Operation Access: Local Medical Volunteerism at Its Finest

of 47. Originally from Costa Rica, Luis has worked and lived in Marin for many years. Uninsured due to his immigration status, Luis was concerned about the potential cost of care he might need. He visited his local community health center Marin Community Clinics (MCC) in San Rafael for help.

After evaluating Luis’s symptoms and test results, his primary care provider at MCC, Frank Tool, FNP, referred him to Operation Access, a Northern California nonprofit, for a colonoscopy. Luis was so happy when he learned that he qualified and his colonoscopy would be donated.

Operation Access matched Luis with Dr. Natalie Lee from Marin Gastroenterology and the Endoscopy Center of Marin (ECM). As Luis’s procedure day came closer, he experienced a mix of thoughts and emotions. He was ready to get the screening but he was also sad, nervous, and couldn’t stop thinking about his father who had died two years earlier from colon cancer. Luis knew that getting this colonoscopy was very important.

Prior to his procedure, Luis carefully followed the prep instructions and showed up early to ECM with his best friend the morning of his procedure. Dr. Natalie Lee and staff were able to calm his nerves and prepped him for his colonoscopy. During the procedure, Dr. Lee removed two polyps for biopsy. Luis was relieved to learn a short time later that the biopsy did not indicate colon cancer.

Access to surgical and specialty care is vital to the health of our community, but many low-income people either do not qualify for, or cannot afford, health insurance. Operation Access provides a solution by coordinating care for uninsured people who need it. They match medical professionals who donate their time and expertise with patients referred from community clinics. This medical volunteerism works to restore health and prevent emergency room visits, and OA’s culturally sensitive and multilingual staff members provide medical volunteers with efficient logistical support to enable them to provide this care. Operation Access coordinates care in a wide variety of specialties throughout the San Francisco Bay Area and is seeking volunteers as it expands to many other communities in Northern California.

Colonoscopy is the most common procedure coordinated by Operation Access. Their patients exhibit above-average risk, such as having found blood in the stool from a positive FIT test. Colon cancer screening rates across all communities have been impacted by COVID, but OA staff are working with patients and their volunteer partners to provide a safe environment for screening to continue despite the virus. While the need for services in Marin County is high, the strain on health care providers posed by the COVID-19 pandemic has temporarily disrupted referral volume to Operation Access as potential patients have deferred nonemergency care. Referrals for 2020 are projected to be 21% lower than 2019. The pandemic has also reduced the service capacity of many specialist volunteers. OA leverages a large and diverse network of partner hospitals and surgery centers to overcome these limitations, but, by year-end, they anticipate service volume will be lower and wait times higher than anticipated at the outset of 2020. Staff are focused on triaging urgent procedures and serving patients at highest risk of colon cancer.

Marin Gastro/ECM specialists Dr. Timothy Sowerby, Dr. Ripple Sharma, Dr. Natalie Lee, Dr. Vikram Malladi, Dr. Christopher Hogan and other staff members have consistently demonstrated their dedication to serving local community members through Operation Access. The ECM team was awarded the All Hands on Deck Award in 2019 for their amazing teamwork and commitment to providing important GI diagnostic screenings throughout the year and during annual Super-GI session events. In 2019 and 2020, they provided record-breaking numbers of GI screenings in a single day through Operation Access- 22 and 24 total procedures respectively!

Thanks to Dr. Lee and the ECM staff, patients like Luis have access to the care they need. He now feels happy and relieved, no longer worried he has cancer. He knows that in five years he will need another screening due to his family history and symptoms, but now he is less fearful of the future knowing there are programs like Operation Access and people like Dr. Lee who want to help others. Luis stated, "My sincere thanks to all who worked hard to help me. Infinite thanks. May God bless you. Keep working hard to help those most in need in our community. Thank you and ‘pura vida’ to all!”

If you are interested in learning more or getting involved with Operation Access, please contact Elise Hilsinger, Marin Program Manager, at elise@operationaccess.org or Dennise Garcia, San Francisco Program Manager, at dennise@operationaccess.org.

Many senior physicians or those with pre-exiting health conditions are reluctant to return to practice. Other reasons include retiring, starting up a new practice, accepting a position elsewhere, selling the practice, divorce, illness, or death. Physicians may be surprised to realize the many unique responsibilities that accompany the decision to close the practice.

There are many people who will be affected by the physician closing a practice. These are your patients, staff, referring physicians, spouses or significant others, heirs, insurance companies, hospitals and vendors.

The most heartbreaking scenario is when a physician dies unexpectedly. The spouse/heirs are grieving yet at the same time, there are many responsibilities for them to complete. The most loving thing a physician can do for the family is to make sure they are fully educated and prepared to close the practice. A living trust is an essential estate planning tool to avoid probate and taxes. Don’t put this off! Please keep a copy of this article with your trust and will. Have your heirs immediately call your local Medical Society. They can assist your spouse, heirs, executor, or estate trustee in many ways. Assure that your heirs can locate passwords, bank accounts, safe deposits, credit cards, income tax reports, lease agreements, malpractice and all health, life, disability insurance policies and staff employment data.

In a physician death, it is wise to have another physician as soon as possible see patients and this can be either a colleague or a locum tenens physician. A spouse can legally run the practice and bill for the deceased physician for six months after death in California. This gives time to either sell or close the practice while still having income flowing in. All the notification tasks outlined when retiring or moving must also be done with death for closing of the practice.

If there is enough time, for example more than one year, it is best to try to sell or transition the practice. If you do not either sell or find a custodian of records, the physician or estate will be responsible for retention of the medical records for as long as the malpractice carrier wishes them to be retained. This responsibility also includes release of information requests from the patient to copy or send records to a new physician. This can be 10 or more years and a significant burden! One of the first tasks is finding out from your malpractice carrier their current records retention guidelines. In one practice, the manager shredded all records more than 7 years from date of service and the malpractice carrier guidelines were 10 or more years. Selling the practice or finding a custodian of records will relieve the physician or estate of maintaining records. In both scenarios, a legal agreement should be written that spells out the responsibilities of the buyer or custodian of records including length of retention, access to the records for departing physician in the case of a professional liability claim and hold harmless agreements for both parties.

The departing physician will need to write a letter to “active” patients to avoid abandonment. A physician can’t just simply put a sign up “retired, gone fishing!” Most malpractice carriers suggest 45 days notice prior to closing the practice. There is no absolute guideline what are “active” patients are but usually the last 2-3 years of patient care is sufficient. Any surgical or cancer follow up patients should receive the letter. If you are selling or engaging a custodian of records, you can combine the notice with an introduction to the purchasing or custodian of records physician. If the patient does not wish to transition to the recommended physician, you can offer a release of information form to transfer the records and also charge the patient for copying records according to California guidelines. These are $4.00 per quarter hour of time plus $.25 per page. Record release requests must be complied within 15 working days.

Please consider writing a warm thank you to your patients for being entrusted with their healthcare and that you are grateful to have been a part of this patient care for these years. A physician showed me a retirement letter that complained about insurance companies, fear of malpractice and other negative reasons for retiring. This is sour grapes and not recommended! The patients want to be assured that you loved being a physician and enjoyed taking care of them. It is also a good idea to take out an ad in the local paper announcing your retirement which also proves you did not abandon patients. It is also recommended to send out a letter to your referring physicians in the community as well for notification.

When to tell staff your plans to close the practice also presents a dilemma. It is recommended a few days or week prior to sending out the letter to patients. You may wish to offer a small severance to encourage them to stay until the closing of the practice. You also need to arrange for continued billing and collection work after the close of the practice. Notify 401k or pension administrators regarding rollover for pension/401K plans. You will need to issue the final paycheck with all vacation accruals paid. If you provide health insurance, the brokers will need to be alerted to send out COBRA information to your staff. Maintain employee files indefinitely.

Medicare, Medi-Cal, insurance payor companies, IPAs and hospital privileging usually require a 90 day notice of closing a practice. Your landlord may require a 30 or 60 day notice. You may be able to extend a lease on a month to month basis until close. Vendors may advance require a notice of discontinuance of services, particularly biohazard waste.

If you have controlled drugs in the practice, you must keep a record of inventory for three years after closing the practice. Also, you should not throw away any drugs, especially controlled drugs into waste receptacles. There are specified companies that will remove controlled drugs. Two times per year, April and October anyone can take controlled drugs to participating police departments free of charge for them to dispose of these drugs. http://www.deadiversion.usdoj.gov/ drug_disposal/takeback

If you no longer wish to practice medicine in any capacity you must deactivate your DEA number (AFTER you have disposed of all drugs) and your medical license in California via the California Medical Board. Professionally shred any prescription pads.

Decide where you wish your mail to go and notify the US postal service of the address. Cancel telephone, internet, websites and utilities. Keep your bank account open for practice checks to be deposited for at least a year. Speak with your CPA regarding closing or winding down a corporation.

Creating a checklist of these tasks with a timeline countdown to the actual closing of the practice is recommended as to not forget any of these important tasks to successfully close the practice.

© Copyrighted 2019, updated 2020 Debra Phairas, Practice & Liability Consultants. (415) 764-4800 www.practiceconsultants.net

Dr. Lee Greenawald NIOSH, 626 Cochrans Mill Road, Building 141, Pittsburgh, PA 15236 Via ppeconcerns@cdc.gov

Dear Dr. Greenawald:

We respectfully submit this comment from the San Francisco Marin Medical Society, a 152-year old association of approximately 3,000 physicians of all specialties and settings practicing in San Francisco and Marin counties, California. When Covid-19 first began to appear here early in this year, San Francisco health authorities and clinicians mobilized quickly in response. But one crucial limiting factor quickly became apparent – as shortage of appropriate PPE, including and especially protective masks. The SFMMS was able to procure a supply from China and distribute to frontline physicians to help fill some of the gap, but critical shortages remained. The San Francisco Emergency Physicians Association conducted a quick survey of members working in emergency departments and received many reports of shortages. The immediate demand for the SFMMS masks from physicians in a wide variety of locales and settings further indicated the problem. We heard many reports also of clinicians re-using masks beyond any likely standard of safety and efficacy. A large distribution of masks and other PPE coordinated by the California Medical Association elicited thousands of requests from medical practices statewide. The need is projected to continue. But ongoing shortages are, candidly, tragic and demoralizing.

Thus, we join the widespread call for more and better PPE, in this case, adopting reusable half-facepiece elastomeric respirators. As noted in a recent NAM report, these are “Commonly used in nuclear power and radiation industries, these respirators can be reused if a rigorous cleaning and disinfection protocol is in place. Elastomeric respirators are well-suited for units that care exclusively for COVID-19 patients. Given postponed elective procedures, central supply employees can be redirected to process and disinfect these respirators.”

There are many reasons to adopt some new standards and products for this type of PPE. These include: Acute shortages of N95 respirators persist, particularly in less-resourced health care settings (skilled nursing, FQHC, correctional facilities, long-term care, EMS); widespread reuse of N95s for prolonged shifts and days, with mixed results of adequate protection; virtually all N 95 decontamination procedures, aimed at re-use, are unreliable, confusing and, most important, unproven; varied adherence to published guidance and unclear efficacy; discomfort and inconvenience of prolonged N95 use; and more.

We are also aware that at least two large health systems have shown that reusable EHMRs, with proper cleaning/disinfection protocols and fit testing, can be safely used in acute care settings, at both the University of Maryland and Allegheny Health System.

For all these reasons, we request and encourage that a new EHMR strategy be adopted, tested, and implemented on a fast-track basis, for the protection of both clinicians and patients in this Covid-19 era. Thank you for your attention. Brian Grady, MD, President Steve Heilig, MPH, Director, Public Health and Education SFMMS