Summer 2013

Global Traveler Local Healer

Marvin Primack, M.D., has touched nearly every corner of the globe, while his medical career has helped elevate the level care to Stockton – one very special place in the world.

PLUS: CMA Health Reform Heats Up MICRA Battle Heats up in 2013 Summer 2013

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Marsh/Seabury & Smith Insurance Program Management and SJMS leveraged the buying power of your fellow members to secure dependable and affordable life insurance benefits at competitive premiums from ReliaStar Life Insurance Company, a member of the ING family of companies.

With first-class life insurance benefits extended at competitive rates, you’ll rest easy knowing you’ve provided coverage for your loved ones through the Group 10-Year and 20-Year Level Term Life Plan.

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It features: • Benefits up to $1,000,000 • Rates that are level for 10 or 20 full years* • Benefit amounts that never change provided premiums are paid when due

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AR Ins. Lic. #245544 • CA Ins. Lic. #0633005 • d/b/a in CA Seabury & Smith Insurance Program Management 777 South Figueroa Street, Los Angeles, CA 90017 • 800-842-3761 • CMACounty.Insurance@marsh.com • www.CountyCMAMemberInsurance.com * The initial premium will not change for the first 10 or 20 years unless the insurance company exercises its right to change premium rates for all insureds covered under the group policy with 90 days’ advance written notice.

The County Medical Associations and Societies/NORCAP/CMA receive sponsorship fees for insurance programs that offset the cost of program oversight and support member benefits and services.

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VOLUME 61, NUMBER 2 • JUNE 2013

{FEATURES}

12 20 36 46 52 SUMMER 2013

{DEPARTMENTS}

CMA HEALTH REFORM

18 MICRA

CMA ACT NOW

24 IN THE NEWS

BEHAVIOR THAT UNDERMINES A CULTURE OF SAFETY

38 SAN JOAQUIN GOLF TOURNAMENT

The Clock Races

Avoiding Medicare Penalties in 2015

Trial Lawyers’ Money Grab Threatens to Overturn MICRA New Faces and Announcements

Managing Professional Risk

40 PUBLIC HEALTH UPDATE

GLOBAL TRAVERLER, LOCAL HEALER

63 HPSJ NEWS

CARE COORDINATION

69 IN MEMORIAM

Marvin Primack, M.D.

Integration Strategies

Read About the Latest in Health News Amy Shin, CEO Health Plan of San Joaquin

SAN JOAQUIN PHYSICIAN 3

PRESIDENT Raissa Hill, DO PRESIDENT-ELECT Thomas McKenzie, MD PAST-PRESIDENT George M. Khoury, MD SECRETARY-TREASURER Ramin Manshadi, MD BOARD MEMBERS Lawrence R. Frank, MD, Moses Elam, MD, Peter Drummond, DO, Dan Vongtama, MD, James J. Scillian, MD, Karen Furst, MD, Kwabena Adubofour, MD, Kristin M. Bennett, MD

MEDICAL SOCIETY STAFF EXECUTIVE DIRECTOR LIsa Richmond COMMUNITY PROJECT MANAGER Vanessa Armendariz MEMBERSHIP COORDINATOR Jessica Peluso

SAN JOAQUIN PHYSICIAN MAGAZINE EDITOR Moris Senegor, MD EDITORIAL COMMITTEE Moris Senegor, MD, Kwabena Adubofour, MD, Mike Steenburgh MANAGING EDITOR Michael Steenburgh

COMMITTEE CHAIRPERSONS MRAC F. Karl F. Karl Gregorius, MD DECISION MEDICINE Kwabena Adubofour, MD ETHICS & PATIENT RELATIONS to be appointed

CREATIVE DIRECTOR Sherry Roberts CONTRIBUTING WRITERS Lita Wallach, Vanessa Armendariz, James Noonan, George Khoury

COMMUNICATIONS Moris Senegor, MD LEGISLATIVE Jasbir Gill, MD COMMUNITY RELATIONS Joseph Serra, MD

THE SAN JOAQUIN PHYSICIAN MAGAZINE is produced by the San Joaquin Medical Society

AUDIT & FINANCE Marvin Primack, MD MEMBER BENEFITS Jasbir Gill, MD NOMINATING Hosahalli Padmesh, MD MEMBERSHIP Ramin Manshadi, MD PUBLIC HEALTH Karen Furst, MD

SUGGESTIONS, story ideas or completed stories written by current San Joaquin Medical Society members are welcome and will be reviewed by the Editorial Committee.

SCHOLARSHIP LOAN FUND Eric Chapa, MD NORCAP COUNCIL Thomas McKenzie, MD

PLEASE DIRECT ALL INQUIRIES AND SUBMISSIONS TO: San Joaquin Physician Magazine

CMA HOUSE OF DELEGATES REPRESENTATIVES Robin Wong, MD, Lawrence R. Frank, MD, James R. Halderman, MD, Patricia Hatton, MD, James J. Scillian, MD, Peter Oliver, MD, Roland Hart, MD

3031 W. March Lane, Suite 222W Stockton, CA 95219 Phone: 209-952-5299 Fax: 209-952-5298 Email Address: lisa@sjcms.org

Kwabena Adubofour, MD, Gabriel K. Tanson, MD, Ramin Manshadi, MD

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MEDICAL SOCIETY OFFICE HOURS: Monday through Friday 9:00 AM to 5:00 PM

SUMMER 2013

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SUMMER 2013

SAN JOAQUIN PHYSICIAN 5

A message from our President – Raissa Hill, DO

Medicine, A Time-Honored and Fullfilling Career This is, not by far, the end of it

It is unbelievable that the year is coming to an end so quickly. I have been honored to serve the San Joaquin Medical Society this year and to work with the capable and outstanding staff.

to increase membership to effect greater visibility for San Joaquin physicians within our state, -further expanding the San Joaquin Medical Society website to include the Health Hub of San Joaquin, which is an

“There is more to conquer. Medicine is a time-honored and fulfilling career. In fact, it is so lusted after that even pharmacists, optometrists, chiropractors, and other allied health professionals are clamoring to help carry the healthcare load for physicians.” - Dr. Raissa Hill

There has been so much that has occurred this year. Some of the highlights for me are: -welcoming a new Executive Director to the San Joaquin Medical Society, Mrs. Lisa Richmond, -continual endeavor

online resource for diabetes (hopefully will expand to incorporate other chronic conditions, i.e. obesity) utilized by patients, health care providers, and allied professionals, -being able to meet and interact with some of our elected officials (We have had some join our monthly meetings and hope to have more of that in the future.) -Dustin Corcoran honoring us with a roundtable type discussion for invited independent physicians on the future of private practice in healthcare

ABOUT THE AUTHOR ­ Dr. Raissa Hill is President of the San Joaquin Medical Society and is a second-generation physician who practices family medicine in Stockton.

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SUMMER 2013

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SAN JOAQUIN PHYSICIAN 7

Please join us for the

ANNUAL MEMBERSHIP DINNER honoring our

2013 Lifetime Achievement Award Recipient

DR. MARVIN PRIMACK Sunday, June 30, 2013 Cocktail Reception 6:00pm / Dinner 7:00pm

Stockton Golf & Country Club

3800 Country Club Boulevard • Stockton, California Member Physicians and Spouse/Guest – $35 per person Non-Members and Invited Guests – $60 per person Additionally, we will honor the passing of the gavel from President Raissa Hill, DO to President-Elect Thomas McKenzie, MD

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SAN JOAQUIN PHYSICIAN

SUMMER 2013

A message from our President – Raissa Hill, DO

(Due to the success of that event we hope to plan more and in other cities.)

However, that is, not by far, the end of it. There is more to conquer. Medicine is a time-honored and fulfilling career. In fact, it is so lusted after that even pharmacists, optometrists, chiropractors, and other allied health professionals are clamoring to help carry the healthcare load for physicians. Masquerading as solutions to improve access to health care, such extensions of patient care only further fragment the health care delivery system.

In fact, what we need are more integrated care models that utilize everyone to the best of their abilities.

Defending MICRA is another battle which demands our attention. Recently, the constitutionality of California’s MICRA law has come under heavy courtroom fire from those who would profit most from its demise. Since 1975 MICRA has proven to be a reasonable, and constitutional, means of limiting meritless lawsuits while still allowing patients with justifiable medical negligence claims to receive compensation. MICRA also ensures that more money goes to injured patients, not lawyers, by using a sliding pay scale to control attorney contingency fees. After more than 35 years of MICRA, it is easy to relax in our defense of this landmark California legislation, but I warn that its foes are more mobilized than ever this time around. Your participation in MICRA’s defense through the CMA/SJMS is more important now than ever.

Finally, there has been so much press about how healthcare and medicine are changing. There is much debate about how to make healthcare affordable. I encourage you to utilize your “voice” and stay active to ensure lobbyists and lawmakers continue to keep the patients and healthcare providers foremost in mind when deciding healthcare’s future.

I equally encourage patients to practice prevention and more participation in their own healthcare. And remember, we all are, and increasingly will, be patients of

SUMMER 2013

whatever healthcare system ultimately prevails.

Make sure it is one you would want to be a patient in!

I sincerely thank you all for allowing me to act as your President this last year. Your

support has been heartfelt, and with that in mind I will continue through the coming year to seamlessly transition leadership to Dr. Mckenzie, the incoming President. Our society is in good hands going forward.

SAN JOAQUIN PHYSICIAN 9

Letter From The Executive Director

STAFF REPORT

BIG SHOES TO FILL I can’t believe it has been 3 months since I took over as Executive Director of SJMS. I guess it’s true that time flies when you are having fun. I appreciate the warm welcome I have received from our Members and Community Partners. I am honored to represent such a talented group of physicians, including those I’ve known for years like Dr.’s Hill, Adubofour and Manshadi. I give credit to SJMS’s Membership Coordinator, Jessica Peluso and Community Relations Manager, Vanessa Armendariz for working hard to making the transition as seamless as possible. A HUGE thank you goes out to Mike Steenburgh for his support and confidence in me. I look forward to his continued mentorship as I settle in to this new position. I have big shoes to fill- quite literally!

LISA RICHMOND

There is nothing like jumping in feet first. With so much going on, there is no time to waste. We know that our providers physicians are concerned about changes we will see later this year with the Affordable Care Act. Uncertainty is difficult, and while we don’t have all the answers, we did want to address some of the concerns looming in the physicianprovider community. In mid-April, SJMS worked with CMA to pull a focus group of our local physicians. Dustin Corcoranhoran, CEO of California Medical Association, spoke to the group about the Future of Medicine for the Independent Physician. Following the dinner, many in attendance, said it made them feel hopeful. Look for more of these meetings offered as a member benefit in the upcoming year.

Also in April, I found myself at the Annual CMA Leg Day with a few SJMS Board and Alliance Members as we talked to our local legislators about the concerns regarding the Scope of Practice Bills which are expertly monitored by CMA’s Government Relations – led by Juan Torres. In addition, we are closely watching the recent attacks on MICRA (page 19). We will keep you updated on all of these issues as developments unfold.

We kicked off May with our 4th Annual SJMS Golf Tournament to benefit The First Tee of San Joaquin and our very own Decision Medicine Program. It was a fun day in the sun supporting two very worthy organizations. See Dr. Khoury’s article (page 38) for more details!

I was very excited to participate in my first Decision Medicine interviews! Vanessa Aremendariz, our own Community Programs Manager and DM Facilitator did an excellent job getting into our local high schools to promote the program, which left us with an all-time high of 160 applicants! After careful consideration by the DM Review Committee, 47 students were selected for an interview. These dedicated students did their best to impress us (and they did) to position themselves for one of the 24 available spots. It was a very difficult decision process as they were all amazing. But, I am excited to announce our Decision Medicine Class of 2013 on page 30.

Finally, we look forward to our Annual Membership Dinner to honor Lifetime Achievement Recipient Dr. Marvin Primack on June 30. I was lucky to spend some time with Dr. Primack during his photo shoot for this magazine. What an accomplished physician, family man and world traveler! You’ll find a wonderful feature on him and his many interests towards the middle of this issue. Read more about Dr. Primack on page 46.

I hope this summer allows you some much deserved relaxation and family time. I am looking forward to my vacation with my husband Mark and our wonderful kids, Riley and Ryan as we travel to visit family on the Big Island of Hawaii. I am a lucky girl.

Aloha,

Lisa Richmond

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HEALTH REFORM HEATS UP AS THE CLOCK RACES More than three years have passed since the Affordable Care Act (ACA) was signed into law, setting in motion some of the most dynamic and volatile years the nation’s health care industry has ever seen.

BY JAMES NOONAN l CMA Staff Writer

S

ince its inception, the Affordable Care Act (ACA) has been a subject of controversy, inspiring hotly contested debates in Washington, D.C., Sacramento and across the entire nation. For some, this dramatic

overhaul of the nation’s health care system represents our national leaders finally making good on the long-overdue promise of “health care for all.” Others claim that the law is a clear overreach of federal authority that threatens to overburden an already fragile economy. >>

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SAN JOAQUIN PHYSICIAN 13

CMA > Health Care Reform

Although the law remains controversial, the United States Supreme Court has ruled that the law is constitutional and active steps are being taken to move forward at the federal and state levels.

Despite being signed into law more than three years ago, the vast majority of activity has yet to come. With many of the provisions set to take effect on January 1, 2014, state officials across the nation are scrambling to make sure they’re ready to implement the law’s sweeping changes.

The road has already been a somewhat rocky one.

Throughout the implementation process, the U.S. Department of Health and Human Services has been narrowly meeting its own deadlines, often times leaving states waiting for federal guidance that could dramatically alter their own implementation plans. With several major deadlines coming in the next few months, many observers expect this problem to only get worse.

Adding to the headache for the federal government is the fact that the ACA has received mixed support from the states, which has complicated implementation efforts nationwide.

As of early February, only 19 states had elected to develop their own state-run “exchange,” an online marketplace where consumers can purchase subsidized coverage. An additional five states will form state-federal partnerships to operate their marketplaces, while the remaining states have declined to participate, meaning the federal government will be responsible for operating exchanges in those areas.

Despite these problems, the march toward reform continues on.

THE NEXT MAJOR MILESTONE The next major milestone toward full implementation is set to take place on October 1, 2013, when state exchanges are set to begin their pre-enrollment.

In the first years following these marketplaces going live, more than 32 million currently uninsured Americans are expected to gain coverage, either

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Millions of Americans will, for the first time, be able to purchase coverage using the federal subsidies promised in the ACA.

through an exchange plan or the ACA’s massive expansion of the Medicaid program. Some analysts expect as many as 5 million of these newly insured to come from California.

Three months after the pre-enrollment begins, January 1, 2014, exchanges are set to go live, meaning that millions of Americans will, for the first time, be able to purchase coverage using the federal subsidies promised in the ACA. In order to navigate this massive undertaking, states will need to decide which plans will be offered through their exchanges, construct the actual online marketplaces through which consumers will purchase coverage and implement major public outreach campaigns to ensure that these citizens – many of whom have never had the benefit of “open enrollment” or a similar purchasing period – understand how and where they can sign up for coverage under the reform law.

The task is daunting on its own, but with a deadline looming only months out, skeptics would be forgiven for questioning whether such a task is even possible.

CALIFORNIA LEADS THE WAY

Despite the uncertainty swirling around the ACA’s implementation, California looks to be on track to meet the coming deadlines.

In the days following the ACA’s passage, California was the first state to establish a health benefit exchange (Utah and Massachusetts were operating their own versions of an exchange before the ACA was signed into law) and has been working toward implementation ever since. That exchange, recently named Covered California, has already launched its online consumer marketplace, www.coveredca.com, and is one of 25 states that have gained conditional approval from the federal government to operate its own insurance marketplace.

There is, however, still much work to be done at the state level.

Unlike most other states, California opted to adopt an “active purchaser” model when building its new exchange, meaning Covered California’s Board of Directors will be

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responsible for selecting which insurance providers will be allowed to offer products on the exchanges. The selected products, known as qualified health plans (QHPs), will be required to meet a set of benefit standards finalized by the Covered California board late last year. The QHPs will be selected through a competitive bidding process set to begin in the coming months, and it’s anticipated that somewhere between three to five QHPs will be selected for each one of California’s 19 geographical rating regions.

While the selection process is still far from over, it looks as though the Covered California board will not be short on options when it comes time to award the QHP designation. In October, more than 30 distinct insurance providers issued a “notice of intent to bid” to the board, and most of the state’s major insurance providers have since gone public with their intent to participate in California’s exchange.

The fact that insurance companies appear more than willing to play ball with the exchange, and

that Covered California was established as an independent government entity operating outside the control of the Legislature and governor, means that the exchange’s Board of Directors has a considerable amount of power when it comes to shaping California’s post reform heath care landscape.

PROTECTING PHYSICIAN INTERESTS Unfortunately several recent decisions by the exchange board have placed California’s physician community on its heels.

The California Medical Association (CMA) has been an active participant in stakeholder hearings and is working to ensure that the interests of physicians and their patients are taken into consideration as the exchange prepares to open for business.

Several of issues of concern arose when the board was working to finalize the benefit standards that interested payors will be required

to meet in order to have their products considered for the QHP designation. One major concern for physicians is how the exchange plans to deal with monitoring and ensuring network adequacy among of QHPs. Throughout the benefit design conversation, exchange staff continued to favor the existing method of network monitoring, which calls for the Department of Managed Health Care (DMHC) and Department of Insurance (DOI) to be responsible for ensuring that plans offered to consumers have enough participating providers. In other words, the status quo. Several stakeholders, including CMA, have noted that those two entities are currently unable to ensure adequate networks among existing plans and would likely be overwhelmed by the added task of monitoring additional exchange products. While CMA asked that the exchange take an active role in monitoring networks beginning in 2014, the DMHC/DOI method remained in the final benefit standards adopted by Covered California’s Board of Directors in August, meaning it could

become the norm once the state’s marketplace goes live.

CMA also voiced concern over the exchange’s handling of the “grace period” provision included in the ACA. Under current California law, patients who are delinquent on their premiums are allowed a full 90 days to settle up before their policy is terminated for nonpayment. However, under the ACA’s grace period provisions, exchange plans will be allowed to suspend payment for services rendered if an enrollee is more than one month delinquent. If the patient fails to settle up within the three-month grace period, the plan can then terminate coverage for nonpayment and deny all pending claims for services. In this scenario, physicians could potentially be on the hook for 60 days worth of services with no avenue for recourse.

CMA has repeatedly asked Covered California’s board to reconcile the state and federal policies, but to date an adequate fix has not been presented.

Given the exchange’s accelerated timeline, as well as the exchange

INDUSTRY REFORMS DRAW NEAR: Beginning next January, a majority of the major insurance industry reforms in the Affordable Care Act (ACA) will go into effect, including a ban on lifetime caps and the “guaranteed issue” provision that prohibits health plans from denying coverage on the basis of health status or pre-existing conditions. In order to successfully offer coverage to these new populations, insurance providers must also draw healthy consumers in their risk pool, which is where the controversial “individual mandate” provision comes into play. Those who elect not to purchase or otherwise obtain coverage will be responsible for paying a penalty under the ACA. However, with some observers noting that the penalty could be as low as $95 in the first year, it remains to be seen whether young, healthy individuals might forgo a year of insurance premiums in lieu of this more affordable penalty payment.

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SAN JOAQUIN PHYSICIAN 15

CMA > Health Care Reform

IMPORTANT DATES: October 1, 2013 – California’s exchange to open up pre-enrollment to those planning to purchase coverage through the new online marketplace.

January 1, 2014 – Exchanges across the nation set to become active, allowing tens of millions of currently uninsured Americans to purchase subsidized coverage through new online marketplaces.

January 1, 2014 – Major insurance industry reforms go into effect, including a ban on lifetime caps and a provision that prohibits health plans from denying coverage on the basis of health status or pre-existing conditions.

RESOURCES: The California Medical Association (CMA) has produced a number of resources to ensure that California physicians are ready to operate in a post reform landscape. Among them: CMA Reform Essentials– a regular publication available to both members and nonmembers covering the activities of the state’s health benefit exchange board and legislation significant to California’s ongoing reform efforts. Subscribe today at www.cmanet.org/newsletters.

CMA’s Got You Covered: A physician’s guide to Covered California, the state’s health benefit exchange –a member-only guide designed to educate physicians on the exchange and ensure that they are aware of important issues related to exchange plan contracting. Available at www.cmanet.org/exchange.

UPCOMING HEALTH REFORM WEBINARS: The California Medical Association (CMA) offers free programs to educate member physicians and their staff on a range of issues, including health reform. For more information on any of these programs, visit www.cmanet. org/events. If you are unable to participate in any of CMA’s live webinars, they are archived for on-demand viewing shortly after the live events in CMA’s online resource library at www.cmanet.org/webinars.

4/24: California’s Health Benefit Exchange: How it Will Impact Your Practice and Change Commercial Insurance 9/11: California’s Health Benefit Exchange: The Positives and Perils of Contracting

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board’s tendency to revisit issues that were previously thought to be decided, it remains possible that both of these matters, along with others that have caused concern to physicians, could see some sort of resolution before 2014.

ACTION UNDER THE DOME

With all of the moving pieces present between the federal government and California’s exchange board, it’s sometimes easy to forget that the state Legislature is also playing a large role in ACA implementation. So large, in fact, that Gov. Jerry Brown saw fit to call for a special session dedicated to health care reform in California.

A total of six bills (three identical proposals being heard in both houses of the Legislature) were introduced during the special session, seeking to address individual market reforms (ABX1-1 and SBX1-1), Medi-Cal expansion (ABX1-2 and SBX1-3) and a proposal to establish a “bridge plan” (ABX1-2 and SBX1-3) that would allow for a seamless transition between Medi-Cal and exchange plans for those individuals whose income may fluctuate past the income thresholds called for in the ACA. Special sessions usually are reserved for a dire situation in need of immediate legislative action, which makes it somewhat surprising that members of the Legislature allowed the spring recess – their “soft deadline” for special session legislation – to come and go without any major action on these bills. As of early April, the individual market reform and Medi-Cal expansion bills had cleared their houses of origin and were set to be heard in committees within the second house, while the bridge plan proposal had yet to be heard on the floor of either house.

There’s also a considerable amount of activity related to health reform taking place outside of the special session, specifically regarding scope of practice expansions as a way of addressing the access to care issues that will inevitably take place when millions of currently uninsured Californians gain coverage beginning in 2014. Three bills, all authored by Sen. Ed Hernandez (D-West Covina), seek to expand the respective scope of practice for pharmacists, optometrists and nurse practitioners, while a fourth, authored by Sen. Fran Pavley (D-Agoura Hills) would call for a similar expansion for physicians assistants.

The ACA had two major goals: First, to expand access to health coverage to all, and second, to ensure efficient, high quality care. Those who are now invoking the ACA as the sole justification for allowing non-physicians to diagnose and treat California patients and perform complex medical procedures are attempting to achieve the first goal by undermining the second. Allowing non-physicians to practice beyond their training can only lead to inferior outcomes, higher costs and greater fragmentation of care.

CMA will be closely following and fighting these scope bills, working to ensure that California meets the ACA’s objectives without eroding quality or jeopardizing patient safety.

To be sure, the next few months will be some of the most important and tumultuous times the medical community has faced in recent memory, but as a CMA member you have the comfort of knowing that your interests are being advocated for in front of all the key players driving the nation’s reform efforts.

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Dameron Hospital’s Weight Loss Surgery Center would like you to meet our knowledgeable medical staff and discover your options for controlling your weight. We offer free seminars and information to help you make successful choices.

Please join us at our FREE Monthly Weight Loss Seminars held on the second Tuesday of every month at 6:00 pm in the Dameron Annex.

Register Today! (209) 944-5476 The experienced Bariatric Surgeons practicing at Dameron Hospital are: Antonio Coirin, M.D., Matthew Coates, M.D., Patrick Coates, M.D., F.A.C.S.

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SAN JOAQUIN PHYSICIAN 17

savings of $ over 93,000 The Medical Injury Compensation Reform Act (MICRA) is California’s hard-fought law to provide for injured patients and stable medical liability rates. But this year California’s Trial Lawyers have launched an attack to undermine MICRA and its protections and we need your help. Membership has never been so valuable!

WAYS SJMS/CMA IS WORKING FOR YOU! San Joaquin County physicians are saving an average of $93,748 this year.

Are you a SJMS/CMA member?

2012 SAN JOAQUIN MEDICAL SOCIETY MICRA SAVINGS CHART

General Surgery

Internal Medicine

OB/GYN

Average

San Joaquin County

Miami & Dade Counties, FL

Nassau & Suffolk Counties, NY

Wayne County, MI

FL-NY-MI Average

$28,147

$7,976

$38,865

$24,996

$190,088

$46,372

$201,808

$146,089

$127,233

$34,032

$204,684

$121,983

$121,321

$35,139

$108,020

$88,160

$146,214

$38,514

$171,504

$118,744

MICRA Savings

$118,067

$30,538

$132,639

$93,748

(Non-Invasive)

San Joaquin Medical Society 3031 W. March Lane Suite 222W Stockton, CA 95219 Phone (209) 952-5299 Fax Line (209) 952-5298 * Medical Liability Monitor - Annual Rate Survey Issue, Vol. 37, No. 10, October 2012. Annual rates with limits of $1 million/$3 million.

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SUMMER 2013

Trial lawyers’ money grab threatens to

overturn MICRA California’s trial attorneys launched an all-out assault on California’s historic tort reform law in early May of this year, which since 1975 has helped keep malpractice premiums in-check and ensured that California’s patients have access to affordable health care.

On May 2, 2013, a coalition—including the Consumer Attorneys of California and the trial lawyer-funded Consumer Watchdog group—announced intentions to seek to overturn California’s landmark Medical Injury Compensation Reform Act (MICRA) through a ballot initiative. The group has until September to submit a proposed initiative to qualify for the November 2014 general election ballot.

If successful, the trial attorney’s efforts will cause malpractice rates to skyrocket, and recreate the same conditions that threatened to throw California’s health care system into crisis during the early 1970s. Prior to MICRA, out-of-control medical liability costs were forcing community clinics, health centers, physicians and other health care providers out of practice.

California’s MICRA has been a national success story with broad public support and has safeguarded both patients and our health care delivery system for decades. Risky reforms like the ones being threatened by the trial lawyers would severely impede our state’s ability to provide health care to the poorest and most vulnerable patients. At a time when we are trying to implement federal health care reform and provide access to health care to all Californians, this is the worst possible overreach at the worst possible time.

“The threat of a ballot measure is nothing more than a money grab by trial lawyers,” says CMA President Paul R. Phinney, M.D. “And one that that will come at the expense of higher health costs for all patients and decreased access for patients and clinics already struggling to keep their doors open. We cannot and will not let that happen.”

SUMMER 2013

Physicians will be victorious in this fight, but in order to do so, we need your help.

DONATE: A fight of this magnitude will be extremely costly. The California Medical Association (CMA) is urging all physicians to consider a donation to CMA’s political action committee (CALPAC), which for the last 38 years has served as the first line of defense for California’s historic physician protections.

JOIN: And if you are not already a member of CMA and SJMS, please consider joining today. By joining CMA / SJMS, you will help to ensure that the voice of California physicians is heard loud and clear in the Capitol and beyond. Together, our unified voice can move mountains.

SPEAK OUT: Sign up to be a CMA / SJMS Key Contact. As a Key Contact, we will provide you with all the tools you need to quickly and effectively deliver your message to legislators, from talking points to sample letters. CMA has some of the best lobbyists, lawyers and other advocates in the Capitol, but the most powerful weapon in advancing the cause of physicians and their patients is you. Hearing from a physician with experience from the frontlines of medicine can make all the difference for a legislator facing a complicated health care issue such as MICRA.

For more information on MICRA, and what you can do to help in the fight, visit www.cmanet. org/micra. or call the SJMS office today at 209.952.5299

SAN JOAQUIN PHYSICIAN 19

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SUMMER 2013

Over the past six years, the Centers for Medicare and Medicaid Services (CMS) has launched a number of initiatives that offer physicians the opportunity to increase their net revenue by participating in quality reporting programs. Until now, most of these programs have been voluntary and physicians have received bonuses for participating. That’s about to

to avoid Medicare penalties in 2015

change. Failure to participate now means physicians could face significant penalties.

Contact: CMA’s member service center, (800) 786-4262 or memberservice@cmanet.org

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SAN JOAQUIN PHYSICIAN 21

CMA > Act Now

The American Academy of Family Physicians estimates that participating in these initiatives in 2013, rather than waiting until 2014, could save a physician $19,000 in avoided penalties.

To help physicians understand the bonuses and penalties associated with key Medicare initiatives, the California Medical Association (CMA) will be hosting a free webinar for members ($99 for nonmembers), “Quality Reporting Programs: What Physicians Need to Know and Do Now to Improve Care and Avoid Penalties.”

During the April 9 webinar, participants will learn directly from CMS Region 9 Chief Medical Officer, Betsy L. Thompson, M.D., about the major quality reporting and e-health incentive programs currently underway for eligible

professionals. The session will cover the basics of the Physician Quality Reporting System, the Medicare and Medicaid Electronic Health Records Incentive Programs, the Medicare E-Prescribing Incentive Program and the new value-based payment modifier. The content will be geared toward physicians, nurse practitioners and physician assistants and what they need to know, although other health care professionals and medical office staff are welcome to attend.

If you are not already familiar with each of these programs, the time to learn about them is now.

Below is a brief summary of the programs and key dates that will be discussed in the CMA webinar.

Meaningful Use Demonstrating meaningful use and getting the most of your EHR (Electronic Health Records) software Meaningful use is the set of criteria on which physicians must report in order to receive federal incentive payments for EHR adoption under the Medicare and Medicaid Electronic Health Records (EHR) Incentive Programs.

Meaningful use is also the necessary foundation for all impending payment changes involving patient-centered medical homes, accountable care organizations, bundled payments and value-based purchasing.

John Selle, D.O. of the San Francisco Medical Society

Bonuses: For the Medicare EHR incentive program, your cumulative payment amount depends on the first year of participation. Physicians who start participating in 2013 can receive up to $39,000; physicians who start in 2014, up to $24,000. The last year to begin participation in the Medicare EHR incentive program is 2014. For the Medicaid (Medi-Cal) incentive program, physicians can receive up to $63,750.

Penalties:

Physicians who do not demonstrate meaningful use by 2015 will be subject to Medicare payment penalties. These reductions increase from 1-2 percent of total Medicare charges in 2015, to 2 percent in 2016 and 3-5 percent in 2017 and beyond. Medicaid rates will not be adjusted for failure to achieve meaningful use.

Electronic Prescribing Computer-based electronic generation, transmission and filling of a medical prescription Medicare’s e-prescribing program provides incentive payments for physicians who e-prescribe and payment penalties for physicians who do not.

Bonuses: This year is the last year to receive a bonus for e-prescribing.

To qualify for the 0.5 percent bonus in 2013, you must have successfully reported e-prescribing activity for at least 25 patient visits between January 1 and December 31, 2012.

Penalties:

Starting in 2012, physicians who did not electronically transmit their prescriptions became subject to payment penalties on all Medicare allowed charges. The penalty in 2013 is 1.5 percent, and in 2014, 2 percent.

The California Medical Association designates this live event for a maximum of 1.5 CME credits, AMA PRA Category 1.5 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

This credit may also be applied to the CMA Certification in Continuing Medical Education.

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SUMMER 2013

Physician Quality Reporting System

Each of these programs has specific

Transmitting quality data to CMS regarding the care provided to Medicare patients

some of which are overlapping, and

The Physician Quality Reporting System (PQRS) is a voluntary quality reporting program that provides incentive payments to eligible professionals who report data on quality measures for services provided to Medicare beneficiaries.

CMA’s webinar will give physicians the

Bonuses: Physicians must report

Penalties: The Affordable Care

the webinar, Dr. Thompson will

on three individual measures or one measures group to receive a 0.5 percent bonus. Physicians participating in a maintenance-of-certification program are eligible for an extra 0.5 percent bonus, for a total bonus of 1 percent.

Act calls for PQRS payment penalties starting in 2015. In the 2012 Medicare Physician Fee Schedule, CMS announced that 2015 program penalties will be based on 2013 performance. Therefore, physicians who do not successfully report on at least one individual measure in 2013 or elect to participate in the administrative claims reporting option will receive a 1.5 percent payment penalty in 2015. The penalty goes up to 2 percent in 2016 and beyond.

deadlines and reporting requirements, are not always simple to understand. information they need to successfully participate in each program. During help participants understand which programs they are eligible for, the associated incentives and penalties for each program, and the deadlines and requirements for participation.

The webinar will be presented on Tuesday, April 9, at two convenient times: 12:15 to 1:45 p.m. and again from 6:00 to 7:30 p.m. Participation is free for CMA members. Nonmembers can register for

Heidi Wittenberg, M.D. of the San Francisco Medical Society

$99. If you are unable to participate in the live webinar, it will be archived for

Value-Based Payment Modifier Program Adjusting Medicare payment rates based on quality and cost of care provided to Medicare patients

on-demand viewing shortly after the live event in CMA’s online resource library at www.cmanet.org/resource-library.

CMA members will be able to receive 1.5 CME credits if they participate in the

The value-based payment modifier was mandated by Congress under the Affordable Care Act. It will adjust physician payment based on the quality and cost of the care they provide. It will take effect in 2015 using 2013 data for groups of 100 or more physicians. By 2017, this modifier will be implemented for all physicians.

live webinar and successfully answer the post-session CME questions.

For more information, or to register, visit www.cmanet.org/events.

Contact: CMA’s member service center, (800) 786-4262 or memberservice@

Bonuses: Participating physicians

cmanet.org.

may receive bonuses based on their quality and cost scores.

Penalties:

Participating physicians may be penalized up to 1 percent based on their quality and cost scores. Physicians who choose not to participate will be docked 1 percent.

SUMMER 2013

Ramin Manshadi, M.D. of the San Joaquin Medical Society

SAN JOAQUIN PHYSICIAN 23

In The News

IN THE

NEWS

Zeiter Eye Offering Latest Technology Zeiter Eye Medical Group Offering Latest Technology in Cataract Surgery Thanks to huge medical advances, cataract surgery has improved dramatically over the past decade. The modern custom cataract surgery offered by Zeiter Eye Medical Group surgeons includes bladeless cataract surgery in a pain-free manner with the patient awake under minimal sedation.

Until now, standard cataract procedures have been performed manually with the surgeon using a blade for portions of the procedure.

A manual procedure allows for a margin of error that can affect outcomes. With the introduction of the first FDA-approved Custom Cataract Laser, the LenSx Femtosecond Laser, surgeons at Zeiter Eye now have the ability to create incisions and reduce astigmatism without using a blade. The LenSx Laser operates with unmatched precision, thus eliminating some of the variables that have complicated cataract surgery results in the past. The laser is more precise than manual techniques for portions of the cataract surgical procedure allowing visual outcomes to be more predictable. With the new Custom Cataract Surgery options at Zeiter Eye, patients often reduce, or even eliminate, their dependency on glasses.

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

CMA Foundation Diabetes SJ County Project Update The CMA Foundation is partnering with the Health Plan of San Joaquin, California Association of Health Plans and the California Diabetes Program to launch their Diabetes Care Coordination-Team Care Model pilot project with a grant from Daiichi Sankyo, for patients with type 2 diabetes in San Joaquin, Merced and Stanislaus Counties.

The project focuses on: 1) developing the capacity of medical assistants to become key diabetes care team members utilizing CMAF’s Diabetes Care Coordination: - A Team Based Care Guide; 2) integrate the use of evidence-based medication protocols into practice; 3) use available data to manage patient populations and improve how care is planned , tracked and coordinated; and 4) link patients to key resources such as Certified Diabetes Educators (CDEs), case management services, dieticians and other available community resources for long term self management support.

The Foundation is excited about this project and will share the lessons learned and best practices as they move forward in working with solo and small physician practices to help improve the care of their diabetes patients.

“Our hope is to replicate this model in other solo/small physician practices as we take lessons learned from this pilot forward”, says Sandra Robinson, Vice President of Programs at the CMA Foundation.

For more information on the Diabetes Project, contact Sandra Robinson, Vice President of Programs at the CMA Foundation. srobinson@thecmafoundation.org or 916-779-6624 New Rotary Supported Medical Clinic Being Planned The Rotary Club of Stockton is considering establishing a Free Medical Clinic in Stockton to treat the uninsured and under-

SUMMER 2013

SJ County Female Physician Group insured . The clinic would be located in downtown Stockton, and function one evening a week. It will be patterned after the 12 RotaCare International Free Clinics located in 12 bay area communities from San Francisco to Monterey. They are thriving. Malpractice is covered for all volunteer physicians, nurses, and clinics.

Please respond to Dr. Joseph Serra via email at joseph.serra@outlook.com.

For more information, please go online to www.rotacarebayarea.org. Stay tuned!

SJ County Female Physician Group Enjoy Tropical Dinner and Lecture The female physician group met at Club Brookside last May 9,2013. The lecture on heart disease was conducted by the first female interventional cardiologist in San Joaquin County Dr. Amardeep Singh. She recently joined the Stockton Cardiology Group . Dr. Singh completed her residency at the University of Southern California and fellowship at UC San Francisco.

Following dinner, there was surprise entertainment provided by a Stockton Hawaiian dance troupe, and everyone enjoyed a relaxing evening with complimentary seated shoulder massages.

The event was sponsored by Dignity Healthcare and dinner was catered by the Breadfruit Tree restaurant.

For more information on the SJC Female Physicians Group, contact Dr. Grace Barzaga at her office.

SUMMER 2013

CMA offers Congress several solutions to the outdated Medicare physician payment localities The California Medical Association (CMA) is urging Congress to fix Medicare’s outdated geographic payment localities as part of any effort to repeal the sustainable growth rate (SGR) payment formula. In a recent letter to Dave Camp (R-MI), Chairman of the House Committee on Ways and Means, and Fred Upton (R-MI), Chairman of the House Committee on Energy Commerce, CMA proposed two solutions to this long standing problem that has underpaid physicians in a number of recently urbanized areas. Reps. Camp and Upton are authoring legislation to repeal and replace the SGR. The first solution proposed by CMA is a pilot project limited to California that would update the California Medicare physician payment localities by changing them to follow the same Metropolitan Statistical Areas (MSAs) used to pay hospitals.

The MSAs used to determine payment rates for hospitals are continuously updated, so that reimbursement accurately reflects local costs to deliver care. The physician payment localities, on the other hand, have not been updated in 15 years. As a result, 14 urban California counties, such as San Diego, Monterey and Sacramento, are still designated as rural. This has caused many California physicians to be paid up to 14 percent per year below what Medicare says they

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SAN JOAQUIN PHYSICIAN 25

In The News

IN THE

NEWS “Helping others and the staff at St. Joseph’s is what keeps me coming back. It feels so good to help someone and I love the staff at St. Joseph’s, they’re just wonderful people,” - Surgery Information and NICU volunteer, Rita Cordova.

should be paid if they were in the correct region.

The pilot would be a temporary, budgetneutral solution that would raise payment levels for urban counties misclassified as rural, while holding remaining rural counties harmless from cuts.

Although the payment discrepancies are most egregious in our state, with California accounting for half of all payment anomalies in the country, a number of other states are experiencing similar problems. According to the Government Accountability Office (GAO), the three states with the worst payment accuracy are California, Virginia and Maryland. The second approach proposed by CMA would be a similar multi-state pilot for these three most impacted states.

In both instances, CMA is urging that the remaining rural counties be “held harmless” from cuts that would otherwise result as the result of budget neutrality requirements.

CMA also suggested that another larger approach could be to develop a supplemental rural payment rate to

offset the rate reductions that would be experienced by physicians in the locality reconfiguration regions and to help attract physicians to rural areas across the country.

Contact: Elizabeth McNeil, (800) 7864262 or emcneil@cmanet.org.

St. Joseph’s Volunteers contribute 27,048 hours of service and $136,000 in 2012 St. Joseph’s Auxiliary recently honored 62 members for their volunteer service to St. Joseph’s Medical Center during an awards luncheon at Stockton Golf & Country Club. Service recognition levels ranged from 100 to 8,500 hours, and 13 members received service awards for 10, 15, and 50 years of service. In 2012 alone, 121 Auxiliary members served 27,048 volunteer hours in 10 service areas, including three Information Desks, Gift Shop, Medical Library, Flower and Coffee Delivery, Fundraising, Welcome to Life, Radiology Transport, Doctor’s Conference and Sewing. Through its volunteer efforts, the

HAVE SOMETHING TO SHARE? We welcome submissions to our In-the-News Section from our community healthcare partners. We prefer Word files and .jpg images and may edit for space restrictions. Send your files to nikki@sjcms.org one month prior to publication (Aug 1 for the Fall issue, Nov 1 for the Winter issue)

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SAN JOAQUIN PHYSICIAN

WINTER 2012

In The News

IN THE

NEWS

Auxiliary donated $136,000 to the Medical Center last year.

“Helping others and the staff at St. Joseph’s is what keeps me coming back.

It feels so good to help someone and I love the staff at St. Joseph’s, they’re just wonderful people,” said Surgery Information and NICU volunteer, Rita Cordova.

Special recognition was given to Marilyn Saccone for 50 years of volunteer service.

Other honorees included: 15 years – Rosemary Bensman, Helen Hori, and Pat McMillan; 10 years – Lucy Apcar, Helen Click, Kay Cole, Larry Cole, Elvira Garcia, Donna Goyette, JoAnn Henderson, Betty Marino, and Bill Sheffield.

Members honored for hours of service include: 8,500 hours – Marion Carlson, Aileen Maderos, and Wilma Romero; 8,000 hours – Jim Shuck; 7,000 hours – Joy Clem; 6,000 hours – Patti Hogue; 5,500

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hours – Rick Tipton; 5,000 hours – Tess Aberle; 4,500 hours - Betty Marino; 4,000 hours – Bill Adams; 3,000 hours – Gerry Beecher, Mary Minard, and Judy Torre; 2,500 hours – Norma DePauli, Ann Espinoza, and Mae Offermann; 2,000 hours – Helen Hori, Lem Phillips, Judy Rafert, and Vicki Stroh; 1,500 hours – Linda Acton, Leonard Gonzalez, Margery Santos, and Mary Jane Tisher; 1,000 hours – Mary Anderson, Helen Click, and Elvira Garcia; 750 hours – Michele Cortez Gallego, Gloria Stetler; 500 hours – Linda Biancalana, Lillian Butler, Sharlene Campbell, Jeanne D’Angeli, Shannon DeJesus, Sherry Leonard, Joan Mattheisen, Joe Mingram, Cecilia Moran, Maria Phillips, and Connie Tracy; 250 hours – Kathy Baba, Carmen Eversman, Mary Pennini, Rita Cordova, Colleen Seibel, Jo Ann Stock, and Linda Vincent; 100 hours – Lynn Hoffman, Claire Imeson, Dennis Jennings, Vaness Kuhlmann, Sheryl Raumann, and Arline Welles.

St. Joseph’s Volunteers extend compassionate hospitality and service to patients, families, and visitors throughout the Medical Center. For more information about available volunteer assignments, call 467-6527, visit StJosephsCares.org, or e-mail the volunteer office at sjmcvolunteerservice@ dignityhealth.org.

CMA’s Got You Covered: A physician’s guide to Covered California, the state’s health benefit exchange In 2010, Congress passed historic sweeping health care legislation, the

Patient Protection and Affordable Care Act (ACA), which reformed the for-profit health insurance industry and beginning in 2014 will provide health insurance to most of the nation’s uninsured. Under the ACA, two thirds of California’s uninsured will be covered by private insurance through a health insurance exchange purchasing pool. The exchange’s goal is to start preenrollment in October 2013.

CMA has developed this toolkit to educate physicians on the exchange and ensure that they are aware of important issues related to exchange plan contracting.

Dr. Manchester Joins Dameron New Physician Joins Dameron Hospital Occupational Health Dameron Hospital Occupational Health, is proud to announce that Dr. Troy Manchester, M.D. has joined the practice. Dr. Manchester brings over 15 years of occupational medicine, urgent

SUMMER 2013

SUMMER 2013

SAN JOAQUIN PHYSICIAN 29

In The News

IN THE

NEWS care and family practice experience to the organization, further enhancing the comprehensive scope of service offered in the program. In his new role, Dr. Manchester will assist the medical staff of Dameron Hospital’s Occupational Health Services as well as the Hospital’s Employee Medical Clinic in continuing their focus on delivering superior and efficient medical care.

Troy Manchester received a Bachelor of Science in Molecular Biology from the University of Arizona and his Doctorate of Medicine from the University of Arizona’s College of Medicine. Dr. Manchester completed his residency in Family Practice through the UCSF program at Natividad Medical Center in Salinas and has maintained a practice focusing on occupational medicine, urgent care and family medicine throughout his career.

His professional interests include the development of exemplary communication across all levels of medical service and the training and retention of highly qualified medical colleagues to assure superior medical care is at the foundation of practice.

Dr. Manchester is a strong advocate in the implementation and development of leading edge medical technologies in the delivery of care and has implemented and developed several technologies such as Electronic Medical Record Systems across large medical networks. His experience also includes systems to enhance best practices, quality assurance, outcome driven measures and customer service. Dr. Manchester has Spanish language skills as well.

Dr. Manchester’s was previously the Northern California Regional Medical

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Director for U.S. HealthWorks Medical Group with the responsibility of 23 separate medical clinics throughout Northern California and the Central Valley. The clinics were part of a national network of over 170 national centers in 15 states. The U.S. HealthWork’s Northern California centers provide occupational health care, as well as urgent care, physical therapy, chiropractic and acupuncture services and industrial medicine throughout the region.

Prior to joining U.S. HealthWorks, his experience also includes ownership of a medical practice, medical directorships and management with the Pinnacle Medical Group and Doctor’s on Duty Medical Group in the Monterey area.

than ever before. In receiving over 160 applications, it was difficult to invite only 45 students to an interview and even harder to select the final 24 participants. Our students represent 14 different high schools, five different cities, and have an average GPA of 4.2. A common theme throughout the interviews revolved around giving back to the community. Most, if not all, of the students were aware of the shortage of primary care physicians in the San Joaquin County, which was a motivating force for them to ultimately come back to serve their community. The program will take place from July 15th-July 26th, with the celebration banquet on July 28th.

“The Dameron Hospital Occupational Medicine practice represents a tremendous opportunity to build upon the history of exceptional care with a forward focus on growth and enhanced services”, says Dr. Manchester. “I’m very fortunate to be part of this successful team.”

2013 Decision Medicine Participants

SJMS Welcomes the 2013 Decision Medicine Participants This year, the Decision Medicine Program received the highest number of applications

Bianca Arao Manteca High School Stephana Charles-Pierre Sierra High School Ian Collis Linden High School Maria Del Villar Edison High School Farwa Feroze Tracy High School

SUMMER 2013

SUMMER 2013

SAN JOAQUIN PHYSICIAN 31

In The News

IN THE

NEWS Alfonso Franco Benjamin Holt College Preparatory Academy Ashley Garcia Sierra High School D’Angelo Garduno Health Careers Academy Amit Grewal Tracy High School Veronica Hall Ronald E. McNair High School Jude Ocampo Millennium High School

mentor

Every year, the students stress that one of the highlights of the program is being able to shadow a physician for the day. All of our students have the passion and drive to become a physician, but what they need is a mentor physician who can motivate them to continue to pursue that dream. If you are interested in becoming a mentor physician, please contact the medical society at (209) 952-5299.

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Cina Kazemi Benjamin Holt College Preparatory Academy Teresa Martinez Edison High School Emily Mayorga Franklin High School Margarito Meza Franklin High School Raul Mondragon Franklin High School Jaspreet Nijjar Bear Creek High School Elizabbeth Orgon Lodi High Schol Jasmine Santos Bear Creek High School Oyinlola Sawyerr Stockton Collegiate International School Carli Schultz Benjamin Holt College Preparatory Academy Lucy Vang Cesar Chavez High School Lee Vang Franklin High School Michelle Vu Cesar Chavez High School

California Medical Association Responds to Court’s Decision on Medi-Cal Cuts

Cutting California’s patient safety net will impact access to care, as State implements health reform This past May 24th, the United States 9th

Circuit Court of Appeals denied an en banc request from the plaintiffs in CMA et al. v.

Douglas et al. to rehear the case ruled on by a three judge panel of the court in December.

A three judge panel of the 9th Circuit court overturned a Federal District Court decision to stop a 10 percent cut to California’s Medicaid program, MediCal. The Federal District Court’s ruling in February of 2012 stated that “California’s fiscal crisis does not outweigh the serious irreparable injury patients would suffer absent the issuance of an injunction.”

“While we are not surprised by the 9th Circuit Court ruling, we are certainly disappointed, as the 10 percent cut to Medi-Cal will have devastating effects on California’s poorest and most vulnerable patients,” said Paul R. Phinney, M.D., CMA president. “California already has the lowest Medicaid rates in the nation and with the implementation of health reform, millions of new patients will be enrolled in the program in coming months.”

In spring of 2011, the California Legislature passed and Governor Jerry Brown signed AB 97, which included a 10 percent reimbursement rate cut for physicians, dentists, pharmacists and other Medi-Cal providers. Federal approval was required before the state could implement its proposed cuts.

“Our fight does not end here,” Dr. Phinney added. “As part of the We Care for California Coalition, we will continue to advocate that these dangerous cuts be stopped. With strong bipartisan support on the issue and on behalf of patients across the state, we intend to make our voices heard on this issue.”

SUMMER 2013

In The News

CMA Offers Two-Day Leadership Course for Physicians – September 15 & 16 - Sacramento

The Leader’s Toolkit is a Socratic seminar (via a didactic “lecture”) that covers the key elements of leadership in a very concise manner. While there will be some theory, the seminar will highlight actionable behavior, tools, and concepts that you will (or should) use every day. Topics covered will include:

• Strategy: Knowing when to change, change management, strategic planning, strategic execution • Leading Your Team: Non-delegatable responsibilities of the leader, setting boundaries – management philosophy, making decisions • Building Your Team: Hiring (and firing) • Managing Your Time: Setting priorities, managing your time • Managing Your Meetings: Running a

You Have a Choice Choose Quality (209) 957-3888 www.hospicesj.org James Saffier, MD On-Site Medical Director Hospice & Palliative Care Internal Medicine

Joint Commission Accredited

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SAN JOAQUIN PHYSICIAN

Meeting, parliamentary procedure • Managing Your Organization’s Money: assessing your financials from the CEO’s perspective and knowing the correct questions to ask • CMA/CMS Structure: Understanding and leveraging this critical relationship from a physician leader’s perspective • Managing Your Message: Communicating by email, communicating one-to-one, having difficult conversations, negotiating, communications with your customer (aka marketing) Tom Gehring, CEO, Executive Director of the San Diego Medical Society, has taught this immensely popular seminar for the past 5 years.

This program is FREE to CMA/SJMS members and offered as a member benefit.

All participants must purchase a set of 12 leadership and reference books which are discussed during the seminar and provide the attendee valuable resources for further study and reference. This collection of books may be purchased directly from Amazon (list will be provided) and most are available as e-Books, hard-bound and/ or as paperbacks and cost between $150 $200 for the set.

Class size is limited to 16 attendees and reservations are taken on a first-come, first-served basis. Meals over the two days will be provided by CMA including dinner on Saturday night. Travel and lodging costs are the responsibility of the attendee.

Discounted room rates are available at the Sheraton Grand in Sacramento (ask for the CMA Corporate rate of $159).

Leader’s Toolkit will begin promptly at 8:00 am on Saturday morning and include a mandatory dinner that evening. Sunday begins at 8:00am as well and concludes at 12 noon. It is critically important that participants not hop into the halls to take phone calls or come late / leave early, so please make sure your clinical schedule and call schedule are cleared for the entire weekend.

To register for Leaders Toolbox call Jennifer Moller, CMS Services at 916.551.2541 or email jennifer@cmsservices.org

SUMMER 2013

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NorCal > Managing Professional Risk

BEHAVIOR THAT UNDERMINES A CULTURE OF SAFETY Managing Professional Risk

D

BY MARY-LYNN RYAN, RISK MANAGEMENT l NORCAL MUTUAL INSURANCE COMPANY AND THE NORCAL GROUP

Disruptive behavior by professionals in healthcare settings is well documented as a threat to quality care and patient safety. Managing disruptive behavior requires a coordinated effort based on a written policy and established procedures that cover reporting, confrontation,

Although there is no universally accepted definition of disruptive behavior, the American Medical Association (AMA) defines it as “personal conduct, whether verbal or physical, that affects or that potentially may affect patient care negatively.”

It also includes “conduct that interferes with one’s ability to work with other members of the health care team.”1 Everyone who behaves inappropriately should be treated in the same manner, including excellent practitioners.2 This expectation should be clear in the policy.

All members of the healthcare team should be aware of the policy and the definitions of disruptive behavior it contains. Leaders who are expected to enforce the policy should be trained in the process for addressing disruptive behavior, as well as the legal ramifications of limiting a practitioner’s practice and the legal protections available to both parties in such an action.1 One goal of a disruptivebehavior policy is to create a safe and supportive environment where everyone knows what is reportable

When the decision has been made to perform an “intervention,” the designated team should plan every step

documentation, response, outside consultation, reprimand, follow-up, and monitoring, as well as support for subject physicians.

36

SAN JOAQUIN PHYSICIAN

and feels empowered to make a report. Research indicates that many instances of disruptive behaviors are not reported because the wouldbe reporter is afraid of reprisal.3 To address this issue, the Joint Commission recommends making the process confidential and including non-retaliation clauses in the policy.

Interviewing reporters in confidence assures them that their reports are being taken seriously.4 A history of delayed or hesitant responses to disruptive behavior can discourage staff from reporting such behavior in the future. Therefore, it is important to investigate and intervene as quickly as possible. Prompt response reassures witnesses and reporters that the problem is being addressed pursuant to the policy.

When the decision has been made to perform an “intervention,” the designated team should plan every step (even rehearsing, if necessary), taking into consideration the effects and consequences of planned actions.

The planning, goals and outcomes of an intervention should be carefully documented. If necessary, the resulting report can serve as evidence that the reported practitioner received due process.

SUMMER 2013

An initial intervention without follow-up will generally not put an end to disruptive behavior, which tends to be triggered by ongoing circumstances in the healthcare environment (e.g., lack of equipment, understaffing, fatigue or practitioner health issues). A reported provider should understand that he or she is being monitored for compliance.3 Treat the reported behavior as a problem with the physician’s behavior, not with the physician. In other words, the physician should not be labeled a “disruptive physician.”4 When it is too difficult to conduct an objective assessment in-house, an outside evaluation can assure the involved parties of the process’s fairness and objectivity. In some cases, the most prudent course will be to involve legal counsel for guidance.4 Disruptive behavior compromises patient care and increases professional liability risk. Although disciplining a healthcare provider for disruptive behavior can be difficult for a variety of reasons, it must be done in a timely, organized and fair manner.

Individual practitioners who struggle with anger/frustration management must also take responsibility for their disruptive behavior and seek help. To create a culture of safety for patients and a supportive and productive environment for all members of the healthcare team, practitioners, Medical Executive Committee (MEC) members and administrators are encouraged to consider the risk management recommendations offered in this article.

It should be noted that in many states (including California) disciplinary actions based on physician conduct are reserved exclusively to the medical staff, not hospital administration.

Although disciplining a healthcare provider for disruptive behavior can be difficult for a variety of reasons, it must be done in a timely, organized and fair manner.

SUMMER 2013

SAN JOAQUIN PHYSICIAN 37

Tourna It was a beautiful day for a golf game. The golfers all strode in smiling and happy to be there.

T

he Brookside Golf course was pristine and the driving range was busy with the players trying to perfect their swings.

Some were practicing their chipping and a few managed to get some putting practice in.

Thanks to the many volunteers, the registration process went smoothly. Players were very generous with their money buying raffle tickets. We are happy to announce that we raised over $5000 to benefit The First Tee of San Joaquin and SJMS’ Decision Medicine program.

Donald Miller and The First Tee of San Joaquin Board Members did a wonderful job in helping the Medical Society Golf Committee get the tournament going. Together, we started planning soon after last year’s tournament.

The Tournament went smoothly and it seemed a good time was had by all. The format was easy and allowed the play to proceed at a good pace. We wrapped up the evening with more fun at the pool for appetizers, raffle and awards ceremony. Apparently, there was a slight miscalculation on the hot appetizers available. We apologize and promise it won’t happen again next year.

We were lucky to have so many community sponsors aid us in this endeavor. Thank you to our hole sponsors, the alcohol and beverage sponsors, and Josh Church with Roger Dunn Golf Shops for coming through with so many wonderful prizes.

38

SAN JOAQUIN PHYSICIAN

SUBMITTED BY GEORGE KHOURY, MD

SUMMER 2013

ament San Joaquin Medical Society 2013 Golf

1st Place Team: Mark Richmond, Matt Faith, Jesse Munoz, Jeff Navarro

2nd Place Team: Josh Church, Jack Love, Lex Chandra, Gary Kiedrowski

3rd Place Team- Kim Smith, Chuck Richesin, Mark Tschirky, Matt Miller

Please save the date for 5th annual Tournament on Saturday, May 3, 2014! It is sure to sold out again, so please register as soon as you get the announcement.

SUMMER 2013

SAN JOAQUIN PHYSICIAN 39

Public Health

Update

SJCPHS REPORT

COCCI CASES

To report a suspected or confirmed Cocci case to San Joaquin County Public Health Services (SJCPHS), please go to: www.sjcphs.org/disease/disease_ control_reporting.aspx For public health consultation concerning Cocci, or to schedule an educational presentation concerning Cocci for your institution, please contact the SJCPHS Communicable Disease Program at 209-468-3822.

Coccidioidomycosis or

“Valley Fever:” Coccidioidomycosis, also known as “Valley Fever” or “Cocci” is an infection caused by Coccidioides, a fungus that lives in the soil and is spread through inhaled fungal spores. Cocci is not transmitted person-to-person. The Coccidioides fungus is found in the soil of the Southwestern United States and the San Joaquin Valley. Historically, research concerning Cocci has not been well-funded, so there are many gaps

40

SAN JOAQUIN PHYSICIAN

Know how to recognize it and what to do

in knowledge concerning prevention, diagnosis, and treatment of this regionally important disease.

There are an estimated 150,000 Cocci infections in the United States each year, but the majority of these infections are subclinical and/or undiagnosed, and thus are not counted by public health surveillance systems. The California counties with the highest rates of reported Cocci infections are Kern County and

Kings County in the southern San Joaquin Valley. Research in other locations has shown that occupational exposure to dust and soil may be an important source of Cocci infection. High risk occupations include construction workers, agricultural workers, archeologists, and military personnel. The proportion of those infected in San Joaquin County whose exposure took place on the job is unknown.

SUMMER 2013

There were 123 cases of Cocci in San Joaquin County in 2011, a 267% increase from 2010.

This case count translates to 17.7 reported Cocci infections per 100,000 residents in 2011, a rate slightly above the 2011 California statewide average of 14.4 infections per 100,000. The reasons for San Joaquin County’s dramatic increase from 2010 to 2011 are not known for sure, and a comparison with final 2012 data is still pending but the numbers have gone down some.

Similar increases in Cocci rates have been seen in other areas of California in recent years.

Some possible explanations for the recent increase include: the institution of mandatory reporting of positive Cocci tests by laboratories in 2010; unique weather or wind patterns; changes in patterns of occupational or recreational soil exposure; and increased awareness and testing on the part of medical providers. Historically the highest number of infections and the highest infection rate in San Joaquin County have occurred in the city of Tracy.

Approximately 40% of Cocci infections are symptomatic, with the remaining 60% being asymptomatic or subclinical. Most symptomatic Cocci infection is pulmonary. Often, the initial clinical presentation of pulmonary Cocci is indistinguishable from community acquired pneumonia. Symptoms may include cough, fever, weight loss, and fatigue. A high index of suspicion for Cocci is warranted in cases of occupational soil or dust exposure, prolonged symptoms, poor response to antibiotic therapy, or when a rash is also present. The classic rashes of Cocci include erythema multiforme and erythema nodosum, but these rashes are only present in a minority of infected individuals.

SUMMER 2013

Complications of pulmonary Cocci include lung nodules and lung cavities.

Approximately 1-2% of individuals with symptomatic Cocci develop disseminated infection. Dissemination can also occur with reactivation of prior latent infection, similar to reactivation of latent tuberculosis. Cocci can disseminate to skin, bones, and joints, and can

months without specific treatment. Antifungal therapy for Cocci is generally reserved for disseminated cases, life-threatening or rapidly progressive disease, and pulmonary cases that are not improving on their own. There is little research to support specific treatment algorithms, but usually a prolonged course of treatment is recommended once it is initiated.

also cause a meningitis syndrome. Certain individuals are at increased risk of dissemination, including those that are HIV-positive, taking chronic corticosteroids, in the third trimester of pregnancy, or immunosuppressed for other reasons. In addition, males, African-Americans, and Filipinos generally appear to be at higher risk for dissemination than the general population.

Laboratory diagnosis of Cocci is usually made with a serologic titer, though Coccidioides can also be cultured from, or seen directly in, specimens such as tissue, sputum or abscess fluid.

Initial Cocci titers may be negative, so it may be necessary to follow titers to confirm a clinical Cocci diagnosis. Following sequential titers may also be helpful to assess for disease improvement and the development of complications. Medical providers are responsible for reporting suspected and laboratory-confirmed Cocci cases to the County health department.

The majority of Cocci cases resolve within 6

Patients with Cocci who are not receiving drug treatment should still be followed closely by their medical providers to ascertain that clinical status is improving, and to rule out complications of disease.

Much remains to be understood about the prevention of Cocci in endemic areas such as San Joaquin County. Commonsense measures such as staying inside during dust storms and windy, dry weather are likely to be helpful, as are measures to reduce environmental dust (such as frequently wetting the soil at a construction site).

The efficacy of wearing a mask or a respirator to prevent Cocci has not been determined, but respiratory protection and worker education concerning Cocci are recommended in certain occupational settings. Unfortunately, skin testing to assess for immunity to Cocci is not currently available, and there is no prospect for a Cocci vaccine in the near future.

SAN JOAQUIN PHYSICIAN 41

Public Health

Update

Additional resources concerning Cocci for clinicians: Free online CME course about Cocci sponsored by the University of Arizona’s Valley Fever Center for Excellence: www.vfce.arizona.edu/Default.aspx California Department of Public Health’s webpage concerning Cocci (includes some patient education materials): www.cdph.ca.gov/healthinfo/discond/Pages/Coccidioidomycosis.aspx Centers for Disease Control webpage concerning Cocci: www.cdc.gov/fungal/coccidioidomycosis/

New Immunization Recommendation for Pregnant Women: Tdap with every pregnancy In February 2013, the Centers for Disease Control (CDC) adopted the recommendation of the Advisory Committee on Immunization Practices (ACIP) for women to receive Tdap vaccine during each pregnancy, regardless of prior immunization status. The optimum time for the immunization is between 27 and 36 weeks gestation, though it can be given at any point in the pregnancy. The rationale for this updated recommendation for maternal revaccination is that the duration of maternal pertussis antibodies is often brief; if a mother receives Tdap vaccine during a first pregnancy, she may no longer be immune by the time of her next pregnancy.

The main goal of maternal immunization is to allow for placental passage of antibodies against pertussis to the fetus; this passive immunity will protect infants against pertussis infection during the crucial newborn period, before the first pertussis vaccine is administered.

In addition, the mother herself will be less prone to becoming infected with pertussis and passing this infection to her newborn. The adoption of this new recommendation is projected to prevent approximately 900 pertussis cases in infants every year in the United States.

“Cocooning,” whereby the close family members of a newborn such as the father, siblings and grandparents receive a single dose of Tdap remains an important prevention strategy as well.

For more information, please see the associated MMWR article: www.cdc.gov/mmwr/preview/mmwrhtml/mm6207a4.htm” http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6207a4.htm For immunization consultation, please contact the SJCPHS Immunization Program at 209-468-3481.

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SAN JOAQUIN PHYSICIAN

SUMMER 2013

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Senior Loss Prevention Representative Kathy Kenady

Join the Insurance Company that always puts policyholders first.

MIEC has never lost sight of its original mission, always putting policyholders (doctors like you) first. For over 30 years, MIEC has been steadfast in our protection of California physicians with conscientious Underwriting, excellent Claims management and hands-on Loss Prevention services, we’ve partnered with policyholders Policyholder Dividend Ratio* to keep premiums low.

50% 47% For more information or to apply: n www.miec.com n Call 800.227.4527 n Email questions to underwriting@miec.com * (On premiums at $1/3 million limits. Future dividends cannot be guaranteed.)

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6.4% 2008

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5.2%

5.2% 2009

2010

DISTRIBUTED

2011

Med Mal Industry (PIAA Composite)

MIEC 6250 Claremont Avenue, Oakland, California 94618 • 800-227-4527 • www.miec.com SJMS_04.26.13

SUMMER 2013

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2012

2013

MIEC

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SAN JOAQUIN PHYSICIAN

practice manager Free to SJMS/CMA Members!

resources

The Office Manager’s Forum empowers physicians and their medical staff with valuable tools via expert led educational sessions from industry professionals who are committed to delivering quality health care.

For more than 130 years, the San Joaquin Medical Society (SJMS) has been at the forefront of current medicine, providing its physician’s and their staff with assistance and valuable practice resources. SJMS is proud to offer the Office Manager’s Forum, a monthly educational seminar designed to enhance the healthcare environment with professional development opportunities while providing solutions to some of the challenges that come from managing a practice.

Attendees gain knowledge on a broad array of topics related to the field of medical staff services, office management, billing and coding, human resources, accounting and back office support.

The Office Manager’s Forum is held on the second Wednesday of each month from 11:00AM – 1:00PM at Papapavlo’s in Stockton and includes a complimentary lunch. Attendance is always FREE to our members. Non-members are welcome and may attend for one month at no cost to experience one of the quality benefits that comes with Society Membership ($35.00 thereafter).

Registration required.

For more information or to be added to the mailing list email Jessica Peluso, SJMS Membership coordinator, at Jessica@SJCMS. org or call (209) 952-5299.

44

SAN JOAQUIN PHYSICIAN

SUMMER 2013

JUNE 12, 2013:

OSHA TRAINING 2013 11:00AM to 1:00PM

Join us for our annual OSHA workshop for physicians and office managers. This annual safety training will cover the latest OSHA information and updates for 2013 and will include the following information: • OSHA Facts and Inspections • Exposure Control plan • Life Safety- Emergency Preparation • 2012-2013 OSHA Updates • Aerosol Transmissible Disease Standard (ATD) Flu & TB • MRSA • Ergonomics • Plus ALL of your individual questions!

Carrie Champness, RN, BSN, Safety Compliance Specialist.

Ms. Champness has over 29 years’ experience in hospital, urgent care and physician office compliance.

JULY 10, 2013:

“2013 HIPAA UPDATES & NAVIGATING CMA ON-CALL: CMA’S ONLINE HEALTH LAW LIBRARY” 11:00AM to 1:00PM:

This presentation will cover the major provisions of the HIPAA Omnibus Rule of 2013 and what physician offices need to know before the September compliance date. Further, learn what’s in CMA ON-CALL, CMA’s online health law library CMA Legal counsel will highlight common legal issues faced by physician office, new content and how to effectively navigate the website Lisa Matsubara is Legal Counsel in CMA’s Center for Legal Affairs. Lisa focuses on privacy and security, HIT and scope of practice issues.

Melanie Newmeyer is Legal

SUMMER 2013

Counsel in CMA’s Center for Legal Affairs. Melanie staffs the legal information line and also assists with physician advocacy in matters relating to public health, drug prescribing and dispensing, fraud and abuse and ADA Discrimination.

AUGUST 14, 2013:

“IMPROVING YOUR COLLECTION RESULTS” 11:00AM to 1:00PM

In this presentation you will be getting a review of Basic Collection Techniques combined with ways to improve in house results before you refer for collection.

Ana Molina, CB Merchant Services Collections Manager with over 30 years accounts receivable and collection experience and is directly responsible for compliance and training of a collection personnel.

SEPTEMBER 11, 2013:

KNOWING YOUR RIGHTS AND STOPPING UNFAIR PAYMENT PRACTICES 11:00AM to 1:00PM

Mark Lane, Associate Director in the CMA’s Center for Economic Services. 18 years of experience allowed him to understand the needs and positions of both Physicians and Payors, making him an ideal candidate to educate providers on overcoming the ever-changing challenges of the healthcare landscape.

ARE YOU READING CPR? CPR contains the latest in Practice Management Resources, Updates and Information.

May 2012

In this issue:

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CMA Practice Resources (CPR) is a free monthly e-mail bulletin from CMA’s Center for Economic Services. This bulletin is full of tips and tools to help physicians and their office staff improve practice efficiency and viability.

SUBSCRIBE NOW

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SAN JOAQUIN PHYSICIAN 45

Marvin Primack, M.D., has touched nearly every corner

“

“It’s amazing. The people, the culture; it will always keep me wanting to travel.”

46

SAN JOAQUIN PHYSICIAN

SUMMER 2013

GLOBAL TRAVELER

LOCAL HEALER

Marvin Primack, M.D., has touched nearly every corner of the globe, while his medical career has

helped elevate the level care to Stockton – one very special place in the world.

I

nside a polar research station perched upon a frozen Antarctic ice shelf, crew members from a nearby tourism expedition vessel gather to witness something truly unusual.

In only a few moments, a passenger, who up until recently most of them had known as “the fig man,” would administer general anesthetic to one of their colleagues while the ship’s physician treated an abscessed tooth.

In short, the situation had developed into a medical emergency in one of the world’s most inhospitable locations For most, this situation would be considered bizarre, a scenario reserved for the world of Hollywood productions and reality television. Fortunately, however, the aforementioned “fig man” happened to be Dr. Marvin Primack, a pioneering anesthesiologist

who helped shaped the high level of care that patients in California’s Central Valley have enjoyed for decades.

“They said ‘Why don’t you ask the fig man to do it,’” Primack said, noting that the very next day, the injured crewman, as well as many of his colleagues had taken to calling him “doc” instead.

It was no accident that this Stockton resident found himself halfway around the world, willing to assist when he was needed most.

In fact, this episode, despite its oddities, could serve as a small, yet revealing, glimpse into Primack’s life, one which has been guided by a passion for family, medicine and global travel.

For Primack, the journey that would eventually lead him and his wife, Bune, to visit 121 counties while at the same time establishing himself as a mainstay in San Joaquin County’s medical community, began in his native Michigan. Following an undergraduate career at Wayne State University in Detroit and completion of Medical School at the University of Michigan, Primack had established a promising career as an anesthesiologist at one of Detroit’s leading hospitals, yet was experiencing an indescribable draw that would

story By James Noonan l photos by dale goff

SUMMER 2013

SAN JOAQUIN PHYSICIAN 47

come to change the course of his career forever.

“I very much wanted to come out west,” he recalls from within his Stockton home, noting that it was a two-week medical conference held in Palm Springs that eventually set his westward relocation in motion.

For years, Primack had suffered from an asthmatic condition related to Michigan’s native flora, yet his time spent in the California desert was virtually symptom free. This new found relief, coupled with tales of snowy Michigan winters coming from his wife back home were all the proof he needed that it was time to search for a new part of the country to call home.

“I called home and asked, ‘What’s the temperature there?’

She (Bune) said minus eight,’ he recalled, laughing at that fact that he was, at the time, enjoying the warm weather typical of the Southern California during most of the year.

“I’d much rather live my life at 95 (degrees) than minus eight,” he said.

Before long, Primack and his wife, along with their young son, began searching the Southwest and West for a place to lay down roots. The search, he said, began in El Paso, Texas, crept north through Arizona before winding into a smog-laden Los Angeles Basin that was quickly crossed from the list.

“Twenty minutes in a convertible and that was enough,” he said.

Stockton, as it turns out, was actually the last stop on the list, but had garnered the recommendation of Dr. Henry Zeiter, a colleague from Primack’s training days who was working to establish an ophthalmology practice in the growing Delta community.

From the moment they arrived, the community of Stockton just felt right, Primack said. Now, after 50 years and dozens of journeys to far-off corners of the globe, the community still has the same welcoming feel it did when he and his family first arrived.

“We travel a lot, but we’re always happy to come home,” he

48

SAN JOAQUIN PHYSICIAN

said. “Always.”

After arriving in Stockton, Primack’s medical career began to flourish.

At St. Joseph’s Medical Center, he quickly rose to be one of the region’s leading anesthesiologists and was instrumental in establishing the hospital’s first cardiac surgery center. In time, his role as a leader in the local medical community was further cemented by a nineyear stint as the St. Joseph’s Chief of Anesthesia and another two-years as the hospital’s chief of staff.

In 1991, however, Primack’s hearing began to deteriorate to the point that long days in the operating room were no longer possible, and he was forced to walk away from his role at St. Joseph’s.

“That was first time I retired,” he joked.

For those that know Primack, it should come as no surprise that the life of a stay-at-home retiree would not suit him well.

“Retirement drove me crazy,” he said, noting that before long he was back, with stronger hearing aids, assisting Dr. John Zeiter, son of his former colleague, Henry Zeiter, with surgeries one day a week.

Word that Primack was back in the medical game spread fast, and before long he was asked by yet another colleague to fill in temporarily at the Lodi Outpatient Surgery Center, a request that would eventually lead to a sort-of second career in medicine.

SUMMER 2013

“At first, it was just for two weeks. Then they asked for another two weeks,” he said.

“Eventually, I said, ‘OK, I’ll give you five years. Fourteen years later, I finally finished.”

By 1993, only two years after his first retirement, Primack was serving as Lodi Outpatient Surgery Center’s Medical Director and primary anesthesiologist, a position which allowed him a more flexible schedule to accommodate his passion for international travel. In 2007, at the age of 76, Primack retired from his role at the center, allowing him to pursue his passion for travel full-time.

This passion, Primack said, began ordinarily enough, when he and his wife took a cruise to the Caribbean as a way to momentarily escape from the demands of a medical practice back home after the birth of their fourth child.

The experience, he recalls, was eye opening.

Before long, the Primack’s had made their way to exotic destinations such as Brunei, Papua New Guinea and Kenya, along the way experiencing new cultures and ways of life that would only further fuel the desire to travel.

“It’s amazing. The people, the culture; it will always keep me wanting to travel,” Primack said.

For those that know Primack, it should come as no surprise that the life of a stay-at-home retiree would not suit him well.

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SAN JOAQUIN PHYSICIAN 49

Local Healer > Marvin Primack, M.D.

“As a Commission member since 1997, Dr Primack has provided consistent leadership and has always offered excellent advice to the Health Plan of San Joaquin balancing the interests of the community physicians and the success of the Plan. He has been consistently engaged with HPSJ programs and activities and has provided me, as Chief Medical Officer with valuable direction, feedback and suggestions on many occasions.”

Dale Bishop, MD Chief Medical Officer, Health Plan of San Joaquin

“Health Plan of San Joaquin has benefitted from Dr. Primack’s 16 years of active leadership on its governing Health Commission. It’s been a pleasure to work alongside somebody who not only gives his time and expertise, but is also incredibly engaged in improving our community’s health, representing physician and provider perspectives, and advocating for the members we serve.”

Kenneth B. Cohen Chair, San Joaquin County Health Commission

Dr Primack was a fellow resident in anesthesiology when I was in Detroit doing my Ophthalmology residency in the late 1950s and early sixties. He knew I had come to Stockton and established practice here, so he came to visit me, on his way to Texas where he was offered a position. I took him and showed him the sights in the San Joaquin area; and wouldn’t you know it, it was the sight of the Delta waterways, their levies and the fertile agricultural land all around us that changed his mind about Texas, and he decided to stay in Stockton. Bune and Carol and Marv and I have been close friends ever since!

Henry Zeiter, MD

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Inside the living room of his Stockton home, it’s difficult to imagine that there are still places in the world where Primack has yet to step foot. His mantle, as well as many of the surrounding walls, is entirely covered by artifacts and collectables from across the globe. Hand carved totems from Africa, bone flutes from Japan and a massive didgeridoo from Australia are all on display, each with their own story and set of memories from Primack’s travels.

He recalls witnessing “sing-sings” in Papua New Guinea, a gathering of villages the showcases dancing, singing and other cultural elements as a display of peace, and literally petting whales in the waters off of Antarctica.

“It’s all been so incredible,” he recalls.

While picturesque landscapes and cultural exchange certainly have their benefits, Primack explains that, for him, one of travels greatest appeals is the way that it bypasses societies tendency to politicize entire countries based on the actions of their governments’.

In locations such as Syria, Iran and Cuba, all of which Primack has had the good fortune to visit; he and his wife were greeted with open arms and came to expect top-notch hospitality during their stay.

“Their government hates our government, but the people just love you,” he said.

As rich in experience as Primack’s life has been, it should come as no surprise that the man, himself, has developed an interest in a wide variety of personal and professional pursuits.

In addition to a career in medicine and an ever-expanding travel resume that includes all seven continents, Primack spent nearly three decades owning and operating an 800 acre fig operation in Merced and Madera counties. At its peak, he said, the operation was producing more than 2 million pounds of figs each year, providing him ample stock to use as give-away samples during his travels, as well as in local medical circles.

“That’s why they called me the ‘fig man,’” he explained.

Given that his life has been so rich and full of experience up to this point, it should come as no surprise that the 81-yearold Primack has yet to slow down, and continue to add new destinations to his list of traveled-to places.

In fact, at time of this article’s writing, Primack was busy island hopping in the Mediterranean between Palermo, Sicily, Vulcano, Stomboli and a host of other islands off the coast of Italy. In October, he and his wife hope to venture to the West Coast of Africa, and, assuming global politics allow for it, make the trip to North Korea that had to be called off a few years prior.

“There are so many places I’ve yet to see,” he said.

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SUMMER 2013

RETAINING INDEPENDENCE WHILE EMBRACING ACCOUNTABILITY:

Care Coordination

and integration strategies for small physician practices

Physicians throughout the country are trying to figure out how to best achieve their professional goals in the changing health care delivery environment. Physician payments are increasingly being structured in a way that incentivizes quality and cost effectiveness over volume, and many place physicians at financial risk. In addition, public reporting of physicians’ performance will now be the norm, rather than the exception, with Medicare’s expansion of its Physician Compare website in 2013. Will physicians need to be employed by a hospital or a large medical group or health system in order to provide the quality and manage the costs that these payment and reporting systems require and take advantage of the emerging opportunities resulting from health system reform?

Not necessarily. While some physicians may ultimately decide that formal alignment with a large medical group or hospital system is their best option, others are actively working to integrate new care coordination and accountability capabilities into their smaller practices.

Indeed, there are a number of avenues that physicians in smaller practices can take that will allow them to retain their independence while also achieving the new capabilities they will need to succeed in this new environment.

SUMMER 2013 2013

SAN JOAQUIN PHYSICIAN 53

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Strength in numbers: Options for physicians to maintain autonomy while collaborating with others AMA has published a new resource to assist physicians in small and solo practices in taking advantage of the opportunities presented by the changing health care delivery environment, entitled “Retaining independence while embracing accountability: care coordination and integration strategies for small physician practices,”

AMA has published a new resource to assist physicians in small and solo practices in taking advantage of the opportunities presented by the changing health care delivery environment, entitled “Retaining independence while embracing accountability: care coordination and integration strategies for small physician practices,” available at www.ama-assn.org/go/ACO. This article will summarize the second section of that resource which focuses on potential options small practices may have to collaborate with other physicians.

Considerations for physicians interested in virtual integration There are plenty of reasons for small practices to be optimistic about their ability to succeed in the future. Many believe that to survive, however, smaller practices may need stronger connections to at least other small practices, so they can use their combined efforts to: (1) reduce overhead through economies of scale; (2) depending upon the degree of integration, improve their negotiating position with third-party payers; and (3) if collaborating with other specialists, increase revenues through ancillary services and retaining referrals within the group. Further, such connections help move away from fragmented care to a coordinated care delivery system.

An independent physician practice can build stronger connections with other independent practices through a number of organizational forms. But an organization should not be created just for the purpose of “organizing” physicians. The success of a new physician-owned and controlled integrated organization will depend largely on the organization’s ability to demonstrate that it can provide value to those individuals and organizations that will be purchasing its services. As the organization’s payment will ultimately be based on its performance with respect to quality and cost-effectiveness measures, a sincere commitment to quality improvement and reducing health care resource utilization will be required.

Establishing an initial planning team An initial leadership planning team, in consultation with advisors such as an attorney and/or practice consultant, will be needed to: Perform strategic planning; Conduct an environmentacan; Assess potential organizational structures and create a strategic plan that meets the organizers’ mission, vision, and values; and Identify and communicate those mission, vision, and values to additional participants.

A planning tool for organizing a physician collaboration is included in Appendix I to the resource to help physicians in this effort.

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AMA > Care Coordination

It is essential for the initial leaders/participants to convene a strategic planning session to define the new organization’s mission, vision and values and assess whether the physicians’ expectations are realistic.

The first part of the process is identifying compatible partners to lead the initial effort for change. It is essential that the physicians on this team trust each other, on both a personal and clinical level, and share the same level of commitment to their patients and community and the success of the new organization. Once this initial team is assembled, it may be advisable to include other professionals in the process, such as office managers, an attorney, and a practice consultant. Doing so will help avoid costly mistakes by ensuring that the interested physicians have adequate information initially, before an ill-advised path is chosen. Professionals can also help identify local market opportunities.

Strategic planning process Defining mission, vision, and values It is essential for the initial leaders/participants to convene a strategic planning session to define the new organization’s mission, vision and values and assess whether the physicians’ expectations are realistic. For example, is the goal simply financial success, or is improving quality of care, outcomes and other values, such as reducing hassles and wasted

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time, also important? The definition of the organization’s mission, vision, and values becomes its foundation and will help guide decision-making and communications with patients, hospitals, and payers.

Business strategy and planning Taking the time to determine the strengths, weaknesses, opportunities, and threats as a means of developing a shortand long-term strategic business plan that makes sense for the participating physician practices and the new physician organization is essential. It is through that strategic business plan that the new organization’s mission, vision, and values must be operationalized.

A strategic business plan will help: Tailor the organization’s mission, vision, values, and the services it will provide, to the individual and organizational purchasers and health insurers to whom it expects to market its services; Identify the specific capabilities that the organization will need to develop and prioritize the sequence in which those capabilities will be acquired.

Identify potential business partners who may help

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AMA > Care Coordination

implement the new organization’s mission, vision, and values and business and clinical goals, e.g., through the availability of financial or in-kind administrative or clinical support, and increase the likelihood of maximizing long-term success and retaining professional autonomy in the context of new health care delivery and payment models.

Local market opportunities Understanding what local market opportunities exist is essential. It makes no sense to form an organization unless there is some understanding of what is occurring in the community (keeping in mind that the relevant market may extend beyond the local geographic area due to medical tourism, telemedicine, etc.). At a minimum, things physicians and their expert consultants should look at include: the individual participating physician practices, including patient demographics and referral

patterns; the local hospital community and the potential relationship of those hospitals to the new physician venture; existing independent practice associations (IPAs), management services organizations (MSOs) or other physician organizations that might obviate the need to create a new organization; thirdparty payers, including Medicare, including their respective market shares and willingness to contract with a new physician organization; major public and private employers that may be willing to contract directly with the new venture, the demographics of their employees and any specific services they may value; potential competitors, including retail clinics, telemedicine providers, urgent or ambulatory care centers, other physician groups; changing technologies which the new venture may need to adopt and their costs (AMA resources on these topics are available at www.ama-assn. org/go/hit); changing patient demographics

and expectations, such as new residential or retirement community developments, large numbers of “baby boomers” who will become Medicare beneficiaries in the near future, or younger people who will demand email consults and social media interactions; and ACA changes or other regulatory developments, such as the potential for a large influx of patients assuming state exchanges become operational in 2014.

Potential organizational structures Much has been written about large medical groups and fully integrated health systems.

Many physicians, however, choose to retain as much autonomy as possible when providing care to their patients. Structures are available that allow physicians to obtain the benefits of a large group practice, yet maintain a considerable amount of independence. Those options are more fully discussed in Appendix II of the resource.

Communication of mission, vision, and values to additional physician participants Once the initial planning is complete, potential physician participants should be identified and the mission, vision, values, and goals of the organization must be communicated and agreed to by everyone. If the structure involves quality improvement and care coordination, it is important that these physicians demonstrate a commitment to team work, acceptance of transparency of data and practice records within the organization, and the ability and willingness to be responsible for improvement using data-driven decision-making. A sample “organizing letter” is included in Appendix III of the resource.

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SUMMER 2013

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AMA > Care Coordination

Organizational and operational issues At the same time, there are a number of key issues concerning the group’s organizational structure and operations that need to be addressed, with the advice of an experienced attorney. The issues cover a host of matters such as liability, office personnel, dispute resolution, term and termination, and restrictive covenants. Some of the more sensitive ones

involve the following: capitalization, ownership, governance, compensation, and buy-sell agreements.

Capitalization For any change to be successful, there must be adequate funding.

First, you need to determine how much money you will need. An attorney and/or

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Second, you have to find the funding you need. Fortunately, many of the services physicians need to start integrating and acquire capabilities required for coordination (such as information systems, scheduling and billing and collections) can be arranged through a contract for a percentage of collections, and therefore do not need an initial source of capital for funding purposes. There are a variety of additional sources for funding that physicians may wish to consider, including commercial lenders, physician participants (upfront cash contribution, loans, salary withholds, and/or their accounts receivables), hospitals, vendors (e.g. electronic health care equipment vendors will often arrange financing of the acquisition of computer systems), payers including Medicare and private health insurers, and grant-making foundations.

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Conclusion The fundamental goal of a more coordinated and integrated health care delivery system is being driven on multiple fronts and will continue in the future. Many options are available for physicians in small and solo practices to survive, and indeed, thrive in the future. Physicians must decide individually which option is best for them and whether they will be able to implement those changes needed to succeed with that option in the future. While the level of change in the current environment may seem daunting, there are many resources available to assist physicians attempting to navigate in the evolving marketplace. But regardless, no collaborative effort can succeed without the enthusiastic engagement of the physician participants and effective physician leadership.

SUMMER 2013

SUMMER 2013

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San Joaquin Medical Society and CMA Members Enjoy: Vast CMA Resources:

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SUMMER 2013

Health Plan of San Joaquin “I want HPSJ to be an established leader in the community, known for developing innovative programs.”

Amy Shin, CEO Health Plan of San Joaquin

Amy Shin, the new CEO of the Health Plan of San Joaquin (HPSJ), knows what it means to feel vulnerable to t he challenges of navigating the healthcare system. As a child, the Korean American immigrant often served as her mother’s interpreter with her doctors. This experience drives her professionally, where she has dedicated her career to making healthcare better.

A seasoned healthcare executive with twenty years of experience in the private and public sectors, Amy was previously a principal consultant with Health Management Associates, a national consulting firm with a focus on publicly financed healthcare programs. Other positions include Chief Administrative Officer with On Lok Lifeways, a health plan program for dual eligible frail seniors based in San Francisco, CA; Senior Vice President, Professional Services, Pharmaceutical Care Network in Sacramento; and Senior Director, Alameda Alliance for Health, Alameda County’s equivalent to HPSJ. She is a licensed pharmacist, having earned her PharmD at the University of Southern California, as well as her bachelor’s degree from University of California, Berkeley. She also

SUMMER 2013

HPSJ NEWS

Amy Shin, CEO

SAN JOAQUIN PHYSICIAN 63

HPSJ > Amy Shin, CEO

completed a two-year leadership fellowship with the California Health Care Foundation.

Amy’s clinical background has, she feels, made her a better administrator. “It’s critical to

She describes herself as a “big fan” of her book club, vinyasa yoga, red wine, and caffeine. She currently serves on the board of the Satellite Affordable Housing Associates, and she is also a

One major focus will be on leveraging technology to improve healthcare services and delivery. “I want HPSJ to be an established leader in the community, known for developing innovative programs,” she said.

have a meaningful partnership between the health plan and the clincians,” she said. “The health plan can promote and coordinate access, but once the patient gets in the door, it’s about that interaction and engagement with the doctor.”

Her first job at a for-profit health plan, where she quickly rose up the ranks, convinced her she wanted to work in healthcare in a different way. “As a Director, the first thing you were expected to do every morning was look at the stock price,” she said. “I began to wonder why I was in healthcare.” Her next stint, at Alameda Alliance for Health, showed her that healthcare could – and should – be different. “I am passionate about healthcare for all, and especially increasing access and improving quality for the underserved population.

Working closely with local providers and in partnership with the community is where my heart is.”

On the personal side, Amy is an avid fan of her alma mater’s football team, the California Golden Bears. She and her husband have been married for 12 years, and she enjoys spending time with her extended family.

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board member of the Cal Alumni Association of UC Berkeley.

Amy believes that Health Plan of San Joaquin is perfectly positioned to take advantage of the opportunities that will be available once the Affordable Care Act is in full effect and beyond. “I completely understand doctors’ concerns and uncertainty about what is going to happen,” she said.

“It is going to be difficult and frustrating at times, and it is going to take work but, in the end, it is going to significantly improve access to healthcare.”

One major focus will be on leveraging technology to improve healthcare services and delivery.

“I want HPSJ to be an established leader in the community, known for developing innovative programs,” she said.

On board at HPSJ since early May, she is is eager to meet the local medical community.

“We have so much important work ahead of us, and while challenging, I know it will also be enormously gratifying,” she said. “I look forward to working in partnership with the medical community to continue to improve our health care system.”

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2013 Education Series JUNE 5

June 5: A Guide to Updating Your Partnership and Shareholder Agreements Debra Phairas • 12:15 – 1:15 p.m.

How long has it been that your partnership or group practice reviewed your agreement to ensure it reflects current trends and issues in the medical environment? As consultants, we are frequently called in when a crisis occurs, for example sudden death, disability or departure of a physician. The agreement the doctors signed many years ago may be vague, contain outdated values for buy-in/buy-outs or none at all, income distribution formulas may be sowing seeds of discontent or the group is suddenly faced with an untimely departure of a revenue producing doctor and also a steep buy-out. This workshop will cover the elements of partnership/shareholder/buy-sell issues and current trends, particularly the differences between junior/senior members.

JUNE 12

June 12: Paid Family Leave: A Valuable Safety Net Employment Development Department • 12:15 – 1:15 p.m.

Paid Family Leave (PFL) is a partial wage replacement component of the State Disability Insurance (SDI) program. Eligible workers may file claims for PFL benefits to care for a seriously ill child, spouse, parent, or registered domestic partner; to bond with a new child; or to bond with an adopted or foster child. The PFL medical certification can be submitted on SDI Online or by completing the new Claim for Paid Family Leave Benefits. Since March 1, 2013, claims may only be filed online or by using new OCR paper forms. Attendees of this webinar will gain a better understanding of the PFL program, and how to submit the required medical certification for a PFL care claim.

JUNE 19

June 19: What to Expect from a Medi-Cal Audit DHCS • 12:15 – 1:15 p.m.

Presented by the Department of Health Care Services (DHCS), this webinar will help you understand the role of utilization oversight and claims monitoring, increase understanding of the audit process and possible outcomes, and understand common problems and methods to improve documentation.

JUNE 26

June 26: Meaningful Use – What You Need to Know for This Year and Stage 2 David Ginsberg • 12:15 – 1:15 p.m.

Many changes are in order for the 2014 edition (Stage 2) of Meaningful Use. This informative webinar will assist you in understanding these changes and how they impact your workflows and use of electronic health records (EHR).

JULY 24

July 24: Protect and Preserve Your Patient Relationships Nancy Heard, M.D. • 12:15 – 1:15 p.m.

Presented by the Department of Health Care Services (DHCS), this webinar will help you increase understanding and awareness of the impact of fraud, waste and abuse on patient care, and discuss methods to prevent abuse and ways to preserve the integrity of the physician/patient relationship.

The above webinars are being hosted by the California Medical Association. Please register at www.cmanet.org/events. Once your registration has been approved, you will be sent an email confirmation with details on how to join the webinar. Questions? Call the CMA Member Help Line at (800)786-4262.

Please note that this calendar does not include CMA’s ICD-10 training courses to be offered in 2013.

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SUMMER 2013

AUG 21

Aug. 21: HIPAA Compliance: The Final HITECH Rule David Ginsberg • 12:15 – 1:15 p.m.

The HITECH Act created the extensive funding incentives and standards for adopting electronic health records; it also created new HIPAA rules or modified existing ones. This webinar will provide an overview of the changes to HIPAA and key steps medical practices can take to comply with these changes.

AUG 28

Aug. 28: Medicare: Proposed Changes for 2014 Michele Kelly • 12:15 – 1:15 p.m.

This webinar will focus on proposed policy changes to the physician fee schedule for the year 2014 (excluding any discussion on the SGR, or revised payment methodology). This discussion will provide an opportunity for physicians to hear how new or revised policies may impact their practice, and allow them to provide input to CMA during the Notice and Comment period.

SEPT 4

Sept. 4: Appropriate Prescribing and Dispensing: New Measures Medical Board • 12:15 – 1:15 p.m.

Representatives from the Medical Board of California will discuss outcomes from the Forum to Promote Appropriate Prescribing and Dispensing, held February 2013, including what the Board is proposing/supporting; what the legislature is proposing, and how these measures will be implemented if adopted.

SEPT 11

Sept. 11: California’s Health Benefit Exchange: The Positives and Perils of Contracting Brett Johnson • 12:15 – 1:45 p.m.

Beginning in 2014, California’s private health insurance market will never look the same – individuals and small employers will be able to purchase health insurance coverage through the state’s health insurance exchange, named Covered California. It is estimated that by the end of 2016, over one in five Californians will get their health insurance through the Exchange. In October of 2013, Californians will be able to access the Covered California website and begin enrolling in plans for the 2014 benefit year. Depending on health plans’ distribution of enrollees, a surge of physician contracting efforts may occur as these plans attempt to ensure adequate networks are in place prior to January 1, 2014. In this presentation, you will learn more about California’s exchange and what it will mean for physicians. You will also gain an understanding of some of the risks and benefits of being contracted to provide services to exchange enrollees.

SEPT 12

Sept. 12: ICD-10 Documentation for Physicians: Part 1 AAPC • 12:15 – 1:15 p.m.

Continued on Sept. 19 and 26.

This three-part series covers the key information necessary to understand key documentation elements to help you not only prepare for ICD10, but for all the regulations surrounding your practice today.

SEPT 18

Sept. 18: Recipe for Financial Success: Key Steps to Increasing Your Net Income Debra Phairas • 12:15 – 1:15 p.m.

Physicians and office managers need business management skills, particularly in the financial area. This workshop will teach critical skills in analyzing the practice profit/loss statement, accounts receivable ratios and staffing patterns and how to access specialty comparison norms.

At least one source of comparison data specific to your medical specialty will be given to each participant.

SEPT 19

Sept. 19: ICD-10 Documentation for Physicians: Part 2 AAPC • 12:15 – 1:15 p.m.

Continued from Sept. 12 and ends Sept. 26.

This three-part series covers the key information necessary to understand key documentation elements to help you not only prepare for ICD10, but for all the regulations surrounding your practice today.

SEPT 26

Sept. 26: ICD-10 Documentation for Physicians: Part 3 AAPC • 12:15 – 1:15 p.m.

Continued from Sept. 12 and 19.

This three-part series covers the key information necessary to understand key documentation elements to help you not only prepare for ICD10, but for all the regulations surrounding your practice today.

OCT 30

SUMMER 2013

Oct. 30: CMS Quality Reporting Programs: What Physicians Need to Know and Do Now to Improve Care and Avoid Penalties CMS • 12:15 – 1:45 p.m.

Presented by the Centers for Medicare & Medicaid Services (CMS), webinar attendees will understand the background and rationale for CMS incentives and payment adjustments that affect physicians, including the Physician Quality Reporting System (PQRS), the ePrescribing (eRx) Incentive Program, the Electronic Health Record (EHR) Incentive Program, and the new Value Modifier (VM) program; be able to define what actions they need to take to receive each incentive and avoid payment adjustments; and know where to go to obtain further information about CMS quality programs and stay abreast of future developments.

SAN JOAQUIN PHYSICIAN 67

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

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SUMMER 2013

In Memoriam

In Memoriam Wilson A. Heefner, M.D., F.A.C.P.

Following his discharge from active duty, he continued his military career in the Army National Guard and the U.S. reserve, retiring in 1990 in the grade of colonel after forty-one years of active duty and reserve component service.

SUMMER 2013

WILSON A. HEEFNER, M.D., F.A.C.P. Dec. 22, 1931 - Feb. 16, 2013

Wilson A. Heefner, M.D., 81, Stockton, was raised to eternal life on February 16, 2013. He was born in Waynesboro, PA, on December 22, 1931, the son of the late J. Wilson and Evelyn N. Heefner. Doctor Heefner was predeceased by his beloved son Jay W. Heefner II, and is survived by his beloved wife of 56 years, Patricia, and his daughter, Annette Rigato and her husband Randy, Linden, CA. He is also survived by his daughter-in-law Alice Heefner. His life was particularly blessed by his grandchildren, Heather, Leah, and Max Heefner, and Ryan Rigato. Other survivors include his brother, Jay Heefner and his wife Pat; his sister, Madolin Harbaugh and her husband Ronald; and sister-in-law Margaret Heefner, all of Waynesboro, PA. His brother, Colin Heefner, predeceased him. Dr. Heefner graduated from high school in June 1949 in Waynesboro, PA. In July 1949 Dr. Heefner enlisted in the U.S. Army. He received an honorable discharge in the grade of corporal in December 1952. â&#x20AC;&#x192; Following his discharge from active duty, he continued his military career in the Army National Guard and the U.S. reserve, retiring in 1990 in the grade of colonel after forty-one years of active duty and reserve component service. In June 1956 he graduated summa cum laude from Gettysburg College, PA. On July 8, 1956, Patricia A. Snodderly, Waynesboro, and he were united in the bonds of holy matrimony. Dr. Heefner received his Doctor of Medicine Degree summa cum laude in June 1960 from the University of Maryland School of Medicine, Baltimore, MD. He completed his internship and residency in pathology in 1965. He was an assistant professor of pathology at the University of Maryland until 1968, when he joined the pathology practice of Doctors Alfred Edwards and W. Robert Sawyer at Dameron Hospital, Stockton, retiring in 1988. â&#x20AC;&#x192; After receiving a Master of Arts degree in 1992 from the University of Hawaii at Manoa, Dr. Heefner began a second career as a military historian and author. Dr. Heefner was a longtime faithful member of Quail Lakes Baptist Church, where he served as an elder. He held membership in various Masonic groups. He was also a member of the American Legion, Veterans of Foreign Wars, AMVETS, Military Officers Association of America, and B.P.O. Elks. Dr. Heefner was a lifetime member of the San Joaquin Medical Society, past president of the local chapters of the American Cancer Society and the Military Officers Association of America.

He served as Chief of Staff of Dameron Hospital.

SAN JOAQUIN PHYSICIAN 69

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