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Politics and Medicine Obamacare: Past, Present, and Future

Medi-Cal Managed: Where Does the Buck Stop?

Prop 29: Tobacco Wars at the Ballot Box

Death and Taxes: An Inverse Relationship


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SAN FRANCISCO MEDICINE October 2012 Volume 85, Number 8

Politics and Medicine



12 Obamacare: Past, Present, and Future Andy Calman, MD, PhD


Membership Matters


Ask the SFMS


President’s Message Peter J. Curran, MD

17 18

Proposition 29: Tobacco Wars at the Ballot Box John Maa, MD, and Steve Heilig, MPH

Medi-Cal Managed: Where Does the Buck Stop? Assemblymember Richard Pan, MD, MPH

21 Death and/or Taxes: An Inverse Relationship Steve Heilig, MPH


10 SFMS Advocacy Activities 11 Editorial Gordon Fung, MD, PhD 32 Hospital News

34 New SFMS Members 23 Slate of Candidates 24 Candidate Biographies

Editorial and Advertising Offices: 1003 A O’Reilly Ave., San Francisco, CA 94129 Phone: (415) 561-0850 e-mail: Web: Advertising information is available by request.

MEMBERSHIP MATTERS Activities and Actions of Interest to SFMS Members

SFMS Career Fair Calling all residents, fellows, and employers! SFMS will be hosting our third annual Career Fair on October 25. The event runs from 5:00 p.m. until 8:00 p.m. and is complimentary to residents and fellows from the four San Francisco-based residency programs. This is an excellent opportunity for physicians looking to practice in the Bay Area to network with representatives from a variety of practice types and settings, and for employers to connect with physician job seekers. As part of an effort to make participation accessible to all, we are offering a tiered pricing structure for employers ranging from $100 to $400; SFMS members in solo/small group practices can exhibit free of charge. For event details or to inquire about exhibiting, contact the Membership Department at (415) 561-0850 or visit

The Financial Fitness Clinic was selected earlier this year for a $10,000 grant by the San Francisco Medical Society and the San-Cop Foundation. Support from SFMS has been instrumental in helping more patients with financial hardship that impacts their health.

SFMS Spotlights Advocacy and Community Health Efforts at General Meeting 

SFMS Supports Heart Disease Prevention and Research

SFMS is proud to be a part of the American Heart Association (AHA) Golden Gate Walk to call attention to heart disease prevention. SFMS leaders raised $2,800 and participated in the September 15 walk as an organization sponsor. We celebrated with survivors, connected with medical staff, and educated the community on heart-healthy lifestyles. This was a wonderful opportunity to increase SFMS’s visibility in the community and showcase our new SFMS Physician Finder tool. The SFMS Physician Finder is a free physician referral service offered by SFMS to connect patients with SFMS physicians; it makes more than 6,000 referrals per year. To update your physician profile, please visit

A wonderful time was had by all at the September SFMS General Meeting at the Golden Gate Yacht Club. With warm enthusiasm, SFMS President Peter Curran, MD, welcomed seventy residents and physicians—many of whom were new members and first-time attendees—to the annual event. Featured speaker San Francisco Board of Supervisors President David Chiu provided an enlightening update on the state of health care in the city. Special guest Luther Cobb, MD, speaker of the CMA House of Delegates, delivered an informative presentation about CMA’s legislative advocacy efforts to preserve MICRA and ensure public safety with AB 2109 and SB 1318. Visit the SFMS Facebook or Flickr page for more photos from the General Meeting.

Adam Schickedanz, SFMS board member and a resident at the UCSF Department of Pediatrics program, is the recipient of the 2012 American Academy of Pediatrics’ Anne E. Dyson Child Advocacy Award. Schickedanz was recognized for his work at founding and coordinating the Financial Fitness Clinic at San Francisco General Hospital. The award, supported by the Dyson Foundation, celebrates the outstanding efforts of three pediatricians in training, selected nationally each year, as they work in their communities to improve the health of children.

2013 membership renewals are right around the corner! Make sure you continue to receive the benefits of SFMS and CMA by renewing your membership beginning in October. There are three easy ways to renew your dues again this year: • Mail/fax in your completed renewal form when you receive it in the mail. • Renew online using your credit card. • Enroll in the Easy Pay (quarterly installments) Automatic Dues Renewal Plan by contacting SFMS at (415) 561-0850 or

Doing Something Right: SFMS Resident Member Receives Prestigious AAP Advocacy Award

4 5

San Francisco Medicine October 2012

Coming Soon to an Inbox Near You: Membership Renewal

October 2012 Don’t forget the great benefits you get with your membership: • Promote your practice through our customizable physician member page on the SFMS website and thePhysician Finder referral service. • Connect with physicians through SFMS social events and our online communities on Facebook, Twitter, and our member-only LinkedIn group. • Resolve contracting, billing, and payment problems with one-on-one assistance from the Center for Economic Services. CES successfully recouped more than $2.7 million from insurance companies on behalf of our physician members in 2010. Assistance ranges from coaching and education to direct intervention with payors or regulators, and it is complimentary as part of your membership. 2012 membership expires after December 31.

Organized Medicine Files California Supreme Court Amicus Briefs in Support of Medical Staff Independence and Self-Governance SFMS/CMA and AMA have filed amicus curiae briefs with the California Supreme Court in El-Attar v. Hollywood Presbyterian Medical Center in support of medical staff independence and self-governance. The briefs argue that a hospital’s lay governing board is not qualified to engage in peer review and thus cannot directly or indirectly commandeer a medical staff’s peerreview functions. The California Supreme Court decided to review this case last November. Briefing in the case is complete and a decision can be expected in the latter half of next year.

HHS Delays ICD-10 Coding to October 2014

The Department of Health and Human Services (HHS) postponed the use of ICD-10 diagnostic codes until October 1, 2014. The one-year delay comes in response to complaints by organized medicine about the administrative burden of converting to ICD-10. SFMS, CMA, AMA, and other medical societies told HHS that converting to the more voluminous and complicated set of diagnostic codes could cost medical practices tens of thousands of dollars and interfere with their migration to electronic health records and electronic prescribing. For more information, please visit

Complimentary Webinars for SFMS Members

CMA offers a number of excellent webinars that are free to SFMS members. Members can register at October 17: Establishing Expectations for High Performance from Medical Staff • 12:15 p.m. to 1:15 p.m. October 24: A Strategic Approach to Managing Your Medical School Debt • 12:15 p.m. to 1:15 p.m. November 7: Understanding ARC and CARC Revenue Codes • 12:15 p.m. to 1:15 p.m.

SFMS Seminar: “MBA” for Physicians and Office Managers

Gain critical business skills in the areas of strategic planning, finance, operations, marketing, and personnel management at SFMS’s popular MBA for Physicians and Office Managers session. Join Debra Phairas for this oneday seminar on October 19 from 9:00 a.m. to 5:00 p.m. $225 for SFMS/CMA members and their staff ($200 each for additional attendees from same office); $325 for nonmembers. Contact Posi Lyon, or (415) 561-0850 extension 260 for more information.

Volume 85, Number 8 Editor Gordon Fung, MD, PhD Managing Editor Amanda Denz, MA Copy Editor Mary VanClay

EDITORIAL BOARD Editor Gordon Fung, MD, PhD Obituarist Nancy Thomson, MD Stephen Askin, MD Erica Goode, MD, MPH Toni Brayer, MD Shieva Khayam-Bashi, MD Linda Hawes Clever, MD Arthur Lyons, MD Peter J. Curran, MD Stephen Walsh, MD Sashi Amara, MD SFMS OFFICERS President Peter J. Curran, MD President-Elect Shannon Udovic-Constant, MD Secretary Jeffrey Beane, MD Treasurer Lawrence Cheung, MD Immediate Past President George A. Fouras, MD SFMS STAFF Executive Director Mary Lou Licwinko, JD, MHSA Assistant Executive Director Steve Heilig, MPH Associate Executive Director for Membership Development Jessica Kuo, MBA Director of Administration Posi Lyon Membership Coordinator Lauren Estrada

BOARD OF DIRECTORS Term: Jan 2012-Dec 2014 Andrew F. Calman, MD Edward T. Melkun, MD Roger S. Eng, MD Kimberly Newell, MD John Maa, MD Richard A. Podolin, MD Elizabeth K. Ziemann, MD

Term: Jan 2010-Dec 2012 Gary L. Chan, MD Donald C. Kitt, MD Cynthia A. Point, MD Adam Rosenblatt, MD Lily M. Tan, MD William T. Prey, MD Joseph Woo, MD

Term: Jan 2011-Dec 2013 Jennifer H. Do, MD Benjamin C.K. Lau, MD Man-Kit Leung, MD Keith E. Loring, MD Terri-Diann Pickering, MD Adam Schickedanz, MD Rachel H.C. Shu, MD

CMA Trustee Robert J. Margolin, MD AMA Representatives H. Hugh Vincent, MD, Delegate Robert J. Margolin, MD, Alternate Delegate

October 2012 San Francisco Medicine


SFMS experts answer practice-related questions

Ask the SFMS connects members with SFMS physicians and partners who can answer questions about a wide variety of topics dealing with the practice of medicine, including practice management, patient education, EHR assistance, health policy, legal/malpractice issues, financial management, and many more! Each issue of San Francisco Medicine features a few commonly asked questions from physicians. For the full archive of questions and answers, or to access extensive information and additional resources relating to each topic, please visit our member-only Ask the SFMS section at http://www.sfms. org/ForPhysicians/AskSFMS.aspx. If you would like to submit a question for our experts, please email

How long does a payor have to approve or deny a request for a prior authorization?

Decisions to approve, modify, or deny a standard request for a prior authorization must be made in a timely fashion appropriate to the nature of the patient’s condition, but not to exceed five business days from the payor’s receipt of the information reasonably necessary to make the determination (Health & Safety Code §1367.01(h), Insurance Code §10123.135(h)(1)). In cases where a serious threat to the patient exists, payors are required to make a determination within seventy-two hours of receipt of the information needed to make a decision. A serious threat is defined as cases where the patient’s condition is such that he or she faces an imminent and serious threat to his or her health, or the five-day time frame would be detrimental to the patient’s health or could jeopardize the 6

San Francisco Medicine October 2012

patient’s ability to regain maximum function (Health & Safety Code §1367.01(h)(2) and Insurance Code §10123.135(h)(1)). These requirements apply to all health plans and their contracting IPAs/medical groups, insurers, and other entities conducting utilization review. Once a decision is made, payors must communicate the information, including the specific service(s) approved, to the requesting provider within twenty-four hours. Phone or fax communications are acceptable but must be followed up in writing. Formal written notice of a denial, delay, or modification to the authorization request must include the name and phone number of the health care professional responsible for the decision. If a payor can’t meet the time frames for a decision, that payor may qualify for additional time but must meet specific criteria and must, at a minimum, notify the physician and the patient of the reason for the delay in writing before the expiration of the above time frames. CMA’s Center for Economic Services is staffed by practice management experts with a combined experience of more than 125 years in medical practice operations. Contact the SFMS member reimbursement helpline at (888) 401-5911 or

I’ve just graduated from residency. Should I contribute toward a 401(k)? Participating in your company’s retirement plan can help reduce your income taxes, provide tax-deferred growth potential of your investments, and be an important source of retirement income. A popular type of plan is called a 401(k) and allows you to make tax-deductible contributions of up to

$17,000 a year in 2012. Individuals age fifty or older can make an additional “catch-up contribution” of $5,500. Most 401(k) plans allow you to invest your contributions in a suite of investment options that may include stock-, bond, and cash-based investments. Unlike pensions that provide a future guarantee of income, a 401(k) provides only what you contributed plus any earnings (and as with any investment vehicle, your investments may lose value). Work with your financial advisor to establish a long-term investment plan that will help dictate how you invest your 401(k). Some employers provide matching contributions, which you should try to maximize. This might require adjustments to your monthly contribution rate. Senior Vice President Investments Denny Boys, CFP®, is with Boys Georgiadis Financial Strategies Group of Wells Fargo Advisors. Contact him at or (415) 291-1286.  Wells Fargo Advisors, LLC, member SIPC, is a registered broker-dealer and separate nonbank affiliate of Wells Fargo & Company. CAR 0812-02682

Should I consider umbrella coverage, and why? The question you really should be asking yourself is, “How much coverage should I buy?” All physicians should have a personal umbrella or excess liability policy to protect their assets. Even though you purchase homeowners, automobile, and possibly watercraft liability policies, the limits generally available through these policies are not adequate to satisfy potential multimillion-dollar settlements. A personal excess liability policy is designed to protect against multimillion-dollar settlements and defense costs resulting from personal injury, bodily injury, or property damage lawsuits. Coverage is designed to extend beyond the required underlying primary limits provided by your homeowners, auto, and other personal policies. You can generally purchase between $1M and $5M limits with limited underwriting and up to $10M of additional coverage with more extensive underwriting. If you have significant assets to protect, have a youthful driver at home, own a dog, have a swimming pool, entertain at home, or drive in an area with a large number of uninsured or underinsured motorists, then an umbrella policy should be in your personal risk-management plan. You can’t afford not to have one. Roy Lyons is the managing director at Marsh, a global leader in insurance broking and risk management. Contact him at (213) 346-5946 or

Matt Dickstein

Business Attorney Representing Medical Practices Since 1994 * Medical Corporations * Stark & Kickback / Regulatory Compliance * Employment & Contractor Agreements * Breakaway Physician Competition * Buying & Selling a Practice * Hospital – Group Contracts * Leases for Medical Offices * Multi-Discipline Practices

Idea of the Month: Always acknowledge a fault. This will throw those in authority off their guard and give you an opportunity to commit more. – Mark Twain

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October 2012 San Francisco Medicine


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Politics and Potted Plants In an election season of local and national importance, I’m reminded of the story of how Senator Joe Dunn, a Democrat and past CEO of the California Medical Association, narrowly defeated a Republican incumbent in the traditionally conservative 34th District of central Orange County, California. He determined that the swing voters in a close race consisted largely of female homemakers, and he mailed each of these 25,000 voters a potted plant—and won the election by two percentage points. Other political strategists use the influence of money to get some constituents to the voting booth, and perhaps to keep others away. As my friend and fellow SFMS Director Dr. John Maa reminds me, looking at history, it is not the vote that matters but rather the counting of votes that matters. This year’s state elections have several interesting stories due to recent voter-approved changes in the state election process, better known as redistricting and the “top-two” primary election format. Gone are the days when elections in California were largely determined by party bosses selecting candidates during backroom deals. Due to Proposition 14, passed by voters in 2010, the toptwo vote getters in statewide congressional elections, regardless of party affiliation, go to a runoff in the November general election. Implemented for the first time during the June 2012 primaries, the top-two election process theoretically should result in more moderate candidates. It certainly has resulted in more expensive campaigns, with candidates having to raise money for a primary and a general election, and it has raised the possibility of one candidate running against another from the same party. With Proposition 11, passed by voters in 2008, voters approved a ballot initiative to create a citizens’ commission for redistricting based on census data. In California, incumbents with large war chests of fund-raising dollars win elections, because of factors that include the large size of districts, the expense of campaigns, and the lack of public financing of campaigns. Perhaps the most entertaining of the races affected by redistricting is the Sherman versus Berman campaign for a House seat representing the San Fernando Valley in southern California. Both candidates are veteran incumbent Democrats who normally would be friends but are now slinging mud at one another, having to compete for the newly created Congressional District 30. Although Sherman has a slim lead in the polls, Berman was able to secure endorsements from two Republican U.S. senators, demonstrating the importance of the once-neglected partisan votes.

On a statewide level, Dr. Richard Pan, a pediatrician from the Sacramento area, is running for reelection in the Assembly in a new district. He represented the house of medicine well during his first term, and he contributes an article in this month’s magazine about the realignment of Medi-Cal and its effect on access to care. In keeping with the spirit of increased competition in state elections, the SFMS has more contested elections this year for the board of directors, CMA House of Delegates, and CMA trustee. The nominations committee, under the direction of Dr. George Fouras, has put together a slate of candidates representing a diverse and talented group of physician leaders in San Francisco. Voting at SFMS has never been easier, with options for online voting and traditional mailin ballot. The time and commitment invested by the leadership at SFMS is truly appreciated, and I trust that our membership will reward that dedication by voting for the next generation of leaders at SFMS.

October 2012 San Francisco Medicine


SFMS Advocacy Activities A PROFESSIONAL VOICE FOR COMMUNITY HEALTH SINCE 1868 The San Francisco Medical Society (SFMS) has been involved in community health issues since the 1868. As the only medical association in San Francisco representing the full range of medical specialties and interests, SFMS health advocacy has been broad. Via policy-making efforts with state and national medical and political leaders and an award-winning journal, SFMS has often been influential far beyond the city. The SFMS agenda and activities continue to focus on the community and the following areas of involvement: • Forming HealthShare Bay Area (see below) to improve patient care and reduce costs • Working with the physician community to promote the adoption of electronic health records to better serve patients • Advocating against cuts to Medi-Cal and Medicare reimbursement to provide continued access to care for all San Franciscans • Preserving the health care safety net and public health programs in times of severe budget cuts • Supporting antitobacco legislation and San Francisco’s law banning the sale of tobacco in pharmacies, and smoking in restaurants and other businesses, and eliminating tax credits for films showing smoking • Supporting the Healthy San Francisco program and participating in legal defenses to preserve the program, while helping to monitor the program’s progress • Providing physicians for medical consultation for San Francisco schools and for volunteer care at community clinics • Working on legislation to allow minors, without parental consent, to receive vaccines to prevent STIs; to prevent bans on medical procedures such as circumcision; and more • Cosponsorship of the Hep B Free program in San Francisco • Advocacy for improving end-of-life care in the Bay Area via new policies, use of new advance directives (such as POLST), and educational outreach to physicians and patients  


HEALTHSHARE BAY AREA Working under the auspices of

the SFMS Community Service Foundation and guided by a diverse board of San Francisco and Bay Area health care industry professionals, the SFMS worked to develop HealthShare Bay Area to provide the infrastructure for a unified electronic health record system. The project originally targeted San Francisco but now includes partners from the East Bay. This service allows providers to have access to secure community-wide patient data. It also permits patients to gain a complete view of their medical records, irrespective of where individual records may reside. HSBA will launch in 2012.

UNIVERSAL ACCESS TO CARE SFMS leaders have long advocated that every San Franciscan should have access to quality medical care. Recent SFMS participation in this effort has included the Mayor’s Health Care Reform Task Force, the San Francisco Health Care Services Master Plan Task Force, and the Mayoral Task Force, which designed the Healthy San Francisco program. SFMS also joined in the lawsuits to preserve that program. SFMS has advo10 San 11 SanFrancisco FranciscoMedicine Medicine October October2012 2012

cated for community clinics since the founding of the original HaightAshbury Free Clinics in the 1960s.


instrumental in passing MICRA, which saves virtually every doctor many thousands of dollars in liability premiums annually and saves hospitals and health systems much more. We have successfully defeated repeated attacks on MICRA by trial lawyers through the years.

REBUILDING/PRESERVING SAN FRANCISCO GENERAL HOSPITAL SFMS spokespersons took a lead in advocating for full

funding of the seismic rebuild and in advising, as members of the Mayoral committee, where and how that would occur.

HIV PREVENTION AND TREATMENT The SFMS was at the center of medical advocacy for solid responses to the AIDS epidemic, being among the first to push for legalized syringe exchange programs, adequate funding, and more.

SCHOOL AND TEEN HEALTH SFMS helped establish and staff a citywide school health education and condom program, removed questionable drug education efforts from high schools, worked on improving school nutritional standards, and provides medical consultation to the SFUSD school health service.

ENVIRONMENTAL HEALTH SFMS established a nationwide educational network on scientific approaches to environmental factors in human health; has advocated on reducing mercury, lead, and air pollution exposures; and much more. REPRODUCTIVE HEALTH AND RIGHTS SFMS has been a state and national advocate for reproductive health and choice.

BLOOD SUPPLY SFMS has long been a partner of the Blood Centers of the Pacific and seeks to help increase donations.

ORGAN DONATION SFMS has been a leader in seeking improved

donation of organs to decrease waiting lists, via education and new polices regarding consent and incentives for organ donation.

OPERATION ACCESS SFMS is a founding sponsor of this local organization providing free surgical services to the uninsured and has provided office space, volunteers, and funds. DRUG POLICY SFMS has been a leader in exploring and advocat-

ing new and sound approaches to treating drug abuse, including some of the first policies regarding syringe exchange, medical cannabis, and treatment instead of incarceration.

MEDICAL ETHICS SFMS has developed and promulgated for-

ward-looking policies and approaches regarding end-of-life care, patient directives, physician-assisted dying, and other topics of interest to patients, physicians, policy makers, and the general public.

EDITORIAL Gordon Fung, MD, PhD

Politics and Medicine As I sat down to research the Politics and Medicine theme for this month, I googled the key words politics and medicine and came up with 810 websites on the combined topics. There were websites that were perfect hits, like, offering daily updates in medical and healthcare policy news. There were medical education updates in multiple specialties, as well as more than 100 medical journals. There was even, which featured an article posted on July 14, 2011, by Dr. Peter Reeg, who says that medicine and politics cannot be separated. (Many nations around the world are dealing with this sort of “integration.”) Then I found the numerous blogs of our politicos, and of the professional medical websites that have active advocacy sections and links to their PACs and that encourage members to join. Needless to say, there are many areas on the Internet alone to get up-to-date information on the topic. But why did we come up with this theme for San Francisco Medicine and its readers? Certainly not just to reiterate everything on the Internet and in textbooks. Our main purpose was to give you a look at the current involvement of SFMS members at the local and national levels. When I entered medical school, the last thing I wanted to be involved in was politics of any kind—especially not the process of getting candidates elected and monitoring the activities of governing bodies and legislators. I just wanted to learn how to be the best physician I could be and spend my time caring for patients. But as I entered the practice of medicine, I was struck immediately by the overwhelming burden of regulations and the cost of malpractice coverage for my field. There was a lot of buzz at the time about a MICRA bill that was going through the California legislature. I paid little attention to the articles and editorials on the subject, since it didn’t really have anything to do with cardiac physiology or treatment of cardiac diseases. Little did I know, then, the impact this bill would have on the practice of medicine in California and how revolutionary it was in liability reform. I started to look at this issue more and more over time, after the bill was passed and implemented. I began to recognize that every professional society included a major section on the activities of the government in medicine, from research to government programs to reimbursement, regulations by credentialing organizations, and constant encouragement for physicians to get involved in the process. The main purpose of the advocacy was to inform physicians of current government programs and proposed laws that affected the practice of medicine. Still, I was reluctant to get involved, as it took precious time away from practice. Over the years, as my practice was increasingly impacted by government intervention, I did become involved. I recently came upon a quote by Plato, from about 428 B.C., on politics. It goes

more or less like this: “Those who are too smart to engage in politics are punished by being governed by those who are dumber.” This truly motivated me to get more involved in advocacy—one of the loftier activities in politics. There is a need to be informed and knowledgeable about medicine and to pass this knowledge on to our legislators, who make the decisions and laws that affect our practice—and who, in some states, are trying to affect the doctor-patient relationship with specific prohibitions on permissible topics for discussion. All of us in medicine who deal with chronic disease know that its definition is that it is incurable but manageable. Chronic disease needs constant attention and monitoring, with interventions as needed. This, I believe, is the physicians’ role in politics: to constantly inform the legislators and governing bodies of the issues of the practice of medicine that are affected by inappropriate laws, and of some of the unintended consequences of laws that make the practice of medicine unsustainable. One way to get involved is to keep abreast of what’s happening in state and federal elections. In this month’s issue, John Maa and Steve Heilig provide an update (at least as much as can be shared at this time) on the recount of votes for the tobacco tax initiative, Proposition 29—a tallying with which they have been intimately involved. We also have an article by Dr. Richard Pan, a California state assemblyman and pediatrician and an active member of CMA and his county medical society, on vaccinations and MediCal reimbursement. In terms of federal elections, one of the major issues on each presidential candidate’s platform is the Affordable Care Act and its implementation. The New England Journal of Medicine recently posted each candidate’s views by the links below. Once you are informed, be sure to vote!

Romney’s Statements

h t t p : / / w w w. n e j m . o r g / d o i / f u l l / 1 0 . 1 0 5 6 / NEJMp1211516?query=TOC

Obama’s Statements

h t t p : / / w w w. n e j m . o r g / d o i / f u l l / 1 0 . 1 0 5 6 / NEJMp1211514?query=featured_home. October 2012 San Francisco Medicine


Politics and Medicine

Obamacare Past, Present, and Future Andy Calman, MD, PhD Editor’s Note: Although this issue’s theme is “Politics and Medicine,” we are very aware that many (if not most) physicians quickly tire of seemingly endless political arguments. Most want to know how real world policies will impact their practices and patients. Andrew Calman, MD, ophthalmologist and chair of the SFMS political action committee, is no stranger to political knowledge and strategy, but has prepared this informed summary of the practical realities of health care reform. We hope you find it useful.

Few people think it’s perfect, or anywhere near perfect. Many Americans believe Obamacare went too far. Others

wish it had gone further and had offered Medicare for all. But love it or hate it, the Patient Protection and Affordable Care Act of 2010—now referred to by both parties as Obamacare—is no longer a bill. It’s the law, and it’s already being implemented. It’s time to get past the politics and familiarize ourselves with the many changes that have already taken place, the flood of newly insured patients arriving in little more than a year, and the longterm changes that will alter—for better or worse—nearly every aspect of how we practice our profession. Only a handful of Capitol Hill staffers and CMS bureaucrats know everything packed into the 907 pages of the PPACA, and the thousands of pages of its enabling regulations. But because every doctor needs to be aware of the key provisions, it is worthwhile to review a succinct implementation timeline. Of course, the November elections could change this equation dramatically. But repeal of Obamacare would not be easy. Sixty of 100 senators, 238 of 435 representatives, and the President would all have to vote for repeal. Considering the uncertainties of electoral politics, this seems unlikely, at least at this writing. Any repeal effort would also have to deal with push back against the provisions of Obamacare that are popular, such as eliminating the Medicare prescription drug “doughnut hole” and allowing young adults to stay on their parents’ policies until age twenty-six. Short of repeal, most of the provisions of Obamacare cannot be altered by a hostile Congress or presidential administration, and the Supreme Court has upheld its constitutionality. At least for the purpose of this discussion, let’s assume the law is here to stay and focus on the practicalities—not the politics.

What Has Already Changed

A number of the provisions of Obamacare have already taken effect. Small businesses employing fewer than twenty-five employees—whose average wages are less than $50,000 per year—can currently receive subsidies of up to 35 percent for insuring their employees during tax years 2010 through 2013. The Medicare doughnut hole has been reduced by 50 percent and will be eliminated in 2020, with phased-in discounts for drugs in 12 13

San Francisco Medicine October 2012

the doughnut hole. Insurers can no longer discriminate against children with preexisting conditions. For adults with preexisting conditions, temporary high-risk pools (Pre-Existing Condition Insurance Plans, have been created to bridge the gap until the state insurance exchanges begin enrollment in 2014. These plans are priced at the same community rates as those for healthy patients, with a maximum annual out-of-pocket of $5,950 and guaranteed issue—an excellent value for cancer patients and others who cannot otherwise obtain insurance. There is also now a ban on lifetime coverage caps, and on rescission of coverage for Americans who get sick. All new individual plans must offer preventive care, including mammograms and colonoscopies, as well as contraception (with exemptions for certain religious organizations), with no co-pays or deductibles. Young adults can now stay on their parents’ policies until age twenty-six, even if they reside elsewhere. States who provide Medicaid up to 133 percent of FPL (federal poverty level) receive federal matching funds. And last month, thousands of astonished Americans received rebate checks from their health insurance companies due to a provision requiring that 80 percent of premium revenue (85 percent for large groups) be spent on actual health care.

2014: Individual Mandate, Medicaid Expansion, and Health Insurance Exchanges

Although many of the provisions implemented so far are popular, some of the provisions that will transform health care beginning in 2014—just over a year away—are more controversial. Americans who are not already covered by public or private health insurance will be required to purchase an individual plan or pay a penalty (or a tax, as Chief Justice Roberts perceived it in his majority Supreme Court opinion). CBO estimates that about 1.2 percent of the population will pay the penalty in 2016. The penalty—1 percent of income, rising to 2.5 percent in 2016, with a minimum of $695 per year for individuals and $2,095 for families—is rather small compared to the cost of health insurance, and many Americans will elect to pay the penalty/tax instead of purchasing expensive coverage. Persons with religious exemptions, such as Christian Scientists, are exempt from the penalty/tax. Additionally, there is an exemption if the least expensive available plan exceeds 8 percent of family income. These people, as well as individuals under thirty, will have the option to purchase cheaper “catastrophic” high-deductible plans instead. Beginning in 2014, the ban on discrimination against people with preexisting conditions will apply to adults as well as children. Annual spending caps will be banned. Consumers and small

businesses will be able to shop for plans in “health insurance exchanges” set up by each state, comparing the cost and features of standardized Bronze, Silver, Gold, and Platinum benefits packages. These benefits packages must provide specified “minimum essential benefits” and will be actuarially standardized so that, for example, a Bronze plan would cover 60 percent and a Platinum plan 90 percent of services for an average population, with the remainder paid by co-payments and deductibles. However, the annual out-of-pocket maximum would be capped at $5,950 per individual ($11,900 per family) for individual plans and at $2,000 ($4,000 per family) for small group plans. Policies offered by the exchanges must offer “guaranteed issue” and “community rating,” where premiums are adjusted only by geographic region, age, and tobacco use, without regard to gender or preexisting conditions. Some states have declined to set up their own exchanges. The department of HHS is empowered to set up exchanges for these states, but funding for these federal exchanges is uncertain and depends on the will of the next Congress.

Medicaid Expansion and Private Insurance Subsidies

The heart of the Obamacare program—and its most costly provision—is an expansion of access to affordable health insurance. This expansion relies on two prongs: a massive expansion of Medicaid for low-income individuals and families, coupled with income-based subsidies for the middle class to purchase private insurance. Under Obamacare, in 2014 Medicaid eligibility will be expanded to cover all individuals and families up to 133 percent of FPL, including adults without dependent children. Federal funds are provided to the states to cover this expansion. However, several states (not including California) have opted out of this Medicaid expansion, fearing long-term runaway costs. Chief Justice Roberts’s decision provided that such states cannot be excessively penalized from opting out. Although they will forfeit the new federal funds for Medicaid expansion, they will not lose their existing Medicaid matching funds. Federal funds are also provided to bring Medicaid physician reimbursement levels up to 80 percent of Medicare allowable. However, these funds will only apply to primary care providers, and only for 2016 and 2017. How these millions of new Medicaid patients will find access to care—including specialty care—is a huge open question, especially in the large states like California that reimburse less than the cost of providing care. For working-class and middle-class families earning between 133 percent and 400 percent of FPL, Obamacare provides sliding-scale subsidies, in the form of a refundable tax credit, to purchase private insurance policies through the state exchanges. For example, a family of four at 150 percent of FPL earning $34,575 would pay no more than $115 per month (4 percent of income) for a Silver plan and would receive additional subsidies to reduce out-of-pocket expenses. A family of four at 400 percent of FPL earning $92,200 would pay no more than $730 per month (9.5 percent of income). These provisions will not completely eliminate barriers to care. However, the nonpartisan Congressional Budget Office estimates that under Obamacare, the number of uninsured

cans will be reduced from 50 million people in 2012 to 20 million people in 2016, a 60 percent reduction. The majority of the uninsured after 2015 will consist of young, healthy adults and low-income individuals in states that have declined to expand Medicaid. Additionally, undocumented immigrants will not be covered under Obamacare. Substantial reductions in uncompensated emergency room and hospital care under EMTALA can be expected, as the vast majority of Americans will be insured. As a corollary, Federal DSH (Disproportionate Share Hospital) subsidies will be substantially reduced.

Employer Subsidies and Penalties

For 2014 and 2015, the subsidies for small employers (fewer than twenty-five employees, with average employee salaries under $50,000) will increase to a maximum of 50 percent of employee premiums. These subsidies phase out with increased numbers of employees and increased average salaries. For example, a small doctor’s office with four employees and an average employee salary of $40,000 would receive a tax credit of 20 percent of employee premiums. However, large employers (fifty or more employees) would be required to provide coverage for their employees or pay a $2,000 per-employee penalty.

After 2014

Beginning in 2015, Medicare physician payment rates will be modified to reflect quality of care, not just volume. The extent to which “quality” will be based on outcomes, use of EHR, low use, patient satisfaction, checking off boxes as in PQRS, or some combination of these is unclear. This is an area where organized medicine will play a crucial role in advocating for payment methodologies that reflect common sense and real quality (rather than meaningless busywork), rewarding neither overuse nor underuse, and maintaining fairness to physicians. Beginning in 2017, states can apply to HHS for State Innovation Waivers to provide alternative, state-based health delivery models, as long as coverage and affordability are not inferior to Obamacare. Vermont has already announced its intention to pursue a waiver for a state-based single-payer system. Legislation has been introduced to allow waivers to be issued as early as 2014. States operating under waivers would be exempt from the individual mandate and employer penalties and would receive federal funding equivalent to Obamacare. In 2018, all existing insurance plans must provide preventive care without co-pays or deductibles. In 2020, the Medicare doughnut hole will be entirely phased out.

Alternative Delivery and Payment Models

A large component of Obamacare is an attempt to “bend the cost curve” and reduce the rate of Medicare expenditure growth. There are several components to this, many of which have been greeted with skepticism from the provider community. It is worth noting that past efforts to limit Medicare spending through Medicare Plus Choice and Medicare Advantage (essentially HMOs and PPOs) have actually increased costs compared to traditional fee-for-service (FFS) Medicare. The HMO experiment has already been done twice and was a failure. However,

Continued on the following page . . .

October 2012 San Francisco Medicine


Obamacare Continued from previous page . . . most members of Congress are not well versed in the scientific method, are convinced that FFS is evil and rewards greedy providers, and are inclined to keep trying similar experiments in the hopes that this time they will actually work. Currently, the Medicare Payment Advisory Commission (MedPAC) makes recommendations to Congress on changes to Medicare payment and program rules, but it has no power to enact such rules itself. However, beginning in 2014, the new Independent Payment Advisory Board (IPAB), dubbed “MedPAC on steroids,” will have the power to set Medicare payment rates and rules for the following year, and its rulings can only be overturned by a Congressional supermajority. The AMA and other physician groups have set the elimination or restriction of IPAB as a high legislative priority, as its powers are viewed by many as excessive and unchecked. In addition to IPAB, Obamacare has established a PatientCentered Outcomes Research Institute to perform comparative effectiveness research. Its recommendations may be considered by CMS but are not binding. There is also a new Center for Medicare and Medicaid Innovation within CMS, which is tasked with overseeing new delivery and payment methods in order to improve care while lowering costs. Obamacare also sets up new entities dubbed Accountable Care Organizations (ACOs), which are groups of providers who contract to provide care for Medicare FFS beneficiaries. These ACOs may include individual providers, IPAs, and/or hospitals. ACOs will, in theory, be rewarded financially for quality and efficiency of care. The initial response from the medical community was lukewarm, with few groups willing to accept the downside risk of bidding for ACO contracts. In response, CMS released updated ACO guidelines in 2011, which streamlined the organizational and reporting requirements and limited the downside risk. Whether ACOs will be a successful component of Medicare remains unknown, but the larger local IPAs, HMOs, and hospital chains can be expected to organize and compete in this arena in the years to come. Individual providers may feel compelled to join with larger entities in order to retain their patient bases and remain viable. Obamacare has also set up a new Federal Coordinated Health Care Office, targeting dual-eligible Medicare-Medicaid beneficiaries, primarily the low-income elderly and disabled, for cost savings. States are encouraged to set up programs to integrate care for these beneficiaries. California, at the behest of Governor Brown, has requested a CMS waiver to expand an existing “pilot project” from four counties (including Los Angeles) to involve the entire state. This project, opposed by CMA, would force California’s low-income seniors into managed care, with a sixor twelve-month “lock-in” provision. Physician fees and access to dual-eligible patients may be severely affected, even though most of the savings from such a forced migration would probably come from long-term care rather than physician services.

What about the SGR?

One of organized medicine’s highest priorities for the past several years has been the repeal of the Sustainable Growth Rate (SGR), which adjusts aggregate Medicare physician payments 14 15

San Francisco Medicine October 2012

based on the gross domestic product rather than the actual demographic growth rate of the Medicare population, the medical inflation rate, or the cost of new technologies. As a result, medicine faces an annual threatened payment reduction of about 30 percent, which is usually averted at the last minute by Congressional action, often after a temporary payment cutoff to physicians. It is worth noting that the House of Representative’s version of Obamacare, championed by our own members of Congress and by House Democrats, contained a complete repeal of SGR and was generally much more favorable to physicians. However, it was the Senate version that prevailed (after the election of Senator Scott Brown provided a forty-first vote for a filibuster, and the final Senate bill was amended through reconciliation), and Obamacare as passed did not address the SGR. The main reason for this is that keeping the SGR in the payment formula allows Congress and the administration to maintain future cost estimates that are artificially optimistic, while averting drastic payment cuts in an annual Congressional drama. However, there is no guarantee that a future Congress, in a deficit-cutting mood, will continue to avert these annual SGR disasters.

How Is Obamacare Paid for?

The main new source of revenue for Obamacare has nothing to do with Medicare. Beginning next year, there is a new 3.8 percent tax on “unearned” income, such as capital gains, dividends, and interest income, for those with total incomes over $200,000 per year ($250,000 for couples). This is coupled with a 0.9 percent increase in the Medicare tax on earned income over $200,000/$250,000. These new taxes on upper-income taxpayers, though receiving little ink or airtime, are among the most important reasons why Obamacare has been targeted for repeal. Other, smaller sources of revenue are a 40 percent excise tax on so-called “Cadillac” health plans (those having premiums over $27,500 per family); taxes on the pharmaceutical, insurance, indoor tanning, and medical device industries; and limitations on cafeteria-plan and health expense deductions. Over the next ten years, Obamacare (including its associated taxes) is estimated by the Congressional Budget Office to result in net savings to the federal government of $109 billion. However, this does not include the cost of SGR repeal, the “crowd-out” phenomenon, employment migration due to the elimination of “job-lock,” increases in medical inflation, and other factors that are inherently difficult to predict and are outside the scope of this article.

What about the “$716 Billion” in Medicare Reductions?

A claim that Obamacare “cuts $716 billion from Medicare” has been made in recent political ads, and it has been debunked by independent, nonpartisan media organizations. Physicians are sophisticated enough, and involved enough in Medicare, to deserve a detailed factual analysis of this claim. The $716 billion figure originated in a July 24, 2012, letter from the nonpartisan Congressional Budget Office in response to an inquiry from House Speaker John Boehner on the cost of repealing Obamacare. The pdf file of the letter is available at files/cbofiles/attachments/43471-hr6079.pdf and is well worth

reading in its entirety. The CBO estimated that if Obamacare were repealed, Medicare expenditures over ten years would increase by $716 billion (see page 14 of the CBO letter to Speaker Boehner). This represents two main areas of Medicare savings that would be lost if Obamacare were repealed: decreased growth in payments to hospitals and home health over the next ten years, and cuts in subsidies to Medicare Advantage insurance companies. These industries actually agreed to these reductions in future Medicare payment growth during the Obamacare negotiations, because they realized they would be offset by gaining millions of new customers on the commercial side. It is also worth noting that the House Republicans’ budget included these same reductions. Benefits to Medicare FFS beneficiaries were not cut by Obamacare. For Medicare Advantage plans, however, there is a reduction in the “stabilization fund” that provided subsidies to insurance companies who provided Medicare HMO, PPO, and private FFS plans. This fund allowed private insurance companies to profit from insuring Medicare beneficiaries, often costing taxpayers 12 percent to 19 percent more than Medicare FFS despite covering a healthier population. The reduction in subsidies to Medicare Advantage insurance companies will restore a level playing field. If Medicare HMOs really are better and more efficient than FFS Medicare—which spends more than 97 percent of revenue on actual health care—these HMOs should be popular and successful. History suggests that, with some exceptions, they will not be. Only about 17.6 percent of Medicare beneficiaries (mostly people in urban areas) are enrolled in Medicare Advantage. For these patients, the reduction in subsidies to their insurance companies may indirectly result in less generous optional benefits such as eyeglasses, hearing aids, dental coverage, and health club memberships. Their co-payments and premiums may also increase. On the other hand, these seniors will benefit from reduced co-payments for preventive services under Obamacare. Nonoptional benefits including outpatient and hospital care, as well as prescription drugs, are not affected.

Miscellaneous Provisions

One of the more interesting provisions of Obamacare is that members of Congress and their staffs will have to participate in the same state health insurance exchanges as ordinary citizens. Obamacare contains only limited provisions for tort reform. Section 10607 allows tort reform demonstration projects by states. Section 10608 extends protection from liability to nonmedical employees in free clinics. Companies offering “mini-med” insurance plans with limited benefits, and companies insuring early retirees under sixtyfive years of age, will receive temporary subsidies to encourage them to maintain coverage. There is a 10 percent Medicare bonus payment for primary care providers and general surgeons practicing in designated health professional shortage areas. This is not an exhaustive list. A number of other changes may occur due to the many pilot projects and commissions created by the PPACA, the results of which cannot be predicted. Impact on Physician Practices Most physicians will be impacted by Obamacare,

less of their specialty and mode of practice. Combined with the subsidies for EHR in the HITECH Act, Obamacare will drive medicine toward more data-driven, technology-intensive, outcomesoriented reporting in order to be eligible for contracting and payment. This has already begun in the Medicare system with PQRI and PQRS initiatives and is spreading to the private insurance sector. Additionally, the ACO initiative will likely accelerate the trend toward practice integration and buyouts by larger entities. In fifteen months, approximately 30 million Americans will begin to enroll in Medicaid and subsidized private health insurance plans. Access problems, especially for Medicaid enrollees, are inevitable. Mandated managed care plans for MedicareMedicaid dual-eligibles may accentuate this problem. Access problems may drive state legislation toward increased scope of practice for limited license practitioners in order to meet the increased need. It should not escape physicians’ notice that “bending the cost curve” is aimed squarely at our profession. In addition to finding new ways to limit physician compensation, Medicare and private insurers will look to physicians to limit their use of costly diagnostics, pharmaceuticals, and procedures and to justify everything we do with outcomes reporting. On the other hand, the health exchanges and subsidies will, for the first time, allow many working-class and middle-class families the opportunity to have real health insurance. We may be shocked in the next few years at the backlog of previously untreated patients who are now crowding our waiting rooms, and we may be gratified at our increased ability to provide the care that these members of our community need. The challenges posed to our profession by Obamacare are real. We will need to become more efficient in the face of increased electronic documentation requirements and declining or stable reimbursements. However, physicians are resourceful and energetic people. Just as we have met the challenges of incorporating new knowledge and techniques and found ways to make the difficult transition from paper charts to computers, we will find ways to handle the transitions of the next few years as well. Regardless of legislative and electoral outcomes, the nation and our patients need our services, and the huge, dysfunctional, but ultimately homeostatic health care economy will find ways to adjust. Obamacare as enacted in 2010 is not the final word on the subject. By staying informed and uniting as a profession to advocate for fair, responsible solutions, we can help shape a positive outcome. Dr. Andrew Calman practices ophthalmology at CPMC-St. Luke’s and teaches at CPMC and UCSF. He is past president of the California Academy of Eye Physicians and Surgeons, and chair of the SFMS’s Political Action Committee, and he served for many years on California’s Medicare Carrier Advisory Committee as well as the National Health Policy Committee of the American Academy of Ophthalmology.

October 2012 San Francisco Medicine



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San Francisco Medicine October 2012

Politics and Medicine

Proposition 29 Tobacco Wars at the Ballot Box John Maa, MD, and Steve Heilig, MPH For the dubious award of “public health enemy number one,” tobacco is undeniably the leading candidate. The illnesses and death related to tobacco use are

well documented and tax our society’s precious health care resources. One of the most effective tools in the long-term battle to curb tobacco’s deadly toll is raising the price of a pack of cigarettes, which reduces youth smoking and provides revenue for treatment, research, and prevention of tobacco-related illnesses. The most recent skirmish in the tobacco wars was waged in June 2012, as California voters were asked to decide the fate of the California Cancer Research Act, or Proposition 29. The tobacco industry gambled more than $50 million dollars to overcome initial strong support, as nearly 70 percent of voters favored Prop. 29 in early polls. After an unknown fate for three weeks after the primary, Prop. 29 was eventually declared defeated by a mere 24,076 votes out of more than 5 million cast—a 50.2 to 49.8 percent margin, the closest for a voter-sponsored ballot initiative in California history. The defeat was a major disappointment for the coalition of health and medical advocates who supported Prop. 29, but that was that . . . perhaps.

 The Confusing World of Absentee Ballots and Recounts

Election laws and details are not topics that surgeons and public health professionals typically delve into. But in the three weeks after the election, many discussed rumors of miscounts in various counties, particularly of absentee ballots—an increasingly dominant form of voting, and one regarded as the most vulnerable to mistakes and even fraud (1). There was valid reason to be concerned; in recent years alone, in Southern California a controversy erupted when tens of thousands of absentee ballots went uncounted for weeks, resulting in a lawsuit that forced the local registrar to include these in the final tally; and in the city of Cudahy in Los Angeles County, election officials were convicted of opening absentee ballots after election day and throwing the ballots away if the votes were not for incumbents. Finally, in September, the Wall Street Journal featured this headline regarding the current Presidential campaign: “GOP is HIt by Voter Fraud”. In American history, only three statewide recounts have reversed an election outcome. In the 162-year history of California, a recount of a statewide initiative has never occurred. A general consensus in elections is to only ask for a recount if the margin is less than 0.1 percent, regarded as the statistical margin of error for counting votes. For the 5 million votes on Prop. 29, the 0.1 percent threshold was 5,000 votes. The Yes on 29 campaign was willing to ask for a recount for a margin as high as 7,500. A Yes on 29 supporter (JM) pledged to contribute $250,000 toward a recount because of peculiar trends noted in the tally and the

recognition that the opponent of Yes on 29 was not a single individual but an entire industry. Strange trends were noted in the final results of the Prop. 29 vote reported by the Secretary of State on July 13. Most relevant was the addition of nearly 20,000 more votes than reported by the fifty-eight counties of absentee ballots left to count on June 25. The initial intent was to explain why nearly 25,000 ballots seemed missing in L.A., and why 26,000 votes suddenly appeared in Placer. During the L.A. recount, a number of issues emerged, such as voters who had voted twice, provisional ballots (those given to voters who arrive at the polling place on Election Day but are not on the list of eligible voters) accidentally counted before confirmation, and large numbers of votes that had been miscounted by machines; more than 50 percent of the precincts contained errors in the machine count identified in the hand recount. In the end, the discrepancy of 25,000 votes in L.A. was the result of an outdated posting on the Secretary of State’s website. Simultaneously, a second voter (SH) stepped forward to make a recount request for Placer County. During that recount, many surprises were revealed, including precincts near Roseville—the site of a Philip Morris/R.J. Reynolds-funded “No on 29” office—with a very high, near-80 percent voter turnout; discrepancies in the numbers of absentee envelopes that required repeat recounts; and the revelation that, unlike most other California counties, Placer did not provide any updates of its vote tally to the Secretary of State until the very end of the canvass. The fundamental question about the discrepancy of 20,000 extra votes remained unanswered and prompted a Public Records Act request to the Secretary of State, and the careful analysis of that data resulted in a recount request for Orange County, which began September 5. Proposition 29 was predicted to prevent a quarter-million kids from starting smoking, reduce health costs by more than $5 billion, and save more than 100,000 lives. Voting has long been called a fundamental, even sacred, American right. What if, even if a majority of Californians voted for these valuable benefits, the election results did not accurately reflect how we voted? And how might that be remedied to reflect the true will of citizens— and to save lives? Dr. John Maa is a surgeon and professor of medicine at UCSF and an SFMS board member. Steve Heilig is on the staff of the SFMS. Their views here are their own.  


1. Fund J, von Spakovsky H. Absentee Ballots: The “Tool of Choice” of Vote Thieves. Ch. 6, Who’s Counting? How Fraudsters and Bureaucrats Put Your Vote at Risk. Encounter Books, 2012. October 2012 San Francisco Medicine


Politics and Medicine

medi-cal managed Where Does the Buck Stop? Assemblymember Richard Pan, MD, MPH In the early 1990s, Medi-Cal faced rising costs and poor access to health care providers, problems that continue to plague the program. The state’s Department

of Health Care Services (DHCS) began experimenting with MediCal and Denti-Cal managed care and implemented Geographic Managed Care (GMC) in Sacramento County as a pilot program in 1994. As the state made the transition, there were only vague references to evaluation criteria and methodology and authority for local decision making. Sacramento County established a commission to oversee the GMC program, which was chaired by past-Sierra Sacramento Valley Medical Society Executive Director Bill Sandberg, but the commission was disbanded in frustration a few years later, since the state allowed it little authority and did not share timely, accurate data on GMC plans with the commission. In 2010, the Sacramento First 5 Commission published a report on Sacramento’s GMC Denti-Cal program, which showed shocking neglect by DHCS of the program and, more important, the children. Use of dental services was as low as 5.5 percent of beneficiaries in one GMC plan, compared to a statewide use of 41.3 percent, and overall use of dental services for children up to three years old was 6.7 percent, compared to 15.9 percent statewide. Calls to selected dental offices accepting Denti-Cal GMC plans revealed that not all staff knew or complied with GMC policy, and professional recommendations were that children should be seen by “the first birthday or the first tooth.” A substantial proportion of Sacramento GMC children did not receive preventive services, although the plans received per-member, per-month payments for all children. In addition, Sacramento GMC Denti-Cal costs were comparable to an equivalent fee-forservice system. Many problems were also found with DHCS oversight of GMC Denti-Cal. Monitoring of plans was reactive, not proactive; and data from internal monitoring reports may have been untimely, inaccurate, or incomplete. The First 5 report noted that the department was not aware that an entire GMC plan’s data was missing from a report until it was pointed out by the Commission’s consultant. It also appeared that the Medi-Cal Dental Services Division did not have the capacity in the number or type of staff positions to fulfill oversight responsibilities for Sacramento GMC Denti-Cal. These problems were no secret to dentists and physicians who, like me, were on the front lines, providing care to children on Medi-Cal who seemed unable to obtain care for their oral health problems. When these problems were brought to light by the Commission and subsequently given public attention in a Sacramento Bee article published in February 2012, public officials including Senator Darrell Steinberg and County Super18 19

San Francisco Medicine October 2012

visor Phil Serna took action. I brought together patients, plans, and providers at a hearing on the history of the GMC Denti-Cal program and partnered with Senator Steinberg to pass legislation to increase state oversight and local engagement over the Sacramento GMC Denti-Cal program. The story of the eighteen-year “pilot” is not over, but it holds important lessons for Medi-Cal managed care, especially given the proposed movement of large numbers of Medi-Cal beneficiaries into managed care, including the aged, blind, and disabled transition; the Dual Eligible (Medi-Cal and Medicare) pilot; expansion of managed care in the remaining fee-for-service counties; the elimination of Healthy Families; and expansion of MediCal into the adult population as a result of the Affordable Care Act. As a physician who cares for many patients on Medi-Cal, I am acutely aware of the numerous problems with the Medi-Cal program, including inadequate payment and high administrative burden on both practices and beneficiaries. Managed care expansion has been touted as a means to improve provider access through plan networks and to improve quality through better care coordination. In addition, managed care is expected to reduce costs, with more than $600 million in state savings expected from the Dual Eligible pilot. Transitioning Medi-Cal into managed care, however, does not absolve the state and DHCS of responsibility for the care of Medi-Cal beneficiaries and appropriate oversight of plans. The aged, blind, and disabled and the Dual Eligible are among the most vulnerable and have access to existing networks of care involving primary care and specialty physicians, other health care professionals, and community supports. Disruption of these networks may have serious, even fatal, consequences for the health and well-being of these patients. It is insufficient for DHCS to respond only to complaints. Waiting for an outside entity to identify departmental neglect, as happened with Sacramento GMC Denti-Cal, is unacceptable. DHCS must take proactive action to monitor the impact of managed care on Medi-Cal beneficiaries through direct contact with beneficiaries and their providers, and through establishing and implementing evaluation criteria and methodologies prior to implementing managed care transitions. DHCS should partner with patient, physician, and other provider groups in developing appropriate evaluations, and DHCS needs sufficient staff capacity to conduct the oversight needed to protect patients. In addition, DHCS should have substantive stakeholder involvement in Medi-Cal. Like Medicaid programs in some other states, Medi-Cal should have a payment advisory commission, composed of physicians and other stakeholders, that has direct access to Medi-Cal data and analysts and can provide the legislature and administration with recommendations to improve quality and access in the Medi-Cal program.

Sacramento County’s eighteen-year experience with GMC Denti-Cal demonstrated that the buck has to stop with the state for Medi-Cal managed care. The state cannot pass responsibility for insufficient or inappropriate care of Medi-Cal beneficiaries on to the plans. DHCS has to exercise oversight and evaluation of Medi-Cal managed care, and that can only occur with the active involvement of stakeholders who are given the authority and means to hold the state and DHCS accountable. We should expect nothing less. Dr. Pan is the chair of the California Assembly Committee on Health. This article first appeared in the Sept/Oct 2012 issue of Sierra Sacramento Valley Medicine. Brown Signs Legislation Requiring Signatures To Opt Out of Vaccination Gov. Jerry Brown (D) signed into law Dr. Richard Pan’s bill AB 2109 AB 2109 requiring parents who choose not to have their children vaccinated to submit a signed statement saying that they received information about the risks and benefits of immunization. The bill was strongly supported by SFMS and CMA as a means of curtailing misinformed refusal of vaccination. The law will take effect in January 2014.

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Artwork copyright © 2012 Dan Harding


Death and/or taxes An Inverse Relationship Steve Heilig, MPH “Sugar, rum, and tobacco are commodities which are nowhere necessaries of life, which are become objects of almost universal consumption, and which are therefore extremely proper subjects of taxation.” —Adam Smith, The Wealth of Nations, 1776  

Some of the nastiest political battles in the health arena these days are over taxation. Of course, such

debates are not new—recall the Boston Tea Party, ignited over British taxation on, yes, tea. But these scuffles have become increasingly common at local, state, and federal levels as the health externalities of various common products become apparent—and as health budgets are ever more strained. “Externalities are costs or benefits arising from an economic activity that affect somebody other than the people engaged in the economic activity and are not reflected fully in prices,” as defined in a recent economics text. A modern example would be environmental pollution, but, as noted by Adam Smith above, other common products entail externalities as well. The irony here is that Smith is regarded as the founding guru of free-market economics, and he coined the phrase “the invisible hand” for how a “system of perfect liberty” might work (the term capitalism was not yet in use). Yet modern politicians tend to out-Smith Smith by signing on to the “no new taxes” pledge of Grover Norquist and hold us all hostage to externalities. (“Who the hell is Grover Norquist, anyway?” former President George H.W. Bush quipped while decrying this pledge recently, showing how more “conservative” the Republican party has become over time.) One critique of such user taxes or fees is that they are “regressive”—everybody pays the same, regardless of income, and poorer people tend to use some of these products more. It’s a valid point, strictly speaking. But viewed in context of the aggressive marketing of tobacco, alcohol, and sugar to people of lower socioeconomic status, it appears we are battling against a kind of “class warfare” and must do what we can to reduce the harms of these products while still preserving the “right” to buy them, albeit without forcing external costs on others. Nor are these really “sin taxes”—smoking, drinking, and eating sweets are not sins in most peoples’ views—although they can be an addiction. What a “no new taxes” pledge really means with regard to unhealthy products is this: “Companies producing X and consumers using X are free to do so all they want to, and it’s just too bad that all of us pay for that via increased health and other costs—and taxes.” So they aren’t truly opposed to taxes, but they just don’t want users and corporations to pay their fair share of costs. Witness these recent skirmishes:

 Alcohol: In 2010, San Francisco considered a tax on alcoholic beverages that amounted to three cents per serving of beer, wine at just under a nickel per glass, and liquor at four cents per shot. But alcohol industry lobbyists camped out in City Hall until they had the votes to kill the fee; two local politicians told me after they would have liked to vote for it but “just couldn’t.” Would people really drink less due to such minor increases? It’s hard to imagine them discouraging anybody from ordering a drink, and the City Controller’s report estimated overall consumption would decline less than 1 percent; but even so, the fee was projected to raise $16 million dollars annually. The City bears the cost of $17.1 million each year for medical care of people with alcohol-related illnesses. If the new fee cost any drinker more than, say, a quarter per day, that’s a different issue that might warrant professional help. Tobacco: Proposition 29, narrowly declared defeated in June, would have raised taxes by $1/pack to $1.87—still in the middle of states in this regard—and using the proceeds for research. “Big Tobacco,” fearing sales losses of up to $1 billion annually, spent $50 million to defeat it. They won, at least so far, even though Prop 29 was projected to save $5 billion and more than 100,000 lives. Sugar: Obesity threatens to become our biggest health issue, for both children and adults. A package of research on sugared beverages, the largest single source of calories for Americans, posted September 21 by the New England Journal of Medicine should put to rest doubts that these products are a significant part of the problem. New York City just banned some portions of sugary drinks, and Richmond, California, led by a cardiologist-turned-politician, is trying to add a pennyper-ounce tax. Yet front groups for the food industry are fighting the proposal mightily (and fighting disclosure of their funding). One criticism is that education should be enough. But in the same NEJM issue, Thomas Farley wrote, “Education about the risks of obesogenic foods and beverages is absolutely necessary, but the continued growth of the obesity epidemic makes it clear that education alone will not solve this problem.” In the meantime, we all will pay more for overconsumption and obesity, whether we fit that profile or not. We’re told death and taxes are unavoidable; is it strange that by not having enough of the latter we get more of the former? Steve Heilig is on the staff of the SFMS. The views expressed here are his own.

October 2012 San Francisco Medicine


“Resources and respect: two of the reasons I’m at Saint Francis.” David Duong, MD, Urologist and Trustee, Saint Francis Memorial Hospital

Saint Francis is led by physicians like Dr. David Duong: urologist, Vietnamese refugee, and Yale graduate who earned his MD at Vanderbilt and completed his residency at Stanford. What brings talented physicians like Dr. Duong to Saint Francis? First-class facilities, advanced technology, and an abiding respect for the professionalism of physicians and the dignity of patients. Saint Francis: Physician founded. Physician led.


San Francisco Medicine October 2012

SFMS SLATE of candidates 2013 Officers | Term: 2013 For President-Elect: Lawrence Cheung, MD For Secretary: Man-Kit Leung, MD For Treasurer: Roger S. Eng, MD For Editor: Gordon L. Fung, MD, PhD

For SFMS Board of Directors

For California Medical Association Trustee

Term: 2013–2015 Seven candidates to be elected to the Board of Directors: Charles E. Binkley, MD Gary L. Chan, MD* David L. Curtis, MD Ralph C. Fenn, MD, PhD Cuyler Goodwin, DO, MPH Katherine E. Herz, MD Justin V. Morgan, MD Ryan Padrez, MD David R. Pating, MD Cynthia A. Point, MD* William T. Prey, MD* Lisa Wing-Yee Tang, MD Joseph W. Woo, MD* * Incumbent Director

Term: October 2012–October 2015 One candidate to be elected as Trustee: Peter J. Curran, MD Shannon Udovic-Constant, MD, FAAP

For Nominations Committee Term: 2013–2014 Four candidates to be elected to the Nominations Committee: Izumi N. Cabrera, MD Poornima Kaul, MD Justin V. Morgan, MD Calvin S. So, MD Yanling Xu, MD

For Solo/Small Group Practice Forum Delegate

For Delegates to the CMA House of Delegates Term: 2013–2014 The candidates receiving the highest number of votes will serve as Delegates; the rest will be Alternate Delegates or on the wait list. The President-Elect automatically becomes the one of the Delegates, according to the SFMS Bylaws: Elizabeth A. Andrews, MD** Peter J. Curran, MD* Cuyler Goodwin, DO, MPH Mihal L. Emberton, MD Steven H. Fugaro, MD** Gordon L. Fung, MD* Robert J. Margolin, MD*** Adam Schickedanz, MD* Judy L. Silverman, MD H. Hugh Vincent, MD* Andrea M. Wagner, MD** Elizabeth K. Ziemann, MD * Incumbent Delegate ** Incumbent Alternate *** Outgoing CMA Trustee

Term: 2013–2014 Eric Tabas, MD (Incumbent Delegate)


2012 President-Elect, Shannon Udovic-Constant, MD, automatically succeeds to the office of President. 2012 President, Peter J. Curran, MD, automatically succeeds to the office of Immediate Past President. Member voting will take place online, IF we have your email address in our database. Please look for a special email from SFMS on October 23 with detailed information regarding the online voting process as well as the link to the online ballot. This is the last year we will mail paper ballots to members, so please provide us with your email address by contacting or (415) 561-0850 extension 200. Paper ballots will be mailed in late October ONLY to SFMS members for whom we have no email address on file. Upon receipt, please mark your ballot and return it immediately in the special envelope provided. All other members must vote online.

Ballots MUST arrive at the SFMS offices by 5:00 p.m., Tuesday, November 13, 2012, whether by mail or electronic means. If mailed, the NAME of the SFMS member (NOT the corporation’s name) must be printed legibly or typed on the return envelope.

Please see candidate biographies and statements on the following pages.

October 2012 San Francisco Medicine




Lawrence Cheung, MD

Man-Kit Leung, MD   Specialty:  Otolaryngology—Head & Neck Surgery

Specialty: Dermatology

Current Job Positions and Hospital and Teaching Affiliations: Solo private practice with volunteer teaching responsibility at UCSF SFMS/CMA Committees or Offices: SFMS (Treasurer, Political Action Committee, Membership Committee, Board of Directors, past Secretary), CMA House of Delegates with participation in HOD Reference Committee A (Science and Public Health) Additional relevant experience: I have been very active in the both the local (SFMS) and state level (CMA). I feel that having actively participated in multiple SFMS and CMA committees has given me a perspective on how to continue to steer SFMS in a positive direction. Why are you interested in serving? SFMS was an invaluable organization for me when I started my solo practice seven years ago and continues to be a resource for me today. The Society serves as my only local advocate and the CMA serves as my only state advocate in matters of public health, patient safety, and physician advocacy. With the looming changes occurring in the profession of medicine, I feel that it is not just a privilege but a duty to make the Society a relevant organization for future San Francisco physicians.

24 25

Current  Job Positions and Hospital and Teaching Affiliations: Private practice in small group; affiliations with Chinese Hospital, St. Francis Memorial Hospital, CPMC, St. Mary’s Medical Center; Adjunct Clinical Instructor, Stanford University School of Medicine Department of Otolaryngology—Head & Neck Surgery  SFMS/CMA Committees or Offices: SFMS Board of Directors, SFMS Executive Committee, SFMS PAC (Vice Chair), SFMS Nominations Committee, Chinese Hospital liaison to SFMS, CMA Alternate Delegate to HOD, CMA At-Large Delegate to COL Why are you interested in serving? I am interested in the position of Secretary so that I can better serve our membership in working toward our shared goals: to advocate for physician and patient rights, to improve medical care for the residents of San Francisco, and to support physicians in creating successful and rewarding practices.


Roger S. Eng, MD, MPH   Specialty: Radiology  

Current  Job Positions and Hospital and Teaching Affiliations: President, Golden Gate Radiology Medical Group; Chief of Radiology, Chinese Hospital SFMS/CMA Committees or Offices: SFMS: Director 2009–12, Executive 2010– 11, PAC 2011–12, Nominations 2011; CMA:  Board of Trustees 1997–98, 2003– 07; Delegate/Alternate Delegate 1995–

San Francisco Medicine October 2012

2012; Young Physicians Section, Chair 2001–02;  IT Committee, Chair 2004– 08; Committee on Nominations 1997–98, 2003–07; Long-Range Planning Committee 2003–07; Chair, CMA Website 2006–07; Health Care Finance Technical Advisory Committee 2004; Committee on Medical Service 1998–99 Additional relevant experience: AMA offices:  AMA Delegate 1996–97; AMA-RPS Delegate 1995–97; AMA-YPS Delegate 1998–99 (Vice Chair, CMA YPS delegation). Related medical affiliations: President Elect, California Radiological Society; Treasurer, San Francisco Bay Radiological Society; Kona Healthcare, Chief Medical Officer; Chinese Community Health Care Association IT Committee 2006–present; Carestream Physician Advisory Board 2005–present; American College of Radiology, Councilor, 2008– present; Chinese Hospital, Medical Executive Committee 2004–2010  Why are you interested in serving? Participating in our local medical society is both a privilege and a community responsibility. As SFMS Treasurer, I will use my eighteen years of organized medicine experience to best serve San Francisco’s physician members and their patients.


Gordon L. Fung, MD, PhD ALSO CANDIDATE FOR DELEGATION Specialty: Cardiovascular Diseases

Current Job Positions and Hospital and Teaching Affiliations: Clinical Professor of Medicine, UCSF Medical Center, Director of Cardiac Services at UCSF Medical Center at Mount Zion, Director of Asian Heart & Vascular Center, Director of Electrocardiography Laboratory at Moffit/ Long Hospitals SFMS/CMA Committees or Offices: SFMS Editor, 2010 to present; Past President, SFMS; CMA Delegate since 2000; Member of Council of Scientific Affairs,

SFMS ELECTION INFORMATION CMA, 2004–present; IMQ Surveyor since 1994 Why are you interested in serving? Communications, education, learning are the jobs of the editor. Over the past two years I have learned much more about the topics and issues facing the clinicians in practice in the community. Working with the SFMS staff, Editorial Board, and Executive Committee and keeping the communication channels open with the membership and other interested parties that interface with SFMS through the San Francisco Medicine has been one of the highlights of my involvement with SFMS. In a sense San Francisco Medicine, our awardwinning journal, is one of the oldest stillviable forms of social media used by the physician community serving San Francisco Bay Area. I truly cherish my time on the board and look forward to serving as your editor for 2013.

Board of Directors

Charles E. Binkley, MD   Specialty: Surgery—Hepatobiliary and Pancreatic  

Current  Job Positions and Hospital and Teaching Affiliations: Attending Surgeon, Kaiser Permanente Medical Center, San Francisco SFMS/CMA Committees or Offices: Nominated to the Council on Ethical Affairs of the California Medical Association   Additional relevant experience: During my residency at the University of Michigan, I served as Vice President of our House Officers Association as well as Administrative Chief Resident. In my previous post at Kaiser Permanente Hayward Medical Center, I was a member of the Credentials Committee and Assistant Chief of Surgery. Currently, at Kaiser Permanente San Francisco Medical Center, I chair the Ethics Committee. I am also active in Bay Area Physicians for Human Rights and on the Host Committee for the Gay and Lesbian Medical Association’s Annual Meeting.

 Why are you interested in serving? I believe that I can serve as an effective leader and advocate for San Francisco’s physicians. I am excited about the opportunity to get to know and represent my colleagues and further strengthen the local medical community. I also look forward to better understanding and helping improve the health of the people of San Francisco. Gary L. Chan, MD (Incumbent Director)

Specialty:  Internal Medicine

Current Job Positions and Hospital and Teaching Affiliations: Private practice, Medical Director of Brown and Toland, Board Trustee at Saint Francis, Chair of credentials at Saint Francis, UCSF clinical faculty  SFMS/CMA Committees or Offices: Currently on the SFMS board of directors, finance committee, executive committee Why are you interested in serving? I have been a member of the SFMS board of directors for ten years and appreciate the work of organized medicine. Physicians’ voices must be heard locally, in Sacramento, and in Washington, D.C. With health care reform, doctors are more confused than ever. SFMS must continue to educate physicians about their options. We must do a better job with the public as well. Physician/patient relationships must be maintained and strengthened. Only with the public trust can we influence health care reform. We must act now for our benefit and to benefit future physicians. We cannot sit on the sidelines bemoaning our fate. Only through organized medicine can we be effective.

David L. Curtis, MD Specialty:  Rheumatology

Current Job Positions and Hospital and Teaching Affiliations: Active private practice   Additional relevant experience: SFMS member since 1983 Why are you interested in serving? I feel it is important to represent the private practitioner and his or her patients in this era of hospital- and large-groupbased medicine. Ralph C. Fenn, MD, PhD   Specialty: Psychiatry  

Current Job Positions and Hospital and Teaching Affiliations: Psychiatrist at Family Service Agency (FSA) since 2008 (FSA has 150 employees and cares for severely mentally ill seniors for SF County), representative of FSA in County Medical Director meetings, supervisor of several nurse practitioners, manager of on-site phlebotomy services, part-time private practitioner near UCSF Additional relevant experience: I will bring the following experience to the Board of Directors: information technology: MIT PhD, 13 years of engineering before medical school; administration: Engineering Manager, Principal Investigator, Harvard/MIT MBA coursework, SFDPH Medical Director meetings; clinical breadth: pathology internship, medpsych consultations, TAY to geriatric clinics, psychiatric emergency interventions, SFPD psychiatrist; setting variety: imaging research, home care, UCSF research partner, public sector, private practice, court-ordered care

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October 2012 San Francisco Medicine


SFMS ELECTION INFORMATION Why are you interested in serving? Most physicians report difficulty accessing outside records for patient evaluations or care coordination. My own geriatric patients are typically poor historians, making outside records essential sources of history. On the Board, I hope use my information technology experience to advance SFMS initiatives to facilitate record sharing as well as other activities. Cuyler Goodwin, DO, MPH ALSO CANDIDATE FOR DELEGATION Specialty: Psychiatry  

Current  Job Positions and Hospital and Teaching Affiliations: Resident Physician, PGY-1; UCSF Department of Psychiatry   SFMS/CMA Committees or Offices: AMPAC Student Advisory Board, 2011– 2012; CALPAC Board of Directors Executive Committee, 2010–2011; SCMA Board, 2010–2012; CMA-MSS Leadership Conference Planning Committee, 2011; SCMS Board, 2008–2010; CMA/AMA Delegate, 2009–2010; CMA/AMA Chapter President, 2009–2010; CMA/AMA Alternate Delegate, 2008–2009; CMA/AMA Chapter Vice President, 2008–2009 Additional relevant experience: Financial Intern, Joan Buchanan for Congress, Congressional District 10, California 2009; Course Creator and Coordinator, Health Policy Elective, Touro University, 2009–2010; Master of Public Health recipient, thesis entitled “Access to Physicians in Marin,” 2012; Speaker, “Legislative Advocacy: How Students Can Get Involved,” CMAMSS Leadership Conference, September 2011; Speaker, “The Legislative Process: The Physician’s Role in Effecting Legislative Change,” Kaiser Permanente Santa Rosa Medical Center, September 2011. Why are you interested in serving? Physicians are strongest when they are organized, when they come together and speak with one voice. This position provides me the opportunity to protect our profession from those who do not have our 26 27

best interests in mind. Additionally, I will work to get my generation more involved. Katherine E. Herz, MD   Specialty:  General Pediatrics  

Current Job Positions and Hospital and Teaching Affiliations: The Permanente Medical Group, Kaiser San Francisco, Department of Pediatrics  SFMS/CMA Committees or Offices: Alternate Delegate, CMA House of Delegates, 2012–2013 Additional relevant experience: I have studied health economics and health policy both as an undergraduate and following residency during a fellowship at Stanford, where I earned a master’s of science in health services research. This background has provided me an in-depth education in the complexities of health care delivery and how policy can affect our work as physicians.  Why are you interested in serving? I enjoy both clinical medicine and population-based interventions that influence health. I would be honored to serve as a director on the SFMS board to help shape both debate and local policy around health care. Justin V. Morgan, MD ALSO CANDIDATE FOR NOMINATIONS COMMITTEE   Specialty: Family Medicine

Current Job Positions and Hospital and Teaching Affiliations: Primary Care Physician with the San Francisco Department of Public Health, Adolescent Health Care Provider at Juvenile Hall, Member of the volunteer faculty at UCSF and U.C. Davis, Staff at San Francisco General Hospital

San Francisco Medicine October 2012

 SFMS/CMA Committees or Offices: Since being invited by friends to become active in SFMS, I’ve attended meetings focused on building membership, a challenged faced by San Francisco’s John Hale Medical Society, where I’ve worked with other African-American physicians interested in keeping our members connected at a time when similar organizations are in decline.  Additional relevant experience: After moving to San Francisco, I helped reorganize and revitalize the AfricanAmerican medical association and was elected president of that organization. As a community leader on health care access issues, I serve as a board member of the San Francisco Black Coalition on AIDS and  was recently a candidate  for a seat on the San Francisco Democratic County Central Committee, where I won 13,625 votes in the June 2012 primary election.  Why are you interested in serving? I’ve always been an active member and leader in physician organizations since medical school, and I welcome any opportunity to support fellow physicians who share with me an interest and enthusiasm for physician community building. Ryan Padrez, MD

Specialty: Pediatrics

Current Job Positions and Hospital and Teaching Affiliations: Pediatric Resident at the University of California, San Francisco, which serves as house staff for UCSF, San Francisco General Hospital, and Kaiser San Francisco hospitals SFMS/CMA Committees or Offices: SFMS Membership Committee Member, SFMS PAC Board Member Additional relevant experience: Prior to medical school, I worked for five years in health policy in Washington, D.C. The majority of that time was spent in health care consulting for clients in government, life sciences, and nonprofits on topics related to Medicare and Medicaid. In medical school I served as the voting

SFMS ELECTION INFORMATION student delegate to AMA, CMA, SFMS, and then to the AAMC. I currently serve as a resident delegate to the American Academy of Pediatrics. Why are you interested in serving? I am a strong believer in the need to better bring physician voices together to advocate for issues affecting our medical practice and patients. As a result, I see serving as SFMS Board Member as a great opportunity to be a young, new physician helping SFMS fulfill this important mission. David R. Pating, MD 

Specialty:  Psychiatry/Addiction Medicine 

Current Job Positions and Hospital and Teaching Affiliations: Chief, Addiction Medicine, Kaiser San Francisco Medical Center; Regional Chair, Addiction Medicine Chiefs, Kaiser Northern California; Assistant Clinical Professor, UCSF; Fellowship Site Director-Addiction Psychiatry SFMS/CMA Committees or Offices: CMA: Committee on the Medical Board (2009), Marijuana Regulation TAC (2011), CMA Gary Nye Award for Physician Health and Well-being (2011); SFMS:  Psychiatry Committee (consultant), SFMS Journal Guest Editor and Contributor, SFMS Daniel Perlman Journalism Award (2011)  Additional relevant experience: Advisor, San Francisco Department of Public Health (Healthy San Francisco Program, Mental Health Services Act, and Suicide Prevention Taskforce); State Commissioner, California Mental Health Oversight and Accountability Commission  (Prop. 63);  Chair, California Coalition on Whole Health  (MH/SUD coalition on implementation of CA Health Exchange);  Board Memberships: CHA-Behavioral Health Board, CPA-Government Affairs, CSAM/ ASAM-Executive Councils, CPPPH-Board, National Quality Forum-Behavioral Health Committee; Past Advisor to Medical Board of California, Diversion Program  Why are you interested in serving? I wish to “give back” to SFMS by participating in its vibrantly influential leadership

in health policy. Whether through its farreaching journal, SFDPH collaborations, or progressive CMA resolutions promoting reform in health care, SFMS is a winner. I hope to make a humbly significant contribution to the SFMS agenda.

Cynthia A. Point, MD (Incumbent Director)

Specialty: Internal Medicine

Current Job Positions and Hospital and Teaching Affiliations: Full-time office-based Internist with an office near St. Mary’s Hospital, on staff at both St. Mary’s and CPMC SFMS/CMA Committees or Offices: Board of Directors, Nominations Committee Additional relevant experience: BOD of Brown and Toland Medical Group, 1994 to 2000; BOD, Children’s Hospital IPA, early 1990s Why are you interested in serving? General medicine (internal medicine, pediatrics, and family practice) will be at the forefront of health care reform as we transition into implementing the Affordable Care Act. We need voices at the SFMS as these changes take place, and I am interested in being one of your voices. The challenge is to find the capacity to cover all previously uninsured people without disrupting long-standing doctor-patient relationships, as some are being cared for by us already. Thank you for the opportunity to serve.

William T. Prey, MD (Incumbent Director)

Specialty: General Psychiatry and Sleep Medicine

Current Job Positions and Hospital and Teaching Affiliations: Solo practice for 27 years, Active Staff at California Pacific Medical Center, Adjunct Professor at Argosy University in Alameda, California SFMS/CMA Committees or Offices: SFMS Board of Directors since 2011, CMA Alternate Representative in the late 1980s Additional relevant experience: I have had several administration positions during my years of practice, including being the Acting Medical Director of the St. Mary’s Hospital Sleep Disorder Center, Psychiatric Director of the Children’s Hospital Eating Disorders Center, and Medical Director/Chief of Staff of the Ross Psychiatric Hospital. These experiences have taught me the importance of teamwork, focused goals, and creative problem solving. Why are you interested in serving? I have learned a great deal about the local politics and complex realities that organized medicine has to face in the Bay Area during my tenure on the board. It is my hope that a renewed term will allow me to have an active voice in helping shape SFMS’s positions on mental health, nutrition, and sleep hygiene. Lisa Wing-Yee Tang, MD 

Specialty:  Family Medicine 

Current  Job Positions and Hospital and Teaching Affiliations: Assistant Module Chief, Family Medicine Module, Kaiser Permanente, San Francisco; Voluntary Clinical Instructor, University of Cali-

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October 2012 San Francisco Medicine


SFMS ELECTION INFORMATION fornia, San Francisco SFMS/CMA Committees or Offices: Nomination Committee, 2010–2012  Additional relevant experience: As the chairperson for the National Task Force on Hepatitis B, focus on Asian and Pacific Islander Americans, I have had extensive experience  fostering coalitions among the scientific community, health professional community, and community organizers, both locally in San Francisco and nationally.  Why are you interested in serving? Having grown up in San Francisco, it would be my privilege to serve on the Board of Directors. Through this role, I will continue my advocacy work. My vision is to be a champion for both patients and physicians at this critical juncture as our nation implements health care reform. Joseph W. Woo, MD (Incumbent Director)

Specialty: Emergency Medicine

Current Job Positions and Hospital and Teaching Affiliations: Medical Director of the Chinese Hospital Emergency Department, Immediate Past Chief of the Chinese Hospital Medical Staff, Current MEC member SFMS/CMA Committees or Offices: SFMS Board of Directors, 2010–12 Why are you interested in serving? I am honored to seek membership to your Board of Directors for another term. I have been attending the SFMS Board meetings for the past eight years as, first, a liaison from the Chinese Hospital and now as a Director. I consider myself fortunate to be among our many intelligent and wellmeaning colleagues and to have learned much from them these past years. I try to represent the viewpoint of doctors in private practice as well as those who are part of our unique community. Also, I have tried to mentor and help other physicians who have any interest in organized medicine. I humbly ask for your vote. 28 29

Nominations Committee

Calvin S. So, MD  Specialty:  Asthma, Allergy, and Clinical Immunology

Izumi N. Cabrera, MD Specialty:  OB/GYN

Current  Job Positions and Hospital and Teaching Affiliations: Attending Physician, OB/GYN at CPMC; Volunteer Clinical Faculty at UCFS Additional relevant experience: Medical committee member of new breast cancer screening program at CPMC; GYN quality committee member at CPMC  Why are you interested in serving? I am eager to participate in committees that will play a vital role in health care and public health. The process of selecting members is a key component in establishing a strong group of physician leaders. Poornima Kaul, MD   Specialty:  Obstetrics and Gynecology  

Current  Job Positions and Hospital and Teaching Affiliations: Full-time Obstetrician and Gynecologist at Pacific Women’s Obstetrics and Gynecology; undertaking patient care at the California Pacific Medical Center (Women and Children’s Center) Why are you interested in serving? Being part of the nominations committee would allow me to gain a better understanding of the issues that shape the health of our community. I would like to be involved in the goals of furthering patient care while providing a conducive environment for practicing physicians.

Current Job Positions and Hospital and Teaching Affiliations: Staff Physician, Kaiser Permanente San Francisco Why are you interested in serving? I’d like to serve on the Nominations Committee to help with the work of the San Francisco Medical Society in finding physicians interested in using organized medicine to help make a positive difference for our patients and our physician colleagues. Yanling Xu, MD

  Specialty:  Internal Medicine  

Current  Job Positions and Hospital and Teaching Affiliations: Internal Medicine/Primary Care Physician at Saint Francis/St. Mary’s Medical Group, Dignity Health Medical Foundation SFMS/CMA Committees or Offices: Membership Committee Why are you interested in serving? San Francisco Medical Society has advocated for our diverse community for years. Outstanding leadership is essential to the future success of SFMS. I feel privileged to serve on the Nominations Committee and to help SFMS continue fulfilling its mission.

Justin V. Morgan, MD ALSO CANDIDATE FOR BOARD OF DIRECTORS. See bio under Board of Directors.

San Francisco Medicine October 2012

SFMS ELECTION INFORMATION Solo/Small Group Practice Forum Delegate

California Medical Association Trustee

Eric Tabas, MD (Incumbent Delegate)


Current Job Positions and Hospital and Teaching Affiliations: Solo Practice; Active: CPMC, Saint Mary’s, Saint Francis; Courtesy: Davies, Mount Zion, UCSF; Associate Clinical Professor of Obstetrics/ Gynecology, UCSF   SFMS/CMA Committees or Offices:  SFMS Member 1987–present, Treasurer 2000, Director 1994–99; SFMS Finance/Investment 1999–2010 (Chair 2000); SFMS Services, Inc., Board 1997–2001(Secretary/Treasurer 1999); Executive 1998–2000; Nominations 1997; Legislative 1988–89; CMA Member 1987– present; Solo/Small Group Practice Forum Delegate, 2006–present Additional relevant experience: I have been in solo practice for twenty-five years. I have been active in our professional groups in an effort to advance policies and legislation for all doctors. An example is my involvement in the recent attempt to ban the medical practice of circumcision. This ban was overturned in court.  Why are you interested in serving? As a delegate of SFMS, I can help shape the issues pertinent to us. SFMS is the only organization that is accessible to all San Francisco physicians. It provides us with a community beyond our individual situations. SFMS is the voice of medicine for doctors, patients, politics, and the media.

Current  Job Positions and Hospital and Teaching Affiliations: St. Mary’s Medical Center, San Francisco: Chairman, Peer Review Committee; Treasurer, Medical Executive Committee SFMS/CMA Committees or Offices: President, San Francisco Medical Society, 2012; CMA House of Delegates Reference Committees three times Additional relevant experience: Two favorite hobbies of mine are politics and baseball, not necessarily in that order. Why are you interested in serving? I truly appreciate the nomination to serve as CMA Trustee representing SFMS. My objectives in this position are to emphasize open communication between CMA leadership and our members and to promote early development of young physicians in organized medicine leadership roles.

  Specialty:  Obstetrics and Gynecology

Specialty:  Cardiovascular Medicine

Shannon Udovic-Constant, MD, FAAP   Specialty: Pediatrics  

Current Job Positions and Hospital and Teaching Affiliations:  Kaiser Permanente Pediatrician; Assistant Clinical Professor, UCSF Department of Pediatrics; Short-Term Director from San Francisco to the Permanente Medical Group (TPMG) Board   SFMS/CMA Committees or Offices: SFMS President-Elect; SFMS Treasurer, 2011; SFMS Board of Directors, 2007–2010 (Executive 2007–current,

Bylaws 2007); SFMS PAC Board, 2006– 2011 (Chair 2009–10, Secretary/Treasurer 2007–08); CMA House of Delegates, 2010–current (Alternate, 2008–09); CALPAC Board, 2011–current; CMA Young Physician Section Executive Committee, At large member, 2003–05; CMA Council on Legislation, member 2010–current Additional relevant experience: I serve on three medical boards: SFMS, TPMG, and ex officio to the American Academy of Pediatrics, California.  I have extensive experience in health care policy and advocacy as cochair for both the AAPCA State Government Affairs Committee and the Northern California AAP Chapter advocacy committee and as a delegate to the CMA House, a member of the CALPAC Board, and a member of the CMA Council on Legislation. This experience allows me to be immediately effective on the CMA Board.   Why are you interested in serving? I am proud to be from the SFMS, with its history of bringing forward important policies that have shaped CMA. I am an outspoken and effective communicator, also skilled at developing coalitions with other physicians. I want to serve SFMS and help the CMA be what San Francisco’s physicians want it to be. 

Delegates to the CMA House of Delegates Elizabeth A. Andrews, MD Incumbent Alternate Specialty:  Internal Medicine, Hospitalist 

Current Job Positions and Hospital and Teaching Affiliations: Staff Physician, Hospital Medicine Department, Kaiser, San Francisco; Core Lead Physician for KP Health Connect  SFMS/CMA Committees or Offices: Alternate Delegate to the CMA House of Delegates, 2011–2012  Why are you interested in serving? In my career I have always had an interest

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October 2012 San Francisco Medicine


SFMS ELECTION INFORMATION in improving the delivery of care, whether by working for a group-model HMO, holding leadership roles at my hospital, or, more recently, working in the area of electronic health records and informatics. The San Francisco Medical Society has a proud tradition of outstanding legislative advocacy for physicians and patients. It was an honor and an eye-opening experience to see the process unfold at last year’s House of Delegates. It would be a privilege to continue serving as one of your SFMS delegates to the California Medical Association’s annual meeting.  Peter J. Curran, MD Incumbent Delegate ALSO CANDIDATE FOR CMA TRUSTEE. See bio under CMA Trustee. Cuyler Goodwin, DO, MPH ALSO CANDIDATE FOR BOARD OF DIRECTORS. See bio under Board of Directors. Mihal L. Emberton, MD   Specialty: Family medicine  

Current Job Positions and Hospital and Teaching Affiliations: Kaiser San Francisco Career-Track Physician; Clinical Teaching Faculty, UCSF Additional relevant experience: Kaiser Permanente, 2011–present: Family Medicine Health Education Champion, LGBTQ Diversity Steering Committee, Diversity Committee; Summa Health System, 2008–2011: Medical Education Restructuring Committee, Patient Safety Initiative, Executive Committee, Diversity Advisory Council, Family Medicine Residency Education Liaison, Graduate Medical Education Committee; Co-President of Class of 2007 at UCD School of Medicine, 2003–2007; Board Member of UCSD Intercollege Resident Housing Association, 1991–1992   Why are you interested in serving? I would like to continue to improve the practice of medicine and the delivery of care from the policy side, where

changes can improve the overall health of Californians and the lives of physicians. I obtained my MPH for exactly this reason. Steven H. Fugaro, MD Incumbent Alternate   Specialty: Internal Medicine Primary Care  

Current  Job Positions and Hospital and Teaching Affiliations: Clinical Faculty at University of California San Francisco; Medical Staff, California Pacific Medical Center   SFMS/CMA Committees or Offices: Consultant on SFMS Board; Member, SFMS Membership Committee; Cochair, SFMS Medical Review Advisory Committee; Member, SFMS Finance Committee; Alternate, SFMS Delegation to CMA HOD; Member, CMA Committee on Legislation; Member, CMA Professional Liability Committee Additional relevant experience: I have been actively involved in organized medicine for more than fifteen years, including being Past President of SFMS. Since that time I have been a member of the SF Tobacco Free Coalition and have worked actively on tobacco control measures at the city and state levels.  Why are you interested in serving? The CMA plays a critical role as the public voice of all physicians in California. The SFMS delegation has had a particularly notable history of successfully advocating for issues important to the physicians and citizens of San Francisco. The CMA HOD is the foremost gathering of physicians in California who have an interest in optimizing the profession of medicine through political advocacy. Gordon L. Fung, MD, PhD Incumbent Delegate ALSO CANDIDATE FOR EDITOR. See bio under Editor.

30 San 31 SanFrancisco FranciscoMedicine Medicine October October2012 2012

Robert J. Margolin, MD Outgoing CMA Trustee   Specialty:  Internal Medicine and Geriatrics  

Current  Job Positions and Hospital and Teaching Affiliations: Primary Care Practice in Internal Medicine; Chief, Division of Internal Medicine at CPMC; Officer of the Medical Staff at CPMC; Board of Directors, Medical Insurance Exchange of California; Associate Clinical Professor, UCSF  SFMS/CMA Committees or Offices: AMA: Alternate Delegate to the House of Delegates; CMA: Board of Trustees, Chair of the Audit Committee, Officer of CALPAC; SFMS: Past President, Past Chair of the Delegation Additional relevant experience: I have spent much of the past twenty years in leadership roles in our medical society and the CMA.  Why are you interested in serving? I have greatly enjoyed my role as your CMA trustee for the past nine years. I believe I have the experience, perspective, energy, and desire to continue to advocate for physicians and their patients and thus ask that you elect me to serve on our delegation. Adam Schickedanz, MD Incumbent Delegate

Specialty:  Pediatrics  

Current Job Positions and Hospital and Teaching Affiliations:  University of California, San Francisco, Department of Pediatrics: Senior Resident; Chief Resident in 2013   SFMS/CMA Committees or Offices:  SFMS Board Member (2012–present), SFMS Executive Committee Member

SFMS ELECTION INFORMATION (2012–present), SFMS Delegate to the CMA House of Delegates (2011–2012)  Additional relevant experience: Fellow of Science and Technology Policy at the Institute of Medicine, National Academies of Science in Washington, D.C. (2008–2009)   Why are you interested in serving? Connecting with the next generation of physicians is how the future of the Medical Society and the CMA will be built. I am committed to bringing the creativity, energy, and industry of young physicians to the Medical Society to start building that future now.  Judy L. Silverman, MD   Specialty: Physical Medicine and Rehabilitation, Pain Medicine  

Current Job Positions and Hospital and Teaching Affiliations:  Private practice, St. Mary’s Spine Center   SFMS/CMA Committees or Offices:  Alternant delegate to CMA, 2010 and 2011 Why are you interested in serving? I approach patient care from a multidisciplinary perspective, integrating different medical issues. At the CMA House of Delegates meeting, this approach is used to develop policy and physician and patient advocacy as a unified front. I feel my perspective as a physiatrist allows me to add to the CMA’s goals. H. Hugh Vincent, MD Incumbent Delegate

Specialty: Anesthesiology

Current Job Positions and Hospital and Teaching Affiliations: Saint Francis Memorial Hospital: Active Staff; Medical Director, Perioperative Services; Vice

Chair, Department of Surgery; Trustee, 1990–2010 SFMS/CMA Committees or Offices: SFMS President, 1992; CMA House of Delegates, 1985–2012; Delegation Chair, 1993–97, Board of Trustees, 1997–2003; AMA Delegate, 1994–2012; Delegation Chair, 1999–2008; Council on Long-Range Planning and Development (CLRPD), 2008–16; Chair Elect, 2011–12; Chair, 2012–14 Additional relevant experience: In my role on CLRPD, it is my privilege to be intimately involved in advising AMA’s Board on evolving trends and stakeholder issues and to participate in its Strategic Planning process. In 2001 I served on the House Select Committee to study internal operations of the AMA. It afforded me great insight into the structure of AMA. It resulted in greatly improved structure and operations of our AMA. Why are you interested in serving? I feel it is my obligation to my profession to leave it a better place, to the best of my ability. It is my wish to make our AMA the vehicle through which all physicians find a common voice to improve their lives and those of their patients. Andrea M. Wagner, MD Incumbent Alternate

Specialty:  Emergency Medicine

Current Job Positions and Hospital and Teaching Affiliations: Medical Director, Northern California for Kaiser EPRP; Staff Physician, Emergency Medicine, Kaiser Foundation Hospital, San Francisco SFMS/CMA Committees or Offices: Alternate Delegate  Additional relevant experience: Board of Directors, California Chapter of the American College of Emergency Medicine, June 2006–June 2012 Why are you interested in serving? I would like to continue in my role in the SFMS delegation to the CMA House of Delegates. We play a critical role for our Medical Society in crafting and promot-

ing policy resolutions. Thank you for your support. Elizabeth K. Ziemann, MD   Specialty:  Family Medicine  

Current Job Positions and Hospital and Teaching Affiliations: Family Physician, Physician Foundation Medical Associates/Sutter Pacific Medical Foundation, August 2010–Present; Hospital affiliation at CPMC/St. Luke’s; Epic EHR Power User, Sutter Pacific Medical Foundation; Epic EHR Implementation Expert, Sutter Pacific Medical Foundation/CPMC; Volunteer Faculty, Sonoma State University, Family Nurse Practitioner Program  SFMS/CMA Committees or Offices: SFMS, Board of Directors; SFMS, Liaison to CPMC/St. Luke’s Hospital; SFMS, Nominations Committee   Additional relevant experience: California Health Care Leadership Academy (recipient of SFMS scholarship), American Academy of Family Physicians (AAFP) Chief Resident Leadership Development Program  Why are you interested in serving? I am interested in this position because I want to learn how to effectively engage in the legislative process. I believe primary care physicians have a unique and vital perspective on health care and need to be leaders in health care reform. 

October 2012 San Francisco Medicine




Saint Francis

Robert Mithun, MD

Diana Nicoll, MD, PhD, MPA

Patricia Galamba, MD

Now that the Justices of the Supreme Court have made their decision regarding various aspects of the Patient Protection and Affordable Care Act, it’s time to continue the work of implementing the many provisions of the law, leading up to and beyond 2014. One relevant component of the health care reform discussions is the mix of “patientcentered health care” and “population-based medicine.” This means we aim to deliver personalized care to patients while using evidence-based approaches to care. Both approaches help reduce waste and reallocate resources appropriately. When done well, patients receive the best care while contributing to the study of best practice for the larger population. This goal is not easy to achieve, and health care organizations all over the country have created pilot projects to mesh these two approaches to patient care. At Kaiser Permanente, we’ve been investing resources and expertise in this combined model for decades with culturally competent care providers, electronic medical records, and evidence-based medicine with a focus on population health. According to Sharon Levine, MD, a pediatrician and associate executive director of the Permanente Medical Group, “Our ability today to measure and monitor the effect of illnesses and interventions gives us information about people who are like the patient. From that we begin to understand the needs, preferences, and clinical concerns of the patient in front of us.” If we continue to apply the basic principles of both patient-centered health care and population-based medicine at Kaiser Permanente and throughout the country, we can begin to truly deliver on the affordability, accessibility, and quality that are so urgently needed moving forward.

32 33

Sleep disorders are common among the elderly; up to 40 percent suffer from sleep disorders such as insomnia and sleep apnea. Dr. Kristine Yaffe, chief of Geriatric Psychiatry at the San Francisco VA Medical Center (SFVAMC), initially evaluated the sleep patterns of more than 1,300 patients over the age of seventy-five. Five years later she assessed their cognitive ability. She found that there was an association between sleep disorders and dementia: Twice as many patients with sleep disorders were found to have developed dementia, compared to those without disturbed sleep. These findings were presented at the annual conference of the Alzheimer’s Association, held in July in Vancouver. More studies are needed to determine the exact nature of the relationship between sleep disorders and cognitive decline. The San Francisco VA Medical Center’s (SFVAMC) outpatient catchment area extends north from San Francisco to the Oregon border, with primary care clinics in Eureka, Ukiah, and Clearlake, California. An expanded telemedicine program increases access to specialty care consultation for veterans in these rural areas by simultaneously linking several primary care providers in different rural communities within our service area to a specialist at SFVAMC. The exchange of information that ensues enables rural primary care clinicians to gain the knowledge needed to provide care that was not previously available to patients in their clinics. Additionally, some veterans with chronic conditions that require complex care can avoid traveling great distances to obtain the care they need.

San Francisco Medicine October 2012

Saint Francis has teamed up with the America’s Cup Oracle Team USA as its official hospital partner. We will provide more than 140 team members, staff, and their families with fast-track admitting in our emergency department as part of our enhanced Concierge Program. This partnership was made possible through the relationship of orthopedic spine surgeon and Saint Francis Trustee Clement Jones with One Medical Group. This sports partnership helps further position Saint Francis as the preferred health care provider for sports teams in the Bay Area. In addition to Oracle Team USA, Saint Francis and Dignity Health also combine as the official health care provider for the San Francisco Giants, and just this past season we became the official health care provider for the San Rafael Pacifics, a minor league baseball team. It seems almost impossible, but we are coming up to the holiday season, and the Saint Francis tradition has been to kick off events with the “Holiday Hobnob on the Hill.” December 7 at the Fairmont Hotel will mark our twenty-fourth annual fund-raising event. Hosted by the Saint Francis Foundation, the evening will begin with a cocktail party and silent auction, followed by a sit-down dinner and dancing. Our guest speaker is New York Times best-selling author Kelly Corrigan, a cancer survivor. Over the years the monies raised at the Holiday Hobnob have gone to support many programs and facilities here at Saint Francis, including our new emergency room, our new surgical department, the reconstruction and expansion of our Bothin Burn Center, the new intensive care units, digital mammography . . . and the list goes on. For more information, contact Bridgett Hart Lanza at

From the SF Department of Public Health St. Mary’s Francis Charlton, MD

Mandatory Influenza Vaccination or Masking of Health Care Workers during Flu Season The San Francisco Department of Health has issued an order mandating that all hospitals, skilled nursing, and other long-term care facilities in the City and County of San Francisco require their health care workers (HCWs) to receive an annual influenza vaccination or, if they decline, to wear a mask in patient care areas during this flu season.

The Affordable Care Act has brought health care reform to the forefront on a macro level. Big changes are certainly in store for all of us, both health care providers and consumers. There is no stopping the tidal wave of change about to engulf us. It is on a personal, micro level, however, where each of us can have our own distinct and crucial impact on the delivery of health care. A disturbing amount of medical expenditures are wasted, for myriad reasons. Fear of litigation is dreadfully overblown as a rationale for excessive testing. Truly informed consent/refusal and documentation thereof can obviate much of this waste. Specious, avaricious, and obsessive desire for completeness/certainty has become standard operating procedure for fee-for-service providers who routinely recommend another test to better define the patient’s pathology. There is always another expensive study that can be ordered. We have allowed our technological capabilities to dictate our practice patterns. History taking, physical examination skills, and clinical judgment all too often take a backseat to high-tech imaging procedures. Cultural expectations often lead us into more waste. Simply put, we are all born to die. Failure to accept the inevitability of death is breaking the bank, not to mention the collateral damage of straining our limited resources and essentially subjecting our soon-to-bedead loved ones to torture. We must educate our patients and families that just because we can provide certain services does not mean that we should provide them in futile settings. The opportunity is there for each of us to get back to basics. We need to pull the stethoscopes out of our bags, put our healing and diagnostic hands on our patients, even if it means going to their homes to do it, and use our skills and knowledge instead of reflexively resorting to the technological monster we have created.

Influenza infection accounts for 36,000 excess deaths in the U.S. each year; 90 percent of these are people over the age of sixty-five. HCWs are both at risk for influenza themselves and can transmit the virus to their patients. The goal is to increase influenza vaccination rates of HCWs, reduce employee absenteeism during the flu season, and reduce HCW-to-patient transmission of influenza. The influenza season is defined as December 15 to March 31.

—Thomas Aragon, San Francisco Director of Public Health For a copy of the health department order, visit the SFMS blog at http:// mandatory-influenza-vaccination.aspx.

Tracy Zweig Associates INC.







Nurse Practitioners ~ Physician Assistants

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October 2012 San Francisco Medicine


NEW MEMBERS SFMS is pleased to welcome more than 150 physicians, residents, and fellows to membership in the medical society. With your membership, you will join more than 1,500 members championing the cause of San Francisco physicians and their patients. SFMS would also like to extend a special thank you to Dr. Robert Mithun, physician in chief, Dr. Shannon Udovic-Constant, Dr. Charles Wibbelsman, Dr. Steven Follansbee, and Dr. George Susens. Under their leadership, TPMG-San Francisco will sponsor membership for any physician within their group who wishes to join SFMS/ CMA. Thank you TPMG-San Francisco for your commitment to organized medicine!


Pedro Aceves-Casillas, MD | Internal Medicine Samira Yasmeen Ahmed, MD | Internal Medicine Jonathan Paul Alexander, MD | Hospitalist Sashi Bindu Amara, MD | Internal Medicine Jacob Asher, MD | Otolaryngology Konstantin Bukov, MD | Family Medicine Ahchean Aqing Chen, MD | Pathology Russell Eugene Ching, MD | Cardiovascular Disease Melody Yao-yin Choong, MD | Hospitalist Fabiola Cobarrubias, MBA, MD | Internal Medicine Justin Paul Collingham, MD | Obstetrics and Gynecology Mark Edmunds, MD | Transfusion Medicine Victoria Alexandra Epstein, MD | Otolaryngology Terry Farrow, MD | Internal Medicine Anita Pravin Ghandy, MD, MPH | Hospice and Palliative Medicine Althaea Greenstone, MD | General Surgery Robyn Joy Goodfellow, MD | Obstetrics and Gynecology Richard Grossman, MD | Plastic Surgery Jill Marie Guelich, MD | Obstetrics and Gynecology Aissatou Haman, MD | Internal Medicine Meredith Heller, MD | Internal Medicine Katherine Elizabeth Herz, MD | Pediatrics Charity Katherine Hill, MD | Physical Medicine and Rehabilitation Rena Rui Hu, MD | Obstetrics and Gynecology Sumie Iwasaki, MD | Internal Medicine Poornima Kaul, MD | Obstetrics and Gynecology Theresa Ann Kemnitz, DO | Internal Medicine Jane Jae Jung Kim, MD | Radiology Yunie Kim, MD | Internal Medicine Ivy Ann Ku, MD | Internal Medicine Erica Pych Kurien, DO | Family Medicine Samantha A Langer, MD | General Surgery Jessica B Lapasia, MD | Nephrology Marc Jay Lee, MD | Diagnostic Radiology Liyun Li, MD | Obstetrics and Gynecology Jennifer Lin, MD | Internal Medicine Alison Carol Lyke, MD | Dermatology Kevin Patrick Martinez, MD | Internal Medicine Constantina L Master, MD | Pulmonary Disease Margaret Mary McNamara, MD | Pediatrics Kunal Mehtani, MD | Hospitalist

Edward Miranda, MD | Plastic Surgery Sophia Mirviss, MD | Family Medicine Robert R Mitchell, MD | Family Medicine Justin Verniea Morgan, MD | Family Medicine Stasia Bochnowski Muhlner, MD | Occupational Medicine Jennifer Joyce Narvaez, MD | Psychiatry Rachel Wai-sum Ng, MD | Internal Medicine Karoline Nowillo, MD | Plastic Surgery Dawn Dodge Ogawa, MD | Obstetrics and Gynecology Stephanie Oltmann, MD | Family Medicine Antonio Jose Otero, MD | Urology Ann-Jerry Peters, MD | Family Medicine Isabella T Phan, MD | Medical Oncology Yiukei Poon, DO | Internal Medicine Robert John Purchase, MD | Orthopaedic Surgery Elizabeth Ollie Ross, MD | Gastroenterology Sooji Lee Rugh, MD | Internal Medicine Ali Salim, MD | Plastic Surgery Hector Luis Santiesteban, MD | Internal Medicine Michael Charles Schrader, MD, PhD | Internal Medicine Meena Seshamani, MD | Head and Neck Surgery Uttama Sharma, MD | Family Medicine Yi Brenda Shue, MD | Endocrinology Silver C Sisneros, DO | Internal Medicine Melissa Renee Sullivan, MD | Anesthesiology Jahan Tavakoli, MD | Oncology Shannon Michele Thyne, MD | Pediatrics Rochelle Joy Tinitigan, MD | Family Medicine Richard E. Topel, MD | Pediatrics Sandra Lissette Torrente, MD | Obstetrics and Gynecology Ailinh Jessica Tran, MD | Internal Medicine Tiffany Nguyet-thanh Troung, MD | Emergency Medicine Binbin Wang, MD | Anesthesiology Christy Sue Waters, MD | Psychiatry Amy Elizabeth Whittle, MD | Pediatrics Roger Manyuk Wu, MD | Psychiatry Yanling Xu, MD | Internal Medicine Kyoko Sayuri Yamada, MD | Critical Care Medicine Pearl Wong Yee, MD | Obstetrics and Gynecology Kimberly Young, MD | Family Medicine

Residents Iris Ahronowitz, Patrick Alore, Ben Alter, Neha Amin, Lilly Bellman, Amy Berger, Christopher Berger, Meghan Bhave, Brittany

Blockman, Melissa Ann Catenacci, Emily Liu Chanan, Sally Chia-chien Chang, Jonathan Cheah, James L Chen, Babak Cohen, Marcus Dahlstrom, Manuel Jose Diaz, Angela Echiverri, Geraldine Edet Ekpo, Cuyler Goodwin, Rachel Greenblatt, Melanie Hall, Sandra Y Han, Christine Hessler, Kyungmin Kang, Bryan Klassen, Sarah Knish, Marianna Kong, Lien Le, Nicole Learned, Rebecca Lindsay, Melissa Rose Lorang, Sabeen T Lulu, Mitchell Luu, Joshua Menke, Gudrun Elizabeth Mirick, David Nguyen, Sandeep Palakodeti, Peter Scott Pressman, Shyam S Raghavan, Aparna Raj, Sameera Rana, Ranjan Ray, Amanda Raymond, Roberto R Ricardo-Gonzalez, Nathaniel Robbins, Sara Sani, Adam Schickedanz, Beamy Sharma, Jeremy Shaw, Fauzia Shujaat, Neil Simon, Karin Sinavsky, Hossein Tabriziani, Abraham P Thomas, Angeline Ti, Paula Tran, Binh Trinh, Neelima Tummala, Alan Justin Viglione, Karen L Wallace, Chia-ching Jackie Wang, Shan Lyn Ward, Jervis Yau, Priscilla Yee, Kurt Yusi, Matthew Zinter Students Abdullah S. Alqahtani, William Feldman, Dennis Hsieh, Allen Seol, Katie Telischak, Wesley Yu 34

San Francisco Medicine October 2012

The Supreme Court’s Decision Doesn’t Change One Thing You still need to make important decisions now about rising health insurance premiums. So what can you do? your medical rates increasing this year, we might • Enroll in a qualified High-Deductible Health Plan be able to help you offset some of that increase. and open a Health Savings Account. This provides significant premium savings that can help • Mercer Select HRKnowHow If you play a role fund your HSA account. With individual-only in your medical group’s health care and benefit coverage, you are eligible to contribute plan decisions, stay current on challenging issues. up to $3,100 to your account or Access is included at no charge for all members $6,250 with family coverage, on a who purchase group health insurance through tax-deductible* basis (members age Marsh/Seabury & Smith Insurance Program 55–64 are eligible to contribute another Management. $1,000). Includes: • Investigate RAF Sales Health plans offer incentives • News and analysis of important benefit issues. through discounts off their risk adjustment factors • Compliance Link tool to assist with health care (RAFs) for you to change health plans. Instead of and group benefit plan administration. * Marsh and the Society do not provide tax, investment or legal advice. Please consult with your professional advisors for guidance on these issues.

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We Celebrate Excellence – Corey S. Maas, MD, FACS CAP Member and founder of “Books for Botox®” community outreach program, benefitting the libraries of local underfunded public schools

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October 2012