Winter 2014

PLUS: Legislative Wrap Up 2014 MICRA Victory, Member Benefits and more!

Winter 2014

Member Benefit News: Open enrollment for the San Joaquin Medical Societysponsored dental plan has started!

You and your family are eligible to enroll in the SJMS-sponsored dental plan only during open enrollment periods.

Apply by December 31, 2014! To be eligible for coverage, applications must be received during the special open enrollment period ending on December 31, 2014.

For more information... Call a Client Advisor at 800-842-3761 for more information.

Or visit www.CountyCMAMemberInsurance.com to download a brochure and application.

Sponsored by:

Mercer Health & Benefits Insurance Services LLC • CA Ins. Lic. #0G39709

777 South Figueroa Street, Los Angeles, CA 90017 • 800-842-3761 • CMACounty.Insurance.service@mercer.com 67119 (12/14) www.CountyCMAMemberInsurance.com • Copyright 2014 Mercer LLC. All rights reserved.

VOLUME 62, NUMBER 4 • December 2014

Dr.Pamela Tsuchiya and Dr.Alan Nakanishi

{FEATURES}

12 30 48 53 winter 2014

New Laws

The California Legislature new laws

The family business

Physicians with a family tie to the medical profession

{DEPARTMENTS} 21 make a wish

22 IN THE NEWS

Why sliding-scale insulin coverage doesn’t work

SJMS Member Benefits

Membership services and discounts

New faces and announcements

56 public health

make insulin work backward

DeLyla, 10, Stockton, CA

Ebola virus disease

60 practice management:

The key to improving patient outcomes

63 new members 65 In Memoriam

Robert Boyd Talley MD January 21, 1931 - September 23, 2014

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President Ramin Manshadi, MD President-Elect John Zeiter, MD Past-President Thomas McKenzie, MD Secretary-Treasurer George Savage, MD Board Members Raissa Hill, DO, Moses Elam, MD, Grant Mellor, MD, Dan Vongtama, MD, Alvaro Garza, MD, Kwabena Adubofour, MD, Mohsen Saadat, DO, Clyde Wong, MD

Medical Society Staff Executive Director Lisa Richmond Community Project Manager Vanessa Armendariz membership coordinator Jessica Peluso

San joaquin physician magazine Editor Lisa Richmond Editorial Committee Ramin Manshadi, Lisa Richmond, Mike Steenburgh Vanessa Armendariz

Committee Chairpersons

Managing Editor Lisa Richmond

MRAC F. Karl , Gregorius, MD

Creative Director Sherry Roberts

Decision Medicine Kwabena Adubofour, MD Ethics & Patient Relations to be appointed

Contributing Writers James Noonan, Alvaro Garza, MD, MPH

Legislative Jasbir Gill, MD Community Relations Joseph Serra, MD Public Health Alvaro Garza, MD

The San Joaquin Physician magazine is produced by the San Joaquin Medical Society

Scholarship Loan Fund Janwyn Funamura, M.D. NORCAP Council Thomas McKenzie, MD

Suggestions, story ideas or completed stories written by current San Joaquin Medical Society

CMA House of Delegates Representatives Robin Wong, MD, Lawrence R. Frank, MD,

members are welcome and will be reviewed by the Editorial Committee.

James R. Halderman, MD, Roland Hart, MD, Grant Mellor, MD, Kwabena Adubofour, MD,

Please direct all inquiries and submissions to:

Gabriel K. Tanson, MD, Ramin Manshadi, MD

San Joaquin Physician Magazine

3031 W. March Lane, Suite 222W Stockton, CA 95219 Phone: 209-952-5299 Fax: 209-952-5298 Email Address: lisa@sjcms.org Medical Society Office Hours: Monday through Friday 9:00 AM to 5:00 PM Closed for Lunch between 12pm-1pm

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Confidence The feeling you have when you are affiliated with Hill Physicians.

Clyde Wong, M.D.

Hill Physicians provider since 2012.

Uses Ascender preventive care reminders, Hill inSite to review eClaims and eligibility and Hill EHR for a comprehensive solution to patient care, practice management and ePrescribing.

At Hill Physicians, we continue to improve upon coordinated care, with remarkable results.

We provide the tools and support that practices need to be financially successful and improve the coordinated care experience for their patients. Our advantages include: • Fast, accurate claims payments • Free eReferrals, ePrescribing and online doctor-patient communications • Experienced RN case management for complex, time-intensive cases • Deep discounts on EPM and EHR solutions to help you meet the federal mandate • Easy preventive care and disease management reminders for patients • Extensive health resources that boost patient engagement • High consumer awareness that builds practice volume That’s why 3,800 independent primary care physicians, specialists and healthcare professionals have joined Hill. Feel confident in the future of your practice and your patients by affiliating with Hill Physicians Medical Group.

For more about the advantages of affiliating, visit HillPhysicians.com/JoinUs.

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Hill Physicians’ 3,800 healthcare providers accept HMOs and many PPOs from Aetna, Anthem Blue Cross, Blue Shield, CIGNA, Easy Choice, Health Net, Humana, SCAN, United Healthcare WEST and Western Health Advantage. Medicare Advantage plans in all regions. Medi-Cal in some regions for physicians who opt-in.

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Letter From The Executive Director

staff report

Victory is Ours!

As I sit here in my office on November 5, I can’t help but breathe a sigh of relief! We did it! Californians spoke loudly and definitively to defeat Proposition 46 by a resounding 67% to 33%! An increase in the Medical Injury Compensation Reform Act (MICRA) cap on non-economic damages has been rejected in California again and again in court, by the legislature and now by the voters. While this has been a stressful time, it has been exciting to see our membership mobilized and united as we fought to protect the profession of medicine and the patients you care for on a daily basis.

Lisa richmond

Now more than ever, I hope that you will be able to appreciate the value of the advocacy and lobbying in which you enjoy as a benefit of your membership. The California Medical Association, led by Dustin Corcoran, CEO did an outstanding job of building an unprecedented broad coalition of organizations to defeat Proposition 46. They worked tirelessly toward this goal, making it the number one priority and essentially turning CMA headquarters in Sacramento into campaign central. I could not be more proud to be part of this challenge and ultimate victory.

Through my work at SJMS, I have had the chance to learn more about what it takes to be become a physician. It is a long road of hard work and carefully calculated decisions beginning in high school and through college. It is not for the faint of heart and you don’t fall in to it accidently. Most physicians feel a passion to serve their patients and community. It remains one of the most highly respected professions in the world for a reason.

We began to wonder about trends with regard to the family tradition of medicine. Were children of physicians more or less likely to become physicians? Did their parents encourage or discourage medicine as a career opportunity? Did they steer their children in to the same specialty?

We set out to learn more from our members through a survey mailed to all active and retired members requesting information about their physician families. The responses were fascinating. Overall, most physicians did recommend medicine to their children and exposed them early to a variety of clinical settings with patients and other healthcare professionals.

We hope you enjoy reading more on this topic in our feature article on page 30. Thank you to all that responded and contributed to the list of SJMS Member Families. As with every list, it tends to be outdated or incorrect the moment it is printed. So, please send us your additions or corrections for our historical database.

We hope to see you at this year’s Holiday Party at Brookside Country Club on Sunday, December 14, 2014 to celebrate a monumental year! Please refer to enclosed ad for details on all of this year’s festivities.

Happy Holidays,

Lisa Richmond

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We believe in 98.6 degrees.

Being a good doctor is about more than practicing good medicine. It’s about preventing illness. Being proactive.

Taking the time to really listen. And giving our patients the personalized care they deserve. So, to all doctors, we’d like to say thanks. Because of you, a healthier life for everyone is as normal as 98.6.

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For more information, visit us online at kp.org/centralvalley SAN JOAQUIN PHYSICIAN

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A message from our President > Ramin Manshadi MD, FACC

We Have Done It We have defeated Proposition 46. It made me proud to see so many doctors fighting for a common goal. We were united.

It was evident as I traveled the state and the country. On an even a broader scale, our health care partners, all acute care hospitals within our county, also stepped up in support.

We are a team. Our team has won. As a head soccer coach, it has been proven to me; when the team plays as a team, we shine.

The voters of California spoke loudly and definitively, sending the trial lawyers’ Proposition 46 to defeat by a vote of 67 to 33. The message is clear – Californians simply don’t want to increase

health care costs and reduce health access so trial attorneys can file more lawsuits. We can now focus our energy on what we do best, help our patients stay healthy and cure their disease.

An increase in the Medical Injury Compensation Reform Act (MICR A) cap on non-economic damages has been rejected in California again and again: 10 times in court, 5 times in the Legislature and now overwhelmingly by voters. This idea now has its own dedicated spot in California’s political trash heap. But this time, we energized the membership of CMA as a whole to fight the fight together, as one unified voice of medicine, representing the patients we so deeply care about and the care that we have committed to provide them.

ABOUT THE AUTHOR ­ Ramin Manshadi MD, FACC is President of the San Joaquin Medical Society and is Board-Certified Cardiologist.

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A message from our President > Ramin Manshadi MD, FACC

The San Francisco Chronicle decried Prop. 46 saying that the measure, “overreached in a decidedly cynical way.”

The Orange County Register, UT San Diego, San Jose Mercury News, Monterey County Herald, Sacramento Bee and dozens of other newspapers echoed these sentiments.

The efforts of the California Medical Association and the county medical associations across the state is a tremendous One of the secret weapons of this effort was showing of what we can do for the future the size and diversity of our coalition. We of health care, the quality of medicine and helped amass one of the largest and most the dedication to patients everywhere. Working together to spread the truth about Prop. 46, was one of the most building coalitions in California across communities and standing strong history and we rose to the occasion. as one united voice is what helped carry us to victory. diverse campaigns in California history. The This was one of the most contentious and breadth of the coalition — which includes high-stakes ballot fights in California history labor, business, local government, health and we rose to the occasion. We must use providers, community clinics, Planned this unity moving forward and showcase Parenthood, ACLU, NA ACP, taxpayers, teachers, firefighters and more – underscores to our colleagues the value the California just how important affordable, accessible Medical Association brings to our great health care is to every Californian. profession, which will help prepare us for

whatever challenge comes next.

In addition, to the groups on the ground talking to voters about the deception and It has proven that it is wise to be part trickery behind Prop. 46, every major of organized medicine to help fight off editorial board in California opposed the aggressions toward our noble profession. In initiative. close, I ask for your support in maintaining

your membership with SJMS/CMA without The Los Angeles Times said, “As worthwhile interruption. We have proven that once we as [Proposition 46’s] goals may be, the are United, we can overcome our hardships methods the measure would use to achieve and clear our way to concentrate our efforts them are too f lawed to be enacted into law.” on providing best possible patient care. It is

an honor to be a physician.

Despite the trial attorney proponents’ attempt to sweeten the deal by adding provisions that polled well– physician drug testing and mandatory checking of a prescription database – voters said NO on Election Night.

As people throughout the state heard from physicians and No on 46 coalition members about the real intentions of the measure’s proponents, there was resounding opposition.

“

“

contentious and high-stakes ballot fights This

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1743

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New Health Laws > 2015

2015

New Health Laws The California Legislature had an active year, passing many new laws affecting health care.

Below are highlights of the new laws likely to impact physicians next year and beyond. For more details, see “Significant New California Laws of Interest to Physicians for 2015,” in the California Medical Association’s online resource library at www.cmanet.org/resource-library.

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>>

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Board of Pharmacy to license a surplus medication collection and distribution intermediary, established for the purpose of facilitating the donation or transfer of medications between entities under a specified unused medication repository and distribution program. Authorizes the intermediary to charge specified fees.

Relates to license renewal. Requires the keeping and maintaining of complete records. Provides that fees collected would be deposited in the Pharmacy Board Contingent Fund.

ALLIED HEALTH PROFESSIONALS AB 1841 (Mullin) - MEDICAL ASSISTANTS Clarifies that medical assistants (MAs) may hand out properly labeled and prepackaged prescription drugs to patients as part of their existing authorization to provide “technical supportive services.” Permits MAs to hand out prescription drugs in non-state operated facilities licensed by the Board of Pharmacy. Requires that a licensed physician and surgeon, a licensed podiatrist, a physician assistant, a nurse practitioner, or a certified nurse-midwife provide the appropriate patient consultation regarding use of the drug.

CONFIDENTIAL INFORMATION AB 1755 (Gomez) - MEDICAL INFORMATION Revises provisions of law requiring licensed health facilities to prevent disclosure of patients’ medical information by extending the deadline for health facilities to report unauthorized disclosures from

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five to 15 business days after unlawful or unauthorized access, use, or disclosure has been detected. This bill also authorizes the report made to the patient or the patient’s representative to be made by alternative means, including email, as specified by the patient. This bill also extends the deadline when reporting is delayed for law enforcement purposes, as specified, from five to 15 days business days after the end of the delay. This bill gives the Department of Public Health full discretion to consider all factors when determining whether to conduct investigations under these provisions.

DRUG PRESCRIBING AND DISPENSING AB 467 (Stone) - PRESCRIPTION DRUGS: COLLECTION AND DISTRIBUTION PROGRAM Establishes a license and regulatory framework for a “surplus medication collection and distribution intermediary” to facilitate the donation of surplus medications in California. Requires the

AB 1535 (Bloom) - PHARMACISTS: NALOXONE HYDROCHLORIDE Authorizes a pharmacist to furnish naloxone hydrochloride in accordance with standardized procedures or protocols developed and approved by both the Board of Pharmacy and the Medical Board.

Requires the development of protocols on the education of the person to whom the drug is furnished and notification of the patient’s primary care provider. Requires the pharmacists to complete related training.

Prohibits furnishing the medication to the patient without consultation. Authorizes related regulations.

AB 1735 (Hall) - NITROUS OXIDE: DISPENSING AND DISTRIBUTING Makes it a misdemeanor for any person to dispense or distribute nitrous oxide to a person if it is known or should have been known that the nitrous oxide will be ingested or inhaled by the person for the purposes of causing intoxication, and that person proximately causes great bodily injury or death to himself, herself, or any other person. Requires each transaction to be recorded in a written or electronic document. Requires a signature and proper identification. Makes it a crime to misuse customer information.

AB 1743 (Ting) - HYPODERMIC

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New Health Laws > 2015

NEEDLES AND SYRINGES Deletes the limit on the number of syringes a pharmacist has the discretion to sell to an adult without a prescription and extends, until January 1, 2021, the statewide authorization for pharmacists to sell syringes without a prescription, as specified. Exempts the possession of a specified amount of hypodermic needles and syringes that are acquired from an authorized source.

HEALTH BENEFIT EXCHANGE AB 617 (Nazarian) - HEALTH BENEFIT EXCHANGE: APPEALS Establishes an appeals process for eligibility determinations for insurance affordability programs (including Medi-Cal and tax credits available through the California Health Benefit Exchange (Covered California) and requires Covered California to contract with the Department of Social Services to serve as the designated entity to hear appeals.

Requires a health care service plan or insurer that provides prescription drug benefits or maintains drug formularies to post those formularies on its website and to update that posting with changes at specified times. Requires the development of a standard formulary template. Requires plans and insurers to use that template to display formularies. Requires the Covered California website provide a link to the formularies for each health plan through the Exchange.

SB 1053 (Mitchell) - HEALTH CARE COVERAGE: CONTRACEPTIVES Requires, effective January 1, 2016, most health plans and insurers to cover a variety of Food and Drug Administration-approved contraceptive drugs, devices, and products for women, as well as related counseling and follow-up services and voluntary sterilization procedures. Prohibits cost-sharing, restrictions, or delays in the provision of covered services, but allows cost-sharing and utilization management procedures if a therapeutic equivalent

HEALTH CARE COVERAGE SB 959 (Hernandez, E.) - HEALTH CARE COVERAGE Prohibits a change in premium rate or coverage for an individual plan contract or policy unless the plan or insurer delivers a written notice of the change at least 15 days prior to the start of the annual enrollment period applicable to the contract or 60 days prior to the effective date of renewal, whichever occurs earlier in the calendar year. Makes several corrections and clarifications to provisions of law governing individual and small group health insurance, including clarifying that health plans and insurers have a single risk pool for enrollees and insureds.

SB 964 (Hernandez, E.) - HEALTH CARE COVERAGE Increases oversight of health care service plans with respect to compliance with timely access and provider network adequacy standards. Authorizes a health plan to include in its contracts with providers, provisions requiring compliance with timely access and network adequacy data reporting requirements. Requires DMHC to annually review health plan compliance with timely access standards and to post its final findings from the review, and any waivers or alternative standards approved by DMHC, on its Web site. Authorizes DMHC to develop, and requires health plans to use, standardized methodologies for timely access reporting, and exempts the development and adoption of the standardized reporting methodologies from the Adm­i nistrative Procedures Act, the body of law governing state regulations, until January 1, 2020.

SB 1052 (Torres) - HEALTH CARE COVERAGE

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drug or device is offered by the plan with no cost-sharing.

HEALTH CARE FACILITIES AND FINANCING AB 1570 (Chesbro) - RESIDENTIAL CARE FACILITIES FOR THE ELDERLY Increases training requirements for licensees and staff of Residential Care Facilities for the Elderly (RCFE). Deletes the existing requirement of 40 hours of classroom instruction for RCFE licensee certification training programs and replaces it with 80 hours of required coursework, which shall include at least 60 hours of coursework that shall be attended in person. Adds personal rights, management of antipsychotic medication, managing Alzheimer’s disease and related dementias, and managing the

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New Health Laws > 2015

physical environment, including maintenance and housekeeping to the list of items covered in the RCFE licensee certification training program.

AB 2044 (Rodriguez) - RESIDENTIAL CARE FACILITIES FOR THE ELDERLY Relates to residential care facilities for the elderly. Requires that at least one administrator, facility manager, or designated substitute who has adequate qualifications be on the premises of a facility 24 hours per day. Requires a facility to employ, and an administrator to schedule, a sufficient number of staff members. Requires certain training to include building and fire safety and the appropriate response to emergencies.

SB 1004 (Hernandez, E.) - HEALTH CARE: PALLIATIVE CARE Requires the Department of Health Care Services (DHCS) to assist Medi-Cal managed care plans in delivering palliative care services, and requires DHCS to consult with stakeholders and directs DHCS to ensure the delivery of palliative care services in a manner that is cost-neutral to the General Fund, to the extent practicable. Authorizes implementation through all plan letters and similar instructions.

SB 1299 (Padilla) - WORKPLACE VIOLENCE PREVENTION PLANS: HOSPITALS Requires the Occupational Safety and Health Administration Standards Board, no later than July 1, 2016, to adopt standards that require specified hospitals to adopt a workplace violence prevention plan as part of their injury and illness prevention plan to protect health care workers and other facility personnel from aggressive and violent behavior. Requires the Division of Occupational Safety and Health to post a report on violent incidents at hospitals on its website. Exempts certain hospitals.

MEDI-CAL SB 396 (De León) - PUBLIC SERVICES Repeals the unenforceable provisions of Proposition 187 relating to public social services, public health care services, public education and other activities of state and local agencies.

SB 1341 (Mitchell) - MEDI-CAL: STATEWIDE AUTOMATED WELFARE SYSTEM Requires the Statewide Automated Welfare System to be the system of record for Medi-Cal and to contain all Medi-Cal eligibility rules and case management functionality. Authorizes the Healthcare

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Eligibility, Enrollment, and Retention System (CalHEERS) to house the business rules necessary for an eligibility determination.

Requires CalHEERS to make the business rules available to the System consortia to determine Medi-Cal eligibility. Requires notices for the Medi-Cal and premium tax credit programs.

SB 1457 (Evans) - MEDICAL CARE: ELECTRONIC TREATMENT AUTHORIZATION Requires requests for authorization for treatment or services in the Medi-Cal program, California Children’s Services (CCS) Program, and the Genetically Handicapped Persons Program (GHPP), excluding those submitted by dental providers enrolled in the Medi-Cal Dental Program, to be submitted in an electronic format determined by the Department of Health Care Services (DHCS) via DHCS’ website or other electronic means designated by DHCS. Requires DHCS to implement an alternate format for submission when DHCS’ website is unavailable due to a system disruption.

Implements this requirement by July 1, 2015, or a subsequent date determined by DHCS. Authorizes all‑county letters, plan letters, or provider bulletins.

MEDICAL EDUCATION AB 496 (Gordon) - MEDICAL EVALUATION: SEXUAL ORIENTATION: GENDER IDENTITY Amends existing law that requires continuing medical education accrediting associations to develop standards for compliance with the cultural competency requirement. Authorizes such associations to update these compliance standards in conjunction with an advisory group with expertise in such issues. Expands a recommendation regarding such care to include appropriate treatment and care of the lesbian, gay, bisexual, transgender, and intersex communities.

AB 2214 (Fox) - EMERGENCY ROOM PHYSICIANS AND SURGEONS Enacts the Dolores H. Fox Act to require the Medical Board of California to consider including a course in geriatric care for emergency room physicians and surgeons as part of its continuing education requirements.

MEDICAL PRACTICE AND ETHICS AB 1577 (Atkins) - CERTIFICATES OF DEATH: GENDER IDENTITY Requires a person completing a certificate of death to record the decedent’s sex to ref lect the decedent’s gender identity. Requires

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New Health Laws > 2015

identity to be reported by the informant, unless the person completing the certificate is presented with a specified document, in which case the person would be required to record the decedent’s sex as that which corresponds with the gender identity as indicated in document. Provides the procedure in the absence of such document.

AB 2365 (Perez, J.) - CONTRACTS: UNLAWFUL CONTRACTS Seeks to make clear in California law that non-disparagement clauses in specified consumer contracts are void and unenforceable. Provides that a contract or proposed contract for the sale or lease of consumer goods or services may not include a provision waving the consumer’s right to make any statement regarding the seller or lessor or its employees or agents concerning the goods or services. Makes it unlawful to threaten or to seek to enforce a provision made unlawful under this bill, or to otherwise penalize a consumer for making any statement protected under the bill. Provides that a provision in violation of this bill is deemed unconscionable and against public policy. Relates to online reviews or comments.

PROFESSIONAL LICENSING AND DISCIPLINE SB 1159 (Lara) - LICENSE APPLICANTS: INDIVIDUAL TAX IDENTIFICATION Prohibits licensing boards under the Department of Consumer Affairs from denying licensure to an applicant based on his or her citizenship or immigration status, and requires a licensing board and the State Bar to require, by January 1, 2016, that an applicant for licensure provide his or her individual taxpayer identification

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number or a social security number for an initial or renewal license.

PUBLIC HEALTH AB 1559 (Pan) - NEWBORN SCREENING PROGRAM Requires the Department of Public Health to expand statewide screening of newborns to include screening for adrenoleukodystrophy as soon as the disease is adopted by the federal Recommended Uniform Screening Panel.

AB 1819 (Hall) - FAMILY DAY CARE HOME: SMOKING PROHIBITION Prohibits the smoking of tobacco in a private residence that is licensed as a family day care home without regard to whether the act occurs during the hours of operation of the home. Makes a conforming change.

AB 1898 (Brown) - PUBLIC HEALTH RECORDS: REPORTING: HIV/AIDS Adds hepatitis B, hepatitis C, and meningococcal infection to the list of diseases that local health officer reports to the Department of Public Health (for the purpose of the investigation, control, or surveillance of human immunodeficiency virus/acquired immune deficiency syndrome and co-infection).

AB 2069 (Maienschein) IMMUNIZATIONS: INFLUENZA Requires the Department of Public Health to post specified educational information regarding inf luenza disease and the availability of inf luenza vaccinations on the department’s website. Authorizes the department to use additional available resources to educate the public regarding inf luenza, including, among other things, public service announcements.

AB 2217 (Melendez) – PUPIL AND PERSONNEL HEALTH: AEDS Authorizes a public school to solicit and receive non-state funds to acquire and maintain an automated external defibrillator (AED). Provides that the employees of the school district are not liable for civil damages resulting from certain uses, attempted uses or non-uses of an AED. Exempts a public school or district, that is in compliance with AED requirements, from civil damage liability.

REPRODUCTIVE ISSUES SB 1135 (Jackson) - INMATES: STERILIZATION Prohibits sterilization for the purpose of birth control of an individual under the control of the Department of Corrections and Rehabilitation or a county correctional facility. Prohibits any means of sterilization of an inmate, except when required for the immediate preservation of life in an emergency medical situation and when medically necessary to treat a diagnosed condition and certain requirements are satisfied. Requires reports of procedures.

Relates to notification regarding sterilization.

These are just a sampling of the new laws impacting health care in 2015 and beyond. For a complete list, see “Significant New California Laws of Interest to Physicians for 2015,” in the California Medical Association’s online resource library at www. cmanet.org/resource-library.

winter 2014

In The News

“ As your MIEC Claims Representative, I will serve your professional liability needs with both steadfast advocacy and compassionate support.”

Senior Claims Representative Michael Anderson

Service and Value MIEC takes pride in both. For nearly 40 years, MIEC has been steadfast in our protection of California physicians. With conscientious Underwriting, excellent Claims management and hands-on Loss Prevention services, we’ve partnered with policyholders to keep premiums low.

Added value: n

No profit motive and low overhead

n

$17.5 million in dividends* distributed in 2014

For more information or to apply: n

www.miec.com

n

Call 800.227.4527

n

Email questions to

Average Dividend as % of Premiums Past five Years

40% 35% 30% 25%

38.6%

20% 15% 10% 5% 0%

MIEC

6.66%

Med Mal Industry

underwriting@miec.com * (On premiums at $1/3 million limits. Future dividends cannot be guaranteed.)

MIEC 6250 Claremont Avenue, Oakland, California 94618 • 800-227-4527 • www.miec.com SJMS_06.17.14

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MIEC

Owned by the policyholders we protect.

SAN JOAQUIN PHYSICIAN

19

The

REMEDY for all your

Financial

NEEDS

As a member of the San Joaquin Medical Association, you’re privy to an exclusive benefit—Financial Center Credit Union membership for you and your staff !

In a time when the safety and soundness of funds is at the forefront of everyone’s minds, Financial Center membership is the perfect prescription for peace-of-mind. Voted Best Of San Joaquin, Financial Center is the most trusted credit union in the Valley. Time and time again, we offer our members the lowest rates on their loans as well as the safest place to save their money.

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.

209-948-6024

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www.fccuburt.org Federally insured by the NCUA.

DeLyla, 10, Stockton, CA Brain cancer I wish to be a pop star!

A Wish Begins Wish You!

DeLyla may appear to be a normal ten year-old girl. She is bubbly, listens to music, and loves to sing. However, in 2012 DeLyla’s childhood took a turn when she was diagnosed with a rare form of brain cancer. Suddenly her playdates with friends turned into extensive treatments at hospitals.

But her battle against cancer never hindered her passion for singing. When her wish to be a pop star came true, she was able to show the world her talent. She visited radio stations, got a makeover, recorded songs and even gave a

“Her smile says it all. If a family needs that sense of hope, Make-A-Wish is it, especially for the child.” - DeLyla’s mom Maline live performance! DeLyla still makes pop star appearances to this day and inspires others through her positivity and perseverance. When you refer a child with a life-threatening medical condition to Make-A-Wish, you are not only impacting the child, but the families and many times an entire community! A wish can make a difference. In fact, 89% of medical professionals believe that a wish granted impacts the physical health of the wish child. Go to necannv. wish.org/referachild or contact Make-A-Wish Northeastern California & Northern Nevada at 916.437.0206.

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In The News

IN THE

NEWS

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

Since 2001, Dr. Kass has been a clinical instructor for Family Practice and Internal Medicine residents training at San Joaquin General Hospital in Stockton, and has held oversight responsibility for Dermatology residents from Stanford working at Kaiser Permanente.

As she enters a new phase of life, Dr. Kass is looking forward to spending quality time with her family and friends and actively participating in the numerous community organizations she supports.

Lodi Health considers Adventist Health affiliation

Dr. Kass Kaiser Permanente Assistant Physician-inChief Elizabeth Kass, MD, retired effective November 3, 2014.

Dr. Kass, a dermatologist, joined The Permanente Medical Group in 1994 and her excellent training and interpersonal skills contributed to her being one of the most active and respected physician leaders in the Central Valley. She served as Chief of Dermatology and in 2009 transitioned into assistant physician in chief for Health Promotion and Innnovations – a role that included organizing the Neighbors in Health community health fairs, as well as establishing teledermatology for patients.

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August 28, 2014 (Lodi and Roseville, Calif.)— Lodi Health announced today that its Board of Directors has voted unanimously for the health care system to enter into a letter of intent to affiliate with Adventist Health.

“We are excited about partnering with Adventist Health to maintain high quality, community-focused health care,” said Steven Crabtree, Lodi Health’s Board Chair. “Adventist Health’s mission-driven culture and values are very similar to ours and truly resonated with board, physicians and staff members. Adventist Health brings the financial and operational resources that will help ensure a strong local hospital for Lodi into the future.”

Through the affiliation, Adventist Health will bring to Lodi Health a significant capital commitment, the deployment of a state-of-the-art electronic medical records system, the maintenance of existing clinical services, and the creation of a local advisory board to ensure local input into key decisions.

“We are very happy about Lodi Health’s decision to join our health care system,” said Scott Reiner, President & CEO of Adventist Health. “Lodi is the kind of community that Adventist Health is called to serve, and Lodi Health is the type of organization that fits perfectly into our communityoriented vision for the future. The system strengths that

Winter 2014

In The News

Adventist Health will bring to Lodi and our commitment to preserve the important relationship between the hospital and the community will make this a great partnership for all of Lodi Health’s stakeholders.”

Adventist Health is a faith-based, not-for-profit integrated health care system serving communities in California, Hawaii, Oregon and Washington. The health system provides compassionate care in 19 hospitals, more than 230 clinics (hospital-based, rural health and physician clinics), 14 home care agencies, seven hospice agencies and four joint-venture retirement centers.

Lodi Health is a private, not for profit, 62-year community-based organization that was built by community members for community members. Lodi Health’s hospital is licensed for 191 beds. Lodi Health also operates 15 medical practices, several outpatient services and centers, an adult day care center, and a child care center.

The two parties will work together over the coming months to negotiate a definitive agreement. The transaction is likely to close in the first quarter of 2015 pending a vote of The Lodi Memorial Hospital Association, Inc.’s membership and the customary regulatory review process.

Cain Brothers has served as financial advisor to Lodi Health, while Juniper Advisory has assisted Adventist Health.

Lodi Health Offers Bariatric Surgery Bariatric surgery, also known as weight loss surgery, is now an option for Lodi Health patients seeking to lose weight and regain their health. Bariatric surgery can help many obesity related health conditions, including type 2 diabetes, high blood pressure, heart disease, sleep apnea and more.

Gill OB/GYN is Proud to be the Only Medical Group Offering Single Site Robotic Surgery in the Valley Gill OB/GYN is pleased to announce their highly skilled minimally invasive surgical Team.

Dr. Afiba Arthur, Dr. Param Gill, Dr. Jacqualin Miller andDr. Jennifer Phung are now offering robotic surgery,including single site robotic surgery by Dr. Param Gillfor women with gynecological issues requiring surgery. This option allows for faster recovery time, reduced pain and discomfort, shorter hospitalization, reduced blood loss, smaller incisions, and minimal scarring. For over 60 years, the specialists of Gill Obstetrics & Gynecology have been trusted to provide innovative, personalized care for women in our community.

fall 2013

SAN JOAQUIN PHYSICIAN 23

In The News

IN THE

NEWS The community is welcome to attend a free, informational seminar at Lodi Memorial Hospital, 975 S. Fairmont Ave., in Lodi, on Nov. 10 and Dec. 8, at 6pm to learn more about bariatric surgery and meet surgeons Benjamin Shadle, MD, and Ruby Gatschet, MD. Those interested can call 209.333.7600 to reserve a spot.

The surgeons will cover the three kinds of bariatric surgery they perform, who are likely candidates for the surgeries and what patients can expect following surgery.

Lodi Health is a private, not for profit health system founded in 1945. Visit the website at lodihealth.org.

Mobile MRI coming to Lodi Health A mobile magnetic resonance imaging (MR I) device is due soon to provide MR I services within the hospital.

This will bring new services to the hospital, and it will reduce the costs for inpatients who have to be ambulanced to Advanced Imaging Center nextdoor.

The mobile unit will be here for about one year and will be located just north of southwest imaging, east of the rotunda. Design for a permanent MR I location has begun. The location being considered is the old ambulance

canopy adjacent to outpatient services. This is conveniently located to outpatient services, and takes advantage of using existing building structure, which would be built-out.

According to Mike Lindsey, director of Lodi Health Imaging, the mobile unit is due in October pending OSHPD and CDPH approval. “We have started MR I Safety Training in the Safe

Have something to share?

We welcome submissions to our In-the-News Section from our community healthcare partners. We prefer Word files and .jpg images and may edit for space restrictions. Send your files to lisa@sjcms.org one month prior to publication (February 1st for the Spring issue, May 1st for the Summer issue, August 1st for the Fall issue and November 1st for the Winter issue).

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SAN JOAQUIN PHYSICIAN

Winter 2014

Day II Swank module for staff, to be completed by the first week of October.

There will be mock drills for code blue preparedness prior to starting the service,” he said.

Doctors Hospital of Manteca Becomes First in the Central Valley to Receive NICHE Designation for Improving Elderly Care Doctors Hospital of Manteca announces it has received designation as a NICHE Hospital. The NICHE (Nurses Improving Care for Healthsystem Elders) designation indicates a hospital’s commitment to elder care excellence.

The NICHE designation signals our dedication to providing patientcentered care for older adult patients.

Through our participation in the NICHE program — a leading elder care nursing program — we are able to offer evidence-based, interdisciplinary approaches that promote better outcomes, positive experiences, and improved care for older adults. This leads to greater satisfaction rates for patients, their families and staff.

“This initiative and the specialized nursing care techniques we are implementing now will be increasingly important to our hospital and our patients,” says Doctors Hospital of Manteca’s CEO Nicholas Tejeda. “We are proud to pioneer this important effort as the first Central Valley hospital to be so-designated and remain eager and ready to provide excellent care for the growing elderly population in our community.”

Doctors Hospital of Manteca Opens Wound Center Doctors Hospital of Manteca opened the Manteca Wound Center on

fall 2013

September 10, 2014. This Wound Care Center, the first of its kind in Manteca, provides treatment of chronic, nonhealing wounds - a wound which has not healed after eight weeks or has not improved after four weeks.

Millions of Americans suffer with chronic open sores as a result of diabetes, pressure ulcers, circulatory problems, wounds related to burns and traumatic and post-operative wounds. People with diabetes commonly suffer with nonhealing foot ulcers, which can lead to amputation if not properly treated.

The Manteca Wound Center specializes in treating these wounds through an aggressive and comprehensive therapeutic outpatient program that addresses both the wound and its underlying causes. This is accomplished by following an evidenced based clinical pathway for wound healing. For information please call 209-823-7190.

Four New Primary Care Physicians Join San Joaquin General Hospital Clinics Four new Primary Care physicians have recently joined San Joaquin General Hospital’s Primary Care Medical Services clinic:

Michael Lin, M.D. has joined San Joaquin General Hospital in French Camp practicing family medicine.

Dr. Lin received his medical degree from the Ross University School of Medicine Miramar Florida He did his family medicine residency in Southern California at R iverside County Regional Medical Center. Dr. Lin will see patients and perform family medical services through San Joaquin General Hospital’s Primary Medical Clinic.

Soujanya Sodavarapu, M.D. an internal medicine specialist has joined San Joaquin General Hospital to see patients in the Hospital’s Primary Care Medical Clinic. Dr. Sodavarapu received her medical degree from the Osmania Medical College in

SAN JOAQUIN PHYSICIAN 25

In The News

IN THE

NEWS Hyderabad, India and did her residency in internal medicine at Santa Barbara Cottage Hospital in Santa Barbara, California.

Dr. Sodavarapu joined San Joaquin General Hospital in June of this year and can be contacted at the Hospital’s Primary Medical Clinic.

Haishan Xu, M.D. Early this year Dr. Xu joined San Joaquin General Hospital in French Camp practicing internal medicine through the Hospital’s healthcare clinic system. Dr. Xu received her medical degree from the China Medical University in Beijing China.

She completed her residency in internal medicine at Berkshire Medical Center in Pittsfield Massachusetts. Dr. Xu is f luent in speaking Mandarin Chinese. She is practicing internal medical care and serving San Joaquin General Hospital’s Primary Medical Clinic.

Megha Goyal, M.D. A board certified internal medicine provider has recently joined San Joaquin General Hospital in French Camp practicing in the Primary Medical Clinic at San Joaquin General. Dr. Goyal completed her medical internship Mount Sinai Hospital Medical Center of Chicago.

She graduated from medical school at Graijra Raja Medical College in Madhya Pradesh, India. Dr. Goyal is active in internal medical services through San Joaquin General Hospital’s Primary Medical Clinic. Dr. Goyal is also f luent in the Hindu language.

SAN JOAQUIN COUNTY... where all students can find a great place to learn!

www.sjcoe.org • 209.468.4802 • 2901 Arch-Airport Road, Stockton, CA

In The News

St. Joseph’s Regional Cancer Center Offers Stereotactic Ablative Radiotherapy St. Joseph ’s Regional Cancer Center is proud to offer Stereotactic Ablative Body Radiotherapy (SA BR), also k nown as Stereotactic Body Radiation Therapy (SBRT), to cancer patients. SA BR is highly

focused radiation treatment that gives an intense dose of radiation concentrated on a tumor, while limiting the dose to the surrounding organs. It has become the treatment of choice for many patients with limited volume tumors but for whom surger y might not be an optimal treatment.

SA BR uses the latest image guidance technologies to ablate tumors with treatment accuracy within 1 millimeter. The ability to spare healthy tissue while intensif ying the radiation dose is the primar y advantage of SA BR over other modalities. Most treatments are done in short outpatient visits of 30 to 1 hour, requiring no hospitalization.

Due to the advanced technolog y and the high level of precision required, St. Joseph ’s Regional Cancer Center, led by Dr. Gaurav Singh, Cancer Center Medical Director, is one of the only cancer programs in Northern California providing this ty pe of sophisticated treatment.

St. Joseph’s Medical Center’s Cancer Care Symposium Returns St. Joseph ’s Regional Cancer Center will be holding the 17th A nnual Professional Cancer Care Symposium, on Februar y 21, 2015.

This year’s conference, titled “Breast Cancer: Thoughts on treatment,” features an update on surgical considerations, genetic implications, and treatment of triple negative breast cancer.

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SAN JOAQUIN PHYSICIAN

winter 2014

In The News

Center recognizes physicians in the community that go beyond clinical excellence to deliver healing with compassion and k indness, also k nown as humank indness. Most recently, Dr. James Morrissey, Dr. Ronald Kass, Dr. Connie Tang and Dr. Benjamin Wiederhold were recognized by their patients and peers for listening , explaining , and

displaying genuine k indness to their patients.

St. Joseph ’s invites you to nominate physicians practicing humank indness at St. Joseph ’s or in the community to receive recognition. Call (209) 467-6486 or email Catherine.

Swenson@dignityhealth.org for more information.

Physicians, as well as radiation therapists, nurses, laborator y technicians, pharmacists, and social workers work ing in all aspects of cancer care are invited to attend.

Continuing education credits will be offered at all levels.

The conference will take place on Saturday, Februar y 21, beginning at 8:00 am and ending with lunch at 1:30 pm, at O’Connor Woods, in Stockton. Cost is $69 to attend. For more information or to register, call (209) 467-6331.

Each quarter, St. Joseph ’s Medical

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John Zeiter, MD, Henry Zeiter, MD, Joseph E. Zeiter, MD and Joseph T. Zeiter, MD

Story by James Noonan

In the San Joaquin Medical Society alone, there are at least 70 physicians with some sort of family ties to the medical profession. Fathers, sons, mothers and daughters, these doctors have followed in the footsteps of physicians before them and built the strong family tradition seen today. >>

winter 2014

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Cover Story > The Family Buesiness

Drs. Vitune & Dan Vongtama

In 2002, a study conducted amongst first year medical students in Canada showed that nearly one in six incoming first-year medical students had at least one physician parent.

In the early 1960s, when American film producer and animation icon Walt Disney famously penned the phrase “a man should never neglect his family for business,” his assumption that these two realms were separate and distinct likely rings true for most of today’s working professionals.

For some, however, the concepts of “family” and “business” are linked – having grown together over the years and now finding themselves bound by a deep sense of familial tradition.

Take for example the Zeiter family, whose Stockton-based Zeiter Eye Medical Group has become something of an institution within the community it serves.

There are currently four Zeiter physicians somehow connected to the family’s medical group, each having come to the practice in a pattern that would make even the most skeptical observer admit a strange coincidence.

The Zeiter family’s medical tradition in Stockton began in 1962, when Henry Zeiter, who was born in Lebanon, spent his teenage years in Venezuela and studied medicine in Canada, found his way to Stockton to open the Zeiter Eye Medical Group.

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In 1982, exactly two decades after Henry first opened the practice’s doors, his nephew Joseph Zeiter, graduated from medical school at the University of California, Davis and joined his uncle’s practice.

Another ten years would pass before, in 1992, John Zeiter, Henry’s son, would earn his medical degree from Baylor University before setting up shop in his father’s practice.

Finally, ten years after John and twenty years after his father, Joseph Zeiter Jr. became the practice’s most-recent familial addition.

In keeping with the family’s strong ties to medicine, John’s son, John Henry, is currently a second-year medical student and, if he were to follow in his father’s footsteps, could potentially join the practice in 2022.

“I don’t really know how to explain it,” said John Zeiter. “Maybe we’re lucky. Maybe it’s providence” For the family and practice’s patriarch, explaining exactly how three generations of men were drawn to the same profession, specialty and even physical location, isn’t nearly as important as simply relishing in the fact that things unfolded the

SJMS Physician Families Alan Nakanishi, MD Pamela Tsuchiya, MD Edward Schneider, MD Adam Schneider, MD Cong Le, MD Lieu Nguyen, MD Quynh-Thu Le ,MD Trinh Vu, MD Anh Le, MD Hugh Vu, MD

Winter 2014

Cover Story > The Family Buesiness

Drs. Jack, Jamie, and Janwyn Funamura way they did.

“It’s unusual, but I don’t try too hard to explain it.” Henry says. “All I know is that I’m happy it’s worked out this way.”

While one would be hard-pressed not to admit that the Zeiter family’s case is somewhat unusual, there’s a mounting body of evidence that suggests that medicine, as a profession, carries a stronger sense of family tradition than comparable profession, such as law, engineering or education.

In 2002, a study conducted amongst first year medical students in Canada showed that nearly one in six incoming first-year medical students had at least one physician parent. Nearly a decade later, an article in The New York Times highlighted a study suggesting that, among medical schools in the United States, roughly one in five students admitted had at least one physician parent. Some campuses, however, saw rates as high as one in three, the study concluded.

Those looking for evidence of a familial tradition in the field of medicine needn’t look much further than right here in San Joaquin County.

In fact, for the purposes of this article, more than 70 physicians who are currently members of the San Joaquin Medical Society were identified as having some sort of family tie to the practice of medicine.

For some, it may have been a father or mother who served as their guide into the field of medicine. Others, saw brothers, sisters, cousins

winter 2014

and uncles lead the way. Regardless of how it happens, it seems that medicine isn’t a profession that simply keeps to an individual, but rather has a tendency to spread through the family.

Drawing solely from his own experiences, John proposed one explanation for such a trend.

“I used to follow my dad around the hospital when I was six or seven years old, so it didn’t take long for me to decide what I wanted to do,” he said. “It actually makes life a little bit easier when you know what you want to do.”

Others have chimed in with similar experiences.

“At age two my parents told me I would say, ‘I want to be a doctor and use a stethoscope.’

Perhaps those words became a seed which, when watered, grows, said Pamela Tsuchiya, MD, a Tracy-based ophthalmologist who can recall accompanying her father, Alan Nakanishi, MD – who is also an ophthalmologist – during hospital rounds when she was a child.

This idea of “watering the seed,” can likely account for many of today’s physicians who decided to follow in their parent’s footsteps.

Tsuchiya, for example, recalls getting “play doctor” kits for at least one birthday – perhaps a not-so-subtle nudge toward the profession supplied by her parents.

For the Zeiters, there were similar suggestions made, which now can be looked back upon with a certain amount of levity.

“My dad basically told me, ‘Look around and choose whatever you want…corneas, glaucoma,

George Westin, MD George Westin Jr., MD Greg Westin, MD Jeffrey Westin, MD Lian Soung, MD Jerry Soung, MD Peggy Soung Sullivan, MD Michael C. Soung, MD Julio Narvaez, MD Elsa Rodriguez, MD Julio Narvaez, MD Fred Manty, MD, DDS Jeffrey Payne, MD, DDS Erik Payne, MD Audrey Payne, MD Alvin Cacho, MD Vince Cacho, MD Valerie Cacho, MD Gabriel Tanson, MD Elvis Tanso, DO Rick Rawson, MD Rick Rawson, MD Julie Zimbelman, MD

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Cover Story > The Family Buesiness

Henry Zeiter, MD John Zeiter, MD Joseph T. Zeiter, MD Joseph E. Zeiter, MD Fram Buhari, MD Shiraz Buhari, MD Cyrus Buhari, DO Renee Marasigan, MD Raissa Hill, DO Richelle Marasigan, DO Marvin Primack, MD Daren Primack, MD Todd Primack, MD

Drs. Shiraz, Fram, and Cyrus Buhari surgeries…” he joked.

“I told him, ‘If you can find a profession that serves humanity better, than go for it,” Henry adds. “I think he made the right choice.”

Others, however, admit that seeing firsthand the demands the medical profession placed on their own parents caused them to think long and hard about entering the medical profession.

“Growing up, I thought it wasn’t very attractive because of the long hours required,” said George Westin Jr., MD, a Stockton-based orthopedist who’s father practiced in the same specialty. “Later, though I realized the value to myself and my patients by the commitment I eventually made.”

It’s worth noting that Westin’s two sons, Greg and Jeffrey, also went on to become physicians.

While gentle prodding and suggestions may have been present in their experience, both John and Henry admit that, in order to be truly successful in this business, the choice to pursue a career in medicine has to be one you make on your own.

“Sure, I might have felt a little bit of pressure, but you need to do it for you,” John said. “I always had my own confidence in what I was doing.”

Years after having made his own decision to pursue a career in medicine,

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John recalls giving his son, John Henry, as much freedom as possible when it came to deciding his own path in life. When the decision was finally made, however, he was overcome with emotion.

“I was so proud,” he said. “It’s an amazing feeling, having them succeed.”

John recalls that his cousin Joseph Zeiter had a similar experience when Joseph Jr. was accepted to medical school.

“When Joe Jr. got accepted to medical school, he (Joe) came into my office and was in tears,” he said. “He couldn’t have been prouder.”

From a business standpoint, with this sense of pride also comes a great sense of relief.

“The young people don’t realize the relief of a father who owns a business when there’s a child waiting to take over,” said Henry, who recently retired after 45 years of practice.

When he finally did end his career in medicine, the transition was made easier by the fact that his son and nephew were waiting to take the reins.

“I just jumped right in where he left off,” John said.

The seamlessness of this switch was no accident, however, with both John and Henry noting that, when John first entered the practice – long before retirement was in Henry’s sights, he was quick to pass on

Vitune Vongtama, MD Yaadbhiroon Vongtama, MD Roy Vongtama, MD Dan Vongtama, MD George Bensch, MD Greg Bensch, MD Helmuth Hoff, MD Mark Hoff, MD James Hoff, MD Laszlo Bela Fodor, MD Alexander Fodor, MD Fred Krueger, MD Kyle Krueger, DO Sherman Saffier, MD James Saffier, MD Sandon Saffier, MD Graciela Barzaga, MD Pearl Barzaga Scott, MD Dora Lee, MD Robing Wong, MD

Peter Salamon, MD Michael Salamon, MD Sarah Salamon, MD Jack Funamura, MD Janwyn Funamura, MD Jamie Funamura, MD Edward Cahill, MD Carol Cahill, MD Kimberly Cahill Peterson, MD Kevin Cahill, MD Christopher Cahill, MD George Chen, MD Andrew Chen, MD George Veldstra, MD Brad Veldstra, MD David Yarbrough, MD John Yarbrough, MD John F. Blinn, Sr. , MD John F. Blinn, Jr. , MD John F. Blinn, III , MD Jonathan Rigdon, MD Michael Rigdon, MD Morris Balfour, MD Stephen Balfour, MD Robert G. Howen, MD Walter E. Howen, MD Javad Jamshidi, MD Neema Jamshidi, M.D. Ramin Jamshidi, M.D. Gordon Roget, Sr., MD Gordon Roget, Jr., MD Vance Roget, MD Donald Nakashima, MD Carol Nakashima, MD

winter 2014

Cover Story > The Family Buesiness

Dr.PamelaTsuchiya &Dr.AlanNakanishi

Others, however, admit that seeing first-hand the demands the medical profession placed on their own parents caused them to think long and hard about entering the medical profession. the more tedious and demanding duties to his freshly-minted physician son.

“The minute he came into the office I told him ‘You’re doing all of the surgeries,’” Henry said. “After doing 30,000 cataract surgeries, I miss it about as much as I would miss trying to speak Swahili.”

This decision allowed Henry to spend considerable more time with patients over the final decade or so of his career, something both father and son agree was in the best interest of the practice.

“It let me retire at my height,” Henry said.

“What you lose in medicine is energy – it’s a grind.” John added. “It’s a grind that starts in college. You’ve got 12 years of training before you see your first patient. Even now, when I see Joe Jr., I think, man, that kid has a lot of energy.”

Now, with five Zeiters having chosen medicine as their path in life, one has to stop and wonder just how long this unlikely chain of father-to-son (or potentially daughter) legacy will continue. In other words, just how long will there be fresh family blood and youthful energy coming into the Zeiter Eye Medical Group?

“Five is pretty much unheard of. Now, if one of my grandkids or Joe’s grandkids were to do it?” John said while smiling. “Well, it would just defy the odds.”

winter 2014

Ernest Fujimoto, MD Scott Fujimoto, MD Donald E. Lamond, MD Roderick G. Lamond, MD Michel G. Khoury, MD George M. Khoury, MD Vincent Pennisi, MD Vincent R. Pennisi, MD Vincent P. Pennisi, MD Vincent B. Pennisi, MD Dominic P. Pennisi, MD

F. Karl Gregorius, MD Theodore Gregorius, MD John Gregorius, MD Stephen Gregorius, MD Joseph Wong, MD Jillian Wong Millsop, MD Paul Waters, MD Brian Waters, MD

Clarence S. Ing , MD Isabel Ing, MD Clarence S.F. Ing, MD Kenneth T.F. Ing, MD Michael B. Ing, MD Luis Arismendi, MD Christopher M. Arismendi, MD Jeffrey Ing, MD *This list was created from responses to the survey that was mailed to all active and retired SJMS members.

SAN JOAQUIN PHYSICIAN

35

v i c victory

tor

On November 4, the voters of California spoke loudly

and definitively, sending the trial lawyers’ Proposition 46 to defeat by a vote of 67 to 33. The message is clear – Californians simply don’t want to increase health care costs and reduce health access so trial attorneys can file more lawsuits.

An increase in the Medical Injury Compensation Reform Act (MICRA) cap on non-economic damages has been rejected in California again and again: 10 times in court, 5 times in the Legislature and now overwhelmingly by voters.

This idea now has its own dedicated spot in California’s political trash heap.

But this time, we energized the membership of CMA as a whole to fight the fight together, as one unified voice of medicine, representing the patients we so deeply care about and the care that we have committed to provide them.

Despite the trial attorney proponents’ attempt to sweeten the deal by adding provisions that polled well– physician drug testing and mandatory checking of a prescription database – voters said NO on Election Night. As people throughout the state heard from physicians and No on 46 coalition members about the real intentions of the measure’s proponents, there was resounding opposition.

One of the secret weapons of this effort was the size and diversity of our coalition. We helped amass one of the largest and most diverse campaigns in California history. The breadth of the coalition — which includes labor, business, local government, health providers, community clinics, Planned Parenthood, ACLU, NAACP, taxpayers, teachers, firefighters and more – underscores just how important affordable, accessible health care is to every Californian.

In addition to the groups on the ground talking to voters about the deception and trickery behind Prop. 46, every major editorial board in California

opposed the initiative.

The Los Angeles Times said, “As worthwhile as [Proposition 46’s] goals may be, the methods the measure would use to achieve them are too flawed to be enacted into law.”

The San Francisco Chronicle decried Prop. 46 saying that the measure, “overreached in a decidedly cynical way.”

The Orange County Register, UT San Diego, San Jose Mercury News, Monterey County Herald, Sacramento Bee and dozens of other newspapers echoed these sentiments.

The efforts of the California Medical Association and the county medical associations across the state is a tremendous showing of what we can do for the future of health care, the quality of medicine and the dedication to patients everywhere. Working together to spread the truth about Prop. 46, building coalitions across communities and standing strong as one united voice is what helped carry us to victory.

This was one of the most contentious and high-stakes ballot fights in California history and we rose to the occasion. We must use this unity moving forward and showcase to our colleagues the value the California Medical Association brings to our great profession and stay united for whatever comes our way next.

ry winter 2014

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ORTHOPEDIC EXCELLENCE

Dameron Hospital’s award-winning orthopedic program includes community educational workshops, surgical and nonsurgical treatment options, treatment of orthopedic injuries and trauma, and rehabilitation. Specializing in spine, hip, knee, shoulder, ankle and joint replacement, Dameron’s physicians, surgeons and nurses work together to minimize pain and shorten recovery time for each patient.

Get back to enjoying the ACTIVE YOU.

209-944-5550 DameronHospital.org

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Rated Best in Stockton Region for Joint Replacement in 2012.

SAN JOAQUIN PHYSICIAN

winter 2014

CMA > Legislative Wrap Up 2014

The Ultimate

Measure

By Janus L. Norman, CMA Senior Vice President

C M A’s 2014 L e g islati v e W rap U p

For more than 150 years, the California Medical Association has upheld the banner for practicing physicians. Year after year, the state medical society has partnered with the local medical societies to diligently strive to ensure the care and well-being of patients and to protect public health by working for the betterment of the profession.

In years of prosperity, the challenge of carrying out this duty is restrained. In years of controversy, the same duty is laborious. This year was full of controversies.

The fight to defend the Medical Injury Compensation Reform Act (MIRCA) may have ended with a ballot box victory in November, but the threat of a statewide ballot measure loomed heavily from the onset of the 2014 Legislative Session. The leader of Senate, President Pro Tempore Darrell Steinberg, introduced Senate Bill 1429 as vehicle to execute the strong-arm strategy of the plaintiffs bar attorneys to eliminate MIRCA’s cap on non-economic damages. Tremendous political pressure and immature bullying tactics were employed in an attempt to force CMA to the bargaining table, but the association held fast to its principle of working to create an economic environment that allows physicians in all specialties the ability to practice throughout California. Rejecting the false choices presented by opponents of MICRA and choosing to make our case before the people of California, CMA united its political allies to ensure Senate Bill 1429 never received a hearing, leaving the trial attorneys’ Proposition 46 ballot measure the only available avenue for overturning MICRA.

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CMA > Legislative Wrap Up 2014

Senator Mark DeSaulnier’s Senate Bill 1258 contained another component of Proposition 46: the requirement for Schedule V controlled substance prescriptions to be reported to the Controlled Substance Utilization, Review and Evaluation (CURES) database.

The bill also would have required the electronic prescribing of controlled substances, expanded government access to CURES and dictated the quantity of controlled substances allowed to be prescribed. Like the mandatory checking of CURES inserted into Prop. 46, SB 1258 was touted as a bill to address prescription drug abuse. However, the impact would have been to legislate the practice of medicine, undermine the patient/physician relationship and reduce patient access to care. CMA was instrumental in killing the bill, which was held in the Senate Appropriations Committee. The committee’s action prevented passage of bad policy and also extinguished Bob Pack’s ability to use the bill as a platform from which to campaign against CMA in the months leading up to the November vote on Prop. 46.

Senate Bill 492, authored by Senator Ed Hernandez, sought to expand to scope of practice of optometrists to included surgical procedures and primary care services. Senator Hernandez, a practicing optometrist and Chair of the powerful Senate Health Committee, worked feverously toward the passage of Senate Bill 492, which passed out of the Senate in 2013 and was resting in the Assembly.

Utilizing his great inf luence and charm, Senator Hernandez, along with the Optometric Association, battled with CMA, the California Academy of Eye Physicians and Surgeons, the California Academy of Family Physicians and the California Society of Plastic Surgeons to win the votes of the members of State Assembly. Hundreds of CMA members made phone calls and wrote emails and letters outlining the f laws within Senate Bill 492 and urging legislators to vote no on the measure. As the coordinated statewide effort moved forward, members of the Assembly began to acknowledge the harm that would have resulted from

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irresponsibly expanding the scope of optometrists to perform surgeries and provide primary care services by publicly committing to stand with the physician community in opposition to Senate Bill 492. With a majority of the members poised to oppose the measure, Senator Hernandez and the optometrists agreed to drop the bill and allow it die quietly on the Assembly Floor.

California’s physician shortage is consistently utilized as an argument for expansion the scope of allied health professionals. To combat this argument and the increase access to quality care, CMA has prioritized improving our state’s physician workforce by increasing the number of residency slots for medical school graduates. Studies have indicated that where a physician completes his or her residency is a primary indicator of where the physician will practice.

CMA pushed the state to make an initial investment in its future medical workforce. The 2014-15 Budget Act signed by Governor Brown included $7 million to support primary care residency slots through the state’s Song-Brown program. Of that $7 million, $4 million will be prioritized to residency programs that wish to expand and train additional residents in internal medicine, pediatrics, obstetrics-gynecology and family medicine.

The 2014-15 state budget also provided significant resources to physicians.

Specifically, the budget includes $3.7 million to draw down $37.5 million in federal funds for technical assistance to Medi-Cal providers on implementing and achieving meaningful use of electronic health records (EHRs). The 10 percent contribution from the state will allow an additional estimated 7,500 Medi-Cal providers to participate in the MediCal meaningful use incentive program and receive the necessary training from the existing technical assistance infrastructure. In addition, CMA convinced the Governor to forgive the retroactive Medi-Cal cuts contained in AB 97 (Chapter 3, Statutes of 2011), which reduced Medi-Cal provider cuts by 10 percent.

For the last several years, CMA led the effort to seek an injunction to invalidate and stop the implementation of the 10 percent Medi-Cal cuts, arguing that this reduction would threaten the ability of physicians to continue to treat Medi-Cal beneficiaries and would create significant gaps in access to care for this population.

The legal process ran its course when the U.S. Supreme Court declined to hear our appeal. CMA was, however, able to convince Governor Brown to not attempt to retroactively collect the portion of the cuts during the period of time the injunction was in place. As a result, physicians will be able to retain $218 million in Medi-Cal payments.

During the last months of the 2014 legislative session, CMA learned of the imminent closure of Doctors Medical Center in Contra Costa County. Doctors Medical Center (DMC) is the area’s main medical facility, serving over 250,000 patients in west Contra Costa County, including the city of Richmond and surrounding areas. Even though over 80 percent of its patient population is insured through Medi-Cal or Medicare, low reimbursement rates prevent DMC from creating a business model that would allow for sustained financial viability. CMA sponsored Senate Bill 883 (Hancock) to appropriate $3 million from the Major Risk Medical Insurance Fund to DMC to provide bridge funding to secure additional avenues of finance and create a new and viable business model for the facility going forward.

CMA sponsored and strongly supported additional legislation that addresses the daily challenges faced by physicians and raised public awareness surrounding critical health care issues.

Assembly Bill 1755, authored by Assembly Member Jimmy Gomez and co-sponsored by CMA and Planned Parenthood Affiliates of California, was signed by Governor Jerry Brown. The bill will improve California’s notice requirement specific to breaches of medical information in order to reduce administrative burdens on providers and health facilities, while also ensuring accurate notification to patients, thereby

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CMA > Legislative Wrap Up 2014

allowing health care providers to put those resources back into patient care.

CMA, joined by various patient advocacy groups, worked with the Legislature and Governor to secure the enactment of Senate Bill 964 (Hernandez), which required Medi-Cal managed plans and insurers offering individual plans through Covered California to provide annual reports to the California Department of Managed Health Care (DMHC) about the adequacy of their provider networks and to make the reports available online.

Our successful advocacy did not come without sacrifices. As CMA battled in the Assembly to defeat Senate Bill 492, Senator Hernandez, Chair of Senate Health, held two CMA sponsored bills hostage in the Senate: Assembly Bill 2400 (Ridley-Thomas), which reintroduced an important discussion in the Legislature about the contracting relationship between physicians and health care plans and health care insurers, and Assembly Bill 1771 (Pérez), which would have ensured physician reimbursement for

non-face-to-face patient management services to help increase patient access to care. Ultimately, CMA stood strong in the midst of controversy and held to its core principle of ensuring the safety of patients, and as a result both measures were held in the Senate. However, CMA was able to convincingly make the policy argument for both measures and to secure bipartisan support for the underling policy, for which we will be advocating again in the near future.

In its first year, the “My CMA Idea” contest produced one of the most hotly debated topics of the year: the negative impact of sugary drinks. CMA cosponsored SB 1000 (Monning), which would have required warning labels on sugary drinks. A strategy to help educate consumers about the risks associated with consuming sugary drinks, the bill was the first of its kind in the country. It generated unprecedented media attention, including coverage by international media outlets. Twenty-four California papers editorialized in support of the bill.

Scholastic News magazine, a teaching

tool distributed throughout the country, included stories on the bill in a way that encouraged classroom debate on the issue. SB 1000 was even referenced in the nationally syndicated cartoon strip “Drabble.”

SB 1000 faced a tough political environment from the outset, with the soda industry pulling out all the stops to defeat it. Though the bill died in the Assembly Health Committee, the campaign supporting the bill showed CMA’s strong commitment to reducing obesity, our willingness to pursue innovative public health policy and – most importantly – helped educate people about the risks associated with consuming sugary drinks.

As Martin Luther King, Jr. famously said, “The ultimate measure of a man is not where he stands in moments of comfort and convenience, but where he stands at times of challenge and controversy.” In 2014, I am proud to say, CMA measured up!

Below are details on the major bills that CMA followed this year.

CMA-Sponsored Legislation AB 1755 (Gomez): Medical Information Status: Signed by the Governor.

This bill improves California’s notice requirement specific to breaches of medical information to reduce administrative burdens on health facilities and ensure accurate notification to patients. Currently, health facilities in the state must report any unauthorized access of a patient’s medical information to the California Department of Public Health (CDPH) and directly to the patient within five business days or face a penalty. This bill makes three small changes to the law: it extends the notification timelines from 5 to 15 business days, providing a longer time frame for health facilities to complete an internal investigation before notifying the patient of the incident; allows patients to designate and alternate address or means for notification rather than the patient’s last known address, as required by current law; and lastly, provides CDPH with discretion on when to investigate a report of unauthorized access rather than requiring investigation of each and every incident no matter how minor.

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AB 1771 (V.M. Pérez): Medical Information Status: Held in Senate Appropriations Committee.

This bill would have required health insurance companies licensed in the State of California to pay contracted physicians and qualified nonphysician health care providers for telephone patient management services.

AB 1805 (Skinner and Pan): Medi-Cal Reimbursement – Provider Payments Status: This bill was an advocacy vehicle. Budget eliminated the retro-cut, which eliminated need for the bill.

This bill sought to restore the 10 percent cut to Medi-Cal provider reimbursement rates that was enacted as part of the 2011 State Budget Act. The Governor presented a budget that included the elimination of the retroactive clawback, which eliminated any attempt to collect the uncollected 10 percent Medi-Cal reimbursement cuts in prior fiscal years, a savings of nearly $42.1 million for all MediCal providers.

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CMA > Legislative Wrap Up 2014 Decision Medicine > 2014

AB 2400 (Ridley-Thomas): Health Care Coverage – Provider Contracts Status: Author pulled bill from Senate Health Committee.

This bill would have prohibited health plan and health insurer contracts issued, amended or renewed on or after January 1, 2015, from containing the following terms: (1) Termination of the health care provider’s contract or participation status in the contract or the provider’s eligibility to participate in other product networks, if the provider exercises the right to negotiate, accept or refuse a material change to the existing contract. Physicians and physician groups and should not be forced to assume such obligations as a condition of maintaining access to their patients covered by commercial plans. (2) A requirement that a health care provider agree to accept or participate in other products or product networks, including future products that have not yet been developed or adopted by the plan, unless the plan discloses the reimbursement rate, method of payment and any other materially different contract terms for those products from the underlying agreement.

The bill also would have extended to health plan and insurer contracts through a preferred provider arrangement (PPO) the existing prohibition on contract provisions allowing for material changes without the changes first having been negotiated and agreed to by the health care provider. It would also have increased from 45 days to 90 days the advance notice a health plan or insurer must give a provider before implementing a material change to the provider’s contract, where the changes are made by amending a manual, policy or procedure document referenced in the contract which, under existing law, triggers the provider’s right

to negotiate and agree to the change or, if agreement is not reached, the right to terminate the contract.

SB 883 (Hancock): West Contra Costa Healthcare District Status: Signed by the Governor.

This bill allocates $3 million in bridge funding from the Proposition 99 Special Fund to Doctors Medical Center in order to allow the hospital to develop a viable financial model for operations.

SB 1000 (Monning): Sugar-Sweetened Beverages Status: Held in Assembly Health Committee.

This bill would have prohibited the sale of most non-alcoholic beverages with added sugar and over 75 calories per 12 f luid ounces without the following warning label: “STATE OF CALIFORNIA SAFETY WARNING: Drinking beverages with added sugar(s) contributes to obesity, diabetes, and tooth decay.” In the last thirty years, Americans’ daily calorie consumption has increased by 250-300 calories. Sugary drinks represented the largest single source of that increase. This bill would have helped to alert consumers about the health risks associated with consuming the empty calories in these types of beverages.

Strongly Supported Legislation AB 357 (Pan): Medi-Cal Children’s Health Advisory Panel Status: Signed by the Governor.

This bill renames the Healthy Families Advisory Board as the Children’s Health Advisory Board and transfers the panel’s advisory and reporting capacity from Managed Risk Medical Insurance Board

to the Director of the Department of Health Care Services on matters relevant to all children enrolled in Medi-Cal and their families.

AB 1522 (Gonzalez): Employment – Paid Sick Days Status: Signed by the Governor.

This bill requires most California employers to provide paid sick leave from commencement of employment to employees who work 30 or more days within a year. Employees will earn a minimum of one hour of paid sick leave for every 30 hours worked. Expanding paid sick leave coverage will help workers avoid going to work when they are most likely to transmit communicable diseases, a public health intervention also supported by leading national public health organizations, the American Public Health Association and the National Association of County and City Health Officials.

AB 1743 (Ting): Hypodermic Needles and Syringes Status: Signed by the Governor.

This bill extends by six years the current sunset of pharmacists’ authority to sell hypodermic needles and syringes without a prescription. It also removes the existing 30 syringe limit. Finally, it establishes a sunset date of January 1, 2018, for the hypodermic needle/syringe exemption in the law that makes possession of drug paraphernalia illegal.

SB 964 (Hernandez): Health Care Coverage Status: Signed by the Governor.

This bill requires all Medi-Cal managed care plans to be surveyed on quality management, utilization review, timely access and network adequacy.

Opposed Legislation AB 1886 (Eggman): Medical Board of California (Neutral) Status: Signed by the Governor.

The original language of AB 1886 would have required the Medical Board of California to post indefinitely all the

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information it posts online about physician discipline, criminal convictions, and reportable malpractice settlements. After negotiations, the author accepted amendments that addressed CMA’s concerns. The amendments allowed for indefinite posting

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CMA > Legislative Wrap Up 2014

of most disciplinary actions (suspension, revocation, surrender, probation), but continued to maintain the current posting limit of 10 years for letters of public reprimand. It also reduced the posting of citations from five years to three years. Additionally, it provided physicians a 30-day window to resolve or appeal a citation before it is posted to the website. Under current law, citations are

posted immediately.

Amendments also reduced the posting requirements for malpractice settlements. The amendments limit the posting of settlement information to when a physician has 3 or 4 settlements (the threshold is based on low vs. high risk specialties) over $30,000 in the last five years and those settlements would be posted for five

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years. This is a decrease from current law, which requires posting when a physician has 3 or 4 settlements of over $30,000 in a 10 year period. Current posting requirements are 10 years for this settlement information. The amendments reflect the concern that settlements are not a reliable measure of a physician’s competence. They also avoid indefinite posting of less severe disciplinary actions.

AB 2015 (Chau): Health Care Coverage – Discrimination Status: Failed in Assembly Appropriations Committee.

The bill would have required health plans to reimburse for services from alternative practitioners such as naturopaths and traditional Chinese medicine without referral from a physician.

AB 2406 (Rodriguez): Emergency Medical Services Authority – Abuse of Emergency Medical Services Status: Failed in Senate Public Safety Committee.

This bill would have expanded the scope of paramedics in the field and would have required Emergency Medical Services Authority to submit a report to the Legislature identifying programs that have been implemented by local emergency medical services agencies to address “misuse and abuse” of emergency medical services. Due to the vague nature of the proposed language, there was concern that the “misuse and abuse” requirement of the report would have negatively affected physicians’ ability to provide care because they would be subject to state reporting on certain aspects of the emergency room.

AB 2533 (Ammiano): Health Care Coverage – Noncontracting Providers Status: Failed on the Senate Floor.

The bill would have prohibited a non-contracting provider that agrees to

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New Laws > 2014

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CMA > Legislative Wrap Up 2014

provide services under these provisions from billing an enrollee or insured for any amount in excess of the in-network reimbursement rate.

SB 492 (Hernandez): Optometrist – Licensure Status: Held on the Assembly Floor This bill would have expanded optometrists’ scope by authorizing them to perform a range of therapeutic laser and scalpel procedures for superficial lesions of the eyelid and adnexa, as well as certain injections and immunizations.

SB 1258 required reporting to CURES of Schedule V controlled substances, created authority for non-sworn investigators who do investigations for Department of Consumer Affairs Boards to request reports from the database to investigate allegations of substance abuse of licensees, and mandated electronic prescribing of controlled substances. It also included a provision that limited controlled substance prescriptions to 30-day supplies unless prescribed for panic disorders, attention deficit disorder, chronic debilitating neurological condition, pain in patients with conditions known to be chronic or incurable or narcolepsy. The bill would have allowed controlled substance prescriptions associated with these conditions to be issued for a 90-day supply. It also prohibited prescriptions for controlled substances within 30 days of a patient receiving a controlled

substance prescription, unless the patient has used all but a seven-day supply of the previous prescription. CMA requested the complete deletion of the sections being amended because the issues with them are so significant. The author did amend the bill in an effort to address our concerns, however the amendments were not negotiated with us and were so poorly crafted that they created more issues than they solved.

SB 1303 (Torres): Public Health – Hepatitis C Status: Held in Senate Health Committee.

This bill would have required health care providers to offer a Hepatitis C screening to individuals meeting certain criteria. The bill would have legislated the practice of medicine.

SB 1215 (Hernandez): Healing Arts Licensees – Referrals Status: Failed in Senate Business, Professions and Economic Development Committee.

This bill would have eliminated the in-office exception to the self-referral law. In general, existing law prohibits physicians from referring patients for specified goods or services in which the physician or physician’s immediate family has a financial interest. However, there is an exception to this general Helping Families Cherish Life AseraCare Hospice® provides quality, compassionate care when you need it most. prohibition that allows Our family-centered, holistic approach ensures that the needs and wishes of our physicians to refer patients patients and their families are met when faced with life-limiting illness. for goods or services that are supplied in the physician’s Our services include: office or the office of a group • Physician managed care practice. This bill would • Admissions 24 hours a day, seven days a week have amended existing law • End-of-life decision making assistance • Special veterans recognition to eliminate this exception for in-office referrals for Rated above average by CalQualityCare.org advanced imaging, anatomic pathology, radiation therapy AseraCare Hospice–Stockton and physical therapy.

SB 1258 (DeSaulnier): Controlled Substances Prescriptions – Reporting Status: Held in Assembly Appropriations Committee.

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Do you know how to make Insulin 48

SAN JOAQUIN PHYSICIAN

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By Bernard P. Shagan, M.D.,

Why Sliding-Scale Insulin Coverage Doesn’t Work This article has been reprinted on behalf of the San Joaquin County Hospitals Diabetes Special Interest Group (SJCH-DSIG) for the reading pleasure of SJMS members.

“It is easy to get a thousand prescriptions but hard to get one single remedy” - Chinese Proverb You are treating a patient admitted to the hospital for Streptococcus pneumoniae pneumonia. You write the following orders:

1. Check the patient’s

4. If it is between 102.1

temperature every four hours.

and 103 give penicillin 1,200,000 units.

2. If the temperature

5. If it is between 103.1

is below 101° F, give no antibiotic.

and 104 give penicillin 2,400,000 units.

3. If it is between 101

6. If it is above 104,

and 102 give penicillin 600,000 units IV.

call the doctor.

work backward? winter 2014

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I am quite sure that any physician reading this article will recognize that the orders above are ridiculous.

They do not address the basic problem aff licting the patient, pneumoccccal pneumonia, but merely one manifestation of that problem, the fever. They allow the patient’s infection to escape from control repeatedly. They do not ref lect our knowledge about the disease, the patient, or our ability to reverse the pathophysiology with proper treatment. Yet there are many physicians who see the inadequacy of these orders but who, when treating diabetic patients, will write insulin orders which similarly bear no relationship to the disease, the patient, normal physiology, and the pathophysiology of the disease.

The system of orders to which I refer is called sliding-scale insulin coverage. It was developed when the normal physiology of insulin secretion and metabolic control was not understood and when the determination of blood sugar was laborious and time consuming. It was not physiological at the time and it remains non-physiological today.

In treating a diabetic patient , it should be our goal

to restore and maintain metabolic normalcy. We should attempt to keep the patient’s blood sugar as stable and euglycemic as possible without causing problems in that attempt (avoiding hypoglycemia particularly). The objective is not to let the patient become repeatedly sick (hyperglycemic, hyperlipemic, hyperosmolar, polyuric) and then to try to treat the problem that we have allowed to occur. Yet, this is precisely what sliding-scale insulin coverage does, in whatever form it is used.

Giving insulin in response

to a high blood sugar as a routine form of treatment is not physiologic, does not protect the patient, is not

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really a way of assessing the patient’s insulin sensitivity, and bears little if any relationship to the insulin needs of the patient under normal circumstances. Indeed, in terms of insulin secretion, infection, and osmotic regulation, this mode of therapy may be dangerous to the patient. It is always playing catch-

of glucose-containing f luids or continuous enteral feeding by tube, then insulin administration should be as continuous as possible, given on a continuous, around-the-clock basis as long as the calories are given on that basis.

up. If our goal is to maintain the patient in the best possible metabolic state, we cannot allow the patient’s glucose utilization and attendant blood sugar and lipid levels to seesaw throughout the day. If our goal is to approximate normal control as closely as possible, then we should do what we can to mimic normal insulin secretion. This entails giving insulin so that it can function prospectively and not attempting to make it work retrospectively.

The BasalBolus Insulin

Except when the patient is so dysmetabolic as to require

insulin without food, insulin should always be prescribed with caloric intake and in relation to that intake.

If the patient’s intake of calories is continuous, as when the patient is receiving continuous infusions

order set is designed to provide a continuous, more normal physiologic state of glycemic control. It is available now for your use and should replace the sliding scale insulin regimen for most diabetic patients outside of the intensive care unit. For questions regarding the use of Basal-Bolus Control orderset, please contact Pharmacy.

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Members-Only Benefits

Contact CMA Today!

When you join CMA, you hire a powerful professional staff to protect the viability of your practice. By protecting your practice from legal, legislative, and regulatory intrusions, your CMA membership lets you focus on what’s really important: your patients.

1-800-786-4262 www.cmanet.org/ benefits

Members can offset the price of their annual dues when using CMA membership services and discounts. Thanks to CMA’s group buying power, members receive deep discounts on everything from magazines to office supplies to insurance products.

Practice Resources CMA On-Call: CMA’s Health Law Library has over 4,500 pages of up-todate legal information on a variety of subjects of everyday importance to practicing physicians. Accessible to members at www.cmanet.org/ cma-on-call or by calling 800.786.4262.

“Practice Management Assistance: Trouble getting paid? Experts from CMA’s Center for

Economic Services provide free one-on-one assistance to members and their staff on reimbursement, contracting and practice management related issues. Services includes educational resources, one-on-one assistance with members or staff, intervention with payors, and seminars to empower your practice. Reach CMA’s reimbursement experts at (888) 401-5911.

Legal Services: CMA’s legal department provides members with information and resources about laws and regulations that impact the practice of medicine. While CMA staff cannot provide physicians with individual legal advice, our health law information specialists, with the support of CMA legal counsel, will help you find legal information and resources on a multitude of health-law related issues.

CME Tracking/Credentialing: CMA’s Institute for Medical Quality certifies CME activity for

credentialing purposes to the Medical Board of California, as well as to hospitals, health plans, specialty societies, and others. CME Certification is $29 a year for CMA members, $49 for nonmembers. IMQ, 415.882.5151 or www.imq.org.

CMA Webinar Series: CMA’s webinar series gives physicians the opportunity to watch online presentations on important topics of interest and interact with legal and financial

SJMS > Member Only Benefits

experts from the comfort of their homes or offices. The webinars are free to CMA members and their staff.

CMA also has 100+ archived on demand webinars available.

CMA Seminar Series: Experts from

CMA’s various centers travel to local county medical societies throughout the state, holding live seminars for members and their staff on a variety of issues. Contact your local county medical society for more information.

CMA Payor Contract Analysis:

CMA members have free access to objective written analyses of major health plan contracts at www.cmanet. org/ces. Each analysis is designed to help physicians understand their rights and options when contracting with a third party payor, as well as which contract provisions are prohibited by California law.

Certified Professional Coder Program: CMA members and their staff receive big discounts on Certified Professional Coder (CPC) training and certificates from AAPC. AAPC’s CPC credential is the gold standard for medical coding in physician office settings. Contact your local county medical society for more information.

Professional Resources

CMA produces a number of publications to keep members up to date on the latest health care news and information affecting the practice of medicine in California. Subscribe to any of these newsletters online at www.cmanet.org/newsletters.

CMA Alert: CMA’s bi-weekly

e-newsletter provides up-to-date

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information on many issues of critical importance to California physicians.

CMA Reform Essentials: CMA Reform Essentials is a regular publication designed to provide readers with the latest developments of California’s implementation of federal health care reform.

CMA’s Press Clips: CMA’s daily news roundup, provides a quick but meaningful overview of the day’s health care news.

CMA Practice Resources (CPR):

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Security Prescriptions: Get 15% off tamper-resistant security prescription pads and printer paper. RX Security, www.rxsecurity.com/cma.php.

Epocrates: CMA members get a discount on all Epocrates mobile and online products. Save 30% on subscriptions to Epocrates products such as the #1 rated Epocrates Essentials. Epocrates provides point-of-care access (via mobile devices and the web) to information on drugs, diseases and diagnostics. For more information visit www.cmanet.org/benefits.

of medical waste at a fraction of the cost charged by competitors. Find out more at www.enviromerica.com or by calling 650.655.2045.

Physician Practice Websites: Mayaco Design and Marketing offers CMA members deeply-discounted website design services for their practice starting at $1,250. Contact Mayaco at 209.957.8629 or visit www.mayaco. com for more information.

HIPAA Compliance: PrivaPlan offers HIPAA privacy and security compliance resource kits custom tailored to California’s regulations to CMA members at a discounted rate.

Find out more at www.privaplan.com.

Staples: Save up to 80% on office

supplies and equipment from Staples, Inc. Visit www.cmanet.org/benefits to access the members-only discount link.

DocbookMD: CMA members are eligible for a free download of the DocbookMD smart phone app which allows them to securely send HIPAA-compliant messages directly from their iPad, iPhone and Android devices. Find out more at www. docbookmd.com or by contacting your county society.

Marsh Insurance Services:

As the primary insurance advisor for CMA and its affiliated county organizations, Marsh offers a wide variety of sponsored insurance

Waste Management: EnviroMerica

offers CMA members heavily discounted medical waste removal and regulatory compliance services.

Through EnviroMerica, CMA members can protect themselves from regulatory fines, receive compliance consultations and properly dispose

plans and services for members.

With healthcare reform impacting members as employers, you need to be speaking with a knowledgeable advisor to consider your medical plan offerings, in or out of the health

Winter 2014 winter

SJMS > Member Only Benefits

exchange, for themselves, their employees and dependents in the months and years ahead. Designed to cover a multitude of insurance needs for your practice and personal needs the sponsored plans include three types of disability plans, three group life insurance programs, workers’ compensation, employment practices (with access to employment counsel

Financial Planning: Enjoy access to our partner, Wells Fargo Advisors, LLC, for financial advice and guidance from medical school through retirement. Dedicated regional advisors are available to address your financial needs. Learn more about these services and special CMA member benefits at www.cmanet.org/wells.

“My membership in the Riverside County Medical Association and CMA represents my commitment to our profession and my desire to protect myself against the legislative threats we face in Sacramento and Washington, DC. Additionally, the professional resources they provide to my practice far exceeds the nominal cost of membership.

As a first generation immigrant and physician, I am committed to preserving our rich history for the next generation – Won’t you do the same?” - Ava Mahapatra, M.D. included ), dental plans and personal insurance concierge services to help with you insurance planning. More information on Marsh’s sponsored benefit program can be found at www.countyCMAmemberinsurance. com or call 800.842.3761

Personal Resources Personal and Professional Banking Services: Union Bank has developed a package of discounted banking services specifically for CMA members, with up to $2,400 in

savings offers for your practice. To learn more about business credit and checking accounts, merchant services, payroll processing solutions and treasury management solutions offered by Union Bank, visit www. unionbank.com/CMA.

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Medical School Debt Management:

GL Advisor is a financial advisory firm that specializes in helping physicians effectively manage their medical school debt and other financial matters. Members receive a $50 discount on 12 months of service. A coupon code is required to access this discount. Get your code at www.cmanet.org/benefits or call 800.786.4262.

Magazine Subscriptions: 50% off

subscriptions to hundreds of popular magazines, with a best price match guarantee. Subscription Services Inc., www.buymags.com/cma or 800.289.6247.

Car Rentals: Save up to 25% on

car rentals for business or personal travel. Members-only coupon codes are required to access this benefit.

Get your code at www.cmanet.org/ benefits or call 800.786.4262.

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Discounted auto and homeowners insurance for CMA members. Mercury Insurance Group, 888.637.2431 or www.mercuryinsurance.com/cma.

Trouble Getting Paid?

In the past three years, CMA’s practice management experts recouped $7 million from payors on behalf of physician members. CMA provides members with one-on-one assistance to identify, prevent and fight unfair payment practices. Reach CMA’s reimbursement experts at 888.401.5911.

Why Join?

When you join your local medical society you join CMA as well, and together we are stronger.

Both CMA and your local Medical Society are aggressively defending the practice of our members, but the benefits of organized medicine extend well beyond these basic protections.

Members can offset the price of their annual dues when using CMA membership services and discounts.

Thanks to CMA’s group buying power, members receive deep discounts on everything from magazines to office supplies to insurance products.

From auto insurance to retirement plans, CMA’s discount programs will save you time and money. Many CMA members save more than their annual dues!

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Public Health

Update

What are the symptoms of flu? high temperature cold sweats, shivers headache aching joint aching limbs fatigue feeling utterly exhausted gastro-intestinal symptoms, such as nausea, vomiting, and diarrhea, are much more common among children than adults http://www.medicalnewstoday. com/articles/15107.php

Ebola Virus Disease

By Alvaro Garza, MD, MPH • San Joaquin County Public Health Officer The ongoing Ebola virus disease (EVD) epidemic in the West African countries of Guinea, Sierra Leone, and Liberia is the largest in history. In the U.S., the situation changes regularly and details and updates can be found on the U.S. Centers for Disease Control and Prevention (CDC) website, www.cdc.gov.

Ebola continues to pose a minimal threat to the U.S., California, and San Joaquin County. The main reason that the risk remains low is because transmission is only through

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direct contact with the body fluids of a person who is already ill with the disease. The infectiousness relates to viral load, which starts with symptoms onset and increases as the disease progresses. The places where there are people sick with EVD are the above-mentioned West African countries.

Clinical basics A non-specific prodrome, around 3 days, can include: fever >100.4⁰F or 38⁰C (87%), joint or muscle pain (39%), weakness (76%), and severe headache (53%),; often

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followed, around day 4, by diarrhea (66%), vomiting (68%), abdominal pain (44%), lack of appetite (65%); and around day 6, multi-organ failure and septic shock may develop along with abnormal bleeding (18%). Lab findings may include leukopenia, lymphopenia, thrombocytopenia, elevated amylase and hepatic transaminases, and coagulopathy.

Initially, EVD can often be confused with more common infectious diseases from those countries such as malaria, typhoid fever, meningococcemia, and other bacterial infections. There are no specific antivirals or vaccines effective against Ebola to date.

The incubation period can range from 2 to 21 days and commonly is 8 to 10 days. The case-fatality rate has ranged from 50% to 70% in past outbreaks. The reproduction (R₀) is less than 2, i.e., one EVD case infects, on average, less than 2 people. In comparison, the measles R₀ = 18, and the HIV R₀ = 4.

Clinicians should suspect EVD ONLY if a patient presents with any combination of the above compatible symptoms AND is within 21 days of travel from one of the three countries (Guinea, Sierra Leone, or Liberia) where they had contact with an ill EVD patient. If both the clinical and risk factors criteria are met, then the patient should be isolated; standard, contact, and droplet precautions followed; and a telephone call made to San Joaquin County Public Health Services (PHS) to help coordinate further evaluation and testing (see algorithm or website: www.sjcphs. org/Healthcare_Providers/Documents/EVD_sjco%20 EbolascreenFlowChart%20v2%2010%2017%202014.pdf).

Community response preparedness The best way to protect our residents from Ebola is to stop the epidemic in Africa. As those efforts are ongoing there, here County partners continue to coordinate collective protective response preparedness in a) the health care system, b) the public health system, and c) information sharing.

For health-care system preparedness, PHS, hospitals, medical care facilities, and emergency medical response partners are regularly communicating and coordinating with State and

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Federal agencies to prepare for and respond to any possible cases appearing here. Health care workers are aware of the issues and plans are in place in facilities to screen anyone as per the stated criteria and respond appropriately and timely. The UC hospitals have agreed and are prepared to take referrals to provide in-patient care for confirmed EVD cases. Prior to referrals, all hospitals should screen, identify and isolate any EVD suspect cases. To stay up-dated, please periodically check the PHS website for EVD-related information, as well as the California Department of Public Health (CDPH) (www.cdph.ca.gov), or the CDC (www. cdc.gov).

For public health system preparedness, PHS staff will communicate and coordinate with CDPH and CDC to determine if a case meets the criteria for testing at the CDC. The PHS lab is prepared to assist hospital or clinical labs with handling and shipping specimens to the CDC. Active contact tracing by public health nurses (PHNs) will be implemented if and when a case is confirmed. Also, PHNs are prepared to contact, assess exposure risks, and monitor travelers returning from those three West African countries during their incubation period. Epidemiologists are prepared to assist with other surveillance and epidemiologic investigation and reporting needs.

For information sharing, if and when a suspect case does present in the County and is confirmed, the news media will be given information to share with the public. PHS sends health alerts, advisories, or updates to the healthcare community and news releases to the public as new information requires. Urgent information sharing and planning is done through conference-call meetings of the Medical/Health Multi-Agency Coordination Group.

CAHAN (California Health Alert Network) sends alerts to health-care professionals regularly. The CDPH has established a telephone ‘hotline’ call center for public inquiries about Ebola: 1-855-421-5921. You can maintain situational awareness by visiting the websites of PHS, CDPH, and CDC that have relevant information updated regularly. Understanding the scientific evidence about Ebola transmission and prevention is the best way to protect the public’s health, our health.

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HEALTH BENEFIT EXCHANGE RESOURCES FOR PHYSICIANS See CMA's exchange resources page for information on exchange plan contracting, patient enrollment and eligibility, and more!

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practice manager Free to SJMS/CMA Members!

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

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

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

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

Registration required.

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

December 10th, 2014: “Medicare Update 2015” 11:00AM to 1:00PM

Join us for our annual Medicare Update workshop for physicians and office staff. This 2 hour seminar will cover relevant information about current, future and proposed changes for the coming year. ~Michele Kelly, Associate Director, CMA’s Center for Economic Services, provides one-on-one assistance to physician members and their staff on reimbursement and practice operations issues. Assistance ranges from coaching and education, to direct intervention with payors or regulators.

Are you reading CPR? CPR contains the latest in Practice Management Resources, Updates and Information.

January 7th, 2015:

“Show Me The Money” 11:00AM to 1:00PM

We are all working through the challenges of health care reform. A recent statistic stated that up to 41% of collections will take place prior to the patient ever seeing the physician in the near future! As we navigate through this change, this presentation will provide insights about how to shift the paradigm within the office from one where payment is received long after the visit, to one where payment is captured up front. There will also be multiple opportunities identified to assist Office Managers in monitoring and improving collection. ~Amy Germann, MBA, FACMPE Health Care Consulting Manager has more than 20 years of experience helping physicians, hospitals and ambulatory surgery centers with performance, business development, strategic planning and effective governance.

February 11th, 2015:

“Revenue Cycle Management” 11:00AM to 1:00PM

Learn the best practices for streamlining and monitoring your practice’s revenue cycle, for both in-house and outsourced billing. ~Amy Wolf, Valley Medical Management Medical Billing, Credentialing, and Consulting

March 11th, 2015: TBD 11:00AM to 1:00PM

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

SUBSCRIBE NOW

Sign up now for a free subscription to our e-mail bulletin, at www.cmanet.org/news/cpr

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Ramiro Zuniga, M.D. Family Practice 500 W Hospital Rd French Camp, CA 95231 (209) 468-6768

Harkawal Hundal, M.D. Cardiology 7373 West Ln Stockton, CA 95210 (209) 476-5120

Jagjit Singh, M.D. Internal Medicine 2350 N California St Stockton, CA 95204 (209) 943-0851

Brian Harris, M.D. Anesthesiology 2151 W Grant line Rd Tracy, CA 95376 (209) 832-6026

Gennady Shiferman, M.D. Radiology 7373 West Ln Stockton, CA 95210 (209) 476-5120

Randeep Bajwa, M.D. Nephrology 2350 N California St Stockton, CA 95204 (209) 943-0851

Rodger Orman, M.D. Anesthesiology 768 Mountain Ranch Road San Andreas, CA 95249 (209) 754-4334

Charlyne Wu, M.D. Radiology 7373 West Ln Stockton, CA 95210 (209) 476-5120

Richelle Marasigan, D.O. Family Medicine 77 W March Lane, Ste A Stockton, CA 95207 (209) 477-5552

Nguyen Vo, M.D. Internal Medicine 500 Hospital Rd French Camp, CA 95231 (209) 468-6000

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In Memoriam

In Memoriam Robert Boyd Talley MD

“I’ve had a good ride.

I’ve met and worked with some of the country’s finest medical practitioners and I’ve had the privilege and satisfaction of helping thousands of human beings.”

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Robert Boyd Talley MD January 21, 1931 - September 23, 2014 On September 23, 2014 Robert Boyd Talley MD passed away peacefully at St. Joseph’s Hospital.

He was 83 years old. Robert (Bob) was born in Scotts Bluff, Nebraska, on January 21, 1931 to Eloise and Richard Talley. He grew up with his sister, Earline, in Wyoming, New Mexico and Colorado. He completed his undergraduate work at Northwestern University in Illinois and received his medical degree from the University of Colorado.

While at University of Colorado he met his wife to be, Louise. After they married the two moved to Michigan for his internship at Wayne County General Hospital. Bob spent two years in the Navy in Albany, GA. At the University of Iowa he completed his internal medicine residency and Gastroenterology fellowship.

While in Iowa their sons, Robert B. Talley, Jr. and Edwin (Ted) Talley were born.

After arriving in Stockton in 1963 Bob began his 33 year medical career and was the first practicing Gastroenterologist between Bakersfield and Redding.

At St. Joseph’s Hospital he served as Chief of Staff, Chief of Medicine and on the Board of Trustees.

He was very committed to the American College of Physicians, San Joaquin Foundation for Medical Care, California United Foundation for Medical Care, and the American Managed Care and Review Association. He was a member of the San Joaquin Medical Society for 50 years.

In 1981 Bob received the distinguished honor of being elected to the Institute of Medicine of the National Academy of Science. In 2002 he received San Joaquin Medical Society’s Lifetime Achievement Award.

In his own words, Bob summed up his medical career, “I’ve had a good ride. I’ve met and worked with some of the country’s finest medical practitioners and I’ve had the privilege and satisfaction of helping thousands of human beings.”

Following retirement his dedication to the community continued as he was involved with, Stockton Symphony Association, St. Joseph’s Hospital Foundation, Mary Graham Children’s Shelter Foundation, Children’s Home of Stockton, Hospice of Stockton and Stockton Golf and Country Club.

Bob knew that behind it all was his loving and supportive wife, Louise. In December, Louise and Bob would have celebrated their 60th wedding anniversary. He will be greatly missed by his wife, Louise, sons Rob and Kim and Ted and Beth Talley, and beloved grandchildren, Caroline, Emily, Nicholas and Andrew Talley.

Bob was a wonderful husband, father, granddad, doctor, golfer, volunteer, neighbor, friend, joke teller, dog walker, and all around great guy! “We will miss you.”

SAN JOAQUIN PHYSICIAN

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