Summer 2020

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COVID-19 Physician Financial Health Survey COVID-19 taking a toll on medical professionals Best Practices for Reopening a Medical Practice

Summer 2020

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VOLUME 68, NUMBER 2 • JUNE 2020

{FEATURES}

14 32 36

COVID-19 PHYSICIAN FINANCIAL HEALTH SURVEY

38 47

BEST PRACTICES FOR REOPENING A MEDICAL PRACTICE

SUMMER 2020

KEEPING OUR COMMUNITY SAFE COVID-19 TAKING A TOLL ON MEDICAL PROFESSIONALS

{DEPARTMENTS} 9 PRESIDENT'S MESSAGE 26 IN THE NEWS 50 PRACTICE NEWS AND RESOURCES 54 PUBLIC HEALTH UPDATE 58 IN MEMORIAM

SENIOR LONELINESS

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

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

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

COMMITTEE CHAIRPERSONS CMA AFFAIRS COMMITTEE Larry Frank, MD

CONTRIBUTING WRITERS Richelle Marasigan, DO, Jo Ann Kirby, Maggie Park, MD

DECISION MEDICINE Kwabena Adubofour, MD MEDICAL EDUCATION PROGRAMS R. Grant Mellor, MD PUBLIC HEALTH COMMITTEE Maggie Park, MD

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

SCHOLARSHIP LOAN FUND Gregg Jongeward, PhD SUGGESTIONS, story ideas are welcome and will be reviewed

CMA HOUSE OF DELEGATES REPRESENTATIVES

by the Editorial Committee.

Robin Wong, MD, Lawrence R. Frank, MD James R. Halderman, MD, Raissa Hill, DO

PLEASE DIRECT ALL INQUIRIES AND SUBMISSIONS TO:

Ramin Richelle Marasigan, DO, Manshadi, MD

San Joaquin Physician Magazine

Kwabena Adubofour, MD, Philip Edington, MD

3031 W. March Lane, Suite 222W

Steven Kmucha, MD, Harpreet Singh, MD

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

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SUMMER 2020

BECOME A MEMBER OF SJMS/CMA

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EXECUTIVE DIRECTOR’S REPORT

THIS TOO SHALL PASS As I sit here putting together the summer issue of this magazine, I cannot help but think about how much things have changed in a couple short months. It is surreal. After the initial denial period and hopes that “this will blow over quickly”, we realized we needed to begin the unpleasant task of postponing/cancelling many important events.

In March, the Nominating Committee selected Drs. Philip Cheng and Peter Garbeff as the 2020 Young Physician and Lifetime Achievement Awards recipients. As you might have guessed we have had to postpone this joyous occasion, but we are excited to celebrate during our holiday party tentatively scheduled for Sunday, December 6. Please save the date!

LISA RICHMOND

The other casualty of COVID-19 was the cancellation of our 2020 Decision Medicine program.

We had already scored applications and invited students to interview, when we realized that it was unrealistic to think we would be able to bring groups of students into any clinical setting this summer. I felt terrible as I hit send on the email that cancelled one more of the opportunities they have worked so hard for and looked forward to. This group of high school students will be nothing, if not resilient!

As we pivoted from some of our usual Spring/Summer activities, we began to ask ourselves, what is our role as a medical society in the midst of a pandemic? How do we support our physician members and community? We were worried about our physicians, those busy caring for Covid patients on the frontlines and those that have been sidelined with practices suffering.

We have been working hard to get helpful resources and information to our members as quickly as possible. CMA has developed an incredible page, rich with resources on telehealth, weekly webinars on a variety of topics, including financial assistance and reopening your practice. For more information, please visit www.cmadocs.org/covid-19.

We are so proud of SJMS Board Member and newly appointed Public Health Officer for San Joaquin County, Dr. Maggie Park, who has worked tirelessly to lead and protect our community through these unprecedented times. She has proven to be the calm during the storm. You can read more about Dr. Park in this issue’s feature article.

Finally, please know we are here for you! Let us know how we can be of assistance. We are truly honored to work for such hardworking physician heroes! As my beloved grandfather always reminded me when faced with adversity, “this too shall pass.”

Stay safe and be well,

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SUMMER 2020

Supporting Health Care Workers Serving on the COVID-19 Front Lines The emotional stress of responding to patients during the COVID-19 pandemic puts the personal and emotional health of front line health care workers at exceptional risk. To provide relief and help alleviate burnout, the California Medical Association (CMA) Wellness Program (CMA Wellness) has launched the Care 4 Caregivers Now program, connecting front line caregivers with a trained peer coach offering remote and confidential sessions at no cost.

SIGN UP TO RECEIVE COACHING If you are a health care worker in constant worry of COVID-19 infection, currently separated from your family, or facing any other emotional difficulty at this time, we invite you to schedule a confidential peer coaching session at no cost. +

Eligible caregivers include, physicians, physician assistants, nurses, nurse practitioners and respiratory therapists

+

There is no cost, and you may receive coaching for up to 30 days

+

Coaching sessions are confidential and conducted remotely via videoconference; access to a computer or smart phone is necessary

While not a substitute for therapy or medical care, your peer coach understands the rigors of the profession and can offer guidance, mentorship and emotional support. Coaches hold space to listen to your concerns. Their goal is to help you feel heard, understood and become more aware of your options.

VOLUNTEER TO BECOME A COACH Care 4 Caregivers Now provides physicians (M.D. and D.O.) and nurses, including those who are recently retired, the opportunity to lend their unique expertise during these unprecedented times. Coaching services are conducted remotely and not considered practicing medicine. All interested volunteers should have: +

Four hours for training, which includes on-demand videos and 90-minute live/small group training session

+

Access to computer audio/video and sufficient broadband (CMA Wellness supplies a Zoom account)

+

At least 4 hours/week for remote coaching and mastermind sessions to share best practices and receive ongoing support

+

Passion for supporting fellow health care providers

+

Compassion, empathy, patience and strong listening skills.

Sign up to receive coaching, or to volunteer as a coach at: Care4CaregiversNow.org.

cmadocs.org/care4caregivers z

SUMMER 2020

CMAwellness@cmadocs.org (800) 241-2466 SAN JOAQUIN PHYSICIAN

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A message from our President > Richelle Marasigan, DO

Are there any positives to take from this COVID-19 pandemic?

The last few months have been unprecedented in our lifetime. We are living in a time of uncertainty, which has impacted everyone in one way or another.

Whether it is a pay cut, job loss or the loss of a loved one we are all in this together. During this time of loss and frustration it is important to remember that through every time of hardship there are positive moments to remember.

Strong Community Bond These COVID times have created strong bonds among the community, especially the medical community. Common complaints of waiting times, cost of medicine and co-pays seem minute. Now the community has come to appreciate health care professionals on the front lines who are at risk while serving the masses. Physicians, nurses, and other health care workers have been called to duty in unprecedented ways. It seems that all have risen to the occasion with a positive attitude, despite the taxing and indefinite toll this will take. This overwhelming response to help others has motivated the rest of the community to get involved in other ways. People are volunteering to feed those in need with food drives. Those that can sew are donating masks.

Small businesses are even halting their businesses to 3-D print face shields for health care workers. Companies are offering virtual exercise classes, access to virtual entertainment and how-to videos. People in our community are giving whatever they can to help us combat this pandemic without a thought of themselves. I am so proud of that. We need more of that.

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

SUMMER 2020

Telemedicine The incorporation of telemedicine into the current model for primary care has been a slow process for a variety of reasons over the past few years. Whether it be lack of training or infrastructure on the provider side, or an acceptance or understanding on the patient side, telemedicine has not been overwhelmingly embraced. COVID-19 has changed all of that. Out of necessity, providers

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A message from our President > Richelle Marasigan, DO

have had to integrate telemedicine into everyday practice to continue to serve the community. For the most part, patients have been quite accepting of the new change.

It has accelerated at an exponential level the growth of telecommunication for medicine. The future of medicine will almost certainly include telephone or video calls at a much higher rate than previously seen.

Time with family If you have not seen it, there is a quote on the internet for my son’s teacher....

“You lied, my son is not a joy to have in class!”

In all seriousness, we have all had to learn to work from home or go to our essential jobs, while balancing new roles within our families- entertainer, chef, and teacher. We have spent more time within our homes than we normally do.

Appreciation of the great outdoors The daily grind of getting the kids to school, practice, games We all miss going out to the movies, restaurants, malls and and playdates is now changed. There is more downtime concerts. However, we can all exercise outside as long to enjoy each other in a different way.

Family dinners, “ You lied, my son is not a joy to have in class!” board game nights, and sitting in the In all seriousness, we have all had to learn to backyard are the new normal, and it’s work from home or go to our essential jobs, kind of nice.

while balancing new roles within our familiesentertainer, chef, and teacher.

as we are socially distant. An unexpected positive that has occurred is the extraordinary amount of people out walking in their neighborhoods. Who knew? I have been telling patients for years to walk at least 30 minutes three times a week, but not much compliance with that one. But, now I “bump” into people on the sidewalk every other day (because I am actually doing it too!). Fortunately, they don’t recognize me with my mask on :).

The lockdown has forced many to work from home and reduce travel, which seems to have had the biggest impact on the environment. It has been said that working from home has the potential to reduce over 300 million tons of carbon emissions per year. The air quality has also been improved with the stay at home orders. Los Angeles seems to be smog-free these days and wild turkeys can be seen roaming the playgrounds in California. This decrease in carbon footprint will surely help us to enjoy the great outdoors in the years to come.

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The novel coronavirus (SARSCoV-2) that causes the disease COVID-19 has changed our lives forever. There have been immeasurable losses of wages, jobs and most importantly lives from this terrible disease. Through all this hardship we have seen some good things as well. People are helping each other, donating items and putting others first. We have been getting more exercise, decreased carbon emissions and see how we practice medicine catapult into the 21st century.

We need to stay positive through this uncertain time.

We need to navigate through it together. And we need to remember to appreciate any small positives we can take from it. Enjoy the calm while you can!

SUMMER 2020

The

REMEDY for all your

Financial

NEEDS

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Follow the doctor’s orders and call us today. And don’t forget to pass this message onto your staff – they (and their wallets!) will thank you.

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SUMMER 2020

SAN JOAQUIN PHYSICIAN

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SUMMER 2020

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SUMMER 2020

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COVID-19 PHYSICIAN FINANCIAL HEALTH SURVEY

For more information, visit cmadocs.org/covid-DZȄ 14

SAN JOAQUIN PHYSICIAN

SUMMER 2020

Across California, physician practices of all sizes are struggling. The COVID-19 pandemic has created an unprecedented threat to the viability of physician practices. At a time when some frontline physicians are in more demand than ever, thousands of medical practices have closed their offices or furloughed employees as they abide by state guidelines and public health recommendations to cease elective and/or nonemergent services.

The fallout from this crisis threatens to fundamentally alter California’s health care delivery system, not just during the COVID-19 outbreak, but for years to come. If policymakers do not take quick, decisive action to help medical practices, it will be more difficult for all practices, particularly small and mediumsized practices, to survive, thus bringing on a new wave of consolidation that increases health care costs and decreases patient access to care.

The California Medical Association (CMA) estimates that more than 13 million Californians – up to 34% of our state’s population – could lose access to their physician unless state and federal lawmakers act quickly to ensure the financial viability of physician practices. Should California lose physicians, it will put more stress on our already overburdened health care system and we will find it impossible to meet the health care needs of California patients now, during and after the COVID-19 surge.

To better assess the financial health of physician practices, CMA, with the assistance of its county medical societies and state specialty societies, conducted a survey of physician practices. In a period of eight days, 3,246 physician practices responded to the survey – a record response rate. The survey results indicate significant practice viability concerns for physicians in all specialties and practice sizes. Virtually every single practice has experienced a significant reduction in patient volume and practice revenue, which has forced physicians to lay off, furlough, cut salaries and reduce hours for both physicians and staff in order to stay afloat. The financial challenges are amplified for smaller practices.

The results on the following pages highlight the immediate need for financial assistance.

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CMA COVID-19 PHYSICIAN FINANCIAL HEALTH SURVEY RESULTS (Rev.04/22/20) SAN JOAQUIN PHYSICIAN 15

95%

Extremely worried

of practices are

Somewhat worried

worried about ďŹ nancial health.

46% 30%

Very worried

Not worried

19% 5%

64%

98%

75% have experienced a revenue decline of 50% or greater

98%: Decreased 2%: Increased

average revenue decline for practices since March 1.

of practices report a substantial decrease in patient volume.

As it looks now, it is likely I will have to close the practice. Volume is down patients are cancelling visits or asking to push back appointments. No new patients

49% of practices have had to layoff or furlough staff.

80%

65% have reduced physician/staff hours 34% have had to cut physician/staff salaries 11% have had to temporarily close their practices

of small practices experienced a revenue decline of 50% or greater, with some counties harder hit:

85% KERN

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90%

MARIN

85%

VENTURA

SUMMER 2020

Survey Summary Physician practices responded en masse to provide feedback on the financial distress of their practices. In eight days, 3,246 physician practices responded, representing all modes of practice in a broad range of specialties across 49 counties.

95% of practices are worried about their practices’ financial health due to the financial stress they are experiencing as a result of the COVID-19 public health emergency.

Virtually all practices (98%) report a substantial decrease in patient volume, averaging a 68% decrease in patient visit volume.

Practice revenue has declined by 64% since March 1, with 75% of practices experiencing a revenue decline of 50% or greater.

Practices have had to implement multiple, drastic measures to remain open.

■

Approximately half (49%) of practices have had to lay off or furlough physicians/staff.

■

65% of practices have reduce physician/staff hours.

■

34% have had to cut physician and staff salaries.

■

11% have had to close their practice temporarily.

Small practices are disproportionately financially distressed: ■

80% of small practices (1-25 physicians) statewide experienced a revenue decline of 50% or greater, compared with 54% of large practices. Some counties saw even greater revenue declines. ●

90% of Marin and 85% of both Ventura and Kern county small practices saw a revenue decline of 50% or greater.

■

Two-thirds (67%) of small practices applied for CARES Act loans. ●

18% of small practices applied for a Medicare advanced payment compared to 8% of large practices.

●

Almost half (49%) of small practices had to lay off or furlough physicians/staff compared with only 2% of large practices.

Physicians desperately need financial assistance. More than half of practices (56%) applied for a loan created by the CARES Act. Consistent feedback was that the loan process was extremely difficult and challenging. Many practices said they were able to apply but were still waiting to hear whether their application was accepted.

Physicians ranked financial assistance (64%), PPE (54%) and temporary housing (47%) as the first or second most important resources they need.

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CMA COVID-19 PHYSICIAN FINANCIAL HEALTH SURVEY RESULTS

(Rev.04/22/20)

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California Physician Survey Results 1.

How concerned are you about your practice’s financial health during and after the COVID-19 pandemic?

Extremely worried........................................... 46.46% Very worried........................................................ 29.51% Somewhat worried ......................................... 19.47% Not worried ......................................................... 4.56%

2.

How has your volume of patients changed since March 1, 2020?

Decreased ............................................................ 97.50% Increased .............................................................. 2.50%

3.

By what percentage has your patient volume decreased?

Average ................................................................ 68%

4.

How much has your practice revenue decreased since the COVID-19 pandemic?

Average.................................................................. 64%

5.

What actions has your practice had to take as a result of the COVID-19 crisis?

Laid off staff and/or physicians ............... ................................................ .................................................18.76% Furloughed staff and/or physicians ..... ................................................ .................................................30.36% Salary reductions for staff and/or physicians .................................. .................................................33.70% Reduced staff and/or physician hours ................................................ .................................................64.41% Used personal savings to keep practice open ................................ .................................................30.92% Took out personal or business loans ... ................................................ .................................................37.07% Reduced the types of services offered ................................................ .................................................52.46% Delayed purchase of equipment, supplies, medications, technology ..............................45.40% Closed some locations (for practices with multiple locations) ...............................................18.10% Closed my practice permanently .......... ................................................ .................................................0.39% Closed my practice temporarily ............. ................................................ .................................................11.28% Other (please specify) ................................... ................................................ .................................................16.87%

6.

If you laid off or furloughed staff, what percentage were laid off or furloughed?

Average.................................................................. 24%

7.

Have you applied for a loan created by the CARES Act from the Small Business Administration or a private lender?

Yes............................................................................. 56.09% No .............................................................................. 43.91%

8.

Please indicate your experience with seeking a loan: The process was easy .................................... 27.17% My lender was not participating ............ 6.76% Too difficult to apply ...................................... 12.90% Was denied ......................................................... 1.18% Other (please specify) ................................... 51.99%

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CMA COVID-19 PHYSICIAN FINANCIAL HEALTH SURVEY RESULTS

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(Rev.04/22/20)

SUMMER 2020

9.

If you applied for the SBA Paycheck Protection Program, what was your experience?

Bank accepted my application and it is pending ........................ ......................................................................... 62.08% Bank not accepting anymore applications ...................................... ............................................................................ 7.20% Bank refusing to accept my application because I don’t have an account with that bank ........... 2.82% Did not apply ...................................................... ................................................ ............................................................................ 7.20% Other (please specify) ................................... ................................................ ...........................................................................20.71%

10. Please indicate why you did not apply for a loan created by the CARES Act: Not needed yet ................................................. 43.32% Cannot afford to pay it back ..................... 7.45% My lender was not participating ............ 4.00% Too difficult to apply ...................................... 10.99% Other (please specify) ................................... 34.24%

11. Have you or do you plan to request an advanced payment from Medicare?

Yes............................................................................. 16.74% No .............................................................................. 49.21% I didn’t know this was an option ............ 34.05%

12. What resources or support would you find most useful? (Please rate your top 5 selections and rank in order of importance using a scale of 1-5, with 1 being the most important.)

CMA continues to aggressively fight 1for more 2 MACRA 3 Billing guidance 13.19% 17.62% 24.27% regulatory relief and to promote physician-led Telehealth/telephone billing guidance 21.89% 21.27% 21.19% alternative payment models, such as 14.34% those in19.61% the CMA Telehealth platform/vendor 27.63% Documentation guidance 9.48% 19.67% 30.68% Medicaid Demonstration project approved but stalled by Care team workflows, triage, etc.

10.57% 22.88% 27.73% the Centers Medicare and Medicaid Services Temporaryfor housing 34.75% 12.13% (CMS).

14.10% Employment advice (payroll, furlough, leave) Financial support Personal protective equipment Physician wellness support

14.93% 46.02% 28.59% 13.99%

28.03% 17.59% 25.17% 17.92%

23.76% 9.58% 16.57% 25.44%

4

21.00% 20.02% 23.29% 25.76% 20.62% 12.46% 20.09% 10.85% 14.99% 20.72%

5

23.92% 15.64% 15.13% 14.40% 18.20% 26.56% 13.19% 15.96% 14.67% 21.94%

13. Please share your personal stories about how the COVID-19 pandemic has impacted your practice and its viability?

As it looks now, it is likely I will have to close the practice. Volume is down significantly, despite moving to telemedicine. Due to financial concerns, even current patients are cancelling visits or asking to push back appointments. No new patients are calling. Viability of the practice is less than 30 days without financial support. Applied for EIDL 10K grant 1 week ago and still waiting for answer. PPP loan application is in process.

Rents and bills are due on a monthly basis, yet the financial help promised is not materializing. This means closing a practice that was viable, in a field (psychiatry) where patients have difficulty finding a provider.

No elective surgeries or procedures and no preventive healthy visits make it nearly impossible to make my rent. I cut my Nurse Practitioner's hours in half and am working with just one employee = receptionist/medical assistant/office manager. I don't sleep at night. I'm quarantining myself in my office, thus working 17 hours/day. Had to cancel all my trips/holidays/meetings scheduled for the next 6 months.

I am lonely. I am scared for my family and peers.

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CMA COVID-19 PHYSICIAN FINANCIAL HEALTH SURVEY RESULTS

(Rev.04/22/20)

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The last 3 weeks have been the most stressful experience I have had. The responsibility of changing all patient treatment plans within a day, the responsibility of financial support/payroll for my staff, the legal ins/out for HR, and then there is self and family when there is nothing left to give but have same concerns as patients, and worse potential financial liability as I am sole provider for my family for the generation above and the generation below. I am very committed to the shelter-in-place and will promote that in words and in each of my actions with patients and staff but the financial implications of it all, but in the present day, but also in the months to come. Understanding that it is not only a short-term financial hit now, but will also translate to a long-term decreased revenue, there is significant fear that I will not breakeven by the end of the year.

I take care of high-risk pregnant patients and they continue to see us in the office -however, this is not the right strategy. I have been applying for grants to get the right equipment to be able to perform Tele health visits therefore reducing the point of care contacts from greater than 10 to under 5. There is a lot of support for telehealth, but not enough support for the devices that we need to be successful in implementing telehealth in a safe way for obstetric practice. Practices cannot support the upfront capital cost of providing these, and I am in an over 90% Medi-Cal practice. Patients cannot afford these devices, which include home blood pressure cuffs and fetal Doppler devices.

The promise of small business financial support has sustained our practice, but if not processed and received in the near future, we are facing permanent practice closure. I could easily retire but am throwing all resources into keeping my practice active to sustain my 20+ employees and support a 30year, 10,000 + patient base of our practice.

I can see my practice failing before my eyes. I fear the financial implications in 2-3 months when no money is coming in and I have been extremely disappointed in the guidance of both my personal financial institution as well as the government.

Patient visits down about 85%, revenue also. We have just started offering Telehealth visits, so are hoping this will improve our financial stability. Doctors and staff are all very concerned that hours have been cut, therefore their pay is less. At least one employee has resigned and will be moving out of state to live with a sibling to be able to make it financially.

We are one of the larger Community Centers in the East Bay. We are trying to diagnose and manage patients with COVID-19. We are doing a great, huge, job, but it is coming at a cost to our organization as a whole. About half of our staff have been furloughed.

As a private primary care practice, we were already struggling with high rent, employee costs, and declining reimbursement. With the loss of the revenue stream from decreased patient visits we are through. I anticipate closing our practice in the next several months.

I can survive only for few weeks, after that closing the practice and early retirement are inevitable.

Privately owned pediatric practice. Furloughed 2 NP's, cut staff hours by 60%, cut MD hours by 38%, revenue down 90%. Without forgivable PPP and EVID loans, doubt our practice can survive.

We have furloughed entire staff. It's not clear when we can re-open. I am concerned my private practice will close permanently.

We are pediatric head & neck surgeons and receive no Medicare payments. In early March we reduced the number of daily office visits, spacing them out and seeing only urgent cases. Also, in early March, I began wearing a surgical mask while seeing patients in the office and hospital-N-95 masks and goggles

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CMA COVID-19 PHYSICIAN FINANCIAL HEALTH SURVEY RESULTS

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(Rev.04/22/20)

SUMMER 2020

were not available then. We closed our office completely when Governor Newsom issued the order. We have no office income since that time. Despite my being 70 and my wife being immunocompromised, I have continued to go to the local hospital ER to see patients. I had to create my own PPE by wearing a standard surgical mask since March, created extra layers within it of cotton material and wrapping my face, head and upper portion of the mask with plastic cling wrap. I was only able to obtain an N-95 mask a week ago. I have encountered ER patients with infections that have been unusually advanced because the delayed coming to the hospital out of fear of being exposed to COVID-19. We have an established medical practice and thus will survive but will require the PPP loan/grant to stay economically viable in the short term through May. If we have to remain closed beyond that time, we will have to seek more financial aid/loans.

We are a one doctor small GYN practice. We are only seeing our GYN patients on an emergent/urgent basis.

Not enough income to support our two staff and overhead, but we refuse to furlough our staff. They have families and bills to pay too. So, we are keeping them on with their regular number of hours each week.

I responded to Gov statement on 3/15 by reducing in-person visits to zero by 3/19. Then the next Monday reopened to telemedicine only and only truly life-saving care that cannot won’t. We laid-off many staff and reduced essential staff to the Work Share Program with EDD. Then we have all staff with own workspace of at least 6 feet, lines on the floor for 6 foot marks, practiced how to pass, signs on door to keep patients with symptoms or other criteria out so we can keep a well space, if a patient Is in the office, they go straight to a room, the staff and doc are in PPE that we must re-use. We went from seeing 55 patients a day to 3-9 a day and mostly telemedicine. And from 4 providers a day to 1. I am worried about getting sick as I have asthma. I have spent 23 days straight on every webinar, applying for everything, and getting no funds in. I am worried about the longevity of this. I am worried I will have to lay-off more staff and we still have patients who need us, and we need to be ready to care for them each day and over time.

Several of our doctors have moved out of their home. RCMA has been an invaluable resource and a true partner during this pandemic. We appreciate all the help they are providing doctors throughout the county. One of our NPs has been unable to work as she has been completely chemotherapy due to increased risk of infection during this pandemic. Previously we were able to provide her a flexible work schedule which allowed her to work while still attending to her personal medical needs. we are quickly trying to launch a telehealth platform so she can continue to work while she is sheltered in her home.

We are seeing about 1/3 the patients we normally see for the last 3 weeks, even though 1/2 of our visits are video visits. We are now seeing 1/3 of the income from these visits. Our doctors have taken a 50% pay cut until further notice so that we can keep our staff as whole as possible but since we only have one doctor in each location, staff are taking 2-5 days off per 2 week pay period. I am not sure how long we can sustain this or how long our staff can sustain such low hours. Hopefully the PPP or EIDL loan will make it possible to recover quickly.

It is only because I've been in practice for 33 years and have substantial saving, that I will be able to continue my practice. I already have injected $175,000 of my personal funds to stay solvent. It will require more funding, mine or PPP loan to remain solvent. This is the first time, since I opened my practice in 1987, that the practice was not able to maintain solvency without outside financial support.

Doing 98% telehealth. My volume from 30-40 patient per clinic is down to 10-20 patients. I can't offer any elective surgeries and I'll see a drastic decrease in payments in the next 2-3 months. It's moral agony to know I have cancer patients but have to delay their care.

Social distancing from my family, slept at work for 2 weeks.

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I am a solo community-based ENT surgeon. Unable to do elective surgeries, we are seeing urgent and emergency patients. Seeing 8-10 patients per day, using masks, gloves, room cleaning between patients. I have only enough money to pay my employees until the end of April.

We have been able to support our employees, and when we get the PPP loan, we will be able to support all of them, but this leaves nothing to the surgeons. We are all working very hard but not taking home a paycheck. It will take years to dig out from this debt. Very unfair to punish the doctors when we are all sacrificing taking care of the crisis.

Despite family members requesting us not to go to work we have decided to continue seeing the patients via telemedicine or in their cars outside the office or very rarely in the office. They are our family too and if we do not then they will end up in the ER, making it hard for ER MD's and also increase patient risk of acquiring COVID-19 infection.

Drastic sudden volume loss, struggling to implement online visits, staff visibly shaken/anxious, fear of economic catastrophe and potential life-threatening infection risk every workday. Yet the amazingly wonderful kindness, humor, compassion and courage shines through anyway....I just shake my head and smile.

I’m hemorrhaging money trying to find PPE and disinfectants, spending hours doing work that I will never be paid for in trying to keep patients out of the office/rescheduling/trying to navigate evolving best practices in clinical care and struggling with telemedicine platform crashes. I work 18-hour days, place my life at risk with inadequate access to PPE, and can only manage to bill for fewer than 8 office visits per week and a handful of telemedicine visits. Insurers are finding ways to deny coverage for all 9944X codes (telephone calls). Before this pandemic I was planning to retire at the end of this year. Now I’m spending so much money trying to keep my practice open through the end of my lease. Don’t know if I’ll ever recover.

Decreased patient volume by 90%, I decided to pay my employees from my own savings.

Although the volume is way down, I am so much more exhausted and under more stress then before.

This comes from the financial downturn of the practice, trying to do right by my employees who often live paycheck to paycheck, and trying to maintain a sense of calm to my very overwhelmed OB patients.

We have a small ophthalmology practice with two locations. We have had to reduce staff hours and salary to 50% and the 2 MD's are not taking a salary. We are hoping to get the PPP loan, but nothing is certain.

We are ENT. Our procedures are high risk and aerosolizing. We are only taking urgent patients with acute pain/hearing loss/nosebleeds and cancer. All our elective cases are pending. I switched my patients to long term antibiotics as surgery is not available now. I was quarantined due to exposure to Covid19. I am most stressed about keeping my staff paid as a lot of them live paycheck to paycheck.

We employ more than 50 employees with 8 offices. We might survive if the PPP loan materializes, but so far nothing but obstacles. We are also seeing urgent care patients without any help in acquiring PPE. If we stop seeing these patients with subacute needs, they will have nowhere else to go except the emergency rooms.

We closed our doors, practice still open via telemedicine. I just feel bad for my office staff if I cannot support their income. The PPP is a mess, no bank/even SBA wants to accept application. I tried on April 3 - first day- no one responding.

Dooms day! Scariest days and nights. For all staff, MDs as well as patients. My family is at edge due to potential COVID-19 exposure, financial strains and mental cloudiness.

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14. How many physicians are in your practice?

1-5............................................................................... 61.84% 6-25 ........................................................................... 18.70% 26-50 ........................................................................ 4.71% 51-100 ....................................................................... 2.98% 101-250 .................................................................... 3.81% 251-500 ................................................................... 2.75% 501-1000 ................................................................. 1.96% More than 1,000 ................................................ 3.24%

15. What county of California do you practice in?

Alameda ................................................................ 4.26% Amador .................................................................. 0.08% Butte........................................................................ 1.06% Calaveras............................................................... 0.04% Contra Costa ....................................................... 2.79% Del Norte............................................................... 0.04% El Dorado .............................................................. 0.15% Fresno ..................................................................... 2.56% Glenn ....................................................................... 0.08% Humboldt ............................................................. 1.06% Imperial ................................................................. 1.55% Kern.......................................................................... 1.24% Kings........................................................................ 0.11% Lake.......................................................................... 0.11% Lassen ..................................................................... 0.04% Los Angeles ......................................................... 15.05% Madera ................................................................... 0.19% Marin ....................................................................... 1.09% Mariposa................................................................ 0.04% Mendocino ........................................................... 0.19% Merced ................................................................... 0.98% Monterey............................................................... 1.06% Napa ........................................................................ 0.53% Nevada ................................................................... 0.45% Orange ................................................................... 8.94%

Placer .......................................................................1.77% Plumas ....................................................................0.04% Riverside ................................................................3.77% Sacramento .........................................................4.60% San Benito ............................................................0.11% San Bernardino ..................................................4.56% San Diego ..............................................................12.71% San Francisco ......................................................2.79% San Joaquin .........................................................2.38% San Luis Obispo .................................................1.70% San Mateo .............................................................2.15% Santa Barbara .....................................................4.22% Santa Clara ...........................................................4.52% Santa Cruz.............................................................0.79% Shasta ......................................................................0.41% Solano ......................................................................0.49% Sonoma ..................................................................2.30% Stanislaus ..............................................................1.24% Sutter .......................................................................0.38% Tulare .......................................................................1.21% Tuolumne ..............................................................0.11% Ventura ...................................................................3.58% Yolo ...........................................................................0.38% Yuba..........................................................................0.11%

16. Please indicate your medical specialty (select all that apply): Allergy ..................................................................... ................................................ .................................................1.66% Anesthesiology.................................................. ................................................ .................................................3.70% Cardiology ............................................................ ................................................ .................................................5.13% Dermatology ...................................................... ................................................ .................................................3.54% Emergency medicine/trauma/urgent care ...................................... .................................................4.68% Endocrinology ................................................... ................................................ .................................................1.51% Gastroenterology ............................................. ................................................ .................................................2.71% General surgery ................................................ ................................................ .................................................2.83% Infectious disease ............................................ ................................................ .................................................0.75%

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Neurology ............................................................. ................................................ .................................................2.22% Nephrology.......................................................... ................................................ .................................................1.06% OB/GYN.................................................................. ................................................ .................................................5.81% Oncology............................................................... ................................................ .................................................1.58% Ophthalmology ................................................ ................................................ .................................................4.68% Orthopedics/orthopedic surgery ........... ................................................ .................................................5.17% Otolaryngology ................................................. ................................................ .................................................2.71% Pain medicine.................................................... ................................................ .................................................1.92% Pathology ............................................................. ................................................ .................................................0.79% Pediatrics .............................................................. ................................................ .................................................9.58% Plastic & reconstructive surgery ............. ................................................ .................................................3.96% Primary Care (internal medicine, family practice, general practice) ..................................21.34% Psychiatry ............................................................. ................................................ .................................................4.75% Pulmonology ...................................................... ................................................ .................................................1.55% Radiology .............................................................. ................................................ .................................................2.49% Rheumatology .................................................. ................................................ .................................................1.36% Surgery................................................................... ................................................ .................................................2.15% Urology................................................................... ................................................ .................................................2.04% Vascular surgery............................................... ................................................ .................................................0.60% Other (please specify) ................................... ................................................ .................................................10.71%

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Thank You To the nurses, doctors, healthcare workers, first responders, and essential workers taking care of our community: Thank you for keeping us safe and healthy. We are grateful for your dedication, courage, and selflessness to combat COVID-19.

You are true heroes!

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888.936.PLAN (7526) | www.hpsj.com/covid19

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In The News

IN THE

NEWS Amwell Offering Live Demos of its “Private Practice” Telehealth Platform California Medical Association (CMA) Physician Services’ telehealth partner Amwell is providing live demos of its Private Practice platform at numerous times over the next few weeks.

CMA Physician Services is committed to ensuring that California physicians can practice in the modality of their choosing, armed with best-in-class tools and technologies.

To that end, CMA Physician Services partnered with Amwell, the nation’s leading telehealth platform, to provide all California physicians with discounted access to its turnkey Private Practice platform, enabling the immediate delivery of virtual care to patients in response to the COVID-19 outbreak and beyond.

Amwell is offering all California physicians (regardless of their CMA membership status) a discounted rate on its Private Practice platform for the next 12 months and with no monthly fees through June 2020.

For more information on the Amwell partnership and how to sign up, please visit: cmadocs.org/telehealth.

St. Joseph’s Nationally Recognized with an ‘A’ for the Spring 2020 Leapfrog Hospital Safety Grade Dignity Health St. Joseph’s Medical Center was awarded an ‘A’ in the spring 2020 Leapfrog Hospital Safety Grade, a national distinction recognizing St. Joseph’s Medical Center’s achievements providing safer health care. The Leapfrog Group is an independent national watchdog organization committed to health care quality and safety.

The Safety Grade is a letter grade assigned to all general hospitals across the country and updated every six months,

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

assessing how well the hospital prevents medical errors and other harms to patients.

“Patient safety is everyone’s goal at St. Joseph’s Medical Center, and I am thankful for the dedication to safety and quality that I see demonstrated by our team every day,” said Don Wiley, president and CEO of St. Joseph’s.

“The Leapfrog Hospital Safety ‘A’ Grade illustrates our commitment to providing the highest quality care to our community, both during this challenging time, and always.”

Developed under the guidance of a national Expert Panel, the Leapfrog Hospital Safety Grade uses 28 measures of publicly available hospital safety data to assign grades to more than 2,600 U.S. acute-care hospitals twice per year.

The Hospital Safety Grade’s methodology is peer-reviewed and fully transparent, and the results are free to the public.

“As the Nation copes with a challenging pandemic, our gratitude extends to hospital leadership and health care workers everywhere for their tremendous dedication,” said Leah Binder, president and CEO of The Leapfrog Group.

“We hope this ‘A’ helps to thank the people who work and volunteer for St. Joseph’s. They are role models in putting patients first, and their service has been extraordinary in our country’s time of need.”

St. Joseph’s Offers The World’s Smallest Pacemaker Which Can Now Treat Av Block St. Joseph’s Medical Center is proud to have been one of the first hospitals in San Joaquin County to offer Micra™ AV, the world’s smallest pacemaker with atrioventricular (AV) synchrony. This new device, indicated for the treatment of patients with AV block, extends the most advanced pacing technology – at one-tenth the size of a traditional pacemaker – to more patients than ever before. The first procedure was

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SJMC offers Micra AV performed by James Morrissey, MD and Cyrus Buhari, MD in February.

AV block is a type of heart block in which the electrical signals between the chambers of the heart (the atria and the ventricles) are impaired. Pacemakers, the most common way to treat AV block, help restore the heart’s normal rhythm and relieve symptoms by coordinating the electrical activity of the atria and the ventricles. When this process – known as AV synchrony – is achieved, patients are healthier and have decreased likelihood of pacemaker syndrome, improved quality of life, and increased blood f low from the left ventricle.

Historically, patients with AV block have been treated with traditional dual-chamber pacemakers which are implanted in the upper chest, under the skin below the collar bone, and connected to the heart using thin wires called “leads.” Identical in size and shape to the original Micra Transcatheter Pacing System (TPS) approved in 2016, Micra AV has several additional internal atrial sensing algorithms which detect cardiac movement, allowing the device to adjust pacing in the ventricle to coordinate with the atrium, providing “AV synchronous” pacing therapy to patients with AV block.

Comparable in size to a large vitamin, physicians at St. Joseph’s Medical Center have elected to use Medtronic’s Micra AV based on its ability to deliver therapy via a minimally invasive approach. During the implant procedure, the device is inserted through a catheter and implanted directly into the heart with small tines. Because Micra AV does not require leads or a surgical “pocket” under the skin, potential sources of complications related to leads and pockets are eliminated - as are any visible signs of the device.

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San Joaquin General Hospital and County Clinics Resume Normal Patient Functions.

San Joaquin General Hospital and San Joaquin County Clinics are resuming all elective procedures and clinic visits. Also being resumed are the many health educational functions of both the Hospital and Clinics. Over the past two weeks there has been a significant decline in COVID-19 cases at San Joaquin County Clinics and the Hospital’s emergency room. The Hospital and Clinics have taken every precaution, due to COVID-19, to move in the direction of normal healthcare operations while safeguarding patients with dependable care that meets the highest standards of safety and quality.

When patients call or are contacted by medical Call Center Agents, Clinic Staff, or Referral Coordinators about an appointment they will be asked a series of questions concerning symptoms they may be experiencing and their recent travel history. Patients will also receive instructions about updated Hospital, Clinic and visitor protocols.

San Joaquin General Hospital and San Joaquin County Clinics recognizes the communities of San Joaquin County for coming together and ensuring the safety of residents and health care workers.

Postponing non- essential medical functions, appointments and surgeries during March and April gave the Hospital and Clinics valuable time to increase our Covid 19 Testing capabilities, ensure the availability of personal protective equipment and introduce new safety precautions.

The Hospital and Clinics have been able to dramatically minimize the risk of Covid 19 transmission including widespread COVID 19 testing of our workforce, screening and testing all patients before procedures.

San Joaquin County residents should refer to the Hospital and Clinic websites for more information regarding patient visits, locations and hours of operation. San Joaquin County Clinics and San Joaquin General Hospital are available to all local residents.

San Joaquin General Hospital Postpones Research Day Due To COVID-19 Restrictions San Joaquin General Hospital has postponed its third annual Research Day on June 5th on the Hospital campus in French Camp due to the COVID-19 pandemic. The event, a production of San Joaquin General Hospital’s Graduate Medical Education division, will be rescheduled to a future date to be determined. The Hospital’s residency programs include board certification training in Family Medicine,

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27

In The News

IN THE

NEWS Internal Medicine and General Surgery.

This annual event showcases the Hospital’s medical residents and their individual research projects. The event features distinguished regional medical speakers. Research Day also highlights San Joaquin General Hospital as a growing research facility and thriving academic hospital.

The annual program is a perfect platform for physicians, directors, educators and medical residents to interact in a spirit of partnership that will allow for an open exchange of conversations regarding all phases of medical research, practice and medical law.

For more information contact Dennis Bashaw, MLIS (209) 468-6642 or email dbbashaw@sjgh.org.

San Joaquin General Hospital Welcomes Frederick Cason, MD, FACS as Director of Surgical Education Dr. Frederick Caso, a practicing surgeon and national surgical education leader has recently joined the Department of Surgery at San Joaquin General Hospital. Dr. Cason joins San Joaquin General as the Hospital’s Director of the General Surgery Residency Program and a distinguished practicing member of the Hospital’s surgical staff.

Dr. Cason graduated from the Saint Louis University School of Medicine, St. Louis, Missouri. He fulfilled his surgical residency at the US Navy Hospital, Oakland and the UCSF/US Navy GME Consortium. He is certified by the American Board of Surgery.

Dr. Cason is an experienced practicing surgeon and was recently a surgical education leader at HCA Healthcare/ University of South Florida Morsani College of Medicine GME Consortium in Tampa Bay, Florida. He is also Adjunct Professor of Surgery and former Vice Chairman of the

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

Department of Surgery and Chief of the Division of Surgical Education at Morehouse School of Medicine in Atlanta, Georgia.

He has served on the faculties of Rosaline Franklin University of the Health Sciences— The Chicago Medical School, The University of Oklahoma College Frederick Cason, MD, FACS of Medicine, The University of Alabama @ Birmingham School of Medicine (Huntsville Regional Campus), The University of Toledo College of Medicine, Case Western Reserve University School of Medicine in Cleveland, Ohio, and Morehouse School of Medicine. He has significant experience in surgical education, the training of surgical residents, and the mentorship of students interested in careers in surgery as well as in the care of patients with complex problems in general surgery and surgical oncology.

Dr. Cason’s primary clinical interests include foregut surgery, gastrointestinal and dermal surgical oncology, and endocrine surgery. He has always been a keen student of medical and surgical history and serves as national archivist and historian for the Society of Black Academic Surgeons and the Surgical Section of the National Medical

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Association. He is a strong supporter of the Surgical History Group of the American College of Surgeons and the Association of Program Directors in Surgery.

Cal Poly San Luis Obispo, a Master of Science in nursing from Walden University and a Doctor of Nursing Practice from Grand Canyon University.

Dameron Hospital Dameron Hospital Chief Ancillary Services Nursing Officer and Executive Nursing Executive Tim Karagounis assumes the role Responsible for overseeing and of Ancillary Services Executive and coordinating Dameron Hospital’s will be responsible for Dameron nursing department and patient Hospital’s ancillary services care services, Jennifer Markovich, including its lab, pharmacy, DNP, RN, PCCN, CNE, has joined Jennifer Markovich, DNP, RN, PCCN, CNE diagnostic imaging services, and Dameron as its new chief nursing facilities. Karagounis has held officer and nursing executive. similar leadership roles at Lodi Formerly with Adventist Health Memorial, Kaiser Permanente, and Sutter Health, and will Lodi Memorial, where she served as a nursing director and be leading Dameron’s teams with his expertise in running director of education and training, Markovich brings a highly efficient and effective hospital support services. wealth of operational, clinical and workforce development Karagounis holds a bachelor’s degree in Healthcare experience to Dameron. She holds a bachelor’s degree from

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In The News

IN THE

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

The new HPSJ Providers/ COVID-19 web page – hpsj.com/covid-19-providerinformation/

Updates include telehealth options, interpretation & American Sign Health Plan of San Language (ASL) services, special Joaquin says: We’re ALL COVID-19 billing codes, pharmacy updates, policies (for example, no still “here” – They remain charges for HPSJ members for open during COVID-19, to COVID-19 screening, testing, and offer practical support for treatment), and current information providers, members, and such as about face coverings and the community guidelines for the announced phases As HPSJ employees are now mostly Tim Karagounis of reopening. The page also serves as working from home, they are measuring a convenient touch-base point for the no interruptions for providers, as well many COVID-related Provider Alerts, as members and the local community. They continue to closely as well as messaging coming from healthcare government agencies, adhere to executive orders from the Governor and are following during this fast-evolving pandemic situation. advisories from the CDC, the California Department of Public Health, each of our local county public health departments, and the Department of Health Care Services (DHCS) and Department of Managed Health Care (DMHC).

The HPSJ message to each valued part of their Provider Network is – • We remain open for business.

• We will be available to every part of our Provider Network throughout this time.

• As always, providers and their staff are welcome to call Customer Service with any questions, at 209-942-6320.

• Providers can continue to rely on their partners at Health Plan of San Joaquin.

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HPSJ COVID-19 pages for members and the community – www.hpsj.com/coronavirus/ Created to be a central Go-To place, these are regularly updated pages with practical, timely information. Sections include Tips for Staying Healthy, mental health supports, links to local county and state health resources, as well as the CDC, Community Resources (including Community Partners), a KIDS CORNER to support families (filled with reading, crafts, and education resources for parents), Help for Seniors, and ongoing messages from HPSJ’s Chief Medical Officer (for example, Social Distancing & Shelter in Place).

SUMMER 2020

Myth Busters – COVID-19 – What Health Plan of San Joaquin broadcasts to community partners, as well as HPSJ members “This is what we know. We each need to act NOW! Please join us in getting this out in the community and help prevent the spread of COVID-19.”

Chief Medical Officer Dr. Lakshmi Dhanvanthari

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Find a printable file for Myth Busters – COVID-19 at https://www.hpsj.com/ hpsj-covid-19-mythbusters/.

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We’re delivering the same comprehensive medical and social care to seniors – remotely, in their homes.

THOUGH THE WORLD HAS CHANGED, our commitment to the health and well-being of our participants has never been stronger. We’ve rapidly shifted to a model of care we’re calling HomePACE, deploying 4G LTE tablets to all participants to help them stay connected to our medical team and stay engaged through games and social activities.

When in-person care is required, it’s done by a single caregiver in the home whenever possible, minimizing potential exposures to Covid-19.

We continue to enroll new participants, helping keep seniors healthy and thriving while also physically distanced to prevent the spread of the virus.

For more information about our program, visit stocktonpace.com.

SUMMER 2020

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r u o g n i p Ke e o m m u n i t y C

SAFE D r. M ag g i e P ar k St e ps Up t o

the Ultimate Challenge 32

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BY JO ANN KIRBY

As the new public health officer for San Joaquin County, Dr. Maggie Park has found herself thrust into the political spotlight as she balances protecting the well-being of San Joaquin County residents against harsh economic realities during the deadly and costly COVID-19 outbreak.

When updating the San Joaquin County Board of Super visors on stay-at-home orders during sometimes tense and jarring sessions, Dr. Park has been praised for her calm stoicism. She faced daunting political pressure to reopen sectors of the local economy other wise deemed nonessential early on in this public health emergency. >>

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“I’m not used to being in the public eye,” she said, admitting that it’s forcing her to overcome her shyness. "It’s not something that medical school trains you for.”

It’s also not a role she stepped into lightly.

Serving as interim public health officer, she made the decision to apply for the job permanently in March when the COVID-19 contagion had prompted California Governor Gavin Newsom to issue the nation’s first stay-at-home order.

“I don’t know if everyone should be laughing at

“ O n e of D r. P a r k ’s m os t a dmir a bl e s t r eng t hs i s h e r abilit y to remain calm under pressure. She is a qu i ck l ea r n e r … . a n d du e t o h e r genuine k indne s s i s a b l e t o r e l at e t o p e op l e f r om a l l w a l k s of l i f e .”

response efforts.”

Blackwell-Rodriquez added that the health officer position is a challenging position even outside of a pandemic and Dr. Park has exceeded expectations with her ability to critically assess the rapidly changing environment and implement health officer orders and guidance to protect and promote the health of all who live, work, and play in San Joaquin County.

“The biggest challenge is remaining grounded in science as political pressures rise, prioritizing limited resources and not taking all the harsh criticism personally,” Blackwell-Rodriquez said.

It’s an observation echoed by Greg Diederich, director of the San Joaquin County Health Care Services Agency, who was pleased to recommend her appointment as public health officer to the board of supervisors.

“San Joaquin County has been served well by the demonstrated health officer leadership that Dr. Maggie Park has provided during these part five months serving as interim, especially during the COVID-19 pandemic and not having all our public health leadership positions filled,” he said.

Perhaps her steel was forged in her past. Dr. Park counts her mother and sister as role models.

“My mom had a strong work ethic and fierce pride in her family,” Dr. Park said. “My sister has boundless energy and always had a can-do attitude.”

Growing up in Baldwin Park, California, she became interested in a career as a pediatrician when her brother was diagnosed with asthma. “l really liked my brother’s pediatrician; his demeanor was comforting and I felt that by giving my mom clear instructions, she felt more empowered,” she said.

Dr. Park was in her residency at St. Vincent’s Hospital and Medical Center in New York City’s Greenwich Village on that fateful day of 9/11 when she looked out the window and saw something she would never forget.

Her first job out of residency was at San Joaquin General Hospital, where she met her husband.

Keeping our Community me or crying with me,” Dr. Park said of taking the job on during a global pandemic. “Why would I do this?

Maybe it’s meant to be me.”

The role of public health officer is to provide medical direction and guidance for PHS and through consultation and education, assure that health care providers in the county are practicing in accordance with current evidence-based protocols for communicable diseases. The health officer also assists the public health director in policy development and coordinating emergency preparedness response efforts.

Already, she’s won praise.

“One of Dr. Park’s most admirable strengths is her ability to remain calm under pressure. She is a quick learner … . and due to her genuine kindness is able to relate to people from all walks of life,” Zienna Blackwell-Rodriquez, director of San Joaquin County Public Health Services, said. “Dr. Park has definitely risen to the challenge during the COVID-19 pandemic and I am not only honored, but count my blessings daily, that I can depend on her to provide the medical leadership for the PHS

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Together they have two sons and reside in north Stockton.

As a pediatrician, an interest in public health was first sparked when she became involved with First 5 of San Joaquin. The nonprofit works in partnership with San Joaquin County agencies and organizations to foster the active participation of parents, caregivers, agencies and the community in the lives of young children and she’s been a commissioner of First Five since 2104. She served as medical director of Children’s Medical Services before taking on the interim public health officer, which led her to her visible role today.

Under her watch, public health has set up a data dashboard on its website that updates daily on COVID-19 cases in San Joaquin County. She’s grateful for the medical community’s response in meeting their surge capacity and forging open lines of communication between hospitals.

There is plenty about the pandemic that keeps her up at night. She worries people might look at the data and assume they are not vulnerable, she’s actively working to get the homeless into housing, she's anxious about the elderly homes alone who don’t have much support, and, always the pediatrician, she’s concerned about the children.

As she takes on this role, she’s been overwhelmed and grateful for the support of family, friends and colleagues.

“The political angle of my job has taught me that I have some great friends,” she said, of a controversy over re-opening golf courses that thrust her into the news. "At this time, you realize how much people care for you. People have been emailing, texting, calling. My good friends understand the pressure I’m under and they say don’t worry about what people are going to think of you.”

While her friends were discovering new hobbies or are homeschooling their children, Park had to leave that most of the home-front tasks to her husband and jokingly looks forward to a day when a new normal gives her a chance to merely catch up on badly-needed sleep or even take on something as mundane as cleaning her house.

In the meantime, she’s attacking the pandemic on multiple fronts. Should efforts to flatten the curve appear to be

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Un d e r h e r w at ch , p ubl ic he a lt h h a s s e t u p a dat a da s h b oa r d on i t s w e b s i t e t h at up dat e s da ily on C OV ID-19 c a s e s i n S a n J oa qu i n Cou n t y.

working, Dr. Park said it will not be a time for complacency.

“I know the CDC director says it could come back in the winter and that does concern me,” she said. “We will meet the challenge by being more prepared with more testing, more tracing and more knowledge.”

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COVID-19 is taking a toll on medical professionals.

Let’s invest in their well-being.

BY EMILY CORIALE AND DAVID LOGAN (MAY 02, 2020)

“She tried to do her job, and it killed her.”

That was the heartbreaking eulogy offered by the father of Dr. Lorna Breen after the Manhattan emergency room physician took her own life earlier this week.

Breen was the medical director of the emergency department at New York-Presbyterian Allen Hospital and treated dozens of COVID-19 patients. She had no history of mental illness, but her family said Dr. Breen, who survived COVID-19 herself, was traumatized by devastating scenes of treating patients with the disease – stories she shared with her family in her final days.

News of Dr. Breen’s death sent shockwaves through the medical community, and received national attention, but for many in the medical profession, it is an all-too-familiar story.

Even before the COVID-19 outbreak, burnout has been a growing concern among physicians, nurses and other medical practitioners – one that is taking its toll on those who take care of us.

Rates of suicide, depression and substance abuse are higher among physicians and nurses than among the general population. A recent report by the American Psychiatry Association found an estimated 300 to 400 doctors kill themselves each year. That’s about 40 of every 10,000 physicians – a rate more than double that of the general population.

To help address the factors that create and cause burnout for health care professionals, the California Medical Association

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has partnered with the Service Employees International Union and the United Nurses Association of California to push for state funding to support Care 4 Caregivers Now. This new initiative has already trained dozens of physicians and nurses as practice coaches who are available to offer guidance and mentorship to their colleagues on the front lines of this crisis and other health care workers facing stress or burnout.

Coaching is a nonjudgmental, engaging, caregiver-centered way of providing emotional support to talk through these difficult times. While not a substitute for therapy or medical care, coaching has been demonstrated to provide several benefits, including relief for emotional exhaustion and reduced levels of self-reported burnout.

Coaching is a recognized method of creating resiliency within the healthcare workforce, helping physicians and nurses cope with the unique mental health challenges workers are facing in the current crisis.

In addition to horrifying accounts of people effectively suffocating to death – many of them dying alone because of strict quarantine protocols – physicians and nurses also have to worry about getting sick themselves and potentially infecting their colleagues and family members.

According to her friends, this was part of what weighed on Dr. Breen before her death. We should not let the death of Lorna Breen be in vain. We should use it as a rallying cry to highlight the need for wellness services for medical practitioners and to ensure stories like this do not happen again.

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Investing in wellness now can pay dividends for health care providers and the patients who depend on them. As California spends money on protective gear to protect the physical wellbeing of healthcare workers, we are imploring Gov. Gavin Newsom to invest in the well-being and mental resiliency of those on the frontline protecting public health.

While we all hope the COVID-19 outbreak will soon pass, we know this pandemic will have lasting impacts will have on our health care system. The horror and stress of treating patients during this time will only exacerbate the problems of burnout, depression and anxiety among physicians, nurses and other medical providers.

The COVID-19 crisis has taxed the limits of our health care system. Our clinicians, who have risen to the challenge, are facing unprecedented risks, including physical safety, significant disruptions in social support, moral dilemmas and emotional distress.

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Understanding their fears and anxieties is critical to meeting the needs of our clinicians. Investing in their well-being will help keep nurses, physicians and other medical professionals on the front lines, and ensure they are getting the care they need as they continue to care for all of us.

Emily Coriale, PharmD, is Chief Operating Officer of the California Medical Association’s Wellness Program. David C. Logan, PhD, is Chief Executive Officer of the California Medical Association’s Wellness Program.

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Best Practices for Reopening a Medical Practice As the COVID-19 pandemic spread throughout the world, California and the United States took steps to limit the transmission and impact of the virus by implementing stay at home orders. While this has so far prevented any surges overwhelming our hospitals, it has also meant that many other parts of the health care system have been idled to preserve resources and capacity in the system and limit opportunity for transmission or exposure of the virus.

As physicians begin to approach safely and cautiously reopening their medical practices for office visits, the California Medical Association (CMA) respectfully offers the following list of best practices.

STEPS TO TAKE PRIOR TO REOPENING A PRACTICE

1. C onsult the Local Public Health Department Local stay-at-home orders vary widely from county to county. When and to what extent a practice can reopen for patient visits will depend on local orders and conditions. CMA recommends that all physicians consult their local public health departments for guidance on the rules in their area.

2. Construct a Financial and Staffing Plan for Reopening Practices that have shut down completely will need to plan for a gradual reopening. It is likely that patient volume will return slowly, and the office may not need to be fully staffed at all times. Practices should plan both their finances and staffing to account for this reality. See Financial and Staffing sections for more detailed recommendations.

3. D evelop Safety Protocols Patients may be fearful about interacting with the health care system. With proper safety precautions in place, a physician’s office is one of the safest places a patient can be. See Universal Safety Precautions for Practices and Facilities for a list of best practices, developed by the CMA Task Force for Reopening the Health Care System.

4. A ssess the Supply of Personal Protective Equipment Both the federal Centers for Disease Control and Prevention (CDC) and the California Department of Public Health have published guidelines for the use of personal protective equipment (PPE). Physicians should assess their supply of PPE based on these guidelines, with some margin in case of a disease outbreak.

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5. Consider the Role Telehealth Will Play in Reopening During the pandemic, many physicians have either implemented or expanded the use of telehealth to continue seeing patients. Practices who have not yet implemented telehealth may wish to consider how it can support safe patient care during reopening. Practices that have implemented telehealth can work on moving to a hybrid model, with patients seen both in office and virtually.

6. C learly Communicate with Patients about Practice Changes As practices reopen, they should communicate with their patients clearly about their safety protocols. As described below, many of the changes a practice might make will require patients changing their usual routines. Informing them upfront will serve to allay their concerns and ensure that they are properly prepared.

7. Be Watchful of Medication Shortages Patients coming back to their doctors, combined with potentially compromised supply chains, may make it difficult for patients to get their usual medication. Physicians should consider alternatives and set expectations with patients if medications become unavailable.

FINANCIAL CONSIDERATIONS

1. Consider the Capital Needs of the Practice and Available Funding Sources As practices reopen, revenue and patient volume may increase slowly and unevenly. Physicians should carefully consider their capital needs for reopening, and all available funding sources, both private (bank loans) and public (such as SBA loans or government grant funds).

For more information about financial resources that can support practices, please see CMA’s COVID-19 Financial Practice Toolkit for Medical Practices.

2. Address Accounts Payable Organize your accounts payable and develop a plan to repay any vendors in which you deferred payment including rent, utilities, vendors, Centers for Medicare and Medicaid Services (CMS) advanced payments or any other payor advanced payment or loans. Maintain open lines of communication with payors and vendors on payments due that you may need to defer.

3. P lan to Meet Existing Obligations Practices should review contractual obligations from managed care payors, such as timely filing limits for claims and appeals, or submission of any encounter and/or quality data required. It is also a good idea to check employment agreements, vendor contracts and lease agreements. Reviewing these agreements and contracts for any clauses regarding termination, late payments, late fees, interest, etc. can save bigger headaches down the road. Maintain open lines of communication with payors and vendors on reporting or other obligations that you may not meet.

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4. D evelop a Monthly Budget This will help on a go forward basis as things move to normal business. Practices can identify what costs the most on a monthly basis and adjust as necessary.

5. Talk to Vendors If vendors know that the office is reopening, and will have revenue again, they may be willing to negotiate reduced rates, deferred payments or other considerations. Practices should contact vendors and see what they are offering to help with startup of the medical practice.

6. Tackle Accounts Receivables Slowly As the office reopens, practices should continue or re-start collection activity and implement an internal process to follow up on outstanding claims. Office staff can pull financial reports (Insurance Aging, Patient Aging, Adjustment Report, ideally starting in the 60 day and older aging buckets). The goal should be to make sure every claim has been followed up on patient schedules for the upcoming one or two weeks.

7. Verify Patient Contact and Insurance Information When patients return to the office, their life circumstances may have changed. Office staff should confirm patient contact information, including address and phone number. Patient insurance eligibility and benefits should be checked to determine if eligibility is effective, or if copay and deductible amounts have changed. If patients have an outstanding balance, practices can offer payment plans. It is important to communicate with patients at the time of confirming appointments.

8. A nalyze Revenue Streams Billing staff should understand the Days Revenue Outstanding (DRO), which is the average number of days it takes to collect on the practice’s accounts receivable. It is important to have an accurate understanding of revenue streams as payments may have been delayed, compared to past revenue trends, or incorrect due to payor delays in implementing telehealth requirements or other related factors.

STAFFING CONSIDERATIONS

1. Right

Size Physician and Staff Work Force As noted above, practice revenue and patient volume may come back slowly, in cycles and unevenly. To prepare for this, practices should consider staffing adjustments, which may include bringing staff and physicians back in different waves. Personnel can be placed on rotating teams or via telecommuting for certain positions if possible.

For more information on employment issues, please see the CMA COVID-19 Toolkit for Physician Employers.

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2. Consider Options for Vulnerable Staff Working in health care immediately puts health care workers at risk and at higher exposure. The risk is even higher for vulnerable staff – those over the age of 60 or with pre-existing conditions.

Having internal policies for these workers can help all employees feel safe while working.

Workers in vulnerable populations may be shifted to different roles that minimize their risk of exposure. This may include various duties, such as consulting with younger staff, advising on the use of resources, keeping staff updated on most recent news, ordering of supplies for the clinic, working from home, phone triage of patients, helping providers and managers make tough decisions, or talking to patients’ family members.

3. G ive Extra Care and Attention to the Emotional and Physical Needs of Staff The pandemic has required physicians and many other health care workers to work long hours in dangerous conditions. As the health care system reopens, practices should pay extra attention for signs of exhaustion, depression, stress and other similar issues.

Practices looking for resources on addressing the mental and emotional needs of their staff should contact the CMA Wellness “Care 4 Caregivers Now” Program at cmadocs.org/care4caregivers.

UNIVERSAL SAFETY PRECAUTIONS FOR PRACTICES AND FACILITIES As physician practices and health care facilities reopen, every precaution should be taken to minimize the risk of infection, for both office staff and patients. CMA recommends that all practices and facilities adopt comprehensive safety protocols. Below is a list of best practices. Some of the recommendations below may not apply to certain practices, so physicians and office staff should adjust them for individual circumstances.

1. M aintain Physical Distancing Physician office space and workflow should be structured to encourage physical distancing.

Here are a few ideas for practices to consider:

•A sk patients to check in by phone or text message and wait in the car until an exam room is ready.

•P rohibit adults and teens from having guests or visitors. Only parents of younger children should be in the office with the patient.

•S chedule patients such that only a few are in the office at any one time. Practices can consider offering evening and weekend hours and leaving more time in between patients.

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2019

Karen Swarer, M.D.

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Rishikesh Kulkarni, M.D.

Anubhi Kulkarni, M.D.

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•P ut away articles such as magazines, toys, coffee, or anything else that may be handled by infected patients.

• I f possible, arrange office flow such that patients enter and leave through separate doors.

•A s able, modify check-out procedures to minimize/avoid any patient time in central area or at check-out desk.

• Consider setting aside clinic hours for vulnerable patients – elderly, immunocompromised, etc.

•S eparate patients with respiratory symptoms so they are not waiting among other patients seeking care.

•C onsider strategies to prevent patients who can be seen at home via telehealth from coming to your facility, potentially exposing themselves or others to germs.

2. Require Universal Face Covering Practices should require everyone who enters the practice – both patients and staff – to wear an appropriate face covering. Physicians should communicate this requirement to patients at the time of scheduling an office visit. Patient communications should also include education about the proper type of face covering. Patients who are not ill do not need N95 or surgical masks, which should be reserved for health care workers. Practices should be aware of the needs of very young children and those with respiratory diseases, who may face difficulties with reduced airflow through face coverings.

3. I mplement Strict Sterilization Procedures Physician offices and health care facilities are already cleaned and sterilized more than most communal spaces. Lowering the risk of infection, however, will involve even more strict sterilization protocols. Staff should familiarize themselves with the CDC Guidelines for Cleaning and Disinfecting of Community Facilities.

4. C ontinue to Use Telehealth, as Appropriate With the support of regulatory guidance and waivers, the health care system has made a massive shift to the use of telehealth. For all “no-touch” services, physicians should continue to engage in virtual care. This will have the effect of limiting the number of patients who appear in the office and preserving precious office time and space for patients who must be seen in person.

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209-855-8150

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Practices that are continuing to use telehealth find it helpful to schedule blocks of time (two or three hours) exclusively for virtual care. Staying in one modality at a time may be easier than moving back and forth.

5. Pre-Screen Patients for Possible COVID-19 Symptoms At the time of scheduling, patients should be asked if they are experiencing common COVID-19 symptoms – dry cough, fever, etc. All patients, regardless of symptoms, should have their temperature checked as they enter the office. Patients displaying COVID-19 symptoms should be screened telephonically, and tested if possible, before coming to the office. Physicians should keep up to date on the recommendations for preventing spread of COVID-19 on CDC’s website.

6. Preservation of Personal Protective Equipment All staff should be trained on the proper use of personal protective equipment. Practices should follow CDC guidelines for extended use and reuse of PPE.

7. Establish a Quarantine Policy Practices should have a policy for workers who have contracted COVID-19, or show symptoms that they may have contracted it, requiring a 14-day quarantine.

ADDITIONAL CMA RESOURCES CMA is working to develop comprehensive resources to help physician practices through the COVD-19 pandemic and beyond. These resources are updated daily, to reflect the most up-to-date information on this ever-changing situation. Practices can visit cmadocs.org/covid-19 for the latest news and most up-todate tools.

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The heroes among us.

As valued partners and dedicated professionals, our health care providers and staff can be relied upon to do their best for our patients every day. But right now, as we manage COVID-19, our people are going above and beyond to ensure we meet the needs of our patients and the safety of our community.

To all our providers and staff, for what you do today and every day, we thank you.

St. Joseph’s Medical Center I St. Joseph’s Behavioral Health Center I Mark Twain Medical Center Dignity Health Medical Foundation

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SUMMER 2020

CORONAVIRUS POSES ANOTHER GRAVE THREAT TO SENIORS:

SI FRANCE, MD

LO NELINES S With so much attention focused on the immediate threat to life posed by Covid-19, another devastating consequence of the virus hasn’t been discussed enough: the further social isolation of the vulnerable seniors in our community.

Loneliness is not merely an emotional health issue, but a major risk factor for seniors’ physical health. The health risks associated with isolation are comparable to the risk of hypertension, smoking, or obesity. Numerous studies have found that social isolation leads to significantly higher risk of dementia, stroke, cardiovascular disease and other serious ailments. >>

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Making things worse, our best efforts to mitigate the spread of the virus have closed many of the outlets where seniors are able to enjoy social activities. Most senior centers, day centers, libraries, parks and other venues have shuttered indefinitely.

Many nursing homes, which have tragically become hotbeds for the spread of the virus, have barred all visitors, including close family members. Frail seniors are often less comfortable using the video chat technologies that have connected many of us during this time, or don’t have access to the required devices or home internet.

Other programs serving vulnerable seniors around the country have stepped up as well. Meals on Wheels, for example, has expanded its offerings to include wellness checks with seniors over the phone. This type of outreach can help keep seniors socially engaged while also physically distanced to help prevent the spread of coronavirus.

But you don’t need to be a medical professional or a social worker to help seniors during the time of Covid-19. With so many people facing social isolation, there’s never been a better time to reach out to an elder MILLIONS OF SENIORS AROUND THE COUNTRY family member WERE SUFFERING FROM LONELINES S AND or S O C I A L I S O L AT I O N B E F O R E T H E PA N D E M I C . neighbor.

Pick up U N D E R O U R C U R R E N T C I R C U M S TA N C E S , I T ’ S the phone to check O N LY G E T T I N G W O R S E in and say hello.

Find a pen and paper and send a hand-written letter. Consider Millions of seniors around the country were suffering from assisting with shopping or helping place an order for grocery loneliness and social isolation before the pandemic. Under our delivery. current circumstances, it’s only getting worse. Even as social These individual actions might feel small, but they’re more distancing requirements and stay-at-home orders are relaxed important than ever these days. You could not only brighten over the coming months, frail seniors will remain at high risk a senior’s day but have a meaningful impact on their physical if they contract the virus, and guidelines may continue to health and wellbeing. encourage the senior population to self-isolate well into the future. *** Si France, MD is Founder and CEO of WelbeHealth, whose mission Senior care providers can be part of the solution. At is to unlock the full potential of our most vulnerable seniors with WelbeHealth, our PACE programs provide not just medical empathy and love. We do it through PACE (Program of All-Inclusive care but group activities, games, and meals to seniors in our Care for the Elderly), a comprehensive medical and social care model day center. As the pandemic escalated, we rapidly shifted to a with a decades-long track record of improved quality of life, life home-based model, providing a video-enabled tablet to every expectancy, and personal empowerment for frail seniors. WelbeHealth participant. This telehealth technology has allowed us not only to manage seniors’ medical needs in a safer environment but operates PACE programs across California, with plans for additional to resume our social and recreational activities remotely. For expansion in underserved communities. To learn more, please visit many of our participants, a video chat with a nurse or a game welbehealth.com. of trivia with one of our activities coordinators may be the only social interaction they have in a day.

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A COMMUNITY BUILT ON

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

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

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Practice News and Resources Free to SJMS/CMA Members!

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

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

Due to COVID-19 , we have suspended the Office Managers Forums for June and July.

More information will be forthcoming. In the meantime, please visit www.cmadocs.org/covid-19 for a full listing of upcoming and recorded webinars. These webinars are available free to all interested parties as part of SJMS/CMA’s ongoing support for physicians during the COVID-19 public health emergency.

DHCS Announces Prior Authorization Flexibilities and Emergency Coverage for Medi-Cal Patients The Califor nia Department of Health Care Services (DHCS) recently made important changes to the prior authorization process and billing for COVID-19-related emergency services to ensure that all Medi-Cal patients will have access to medically necessary COVID-19 testing and treatment.

Coverage of Emergency COVID-19 Related Ser vices Emergency services are covered for all Medi-Cal patients, including undocumented beneficiaries, when necessary to treat an emergency medical condition.

During the ongoing public health emergency, DHCS is deeming COVID-19 testing and related medically necessary treatment services to be emergency services. There is no copay for emergency services including testing, evaluation and treatment for COVID-19.

When billing emergency COVID-19 testing and treatment service in an office/outpatient setting physicians should:

1. Report Emergency Indicator=Y in field 24C of the CMS-1500 form 2. Report Emergency indicator=81 on the UB 04 form 3. I ndicate emergency treatment on the claim and include “PATIENT IMPACTED BY COVID-19” in box 19 of the claim form 4. Use ICD-10 U07.1 as the primary diagnosis code.

5. I nclude relevant clinical information about the patient condition and why the emergency services rendered were considered immediately necessary.

CMA asked DHCS for clarity on how physicians can comply with the requirement to include relevant clinical information about the patient’s condition and why the emergency services were immediately necessary. DHCS advised that including the appropriate COVID-19 diagnosis code, documenting the emergency condition in the medical record and complying with existing signature requirements on the claim form will ensure compliance.

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Treatment Authorization Flexibilities Although Treatment Authorization Requests (TAR) are still required during the public health emergency, TARs can be submitted after services have been rendered. Providers should put “PATEINT IMPACTED BY COVID-19” in the “miscellaneous information” field on the TAR. TARs with this designation will be expedited and approved as appropriate. Physicians must still submit supporting documentation to justify the need or medical necessity and maintain documentation of medical necessity in the patient’s medical file.

For TARs that are already authorized, providers can extend the “through date” if needed through the eTAR system. Physicians should put “PATIENT IMPACTED BY COVID-19” the “miscellaneous information” field.

Questions regarding COVID-19 billing can be directed to DHCS at (800) 541-5555.

CMS Announces Payment Parity for Audio-Only Telephone Visits The Centers for Medicare and Medicaid Services (CMS) announced on Thursday a significant expansion of telehealth services so physicians and other providers can deliver a wider range of care to Medicare patients in their homes. Most notably, CMS will now be increasing payments for telephone visits to match payments for similar office and outpatient visits. This change is retroactive to March 1, 2020.

The Califor nia Medical Association and the American Medical Association have been pushing for this change, which is a major victory that will enable physicians to care for their patients— especially their elderly patients with chronic conditions— who may not be able to navigate or do not have access to audio-visual technology or high-speed internet. The rule change was part of a broad package of waivers and other changes intended to expand access to telehealth and facilitate COVID-19 testing.

According to the CMS, when a clinician provides an E/M service using audio-only technology, they should bill using the telephone services E/M code (99441-99443), provided that the required elements in the applicable code description are met.

Using new waiver authority, CMS is also allowing many behavioral health and education services to be fur nished via telehealth using audio-only communications. Click here for the full list of telehealth services, including which services are eligible to be fur nished via audio-only technology.

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Public Health

Update

The Impact of COVID-19 on our Youth

By Maggie Park, MD

According to the CDC, 2% of confirmed COVID-19 cases in the United States are among persons younger than age 18.

Despite the relatively low risk that the disease poses to children, we know that children are not immune. COVID-19 has the ability to cause significant respiratory and gastrointestinal illness in children. As with adults, hospitalized children with preexisting co-morbidities have fared worse than others. Reports of Kawasaki-like illnesses in COVID-positive children have led to the identification of a newly named condition, Pediatric Multi-System Inflammatory Syndrome. On top of the possibility of severe outcomes in pediatric patients as a direct effect of the novel coronavirus, there are other physical consequences that are quite concerning. Fear of exposure has led parents to put off well-child checks, and vaccination rates started dropping in

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Coronavirus (COVID-19)

mid-March. In its May 15 Morbidity and EMERGENCY Mortality Weekly Report, the CDC warned that “communities face increased risk for CHILD CARE outbreaks of vaccine-preventable diseases” PROGRAM and asked physicians to remind parents of the vital need for vaccine prevention Supporting Health Care Workers, First Responders, and Essential Workers even with the pandemic continuing.

If you are an essential worker on the frontlines of responding to the COVID-19 health crisis, you may be eligible for free or low-cost child care through the Emergency Child Care Program.

COVID-19 has also led to an increase Emergency Child Care supports healthcare workers and first responders in San Joaquin County. in accidental poisonings from cleaning Go to www.frrcsj.org to complete your request with products, with the CDC reporting our easy 3-step application process. You may submit Child care is offered for 0-12 yrs of age that calls to poison control centers that all forms safely via email to Raksan Kasem-Houy at Full and part-day care available rhouy@frrcsj.org or Elva Lopez at elopez@frrcsj.org Small group settings were related to bleach and disinfectant If you are in need of printed forms please call us at Care is aligned with CDC COVID-19 exposures increased by 20.4% in 2020 (209) 948-1553. For child care referrals to licensed Health Department childcare providers call 209-461-2908 or email guidelines. compared to 2019, for the January to referralhotline@frrcsj.org March time period.

Funding and child care slots are limited and There are additional physical risks available through June 30, 2020. imposed by the way this pandemic has changed our lives. Families are isolating at home for prolonged periods of time. past few weeks.

Parents may be unemployed or facing unemployment. People Dr. Nadine Burke Harris, California’s Surgeon General and are anxious that their families could get sick. All of this leads to expert on toxic stress, has created a playbook entitled “Stress Relief mounting stress levels, and research has shown that stress in the for Caregivers and Kids during COVID-19”. home is associated with increased rates of child abuse. Regional https://covid19.ca.gov/pdf/caregivers_and_kids_california_ statistics are concerning, with decreases in reports made to child surgeon_general_stress_busting_playbook_draft_v2_clean_ welfare services, reflecting the fact that children are isolated from ada_04072020v2.pdf adults who look out for them in school, child care, primary care In it, the following resources are offered: clinics, and places of worship. San Joaquin’s Child Protective •T he National Domestic Violence hotline is Services has seen a decrease in the total number of child abuse and 800-799-SAFE (7233) neglect referrals, with 445 referrals in April 2020 compared to 923 •T he National Sexual Assault hotline is in April 2019.

800-656-HOPE (4673) In order for children to be heathy, their caregivers need to be •T o reach a crisis text line, text HOME to 741-741 healthy. Therefore, in this time of crisis, emphasis is placed on •C hildhelp National Child Abuse Hotline: You can call helping caregivers manage their stress. Caregivers are encouraged 1-800-4-A-CHILD to stay connected with friends and family via phone and video, •T he National Suicide Prevention Lifeline is 800-273-TALK take time out to do physical exercise and breathing exercises, (8255) eat healthy, and get enough sleep. This sort of advice to practice self-care can certainly help our patients but may be difficult to Locally, we’ve got 211 as well as many 24/7 hotlines: attain for more vulnerable adults. Some may need to deal with • Child Abuse Reporting Hotline is 209-468-1333 more pressing needs such as food and housing. Some may have • Domestic Violence is 209-465-4878 difficulty taking care of themselves without support systems such • Sexual Assault is 209-465-4997 as in-person Alcoholics Anonymous meetings. And some may • Youth/Human Trafficking is 209- 948-1911 have their lives complicated by domestic violence, which also • Crisis Phone is 209-468-8686 seems to be on the rise due to COVID-19. The Women’s Center of San Joaquin has been tracking data, and although reports of Even for those not dealing with serious trauma in their lives, domestic violence may not have increased in the initial stages of COVID-19 has been challenging. With schooling being moved the current crisis, there appears to be an increase in calls over the   

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into homes, parents are having to juggle work and childcare responsibilities. This is a balancing act, and experts say that parents must first learn to forgive themselves if they don’t feel they are handling this new experience perfectly. Any anxiety associated with change is understandable, and caregivers and children alike should be encouraged to recognize their stress and express their thoughts and feelings. Watching news coverage about the virus can be overwhelming to children and cause them to feel stressed about their own health or the health of a loved one. Caregivers should give children the opportunity to talk about their concerns.

The American Academy of Pediatrics recommends these tips when talking to children about COVID-19: • S imple reassurance. Remind children that researchers and doctors are learning as much as they can, as quickly as they can, about the virus and are taking steps to keep everyone safe.

•G ive them control. It’s also a great time to remind your children of what they can do to help – washing their hands often, coughing into a tissue or their sleeves, and getting enough sleep.

•W atch for signs of anxiety. Children may not have the words to express their worry, but you may see signs of it.

They may get cranky, be more clingy, have trouble sleeping, or seem distracted. Keep the reassurance going and try to stick to your normal routines.

•M onitor their media. Keep young children away from frightening images they may se​e on TV, social media, computers, etc. For older children, talk together about what they are hearing on the news and correct any misinformation or rumors you may hear.

• B e a good role model. COVID-19 doesn›t discriminate and neither should we. While COVID-19 started in Wuhan, China, it doesn’t mean that having Asian ancestry – or any other ancestry – makes someone more susceptible to the virus or more contagious. Stigma and discrimination hurt everyone by creating fear or anger towards others.

When you show empathy and support to those who are ill, your children will too.

In addition to talking about the coronavirus with kids, families should make plans that include creating routines for kids and scheduling breaks from tele-work, eating healthy meals together, using social media for good (eg., checking on friends), planning video chats for kids with their friends, communicating with teachers, and family game nights.

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Even babies can sense when their parents are stressed, and the AAP offers tips for calming fussy babies such as checking on their diapers, swaddling, rocking and singing.

For young children, parents are recommended to engage them in constructive activities to beat boredom, help kids sort through their fears, call appropriate time-outs, know when not to respond to bad behavior, catch them being good, and give them your attention.

For adolescents, parents should recognize that being deprived of social contact with friends and of major milestones such as graduation ceremonies can cause disappointment and grief. Help them stick to schedules that allow for school time, meal time, down time, and proper sleep. Watch TV together, take virtual tours of museums together, and involve teens in family projects or volunteerism.

The Surgeon General’s Playbook offers 6 Stress-Busting Strategies for Kids as a way for kids to handle rising stress levels that could increase stress hormones and result in maladaptive biological changes.

For parents who are not working at home and continue to need child care, the difficulty with finding the child care is another issue that has arisen as a result of the COVID-19 pandemic. First 5 San Joaquin reports that the number of active private child care centers in the county fell from 894 in January 2020 to 702 in April 2020. Not only are 181 centers now temporarily closed, those that remain open are serving significantly less children than before. Agencies including First 5, Family Resource and Referral Center, San Joaquin Office of Education, and Child Abuse Prevention Council have been working to support these financially challenged child care providers.

In addition, a child care program has been established for essential frontline workers: San Joaquin County Public Health Services continues to operate our Children’s Medical Services and Maternal Child and Adolescent Health programs. Our COVID-19 team continually updates our website at sjcphs.org. More great resources for COVID-19 information can be found on the First 5 San Joaquin website at sjckids.org.

This is understandably a stressful time for families, perhaps even more so for medical providers and their families. We encourage you to take opportunities to have calming breaks.

Consider reading a book to your child, and remember that time spent together can bring some joy and laughter back to the day.

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San Joaquin Medical Society Member Only Benefits • Security and Risk Assessment of your IT Infrastructure (valued at $500) • 10% Discount of Monthly Managed Services for the first year (valued at a maximum of $5,000) • 5% Discount on Monthly Managed Services for VoIP Phone Systems for the first year (valued at a maximum of $1500) • Waived Set-up Fee (valued at $1,000 - $2,000 – user # dependent) • Monthly newsletter and Weekly Tech Tips for Cyber Safety Call Shari Peck @ 209-623-1026 or email shari@ce-technology.com SUMMER 2020

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In Memoriam

In Memoriam DONALD L. BECKER, MD 1935 - 2020

In his spare time, Don was an avid reader, photographer and also enjoyed racquetball, bicycling, dancing, traveling and wine tasting.

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He was a kind, gentle man of few words who was boundlessly generous with his time and talents. Family doctor, teacher, husband, father, and grandfather. Donald Lee Becker was born on July 5, 1935 and passed away at home on February 18, 2020, surrounded by loved ones. Dr. Becker was the son of Dr. Rollin and Ardath Becker and was raised in Dallas, Texas. He graduated from Texas State College in 1955 and Southwestern Medical School in 1959.

After a one-year internship in Yakima, Washington, he served for three years in the U.S. Air Force as a Flight Surgeon stationed in Germany. Returning from Germany, he completed a two year general practice residency at Sacramento County Hospital. He then moved to Lodi where he practiced medicine for 35 years engaging in a widely diverse practice including general medicine, surgery, and obstetrics and gynecology. Don delivered 1,800 babies during his career before retiring in 2000. When out in the community, Don would frequently hear, “Dr. Becker, you delivered me!� He was consistently a passionate patient advocate. Don also served as a community preceptor teaching Family Medicine residents at San Joaquin

General Hospital for over 30 years. He also volunteered at the Salvation Army Clinic in Lodi and was past president of the San Joaquin Medical Society.

In his spare time, Don was an avid reader, photographer and also enjoyed racquetball, bicycling, dancing, traveling and wine tasting. Don especially loved traveling to Mexico, Central & South America where he could always be seen with several cameras around his neck and his monopod in hand. His love of people and culture and scenery shone through the photos he took. He could tell a story about each photo--and he loved to tell about them.

He also loved classical music and enjoyed attending the Stockton symphony where he was a loyal patron for more than 30 years.

He is survived by and was lovingly cared for by his wife of 32 years, Maureen.

He is also survived by his children, Bruce (Sandy) of Stockton, Laura of Sacramento, and Craig (Raini) of Florida; grandchildren, Seth and Blake; and sister, Ginny (Dean) of Austin Texas, along with five nieces.

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In Memoriam

In Memoriam JEROLD YECIES, MD

1940 - 2020

Dr. Jerold Joseph Yecies died in Stockton, CA on March 12,2020. He was born May 21, 1940 in Pittsburgh, PA to William Yecies (1906-1976) and Ann Sherrin Yecies (1912 -1992). Jerry graduated from McKeesport High School in 1958 where he was an all-state clarinetist. He received a scholarship and graduated with a degree in chemistry from Western Reserve University in Cleveland, OH in 1962. In 1961 Jerry married his high school sweetheart Judith Roslyn Weiss and they were married 58 years. He received his medical degree from Hahnemann Medical College in 1966.

Jerry did a residency in pediatrics at Johns Hopkins. His residency was split by his military service and he served as epidemiologist for the US Navy’s Sixth Fleet based in Naples, Italy. He left the Navy as a Lt. Commander. Dr. Yecies completed his medical training with a fellowship in allergy and immunology at National Jewish Hospital in Denver, CO. He was board certified in pediatrics and in allergy and immunology.

He moved to Stockton to establish his medical practice in 1973 with his partner Dr. George Bensch and opened his first office in the Hunter Building on Flora Street. He practiced medicine in San Joaquin and Stanislaus counties for 47 years. He was active in the local community and served as President and Director of Temple Israel. He also served as President of the San Joaquin Medical Society and received the Society’s Lifetime Achievement Award in 2018.

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He was a supporter and donor to many local charities. He had a passion for travel and visited all seven continents in his lifetime. He was predeceased by his brother Robert Yecies of Cherry Hill, NJ (19421992) and is survived by his brother Richard Yecies of Southampton, PA and his wife of 58 years Judith Yecies. He is survived by his three children: Steven and Laura Yecies of Woodside, CA, Michael and Nancy Yecies of Gladwyne, PA, and Carolyn Yecies Heller of Menlo Park, CA; his nine adult grandchildren Dr. Derek and Jessica Yecies of Emerald Hills, CA, Drs. Todd and Emmanuelle Yecies of Pittsburgh, PA, Margot Yecies, Adam Yecies, Noah Yecies all of New York, NY, Avery Yecies, Madeline Heller both of Los Angeles, CA, Maxwell Heller of Ann Arbor, MI and Curtis Heller of Menlo Park, CA. Dr. Yecies had five great grandchildren; James, Juliette, and Jack Yecies of Emerald Hills, CA and Benjamin and Nathan Yecies of Pittsburgh, PA.

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

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Permit No. 60 Stockton, CA

Proudly welcoming

Sukhmine Nedopil, MD GENER AL SURGERY

Specialties Breast cancer surgery Colon cancer surgery Gallbladder Hernia repair

Education General Surgery Residency: San Joaquin General Hospital French Camp, Calif.

Medical Degree: University of California, Davis, Calif.

Bachelor’s Degree in Chemistry: University of California, Berkeley, Calif.

Certifications American College of Surgeons

Languages English, Punjabi and German

Adventist Health Physician Network Medical Office – Surgery 999 S. Fairmont Avenue, Suite 100 Lodi, CA 95240 209-334-8510 AdventistHealthLodiMemorial.org