Fall 2009

STEALING

YOUR MONEY Fraud and Embezzlement In The Medical Practice Fall Issue 2009 FALL 2009

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Now, more than ever.

Becoming disabled could stop your income. Do you have a reliable financial source to help replace it?

Three in ten entering the workforce today will become disabled before retiring1. A disabling injury will sideline one in five Americans for at least a year before they reach age 652; one in seven for five years or more3.

San Joaquin Medical Society members can turn to the SJMS-sponsored Long Term Disability Insurance Plan. This plan is designed to provide a monthly benefit of up to $10,000 if you become Totally Disabled.

Members age 50–59 are eligible to apply for up to $6,000 per month.

Visit www.MarshAffinity.com/ cmadownload.html for more information and an enrollment kit.

Administered by:

Please call a Client Service Representative at 800-842-3761 or visit www.MarshAffinity.com/ cmadownload.html to download an enrollment kit.

Let us show you how your membership in the Society can save you money.

Social Security Administration, Fact Sheet January 31, 2007 Life and Health Insurance Foundation for Education, November 2005 3 ”Commissioners Disability Table, 1998,” Health Insurance Association of America, the New York Times, February 2000 1 2

Underwritten by:

Sponsored by:

42640 (9/09) ©Seabury & Smith Insurance Program Management 2009 d/b/a in CA Seabury & Smith Insurance Program Management • CA License #0633005 777 South Figueroa Street, Los Angeles, CA 90017 • 800-842-3761 • CMACounty.Insurance@marsh.com • www.MarshAffinity.com Marsh is part of the family of MMC companies, including Kroll, Guy Carpenter, Mercer and the Oliver Wyman Group (including Lippincott and NERA Economic Consulting).

Hartford Life and Accident Insurance Company, Simsbury, CT 06089. The Hartford® is The Hartford Financial Services Group, Inc., and its subsidiaries, including issuing company Hartford Life and Accident Insurance Company. All benefits are subject to the terms and conditions of the policy. Policies underwritten by Hartford Life and Accident Insurance Company detail exclusions, limitations, reduction of benefits and terms under which the policies may be continued in force or discontinued. (AGP-5719) • #3-924

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SAN JOAQUIN PHYSICIAN

SUMMER FALL 2009

Volume 57, Number 3 • Fall 2009

34 48 52 FALL 2009

{feATUreS} STeAlINg yOUr MONey Fraud & Embezzlement in The Medical Practice

The wArM heArT Of AfrIcA Africa and it’s health care needs through the eyes of Joseph Serra

decISION MedIcINe

Drastic Changes in Decision Medicine Since 2001

{dePArTMeNTS} 18

MANAgINg yOUr PrAcTIce Doing More With Less

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IN The NewS New Faces and Announcements

28

rISk MANAgeMeNT Prescribing Practices

40

PUBlIc heAlTh cOrNer Pandemic influenza H1N1 Vaccine is Coming soon!

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MeMBerShIP BeNefITS Ask The Membership Coordinator

44

hOSPITAl TechNOlOgy Dameron Hospital’s Genexpert

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Helping doctors treat and patients heal.

The Advanced Imaging Center at Lodi Memorial Hospital offers Board certified radiologists, comprehensive diagnostic services, and a convenient location for patients.

Lawrence R. Frank, MD President James Halderman, MD President-Elect Robin Wong, MD Past-President George Khoury, MD Secretary-Treasurer Board Members

High Field MRI Breast MRI Digital X-ray (walk-in’s welcome)

Shiraz Buhari, MD Thomas McKenzie, MD Javad Jamshidi, MD

Moses Elam, MD John Olowoyeye, MD Raissa Hill, MD Jerry Soung, MD

Trinh Vu, MD Anil K. Sain, MD Kristin M. Bennett, MD

Medical Society Staff Michael Steenburgh Executive Director Debbie Pope Office Coordinator Gena Stoddart Membership Coordinator

(209) 333-7422

Committee Chairpersons MRAC F. Karl Gregorius, MD

Decision Medicine Kwabena Adubofour, MD

Ethics & Patient Relations to be appointed

Communications Morris Senegor, MD

Legislative Patricia Hatton, MD

Community Relations Joseph Serra, MD

Audit & Finance Marvin Primack, MD

Member Benefits Jasbir Gill, MD

Nominating Hosahalli Padmesh, MD

Membership to be appointed

Public Health Karen Furst, MD

Scholarship Loan Fund Eric Chapa, MD

NORCAP Council Sandon Saffier, MD CMA House of Delegates Representatives Shiraz Buhari, MD Patricia Hatton, MD James J. Scillian, MD

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Lawrence R. Frank, MD Francis Isidoro, MD Gabriel K. Tanson, MD Peter Gierke, MD

James R. Halderman, MD Peter Oliver, MD Robin Wong, MD

FALL 2009

When was the last time a doctor came to YOU?

I’m Dr. Jon Wack, Medical Director of the Vascular Institute at California Pacific Medical Center, a unique program with specialists from four disciplines—interventional radiology, cardiology, vascular surgery and neurosurgery —working together to provide the most sophisticated array of treatment options for all aspects of vascular disease.

Since the 1970’s, we’ve been on the forefront of new technologies —from aortic aneurysms to claudication; from uterine fibroids to neoplasms. Today, we are the only private California hospital using the Yttrium 90 treatment. We have the experience to know what works—and what doesn’t— in minimally invasive treatment.

I’d like to make an appointment to see you in your office. Why? I, or one of my team mates, would like to take just a few minutes to familiarize you with our facilities, equipment, staff —and discuss treatment options for your next complex patient.

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MeSSAge > executive director

Doing Good for those Doing Good A colleague of mine has a favorite saying when asked the question, “What exactly is the purpose of a county medical society?” And I like his response so much I think I will begin using it as well. He simply replies, “We do good for those who do good — we help physicians so that they can help their patients.” Pretty simple, but well stated.

Our focus for over 136 years (yes that number is correct – we are one of the oldest medical societies in the state!) has been on serving physicians.

Likewise, our member physicians’ office staffs do good so the physician can do good as well, and our mission is to support them in their endeavor. A good office manager can improve your practice’s efficiency and increase its productivity. And that’s where your SJMS can help.

Your office manager’s responsibilities run the gamut from administrative duties to accounting duties, from human resources oversight to information technology support and oh, finally ... ensuring you’re happy as well.

“We do good for those who do Which is where we come in. good — we help physicians so Along with assembling a robust that they can help their patients.” portfolio of member physician benefits, we have for the past year been working toward developing an equally robust set of benefits for your office manager, which begins with Gena Stoddart, our full-time, SJMS Membership Coordinator and office manager advocate. Gena is here to serve you and your staff. If it’s a complicated issue that requires involvement from CMA or a simple request for more directories for the front office – she’s on it!

So when you’re done reading this issue please pass it along to your office manager and let him or her know that we’re here to help. They can contact Gena at 952-5299 or at gena@sjcms.org with any questions or requests they have.

Soon each of you will be receiving your 2010 membership dues invoice in the mail and so I want to take this opportunity to thank each of you for your membership in SJMS and CMA – we never take it for granted.

All the Best,

Mike Steenburgh Executive Director

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Moris Senegor, MD Editor Editorial Committee Shiraz Buhari, MD Kwabena Adubofour, MD Robin Wong, MD William West Managing Editor William@sjcms.org Michael Steenburgh Contributing Editor Sherry Roberts Creative Director/Graphic Designer sherry@sjcms.org Contributing Sources California Medical Association Los Angeles County Medical Association San Diego County Medical Society The San Joaquin Physician magazine is published quarterly by the San Joaquin Medical Society Suggestions, story ideas or completed stories written by current San Joaquin Medical Society members are welcome and will be reviewed by the Editorial Committee.

Please direct all inquiries and submissions to: San Joaquin Physician Magazine 3031 W. March Lane, Suite 222W Stockton, CA 95219 Phone: 209-952-5299 Fax: 209-952-5298 Email Address: gena@sjcms.org Medical Society Office Hours: Monday through Friday 8:00 AM to 5:00 PM

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Back in the saddle.

Physician, horse lover, cancer survivor.

Accredited by Commission on Cancer

As a St. Joseph’s radiation oncologist, Dr. Lynette Hart was no stranger to cancer. After years of caring for cancer patients, Dr. Hart was now a patient herself, facing the same fears, questions and uncertainties. Choosing to get care at St. Joseph’s was an easy decision. Dr. Hart knew that St. Joseph’s Cancer Center’s technology and staff were second to none.

St. Joseph’s Regional Cancer Center is proud to announce that it has received another three-year designation as a Commission on Cancer (CoC) approved program by the American College of Surgeons (ACoS). Only one in four hospitals that provide cancer services meet the rigorous evaluation process by the Commission and receive this special designation.

To learn more or schedule a private demonstration of our state-of-the-art Trilogy technology, contact our Cancer Center at 467-6560.

miracles happen.

(209) 943-2000 StJosephsCares.org FALL 2009

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1800 N. California St., Stockton, CA 95204 SAN JOAQUIN PHYSICIAN

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Message > from the President

The Value of Membership It won’t be long before we’ll all be receiving our 2010 invoices for SJMS and CMA membership dues which normally invites me to reflect upon its value to me as a member and maybe you do the same? So, I thought for my first presidents column it would be helpful if I briefly highlighted a few of the values San Joaquin county physicians receive and its potential impact upon our practices.

“In spite of news of hostile Town Hall Meetings with congressmen regarding health care reform, the majority of health care professionals and the public want changes in how care is delivered (read: systems change).”

ABOUT THE AUTHORLawrence Frank, MD is the 2009-2010 President of San Joaquin Medical Soceity.

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Our growing (and aging) county will need many new physicians. As many training program graduates remain in the areas where they trained, the SJMS has been a strong supporter of establishing a new medical school at UC Merced. Their students would do some of their clinical work here at SJGH and SJMC and we have published several articles on its progress and will continue to do so. Also, relating to education and future physicians, SJMS has just completed its ninth Decision Medicine program. Twenty four talented and motivated high school students interested in a medical career had two weeks of exposure to the practice of medicine here in Stockton at our hospitals. These young men and women, upon successful completion of their schooling, are also very likely to return to this county to provide health care. This program is now so successful that many other county societies are using it as a model for their own mentoring programs.

In spite of news of hostile Town Hall Meetings with congressmen regarding health care reform, the majority of health care professionals and the public want changes in how care is delivered (read: systems change).

Is there a San Joaquin physician who does not have to hire several people just to deal with third party payers (including Medicare and Medi-Cal) to justify medical care and get properly reimbursed? Is there an insurance

company that does not pay an army of clericals to deny claims that ultimately are approved? None of this adds value to health care but consumes considerable amount of money. As yet, no reforms are set in stone.

Some proposed changes could make our work more satisfying and rewarding; others might not.

As physicians are the principal providers of health care, our concerns must be addressed in shaping reform. The SJMS Executive Board has had two meetings with Congressman McNerney who was attentive to our issues and perceptions of needed changes.

Closer to home, we must be involved in legislation regarding California’s health care.

The CMA recently succeeded in preventing a 10% cut in Medi-Cal reimbursement.

Look for this fight to continue, particularly with California’s current budget crisis. Some of the legislative issues supported by the CMA include AB2 which would require an independent review for appropriateness of an HMOs or insurers decision to rescind a patient’s coverage. Regarding Peer Review, the CMA supports AB 120 which would prevent physicians’ removal from hospital staffs for non-quality issues but would promote more timely address regarding physicians providing substandard care, minimizing risk to patients.

However, SB700 is opposed as it would require filing an 805 report prior to an 809

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hearing testing the validity of charges against the physician.

You may be tired of hearing about MICRA but without it, medical malpractice premiums would be unsustainable for many of us. As an Internal Medicine resident in California in 1975, I had to say good bye to a fellow resident married to a freshly minted orthopedist who had to leave the state; his malpractice premiums were higher than his first year’s salary. Since MICRA, malpractice premiums have descended from the stratosphere.

San Joaquin county could ill afford to lose physicians who might have to leave to state because of skyrocketing malpractice premiums should MICRA be defeated. Then even fewer of our seniors and poor would have medical care access. The success of MICRA in helping keep physicians in California has helped defeat efforts to overturn it.

Every year since enacted, personal injury lawyers have tried to overturn MICRA – unsuccessfully, thanks to the CMA (see sidebar story).

Arguments put forth against MICRA include that the cap on non-economic damages hasn’t kept up with inflation.

However, recompense to injured parties for additional medical costs and lost wages have more than matched inflation and are unaffected by MICRA. Increasing compensation for non-economic damages won’t improve medical care; it would increase recompense for personal injury lawyers. Many injured patients and/or their families only receive a fraction of the large non-economic injury awards; a large percentage of those awards go to their attorneys.

The current increased media attention to medical errors in hospitals will very likely lead to another attack on MICRA; a recent article, “Death by Mistake” in the San Francisco Chronicle ended with an editorial comment that the family of a decedent

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whose award for $7.4 million with $6 million in non-economic damages was reduced to $1.6 million (because of the cap on non-economic damages).

The family has appealed for reinstatement of the full award. The article implied that maximizing penalties would provide incentives to minimize medical errors and behaviors that cause them. The airline industry led the way in demonstrating that non-blaming investigation and study of errors followed by altering systems of delivery of service improved safety.

The same principles applied to medicine should have similar positive results; that was the thrust of the Institute of Medicine’s To Err is Human report Immediate Past President, Robin Wong, MD, noted that with the current push for EHRs and EMRs, physicians are under pressure to invest in health information technology with (as yet) little guidance. Last month, the SJMS and Health Plan of San Joaquin held a conference that offered good information on how to go about deciding what to buy (with consideration of how your office works), noting start up expenses were steep (but for which Federal dollars would help) and that continued expenses must be factored in.

The CMA continues to provide updated information on Health Information Technology at its HIT Resource Center to its members and our own society is actively involved in bringing this valuable information directly to its members in the form of seminars, articles, etc.

To those of you who’ve read this far, thank you for your attention. I hope you will find that SJMS and CMA membership is of significant value to you and that you will renew. If you can bring in a new member, that would be magnificent.

Live long and prosper.

Supreme Court Upholds Constitutionality of California’s Landmark Malpractice Reform Law The California Supreme Court last week declined to review an appeals court ruling that upheld the constitutionality of California’s landmark Medical Injury Compensation Reform Act (MICRA). Under MICRA, patients can recover up to a quarter of a million dollars in noneconomic or “pain and suffering” awards. Injured patients are also entitled to unlimited medical and economic compensation, which often amount to millions of dollars to cover true damages, such as lost wages, medical expenses, and long-term care costs. Physicians support such full compensation of injured patients.

CMA sponsored and won passage of this forwardthinking law in 1975 with overwhelming bipartisan support in response to a crisis of runaway medical liability costs and the resulting shortage of health care providers, most predominately in high-risk specialties.

In this case, James Van Buren v. Sian Evans, M.D. and Yosemite Surgery Associates, the personal injury attorneys argued that MICRA's $250,000 cap on noneconomic damages deprived Mr. Van Buren of his constitutional rights to a jury trial. They also argued that the cap violates constitutional provisions that prohibit the legislature from exercising judicial powers, as well as the equal protection clauses of the state and federal constitutions.

CMA along with its coalition partners filed an amicus brief opposing this attack on MICRA and presented oral arguments before the appellate court. CMA told the court that MICRA's limit on noneconomic damages is a key component of a complex and balanced legislative plan that has ensured the availability of medical care in California.

In its ruling, the appellate court agreed with CMA and rejected each of the trial attorneys' constitutional arguments. As the court noted, the legitimate state interest is to limit medical malpractice insurance costs because without MICRA insurance rates pose “serious problems for the health care system in California, threatening to curtail the availability of medical care in some parts of the state and creating the very real possibility that many doctors would practice without insurance, leaving patients who might be injured by such doctors with the prospect of uncollectible judgments.”

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8th Annual

Community Health Forum “Embrace Change and Prepare for the Future” Healthcare Reform - The Big Picture How we Deliver Healthcare Today and Tomorrow

Friday, November 13, 2009

University of the Pacific - Student Center 7:30 AM - 11:00 AM

Breakfast and Refreshments will be served

“Bringing health, business and education leaders together for strategic discussions about the healthcare issues are needed, and the annual Community Health Forum accomplishes that goal” Moses Elam, MD, The Permanente Group, Inc. For More Information contact: Lita Wallach, Community Health Forum Director at (209) 210-8898

Rita Stolp Vice President Pacific State Bank 1889 W. March Lane Stockton, CA

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Dr. Hugh Vu is the Medical Director of Plastic and Reconstructive Surgery for the California Wound Care Institute, Inc. (CWCI). Dr. Vu is Board Certified in Plastic Surgery with a subspecialty in burn reconstruction, reconstructive surgery and wound reconstruction.

Dr. Otashe N. Golden, FAPWCA is the Team Leader of Inpatient Wound Care for the CWCI. Dr. Golden is a Fellow with the American Professional Wound Care Association, the first organization to offer a physician specific certifying administration to achieve the status of Fellow in the practice of Wound Care.

Dr. Gregory G. Smith is the CWCI principal investigator. Dr. Smith’s twenty years of research experience will aid in our development of new and exciting innovations in wound care.

Dr. La Donna R. White is the Palliative Care Team Leader. Dr. White brings ten years of palliative care experience to the team. She is available for discussions with wound care patients and their families facing end of life issues.

Karen Cuslidge, R.N., W.C.C. is a Registered Nurse with Wound Care Certification for the CWCI. Ms. Cuslidge has ten years of nursing experience and provides support to the physician managed Wound Care team.

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Message > from the Editor

The Value of Human Life

A Hidden Foundation of the Health Care Crisis

Are you all sick and tired of health care reform?

“Live long and prosper”, the saying goes. For the ancients this used to be the exception. For current citizens of developed countries it’s a widespread reality that would leave their ancestors green with envy. And yet all is not well.”

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How about those of us who have been around in the 1990’s, now experiencing a new push for reform a second time? It seems like déjà vu, a sequel to what was originally a bad movie. Was it meant to be a comedy or tragedy? I don’t know.

And how will it play this time around?

So far, the first act seems similar to that which starred Hillary. A lot of talk and no substantive action, while various interest groups engage in stealth battles to protect their turfs.

The continuation is anyone’s guess, but the end clearly does not seem near.

Regardless of how our current star Obama plays out, being a student of history, I am more intrigued with the back story of health care rather than its future. In particular, I wonder why this issue has become such a top national concern, not to mention international, since most developed countries seem to have a version of a similar crisis in their own homes. Health care policy has never been on the top echelon of

political activity in the entire history of civilized humanity. Over the ages leaders have concentrated on war and defense, protection and development of trade, and religious strife. I suppose pestilence such as plagues, T.B., malaria etc have at times been high level concerns, but only as threats to be countered no different than Barbarians at the borders. How to provide proper and affordable healthcare to the populace ABOUT THE AUTHORMoris Senegor, MD serves as the Chairperson of the Publications Committee for the San Joaquin Medical Society and Editor of its flagship publication the San Joaquin Physician.

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Message > from the Editor

If you study the 1850 U.S. census you will find that out of a population of 28 million, 18% were over 40 years of age;

2.7% were over 60. only

The most recent census, that of 2000, by contrast, features a population of 281 million of which 35% were over 40, and a whopping

16.2% over 60

.

This translates to 6.1 million middle aged and elderly then, versus 45 million now.

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never bothered the kings and emperors of centuries past.

This begs the question: why now?

To be sure, humans, being what they are, have always longed for the best healthcare available. What they had then was simple and crude.

The shamans, barbers, and blood-letters of times past do not compare in price and complexity with modern medicine and surgery. It was thus easier for the ancients to receive cheap, “satisfactory care”, compared to current seekers, mainly because of the simplicity of it all. Complexity and high tech sophistication with its high price tag is commonly blamed for our current state of economic crisis in health care. But in my opinion two other factors play a larger role in the elevation of health care to its current top position as a policy problem.

The first is the aging of the population. We now live in a world where there are more old people than have ever existed before. Take the United States as an example.

If you study the 1850 U.S. census you will find that out of a population of 28 million, 18% were over 40 years of age; only 2.7% were over 60.

The most recent census, that of 2000, by contrast, features a population of 281 million of which 35% were over 40, and a whopping 16.2% over 60.

This translates to 6.1 million middle aged and elderly then, versus 45 million now. Both in percentage and absolute numbers we have a lot more “old” people who are likely to get sick and seek care. They are also some of our most vociferous voters, influencing political decisions at all levels

of government in their favor.

Variations of this same theme exist in most developed countries.

As necessity is the mother of invention, modern medicine has stepped up to the plate and provided all these folks with a massive smorgasbord of expensive treatments. And now the cost of these, in conjunction with current demographics has led to what might be called a financial perfect storm.

There is a second, and in my opinion even larger factor contributing to this storm. It is the substantial increase, hitherto never before seen, in the value of an individual human life. Since there are no “stock markets” which track this, we don’t notice it, and simply take it for granted.

But be aware folks! A current human life is worth a hundred if not a thousand lives compared to Roman or Medieval times, not to mention the first half of the 20th century. Historically human societies have always had a small element, regal, aristocratic or ecclesiastic, whose lives have been worth much more than the remaining masses. The former have traditionally been recipients of whatever good fortune their societies bestowed upon them, including the best health care available, never mind that it happened to be a shaman. The remaining masses have been abused, exploited, and expanded in endless wars. More have perished by the millions from poor hygiene and epidemics. Yes, life was cheap then.

Beginning with the Renaissance and European Enlightenment the value of individual human life started to rise. In such societies as the new United States and revolutionary France a middle class was added to the top echelon usurping a larger than fair share of the bounty. For the peasants,

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urban poor, slaves, and colonial subjects, by far the majority of the population, life remained cheap.

In the first half of the 20th century, more than 100 years after the American and French revolutions, a further rise in social equality in Western nations and worldwide elimination of slavery promised to increase the value of human life. However, this trend was countered by an even bigger one, an unexpected side effect of the Industrial Revolution: humans discovered ways to kill each other in industrial proportions. This horrific fact did not dawn upon us until the carnage of World War I, when tens of thousands were fed to the cannons daily across the trenches of European, African and Asian battlefields. Then came the even greater slaughter of World War II with death delivered in yet more industrial efficiency to greater numbers. Human life was cheaper in the first 50 years of the 1900’s than it has ever been.

Finally, faced with the specter of total destruction of life as we know it in the hands of nuclear weapons, humanity pulled the reins on its murderous lust, and from 1950’s onwards wars began to wax and wane into regional affairs with much less bloodshed. In the second half of the 20th Century, in the wake of World War II, humanity gradually transitioned to the most peaceful time in its entire history. Proportionate to the world population, those killed by their fellow humans are now the lowest in number.

So are those who die from plagues. This unprecedented period of peace also brought unprecedented prosperity as resources devoted to war were rechanneled to peaceful purposes. Technological

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improvements made to win the big wars, everything from chemicals to transportation, communication to nuclear power were also harnessed to improve the lives of citizens largely living in peace.

Many such improvements formed the basis of the expensive high tech medicine we now enjoy. It is this peace and prosperity that has shifted the demographics of developed nations towards an older median age, as it has also raised the value of individual human lives.

“Live long and prosper”, the saying goes. For the ancients this used to be the exception.

For current citizens of developed countries it’s a widespread reality that would leave their ancestors green with envy. And yet all is not well. We now have a new problem: how do we keep all these prosperous old people healthy!

The first U.S. President whose

name is associated with health care reform as high level public policy is Harry Truman. He was a pioneer in failed reform, which many of his followers then inherited. It is no accident that health care reform begins with Truman. After all he presided over our transition from World War II to current peace and prosperity (he didn’t know it of course; the Cold War and butchery in Korea did not seem like harbingers of world peace at the time, but from our longer term perspective that’s how it plays out). The decades that followed Truman featured collapse of colonialism, world wide reduction in totalitarianism, beginnings of racial equality (which still has not culminated), and with it, a gradual elevation of millions of “worthless” lives to a value previously carried only by a small elite in their societies.

Modern health care, with all its

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complexity, is a now a giant Medusa, a benevolent one, offering cure from suffering and death. Nowadays not only does this monster cater to a historically massive population of seekers, but it has to deliver with social equality to all. While this ideal of equality has never been fully realized anywhere, it remains an expectation from the seekers, in a way that never was before. The overall price tag of the care then parallels the novel high value of human life spread across a much larger swath of society than before.

In the United States, as the price of healthcare approaches 20% of gross national product, this giant benevolent Medusa now appears menacing.

Numerous candidates have appeared from Nixon, to the Clintons as possible heroes to rein in the beast, all so far unsuccessful. Obama is our latest candidate for Perseus.

He has a big problem, as does anyone who attempts to play this role: there is no way to successfully slay the beast without cheapening the value of human life for a substantial portion of society, and in so doing he faces the tragic irony that with success, his heroism will be equally regarded as evil, depending upon whose lives are affected one way versus the other.

When it comes to health care, once the genie of “equality” is out of the bottle, it is impossible to rein it in. In the meanwhile we continue to live with another irony that history has bestowed upon us, in the form of a health care crisis for the price of prosperity and long life.

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managing > your practice

Doing

more

with less …the hidden costs in a medical practice

Health care providers are not faring well when it comes to trends in reimbursement. If it is not a reduction in payments from a significant payor, it is Medicare reminding us all that reimbursement, after the cycle of freezes, will have to be reduced until Congress can legislate other options.

Medical practices are eager to examine every item on the financial statement to identify areas for reducing costs, but some of the most significant costs are not to be found there. The hidden costs pose more of a challenge to identify and manage. Below you will find some of the more common areas that can have a significant impact on net income.

The Schedule

Scheduling all of the practice resources from the provider, staff, and facilities to achieve an optimum schedule has to be a priority for all practices. The coordination and management of the schedule can easily be compromised by the preferences and perceptions of individuals that may be distracted by the office environment and immediate requirements for attention to other matters. Optimum productivity can only be achieved when all of the resources are focused toward a common goal.

Coding

Provider coding has been a source of concern for years. It’s about the documentation; it’s about the medical necessity; or it’s about bullet points. It may however, be about educating the providers to be aware of all of the cognitive and process oriented components he or she performs in a day, and how to best capture that information in codes that best define the effort.

Contract Payments

Contracting with payors to allow reimbursement amounts at levels that exceed the cost of providing the service or at a level

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that is documented and verified regularly is a challenge for many practices. The statistics that show how many inappropriate payments are accepted by providers is alarming. Efforts to ensure the monitoring of contracted payments will always pay off.

Co-pays

Co-pays are a way of life for all practices that accept insurance, and the ratio of patient to insurance payments continues to grow.

Most co-pays are for amounts under $25. The chance that a practice can experience a positive cash flow when a staff person makes the decision to wait, bill and collect the funds after the visit is almost non-existent.

Staff turnover

The expense of staff turnover is underestimated by the majority of practices. To minimize the expense to the practice of recruiting, training, and team work building for new staff members, choose the least expensive option, pay a competitive salary and provide a positive workplace environment.

FALL 2009

Employee Productivity

Many practices make the mistake of molding the job to the person. Determine the needs of the practice, the contribution for each staff person, and then find the right person for the job.

Equipment Maintenance

Downtime is expensive. Look at the performance and reliability of each investment. Don’t just shop for price.

Fee Schedule

The fee schedule dictates the maximum financial opportunity for each service performed. A fee schedule that reflects the opportunity available from all contracting opportunities will optimize revenue.

Patient Satisfaction

Patients that have an excellent relationship and respect for the provider and staff will be more cooperative, considerate of the provider’s time, and enhance the ability of the practice to achieve an organized and efficient visit. Regular and consistent communication is the key to a more cost effective visit.

Referral Sources

Where do your patients come from? Who is your customer?

If you haven’t taken the time to communicate with, and educate the referring physician base about your practice, your preferences, and your results, then now is the time to organize this process. For your practice, it may be the most single most important source for new revenue through referrals.

With the above being just a few areas of common hidden costs, it is time to examine your practice for the opportunities to improve all aspects of performance and productivity. While some practices choose to invest in the resources required to improve performance, others focus on short term cutbacks and savings to address the shortfall in net income. If you need assistance identifying your net income opportunities, please let us know.

We have the industry focused accountants and consultants that can effectively address your concerns.

Change is rarely realized by eliminating or reducing the resources required for the practice to succeed.

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FALL 2009

cMA fOUNdATION > diabetes

A PlAN TO IMPrOve The QUAlITy Of dIABeTeS cAre develOPed dUrINg SyMPOSIUM

The California Medical Association (CMA) Foundation recently held the Diabetes as a Cardiovascular Disease: strategies and Partnerships to improve Health symposium for more than 100 participants, including health care providers as well as representatives from patient advocacy groups, ethnic physician organizations, health plans, physician specialty groups, state and local government, and health care associations. Presentations addressing diabetes care issues included topics such as patient self-management, medication adherence, and transformation of partnerships. in breakout and panel discussions, participants provided ideas which will guide the next phase of CMA Foundation’s Advancing Practice Excellence in Diabetes.

Peggy Yelinek, MBA, McKesson, shared information on, “Understanding Adherence: Putting the Patient First.” According to Ms. Yelinek, “If we gain a better understanding of why a patient is non-adherent and can simultaneously engage patients in a consumer-friendly way, we will empower them to better manage their disease. Ultimately, it is the patient that is the decision-maker but we can all play an important role in helping them towards a healthy outcome. “ The CMA Foundation began Advancing Practice Excellence in Diabetes in 2006, initiating its Quality Collaborative to help improve the quality of diabetes care provided in solo and small group practices. The Collaborative involved practices in San Joaquin County, as well as counties in two other California regions. San Joaquin County was chosen because of its ethnically diverse population. Key statistics are that 50% of the Hmong community in the United States resides in California’s central and north valley regions, totaling more than 65,000 Hmong residents, almost three quarters are first generation immigrants.

High rates of diabetes and hypertension are found in the Hmong community, particularly among those with lower education and household income levels and limited English proficiency. The prevalence of diabetes has been documented at roughly 15%, similar to the high rate of diabetes found in the Native American community. Hmong patients are most likely to seek care in an advanced disease state, resulting in greater difficulty in managing their diabetes and a high prevalence of complications associated with diabetes, including heart attacks

FALL 2009

and stroke. Before coming to the US, there was no concept of diabetes among the Hmong community.

Disparities also exist in the diagnosis and treatment of diabetes in African Americans and Hispanics. The US Centers for Disease Control and Prevention (CDC) have estimated total (diagnosed and undiagnosed) diabetes prevalence at 14.7% (3.7 million) in 2007 among non-Hispanic blacks and 13.7% of Hispanics in 2005.

Involvement of the Stockton medical practice of Carlos Meza, MD, was extremely valuable to the CMA Foundation’s project as it is reflective of San Joaquin County’s cultural diversity. Firmly committed to providing the highest quality care to his patients with diabetes, Dr. Meza states, “The project enabled us to reach a larger number of patients who carry a diagnosis of diabetes.

We were also able to introduce changes in office procedures to improve follow-up, to provide personalized patient education, and execute aggressive screening of populations at risk.”

The Advancing Practice Excellence in Diabetes project will now be moving statewide and looks forward to the opportunity of broadening opportunities for partnerships around the state.

For more information, please contact Sandra Navarro, PhD, MPH, Director of Clinical and Quality Improvement, CMA Foundation, at snavarro@cmafoundation.org. To download a copy of the Foundation’s Diabetes Quality Collaborative Executive Summary, please visit the Advancing Practice Excellence in Diabetes section of our web site, www.thecmafoundation.org.

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COMMUNITY > news

IN THE

NEWS

Trinity Plaza Surgery Center

St. Joseph’s Foundation Awards Over $21,000 in Scholarships St. Joseph’s Foundation awarded scholarships to twenty-six students pursuing health care careers in nursing and nursing management, respiratory therapy, nuclear medicine, social work,

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Providing staff, physicians and patients with relevant & up to date information 10200 Trinity Parkway, Suite 101 Stockton, CA 95219 Bus: (209)323-3480 Fax: (209)472-9102 www.trinityplazasurgery.com There is a new option in Stockton for Ambulatory Surgery care that opened in May and is accepting most insurance.

Trinity Plaza Surgery Center is a state of the art, 12,000 square foot facility located in the heart of Stockton, CA. The Surgery Center is a Medicare Certified, Joint Commission accredited facility with a highly-trained, dedicated professional staff. The surgery center has three operating rooms and a procedure room with the ability to recover patients up to 23 hours.

This Ambulatory Surgery Center is conveniently located in Trinity Plaza, Stockton, CA, with easy access at 8 Mile Road and I-5. It is part of a medical office complex that will eventually consist of two 40,000 square foot office buildings, including a primary care clinic, an imaging center and physician offices providing convenience for all patients.

Trinity Plaza Surgery Center is a multi-procedural facility offering the following services: Orthopedics and Sports Medicine, including arthroscopy of the knee, shoulder, ankle, and elbow; fracture and tendon repairs; and hand surgery including carpal tunnel release.

Gynecology and Women’s Health, including D&C; cervical biopsy; breast biopsy and mastectomy; hysteroscopy;

clinical pastoral education, laboratory science, biochemistry, healthcare administration and medicine while attending San Joaquin Delta College, UC Berkeley, UC Davis, Chico State University, Loma Linda University, Modesto Junior College, Grand Canyon University, University of Phoenix and the California State University at Stanislaus. Candidate selection is

based on academic performance and clinical excellence demonstrated in the patient care environment, as well as community service. The awards were made during an annual scholarship luncheon at St. Joseph’s Medical Center.

Cathy Calvin was awarded the Women’s Connection Scholarship; Andrew Frando, Erin O’Rourke and Cristina

>> FALL 2009

news < COMMUNITY laparoscopy; and tubal ligation.

General surgery, including hernia repair; laparoscopic cholecystectomy; and varicose vein ligation.

Ear, Nose and Throat, including endoscopic sinus surgery, tonsillectomy, septoplasty; and myringotomy (ear tube placement).

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Urology, including cystoscopy and lithotripsy.

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For more information or to request credentialing packets please call

and UCSF. What this means is a trauma, cardiac or perinatal patient can receive the same standard of care that the teaching institutions provide to their patients”. Vice President David Bespalko of Beckman Coulter Incorporated.

Dameron Hospital is one of the few remaining independent hospitals in the state funded entirely from local revenue sources. Dameron Hospital administration

Beckman Coulter share in the innovative vision of increasing productivity and safety while reducing monetary costs, labor hours, contamination, process steps and errors by keeping the caps on the patient sample tubes. By investing now in the innovative technologies of the future Dameron Hospital is one of the most technologically advanced in the country and can expect to provide the best future patient care for their community.

New MRI Coming Soon to Sutter Tracy Hospital

It won’t be long now until Sutter Tracy unveils its new digital magnetic resonance imaging (MRI) machine. The top-of-theline, $2 million Signa Horizon HDx system from General Electric will replace the MRI Dameron machine the hospital Hospital bought seven years ago.

Laboratory “The new MRI is Honored Dameron Hospital Laboratory Honored more powerful than the Beckman Coulter older model and has honored Dameron many new Hospital Laboratory Director Richard features, which will enable us to offer and Board of Directors have invested in the Wong and Dameron Hospital new services like breast MRI,” latest medical and technological advances.

Administration for significant advances in says David Bowlsby, imaging services Beckman Coulter partnered with Dameron laboratory innovation. manager.

“In the past, women had to Hospital Laboratory Administrative “In fact Dameron has made significant travel to Stockton or Sacramento for a Director, Richard Wong, to assist the investment in “cutting edge” technology breast MRI.” >> facility in becoming the first Closed Tube that puts them on par with even Stanford

Vargas received Sr. Mary Gabriel, OP, Endowed Scholarships; Samantha Chan, Jillian Farrell and Angeline Paraskevas received St. Joseph’s Auxiliary Scholarships; Stefanie Mason, Sandrine Ngandjio, Father George Okoro, Beverly Ortega, Karen Quines and Najia Sadiq received Luck-Lewis Scholarships; and Julie Ballesteros, Janelle Corso, Ginger Hamilton, Mary Hickman, Sarvjeet Kaur, Alicia Kirton-Loung, Lisa Kovac,

FALL 2009

laboratory in the country. Richard and

Richel Ladrido-Glodowski, Tamara Lefief, Lynda Penaflor, Christina Truell, Breana Wright, Mohammad Zaki were awarded St. Joseph’s Foundation Scholarships.

“It is always rewarding to offer students support for continuing their education in some aspect of healthcare,” stated Mike Ricks, Chief Operating Officer of St. Joseph’s Medical Center. “These students are our future nurses, physicians, social

workers, and healthcare administrators.

St. Joseph’s Foundation is honored to have the opportunity to help them succeed.”

In addition to Ricks, Ginger Manss, RN, MSN, AOCN, Director of Cancer Services; Virginia Wallace, Director of Nursing Education; Manzanita Lowarch, First Line Supervisor, Multiple Units; and Cindy Wong, Laboratory Hematology Supervisor, presented scholarships.

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COMMUNITY > news

IN THE

which will help physicians make more accurate diagnoses,” says T. Tejpal Singh, M.D., medical director for Sutter Tracy’s Radiology Department. The new MRI is faster and more tolerant of movement, which makes it easier to get high quality images of children and other people who have trouble lying still.”

Expected to be up and running this spring, the new MRI is one of the many state-of-the-art imaging services Sutter Tracy offers along with digital X-ray, mammography, computed tomography (CT), and stereotactic breast biopsy.

St. Joseph’s Cancer Center Offers Weekend Retreat for Families Dealing with Cancer St. Joseph’s Regional Cancer Center is hosting a weekend retreat for families dealing with cancer on October 10 – 11, 2009. The annual “We Can” Weekend retreat provides cancer survivors and their families with the benefits of a healing environment in a serene foothill setting coupled with people who understand and care. The retreat features education related to cancer and treatment options, support groups for patients and families, a children’s program complete with campfire skits, workshops on spirituality, and time to enjoy the peace of this natural setting. A full complement of oncology trained professionals and cancer survivor volunteers will staff the retreat.

The retreat site is secluded in the midst of woodsy trees about 45 minutes above Jackson. All campers stay in heated facilities complete with hot showers.

The meals are prepared by the retreat-site staff and served in a rustic dining hall with balconies that overlook the grounds. If you would like to be pampered while experiencing the healing benefits of a serene setting coupled with people who understand and care, consider registering for “We Can” Weekend. A full complement of oncology trained professionals and “cancer

effective August 10, 2009. Both Drs. Daftary and Belogorsky are internal medicine specialists and have practiced in Stockton for over 30 years. Their new offices will be at the St. Joseph’s Medical Group North Stockton location at 3132 W. March Lane in Stockton. Prior to joining St. Joseph’s Medical Group, the physicians’ practices were part of Sutter Gould Medical Foundation.

Dr. Ashok Daftary is board certified in Internal Medicine and Geriatric Medicine.

He obtained his medical education at the University of Bombay in India, and completed his residency at San Joaquin General Hospital here in Stockton. Dr. Daftary speaks Hindi as well as English, and has a special interest in Health Care Policy.

He has been on the medical staff of St. Joseph’s Medical Center since 1977.

NEWS How it works MRI uses magnets, radio waves and special computer software to create detailed images of the inside of the body. Totally painless, MRI can be used on most parts of the body, including the brain, spinal cord, circulatory system, internal organs and joints.

“This is one of the most advanced MRI systems on the market. We will be able to see much smaller and clearer structures than ever before,

Prominent Stockton Physicians Join St. Joseph’s Medical Group James Belogorsky, M.D. Ashok V. Daftary, M.D. St. Joseph’s Medical Group of Stockton is pleased to welcome Ashok V. Daftary M.D. and James Belogorsky M.D., two prominent Stockton physicians, to their team of Family Practitioners, Pediatricians, and General Medicine Practitioners

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FALL 2009

COMMUNITY > news survivor” volunteers will staff the retreat.

Reservations for the retreat are accepted on a first come, first served basis. In the event it is necessary, first-time campers will be given priority consideration. For more detailed information call St. Joseph’s Cancer Center at (209) 467-6550 or email SJCancerInfo@chw.edu.

Hill Physicians Medical Group Designated “Elite” Status Statewide Annual Survey Looks for Quality and Affordability San Ramon, CA (July 1, 2009) – Hill Physicians has received “Elite” status designation -- the highest level possible -- in the 2009 Standards of Excellence program conducted by the California Association of Physician Groups. This marks the second year in a row the highest level has been awarded to Hill Physicians Medical Group.

The annual survey ranks medical group performance across the state. From over 150 medical groups in California, 85 voluntarily agreed to be objectively measured based on care management, patient-centered care, accountability and transparency, and information technology. Of those, only 20 received the highest possible score.

“It’s gratifying to be recognized for the hard work,” says Hill Physicians CEO Steve McDermott. “We strongly believe in accountability to our patients and our physicians.

The glue that holds this performance together is our unifying goal of providing quality patient care.”

As momentum builds for healthcare reform, one area under increasing scrutiny is the healthcare delivery system because it sometimes rewards doing more rather than doing better. That’s one reason CAPG began its annual assessment program, which ranks the performance of coordinated healthcare organizations in how well they bring quality and affordability to individual patients and large populations. The Association notes that many groups use the evaluation process as a roadmap for improvements they need to make. McDermott advocates the Accountable Care Organization (ACO) model of care which monitors specific measurements of quality such as the readmission rate for patients after discharge from a hospital. “By keeping a close eye on each step in the process, the patient’s experience and outcome will be improved,” he says. The scorecard for all participating groups can be seen at www.capg.org.

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Dameron Hospital Graduates Versant RN Residency Cohorts

Dameron Hospital is proud to announce the graduation of the first Versant Cohorts: Barinderpal Chohan, RN; Kellen Cody, RN; Jarrell Gilmore, RN; Kim Little, RN; Kyle Nunes, RN; Rachael Ramsey, RN; Kristie Reale, RN; Steve Tabin, RN; Gaye Valadez, RN., Erin Shelby, RN class speaker at the ceremony held on July 17th, 2009.

The Versant RN Residency Program is a comprehensive education and training system designed specifically to transition newly graduated register nurses from students to safe and competent professional practitioners.

Integrated into Dameron Hospital’s education structure the Versant RN Residency program includes guided clinical experience, instructor led core curriculum, led by Roberta Boshears, RN that includes a formal mentoring program, debriefing/self-care sessions and 360 degree evaluation.

“The next Versant RN Cohort beginning August 2009 received over 300 applicants from all over Northern California for the eight open positions. We are very proud of our first residency graduates and impressed with the caliber of new graduates applying,” stated Janine Hawkins, CNO.

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COMMUNITY > news

IN THE

NEWS

Three new members appointed to St. Joseph’s Community Board of Directors

St. Joseph’s Medical Center announces the appointment of three new members to its Community Board, which is responsible for governance of St. Joseph’s Medical Center and St. Joseph’s Behavioral Health Center in Stockton. The newest members are Michael Patrick Duffy, Michael D. Coughlan and Kathleen Lagorio Janssen. Each will serve an initial one-year term effective July 1, 2009, and be eligible for reappointment for two additional three-year terms.

Michael D. Coughlan is a former civil litigation attorney and current Judge of the Superior Court, San Joaquin County, appointed in 2005. Judge Coughlan has been a Stockton community resident

for more than 35 years. He is a graduate of the University of the Pacific, and a graduate of the UOP McGeorge School of Law. Michael Patrick Duffy is President and Chief Executive Officer for Financial Center Credit Union, specializing in marketing, finance, and strategic planning.

Mr. Duffy earned his BA in International Relations at San Francisco State University and graduated with his MBA from Pepperdine University.

Kathleen Lagorio Janssen is a retired teacher/credentialed school administrator who now manages her family’s agribusiness companies. Mrs. Janssen received her MA from the University of San Francisco and her BA, California Elementary Teaching Credential and California School Administrator Credential from the University of the Pacific.

Stockton MRI & Molecular Imaging Medical Center Installs New Siemens 128 Slice CT Scanner With Stockton MRI & Molecular Imaging Medical Center’s commitment to provide the best care for their patients and offer the latest in scanning technology, they have recently installed a new Siemens SOMATOM Definition AS+ (128) CT scanner. This Multiplanar CT offers the fastest scanning time in medical imaging which in turn provides the least radiation exposure to the patient.

Dr. Javad Jamshidi of Stockton MRI states, “Every patient is different, and so is every clinical question. Our new Siemens Somatom Definition AS+ (128) CT, is the only CT capable of adapting to any patient and any clinical need and with 128 slices in 0.3 seconds, it covers all aspects of these questions with the fastest and the lowest dose of radiation in children to cardiac and coronary examinations.”

This is only the third installation of the new Somatom Definition AS+ (128) in California. For further information and scheduling, please call Stockton MRI’s New Siemens 128 Slice CT Scanner 209-466-2000.

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FALL 2009

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risk management > prescribing practices

Managing Professional Risk Tips for Steering Clear of Problems with Pain-Med Prescribing The following tips will help you prescribe narcotics/opioids appropriately to patients in chronic pain: Obtain a thorough history and determine the specific cause of pain. In an article on treating patients’ pain, Eliot Cole, MD, a physician associated with the American Academy of Pain Management, advises, “Do not call [a patient’s] pain a headache or backache but try to find a specific pathological process to explain why your patients hurt.”1 Stephen Richeimer, MD, Chief of Pain Medicine at the University of Southern California, says, “Assessment is a key issue. The history and physical examination provides the information that allows the physician to judge if the patient is legitimately in pain or if the patient is improperly seeking drugs.”2 Document well. Cole advises, “Chart everything you see, think, feel, and hear about your patients. Leave nothing to the imagination of the future reader… Explain what you are doing, why you believe opioid analgesics will be helpful or continue to be helpful, what alternatives have been considered, that your patient agrees to the treatment, and how you intend to follow

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your patient over time.”1 Richeimer agrees: “Good record keeping is part of good medicine, and it is also your best protection from frivolous lawsuits,” he says.2 Ask chronic-pain patients to agree to use a single pharmacy. Discussing pain treatment with the patient and getting the patient to agree to certain parameters associated with long-term pain management are mutually beneficial strategies: they help you avoid inadvertently supplying medication that might be diverted for street sale, and they reassure the patient in pain that he or she can count on obtaining needed medication. An especially useful rule is that the patient will use a single pharmacy for all pain medications.

Make use of a written pain medication agreement with chronic-pain patients. A signed agreement by the patient that he or she will follow rules for obtaining pain medication will improve the likelihood of appropriate behavior by the patient.

It discourages patients from seeking an unlimited supply of medication and helps staff members verify the legitimacy of refill requests.

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Monitor patients over time on their needs for and use of pain medication. Richeimer observes that patient trustworthiness “can only be assessed by monitoring the patient over time.”2 Cole suggests talking with patients periodically to reduce dosage appropriately, as well as periodically ordering “urine drug screens for… patients of concern to document that you are able to recover their prescribed medications.”1 If you keep controlled substances in your office, establish a reliable process for safeguarding and reconciling such medications and for tracking their distribution. The federal Drug Enforcement Administration (DEA) requires physicians who administer or dispense controlled substances from their offices to have effective controls to guard against theft and diversion. Controlled substances must be stored in a securely locked, substantially constructed cabinet. Using a controlled substances inventory log can help you account for each and every dose of medication that goes through your office.

These strategies are aimed at fostering appropriate pain management within the limits of professional practice. Furthermore, they can help physicians and staff consistently meet regulatory requirements on the management of pain medications.

Presented By :

References 1. Cole E. Prescribing opioids, relieving patient suffering, and staying out of personal trouble with regulators. The Pain Practitioner. 2002;12(3):5-8. Available at: http://www.aapainmanage. org/literature/PainPrac/V12N3_Cole_PrescribingOpioids. pdf. Accessed June 3, 2009.

2. Richeimer S. Opioids for pain: risk management. California Society of Anesthesiologists Online CME Program.

Available at: http://www.csahq.org/cme2/course.module. php?course=3&module=12. Accessed June 3, 2009.

Managing Professional Risk is a quarterly feature of NORCAL Mutual Insurance Company and the NORCAL Group. More information on this topic, with continuing medical education (CME) credit, is available to NORCAL insureds. To learn more, visit www.norcalmutual.com/cme.

Complimentary Dinner / Seminar for San Joaquin Medical Society Members with...

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Thursday, November 5th, 2009 Reservations are Required!

Please call the medical society office at (209) 952-5299 to reserve your seat.

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STEALING YOUR MONEY

Fraud and embezzlement in the medical practice

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FALL 2009

cOver STOry > fraud & embezzlement

As the economy goes down fraud goes up, and your medical practice is as much a target as any other small business.

Perhaps more so because you deal in large numbers of customers and numerous financial transactions. This can create a maelstrom of activity that can mask embezzlement.

“Most doctors are busy working hard and don’t really pay attention to the financial details,” said a local physician who suffered theft in his practice and requested anonymity for this story. “Finally, it was my wife who got suspicious. She felt that the practice wasn’t bringing in as much money as it should. I consulted with my accountant and he indicated that my practice income was comparable with similar practices. But my wife pressed on and found the theft. And the thief.”

Stephen Taylor, San Joaquin County Deputy District Attorney who specializes in fraud cases, sees a pattern that is common to most business crime.

“The wife story is not at all uncommon,” said Mr. Taylor. “They have a strong vested interest in what is going on. It can be another relative, but the wife is often the one who notices before the husband.”

Mr. Taylor is uniquely qualified in his understanding of problems a medical practice might face. He kept the books for his physician father and six other doctors in an Oakland group practice while he was attending college and law school. The Hastings graduate has been with the S.J. District Attorney’s office since 1981 and has been concentrated on white-collar crime since 1982.

“The biggest mistakes by any small business are that they think of their employees as family, they don’t do background checks when they hire people, and they don’t have controls in place,” Mr. Taylor said.

How widespread is the problem?

The Association of Certified Fraud Examiners’ Report to the Nation on Occupational Fraud and Abuse, based on data compiled from 959 cases of occupational fraud that were investigated between January 2006 and February 2008, states that the industries most commonly victimized by fraud in the study were banking and financial services (15% of cases), government (12%) and healthcare (8%).

FALL 2009

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Physicians’ Office Catastrophes

By STEPHEN J. GROOM

Often, physicians who are excellent at their occupations (and as a result may produce large volumes of cash-flow) may be forced to delegate the recordkeeping and management functions to others.

This may be so for a variety of reasons; unfamiliarity with things financial, lack of time or interest, etc. When a trusted employee commits the unthinkable; theft, embezzlement, or other crime, the physician is left with a mixture of emotions, concerns, and expenses to determine the extent and duration of the losses.

The prudent physician/owner will take steps to prevent or deter such catastrophes. The first step is to recognize the fallacy behind the “It can’t happen here” thinking. All that is needed is a lax oversight process (opportunity) and any sense of need or entitlement by the employee (motive), such as being passed over for a raise or promotion, or perhaps having a family member with a drug or gambling problem.

Among the obvious signs are lifestyle maintenance in excess of apparent means, spouse or children of employees in distress over the aforementioned addiction problems or various medical issues, financial needs, lawsuits, or other stressful situations.

Some helpful (but by no means exhaustive) steps include the following.

Periodically ask for selected financial information such as, “Let me see last month’s accounts receivable journal and the bank statement.” This is essential, even if the owner can’t read the statements. The perception is that the owner is savvy and

Participants in the survey estimated that U.S. organizations lose 7% of their annual revenues to fraud. Applied to the projected 2008 United States Gross Domestic Product, this 7% figure translates to approximately $994 billion in fraud losses.

“I know of hundreds of cases of embezzlement or fraud,” said Yvonne Fox, a practice management consultant with more than 30 years experience.

“Most of them go unreported because doctors are embarrassed.

And, yes, there are a lot of ways to steal from a medical practice, but I won’t tell you in detail because I don’t want this to be a primer for a thief.”

How to prevent embezzlement is one of the most popular speeches that Ms. Fox gives in her business.

“I gave the speech at Cedars Sinai in 1986,” said Ms. Fox, whose business is based in Southern California. “There were guards at the door to keep everyone except physicians out.

No administrative people, no spouses. The handouts were strictly regulated because they told exactly how to commit fraud.

My method is very didactic.”

At a minimum, she recommends keeping an eye on expenses and see documentation for each expense. Doctors should be the only one to sign checks.

“Online banking is something to be especially wary of and that’s a whole new problem,” Ms. Fox said. “The big takeaway is monitoring. Physicians should monitor expenses the way they monitor patients.”

Both Mr. Taylor and Ms. Fox agree that taking out an insurance bond on employees is a good idea. Then you must follow the covenants of the bond, which means you must institute good financial controls. When

an employee is bonded the insurance company would do the background check for you.

A difficult truth to accept is that your most trusted employee is in the best position to steal.

Mr. Taylor agrees.

“I can’t emphasize enough that every single complainant that comes to me says they can’t believe that so-and-so stole from them,” Mr. Taylor said. “When I ask if this trusted employee, who they all describe as ‘like family’, was the only one to handle the money and billing, the answer is always yes. These people are not your family.”

So, what should a physician do?

“One way to find a red flag is to understand your financial ratios,” said Mr. Taylor. “Track your cash payments as a percentage of your practice income. If it suddenly varies wildly, that is something to check immediately.

A dentist had always seen eight percent of his payments in cash.

This was tracked over years.

When it suddenly became seven percent and then six percent, he investigated and found his trusted employee was diverting the money.”

There are standard financial ratios for most industries but the most effective way is to track your own.

Ms. Fox maintains that employers don’t know what is going on with their employees, including the veterans.

Desperation for money because of health problems or a relative who needs money for a lawyer can motivate theft.

“One practice decided to cut back on expenses, including providing in-office snacks and health insurance,” related Ms. Fox. “This prompted one employee to steal because they thought they were being Continued on page 38>>

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FALL 2009

FALL 2009

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monitoring on a timely basis. This perception is a huge deterrent to financial loss.

Review the bank reconciliations for unusual or old reconciling items. A deposit that hasn’t cleared for several days (or longer) needs immediate scrutiny. Old uncleared checks, less so.

If cancelled checks (or copies) are returned by the bank, inspect the signatures for irregularities. Do the endorsements on the back of the checks match the payees on the front of the check?

Is there adequate separation of duties? This means that (ideally) the person who opens the mail or collects payments should be different from the person who makes the deposits and reconciles the bank.

In the accounts receivable journal or file, are there a large number of unexplained credits (non-cash adjustments) to the account balances? If so, someone may be collecting and keeping cash, but the patient’s account balance will still be accurate.

Do you monitor credit card charges by those authorized in your office? Ask for billing statements randomly throughout the year.

Are there an unusual number of complaints by patients about incorrect account balances or slowness in crediting of payments? If so, kiting may be involved.

On a random basis, trace sample payment records (from patient co-pay, Medicare or MediCal records) to specific deposits.

Use your financial/statements. Compare current period results with those of prior years and with budgeted amounts. Are there unusual trends or inconsistencies?

When hiring, call and check out referrals.

Consider having a background check (at around $70-75 per check, it may be money well spent).

This list is by no means all-inclusive but is intended to get the thought processes in motion and help deter future problems. For more complete help, make an appointment with your accountant. Even if no fraud is detected, your controls will be stronger and you may find ways to become more efficient.

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mistreated. They had justified the theft to themselves.”

Embezzlers start small and test their thievery systems. As each theft is successful they increase the amounts of the theft. Sometimes the process takes place over the span of years. Mr. Taylor relates one case where the amount began at about $8000 per year and eventually reached $100,000 before it came to light.

A classic scam is to pay personal bills along with practice bills. The responsible person pays your phone bill and their own at the same time.

And what did our anonymous local doctor do when he found out he was being robbed by an employee? He went to a computerized system, he has more than one person handling the money and an independent third person reconciles the receipts. He wants to let his fellow physicians know that it was a trusted, long term employee with family issues who was the malefactor. True to what the experts said, the amounts stolen went up over the years.

One last thing he adds, “Don’t ever sign a blank check.”

Here are some additional points to remember to avoid in-house theft: • Personally sign if you using paper checks. Be sure invoices are attached to the checks and that the payee and amount mirror the invoice.

• Keep an eye on the bank account. A password could be assigned to the bank account known only to the physician. Bank statements should be sent to a secure post office box.

• Monitor mail because stolen office mail is one way a fraudster works. Some physicians actually have the only key to the mailbox and look at the mail before handing it to staff.

• Some doctors arrange for receivables to go directly to the bank or even a lock box.

Payments go to the bank rather than the office.

Daily recaps of the incoming checks and totals are sent to the doctor.

Here are some warning signs: • An employee doesn’t take vacations.

• Accounts receivable have slowed, while patient visits are up.

• Patients are complaining about receiving past due bills after they’ve paid.

• An employee stops coming to work without any notice or explanation.

FALL 2009

Not a Member of San Joaquin Medical Society or CMA?

Why Not! Here are just a few of the Benefits youâ&#x20AC;&#x2122;re missing ...

Vast CMA Resources: Serving the counties of San Joaquin, Calaveras, Alpine, and Amador

Phone (209) 952-5299

r r r r r r r

Contract Analysis Reimbursement Hotline Legal Hotline Legislative Hotline HIPPA Compliance Seminars and Conferences Extensive Online Resources including over 200 letters, agreements, forms, etc. r Plus - Free Legal Advice with CMA ON-CALL Documents!

San Joaquin Medical Society Resources: r r r r r r r r r r

Annual Directory Member Seminars Cost Saving Benefits Quarterly Publication Classified Advertising Insurance Savings Alliance Membership Annual Social Events Patient Referrals Office Manager Forum and Practice Resources

Federal, State, and Local Advocacy: Your Dues are an Investment which Supports our Efforts in Protecting Your Rights.

If we Donâ&#x20AC;&#x2122;t Fight for You ... Who Will?

FALL 2009

SAN JOAQUIN PHYSICIAN

39

PUBlIc heAlTh > swine flu

PUBlIc heAlTh cOrNer PaNdeMiC iNflueNza H1N1 VaCCiNe is CoMiNg sooN! The California Department of Public Health and California’s local health departments are calling all parties interested in providing this vaccine…

• Clinics, public and private • Community Health Centers • Community vaccinators • Employee health programs • Health plans • Hospitals • Pharmacies, chain and independent • Physicians • Other vaccinators Starting by September 1, 2009, go to www.CalPanFlu.org.

1. Pre-register for vaccine Sign up to receive H1N1 vaccine as it becomes available.

Pre-registration: 40

SAN JOAQUIN PHYSICIAN

• is not a binding commitment to provide vaccine • can only be done by (or in conjunction with) a physician licensed to practice medicine in California • lets California Vaccines for Children (VFC) providers use their PIN number for fast-track identification 2. Order vaccine Vaccine is in production and currently expected to first be available by midOctober. Vaccine and basic supplies will be delivered at no cost to you. Providers may bill public and private insurers for vaccine administration fees.

• HOW: Pre-register and order early to minimize delays. (Note: Pre-registration and ordering do not guarantee receipt of vaccine) • WHEN: Timing and amount of vaccine deliveries will depend on available

inventory. First deliveries are expected by mid-October or later.

• WHO: Initial orders will go to vaccinators serving at-risk population groups. Other requests will be filled in turn, as supply permits.

3. Receive vaccine information and updates • vaccine availability • storage and handling • training on vaccination • the pandemic in California 4. Report your H1N1 vaccine usage • Instructions are available to complete a simple weekly report on H1N1 vaccine at your medical practice Additional information will soon be available at www.CalPanFlu.org.

Thank you for your interest in protecting California from pandemic influenza!

FALL 2009

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41

membership > benefits

SJMS Membership Coordinator Gena Stoddart (center) meets with Pediatrician Linda Sakimura and Practice Manager Sue Zumwalt of Pediatric Associates of Stockton.

Ask the Membership Coordinator San Joaquin Medical Society members can take great pride in being one of only a handful of county medical societies that employ a full-time Membership Coordinator whose job description includes spending two to three days of each week outside the office meeting our members and assisting them with a wide array of services.

Gena Stoddart fulfills the role of Membership Coordinator for the society with enthusiasm and genuine care for each member she comes into contact with. Whether she’s assisting a member with setting up their new practice, coordinating help from CMA’s vast resources, providing answers to current issues plaguing office managers, or handling the various medical societies social functions held throughout the year, she’s doing it with a smile on her face and helpful attitude.

Beginning with this issue of the San Joaquin Physician, we will feature this column to provide you the opportunity to learn from what other offices are asking us and to highlight a few of the unique services that your medical society and CMA provides at no cost at all.

Monthly Office Managers Forum Many of our members count our monthly Office Managers Forum and the impact it has had on their practice, as one of the most valuable benefits of medical society membership. For those that routinely attend, and that consists of about 20-25 office

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managers and a handful of physicians themselves, the meeting includes a speaker sharing information on a current topic, an opportunity to network with fellow peers willing to share ideas, new methods and common frustrations and enjoy a pleasant lunch together.

The fact that this meeting is free to current society members causes many to wonder why the room isn’t packed with office managers or other staff representatives seeking this information.

Held the second Wednesday of each month from 11:00am to 1:00pm at the popular Valley Brew Restaurant, chosen for it’s great food and convenient location on the Miracle Mile, attendees have recently received information on topics including last year’s Palmetto fiasco (we helped over 30 practices challenged with this issue), the recent ruling on Red Flag Identity Theft implementation, the use of CMA’s powerful ON-CALL Legal Documents, safe-guarding your practice from simple Risk Management mistakes and many other topics.

FALL 2009

Q: Does the Red Flags Rule require that I have any specific practices or procedures in my Written Identity Theft Detection and Prevention Program?

A: No. The Rule does not require you to implement any specific practice or procedures. It only requires that you have a written program that identifies common red flags of identity theft that might arise in your practice, provide for measures to detect these red flags and have a protocol to respond to a given red flag if it does arise. Within this overall framework, the Rule gives you the flexibility to tailor your written program to the nature of your business and the degree of risks it faces. Although checking ID when registering a new patient is probably good business practice, doing so is not an absolute requirement of the Rule for every business. For example, if you are at “low risk” of identity theft (e.g., you can recognize and know most or all of your patients already), you can satisfy the Rule without having a policy of checking ID. There may be other good reasons to check ID, but in this case, the Rule probably would not require it. However, businesses with a high risk of identity theft may need more robust procedures, like using other information sources to confirm the identity of new customers or incorporating fraud detection software.

The Federal Trade Commission (FTC) recently announced it would again delay enforcement of its new Red Flag Rule, which requires “creditors” – including many physicians – to develop and implement identity theft detection and prevention programs.

The new regulations are now scheduled to take effect on November 1, 2009.

According to the FTC, it will also release additional guidance to help “creditors” — particularly small businesses and those with a low risk of identity theft—to understand their obligations under these regulations.

For more information on the Red Flag rule, see CMA’s Red Flag Rule toolkit and webinar, available to free members, at the members-only website.

Contact: Samantha Pellon, 916/551-2872 or spellon@cmanet.org.

Q: We received a request from a lawyer for one of our patients’ medical records. This lawyer also wants all of the previous records from the previous physicians that this patient had care with. We have these records in our possession because the patient provided them to us when we took over their care. Do we have to provide these records as well?

A: Yes. Prior to the filing of any action or the appearance of a defendant in an action, an attorney or an attorney’s representative may present a physician with a written authorization for a records release signed by an adult patient, the guardian, or conservator of the patient or his or her estate, the parent or guardian of a minor, or the personal representative or heir of a deceased patient. That form must meet the requirements imposed by the HIPAA privacy rules (for an example of what this form should contain, please see CMA ON-CALL document #1127, “Attorney Pre-litigation Request for Medical Information”). The physician must then make all the patient’s records in his or her custody available for inspection and copying by the attorney or attorney’s representative during business hours within five days.

When a patient requests records, a physician may exclude information that has been provided in confidence by the patient’s spouse or others, except that a physician may not exclude information and records that have been provided by other physicians or healthcare providers or the patient.

FALL 2009

Best Practices:

Understanding Your Revenue Stream In today’s increasingly complex health care environment, it is imperative for physician practices to understand and proactively manage their revenue stream. Financial crises, even shortterm ones, can jeopardize the viability of your practice and impact the quality of care you are able to provide to patients. The key to preventing revenue shortfalls is actively monitoring what is coming in the door.

Chapter 5 of CMA’s Best Practices toolkit will help physicians understand how to manage accounts receivable through proven best practices in a number of areas: measuring and minimizing days in accounts receivable, managing self-pay revenue, and benchmarking key financial indicators.

CMA published the 140-page toolkit, with generous support from the Physicians’ Foundation, to help physicians improve the efficiency, and in turn the quality, of their practices.

In addition to learning how to manage your revenue stream, the toolkit will also teach you:

•

What every physician needs to know about running a practice;

•

How to find and keep qualified staff;

•

Why your receptionist can make or break your business;

•

How to build a defensible fee schedule;

•

When it makes sense to cancel a payor contract;

•

And much more.

The Best Practices toolkit, available free to all physicians, is organized into nine chapters that can be read sequentially or on an as-needed basis.

Download the toolkit today at CMAnet. org or call Gena who will gladly drop you a copy in the mail.

SAN JOAQUIN PHYSICIAN

43

X hOSPITAl > technology

dAMerON hOSPITAl’S geNeXPerT fasT MRsa deTeCTioN

By WILLIAM WEST

Dameron Hospital’s GeneXpert system can detect Methicillin Resistant staphylococcus aureus (MRsa) in less than two hours, which means that infection control and treatment protocols for infected patients can be implemented quickly.

The device is part of a stringent infection control regimen.

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FALL 2009

“We already had a low hospital acquired infection rate for MRSA and this was due to our aggressive infection control plan,” said Richard Wong, Administrative Director of the CORE lab at Dameron.

“What the MRSA PCR by GeneXpert did was give our clinicians and caregivers an answer in a two-hour window as opposed to a 24-hour window (Chromagar MRSA). Currently the State of California has mandated MRSA testing and made it reportable, but we were ahead of the mandate.”

Mr. Wong, who graduated from the University of the Pacific in 1970 with a biology degree, explained the GeneXpert system during a recent tour of the lab.

“When the MRSA test is complete, the Laboratory technical assistant gets a printout of the results by patient,” Mr. Wong said. “Results can also be accessed via the computer and displayed on a monitor. All negative results automatically flow into our laboratory information system (Siemens NOVIUS), using a process called ‘Auto validation’. From the laboratory information system it goes to the repository in the hospital information system (Siemens MS4) where physicians can access the results.”

The miraculous GeneXpert has a humble appearance. The overall visual affect is that of looking at a moderately sized file system where rows of modules are arranged horizontally and vertically like a group of mailboxes.

Using a Polymerase Chain Reaction (PCR) as part of the process, the GeneXpert automates what was a long series of manual lab processes. PCR, which replicates DNA in order to obtain enough quantities for identification and testing, takes place in sealed modules in the GeneXpert.

A remarkable cycle of heating and cooling occurs as part of the process of DNA replication.

FALL 2009

Each module comes fully prepped from the developer of GeneXpert, the publicly traded Santa Clara company called Cepheid.

“It is really a sophisticated incubator, among other things,” Mr. Wong said.

Inside the modules are cartridges that are the heart of the system. These are the microfluidic cartridges that contain several chambers. When the nucleic acid is extracted, it is moved from the processing chamber in the cartridge to the cartridge reaction tube where amplification and detection take place.

The modules perform rapid heating and cooling cycles required for highly reliable, real-time PCR in the reaction tube of the cartridge.

According to Cepheid, the modules continuously monitor each cartridge to quickly create enough copies of nucleic acid for accurate measurement. The modules work independently and can be used for different tests simultaneously.

They can detect multiple target nucleic acids in the same cartridge and the test shuts off when the targets are detected.

This shortens test times. The machine also confirms testing with a second reaction based on the results of the first. All of this happens without human intervention.

Dameron did look at other PCR testing systems like the BD GeneOhm system.

“This system was highly complex, which requires someone who has expertise in PCR testing,” said Mr. Wong.

“It required a special room, and did not have the testing menu of the Cepheid GeneXpert at the time of selection.”

The GeneXpert, which has been in place for a little over a year, sits in the three-year old Dameron laboratory that is situated across the street from Dameron Hospital proper and is fed samples through a pneumatic tube system built underneath Acacia Street.

Introducing

Nhat H. Tran, M.D. Specializing in Non-Operative Spine Dr. Tran has recently joined

Alpine Orthopaedic Medical Group, Inc. He treats patients with spasticity and spine problems and is Board Certified in Physical Medicine, and Rehabilitation. His areas of special interest are:

Interventional Spine Spasticity Management Dr. Tran is accepting new patients and is a provider of most health plans. To schedule an appointment, call (209) 946-7200.

“I am very fortunate to work with an established group such as Alpine Orthopaedic Medical Group, Inc. I look forward to meeting all of the local physicians and to be a part of the Stockton Community.”

SAN JOAQUIN PHYSICIAN

45

The lab is the result of years of planning and consultation with experts.

Mr. Wong, who has been with Dameron for 38 years, the last five as Administrative Director, was looking at retirement but saw the director’s position as a chance to dramatically improve patient care.

He had been around long enough to understand the value of a modern, fast lab.

“Patient care is what drives me,” said Mr. Wong.

Mr. Wong did his clinical laboratory training at San Joaquin General Hospital Clinical Laboratory and was hired by Dameron Hospital as a Clinical Laboratory Scientist in 1971. He was the Technical Supervisor of Chemistry from 1980-2004. He became Administrative Director in 2004.

“The experience I gained working at Dameron, networking with others in the clinical laboratory field, has given me a perspective of how to deliver better laboratory services to our customers: the patients, physicians and other caregivers,” said Mr. Wong. “In addition, I wanted to make an impact at Dameron by providing good patient care through today’s technology. One of the motivations for taking the Administrative

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Director position was a once-in-alifetime opportunity to build a clinical laboratory from the ground up.”

Miller Go, who was a consultant in the lab’s planning, points out that the GeneXpert is in clinical trials for FDA approval of tuberculosis detection.

“The standard turn-around time (specimen receipt to final result) for TB cultures is six weeks to rule out negative result,” said Mr. Go. “Positive specimens are detected by culture usually in two weeks depending on the amount of TB bacteria present. Most public health laboratories that perform TB testing offer direct DNA probe for TB with turnaround time in 24 hours and culture with a turn-around of four to six hours.”

The testing capabilities of the system also include tests for multiple viruses in the same module.

“This is called Multiplex PCR, when simultaneous amplification on many targets (genes) of interest occur in one reaction,” Mr. Go said. “This technology is in the GeneXpert pipeline. For now, GeneXpert is FDA cleared for testing enteroviruses in cerebrospinal fluid (CSF). Enteroviruses are group of viruses including polio, coxsackie, corona, and echovirus. These viruses are

common cause of aseptic meningitis.”

The GeneXpert can handle almost any sort of airborne, liquid, or solid sample. Human specimens can be drawn from whole blood, urine, vaginal, anal, and nasal swabs, bone marrow, sputum, serum, plasma and cerebral-spinal fluid.

Advanced ultrasonic techniques enable rapid lysing of all cell types. Because of its small footprint and low power requirements it can be used in almost any indoor setting. This versatility and ease of use attracted the Bill and Melinda Gates Foundation because it can be a boon for locales where a lack of technicians prevents diagnosis and treatment of large populations.

“That is helpful here, as well,” said Mr. Go. “There are shortages of clinical laboratory scientists but the GeneXpert can be handled by a lab technician with no special training.”

As of June 30, 2009, Cepheid had placed 1.147 GeneXpert Systems worldwide. Besides MRSA Surveillance, tests available include MRSA/SA Skin and Soft Tissue, MRSA/SA Blood Culture, GBS, EV, and approved by the FDA in July, Clostridium Difficile.

FALL 2009

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community service > off the charts

Malawi, Africa

The Warm

Heart Of Africa I have been going to Malawi for the past 28 years, and several years ago wrote an article for our magazine about our project to operate on polio victims called “crawlers.” These were children, teens and adults afflicted with paralysis in their legs due to polio, thus preventing them to stand and walk. Thus the term “crawlers.”

Story and Photos By Joseph Serra, MD 48

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In 1981, Rotary International provided a humanitarian grant of $250,000 for a project to operate on selected crawlers to straighten their legs, fit them with braces and crutches, and teach them to walk upright. Eight orthopedic surgeons were selected from around the world, four from the US, to go to Malawi; one every three months, and staying from one to two months to do the surgery. The project had a full-time physician from the UK, who along with his physician wife moved to Malawi for three years to be medical directors of the project. We had four physical therapists full-time, and two medical assistants who we trained to apply and remove casts, assist in surgery, do dressing changes, and other tasks. So the program had continuity of followup and patient selection which made it function extremely well. For example, when I would arrive in Malawi at Queen Elizabeth Central Hospital, there would be 30 to 40 patients already selected as potential surgical candidates ranging in age from five years to the early twenties. For the next four-to-six week stay, my work was to do as many surgeries as possible two or three days a week, and conduct pre-op and post-op clinics the rest of the time. The team worked well, and excellent records were kept on each patient so the next orthopedist could continue with the follow-up care, and do surgery on new arriving patients.

The project worked so well that the project continued for three years. During that time, the eight of us and our team saw more than 5,000 crawlers, and operated on over 2,300. Some crawlers did not require surgery, but merely needed braces and crutches. Others were not good candidates for surgery, and were fitted with wheelchairs, both two-wheeled, and some three-wheeled tricycle chairs for hand cranking.

This is why I went to this beautiful country of mountains, lakes, tea plantations, and incredible vistas; and above all the kindest, gentlest and appreciative people one could meet. I returned to Malawi four times by 1989.

The polio surgery expanded to include knee fusions, foot fusions to provide

FALL 2009

stability, and realignment of femurs and lower legs. Also, there were no orthopedic surgeons in Malawi in 1981 so we did fracture care and club foot surgery. Many of the general surgeons in the country wanted to learn about orthopedics since they were the only ones treating trauma.

So this is why I have returned to Malawi for eight visits averaging one month each. But now my main mission is to teach orthopedics. â&#x20AC;&#x192; In 1985, an eighteen-month course was developed to train Medical Assistants to do basic orthopedics at the three central hospitals and 28 district hospitals throughout the country. There students have had two years of college, and a minimum of three years working in hospitals prior to applying to this program. There is full-time faculty in charge of the program, and orthopedists like me go to Malawi to assist in teaching, and visit the graduates in practice in various hospitals. They learn to do fracture care, reduce dislocations, apply skeletal traction, drain septic joints, recognize tumors, tuberculosis, and other conditions. These graduates are called Orthopedic Clinical Officers, and are assigned to hospitals and clinics throughout the country to do the basic orthopedic care. It is amazing to see how well most of them do in practice. When they see cases they canâ&#x20AC;&#x2122;t handle, they refer them to the orthopedic surgeons at the three medical center hospitals. There are four orthopedists at Queen Elizabeth Medical Center and three at the Cure International Childrenâ&#x20AC;&#x2122;s hospital.

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Cure International is a non-profit organization based in Lancaster, PA., that has built four hospitals in Africa with Malawi being the third. It was built seven years ago, and is a modern state-of –the- art facility with 60 children’s beds, and ten adult beds. The adults pay for their care, and this provides free care for the children. The children are similar to Shriner’s patients with trauma, congenital anomalies, and burns. Their treatment is superb. The adults’ treatment includes joint replacements, spine surgery, and trauma. The three orthopedists are from the UK, and are excellent. One would not expect to see a modern hospital such as this in Africa.

In fact the University of Pacific Doctorate Physical Therapy program now has an intern at Cure for eight weeks doing adult and children’s physical therapy. This is the first year, and will be continued annually.

My one month tour is under the auspices of Health Volunteers Overseas in Washington, D.C. From six to eight orthopedists from around the world go to Malawi each year as visiting professors. Housing and an auto are available for use.

We see some fascinating cases that are rarely seen in practice.

Trauma is a major problem due to road traffic accidents.

Malawi is a beautiful country little known to tourists, but slowly being recognized as such. Lake Malawi, the game parks, the scenic mountains and plateaus, and especially the people bring visitors back to Malawi. I have been there three times in the past eighteen months, and will return again in June, 2010.

Through Rotary we will be sending a 40-foot container of medical supplies and equipment to Queen Elizabeth and Cure Hospitals with the assistance of MedShare International. You have probably noticed the recycle barrels at St. Joseph’s where unused supplies are placed rather than thrown out. MedShare collects, sorts, and packages these supplies, and then displays them on a website where the receiving hospitals can select what they really want and need. This is then placed in a container and shipped. But that’s another story.

community > decision medicine

The changing face of dec The Decision Medicine P changed drastically since 2001. When it was first in 6 students were selected high school, to participat Later, the program grew students from about five schools. Now, 24 studen to participate in the 2 we program and they repres of the high schools in the County. The reason the p to expose more students field. In the San Joaquin C a shortage of doctors, esp care physicians, and we n problem head-on. One o program is to motivate yo become physicians so th they could come back an our community. With th allow students to truly se to work in the medical fie them to shadow various health professionals. In a to ask questions and witn accounts of the physician interaction, the students valuable knowledge and relationships.

Since the program has gr been a challenge for the h allow access to such a lar So in order to accommo students, they were divid groups when visiting cert and facilities. Each day, tw students from each team day’s reporting responsib as a reinforcement of the experience and also as an the 2009 Program. This e cleverly called “Daily Rou this part of the program, two reporting positions: and the Photographer. Th responsibility was to sum particular day’s events in or more and upon return needed to email their fina This task was instituted to

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Nineteen-year-old Vanessa Armendariz, cision medicine a Franklin High School graduate who Program has now attends Johns Hopkins University, e its inception inwas inspired to become a doctor in the ntroduced, onlyDecision Medicine Program. Vanessa from one local has spent 1,200 hours in volunteer work and extracurricular activities in te in the program. addition to a rigorous class schedule. She to serve 12 different high is a vice president in the Multicultural nts are selected Student Volunteers, publicity chair of eek summer La Organizacion Latina Estudiantil, sent almost all mentor in the Mentoring Assistance e San Joaquin Peer Program, and a member of Global program grew isMedical Brigades. She went to Honduras s to the medical for a week to help in medical clinics. She County, we havecredits her chemistry teacher at Franklin pecially primary for telling her about Decision Medicine.

“Many people told me I couldn’t make need to tackle this of the goals of theit, but my chemistry teacher and others oung students toinspired me to try,” Vanessa said. “Johns hat in the future, Hopkins is tough and there is some nd help serve culture shock, but the study groups his program, we we are all in help very much. Decision ee what it is like Medicine changed my life.” eld by allowing physicians and allowing them ness firsthand n-patient are able to gain make lasting

The Changing Face of

Decision Medicine The Decision Medicine Program has changed drastically since its inception in 2001. When it was first introduced, only 6 students were selected from one local high school, to participate in the program. Later, the program grew to serve 12 students from about five different high schools. Now, 24 students are selected to participate in the 2 week summer program and they represent almost all of the high schools in the San Joaquin County. The reason the program grew is to expose more students to the medical field. In the San Joaquin County, we have a shortage of doctors, especially primary care physicians, and we need to tackle this problem head-on. One of the goals of the program is to motivate young students to become physicians so that in the future, they could come back and help serve our community.>>

rown it has hospitals to rge group. odate the 24 ded into three tain hospitals wo different m assumed the bilities to serve eir learning n archive for exercise was unds.” For there were the Reporter The reporters’ mmarize that n 100 words ning home alized essay. o add a level

Story by Priscilla Ambrocio and Vanessa Armendariz who served as our 2009 Program Facilitators l Photos by 2009 DM Students

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Hospital > technology community > decision medicine

Vanessa Armendariz Nineteen-year-old Vanessa Armendariz, a Franklin High School graduate who now attends Johns Hopkins University, was inspired to become a doctor in the Decision Medicine Program. Vanessa has spent 1,200 hours in volunteer work and extracurricular activities in addition to a rigorous class schedule.

She is a vice president in the Multicultural Student Volunteers, publicity chair of La Organizacion Latina Estudiantil, mentor in the Mentoring Assistance Peer Program, and a member of Global Medical Brigades. She went to Honduras for a week to help in medical clinics. She credits her chemistry teacher at Franklin for telling her about Decision Medicine.

“Many people told me I couldn’t make it, but my chemistry teacher and others inspired me to try,” Vanessa said. “Johns Hopkins is tough and there is some culture shock, but the study groups we are all in help very much. Decision Medicine changed my life.”

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With this program, we allow students to truly see what it is like to work in the medical field by allowing them to shadow various physicians and health professionals. In allowing them to ask questions and witness firsthand accounts of the physicianpatient interaction, the students are able to gain valuable knowledge and make lasting relationships.

Since the program has grown it has been a challenge for the hospitals to allow access to such a large group. So in order to accommodate the 24 students, they were divided into three groups when visiting certain hospitals and facilities. Each day, two different students from each team assumed the day’s reporting responsibilities to serve as a reinforcement of their learning experience and also as an archive for the 2009 Program.

This exercise was cleverly called “Daily Rounds.” For this part of the program, there were two reporting positions: the Reporter and the Photographer. The reporters’ responsibility was to summarize that particular day’s events in 100 words or more and upon returning home needed to email their finalized essay.

This task was instituted to add a level of accountability and to make sure the students would fully benefit.

The photographer had a similar task.

With the cameras provided, they were responsible for taking pictures of the day’s activities especially those highlighting their teammate’s interest. These journal entries, as well as the photos, will be used on the Decision medicine website as well as all promotional material.

Not only was the size of the program expanded, but there were also many new additions to the program. One of the new facilities visited was the Community Center for the Blind. There, the group was able to meet Christopher Sanchez, who is visually impaired. He told everyone that the blind learn to “do the same things, but just in different

ways.” Students were able to observe them making ceramic chimes and statues, weaving intricate blankets and quilts, using different computer software programs, and they even had a chance to learn about how the Stockton Stingrays, a blind athletic team, play Beep Ball, which is baseball that is modified for the visually impaired.

In addition, two students got to watch two live surgeries performed

by Dr. Rawson at St. Joseph’s Hospital. Since the surgery was a laparoscopic gallbladder removal, there was not a large amount of blood to be seen, which put both James Cwick, a senior from Ripon High and Claire Dougherty, a senior from St. Mary’s High, at ease. “The anxiety didn’t really hit me until I was getting dressed up in the surgery scrubs,” said Claire. It left such a lasting impression that James, who was initially interested in research and microbiology, is now interested

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in becoming a surgeon. Both students expressed that they felt very welcomed by the surgical team because during the surgery, the doctor described and explained his actions throughout the entire procedure. They both agree that if it was not for the Decision Medicine Program, they would have never got to experience watching a live surgery. James defined the pivotal experience by saying that it “gave [him] more motivation to continue pursuing [his] dream of becoming a physician.”

The highlight of the program was our last outing, which was to the Sutter Pacific Hospital in San Francisco. The students toured the new $90 million renovated hospital wing for recovering neurosurgeon patients and partook in one of the nation’s most technologically advanced simulation labs with two test dummies totaling over $200,000 each. The students were also graced by the presence of Dr. James Avery, who explained the Ventricular Assist Device (VAD). The VAD is a mechanical

FALL 2009

pump-type device surgically implanted in patients whose heart continues to fail.

The experience was heightened when an actual patient with the VAD shared their experience. Lastly, the students were able to tour the California Pacific Regional Rehabilitation Terrain Park, which helps patients practice every day obstacles such as crossing streets and walking on different terrains such as sand, bark, and asphalt. At the end of the day, the students enjoyed a boat ride in the San Francisco Bay and as the sun set they had dinner at the world famous Pier 39.

To celebrate the conclusion of the Decision Medicine Program, students were honored at a beautiful banquet at Stockton Golf and Country Club. As a special treat, the three groups performed a prepared skit in front of their families and visiting doctors. The students had no restrictions but had to represent what they learned throughout the program. They were even supplied with props, both medical and other random

objects, which would work as a catalyst for their imaginations. The skits ranged from flash backs to first aid scenarios, all different but evident of the skills the students learned throughout the weeks.

Due to the success of the program, the number of applicants has grown, new additions have been implemented, and it is now expanding to target students at a younger age. Starting this September, fourth graders at Hamilton school will participate in the Decision Medicine JR Program. Every month, health care professionals will visit their class and introduce them to the field of medicine.

Not only has the program impacted San Joaquin County but the California Endowment has given a grant to explore the possibility of implementing the Decision Medicine Program in other Counties. A decade ago, Decision Medicine was only an idea from a few dedicated doctors, but with the support of many partners and organizations, it is now a successful program that continues to grow and impact the lives of many.

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community > decision medicine

Day One – Team Building on the Ropes Course!

The first day aimed towards building group cohesiveness, developing openness to new ideas and problem-solving skills, and teaching students the importance of teamwork, especially in the medical field. They were challenged both physically and mentally, which prepared them for the days to come.

Day Two – St. Josephs Medical Center and Learning First Aid The first hospital that the students toured was St. Joseph’s Medical Center. The students visited a variety of departments including Radiology, the pathology lab, and the ER. They were also able to work with the simulation dummy, which allowed the students to practice as if it were a real patient. Later, the students were First Aid certified.

Day Three – Making Rounds with SJGH Residents The third day started with the students splitting into two groups: one group went to the San Joaquin Department of Public Health and the department of Behavioral Health, while the other group was at San Joaquin General Hospital. At SJGH, the students were able to go on rounds with the residents, interns, and doctors, and visit the pathology lab, NICU, and Radiology.

Day Four – Meeting Your Physician Mentor This day, the students were matched with mentor physicians to experience a day in their lives as doctors. They spent the entire morning shadowing the physician’s in their office and some were then escorted to s special lunch with their mentor. In the afternoon, they were CPR certified.

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Day Five – A Visit to UC Davis Medical School and Shriner’s Children’s Hospital The students spent the last day of their first week in Sacramento visiting the UC Davis Medical School and Shriner’s Hospital.

The students were greeted by the Director of Admissions for the Medical School, challenged with multiple interactive activities, and were able to ask current medical students questions about their paths to medicine. The day ended with a tour of Shriner’s Hospital.

Day Eight – Public Health and Behavioral Health Case Studies Students visited the San Joaquin Department of Public Health and were challenged by various medical presentations during the morning and were then able to go on patient visits with the nurses to see real life case studies. The students then toured the department of Behavioral Health, where they met with various medical professionals who shared their personal career stories and provided a glimpse of the significant work they do for the citizens of San Joaquin County.

Day Six – Dameron Hospital This day was spent at Dameron Hospital, rotating in the department of Radiology, NICU, and the Pathology lab. One of the major highlights of the day was the Forensic Pathology PowerPoint presentation by Dr. Robert Lawrence, where he showed the students pictures of real life crime scenes as he challenged the students to try and figure out what happened in each scenario.

Day Seven – A tour of UOP and visits to Hospice of San Joaquin and the Blind Center This day was spent at the University of Pacific, the Hospice of San Joaquin, and the Community Center for the Blind. The students toured the UOP Campus while listening to multiple presenters in the fields of physical therapy, Pharmacy, and Speech Pathology.

The students were then able to witness the daily obstacles that the visually impaired go through, but they were quick to learn that they can do the same things as we can, just in different ways!

Day Nine – Kaiser Permanente Tour and a Work Project at St. Mary’s Medical Clinic The students were able to tour the departments of Orthopedics, Physical Therapy, and Internal Medicine at the Kaiser Clinic. They were also able to talk with Internal Medicine specialist Dr. Fakhouri, who motivated and inspired them to follow their dreams. The second half of the day was spent at St. Mary’s Medical Clinic, where students toured the facility and helped separate hundreds of shoes for their annual shoe drive.

Day Ten – An Amazing Day and Evening in San Francisco!

The last day was spent at the California Pacific Medical Center in San Francisco.

The students toured the new $90 million renovated hospital wing for recovering neurosurgeon patients and partook in one of the nation’s most technologically advanced simulation labs. The students also met worldrenowned thoracic surgeon Dr. James Avery who heads CPMC’s amazing heart transplant team. The students were then treated to a special dinner and boat ride at Pier 39.

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Learn, Lead, Grow : Career Essentials for Effective Physicians • With Susan Reynolds, MD, PhD, President and CEO, The institute for Medical Leadership • November 7, 2009 • Noon - 4:00pm • Lunch Included • Stockton, CA To register, please contact the San Joaquin Medical Society at (209) 952-5299 Professional Development This leadership training seminar will provide materials and use interactive discussion and group exercises to train physicians to be more effective leaders in their medical associations, medical groups, and/or hospital medical staffs. Dr. Reynolds will present on: • Physicians as successful organizational leaders • Building a dynamic medical organization • Mentoring partnerships that support your career • Effective communication for political action Why would I want to attend?

In today’s health care environment, physician leadership skills are necessary to ensure that quality of care is advanced and to galvanize your colleagues to take action when needed. Learn about current issues facing our profession such as legislation affecting medical malpractice and HIT so you can be knowledgeable, prepared, and effective as a physician leader.

Special thanks to the Cooperative of American Physicians and Pfizer for their generous support of this program.

In Conjunction With:

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FALL 2009

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medical society > membership

24 New

Members in the Past 60 Days! ...and even more on the way.

Sean Anderson, MD Anesthesiology 700 Mtn Ranch Road, Ste C1 San Andreas, CA 95249 Office: (209) 754-4334 University of Arizona: 2002

Virgil Graham, MD Obstetrics & Gynecology Kaiser Permanente 7373 West Lane Stockton, CA 95210 Medical College of Wisconsin: 1985

Enelyn Canio, MD Internal Medicine Kaiser Permanente 7373 West Lane Stockton, CA 95210 Office: (209) 476-3175 Howard University: 1995

Nejat Jalisi, MD Family Medicine Sutter Gould Medical Foundation 2151 W Grant Line Road Tracy, CA 95377 Office: (209) 832-0535 Ahwaz School of Medicine: 1993

Andrew Chao, MD Obstetrics & Gynecology P Gill OB& GYN Medical Group 1617 N California St, Ste 2A Stockton, CA 95204 Office: (209) 466-8546 University of Pennsylvania: 1977

Priya Kandaswamy, MD Family Medicine Sutter Gould Medical Foundation 830 S Ham Lane, Ste 28 Lodi, CA 95240 Office: (209) 366-2008 Coimbatore Medical College: 2004

Dmitri Gelfand, MD Vascular Surgery Sutter Gould Medical Foundation 1805 N California St, Ste 310 Stockton, CA 95204 Office: (209) 941-0127 University of California: 2001

Mallareddy Maddula, MD Nephrology 1610 N El Dorado St, Ste 16 Stockton, C A95204 Office: (209)546-1868 Andhra Medical College: 1994

Otashe Golden, MD Family Medicine 530 W Acacia St Stockton, CA 95203 Office: (209) 461-3105 Albany Medical Coll, Union Univ: 1998

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Thomas Mahoney, MD Family Medicine 7210 Murray Drive Stockton, CA 95210 Office: (209) 373-2800 University of Massachusetts: 1994

Donald Matthews, MD Family Medicine University of California SF: 1966 Alan Mc Innes, MD Ophthalmology Zeiter Eye Medical Group 255 W Weber Ave Stockton, CA 95202 Office: (209) 466-5566 University of Utah: 2000 Sundar Natarajan, MD Internal Medicine 3215 N California St, Ste 1 Stockton, CA 95204 Office: (209) 461-0500 New York Medical College: 1998 James Ngo, DO Family Medicine Sutter Gould Medical Foundation 2505 W Hammer Lane Stockton, CA 95209 Office: (209) 957-7050 Touro University: 2006 Joseph Nguyen, DO Family Medicine 10200 Trinity Parkway, Ste 102 Stockton, CA 95219 Office: (209) 948-0808 Touro University: 2001 Jennifer Phung, MD Obstetrics & Gynecology P Gill OB& GYN Medical Group

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1617 N California St, Ste 2A Stockton, CA 95204 Office: (209) 466-8546 Ross University: 2005 Rajan Saini, MD Hospitalist Sutter Gould Medical Foundation 2505 W Hammer Lane Stockton, CA 95209 Office: (209) 524-1211 Kottayan Medical College: 2001 Tatyana Sarkisova, MD Family Medicine Sutter Gould Medical Foundation 2505 W Hammer Lane Stockton, CA 95209 Office: (209) 957-7050 Yerevan State Medical Univ: 1989 Juan Sarti, MD Anesthesiology Sutter Gould Medical Foundation 8011 Don Ave Stockton, CA 95209 Office: (209) 524-1211 Universidad Nacional de La Plata: 1996 Ajitpal Sethi, MD Hospitalist Sutter Gould Medical Foundation 600 Coffee Road Modesto, CA 95355 Office: (209) 524-1211 Government Medical College: 1999 Olga Thorne, MD Obstetrics & Gynecology Sutter Gould Medical Foundation 1407 N Tracy Blvd Tracy, CA 95376 Office: (209) 835-0100 Altai State Medical Univ: 1996 Lakshma Tiyyagura, MD Internal Medicine 420 W Acacia St, Ste 18 Stockton, CA 95203 Office: (209) 466-4685 Guntur Medical College, Andhra Univ: 1990 Nhat Tran, MD Physical Medicine & Rehabilitation 2488 N California St Stockton, CA 95204 Office: (209) 948-3333 New York Medical College: 2003 Vanessa Tsuda-Nguyen, DO Family Medicine 10200 Trinity Parkway, Ste 102 Stockton, CA 95219 Office: (209) 948-0808 Touro University: 2002

FALL 2009

Saturday

Oct 3 9amâ&#x20AC;&#x201C;1pm Brookside Country Club Stockton

Specialized Tax, Estate, and Financial Strategies for Physicians and their Wives

RSVP to Stull Financial Services (209) 957-1673

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Breakfast Buffet

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Presenter: Christopher Engh, Esq. a partner with the Stockton

law firm of Kroloff, Belcher, Smart, Perry & Christopherson since 1984. Mr. Engh is certified as a specialist in estate planning, trust and probate, and trust and estate litigation. Mr. Engh taught Wills and Trusts at Humphreys College of Law.

10:30am Tax Strategies that Could Save You Thousands in an Uncertain Tax Environment Presenter: Kelly Clark of Bradford & Company, Inc.,

founded by W. Murray Bradford, CPA, tax specialist and author of the Prentice-hall Business Tax Deduction Master Guide. Bradford & Company are featured advisors for The Wall Street Journal, USA Today, Money Magazine, The Washington Post, Fortune and other prominent magazines, as well as presenters on tax reduction strategies for The California Medical Society, The American Institute of CPAâ&#x20AC;&#x2122;s, The American Dental Association, the American Psychiatric Association, and 100s of other groups. Kelly is a recognized tax professional having presented over 650 sessions locally on tax strategies.

11:30am Financial Planning for Physicians in an Uncertain Economic Environment Presenter: David J. Stull, CLU, ChFC. David is the owner

of Stull Financial, a local independent financial advisory firm that provides private retirement and estate planning strategies for physicians and affluent entrepreneurs. David has been a regular contributor of financial advisory articles to The San Joaquin Physician magazine. David is current President of The Stockton Estate Planning Council, and is a member of The Brookside Country Club.

Knowledge is Power.

This Tax, Estate & Financial Planning Forum, with its featured experts in various fields, will certainly provide the Knowledge.

SAN JOAQUIN PHYSICIAN

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1617 N. California St, Suite 1A 7 1B Stockton CA 95204

Frank S. Callcott, M.D.

64 Slice CT High Field MRI Open MRI PET Fusion Breast Ultrasound, MRI, and Biopsy Digital Mammography Digital X-Ray Ultrasound Fluoroscopy Bone Density Varicose Vein Treatment Uterine Fibroid Embolization

For appointments call: Lodi: (209) 333-7422 Stockton: (209) 466-5027 w w w. d e l t a r a d . c o m FALL 2009

SAN JOAQUIN PHYSICIAN

63

PRSRT STD. U.S. POSTAGE

San Joaquin Medical Society 3031 W. March Lane, Suite 222W Stockton, California 95219-6568

PAID

Permit No. 60 Stockton, CA

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