Spring 2020

Curing the San Joaquin Valley’s

DOCTOR SHORTAGE CalMedForce helps grow local residency programs

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Spring 2020

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SPRING 2020

VOLUME 68, NUMBER 1 • MARCH 2020

{FEATURES}

12 14 30 44

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HOLIDAY PARTY FEDERAL ADVOCACY UPDATE CURING THE SJV'S DOCTOR SHORTAGE OPPOSE THE FAIRNESS FOR INJURED PATIENTS ACT

{DEPARTMENTS} 9 PRESIDENT'S MESSAGE 20 IN THE NEWS 38 RISK TIP 50 PRACTICE NEWS AND RESOURCES 52 PUBLIC HEALTH

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PRESIDENT Richelle Marasigan, DO PRESIDENT ELECT Hyma Jasti, MD INTERIM TREASURER John Zeiter, MD BOARD MEMBERS Sanjay Marwaha, MD, R. Grant Mellor, MD, Shahin Foroutan, MD, Neelesh Bangalore, MD, Benjamin Morrison, MD, Raghunath Reddy, MD, Maggie Park, MD, Cyrus Buhari, DO, Nguyen Vo, MD, Sujeeth Punnam, MD

MEDICAL SOCIETY STAFF EXECUTIVE DIRECTOR Lisa Richmond MEMBERSHIP COORDINATOR Jessica Peluso ADMINISTRATIVE ASSISTANT Maria Rodriguez-Cook

SAN JOAQUIN PHYSICIAN MAGAZINE EDITOR Lisa Richmond EDITORIAL COMMITTEE Richelle Marasigan, DO, Lisa Richmond MANAGING EDITOR Lisa Richmond CREATIVE DIRECTOR Sherry Lavone Design

COMMITTEE CHAIRPERSONS CMA AFFAIRS COMMITTEE Larry Frank, MD DECISION MEDICINE Kwabena Adubofour, MD

CONTRIBUTING WRITERS Richelle Marasigan, DO, Jo Ann Kirby, Maggie Park, MD, Gwen Callaway, MPH, and Todd Davenport, PT, DPT, MPH

MEDICAL EDUCATION PROGRAMS R. Grant Mellor, MD PUBLIC HEALTH COMMITTEE Maggie Park, MD SCHOLARSHIP LOAN FUND Gregg Jongeward, PhD

CMA HOUSE OF DELEGATES REPRESENTATIVES Robin Wong, MD, Lawrence R. Frank, MD,

THE SAN JOAQUIN PHYSICIAN MAGAZINE is produced by the San Joaquin Medical Society SUGGESTIONS, story ideas are welcome and will be reviewed by the Editorial Committee.

James R. Halderman, MD, Raissa Hill, DO, Ramin Richelle Marasigan, DO, Manshadi, MD,

PLEASE DIRECT ALL INQUIRIES AND SUBMISSIONS TO:

Kwabena Adubofour, MD, Philip Edington, MD,

San Joaquin Physician Magazine

Steven Kmucha, MD

3031 W. March Lane, Suite 222W Stockton, CA 95219 Phone: (209) 952-5299 Fax: (209) 952-5298 E-mail Address: lisa@sjcms.org MEDICAL SOCIETY OFFICE HOURS: Monday through Friday 9:00am to 5:00pm Closed for Lunch between 12pm-1pm

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Sometimes You Just Need a Little Help.

EXCI

RAFFTING PRIZ LE E S

Eleventh Annual Golf Tournament Join fellow San Joaquin Medical Society members and invited guests for a relaxing round of golf, BBQ lunch, dinner and after golf party. Exciting and generously donated raffle prizes you don’t want to miss. Plus an opportunity to benefit our local The First Tee of San Joaquin and SJMS’ Decision Medicine programs. Your hosts, Drs. Kwabena Adubofour, George Herron, and George Khoury are committed to making this an event to remember!

Sunday April 26, 2020 • Stockton Golf & Country Club • 4 Person Scramble $175 per golfer - Price includes green fees, golf cart, lunch, after golf dinner and party! See registration form for details. $50 of every entry fee goes to The First Tee of San Joaquin program Hole Sponsorships benefit SJMS’ Decision Medicine Program

Registration and Range Open 11:00am • Putting Contest Qualifying 11:00am - 12:30pm Buffet Lunch 12:00pm • Shotgun start 1:00pm

To sign up, please call the San Joaquin Medical Society office at 209-952-5299 SPRING 2020

Eleventh annual

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EXECUTIVE DIRECTOR’S REPORT

HERE WE GO AGAIN While it feels like just yesterday, it has been 5 years since the California Medical Association led the effort to defeat Prop 46. Unfortunately, late last year, a wealthy out-of-state trial attorney filed a new initiative for the November 2020 ballot that would essentially eliminate the Medical Injury Compensation Reform Act (MICRA) and substantially raise health care costs for all Californians, reduce access and exploit patients for profit. Just like last time, it will take a grassroots effort to educate your patients and our community.

Please read more about this latest attack on MICRA and stay tuned for future updates.

LISA RICHMOND

On a brighter note, in January, along with Physicians for a Healthy California, we were excited to present giant checks totaling $3,150,000 from the CalMedForce Grant to support 14 new and expanded residency positions at San Joaquin General Hospital and St. Joseph’s Medical Center. We feel hopeful that as our community transforms to a hub for graduate medical education, we are closer to ending the physician shortage and increasing access to care for patients. We know you will enjoy reading more about CalMedForce and its local awardees on page 32.

You may notice our newly designed Practice News and Resources pages which will expand beyond just details about our monthly Office Managers Forum. We will share information helpful to both practice managers and physicians, including CMA offered webinars (when available), as well as highlight other announcements that impact your practice. If haven’t already, please also subscribe to CMA Practice Resource (CPR) newsletter at www.cmadocs.org/cpr.

On Sunday, April 26, we will be hosting our 11th Annual Golf Tournament at the beautiful Stockton Golf & Country Club, benefitting The First Tee of San Joaquin and our Rick Halligan Memorial Scholarship, which is presented to exceptional Decision Medicine alumni entering their freshman year of college. We hope that you will plan to join us for a fun day of golf and fellowship. See enclosed ad for all of the details and information.

Registration is open!

Finally, please save the date for our annual Young Physician and Lifetime Achievement Award dinner on Sunday, June 7.

Best Wishes,

Lisa Richmond

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A message from our President > Richelle Marasigan, DO

Nothing is Constant but Change In medicine, as in life, change is inevitable. The way we practice medicine is always changing, and health care policy is constantly evolving as well. With these changes in practice and policy come changes in the way patients interact with these new changes as well. One example is the unanticipated recent decline in primary care physician (PCP) visits across all populations with the increased accessibility to care due in part to the Affordable Care Act (ACA).

The California Medical Association (CMA) physicians have always been an advocate for health care coverage for all Californians and improved access to care.

In 2010, California adopted the Affordable Care Act (ACA) and expanded coverage to more than 5.4 million previously uninsured Californians through the Covered California State Exchange and the Medicaid Expansion for very low-income adults.

This led to a drop in rate of uninsured from 17 percent to 7 percent of the total population. During the last few years there have been a number of essential health care reforms brought about by the Affordable Care Act to help reduce financial barriers and focus on prevention and wellness. However, there are still issues that are constantly under debate including: universal coverage, instability in the individual marketplace and rising health care costs.

ABOUT THE AUTHOR ­ Dr. Richelle Marasigan is the President of the San Joaquin Medical Society and is a secondgeneration physician who practices family medicine at HT Family Physicians

SPRING 2020

One particular study showed the number of primary care visits among commercially insured adults decreased 24.2% over 9 years while specialist visits remain largely unchanged. This information is of particular concern due to the fact that consistent primary care has been associated, at a population level, with lower mortality and better health care outcomes as well as less need for emergency care, lower costs of care and better patient satisfaction. There are reasons for the decline in visits including the following: More patients are seeking medical care online. In the age of telemedicine and the internet patients are technologically savvy and becoming increasingly comfortable with obtaining medical advice online via online consults and internet searches.

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A message from our President > Richelle Marasigan, DO

Rising deductibles and out-of-pocket costs for care. The decline in PCP visits is the largest in low-income communities. Health care is more difficult to obtain with high out-of-pocket costs, estimated to be increased as much as 32% for problem-based visits and an increase in the percentage of visits that involve a deductible.

Seeking care other places. Patients have also been noted to visit urgent care centers, retail clinics, telemedicine visits, and emergency departments.

Longer appointments that are necessary to address more complex medical problems. The electronic health records have made it possible to provide more preventative services and procedures, like vaccines and wound care.

Physicians now offer more non face-to-face care.

Secure messaging and virtual care make it easy to relay followup questions to the PCP and also obtain lab results without having to come in for an appointment.

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The decline of PCP visits does not necessarily occur with the population of healthy patients who, in all likelihood, are least likely to be affected by missing appointments. Those that are showing the most decline are those with chronic conditions that need to be monitored, such as asthma and diabetes mellitus.

The lack of regular visits could lead to serious complications in the future, which would lead to a much greater cost and burden to the system and to the patient. The steady decline in the PCP visit rates across all populations may be the unintended consequence of using cost sharing to reduce unnecessary care in an uncoordinated health care system. Cost-sharing and highdeductibles have been designed to decrease use of unneeded care and require patient investment, however needed care is also being decreased. It will be interesting going forward to see how this will impact health care reform. These are the studies that can help the CMA to pursue their goal to ensure that Californians maintain access to physicians and meaningful, affordable coverage.

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BECOME A MEMBER OF SJMS/CMA

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San Joaquin Medical Society Resources: • Annual Directory • Quarterly Magazine • Social Events • Office Managers Forum • Leadership Opportunities • Patient Referrals

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Federal, State, and Local Advocacy: Dues support advocacy efforts to protect the profession of medicine and your patients

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Federal Advocacy Update 14 SPRING SAN2020 JOAQUIN PHYSICIAN

SAN JOAQUIN PHYSICIAN SPRING 2020 14

What to expect in 2020 While some believe that the 2020 election politics, Presidential impeachment, and escalating tensions with Iran will scuttle Congress’ ability to legislate, there are two bipartisan health care issues extremely important to voters - surprise medical bills and skyrocketing costs of prescription drugs - that might rise above the fray and move to the President’s desk. The question is whether Democrats and Republicans want to compromise to give each other a victory in an important election year.

A BALANCED SOLUTION TO SURPRISE MEDICAL BILLS

in-network physicians, and on-call

The early priority will be to protect

emergencies. Speaker Pelosi blocked the

patients from surprise medical bills.

HELP and E&C bills at the end of session

While insurers had the upper hand for

so that the House Ways and Means

the first half of 2019, physicians and

Committee could weigh-in with a more

hospitals began to tell their story and

balanced approach in 2020.

physician specialists caring for patients in

legislators became concerned that the bills tipped the scales too far in favor

The ways and means committee

of the insurers and did not protect

released a legislative outline at the end

access to physicians and hospitals. CMA

of 2019 and they plan to move a full

effectively educated Congress about the

bill in January. The basic framework

unintended consequences of California’s

appears to be an improvement over

law and we were key in the fight to

the other committee bills. It does not

ensure a more balanced solution that

set a benchmark payment rate but

protects patients from surprise bills but

rather allows it to be determined in

establishes a fair process for insurers

an independent dispute resolution

and physicians to resolve disputes. CMA

(IDR) process and without a monetary

helped to lead the fight with our key

threshold for accessing IDR. It also

California Congressional leaders to stop

addresses network adequacy. Their

the Senate HELP and House Energy

proposal would need to be reconciled

Commerce (E&C) Committee bills. These

with the House Energy Commerce/

bills would have imposed more than

Senate HELP proposals. CMA will

20% payment cuts on non-contracting,

continue to aggressively advocate for a

as well as contracting physicians,

balanced solution that protects physician

and negatively impacted access to

contracting and access to care. >>

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While some believe that the 2020 election politics,

non-contracting, as well as contracting physicians,

Presidential impeachment, and escalating

and negatively impacted access to in-network

tensions with Iran will scuttle Congress’ ability

physicians, and on-call physician specialists caring

to legislate, there are two bipartisan health care

for patients in emergencies. Speaker Pelosi blocked

issues extremely important to voters - surprise

the HELP and E&C bills at the end of session so

medical bills and skyrocketing costs of prescription

that the House Ways and Means Committee could weigh-in with a more balanced

These bills would have imposed more than 20% payment cuts on non-contracting, as well as contracting physicians, and negatively impacted access to in-network physicians, and on-call physician specialists caring for patients in emergencies.

approach in 2020.

THE WAYS AND MEANS COMMITTEE released a legislative outline at the end of 2019 and they plan to move a full bill in January. The basic framework appears to be an improvement over the other committee bills. It does not set a

drugs - that might rise above the fray and move

benchmark payment rate but rather allows it to be

to the President’s desk. The question is whether

determined in an independent dispute resolution

Democrats and Republicans want to compromise

(IDR) process and without a monetary threshold for

to give each other a victory in an important

accessing IDR. It also addresses network adequacy.

election year.

Their proposal would need to be reconciled with the House Energy Commerce/Senate HELP

A BALANCED SOLUTION TO SURPRISE MEDICAL BILLS

proposals. CMA will continue to aggressively

The early priority will be to protect patients from

physician contracting and access to care.

advocate for a balanced solution that protects

surprise medical bills. While insurers had the upper hand for the first half of 2019, physicians and

CURBING PRESCRIPTION DRUG COSTS

hospitals began to tell their story and legislators

While Congress faces an even greater challenge

became concerned that the bills tipped the

on prescription drugs costs, it is a top health

scales too far in favor of the insurers and did

care priority for voters. Speaker Pelosi and

not protect access to physicians and hospitals.

Democrats will push HR 3 which allows Medicare

CMA effectively educated Congress about the

to negotiate drug prices with the pharmaceutical

unintended consequences of California’s law and

manufacturers. It focuses on the most expensive

we were key in the fight to ensure a more balanced

and most commonly prescribed drugs and uses

solution that protects patients from surprise bills

120% of international drug prices as a payment

but establishes a fair process for insurers and

guideline. Republicans have been critical of this

physicians to resolve disputes. CMA helped to lead

approach although President Trump promoted it

the fight with our key California Congressional

during the Presidential campaign. Senate Finance

leaders to stop the Senate HELP and House Energy

Committee leaders have a bipartisan proposal that

Commerce (E&C) Committee bills. These bills would

would limit annual drug price increases to the rate

have imposed more than 20% payment cuts on

of inflation. But Senate Republicans are divided

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SPRING 2020

Legislature Clarifies Law Requiring Physicians to Offer Naloxone to Patients In January, a new law took effect that

a patient with a history of opioid use

requires opioid prescribers to also offer

disorder, or a patient at risk for returning

prescriptions for opioid-overdose reversal

to a high dose of opioid medication to

drugs such as naloxone. The California

which the patient is no longer tolerant.

Medical Association (CMA) received numerous calls from physicians regarding

In addition, the law now specifies that

the ambiguity of the new requirements.

the education physicians must provide patients who are prescribed naloxone or

The California Legislature recently enacted

other similar drug must be about opioid

a bill that clarifies the circumstances

overdose prevention and use of the opioid

under which physicians are required

reversal drug. Physicians do not need

to offer opioid-overdose reversal drugs.

to provide the education if the patient

Effective September 5, 2019, AB 714

declines or if the patient has received the

specifies that the requirement to offer

education within the past 24 months.

naloxone applies only if the patient is receiving a prescription for an opioid or

The new law further clarifies that the

benzodiazepine medication.

requirement to offer naloxone do not apply when the opioid or benzodiazepine

If a patient is receiving such a prescription,

medication is being administered in a

the law requires that the prescriber offer

facility or prescribed to a patient who is

naloxone or other similar drug if:

terminally ill.

The prescription dosage for the patient

To learn more about prescribing

is 90 or more morphine milligram

controlled substances, including this new

equivalents of an opioid medication per

requirement, see CMA health law library

day

document #3201, “Controlled Substances: Prescribing.”

An opioid medication is prescribed within a year from the date a prescription for

This document, as well as the rest of CMA’s

benzodiazepine has been dispensed to the

online health law library, is available free

patient

to members at cmadocs.org/health-law-library.

The patient presents with an increased

SPRING 2020

risk for opioid overdose, including a

Nonmembers can purchase documents

patient with a history of opioid overdose,

for $2 per page.

SAN JOAQUIN PHYSICIAN

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on this approach. CMA has long-standing policy

process to reduce burdens on physicians and

strongly supporting HR 3. It is a monumental bill

eliminate delays for patients. See CMA talking

that would effectively reduce escalating drug costs

points attached.

for patients.

The legislation also produces a Medicare cost-

Physician Public Service Loan Forgiveness Fix for California and Texas Physicians

savings that could help to permanently fund other

The fate of CMA’s statutory clarification (HR 4607 Harder D-CA/Cook R-CA) that gives California physicians access

These bills would have imposed more than 20% payment cuts on non-contracting, as well as contracting physicians, and negatively impacted access to in-network physicians, and on-call physician specialists caring for patients in emergencies.

to the federal public service loan forgiveness program without being directly employed by a hospital is tied to the massive Higher Education Reauthorization Act which needs to move through Congress soon. CMA is pushing on all fronts to get a fix as soon as possible.

important health care programs, such as the

REGULATORY ADVOCACY

teaching health center primary care GME program,

New Medicaid Financing Regulation Reduces the

and Medicare payment updates to maintain

Federal Commitment to States, Providers and

seniors’ access to care.

Patients

PUBLIC HEALTH PROTECTIONS

In late November, the Centers for Medicare and

The teen e-cigarette epidemic will continue to gain

Medicaid Services (CMS) released a Medicaid

Congressional attention. Unfortunately, there won’t

fee-for- service financing rule that dramatically

be meaningful action to prevent gun violence.

departs from how Republican and Democratic Administrations have allowed states to finance

CMA-SPONSORED BILLS

Medicaid programs for decades. In essence, the

Prior Authorization Reform, Medicare Payment

rule prohibits states from using hospital fees,

Updates, MACRA Regulatory Relief

Medicaid managed care plan taxes, and special

The Speaker’s grand plan is for a surprise billing

funds to draw down federal Medicaid matching

solution, the Medicare drug pricing legislation,

funds. At least 34 states employ these funding

and an extension for the expiring health care

sources. CMA is assessing how the rule impacts

programs to be included in one legislative package

the Prop 56 tobacco tax funding. CMA is concerned

and adopted by Congress by May 22, 2020. CMA

that the proposed rule would significantly reduce

is working to ensure that the following CMA-

both state and federal Medicaid (Medi-Cal) funding

sponsored issues are included in the package: a

which would cause substantial state Medicaid

Medicare payment update, MACRA regulatory

budget shortfalls, reduce all provider payments

relief, and HR 3107 (Bera, MD D-CA) that reforms

and therefore, participation in the program and

the Medicare Advantage prior authorization

exacerbate access to care challenges for patients.

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CMA is working with a coalition of California stakeholders, and leading a coalition of state medical associations to oppose

Knowledge, Quality & Accuracy Matter!

the rule.

Regulatory Relief and Physician-Led Alternative Payment Models CMA continues to aggressively fight for more MACRA

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regulatory relief and to promote physician-led alternative payment models, such as those in the CMA Medicaid Demonstration project approved but stalled by the Centers for Medicare and Medicaid Services (CMS).

holding the affected physician claims while they test and implement the correct payments. If any claims need to be reprocessed, Noridian will begin reprocessing in late January. Physicians do not need to do anything for now. CMA believes this is the least disruptive way

CMA continues to aggressively fight for more MACRA regulatory relief and to promote physician-led alternative payment models, such as those in the CMA Medicaid Demonstration project approved but stalled by the Centers for Medicare and Medicaid Services (CMS).

to handle the impacted claims.

The corrections will impact all California physicians EXCEPT those practicing in Orange, Ventura,

California Medicare Geographic Payment Errors – 2020 Claims to be Reconciled In the 2020 Medicare Physician Payment Rule, CMA physician analysts, Edward Bentley, MD and Larry DeGhetaldi, MD found numerous errors in the California geographic payments. While the payment errors they identified in the proposed rule were corrected by the Centers for Medicare and Medicaid Services (CMS), additional mistakes

Los Angeles, San Francisco, Santa Clara, Alameda, and Contra Costa counties. CMA will provide additional information.

The future of health care remains as unsettled and dynamic as ever. March 2020 is the 10th anniversary of the embattled Affordable Care Act (ACA) and there will be historic court cases decided this year that determine its future.

were made by CMS in the final rule. CMS recently acknowledged the errors and concur with the Bentley/DeGhetaldi findings. CMA is working with CMS to make the changes to ensure accurate payments. Noridian (the payment contractor) is

SPRING 2020

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In The News

IN THE

NEWS

Issa Fakhouri, MD Issa Fakhouri, MD Receives 2019 Sidney R. Garfield Exceptional Contribution Award Less than a decade ago, Kaiser Permanente Northern California ranked in the low 100s in the country for diabetes management. But thanks to a program Dr. Issa Fakhouri implemented in the Central Valley and then helped spread throughout the region, KP Northern California now ranks in the top 5.

For Dr. Fakhouri, who grew up in Stockton, diabetes is personal. His grandfather had diabetes and high blood pressure and received sporadic, inconsistent care, which ultimately led to an early death in his mid-50s. When he joined The Permanente Medical Group in 2000, he knew he wanted to make a difference by ensuring patients with diabetes get the very best care.

Dr. Fakhouri f lipped the conventional model of diabetes care management, in which 95% of patients with type 2 diabetes consulted with their primary care physician, and

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Providing staff, physicians, and patients with relevant & up to date information

5% whose blood sugar was not in good control partnered with a chronic condition manager. Under the new structure, patients who found it more difficult to manage their diabetes continued to consult with their primary care physician, and the remaining 95% with type 2 diabetes got help controlling their condition from an accountable care manager (ACM) or physician extender, who is a pharmacist or registered nurse.

“I wanted to disrupt the conventional practice of episodic care—the model in which people get help only when they are sick. We must work further upstream, so that people with diabetes, for instance, receive consistent, proactive care.”

Once the program was successful in the Central Valley, Dr. Fakhouri helped get more than 216,000 patients throughout KP Northern California connected with their local ACM. Today the majority of patients with diabetes have a dedicated pharmacist or nurse who partners with the patient’s personal physician to provide long-term, consistent, and comprehensive care.

“Dr. Fakhouri implemented a program in which all patients, rather than only the sickest ones, get appropriate education and care for their diabetes,” says Sameer Awsare, MD, TPMG associate executive director. “His tremendous passion for and commitment to delivering exceptional and highly efficient care has translated into better outcomes for patients, including fewer heart attacks and strokes.”

Sidney R. Garfield, MD, was the physician founder of Kaiser Permanente and one of the great innovators of 20th century American health care delivery. The Exceptional Contribution Award recognizes TPMG physicians who exemplify Dr. Garfield’s innovative nature. These physicians developed systems and programs that have a significant impact on patients, colleagues, and the broader community.

SPRING 2020

attorney general will be asked to approve Dameron joining Adventist Health.

Roseville-based Adventist Health operates 22 hospitals, more than 280 medical offices, home care services and retirement centers in rural and urban communities in California, Oregon, Washington and Hawaii with a workforce of 37,000. Since Lodi Memorial joined the faith-based, nonprofit system, the medical center’s emergency visits have risen by 60% and its inpatient stays by 30%.

Daniel Wolcott Adventist Health now managing Dameron Hospital To expand healthcare choices and access in the Stockton area, Adventist Health began managing Dameron Hospital on January 1, 2020, under an agreement between the nonprofit healthcare organizations.

Dameron, a 202-bed medical center, chose Adventist Health to manage the hospital because the two organizations share a commitment to community and because Adventist Health brings the expertise and resources of a large healthcare system to Stockton.

“Dameron leadership and staff want to do more for their community, and this agreement makes that possible,” said Dameron Hospital Board Chairman Bill Trezza. “Adventist Health has expanded and improved healthcare services in Lodi since joining the community in 2015, and we’re eager to build San Joaquin County healthcare services together. With the many changes and challenges in healthcare, being connected to a system offers many advantages for a freestanding hospital like Dameron.”

Adventist Health is honored to have been selected for this agreement, said Daniel Wolcott, president of Dameron Hospital and Adventist Health Lodi Memorial. “Dameron has a heritage of healthcare excellence, and we look forward to building on that.” During the management period, Adventist Health will work toward a more formal affiliation that would benefit the hospital and community. If that path is taken, the

SPRING 2020

Dameron Hospital recognized on 2019 California Patient Safety Honor Roll Dameron Hospital was recognized by the California Health and Human Services Agency, Hospital Quality Institute and Cal Hospital Compare for achieving their 2019 Patient Safety Honor Roll Award. To achieve this 2019 award, Dameron Hospital maintained a high patient safety profile in comparison to other hospitals across a variety of domains including hospital-acquired infections, adverse events, sepsis management, patient experience and Leapfrog Hospital Safety Grade. Honor Roll hospitals had to meet a rigorous threshold by having at least two-thirds of measure results above the 50th percentile and no measure result below the 10th percentile and/or Leapfrog Hospital Safety Grade A for the past three reporting periods.

Dameron Hospital was among 77 out of 327 adult, acute care hospitals in California considered for the Honor Roll and is the only hospital in Stockton selected for this list.

This Honor Roll offers Californians a rigorously evaluated list of hospitals that have consistently demonstrated a strong culture of safety across multiple departments and offers hospitals a valuable tool to evaluate and celebrate their own performance in comparison to others.

Adventist Health Lodi Memorial recognized for Straight A’s in the Leapfrog Hospital Safety Grade The Leapfrog Group, an independent national watchdog organization driven by employers and other purchasers of health care, today announced the fall 2019 Leapfrog Hospital Safety Grades and once again awarded Adventist Health Lodi Memorial an ‘A’ for achieving the highest national standards in patient safety. Adventist Health Lodi Memorial is one of only 36 hospitals in the United States to be awarded an ‘A’ every grading cycle since 2012.

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In The News

IN THE

NEWS “We are so proud of our physicians, nurses and other clinical staff who are committed to offering excellent quality of care to our patients,” said Dr. Patricia Iris, Adventist Health Lodi Memorial Medical Officer. “To be among this elite group of hospitals for the second time means our hospital is maintaining a high level of excellence for the individuals, families and communities we serve.”

“This outstanding achievement shows longstanding commitment to a culture of safety that puts patients first,” said Leah Binder, president and CEO of The Leapfrog Group. “For Adventist Health Lodi Memorial, saving lives by preventing accidents, injuries, infections and errors is business as usual, and your community should be proud. We commend the staff, faculty, volunteers, leadership and board of directors for their never-ending quest for the highest standards of patient safety.”

The Safety Grade assigns letter grades of ‘A’, ‘B’, ‘C’, ‘D’ and ‘F’ to hospitals across the country based on their performance in preventing medical errors, infections and other harms.

Developed under the guidance of a national expert panel, the Leapfrog Hospital Safety Grade uses 28 measures of publicly available hospital safety data to assign grades to more than 2,600 U.S. acute-care hospitals twice per year. The Leapfrog’s grading system is peer-reviewed, fully transparent and free to the public.

Adventist Health Lodi Memorial welcomes surgeon Sukhmine Nedopil, MD Sukhmine Nedopil, MD, has joined the medical staff at Adventist Health Lodi Memorial. She is a general surgeon and provides care to patients with a range of needs, including breast cancer, colon cancer, gastrointestinal conditions, hernia and more.

Nedopil earned her medical degree from the University of

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Providing staff, physicians, and patients with relevant & up to date information

California, Davis; a master’s degree in medical science from the Boston University, School of Medicine; and a bachelor’s degree in chemistry from the University of California, Berkeley. She completed her general surgery residency at San Joaquin General Hospital in French Camp.

Sukhmine Nedopil, MD With the goal of pursuing a career where her work would positively impact others, initially Nedopil entered the field of medical research. “It was while performing cancer drug research that I realized practicing medicine would allow me to directly improve the quality of individual lives,” she said.

Nedopil and her husband, who also is a physician, have one son and are expecting another. In addition to time with family and friends, she enjoys cooking, crafts and outdoors. She is fluent in English, Punjabi and German.

Nedopil is accepting patients at Adventist Health Physician Network Medical Office - Surgery, located at 999 S. Fairmont Ave., Ste. 100 in Lodi. More information and appointments are available by calling 209-334-8510.

SPRING 2020

Doctors Hospital of Manteca Names Dr. Murali Naidu Chief Executive Officer Doctors Hospital of Manteca has appointed Murali Naidu, MD, FACS, as its new Chief Executive Officer (CEO).

Effective Feb. 24, 2020, Dr. Naidu has assumed responsibility for all hospital operations, executive planning and directing medical services.

“Dr. Naidu brings with him a fresh perspective and new energy to enhancing and expanding our healthcare delivery,” said Warren Kirk, CEO of Tenet’s Northern California Group.

“We value his strong commitment to providing the highest level of quality care to our patients in the Manteca community and surrounding areas.”

Dr. Naidu joins Doctors Hospital of Manteca from Managed Care Systems out of Bakersfield, Calif., where he serves as the chief physician executive. He played a pivotal role in supporting the on-boarding of 140,000 members and 750 physicians. He previously served as System Chief Clinical Officer at Sentara Healthcare in Norfolk, Va., and as Vice President of Perioperative Care for Dignity Health’s 39 hospitals.

Dr. Naidu earned his A.B. in Molecular & Cell Biology

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from the University of California, Berkeley and his Doctor of Medicine degree from the University of California, Los Angeles School of Medicine. He is a laparoscopic surgeon who practiced for more than ten years prior to his full-time leadership roles.

He has served on the USC Murali Naidu, MD Schaeffer Center for Health Policy & Economics Advisory Board in Los Angeles, and the Roundtable on Quality Care for People with Serious Illness at the National

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In The News

IN THE

NEWS

Providing staff, physicians, and patients with relevant & up to date information

Academies of Sciences, Engineering and Medicine in Washington, D.C. He currently serves on the Board of Directors for Blue Skies for Children, a nonprofit childcare education center in Oakland that is committed to providing high-quality support to children and their families.

St. Joseph’s Medical Center Recognizes Dr. Richard Waters and Dr. Benjamin Wiederhold as Physician Champions Each year St. Joseph’s Medical Center’s medical staff physicians are called upon to nominate their deserving peers to be recognized as part of St. Joseph’s annual Richard Waters, MD Benjamin Wiederhold, MD Physician Champion Awards. The awards recognize a “Champion of Community,” described as a physician who has demonstrated a commitment to improving and one of the Medical Directors of the Structural Heart the health status of the community, and a “Champion of Program.

Quality,” a physician who continuously pursues quality Dr. Benjamin Wiederhold is an Emergency Medicine improvement through innovation. specialist and has been a member of the St. Joseph’s Medical This year’s awardees are Richard Waters, M.D. for Center Medical Staff since 2011. Through his leadership of Physician Champion of Quality and Benjamin Wiederhold, the Emergency Department he has profoundly impacted the M.D. for Physician Champion of Community. health of our community, championing numerous initiatives Dr. Richard Waters has been a member of the St. Joseph’s that have increased access to care, leading the development Medical Center Medical Staff since 2005. He has contributed of Graduate Medical Educational programs in the Medical to the quality of care for patients at the Medical Center in Center, and enabling quality programs that have touched the innumerable ways through his work as an interventional lives of the most vulnerable members of our community. cardiologist and structural heart specialist, and served as Chairman of the Cardiovascular Department Quality Committee, Chairman of the Cardiovascular Department,

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SPRING 2020

San Joaquin General Hospital Announces Its Third Annual Research Day June 5th 2020 San Joaquin General Hospital welcomes local physicians and all associated medical community members to attend its third annual Research Day on June 5th on the Hospital campus in French Camp. The event will begin at 7:30 AM and will run through 1:00 PM. Research Day 2020 is a production of San Joaquin General Hospital’s Graduate Medical Education division. The Hospital’s residency programs include board certification training in Family Medicine, Internal Medicine and General Surgery.

This annual event showcases the Hospital’s medical residents and their individual research projects. The event will feature distinguished regional medical speakers. This year, the event will also include other regional medical residency programs in the aim of building a consortium of working local partnerships in medical research and advancing clinical science in San Joaquin County.

Research Day will also highlight San Joaquin General Hospital as a growing research facility and thriving academic hospital. This annual program is a perfect platform for physicians, directors, professors and medical residents to interact in a spirit of partnership that allows for an open

exchange of conversations regarding all phases of medical research, practice and medical law.

Attendees are also welcome to tour the San Joaquin General Hospital medical campus to get acquainted with the Hospital’s technology, specialty medical staff and hospital facilities at their professional disposal.

To RSVP as well as receive more information contact Dennis Bashaw, MLIS (209) 468-6642 or email dbbashaw@sjgh.org

St. Joseph’s Awards $370K in Community Grants Dignity Health - St. Joseph’s Medical Center has awarded $372,594 in grant funding to seven local community-based organizations seeking to provide health and human services to residents most in need in San Joaquin County. Grants were awarded to organizations and projects working to address underlying causes of illness, such as lack of access to primary and preventive care, obesity/diabetes, substance use, access to housing, mental health, as well as violence prevention and youth growth & development.

Call Today to Schedule a Tour!

To qualify for Stockton PACE enrollees must meet all of the following: • Be age 55 or older • Reside in San Joaquin or Stanislaus counties (zip codes are listed at stocktonpace.com) • Be certified by the State as eligible for nursing facility level of care • Be able to live safely at home and in the community with PACE services without jeopardizing health and safety of themselves and others

582 E. Harding Way • University Park • Stockton, CA 95204 209-442-6077 • StocktonPace.com SPRING 2020

SAN JOAQUIN PHYSICIAN

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In The News

IN THE

NEWS

Providing staff, physicians, and patients with relevant & up to date information

Seven projects were a major milestone, awarded funding this year, recently completing with each grant recipient their 200th TAVR working in partnership procedure, bringing with other community new hope and organizations. Projects changing the lives of include Community 200 patients who were Health Connectors, suffering from aortic Mentoring for Higher valve stenosis.

Education, the Mobile “St. Joseph’s Child Care Farmer’s has a long legacy of Market, Igniting Health excellence in cardiac and Opportunity services,” said Don Program for youth, the The transcather aortic valve replacement (TAVR) team Families Connect Project, Wiley, Hospital Hope Family Shelter’s President and CEO. Project Hope, and Peer “Right here at St. Recovery Coaches.

Joseph’s, our community has a high volume, high quality The Community Grants Program was established in 1990 cardiac surgery program with a strong track record and a to provide funding to community-based organizations that history of ‘firsts’ in advancements.” provide services to individuals in need. Since its inception, the TAVR is a minimally invasive procedure that treats aortic program has distributed over $3.4 million in grant funding to stenosis without requiring open chest surgery. TAVR uses a deserving nonprofit community benefit organizations with catheter to replace the heart valve instead of opening up the an interest in building healthier communities by improving chest and completely removing the diseased valve. The valve health and living conditions. St. Joseph’s Medical Center used during TAVR is inserted within the diseased aortic valve. annually sets aside revenues from operations to fund the Patients are evaluated by a multidisciplinary team at St. community grant awards.

Joseph’s Valve Clinic, which specializes in treating patients St. Joseph’s Heart & Vascular Institute Performs 200th TAVR Procedure The transcather aortic valve replacement (TAVR) team at St. Joseph’s Heart & Vascular Institute is proud to have reached

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with various stages of heart disease, from advanced procedures including TAVR, to disease management. Once a patient is referred to St. Joseph’s Valve Clinic a team of experienced physicians and staff develop a personalized plan of care.

To learn more about St. Joseph’s TAVR program, visit StJosephsCares.org/TAVR.

SPRING 2020

St. Joseph’s Offers New Technology for Heart Patients St. Joseph’s Heart & Vascular Institute is now offering a procedure called TransCarotid Artery Revascularization (TCAR) to treat patients with carotid artery disease who are at risk for traditional open surgery. Like carotid endarterectomy, the TCAR procedure involves direct access to the carotid artery, but through a much smaller incision at the neckline just above the clavicle instead of a longer incision on the neck.

During the TCAR procedure, a tube inserted into the carotid artery is connected to a system that temporarily directs blood flow away from the brain to protect against dangerous debris from reaching the brain during the procedure. Surgeons then filter the blood before returning it to a vein in the groin, and a stent is implanted directly into the carotid artery to stabilize the plaque and prevent future strokes.

Additionally, St. Joseph’s now offers the WATCHMAN, a left atrial appendage occluder device which reduces the risk of stroke from non-valvular atrial fibrillation. This is the only FDA approved implant to reduce the risk of stroke in people with afib who are not candidates for medical treatment with the anti-coagulant warfarin. WATCHMAN is a permanent implant designed to close the left atrial appendage. Since 90% of stroke causing clots that come from the heart are formed in the left atrial appendage, closing the LAA is an effective way to reduce stroke risk.

To learn more about WATCHMAN OR TCAR, please call St. Joseph’s Heart Patient Navigator at 209.467.6540.

Kaiser Permanente Hospitals in Modesto and Manteca Receive Top Patient Safety Score The Leapfrog Group presented Kaiser Permanente Medical Centers in Modesto and Manteca the top score of “A” in its biannual safety report, which examined and graded more than 2,600 hospitals throughout the United States.

“High-quality medical care and patient safety are our focus and commitment at Kaiser Permanente,” said Area Quality Leader for the Central Valley, Jerry Grandon. “Our emphasis on infection control, adherence to the safest surgical standards, and the personal attention our highly trained physicians and staff show to each of our members makes our hospitals among the safest in the nation.”

In all, 23 Kaiser Permanente hospitals in California

SPRING 2020

received “A” grades from Leapfrog. The 10 Kaiser Permanente hospitals in Northern California include Fresno, Manteca, Modesto, Redwood City, Roseville, Sacramento, Santa Clara, South Sacramento, South San Francisco, and Vallejo.

“We are proud to be recognized for providing safe patient care to our members in the Central Valley,” added Grandon.

“This recognition reflects on our commitment to putting safety first.”

Only 750 of 2,600 hospitals surveyed in the U.S. received an “A” rating in the biannual report which began in 2012.

NEW Provider Incentive Program from Health Plan of San Joaquin HPSJ is in the process of rolling out its 2020 Provider Incentive Program for Quality Preventative Care. This unique program will pay providers an incentive for Health Care Effectiveness Data Information Set (HEDIS) and Managed Care Accountability Sets (MCAS), with emphasis on preventive quality measures performed in the primary care office setting.

To participate in this new HPSJ incentive program, providers must have a minimum enrollment average of 500 HPSJ members per provider and be open to new membership assignment, among additional qualifiers. To avoid duplication with other incentive reimbursements, OBGYNs and PCPs have an opportunity to receive incentives through the Department of Health Care Services (DHCS) Value Based Payment Program for select measures and these are not included in the new HPSJ physician incentive program. For more details, including more on how to participate, please go to https://www.hpsj.com/planscan/ for the Winter 2020 cover story in the HPSJ’s PlanScan quarterly. PlanScan also features the article: What Prop 56 Means for Your Practice – Value Based Payment Program Details and will be of interest to OBGYNs and PCPs. e-Compliance Tool Kit available on Health Plan of San Joaquin website To help busy members of the HPSJ Provider Network meet several annual training requirements, HPSJ has created the following online pieces.

SAN JOAQUIN PHYSICIAN

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In The News

IN THE

NEWS Annual Cultural Sensitivity Training and Attestation This training is mandated for all Medi-Cal providers. HPSJ offers the approved training via their website, along with a required attestation form. Providers are required to attest to receipt of the training materials, confirm the materials have been reviewed, and acknowledge they have taken part in the training. The following subjects are covered in the online training: •Q uality Healthcare for Lesbian, Gay, Bisexual, and Transgender people •A Physician’s Practical Guide to Culturally Competent Care •C ultural Competency Training for Healthcare Providers: Connecting with your patients •C ultural Awareness and Sensitivity in Women’s Health Care To schedule a training or receive more information, contact HPSJ’s Provider Services at 209-942-6340, or go to https://hpsj4.wpengine.com/cultural-competency-training/.

Annual Fraud, Waste, and Abuse (FWA) Training & Attestation Medi-Cal providers are required to either complete the FWA training offered on the HPSJ website and send HPSJ a signed attestation, or attest that they have completed another, acceptable FWA training. The HPSJ online training is available at www.hpsj.com/fraud-waste-and-abuse-prevention-training.

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Providing staff, physicians, and patients with relevant & up to date information

Palliative Care Options Program: Health Plan of San Joaquin Invites Providers Local providers increasingly are turning to HPSJ’s innovative Adult and Pediatric Care Services for Palliative Care Options.

For HPSJ members, Palliative Services provide compassionate care, education, support, and practical assistance to patients and families facing the chronic or life-limiting diagnoses of end-stage Congestive Heart Failure, Chronic Obstructive Pulmonary Disease (COPD), Advanced Cancer, and andstage Liver Disease. HPSJ Providers are invited to call or fax their referral into HPSJ’s Palliative Care partner – in San Joaquin County: Pacific Palliative Care (209-922-0263, fax/209-922-0321).

Are Diabetic Shoes Right for Your Patients?

Proper fitting shoes are very important for diabetic patients.

Anyone with diabetic neuropathy, poor circulation, or nerve damage can benefit from diabetic footwear.

Did you know that Medicare covers the cost of one pair of shoes and three pairs of inserts per calendar year? Shoe specialists are able to carefully evaluate and measure your patients’ feet to provide them with a professionally fitted shoe that is right for them.

There is no paperwork for you to worry about; we take care of all of it! For more information or consultation appointment, please contact Odessa Mosley, your Diabetic Shoe Specialist at (209) 476-8099.

SPRING 2020

Calling All Mentors!

Do you worry about who will take care of your patients when you retire? Are you looking for a meaningful way to give back to your community? If so, look no further! SJMS is currently recruiting volunteer mentors to join our Bridge to Medicine (BTM) committee. BTM guides high achieving students (high school & college) along their academic journey so that they have the best chance of being accepted to medical school and ultimately, return to practice in our community.

The committee meets every other month and consists of physicians (working & retired), alliance members and even a local college professor. Most importantly, you don’t need to be an expert! We have committee members with a wide array of skill sets and resources, so you are never alone. For more information please contact Lisa Richmond at 952-5299 or Lisa@sjcms.org.

SPRING 2020

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Curing the San Joaquin Valley’s

DOCTOR SHORTAGE 30

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SPRING 2020

CalMedForce helps grow local residency programs

By Jo Ann Kirby

Grants from new state tobacco tax revenues are pumping critical dollars into Graduate Medical Education programs in San Joaquin County to address a dire physician shortage in an already underserved community.

SPRING 2020

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St. Joseph’s Medical Center and San Joaquin General Hospital were awarded CalMedForce grants in January with S.J. General’s decades-old residency program receiving an injection of $450,000, while St. Joseph’s newer program was given $2.7 million.

Residency programs have been unable to keep up with the demand for slots, in part due to inadequate funding. A Medicare support cap for GME imposed by the Balanced Budget Act of 1997 gives new teaching hospitals just five years to establish their ceiling on their number of residency positions, specifically the cap is set at the number of residents at “It costs about $150,000 per resident per year to support the institution five years after the first resident begins to work a resident,” Lupe Alonzo-Diaz, chief executive officer of there. The result is that programs have tended to piece-meal their resources in order to fund “It costs about $150,000 per resident per year to support a resident. the average So, these grants have allowed some GME programs to either keep $150,000 per their programs and or expand their programs and thereby increase the resident year number of physicians trained in underserved areas.” - LUPE ALONZO-DIAZ that it takes, Alonzo-Diaz Physicians for a Healthy California, which administers the said. S.J. General’s cap has long since been set but St. Joseph’s is CalMedForce grants, said. “So, these grants have allowed some a couple of years away from the five-year mark.

GME programs to either keep their programs and or expand their programs and thereby increase the number of physicians “We are currently training 69 residents,” said Dr. Sheela Kapre, trained in underserved areas.” who serves as Chief Medical Officer and chair of Graduate

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SPRING 2020

Medical Education at San Joaquin County General Hospital, said. However, Kapre said S.J. General’s Medicare support cap is 41.14 full time equivalents, so anything over the cap has come from institutional funds. But now, Cal Med Force is a new source of dollars. This year’s $450,000 grant is funding three new preliminary residency slots in internal and family medicine at the county.

“Expansion of the residency programs has been difficult without availability of additional funding. The funding from the CalMedForce grants has been of tremendous assistance,” Kapre said.

A critical physician shortage in the Central Valley, where scores of people live in federally designated Health Professional Shortage Areas, is already felt in San Joaquin County. In addition to a lack of newly-minted primary care physicians, a third of doctors in California are over the age of 55 and looking to retire soon, according to a study by the Healthforce Center at UC-San Francisco. Factor in an aging population and an increase in the number of Californians who have health care coverage, and there is a looming emergency.

The UCSF study, California’s Primary Care Workforce: Forecasted Supply, Demand, and Pipeline of Trainees, 20162030, found the underserved Central Valley will have the worst shortages in the next decade as the region is expected to have higher rates of growth in demand for primary care clinicians than California overall.

The federal government’s Council on Graduate Medical Education recommends 60 to 80 primary care doctors per 100,000 people. But in the San Joaquin Valley, that number is already down to 39, according to The Future Health Workforce Commission.

“The Central Valley continues to struggle with recruiting and retaining physicians to this area,” Donald Wiley, CEO of St. Joseph’s, said. “We specifically are focused on residency candidates who were raised in and have strong ties to California.”

A lack of funding for residency programs causes California to lose its medical students when they are forced to search for

SPRING 2020

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available residency slots in other states. But nationwide, 54.2 percent of individuals who completed residency training from 2008-2017 are practicing in the state where they trained. That percentage is even higher for California.

San Joaquin General has a longstanding commitment to GME and has trained physicians since 1932, Dr. Kapre said, noting that approximately 45% of SJGH’s residents in the three residency training programs have stayed and are practicing in the area.

“The impact of physician shortages on communities in San Joaquin County is profound,” Dr. Scott Neeley, vice president and chief medical officer of St. Joseph’s Medical Center, said.

“In some instances, patients defer care or do not have access to health care, while in others the lack of access to medical specialist forces people to travel great distances for care.”

New residency programs are a huge economic investment, Wiley said of St. Joseph’s program. But one, he knows will pay off. Establishing the program required a multi-million dollar investment in people as well as facilities and equipment.

“The CalMedForce grant has strengthened our confidence in starting these primary care residencies, especially given the uncertain economic climate in health care,” Willey said.

“The impact of physician shortages on communities

in San Joaquin County is profound. In some instances, patients defer care or do not have access to health care, while in others the lack of access to medical specialist forces people to travel great distances for care.” - DR. SCOTT NEELEY

At St. Joseph’s, the residency program is set to welcome its third class of nine emergency medicine residents this year for a total of 27 residents in that program. In addition, they will host their third class of six family medicine residents, for a total of 18 in that program. St. Joseph’s will also have their first ten internal medicine residents and their first 10 transitional year residents.

Dr. Kapre cites several success stories to retaining graduates of San Joaquin General’s residency program.

“The current chief medical officers, the chair of the internal medicine department, the program director of the internal medicine residency program and all the teaching hospitalists graduated from the Internal Medicine residency program at SJGH,” she said. “In addition, our rheumatologist and critical care pulmonary specialist graduated from the Internal Medicine residency at SJGH before entering their respective fellowships. They both returned to become full time faculty.”

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CalMedForce, funded by Prop. 56, awarded $38 million in its inaugural 2019 cycle and another $40 million in 2020 for graduate medical education programs in California.

In its inaugural cycle, CalMedForce received funding requests for nearly 600 residency positions from 131 residency programs totaling more than $147 million. The funding it ultimately awarded in 2019 represents 156 residency slots in programs across the state, 80 are existing residency slots that might have been cut and the others were newly created placements.

As a perfect storm of an aging population, a surge in the number of Californians with health coverage, a dire physician shortage and the lack of residency slots converge, the Prop.

56 funding is California’s attempt to triage what could be a dire problem by 2025 when the UCSF study forecast that the primary care clinician shortages would require an extra 4,700 primary care clinicians plus another 4,100 in 2030 to meet demand. In addition, California has also created the CalHealthCares loan repayment program for practicing physicians and residents to use toward student loan forgiveness. Eligible physicians and dentists may apply for up to $300,000 in loan repayments.

SPRING 2020

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Strong community partnerships lead to happier, healthier people.

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SPRING 2020

You had us at hello.

After 120 years, allow us to reintroduce ourselves.

If these walls could talk, they would tell tales of humble beginnings, when in 1899 the physicians in this community advocated for Father William O’Connor to build a hospital in addition to a care home. Or perhaps they’d share the stories of thousands of lives that have been touched since the doors opened more than a century ago.

Through the years, St. Joseph’s Medical Center has grown as our community has grown, continuing to serve the needs of all, while staying true to its roots. The hospital is located where it has always been—on North California Street—ready to serve all who enter its doors seeking healing.

Thank you for partnering with us to care for our community.

SPRING 2020

SAN JOAQUIN PHYSICIAN

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RISK TIP

CULTURAL DIVERSITY CREATES

LANGUAGE BARRIERS:

REDUCING CLAIMS WITH MULTILINGUAL PATIENTS RICH CAHILL, JD, VICE PRESIDENT AND ASSOCIATE GENERAL COUNSEL, AND SUSAN SHEPARD, MSN, RN, SENIOR DIRECTOR, PATIENT SAFETY EDUCATION, THE DOCTORS COMPANY

Ms. D., a naturalized U.S. citizen from Southeast Asia, presented to Dr. P. for a consultation regarding extensive acne scarring on her face and neck. The patient reported that she felt self-conscious about her appearance and sought advice on possible treatment options. According to the chart, Ms. D. spoke limited English. Her reading proficiency was not noted. >>

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SPRING 2020

Following an examination of the affected area, Dr. P. offered CO2 laser resurfacing. The benefits and potential disadvantages of the procedure were discussed, including the possibility that her complexion type posed an increased risk of scarring and changes in pigmentation.

Ms. D. subsequently agreed to undergo laser resurfacing and signed a written consent that specifically identified scarring and changes in skin color as possible postoperative outcomes.

The patient returned the following week. The treatment record ref lects that Dr. P. performed the procedure under local anesthesia and conscious sedation. The surgery was uneventful, and no intraoperative complications occurred.

Ms. D. presented on numerous occasions over the next several months. Hyperpigmentation was noted, and Solaquin Forte 4% and Pramosone lotion were prescribed.

At one point, the patient complained of experiencing a burning sensation on her face. Approximately one year after the procedure, Ms. D. returned for further evaluation. The scarring was barely visible; the discoloration on her neck was noticeably improved. However, the patient expressed dissatisfaction with the result.

Ms. D. thereafter retained counsel and initiated suit alleging causes of action for medical malpractice and negligent inf liction of emotional distress. In substance, the patient claimed that because of her limited proficiency with English and the failure by the physician to utilize any translation services, including for any preoperative documentation, there was no informed consent.

PROVIDING LANGUAGE SERVICES: OBLIGATIONS AND BENEFITS Clear and unambiguous communication constitutes the key component of the physician-patient relationship.

Misunderstandings often create frustration and distrust, especially when an adverse event occurs, and can result in professional liability litigation or reports to state medical

SPRING 2020

boards and third-party payers by disgruntled patients and family members. Proactively implementing office procedures for both physicians and staff to promote optimum communication reduces the risk of surprise and the potential for expensive, protracted, and unpleasant disputes.

With our culturally diverse national population, including many who speak a language other than English at home, language barriers raise the risk for an adverse event. The Department of Health and Human Services (HHS) Revised Guidance Regarding Title VI Prohibition Against National Origin Discrimination Affecting Limited English Proficient (LEP) Persons outlines the requirements for recipients of federal financial assistance from HHS to take reasonable steps to ensure LEP persons have access to language services. (These recipients do not include providers who only receive Medicare Part B payments. However, providers that receive funding from any government program such as Medicaid or Medicare Advantage are subject to the requirements.)

To determine the extent of the obligation to provide language assistance, analyze the following four factors: • Number: The greater the number or proportion of LEP persons served or encountered by your clinic, the more likely language services will be needed.

• Frequency: Even if unpredictable or infrequent, there must be a plan for providing language assistance for LEP persons.

• Nature: Determine whether a delay in accessing your services could have serious or life-threatening implications. The more important the nature of the services you offer, or the greater the consequences of not accessing treatment, the more likely language services will be needed.

• Resources: Consider the resources available and the cost to provide them. As a solo practitioner, you are not

SAN JOAQUIN PHYSICIAN

39

expected to provide the same level of service as a large, multispecialty group. Investigate technological services or sharing resources with other providers.

It is not recommended to use a family member as an interpreter. Lay personnel are rarely familiar with medical terminology. Additionally, the patient may not want a family member to access their confidential health information.

An adult family member should serve as interpreter if a family member must be used—unless no adult is available, and care must be provided immediately to prevent harm.

It is preferable to have a trained clinical staff member provide interpretation; alternately, your practice can use certified interpreter services. Consult your local hospital or the patient’s health plan for a list of qualified interpreters.

Other resources include a local nationality society, the Registry of Interpreters for the Deaf, or the local center for the deaf. Also, keep consent forms—especially for invasive procedures—translated into the applicable non-English languages by a certified translator.

The Agency for Healthcare Research and Quality (AHRQ ) has prepared a guide, Improving Patient Safety Systems for Patients With Limited English Proficiency, which recommends that practices focus on the following: • Medication use: Understanding medication instructions is complicated for all patients, but even more difficult for LEP patients. Both patients and providers need to communicate accurately about mode of administration, allergies, and side effects.

• I nformed consent: Obtaining informed consent remains a hallmark of patient safety and a critical medical and legal responsibility. Achieving truly informed consent for LEP patients may require extra effort, but LEP patients should not be excluded from learning about choices that might affect their health and well-being.

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• Follow-up instructions: Understanding discharge instructions is especially challenging for LEP patients.

Speaking Together: National Language Services Network, a project funded by the Robert Wood Johnson Foundation, which created the Speaking Together Toolkit, found the need for greater use of interpreters at key moments of information exchange, such as at assessment and discharge—not just during the acute phase of treatment.

Relatively simple communication tools can provide some helpful solutions. These include: • A skMe3™: Rx for Patient Safety: Ask Me 3 • The teach-back method: AHRQ: Use the Teach-Back Method: Tool #5 • The SHARE approach: AHRQ: The SHARE Approach—Using the Teach-Back Technique: A Reference Guide for Health Care Providers • Patient experience surveys: The Doctors Company: Patient Experience Surveys To protect your patients from harm resulting from their LEP, develop and implement a plan for language access in your practice. For more information, see the Centers for Medicare and Medicaid Services’ Guide to Developing a Language Access Plan.

The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

SPRING 2020

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SPRING 2020

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209-948-6024

•

www.fccuburt.org Federally insured by the NCUA.

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PROTECT ACCESS AND CONTROL HEALTH CARE COSTS FOR CA PATIENTS; Oppose the so-called “Fairness for Injured Patients Act”

Late last year, wealthy out-of-state trial attorneys filed an initiative for the November 2020 ballot that would substantially raise health care costs for all Californians, reduce access and exploit patients for profit. While most reporting to date has focused on the proposed changes to California’s existing law—the Medical Injury Compensation Reform Act (MICRA)—this misguided initiative would effectively eliminate California's medical lawsuit limits to create new financial windfalls for California's trial lawyers.

Proponents of this measure must collect 623,212 valid signatures, which must be verified no later than June 25, 2020. Recent reports show that they’re on track to meet those numbers and qualify for the November ballot, which is why we need your commitment to oppose this dangerous initiative now more than ever.

In 2014, our coalition fought and handily defeated Proposition 46, clearly saying NO to changes in MICRA that would have quadrupled the cap on non-economic damages. This measure goes far beyond what Proposition 46 would have done and the cost to taxpayers would be substantially greater. As recently noted by the independent Legislative Analyst Office, the "Fairness for Injured Patients Act" will cost California taxpayers tens of millions "to high hundreds of millions of dollars annually" in health care costs.

Proposition 46 taught us the power of a strong coalition, and this time around it will be even more important. To learn more about the new initiative, and to donate to the “no” campaign, please visit protectmicra.org. >>

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WHAT IS MICRA AND WHY IS IT IMPORTANT? In the mid-1970s, California physicians were

that involved CMA and other health care

embroiled in a malpractice insurance crisis.

providers, the insurance industry and

Driven by frivolous lawsuits and excessive

trial lawyers continued until September

jury awards, medical liability insurers levied

11, when the Legislature passed AB 1XX, a

massive insurance premium increases

collection of statutes that is now known as

and canceled insurance policies for many

the Malpractice Insurance Compensation

physicians across the state. The situation

Reform Act (MICRA).

worsened in early 1975 when malpractice carriers announced that premiums for some

Governor Brown signed the CMA-supported

physicians would increase by as much as

bill on September 23, 1975, and MICRA today

400 percent, effective May 1. Many medical

remains the model for national medical

physicians had four choices, none of them

liability tort reform, as the law has been

acceptable: Raise fees and make medical

hugely pivotal in making access to care a

care unaffordable for many patients,

reality for patients.

drop their professional liability insurance coverage, leave the state, or quit practicing

Fast forward to current times, and on

medicine.

November 4, 2014, the voters of California spoke loudly and definitively, sending the

Seeking a stronger focus on the issue,

trial lawyers’ attempt to change MICRA

the California Medical Association (CMA)

(Proposition 46) to a solid defeat by a vote of

channeled physician outrage into a

67 percent to 33 percent. The message was

massive grassroots campaign that

clear – Californians don’t want to increase

mobilized thousands of physicians, patients,

health care costs and reduce health access

and other medical professionals to call

so trial attorneys can file more lawsuits.

and write their legislators to demand that

An increase in the MICRA cap on non-

the state act to cut the cost of malpractice

economic damages has been rejected

insurance.

in California again and again: 10 times in court, five times in the Legislature and

On May 13, 1975, CMA led more than 800

overwhelmingly by voters in 2014.

physicians, nurses, lab technicians and hospital personnel in a Capitol rally calling

The efforts of the California Medical

on then Governor Jerry Brown to convene

Association (CMA) and the component

a special session of the Legislature to deal

medical associations across the state

with the crisis. Three days later, on May

proved what we can do for the future of

16, Brown yielded, issuing a proclamation

health care, the quality of medicine and the

for a special session that began on May

dedication to patients everywhere.

19. Negotiations and legislative hearings

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A COMMUNITY BUILT ON

COLLABORATION Doctors Hospital of Manteca is excited to introduce a first-of-its-kind resource for physicians and patients in Manteca: the da Vinci Xi robot. Local access to roboticassisted surgery techniques provides doctors the ability to offer helpful benefits for treating a range of conditions with less invasive surgery, shorter hospital stays, faster recovery times and less scarring.

To learn more about the program, call (209) 923-6370.

SPRING 2020

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2019 YEAR IN REVIEW In the legislative, legal and regulatory arenas, the California Medical Association won key victories to improve public health, expand access to care, remove administrative burdens and ensure physicians are fairly compensated for the work they do. We will build on these victories in the new year to ensure California’s physicians have a strong voice in Sacramento and in Washington, D.C., and that we can transform our state’s health care system into a model for the entire nation.

Led the fight to pass SB 276, which cracks down on fraudulent medical exemptions for childhood vaccinations.

Sponsored AB 744, which revamps the rules regarding telehealth services to increase access to care and ensure physicians are fairly compensated for telehealth services.

CalMedForce awarded $76 million in tobacco tax revenues to fund more than 300 physician residents across the state.

Grew our membership to record levels, now representing more than 46,000 California physicians.

Secured $2.2 billion in provider rate increases through the Proposition 56 tobacco tax.

Announced the first ever CalHealthCares awards, which will pay off $67 million in student loans for 240 physicians and 38 dentists who commit to see more Medi-Cal patients.

Recouped more than $1.3 million from payors on behalf of CMA’s physician members.

Fought legal battles to ensure access to women’s health care and for care for immigrants and transgender patients.

Secured passage of new federal regulations that strengthen enforcement of EHR interoperability to allow health providers to better share medical information.

Supported a state-level individual mandate to strengthen the Affordable Care Act in California.

Visit cmadocs.org for more information.

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Practice News and Resources Free to SJMS/CMA Members!

The Office Managers Forum empowers physicians and their medical staff with valuable tools via expert led educations sessions from industry professionals who are committed to delivering quality healthcare. This monthly forum is held on the second Wednesday of the month from 11am- 1pm at Papapavlo’s Bistro in Stockton and includes lunch. Attendance is always FREE to our members. Nonmembers are welcome may attend one session free to experience one of the quality benefits of SJMS membership ($35 thereafter). Registration is required.

For more information or to be added to the mailing list, please contact Jessica Peluso, Membership Coordinator at Jessica@sjcms.org or (209) 952-5299

NEWS March 17, 2020 • 11am-1pm 2020 Employment Law Update

Each year, the area of employment law changes and evolves. Come lear n about the new laws that will affect your business in the new year. Topics covered will range from recruiting and hiring to leave of absence issues to pay stub requirements.

Speaker: Jamie Bossuat from Kroloff, Belcher, Smart, Perry & Christopherson Jamie represents private and public employers in a wide range of matters including sexual harassment, disability discrimination and accommodation, age and sex discrimination, pregnancy and medical leave, wage claims, and whistleblower retaliation. She is a frequent presenter on issues involving employers.

April 8, 2020

Cancelled for Spring Break

May 13, 2020 • 11am-1pm New Laws Effecting Physicians 2020

Presented by Stacey Wittorff, Senior Legal Counsel at CMA

June 10, 2020 • 11am-1pm

Customer Ser vice: Improving the Patient Experience by Seeing it Through Their Eyes Presented by Mitzi Young, Physician Advocate for CMA and RCMA

Noridian will Reprocess Claims Impacted by Errors Noridian, the California Medicare contractor, has recently advised that it will begin reprocessing claims impacted by errors in the Centers for Medicare and Medicaid Services (CMS) Geographic Practice Cost Indices (GPCIs) file.

In the proposed 2020 Medicare Physician Payment Rule, California Medical Association (CMA) physician analysts Edward Bentley, M.D., and Larry DeGhetaldi, M.D., found numerous errors in the California geographic payments. After CMA notified CMS, those errors were corrected in the final rule. However, Drs. Bentley and DeGhetaldi found that CMS made additional mistakes with the California geographic payments in the final rule. Once again, CMA notified CMS and they have acknowledged the errors. CMA continued working with CMS to make the changes to ensure accurate Medicare payments are made to California physicians in 2020 and 2021 and to avoid recoupments in future years.

Now that the corrected payment amounts are in its system, Noridian will begin to process and mass adjust all affected claims beginning the week of February 10, 2020. Physicians do not need to take any action.

Physicians with questions can call (855) 609-9960 or visit the Noridian website for more information.

Public Health

Update

ACEs: The Quiet Cause

By Gwen Callaway, MPH, Todd Davenport, PT, DPT, MPH; and Maggie Park, MD The story of one of the biggest breakthroughs at the intersection of public health and clinical care began in the 1980s at an obesity clinic in San Diego. Dr. Vincent Felitti wanted to know why nearly half the patients in his program dropped out even though most of them reported successfully losing weight. He found that the majority of the nearly 300 people he interviewed had suffered sexual abuse as a child. As a result, he theorized that their weight gain may have been a coping mechanism for mental health illnesses resulting from unresolved childhood trauma. Later, he launched a landmark study at Kaiser identifying strong associations between health challenges in adulthood and childhood adversity.

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(Fig. 1: CDC) Today, these are known as adverse childhood experiences (ACEs) which are potentially traumatic events or circumstances that occur during childhood and adolescence and are broadly grouped into three categories: abuse, neglect, and household dysfunction.

These experiences may include sexual abuse, domestic violence, parental substance abuse, divorce, incarcerated relatives, discrimination, neighborhood violence, food or housing insecurity, intimate partner violence, or being in foster care. The effects of these events build upon each other and lead to toxic stress within the body that inhibits proper brain development, changes gene expression, unbalances the endocrine and immune systems, and increases the incidence of chronic disease. The number of categories of ACEs (ie. a person’s ACE score) is positively associated with the frequency of ischemic heart disease, cancer, chronic lung disease, skeletal fractures, liver disease, obesity, depression, and drug abuse. There is even growing evidence that long-term exposure to toxic stress can alter DNA structure. For children, these physiological changes translate to a higher likelihood of being disengaged from school; having social emotional challenges; adopting health risk behaviors; developing any number of chronic diseases, and therefore missing out on opportunities for education, employment, and income.

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ACEs also occur more often in populations with greater socio-economic disparity. It has been estimated that 15 to 20% of the association between a person’s number of ACEs and their adult health risks are actually attributable to their socioeconomic conditions. In one particular study, the health effects of three ACEs (exposure to domestic violence, parental divorce, and residing with a person who was incarcerated) were entirely explained by an individual’s socioeconomic position in adulthood. This is further evidence of the close interchange between ACEs and the conditions in which a person lives, works, and plays.

Compounding this issue, parents can pass on the effects of their own ACEs to their children. In one study, each additional parental ACE led to worsening overall health status, increased rates of asthma, and increased excessive media use among children. These effects are cumulative so, for example, in the case of a parent with 6 or more ACEs their child is at greater than six times the risk of developing asthma.

But there is good news when it comes to combating the deleterious effects of ACEs on a child’s growth, development, and future– and it starts with the provider/ family relationship. Data from the National Survey on Children’s Health 2016 (NSCH) tells us that children with

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two or more ACEs whose parents report that their child’s healthcare providers “always” listen, spend the needed time, and give needed information are more than 1.5 times more likely to live in families that practice four basic resilience skills. And there is evidence that those resilience skills can mitigate the effects of ACEs. According to the NSCH, children ages 6-17 years who have had two or more ACEs, but learned to stay in control when faced with challenges are more than three times more likely to be engaged in school compared to peers without those skills.

Providers can access various ACEs screening tools online where there are versions for parents, teens, and children with most taking the form of an approximately one page survey.

Parents complete the survey on behalf of their children and a point is given for each scenario experienced. The point total is the child’s ACE score. Once the ACE score has been determined, discussing the results during the appointment is vital. The goal is to provide a safe space for families and to educate about trauma, its long-term effects, and feasible strategies to lessen them.

Broadly, one such strategy is to increase the number of positive childhood experiences (PCEs). These PCEs include the child having:

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(1)

felt able to talk to their family about feelings;

(2)

felt their family stood by them during difficult times;

(3)

enjoyed participating in community traditions;

(4)

felt a sense of belonging in high school (not including those who did not attend school or were homeschooled);

(5)

felt supported by friends;

(6)

had at least 2 non parent adults who took genuine interest in them;

(7)

felt safe and protected by an adult in their home.

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As part of trauma-informed care, clinicians are encouraged to discuss positive parenting practices, connect children with mentoring and after-school programs, refer families to early childhood home visitation services, and help families set goals for themselves.

In a study of providers, the most often cited concern about screening for ACEs was the time constraints on appointments and being ill-equipped to handle a potential opening of the floodgates of emotional trauma. However, after piloting screening programs, doctors have found these fears to be unwarranted and consider ACEs screening to be a powerful and informative tool. To that end, the ACEs Aware initiative, led by the California Office of the Surgeon General and the Department of Health Care Services, is training Medi-Cal providers on how to use ACEs and receive the $29 payment for each screening.

Locally, there have been some efforts to increase awareness of ACEs and trauma-informed care within the health care community. Last year, through a community grant from Dignity Health, the Child Abuse Prevention Council was able to collaborate with San Joaquin General Hospital pediatricians on their “ACEing Parenting” pilot project.

Modeled on a program developed by pediatricians in Portland, Oregon, this program sought to boost provider confidence with screening and educate parents about their own ACE scores and how their childhood experiences could affect their parenting styles. In-home social support was provided, with parent coaching and activities to enhance parent-child attachment and bonding in an effort to mitigate abuse or neglect. These interventions strive to reduce the likelihood of intergenerational trauma.

Many community-based organizations in San Joaquin have been working to increase awareness around ACEs, both within their organizations and within the community.

These efforts are now converging with the formation of a coalition led by St. Joseph’s and Reinvent South Stockton.

This initiative, focused on addressing ACEs and creating

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Adverse Childhood Experiences Revised Questionnaire California Surgeon General’s Clinical Advisory Committee

Our relationships and experiences—even those in childhood—can affect our health and wellbeing. Difficult childhood experiences are very common. Please tell us whether you have had any of the experiences listed below, as they may be affecting your health today or may affect your health in the future. This information will help you and your provider better understand how to work together to support your health and well-being.

Instructions: Below is a list of 10 categories of Adverse Childhood Experiences (ACEs).

From the list below, please add up the number of categories of ACEs you experienced prior to your 18th birthday and put the total number at the bottom. (You do not need to indicate which categories apply to you, only the total number of categories that apply.)

Did you feel that you didn’t have enough to eat, had to wear dirty clothes, or had no one to protect or take care of you?

Did you lose a parent through divorce, abandonment, death, or other reason?

Did you live with anyone who was depressed, mentally ill, or attempted suicide?

Did you live with anyone who had a problem with drinking or using drugs, including prescription drugs?

Did your parents or adults in your home ever hit, punch, beat, or threaten to harm each other?

Did you live with anyone who went to jail or prison?

Did a parent or adult in your home ever swear at you, insult you, or put you down?

Did a parent or adult in your home ever hit, beat, kick, or physically hurt you in any way?

Did you feel that no one in your family loved you or thought you were special?

Did you experience unwanted sexual contact (such as fondling or oral/anal/vaginal intercourse/penetration)?

Your ACE score is the total number of yes responses.

Do you believe that these experiences have affected your health?

Not Much

Some

A Lot

Experiences in childhood are just one part of a person’s life story.

There are many ways to heal throughout one’s life.

Please let us know if you have questions about privacy or confidentiality.

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trauma-informed strategies, is in its formative stages, but is anticipated to offer a broad community-wide vision, mission, and action plan.

Medical providers of any specialty can implement screening programs in their practices and initiate conversations with their patients about ACEs. A good place to start would be to gain some insight into yourself and calculate your own ACE score. Remember, ACEs are common!

Studies have shown that the conversation with patients typically lasts 3-5 minutes, and it may take time to become comfortable triaging your visits. Consider learning more about motivational interviewing and visit the ACEs

Aware website even if you’re not a Medi-Cal provider.

Have resources and referral tools ready for patients with positive ACE scores. Even if you don’t go as far as gathering ACE scores from your patients, some validation of their experiences and the impact of trauma on their lives can be therapeutic. In the words of Dr. Felitti himself, “Asking and listening…was in itself a very profound form of doing.”

Figure 1: https://www.cdc.gov/violenceprevention/pdf/ preventingACES-508.pdf (page 10/40)

ARE YOU READING CPR? CPR contains the latest practice management news, and tips on reimbursement and contracting related issues.

SUBSCRIBE NOW Sign up now for a free subscription at www.cmadocs.org/subscribe

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San Joaquin Medical Society Member Only Benefits • Security and Risk Assessment of your IT Infrastructure (valued at $500) • 10% Discount of Monthly Managed Services for the first year (valued at a maximum of $5,000) • 5% Discount on Monthly Managed Services for VoIP Phone Systems for the first year (valued at a maximum of $1500) • Waived Set-up Fee (valued at $1,000 - $2,000 – user # dependent) • Monthly newsletter and Weekly Tech Tips for Cyber Safety Call Shari Peck @ 209-423-2760 or email shari@ce-technology.com SPRING 2020

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18 NEW

SJMS MEMBERS THIS WINTER!

...and even more on the way.

Roopa Meda, M.D.

Frank Kennedy, M.D.

Ferouz Sidhwa, M.D.

445 W Eaton Ave Tracy, CA (209) 835-0100 Kuvenpu University J.J.M. Medical College

500 W Hospital Rd French Camp, CA (209) 468-6000 Keck Sch Of Med Of The USC

500 W Hospital Rd French Camp, CA (209) 468-6000 University of Texas Medical School at San Antonio

OB/GYN

Bhupinder Romana, M.D. Gastroenterology

782 E Harding Way Stockton, CA (209) 546-5200 Armed Forces Medical College, Pune, India

Gurtej Malhi, M.D. Ophthalmology

782 E. Harding Way Stockton, CA (209) 546-5200 Government Medical College and Hospital

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Critical Care Surgery

Ye Aung, M.D.

Internal Medicine 500 W Hospital Rd French Camp, CA (209) 468-6000 Far Eastern University

Rashna Ginwalla, M.D. Tramatic Surgery

500 W Hospital Rd French Camp, CA (209) 468-6000 University of Southern California Keck School of Medicine

Critical Care Surgery

Jaspreet Sidhu M.D. Orthopaedic Surgery

2488 N California Street Stockton, CA (209) 946-7200 Maharshi Dayanand University P.T. Bhagwat Dayal Sharma Medical College

Pratik Gandhi, M.D. Orthopaedic Surgery

2488 N California Street Stockton, CA (209) 946-7200 Autonomous University of Guadalajara Faculty of Medicine

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Jeffrey MacLean, M.D.

Larry Edwards, M.D.

2626 N California St, Ste B Stockton, CA (209) 946-7200 University of Vermont College of Medicine

7373 West Lane Stockton, CA (209) 735-4176 Ross University School of Medicine

Sailaja Kalidasu, M.D.

Manpreet Gill, M.D.

7373 West Lane Stockton, CA (209) 735-4176 Ross University School of Medicine

7373 West Lane Stockton, CA (209) 735-4176 American University of the Caribbean School of Medicine

Orthopaedic Surgery

Internal Medicine

Preeti Borgohain, M.D. Pediatrics

1721 W. Yosemite Ave. Manteca, CA (209) 735-4176 Silchar Medical College

Mayank Gupta, M.D. Psychiatry

1721 W. Yosemite Ave. Manteca, CA (209) 735-4176 Government Medical College

Family Medicine

Family Medicine

Natasha Loudin, M.D. Opthalmology

7373 West Lane Stockton, CA (209) 735-4176 Stanford University School of Medicine

Dheeraj Nandanoor, M.D. Family Medicine

1801 E March Ln, Ste D460 Stockton, CA (209) 472-2300 Kamineni Institute of Medical Sciences

Rafia Khan, M.D. Internal Medicine

1721 W. Yosemite Ave. Manteca, CA (209) 735-4176 Medical College for Women & Hospital

SPRING 2020

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