, family members, and peers, helping them reconnect with their purpose and motivation as caregivers. Building on the success of this program, SFVAHCS has expanded its partnership with Cal Humanities to include a “War and the Human Experience” discussion group that brings together veteran patients and staff to discuss books, poems, and essays written by veterans about experiences of war and of coming home. These innovative educational programs are part of SFVAHCS’s broader commitment to patient-centered cultural transformation. WWW.SFMS.ORG
Bill Black, MD, PhD
Educating patients and making sure they are adequately informed is key to our care. The best care includes making sure patients understand their medical condition and know what they can do to be as healthy as possible. At Sutter Pacific Medical Foundation (SPMF), physicians have techniques and tools that can help, though each patient is different and may need a customized approach. “I spend a lot of time educating and listening to patients,” says Michelle Malcolmson, MD, an internist at SPMF. “Regarding behavioral change, I listen to see what each particular patient needs and work with the patient to achieve those specific goals.” Her approach is often based on collaborative care, involving the patient in decision making and presenting the pros and cons of medical management. Motivational interviewing—asking questions that allow patients to come to their own conclusions—has also been successful in behavioral change. She provides an After Visit Summary (see below) and often adds a personal touch to help patients adopt healthy behaviors. In the case of prediabetic patients or those with weight issues, she may give them recipes to improve diet. Technology has delivered more ways to educate patients. More than 1 million adult patients are connected to Sutter Health’s My Health Online (MHO), which allows patients to email their doctors, view their test results online, request appointments, and find educational materials on dozens of conditions. Particularly helpful is the After Visit Summary, a receipt given to the patient summarizing treatment. Physicians can add educational information that patients can refer to at their leisure. No longer do patients have to rely on notes scribbled during the appointment, says Deborah Wyatt, MD, an SPMF pediatrician who leads a team of clinicians charged with optimizing use of MHO and electronic health records. Also, the physician doesn’t have to rely on the patient to remember to make follow-up appointments, as reminders can be sent via MHO.
Edward Eisler, MD
The CPMC Epilepsy Program, under the medical direction of Dr. Kenneth Laxer, has been recognized as a Level 4 Epilepsy Center by the National Association of Epilepsy Centers. The Level 4 designation means that the program has the professional expertise and facilities to provide the highest-level medical and surgical evaluation and treatment for patients with complex epilepsy. For the 30,000 people in the U.S. with amyotrophic lateral sclerosis (ALS), progressive neurodegeneration and death of motor neurons causes loss of control of voluntary muscles and resulting symptoms, including muscle weakness, spasticity, slurred speech, and respiratory difficulties. Dr. Robert Miller, Dr. Jonathan Katz, and their colleagues at CPMC’s Forbes Norris MDA/ALS Research and Treatment Center have begun new studies of approaches to reduce the neuroinflammation suspected to underlie the gradual progression of ALS. One of the newest classes of agents to treat melanoma and other types of cancer, checkpoint inhibitors, have emerged as promising therapies in causing tumor regression. With the U.S. FDA approval last year of the checkpoint inhibitor nivolumab for the treatment of melanoma, the immunotherapy drugs are expected to bring new hope to the more than 76,000 people in the U.S. diagnosed annually with this deadly form of skin cancer. The results were published this week in the New England Journal of Medicine in a study coauthored by CPMC clinicianscientist Dr. David Minor. CPMC’s Stroke Telemedicine partnership was recently voted by Sutter Health employees system-wide as the first place winner of the inaugural “We Plus You” President’s Partnership Award. The new award celebrates and funds innovative homegrown projects that are made possible through partnership initiatives in the Sutter Health system. The Stroke Neurology team, led by Dr. David Tong, uses technology to link to other hospitals where they deliver expert stroke care to patients. Currently, the program partners with more than twenty hospitals throughout Northern California. JUNE 2015 SAN FRANCISCO MEDICINE
UPCOMING EVENTS 6/24: SFMS Member Networking Mixer | 6:00 p.m.–8:00 p.m., Palmer’s at 2298 Fillmore Street, San Francisco | Networking is ranked as one of the most valuable services provided by SFMS. To realize the full power of networking, SFMS will cohost a series of networking events with the Cooperative of American Physicians that will help members connect in a relaxed, no-agenda format aimed only at networking! It’s a great way to meet fellow SFMS members from the local community and share your experiences. RSVP is required. Please visit http://www.sfms. org/Events.aspx for event details and to RSVP. Wine/beer and hors d’oeuvres will be provided by SFMS. Please note this is an exclusive SFMS members-only event.
6/25-26: US Mobile Healthcare Technology Congress | Crowne Plaza San Francisco Airport, 1177 Airport Boulevard, Burlingame, CA | Hear about new innovations and strategies to improve health care delivery with mobile and telehealth technology from academics, government, and industry leaders at the 2015 Mobile Healthcare Technology Congress. This exclusive event is limited to 150 attendees, where representatives from health systems, payers, and policy organizations come together to share experiences and gain practical guidance on integrating the latest technologies into health care. Sessions will feature evidence based case studies on how mobile and telehealth technology has reduced cost overheads and improved patient care. Visit http://www.arena-international. com/mhealthus/. SFMS members are eligible for complimentary registration on a first-come, first-served basis by contacting info@ sfms.org or (415) 561-0850. 7/9: Dinner and Talk with AMA President Robert M. Wah, MD 6:00 p.m. reception, 6:30 p.m. dinner and program, ACCMA Offices, 6230 Claremont Avenue, Oakland | San Francisco Medical Society and Bay Area county medical societies invite physicians and their guests to a special dinner program featuring AMA President Robert M. Wah, MD. Dr. Wah is a reproductive endocrinologist and ob/gyn in McLean, Virginia, and is the first Asian-American president of the American Medical Association (AMA). Dr. Wah will speak about the AMA’s leadership in health care reform and the challenges facing physicians today. He will also discuss health information technology and its role in improving patient care delivery. The event is free to SFMS members and their guests; $45/person for nonmembers. Please RSVP by contacting ACCMA at (510) 654-5383.
7/21-22: ICD-10-CM Training | 8:00 a.m.–5:00 p.m., San Mateo County Medical Association Office, 777 Mariners Island Blvd, Suite 100, San Mateo | The transition to ICD-10 is set to take effect in October 2015. Current code sets will undergo a significant restructuring, increasing from 14,000 to 69,000 codes. To help local practices prepare, the SMCMA is holding a special two-day code set training with the American Association of Professional Coders (AAPC). The training is designed to give attendees a comprehensive understanding of guidelines and conventions of ICD-10, as well as fundamental knowledge of how to decipher, understand, and accurately apply codes in ICD-10. SFMS members are eligible for the reduced member price of $399. Regular registration is $799. For more information, please visit http:// www.smcma.org/ICD10-Training. 34
9/14: SFMS General/All-Member Meeting | 6:00 p.m.–7:30 p.m., Golden Gate Yacht Club | Calling all SFMS members! Join SFMS at our General Meeting at the Commodore Room inside the Golden Gate Yacht Club. Members are welcome to stay for the board meeting immediately following the General Meeting. This is a good opportunity to meet with SFMS leadership and to learn firsthand the issues SFMS and CMA are advocating for on behalf of physicians and their patients in San Francisco and California. Please RSVP to Posi Lyon at email@example.com or call (415) 561-050 x260. 9/19: Zero Prostate Cancer Run/Walk | 9:30 a.m., Lake Merced (Skyline & Harding Rd) | Join SFMS physician members from Golden Gate Urology for the annual Zero Prostate Cancer Run/ Walk. This tight-knit community activity brings together athletes, doctors, cancer survivors, and those who care about them to end prostate cancer. Visit http://bit.ly/1EknsZh for more information on how to get involved.
10/30-31: 2015 Latino Health Conference | Oakland Marriott City Center | The 2015 Latino Health Conference seeks to address health disparities in the Latino/Hispanic community by sharing evidence-based practices and clinical research, promoting diversity in the health care workforce, and creating linkages between community health organizations and health care providers. Conference participants will receive evidence-based strategies, practice tips, tools, and patient education resources to improve their clinical practice and patient care. Visit http://latinohealthconference.com/lhc/ for program and registration details.
Family Medical Practice for sale. East San Francisco Bay, CA Multi-discipline practice serving the Asian community. Revenue over $1 million. Multi-language staff; buyer doctor must be fluent in one Chinese dialect. EMR; high profit margin; seller will train buyer in proprietary systems. $682,000. Real estate also available. info@PracticeConsultants.com. 800-5766935. www.PracticeConsultants.com
Welcome New Members PHYSICIANS Matthew John Fagan, DO | Family Medicine Ahmad Y. Sheikh, MD | Cardiothoracic Surgery Marc Miller Solomon, MD | Internal Medicine Michelle M. Van Ooy, MD | Obstetrics and Gynecology RESIDENTS Joseph Hall, MD | Psychiatry Daria Thompson, MD | Pediatrics
SAN FRANCISCO MEDICINE JUNE 2015 WWW.SFMS.ORG