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Decision Medicine: Opening New Horizons Students Observe Live Surgeries in Expanded Program Fall Issue 2010 FALL 2010

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Volume 58, Number 3 • September 2010

{FeATUReS}

10 18 32 40

DR. JIM HAlDeRMAN HALDeRMAN A Few Minutes with our New President

{DePARTMeNTS} 22 MeDICAl MeDICAL leADeRSHIP LeADeRSHIP COUNCIl COUNCIL (MLC) Report

COMMUNICATINg WITH HOSPITAlISTS HOSPITALISTS

26 IN THe NeWS

ACCOUNTABle ACCOUNTABLe CARe ORgANIzATIONS ORgANIZATIONS

38 lOCAl LOCAL CMe OFFeRINgS 48 MeMBeRSHIP BeNeFITS

DeCISION MeDICINe:

63 IN MeMORIAM 68 HeAlTHCARe HeALTHCARe HAPPeNINgS IN PICTUReS

Opening New Horizons

New Faces and Announcements

CMA launches new monthly resource

ON THE COVER: Orthopedic Surgeon George Westin performs a full knee joint replacement while Decision Medicine student Jasmyne Sermeno observes. Jasmyne was being mentored by Dr. Robin Wong who is pictured assisting Dr. Westin at St. Joseph’s Medical Center.

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

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

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

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

Moses Elam, MD Wendi J. Dick, MD Raissa Hill, MD Jerry Soung, MD

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

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

(209) 333-7422 Frank M. Hartwick, M.D. Majid Majidian, M.D. R. Brandon Rankin, M.D. Grant W. Rogero, M.D. Roger P. Vincent, M.D.

Committee Chairpersons MRAC F. Karl Gregorius, MD

Decision Medicine Kwabena Adubofour, MD

Ethics & Patient Relations to be appointed

Communications Moris Senegor, MD

Legislative Jasbir Gill, MD

Community Relations Joseph Serra, MD

Audit & Finance Marvin Primack, MD

Member Benefits Jasbir Gill, MD

Nominating Hosahalli Padmesh, MD

Membership to be appointed

Public Health Karen Furst, MD

Scholarship Loan Fund Eric Chapa, MD

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

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Lawrence R. Frank, MD Francis Isidoro, MD Gabriel K. Tanson, MD Roland Hart, MD

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

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MeSSAge Message>>executive ExecutiveDirector Director

““ Individually, Individually, we we are are one one drop, drop, but but together together we we are are an an ocean.” ocean.” Th ose words Those wordswere werespoken spokenbybyDr. Dr.Susan SusanKaweski, Kaweski,San SanDiego DiegoCounty CountyMedical MedicalSociety’s Society’snew new president during her recent installation ceremony. She further stated, “and united president during her recent installation ceremony. She further stated, “and unitedwe wemust mustbe, be, especially ese are cult times especiallyininthese thesetumultuous tumultuoustimes” times”totowhich whichI Icouldn’t couldn’tagree agreemore. more.Th These arediffi difficult times for forphysicians physiciansand andthe themedical medicalcommunity communityasasa awhole. whole.Far-reaching Far-reachingchanges changesare arehappening happening atata abreak-neck break-neckpace paceininWashington, Washington,D.C., D.C.,and andatatour ourown ownstate statecapital. capital.AsAsDr. Dr.Kaweski Kaweskisoso eloquently eloquentlystates, states,we weneed needsolidarity solidarityamongst amongstour ourranks rankslike likenever neverbefore. before.One Onevoice voicemay maybebe ignored y hard ignoredand andno noone onenotices, notices,but butwhen whena achorus chorussings singsininharmony harmony––it’s it’sprett pretty hardtotonot nottake take notice. notice. Membership en perceived Membershipisisoft often perceivedasasa anon-essential non-essentialcost costofofdoing doingbusiness. business.Something Somethingyou yousign sign upupfor out of habit or peer pressure. Some see it as a duty, having joined early in their medical for out of habit or peer pressure. Some see it as a duty, having joined early in their medical career careerand andnever nevertaken takenthe theopportunity opportunitytotobecome becomemore moreinvolved involvedororseek seekany anyofofour ourservices services and andsososadly, sadly,never nevertruly trulysee seethe thevalue valueofofmembership membershipbecause becausetheir theirown ownperception perceptionisisskewed skewed towards le ororno towardsititbeing beingsomething somethingofoflittlittle novalue. value.Nothing Nothingcould couldbebefurther furtherfrom fromthe thetruth. truth. Membership ts, but Membershipnot notonly onlyprovides providesyou youextensive extensivepersonal personalbenefi benefits, butopens opensa awide widearray arrayofof services ll several servicestotoyour yourpractice practicemanagers managersand andstaff staffasasa awhole. whole.Beyond Beyondthat, that,we wecould couldfifill severalpages pages with the extensive list of services CMA provides as well. with the extensive list of services CMA provides as well. To Totruly trulyappreciate appreciatemembership, membership,you youhave havetotoexperience experienceititororatatleast leastappreciate appreciatethe theextensive extensive lobbying lobbyingtaking takingplace placeevery everyday dayon onyour yourbehalf behalfininboth bothSacramento Sacramentoand andD.C. D.C.For Forthose those members memberswho whohave havehad hadtotocall callususand andrequest requestassistance assistancewith witha acollection, collection,billing, billing,coding, coding, contract contractororpersonnel personnelissue, issue,membership membershipvalue valueisiseasy easytotocomprehend comprehendand andseldom seldomenters enters their er help ended our theirthoughts thoughtsaftafter helphas hasbeen beenrendered. rendered.For Forthose thosethat thathave haveattattended ourannual annualHouse House ofofDelegates Delegatesororyearly yearlyvisit visittotothe thecapital capitalfor forLegislative LegislativeDay, Day,value valueisisagain againsecurely securelyreinforced reinforced because rst-hand the ed voice becausethey theysee seefifirst-hand theimpact impactour ourunifi unified voicehas hasininthese thesearenas arenasofofthought. thought. My rst-hand the Myhope hopeisisyou youhave havehad hadthe theopportunity opportunitytotosee seefifirst-hand thevalue valueofofyour yourmembership membershipand and feel feelpositive positiveabout aboutthe thecontribution contributionyou’re you’remaking makingininthe thefuture futureofofmedicine medicinebybybeing beinga apart partofof something somethingmuch muchbigger biggerthan thanyourself. yourself.Possibly Possiblyeven evenananocean. ocean. All Allthe theBest! Best!

Mike MikeSteenburgh Steenburgh Executive ExecutiveDirector Director

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Moris MorisSenegor, Senegor,MD MD Editor Editor Editorial ee EditorialCommitt Committee Shiraz ShirazBuhari, Buhari,MD MD Kwabena KwabenaAdubofour, Adubofour,MD MD Robin RobinWong, Wong,MD MD William WilliamWest West Managing ManagingEditor Editor William@sjcms.org William@sjcms.org Michael MichaelSteenburgh Steenburgh Contributing ContributingEditor Editor Sherry SherryRoberts Roberts Creative Director/Graphic Creative Director/GraphicDesigner Designer sherry@sjcms.org sherry@sjcms.org Contributing ContributingSources Sources California CaliforniaMedical MedicalAssociation Association Los LosAngeles AngelesCounty County Medical MedicalAssociation Association San SanDiego DiegoCounty CountyMedical MedicalSociety Society Th e San The SanJoaquin JoaquinPhysician Physicianmagazine magazine isispublished publishedquarterly quarterlybybythe the San SanJoaquin JoaquinMedical MedicalSociety Society Suggestions, Suggestions,story storyideas ideasoror completed stories completed stories writt en bybycurrent written current San SanJoaquin JoaquinMedical MedicalSociety Society members members are arewelcome welcomeand andwill willbebereviewed reviewedbyby the ee. theEditorial EditorialCommitt Committee. Please Pleasedirect directallallinquiries inquiries and submissions and submissionsto: to: San SanJoaquin JoaquinPhysician PhysicianMagazine Magazine 3031 3031W.W.March MarchLane, Lane,Suite Suite222W 222W Stockton, Stockton,CA CA95219 95219 Phone: Phone:209-952-5299 209-952-5299 Fax: Fax:209-952-5298 209-952-5298 Email EmailAddress: Address:gena@sjcms.org gena@sjcms.org Medical ce Hours: MedicalSociety SocietyOffi Office Hours: Monday Mondaythrough throughFriday Friday 8:00 8:00AM AMtoto5:00 5:00PM PM

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San Joaquin Medical Society and CMA Members Enjoy: Vast CMA Resources: Serving the counties of San Joaquin, Calaveras, Alpine, and Amador

“My Membership provides me a Voice in Sacramento and Washington DC.” Thomas McKenzie, MD

• • • • • • •

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

San Joaquin Medical Society Resources: • • • • • • • • • •

Annual Directory CMA Member Seminars Cost Saving Benefits Quarterly Publication Website/Online Resources Insurance Savings Alliance Membership Annual Social Events Patient Referrals Office Manager Forum and Practice Resources

Federal, State, and Local Advocacy: Your Dues are an Investment which Supports our Efforts in Protecting Your Rights. If we don’t Fight for You ... Who Will?

Phone: (209) 952-5299

www.sjcms.org

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MeSSAge > From The President

A Few Minutes with our New President Dr. Jim Halderman You practice and live in Tracy, but you’re not a native of California, tell us a little about yourself: My medical career began back in Arkansas in 1991. That was the year that I entered the University of Arkansas School of Medicine. In the summer of 1995 I moved to New York and entered my internship year at Flushing Hospital which was a large community hospital in Queens. That was a smart move because Flushing Hospital was one of a few hospitals in the country that still truly allowed the junior training staff to take on nearly full responsibility for their patients ‘ in –house medical care. That level of freedom for interns and junior residents is nearly extinct now due to liability

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concerns and Medicare practice guidelines. Once I had completed my Anesthesiology training at New York Hospital, I moved to San Francisco for a year to learn about Pain Medicine. I found an opening at Sutter Tracy Community Hospital in Tracy the following year and have lived and worked there for 10 years now. You have served on the San Joaquin Medical Society Board since 2004, what interests you most about society leadership? Five years ago, the San Joaquin Medical Society fell on hard times. The Society was under threat of a lawsuit and costly financial losses due to an obsolete business model. I received a call from Dr. Marvin Singleton who was the Society’s incoming President that year. He asked me to serve on the Board and I agreed to do that. I enjoy politics and I like to dabble in financial matters too. Serving the Society as a board member and as a delegate to the California Medical Association (CMA) House of Delegates allows me to pursue those interests.

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lifestyle of a solo practice doctor is indeed more demanding In your opinion, what is the greatest on both the doctor and his family; especially if the doctor is challenge facing Physicians today and how also a wife and mother. The historic demands of solo practice can the medical society help? have led many younger doctors (and a few older ones too) The single greatest challenge to physicians and the patients for into joining group practices that disperse the workload to a whom we care is the “uncertainty” that hangs like a pall over more tolerable level. However, there is something else going our future ability to provide the care that our patients need. on here too. As medical practice has faced greater and greater Frankly, the medical “entitlement” establishment is financially intrusions from the financiers and the regulators from both bankrupt and there is a lack of understanding of the situation the government and the third party payers, our practices among the political class at the state and national levels. This have become more cumbersome to manage. Ask any doctor lack of understanding of both the medical practice patterns how much paper and the economics work, red tape, and of medical practice byzantine bureaucracy realities has created their office staff must even more confusion “Clearly, we are at a crossroads of navigate to complete a this past year as great competing visions for the future. It is billing or just to receive changes have rapidly an authorization to come to pass in the imperative that we all participate in this treat, and you will get political and regulatory epic ebb and flow of ideas in order to an earful. The basic arena. It is crucial that preserve what is thought to be the finest economics of such physicians and patients gratuitous non- medical band together and come medical care available in the world. work that must be done to a clear consensus The best way for doctors to make their and that is also poorly of what must be done paid will likely continue to improve access to voices heard is to join the San Joaquin to break many solo high quality medical Medical Society and The California practices. care. The current that Medical Association and participate in is moving across the What excites medical- government the arena of ideas” you about the complex right now is - Jim Halderman, MD future of the San counterproductive. Joaquin Medical Recent political Society? maneuverings at the San Joaquin County national level have Medical Society suffered some hard times in years past. taken on an approach that places access to quality medical Much of that was caused by hanging on to some unviable care second to a process of generalized redistribution of business ventures. We also had difficulty agreeing on what wealth from upper economic classes to the lower classes. This our mission was to be. I certainly don’t blame anyone for the philosophical “class conflict” is a short -sighted distraction and past. We are doctors, not Wall-Street tycoons. Over the past is not a useful tool to improve access to medical care today. several years we’ve been blessed with strong leadership at This ulterior motive must be abandoned if access to medical the board level and now have a stable management team in care is to continue at the level that Californians, and especially place with Mike Steenburgh at the helm, and he is assisted by those on Medicare or Medi-Cal expect. Gena Welch as our dedicated membership coordinator, and Debbie Pope as our Office Coordinator. Our membership Solo physicians are having difficulty has grown under their stewardship more than anyone keeping their practices afloat; do you see expected. any positive changes coming?   We also have seen our community service programs such I am disappointed to see solo medical practices decline to as Decision Medicine flourish. I’m especially pleased to see such an extent. I and many other doctors chose a career in that. Lastly, but not least, I’m pleased that many local doctors medicine precisely because the solo career choice allows a and more doctors from the foothill counties in our society doctor and patient to gain the closest and most mutually have become active in the society. The past few years we have appreciative professional relationship. Many of us and our seated a full complement of delegates from our region to the patients may well have known only one doctor for most CMA House of Delegates. A few important policy measures of our lives. Sadly, this has become a relic of the past. The

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Message > From The President that affect our region were decided on narrow vote counts that probably would have failed if not for the doctors who chose to take time off from their busy practices and travel out of town to represent our society. As the incoming President, have you set goals for The San Joaquin Medical Society? My goal as President of the Society, and the board members as well, is first and foremost to safeguard our finances. That is

job #1. Secondly, I wish to help our fine society staff grow the Society’s membership as much as possible. I believe that is how we can best voice our concerns to the political decisionmakers in Sacramento and Washington DC. Thirdly, I am pleased that we have succeeded in funding many more community service projects and hope to further that as well. As a Delegate to CMA’s House of Delegates, what bills or resolutions do you see coming along? The House of Delegates is a fascinating assembly. Every year there are resolutions put forth which address everything from vaccines for children to statements of concern for the well being of Buddhist Monks in Tibet. What comes through the pipeline each and every year are questions concerning practice guidelines, public health, medical care financing, and a few other important issues. This year I expect to see those again in various shades as our practice environment does change somewhat from year to year. I am certain we will see plenty of material relating to President Obama’s healthcare plans.

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(209) 957-3888 caring support guidance choices

If you could spend one minute with every physician in the San Joaquin County area, what would you say? I would tell each physician I meet that the most monumental changes in the medical field in the last 100 years are happening right now under their watch. We are the doctors’ the patients, the insurers, the employers, and the politicians are counting on. Clearly, we are at a crossroads of competing visions for the future. It is imperative that we all participate in this epic ebb and flow of ideas in order to preserve what is thought to be the finest medical care available in the world. The best way for doctors to make their voices heard is to join the San Joaquin Medical Society and The California Medical Association and participate in the arena of ideas.

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Message > From The Editor

Reflections on Medical Staff Leadership What Rats and Pigeons have to teach Us

The following is the first in a series of essays reflecting on my years in Medical Staff leadership and what I learned. I hope current and future members of Medical Staff committees find my ruminations helpful.

As humans, regardless of our age, education or social class, we are bound by the same psychological rules that govern our lives, and as it so happens sometimes, those of the common laboratory rat and pigeon. ABOUT THE AUTHORMoris Senegor, MD serves as the Chairperson of the Publications Committee for the San Joaquin Medical Society and Editor of its flagship publication the San Joaquin Physician.

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For many years I attended joint psychotherapy sessions with my ex-wife to co-ordinate the rearing of our children. These sessions, by and large coincided with my nearly decade long stint as a medical staff leader at St. Joseph’s Hospital, first as Chief of Surgery and later as Chief of Staff. It may seem like there was no common ground between these two activities. To my surprise one rapidly emerged. I discovered that the treatment of errant or disruptive physicians relied on the same principles as that which I was being counseled on for my then small children. The advice was simple: establish clear, unambiguous rules and enforce them consistently. Carrying this out proved to be arduous both at home and in the hospital. Those of you who are parents and/or medical staff leaders know what I mean.   One piece of advice the counselor repeated more often than others related to the classic theory of B. F. Skinner that we learned in Psychology 101 and subsequently shelved into a dark recess in our minds. It had to do with his theory of operant conditioning, and simply stated it went something like this: intermittently reinforced behavior is hard to eradicate.   Let’s recall Skinner’s classic experiment performed on rats and pigeons. The subject

animal presses a bar and is either rewarded or punished for this act, what Skinner calls positive or negative reinforcement respectively. It turns out that the animal which consistently gets either a reward or punishment quits engaging in the barpressing behavior. In the case of regular rewards it eventually gets sated; in the case of consistent punishment it quits as expected, naturally avoiding a predictable noxious stimulus. But what if the animal is intermittently rewarded? It turns out that in this paradigm, the animal keeps pressing the bar incessantly. It’s captivated.   Seemingly addictive behavior despite non-addictive stimuli are prevalent in our daily lives. Many hobbyists seen as “avid” tend to derive their motivation from Skinner’s basic principles of operant conditioning. My two favorite examples are fishing and golf, activities I personally find inconceivably boring. The non-commercial fisherman goes out there in his spare time and sometimes catches fish, sometimes doesn’t. Would he be as avid a fisherman if he caught fish every time he cast his rod? No! That would be unexciting. Where is the challenge of the sport if it were so easy? 100% success in fishing would lead one into other hobbies. What if he never caught a fish?

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Y BACK B Well, that’s even easier. One would have to be out of their mind to go fishing weekend after weekend for years, if they never caught a fish. It is that intermittent success, the occasional fish snagged, which hooks these people (no pun intended) and gets them addicted. In the case of golf, it has to do with the difficulty of consistent success with the sport (if you can call it that!). Hitting a ball into a tiny hole hundreds of yards away in so many strokes, over landscapes with numerous obstacles is just plain difficult. Add to it variations in players having good versus bad days, adverse weather conditions, and opponents with variable strength, and you have the makings of an activity in which true perfection remains elusive. But for those who display some aptitude at it, golf offers the same intermittent reinforcement, the occasional good game, amazingly addictive, as that received by Skinner’s rats. Not all intermittently reinforced behaviors are benign. Take gambling for example. The gamblers that lose the most are the ones who, every so often hit it big with whatever they are playing. Anyone with common sense knows that there is no logic to playing the casinos of Vegas or Reno where the odds are heavily stacked in favor of the house. Yet many do it, both because they expect some “special” personal luck, and because once engaged in it, they lose themselves in the magnetism of the intermittent rewards. In fact, those solitary figures pulling levers at countless slot machines come closest to actually resembling bar-pressing rats and pigeons in Skinner’s cages. Unlike fishing and golf, ultimately harmless activities where avid practitioners are well respected, gambling can be quite destructive to those hooked on it, and thus represents a negative example of such conditioning. Anyone can find examples of Skinnerian conditioning in their personal lives, sometimes in unexpected corners, if they look hard enough. I can site a couple from my own. I am writing this essay during the Soccer World Cup of 2010, currently being conducted in South Africa. I am as avid a watcher of these games as any red blooded fan of a given team, even though I am not rooting for anyone in particular. When a game is on, I will not take my eyes off the TV screen lest I miss an exciting play at the penalty zone, or, heaven forbid, miss a goal, both rare occurrences in this game. I won’t even go to the bathroom while the play in on. Thank God each half is only 45 minutes and I am still young enough to hold it that long. What’s my problem? Goals in soccer are so uncommon, and when they happen, so exciting, that they provide intermittent positive reinforcement that gets me glued to the TV while the game is on. My wine tasting group – myself included - has spent many precious dollars for some of the worst wines that we ever experienced, in search of what our wine-guru, the late John Morozumi used to call “the Holy Grail”. The wines were French Burgundies, the original home of the pinot noir, a heterogeneous region where wine quality varies tremendously from year to year and from maker to maker. A really good Burgundy has a uniquely smooth, silky texture in the mouth, what wine tasters call a “feminine” feel. Unfortunately we had to go through countless rough, worthless bottles to get to that one silky experience. But when we did….It was heaven. And so we kept buying Burgundy and putting up with numerous bad bottles for every good one we encountered. It took quite a few years of personal effort for me to quit this wasteful and fruitless behavior. Weaning oneself from intermittently reinforced behavior is not easy. As humans, regardless of our age, education or social class, we are bound by the same psychological rules that govern our lives, and as it so happens sometimes, those of the common laboratory rat and pigeon. There is no human being out there who does not exhibit attraction to activity based on some type of intermittent reinforcement. If they did, they would no longer be human. When it came to rearing my children, my counselor’s advice was to recognize that as a distributor of rewards and punishments I needed to avoid intermittent reinforcement with them. For instance if they asked for candy or ice cream, saying “yes” at times, and “no” at others would condition them to keep incessantly asking. I either had to give in every time and buy them the candy, or consistently say “no”. On the other side of the coin, inconsistent punishment of their bad behavior, sanctioning some and overlooking others, would also result in propagation of such behavior, since they would view the excused ones as positive reinforcement. The same principle applies to disciplining physicians in a Medical Staff. Any potential recipient of punishment needs to be treated with similar consistency and a high awareness of potential traps of “intermittency”.

DEMAN R A L U P PO

SAN JOAQUIN MEDICAL SOCIETY INVITES YOU TO A

HOLIDAY PARTY Featuring Live Music from the Golden Era of the 30’s and 40’s

WEDNESDAY

DECEMBER 15, 2010 STOCKTON GOLF AND COUNTRY CLUB 6:30pm – 9:30pm $20 per person for Physician members (2 drink tickets included) $35 per person for non-members and invited guests (2 drink tickets included) Enjoy an evening of Served Hors d’oeuvres, Carved Baron of Beef, various gourmet stations and a wide array of decadent Desserts to complete the evening.

Special Entertainment: Dance to the Big Band sound of

THE MONDAY NIGHT BAND featuring Patrick Langham (20 member swing band) playing and singing the greatest sounds of the 30’s and 40’s and your favorite Holiday classics. For more information, please call the medical society office at (209) 952-5299

WATCH FOR YOUR PERSONAL INVITATION FALL 2010

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Message > From The Editor   Punishing fellow physicians is not easy. After all, they are not children even though some behave that way. When it comes to being sanctioned however, they sure do not tolerate being treated like children. Many disruptive physicians are successful members of their Staffs and act as prima donnas, adding further difficulty to any disciplinary action. These physicians generate a series of negative incidents over an extended period of time, usually spanning beyond the limited terms of given Staff leaders. Different leaders have different thresholds for enforcing rules. Some look for any excuse to get their colleague “off the hook”, others rise to the occasion and issue sanctions with the backing of their

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Bylaws and Staff Committees. From the standpoint of the disruptive physician, the experience is one of “intermittency”. They sometimes receive punishments of varying severity, and other times get away with their behavior. Over the long term, more often than not, their behavior is excused or given a “slap on the wrist”, ineffective, meaningless sanctions like letters of reprimand issued to their files. The end result is entrenchment of their troublesome behavior.   I had a six year term as Chief of Surgery, a reasonably long period of time to remember prior acts and treat them consistent with the rules. In that time I inherited several cases of chronic, well ingrained disruptive behavior which were by then, hard to eradicate. Serious, meaningful negative reinforcement applied to such physicians, induced indignation not only from them but also from their friends, colleagues, and allies. Converting their behavior to “mainstream”, more in line with the vast majority of their peers, became huge battles. All this could have been avoided if predecessors had treated them consistently, and within the same rules observed by the rest of the Staff. These physicians were, in effect, victims of Skinneran operant conditioning applied to them by their own leaders, with neither side, unfortunately, aware of the process. After all Medical Staff activities do not resemble a conditioning box the way slot machines do, and they are not set up to allow a string of leaders to assess the consequences of their policies in the long term.   I myself did not gain insight into this phenomenon until my own term was over, and I had a chance to reflect upon my decade long experience afterwards. Had it not been for the counselor who incessantly admonished me about the dangers of intermittent reinforcement for my children, I would never have acquired it. By a strange coincidence my counseling sessions happened to immediately follow Surgery Committee meetings that I chaired for all those years, and allowed me to intermix the contents of the two as I drove back and forth.   I suppose the lesson I learned from the experience could be summarized in a simple admonishment to Medical Staff leaders: treat your adversaries in the Staff whom you have to sanction, as you would your own children.

FALL 2010


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RISK MANAGEMENT > Hospitalist Model

Communication Important in

Hospitalist Model By Karen Davis

Hospitalists are becoming well established in the U.S., and the concept of hospital medicine has expanded to pediatrics, obstetrics, and some other fields. Recognized benefits of the hospitalist model have fostered its quick and enthusiastic acceptance across the country. However, one concern about the hospitalist model is that it intentionally disrupts the continuity of care.

Risk management experts often advise physicians to concentrate on the continuity of patient care because gaps in physicianpatient communication can lead to bad outcomes. The hospitalist model has the potential to disrupt continuity of care by setting up a deliberate break in communication between the patient and his or her usual physician in the form of the transfer to another provider—the hospitalist.   Robert M. Wachter, MD, who coined the term “hospitalist” and who has been a leader in the development of the hospitalist concept, notes that from the early days, organizations using hospitalists have had to “[focus] on ensuring a smooth ‘hand off’ to prevent any ‘voltage drops’ at the inpatientoutpatient interface.”1   Because the transfer is premeditated, physicians can develop protocols to bolster and protect communication. Hospitalists and outpatient physicians should discuss the potential for communication failures and make specific plans for transferring patients and for communicating about the care they each render. Communication protocols can include: • A method for the outpatient physician to discuss with patients how the hospitalist will be involved in care; • A plan for the outpatient physician to communicate with the hospitalist at or near the time of the patient’s admission; • A plan for sharing treatment and discharge information; 18

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• A plan for the hospitalist to be available to the patient if needed between discharge and the first visit back to the outpatient physician; • A plan for the hospitalist to phone the patient after discharge; and any other procedures that facilitate clear and timely interaction between the patient and the physicians involved in care.   Communication is especially crucial when new information about a patient becomes available after the patient has been discharged from the hospital. How does follow-up occur when, for example, a tissue sample evaluated as benign is subsequently interpreted as showing malig­nancy? Because follow-up is a known risk area, it is a good strategy to have a protocol for notification when new information comes to light after a patient is discharged. A good protocol has provisions for notification of both the outpatient physician and the patient.   Hospitalists and the physicians who refer patients to them should think about areas where their communication with each other and with patients might be vulnerable to collapse. Any actions they can take to identify and diminish risks will improve patient care and decrease the likelihood of lawsuits. Reference: 1. Wachter RM. The state of hospital medicine in 2008. Medical Clinics of North America. 2008;92(2):265-273. Managing Professional Risk is a quarterly feature of NORCAL Mutual Insurance Company and the NORCAL Group. PMSLIC is a wholly owned subsidiary of NORCAL Mutual. More information on this topic, with continuing medical education (CME) credit, is available to NORCAL insureds. To learn more, visit www.norcalmutual.com/cme.

FALL 2010


FALL 2010

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A LOCAL HEALTH PLAN FOR LOCAL PEOPLE... Health Plan of San Joaquin is your community health plan – created by local people for local people. That means decisions about our programs and services are made right here at home by people who know and understand San Joaquin’s community health needs. It also means the personal doctors, pharmacists and area hospitals you trust can access our medical leadership to discuss your individual needs as a patient and assure you’re getting the best treatment for you. Long time community physicians David Eibling, M.D. (Associate Medical Director) and Dale Bishop, M.D. (Medical Director) bring nearly 50 years of community health leadership in guiding Health Plan of San Joaquin.

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Call Health Plan of San Joaquin today to find out why a local health plan can make a difference for your family.

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1-888-936-PLAN (7526) www.hpsj.com 1-888-936-

FALL 2010


Independent But Not Alone.

Steven Wall, M.D. Hill Physicians provider since 2004. Uses Hill inSite, Hill EHR, Ascender and RelayHealth for eClaims processing, electronic health records, practice management, preventive care reminders and secure online communications with patients.

Independence and strength are not mutually exclusive. Practices affiliated with Hill Physicians Medical Group retain independence while enjoying the strength that comes from being part of a large, well-integrated network of physicians. Hill’s advantages include: • Fast, accurate claims payments • Free electronic communication capabilities via RelayHealth • RN case management for complex, time-intensive cases • Deep discounts on EPM and EHR solutions for the federal mandate • Preventive care and disease management reminders for patients • High consumer awareness that attracts patients That’s why 3,500 independent primary care physicians, specialists and healthcare professionals have made Hill Physicians Medical Group one of the country’s leading Independent Physician Associations. Get more for your practice with Hill.

Your health. It’s our mission.

Get more information about Hill Physicians at www.HillPhysicians.com/Providers or contact: San Joaquin area: Paula Friend, regional director, (209) 762-5002, Paula.Friend@hpmg.com Sacramento area: Doug Robertson, regional director, (916) 286-7048, Doug.Robertson@hpmg.com Bay area: Jennifer Willson, regional director, (925) 327-6759, Jennifer.Willson@hpmg.com Hill Physicians’ 3,500 healthcare providers accept commercial HMOs from Aetna, Alliance CompleteCare (Alameda County), Anthem Blue Cross, Blue Shield, CIGNA, Health Administrators (San Joaquin), Health Net, PacifiCare and Western Health Advantage. Medicare Advantage plans in all regions. Medi-Cal in some regions for physicians who opt-in. FALL 2010

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FALL 2010


Workforce Disparities < COMMUNITY

Medical Leadership Council Update T

he Medical Leadership Council on Cultural Proficiency (MLC) met May 19 in Oakland, convened by The California Endowment. This leadership group, comprised of executive and elected leaders of the state’s medical specialty societies and county medical associations, as well as health plan and health system leaders, works to improve the provision of language services and culturally proficient care, increase the diversity of California’s health care workforce, and eliminate health care disparities.   Meeting topics included ways that the new national health care reform law supports cultural proficiency; new NCQA standards on multicultural health care; new health information technology funding to assist primary care physicians in solo and small practices; and new MLC resources. In addition, the cultural proficiency educational component at this meeting was an overview of health care disparities among transgender men and women.

National Health Care Reform Law Supports Improved Care for Diverse Populations

The new Patient Protection and Affordable Care Act includes several measures designed to improve the health of minority populations. Tom Riley, principal at Cal Capitol Group, outlined some of the highlights, including:   The National Center on Minority Health and Health Disparities at the National Institutes of Health is designated a full institute, reflecting an enhanced focus on minority health.   The Office of Minority Health and related offices are formalized in the Department of Health and Human Services (HHS) to monitor health, health care trends, and quality of care among minority patients and evaluate the success of minority health programs and initiatives.

FALL 2010

Investments are increased in data collection and research on health disparities.

Initiatives to increase the racial and ethnic diversity of health care professionals are expanded, including additional scholarship and loan repayment opportunities for disadvantaged students who commit to work in medically underserved areas.   Cultural proficiency training among health care providers will be strengthened through expanded programs to support development and use of cultural proficiency curricula in health professions schools and continuing education programs.

NCQA Establishes Multicultural Health Care Standards

In March 2010, NCQA released standards for the voluntary Multicultural Distinction Program available to health plans, disease management/wellness organizations, and managed behavioral health care organizations. The standards become effective July 1, 2010.   The purpose is to evaluate race/ethnicity and language data; language services; practitioner network cultural responsiveness; incorporation of national Culturally and Linguistically Appropriate Services (CLAS) standards; and efforts to reduce health care disparities, said presenter Jessica Briefer French, MHSA, Senior Consultant, Research at NCQA.   The standards evaluate such areas as whether data on race/ ethnicity and language are collected; competent interpreter services are provided and patients are informed the services are available; a network’s capacity to meet cultural and linguistic needs is analyzed and improved; and data is used to assess and reduce health care disparities. For more information, see the NCQA Standards and Guidelines for Distinction in Multicultural Health Care.

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COMMUNITY > Workforce Disparities New EHR Funding Support for Primary Care Providers Will Benefit Underserved Communities

The California Health Information Partnership Services Organization (CalHIPSO), one of the new California organizations called Regional Extension Centers (RECs) formed to assist providers in qualifying for federal funding to support the purchase and use of electronic health records (EHRs) and to achieve “meaningful use,” will initially focus on “priority primary care providers,” said Speranza Avram, MPA, executive director.   These providers include MDs, DOs, physician assistants and nurse practitioners at small private physician practices, community health centers, primary care and rural health clinics, public hospitals, and ambulatory care clinics connected to critical access and rural hospitals.   Practices that purchase and implement EHRs to meet the federal “meaningful use” criteria can qualify for incentive payments to help defray the costs.   By 2015, all providers receiving Medicare and Medicaid funds are required to have implemented EHRs and be meeting the meaningful use standard.   The 2009 federal stimulus bill, the American Recovery and Reinvestment Act (ARRA), includes the Health Information Technology for Economic and Clinical Health (HITECH) Act, which establishes programs under Medicare and Medicaid to provide incentive payments for using EHRs. The California Medical Association, California Association of Public Hospitals and Health Systems, and California Primary Care Association formed CalHIPSO to serve as a Regional Extension Center (REC) to serve all of California except Los Angeles and Orange County. The HITECH Act provides for the establishment of RECs to provide education, outreach, and technical assistance to help primary care providers in their geographic service areas to select, successfully implement, and meaningfully use certified EHR technology. For more information, visit the CalHIPSO Web site.

MLC Education: Providing Culturally Proficient Care to Transgender Men and Women

When considering the need for cultural proficiency in health care, the transgender community often is overlooked. The term transgender describes people whose gender identity is different from the gender they were assigned at birth. Gender identity is one’s internal understanding of one’s own gender. For many transgender people, their gender identity doesn’t match their birth-assigned gender.   Because of biases against and lack of understanding of transgender men and women, they find that adequate health care often is unavailable or denied them, said Jamison Green, Primary Care Protocols Manager at the University of California, San Francisco Center of Excellence for Transgender Health.

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  Some insurance companies refuse to provide any coverage at all to transgender people, for example, and others refuse to cover surgery and hormone therapy required for transition, the process some transgender people undergo to align their outward gender expression with their gender identity.   Mr. Green explained that physicians need to know how to treat transgender patients with respect; understand their health concerns, which may or may not be related to their transgender status; and learn how to provide competent medical care to this population. Many transgender people avoid seeking health care out of a fear of discrimination or rejection, yet access to appropriate health care is essential, particularly for a population that research shows is at high risk for alcohol and drug dependency, depression, and suicidal feelings, among other health threats. For more information, visit the Center’s Web site at www.transhealth. ucsf.edu.

MLC Resources Help Improve Access to Language Services and Culturally Proficient Care

A major part of the MLC’s work since its founding 8-1/2 years ago has been the development and dissemination o resources addressing language access, cultural proficiency, workforce diversity in health care, and health disparities. Most of these resources are available on the MLC Web site, www.MedicalLeadership.org, which also hosts the searchable Language Access Database offering Californiacounty-specific resources. Deputy Executive Vice President Shelly Rodrigues, CAE, CCMEP of the California Academy of Family Physicians, the lead administrative organization for the MLC, provided an overview.   Print materials on the site include toolkits to assist physician offices in providing language services and culturally proficient care; a coding and billing tip sheet; information on assessing staff members’ bilingual capabilities; and many other topics.   Videos include education about reasons for providing, and how to provide, language services and culturally proficient care; an overview of the MLC member organizations’ work on these issues; and ways medical assistants can assist their practices in providing culturally proficient care.   Resources provided in-person include the Decision Medicine program, designed to encourage diverse students to choose careers in health care; grant writing workshops; and a medical assistants’ training.

Looking forward

The California Endowment has undertaken an ambitious 10-year initiative to address health care, social services, educational and environmental issues in 14 specific California communities. Future MLC work will overlap with that initiative. The next MLC meeting will be held in Los Angeles on November 17, 2010.

FALL 2010


Where will you be when the Thunder plays on pink ice for more than just a win? Join San Joaquin Medical Society in supporting...

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Friday, Nov. 5 at 7:30 pm - Saturday, Nov 6 at 7:30 pm Sunday, Nov. 7 at 4:00 pm A $2 donation from each ticket sold will benefit American Cancer Society – Stockton Field Office and St. Joseph’s Foundation – Breast Cancer Services

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COMMUNITY > news

IN THE

NEWS

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

technicians and other general healthcare professions. “Health Plan of San Joaquin is firmly committed to advancing future health care providers’ education with the support of continuing education scholarships. We recognize that increasing demands for health services and improved access has resulted in an increased need for medical professionals in our communities,” says Dr. David Eibling, assistant medical director, Health Plan of San Joaquin.   This program endeavors to ensure the success of future health care delivery in San Joaquin County by encouraging high performing students to seek careers in health related fields. “Every effort that St. Joseph’s Auxiliary Members Celebrate is made to encourage local high school Completion of $1 Million Pledge students to pursue a career in healthcare in the Central Valley is important. Health Health Plan of San Joaquin Encourages Health Plan of San Joaquin’s Continuing Education Careers Through Scholarship Program Scholarships puts resources on the table to help students achieve Health Plan of San Joaquin (HPSJ) honors seven students their dream,” says Mike Steenburgh, executive director, San who received scholarships in 2009 and are continuing their Joaquin County Medical Society. higher education with the assistance of an HPSJ Health Careers   To learn more about the Continuing Education Health Continuing Education Scholarship in the amount of $1,000 for Careers Scholarship Program, contact Shani Richards, the 2010-2011 academic school year. These students included: Community and Legislative Affairs Liaison at (209) 461-2284 or Kimiko Agari - University of the Pacific at srichards@hpsj.com Allen Chang - John Hopkins University Diana Furukawa - University of the Pacific St. Joseph’s Auxiliary Members Celebrate Valleri Gammon - California State University – Stanislaus Completion of $1 Million Pledge Jordan Giudice - Pepperdine University In September 2005, the St. Joseph’s Auxiliary took a leap of faith Hansel Poerwanto - University of the Pacific to make a $1,000,000 pledge which became the lead gift to St. Maria Yepez University of California - Santa Barbara Joseph’s Foundation’s Investing in Miracles Capital Campaign. Health Plan of San Joaquin is very pleased to support these With their act of generosity, they led the way in supporting this deserving students as they seek to further their education in the critically important campaign, in part to build the new Patient healthcare industry. Health Plan of San Joaquin continues its Pavilion. By March of 2010, they had reached a total of $927,280 partnership with the San Joaquin County Office of Education - not quite, but ever closer. In May, an anonymous - and very Foundation to administer the scholarship funds to the students. generous - donor stepped forward and wrote a check for the The goal of the scholarship program is to support students who remainder of the pledge: $72,720. Congratulations to the St. need financial assistance and who plan to practice in San Joaquin Joseph’s Auxiliary for fulfilling this ambitious pledge, and our County in healthcare careers such as doctors, nurses, laboratory deepest thanks to that mystery donor!

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news < COMMUNITY Joseph’s is one of 21 hospital winners and three healthcare systems nationwide.   There were 3,788 hospitals and 346 healthcare systems that were eligible to receive the AFQ. The award recognizes leading healthcare organizations that efficiently provide outstanding patient care and consistently set the standard in clinical excellence.   The AFQ’s performance-based criteria including clinical quality outcomes, resource utilization, and clinical process indicators measures top performers at the overall hospital level.   “St. Joseph’s prides itself on the quality of care we provide our patients as a result of our ongoing efforts to improve our care delivery systems, as well as our focus on patient-centered care,” said Donald J. Wiley, President of St. Joseph’s. “This award recognizes the exemplary care that our staff delivers to each and every patient we treat.”   “The AFQ honors the efforts of industry leaders to provide highquality care,” said Susan DeVore, Premier President and CEO. “As we celebrate the achievements of Annual Diabetes these facilities, the alliance is helping Conference Scheduled to further improve the health of for December 14 at communities across the nation.” University of the Pacific All acute care inpatient facilities in Dr. Kwabena Adubofour invites you the United States that submitted to once again join him as he hosts data to the Centers for Medicare & his annual Diabetes Conference. Medicaid Services (CMS) and the This years conference is moving CMS Hospital Compare project to the beautiful Donald DeRosa were considered for the AFQ. Using Student Center at the University MedPar 2008 data, Quality and of Pacific and will take place on Efficiency Indexes were calculated Saturday, December 14th from for 60 disease groups and at the 8:00am – 3:00pm. A continental overall hospital level. Quality was breakfast and lunch will be provided measured by the incidence of for attendees and there is no charge for this enriching program. Annual Diabetes Conference three adverse outcomes: mortality, morbidity and complications, which This year’s program will not are combined into a single Quality include CE credit, but will feature Index using the preference weightings from the Corporate multiple speakers representing the latest discoveries and Hospital Rating Project (CHRP). The efficiency index treatment plans in the fight against diabetes. Physicians, was generated using length of stay to proxy for resource Pharmacists, PAs, NPs, Dietitians, Certified Diabetes utilization. Educators and RNs are all invited to attend at no charge.   Acute care facilities attaining the top 1 percent For more information or to sign up, please call the medical designation are identified as having scores in the top society office at 952-5299. two quintiles for process of care, and in 10 out of 60 disease groups and at the overall hospital level for St. Joseph’s Medical Center Nationally quality and efficiency. Hospitals had measures for Recognized for High-Quality Patient quality and efficiency that were equal to or exceeded Care, Operational Efficiency expected outcomes. In addition, new for 2010, Premier St. Joseph’s Medical Center recently announced it has measured aggregation to the system level, with the same been recognized by the Premier Healthcare Alliance as methodology, for healthcare system awards. a winner of the Premier Award for Quality (AFQ ). St. The Auxiliary recently honored 67 members for their volunteer service to St. Joseph’s Medical Center during an awards luncheon at Stockton Golf & Country Club. Service recognition levels ranged from 100 to 15,500 hours, and five members received service awards for 25, 30, or 35 years of service. In 2009 alone, 141 Auxiliary members served 27,740 volunteer hours in 12 service areas, including Information Desks, Gift Shop, Medical Library, Flower and Coffee Delivery, Fundraising, Baby Photo, Radiology Transport, and Sewing. The Auxiliary’s 2009 fundraising efforts resulted in a $150,000 donation to St. Joseph’s.   “I really do feel like I make a difference, not just to the visitors who come to the hospital, but also to the staff and patients” said Escort and Information volunteer Mary Anderson.   The Auxiliary, founded in 1957, provides important volunteer services to patients, families and visitors throughout the Medical Center.

FALL 2010

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COMMUNITY > news

IN THE

NEWS SJMS 2nd Annual Community Golf Tournament Benefits First Tee Youth (include First Tee logo next to story) Join fellow medical society members at Brookside Country Club on Saturday, November 6th for a relaxing round of golf, lunch and an opportunity to benefit our local First Tee of San Joaquin program. Drs. Kwabena Adubofour and George Khoury will be your host for this fun event and all golfers of every level are invited to play. The day will begin with free range balls at 10:00am for practice, a wonderful lunch on the patio and a noontime start. The day will be capped with a brief presentation of all proceeds to First Tee Youth who will be present. For more information or to sign up, please call the medical society office at 952-5299.

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Claim your share of the $350 million UnitedHealth settlement Don’t miss the chance to claim your share of the $350 million UnitedHealth Group settlement. The settlement is the result of a class action lawsuit, initially filed in 2000 by the American Medical Association and other health care provider and patient groups, alleging that United conspired to defraud consumers by manipulating out-of-network reimbursement rates, shortchanging physicians and patients by hundreds of millions of dollars over the past 15 years.   The deadline to submit claims for payment from the settlement fund is October 5, 2010. Physicians are eligible to file for damages if they provided covered out-of-network services or supplies between March 15, 1994, and November 18, 2009, to patients covered by UnitedHealth or its subsidiaries, including PacifiCare. Physicians may recoup underpayments for out-of-network services provided to PacifiCare subscribers at any time during the claim period, even before PacifiCare became a subsidiary of United.   Physicians will be paid according to their total “recognized loss” between 1994 and 2009, which

is calculated by determining the difference between a physician’s billed amount and the “allowed amount” that United actually paid for covered out-of-network services. If the total amount of submitted claims exceeds the settlement fund, physicians will receive a pro rata share based on their total recognized loss. United has submitted data to the claims administrator showing all the payments it made (i.e., the allowed amounts) for covered out-of-network services from January 1, 2002, to May 28, 2010. Physicians can request a copy of their own claims data from the claims administrator. It may take several weeks to receive the report, so the sooner you request your copy, the better. A hearing to determine final approval of the settlement is scheduled for September 13, 2010, in U.S. District Court in New York.   For more information about the settlement and what physicians need to do to claim their share, visit the California Medical Association’s

FALL 2010


San Joaquin County’s only

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TA I NA L

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EY PE

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Andrew Chao, M.D. Obstetrics & Gynecology (FACOG)

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COMMUNITY > news sett lement resource center. There physicians can fi nd CMA’s United Healthcare/Ingenix Sett lement Guide, claim forms, and a number of other helpful resources. For further help, please contact Gena Welch, San Joaquin Medical Society’s Membership Coordinator who will personally take your information and put you into contact with our CMA contact.

New SJMS/CMA Member Benefit Offered by Heartland Merchant Services In addition to the Heartland Payment System’s Merchant Services, Payroll Services and Check Management services which are offered at a member only discounted rate, Heartland is now offering the Confi rmPay program –a Patient Payment Management Solution. Confi rmPay Provides:

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• Real time insurance eligibility verification to over 440 payers, including detail on a patient’s remaining deductible, co-pay and co-insurance • The ability to “Estimate” reimbursement from both payer and patient for specific procedures based upon contracted rates and a patient’s benefits • The ability to provide a “patient friendly” printout of a patient’s benefits, enabling a practice to start dialogue with patient’s about what they will owe. • Acceptance of any form of payment (Credit, Debit, ACH, Cash, Check) from any location (Point of Care, Telephone, Mail, 3rd Party Billing Partners, Online). • A set of payment management tools to make it easier to collect from patients (Secure Card on File, Recurring Payments, Online Patient Payment Portal). • A robust reporting to enable you to track and manage collections across multiple locations and through multiple parties. • The ability to automatically link all payments with a patient and to post all patient payments directly into your practice management or practice billing system. Heartland also provides direct processing for Visa/MasterCard, all-inclusive electronic Payroll Processing, Check Management and Gift Cards. We encourage you to contact our local Heartland representative, Linda Mangum, at (209) 604-7588 for more information or to arrange an appointment.

www.vervenetworks.net

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FALL 2010


9th Annual

Community Health Forum Healthcare Reform - Implications of Cost and Care in the Central Valley Keynote Speaker - Edward O’Neil, MPA,Ph.D, FAAN

Monday, November 15, 2010

University of the Pacific - DeRosa University Center 7:00 AM - 10:30 AM

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

Stockton Golf & Country Club tradition • private setting • heritage 3800 W. country club blvd • stockton, ca

Call for special membership pricing (209) 466-4313

State of the art fitness center

FALL 2010

Swimming Pool and Clubhouse

Clubhouse Amenities: - Grand Ballroom for events - Casual & Formal Dining Rooms - Grill Room overlooks 18th Green - Locker rooms with Spas/Steam Room

SAN JOAQUIN PHYSICIAN

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PRACTICE MANAGEMENT > ACOs

Are Accountable Care Organizations (ACOs) in your future?

A

s physicians in this era of health care reform, we are facing unparalleled challenges. We have also been presented with some unique opportunities to move further toward a patient-centered and physician-led health care system. We certainly must now act swiftly to educate ourselves and each other about newly authorized hospital-physician organizations. We will need to make prudent decisions in the near future about our interest in participating, if we are to take advantage of the potential opportunities the changes in law and regulation will present. By J. Brennan Cassidy, MD â&#x20AC;˘ President California Medical Association

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FALL 2010


savings by meeting a cost benchmark, Medicare will share a Moving further toward a Physician-led, Patientportion of the cost savings with the ACO. ACOs must have a centered Health Care System legal and administrative structure to distribute the savings to Many physicians across the state are being approached by physicians. hospital systems to join new hospital-physician organizations. ACOs do not have to involve a hospital and may be physicianThese new entities contemplate being organized either through led and comprised of physicians only. CMA fought very hard to state law as 1206(l) Medical Foundations, or through Medicare, maintain such physician autonomy in the legislation. ACOs can as Accountable Care Organizations (ACOs), which were be primary care or multi-specialty medical groups, or they can be recently authorized by Congress in the federal health care IPAs or other networks of individual physician practices, all with reform legislation. Some physicians are concerned that hospitals or without integration with hospitals. The ACO must, among are forming these organizations to exert more control over other things, establish a mechanism for shared governance, and physician practices and to better position themselves financially agree to be accountable for cost, quality and the overall care in an environment of scarce resources. Other physicians would of the Medicare like to join these patients assigned organizations, but to it. ACOs must need to understand Dr. Brennan Cassidy is president of the 35,000 member California Medical participate in the their rights. And Association and serves as the chair for CMA program for at some physicians Board of Trustees. He is also a past president least three years, are seeking to form of the Orange County Medical Association and has participated on many committees and must have their own ACOs. throughout his 36 years as a member an adequate CMA is working of CMA. Dr. Cassidy has taught at the network of to help you University of California, Irvine as a clinical primary care instructor and an assistant clinical professor navigate these of family medicine. He is board certifi ed in and specialist negotiations with emergency medicine and family practice, physicians to your colleagues and has been on the staff of Hoag Memorial serve at least and possibly your Hospital Presbyterian in Newport Beach since 1971 and currently works in private 5,000 Medicare local hospitals, practice at West Coast Laser Dermatology patients. While and to help you Congress only plan a future contemplated where physicians a fee-for-service have financial and model, some medical groups are asking Medicare to expand the clinical autonomy in the Medicare program, and the private program to allow capitation. marketplace. To help you understand your right and options, The creation and operation of an ACO could require CMA is developing educational programs and materials, substantial clinical, technical and financial resources. While including legal and financial models to help you understand creating an ACO or joining one may sound like a daunting task, how to form these organizations, practical tips to assist the ACO concept is not new in California. Many California physicians joining with hospitals, and policy to guide regulatory physicians have been at the forefront of designing physician-led, implementation advocacy. patient-centered medical group/IPA delivery models, which effectively function as ACOs already. CMA will rely on this Accountable Care Organizations (ACOs) experience and expertise, to ensure that as members, you have Congress authorized ACOs, which are intended to create the necessary tools and information to make the right decisions incentives for physicians who work together to coordinate care, about your practice. improve quality and reduce unnecessary costs at the local level ACOs could also provide a path to anti-trust relief for for a specific population of Medicare patients. Bear in mind that physicians in the private sector. Some physicians are forming the final rules of how ACOs will operate depends on regulations ACOs to eventually negotiate and contract with private payers. that have yet to be written at both the federal and state levels. The Federal Trade Commission (FTC) has allowed medical The ACO concept couples payment and delivery system groups that meet certain standards for clinical integration, to reform. ACOs are paid through a shared savings payment collectively negotiate with private payers. FTC Chairman, approach. ACOs allow physicians to be jointly rewarded for the Jon Leibowitz, recently stated that he does not see much efficiencies they achieve in both the Medicare Physician Part enforcement risk with respect to ACOs in the Medicare B and the Hospital Part A programs. Physicians in ACOs will program, and he believes there is room for ACOs to use joint continue to bill Medicare under the traditional fee-for-service contracting with respect to private payers, as long as they program. If an ACO reports on quality measures and achieves

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Practice management > ACOs comply with the FTC’s well-established financial or clinical integration guidelines. ACOs could be financially integrated by virtue of distributing a shared savings, and clinically integrated through systems such as electronic health records, collaborative referrals and quality reporting. Of course, the FTC will be monitoring

which codifies the foundation law, was adopted to benefit two non-profit, multi-specialty physician-controlled medical clinics and the communities that they serve. The 1206(l) law exempts a clinic from the clinic licensing law if it is operated by a non-profit corporation that “conducts medical research and health education and provides health care to its patients ACO market power in through a group of 40 or more The ACO concept couples payment the private sector. physicians and surgeons, who and delivery system reform. ACOs are 1206(l) Medical are independent contractors paid through a shared savings payment Foundation Model representing not less than approach. ACOs allow physicians to be In an effort to capture the 10-board-certified specialties, potential cost savings of and not less than two-thirds of jointly rewarded for the efficiencies they ACOs, provide capital to whom practice on a full-time achieve in both the physician practices, and/ basis at the clinic.” Medicare Physician Part B and the or compete with physician   While the exemption Hospital Part A programs. groups, some hospital systems was enacted to provide and their associations are benefits to the communities seeking to create hospital-led that they serve, the Medical 1206(l) Medical Foundations. Foundation model is sometimes Contrary to the current trend, foundations can be, and used as a hospital-physician alignment strategy in order to, often are, physician-led and not necessarily affiliated with a among other things, address declining reimbursements and hospital. Indeed, Health and Safety Code Section 1206(l), increased financial pressures, and improve quality of care.

Procedures performed at our center currently include:

• Colonoscopy • Bronchoscopy • Gastroscopy • Biopsy

Conveniently located across the street from Lodi Memorial Hospital 840 S. Fairmont Suite 1 Lodi, CA 95240

The Endoscopy Center of Lodi is a beautiful state of the art facility providing modern outpatient care. The Center is equipped with one fully state licensed operating room and a procedure room.

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(209) 371-8700 www.endoscopyoflodi.com

FALL 2010


Unfortunately, today some hospitals are seeking to inappropriately apply the foundation model to gain control over physician practices, since they have failed to change state law to employ physicians and are facing increased financial pressures. CMA’s Proactive Assistance for Physician Members CMA’s overarching goal is to provide the best possible information to help physicians make individual decisions about the best practice arrangement for their professional situation. Some physicians will decide to join Foundations or ACOs – whether led by physicians or hospitals. CMA will provide information to help those physicians negotiate optimal arrangements. Other physicians will choose to form their own organizations. CMA will provide information, tools, and models to help physicians establish such organizations. (see sidebar) Concierge Practice Opportunities While CMA is working to help physicians build collaborative organizations or make decisions about other models, we will also be offering a program at our annual Leadership Academy in June 2011, to help physicians explore the possibility of establishing a non-contracted status or a concierge practice. Many physicians across the state have successfully cancelled their private health plan contracts, and participation in Medicare, to contract directly with their patients. It is not a model that can work in every specialty, or in every region of the state, but we will help physicians make those assessments and learn from others who have done it successfully. It is a model that has allowed some physicians to spend more time with their patients, and to provide high quality care, without the interference from health plans, without reducing and sometimes increasing their net revenues. CMA Goal As your organization, CMA’s goal is to help you take charge of your own destiny in these challenging and changing times, particularly related to the health reform legislation and the regulatory changes it will generate. We want to ensure that medical decisions remain in your hands so that you can serve your patients. We look forward to working with you.

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Resources: CMA has launched a series of webinars on Accountable Care Organizations, other payment models and the health care reform law in general, to help familiarize physicians with the new law and educate physicians about its impact on their practices. Upcoming webinars will be posted at http://www.cmanet.org/calendar and announced in CMA Alert. Archived Webinars: If you missed any of our recent webinars, they are available for on-demand viewing at the CMA website. Go to http://www.cmanet.org/ calendar/ and click on “Webinar Archive - Members click here” or go directly to the member side link http://www.cmanet.org/member/memberdoc. cfm?docid=205. ACO/Payment Model Issue Briefs: CMA has prepared a series of issue briefs on the Accountable Care Organizations and Medical Homes which can be found on our website on the CMA Federal Health Reform page (http://www.cmanet.org/healthreform/) on the sidebar under the title “Federal Health Reform Series.” CMA will also soon be providing links to other noteworthy articles and white papers on the ACO concept on our website at http://www.cmanet.org. 1206(l) Foundation Model CMA “On-Call” Document: A new CMA document explaining the 1206(l) Foundation Model, #0218, Legal and Practical Considerations Concerning Medical Foundations, can also be found on our website through the CMA On-Call system at www.cmanet.org. The document explains the legal requirements for these Foundations, and any practical considerations involved when deciding whether to join one. CMA Physician-Hospital Alignment Committee: Finally, CMA has formed a Physician-Hospital Alignment Technical Advisory Committee to advise the Board of Trustees on the development of future physician empowerment strategies, to guide our policy goals, to oversee the documents, tools and models provided to CMA physician members and to guide CMA advocacy through the legislative and regulatory arenas.

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Upcoming CME Events Risk Management & Patient Safety CME Program Presented by:

Learning from Lawsuits: Strategies and Resources for Reducing Risk Presented by:

Wednesday, September 8, 2010 Dinner Served at 5:30pm • Program 6:00 pm to 9:00pm Stockton Golf & Country Club

Saturday, October 16, 2010 Program 8:00am to 10:00am • Full Breakfast will be served. Stockton Golf & Country Club

This interactive and informative three-hour program offers practical tips to help physicians reduce their chances of being served in a malpractice lawsuit, and maintain positive doctor-patient relationships. Program Highlights: • Issues most often seen in professional liability lawsuits. • The doctor-patient relationship and the physician’s role as patient advocate. • Medical conditions most prone to diagnostic error. • Guidelines for informed consent and appropriately addressing culture and language barriers. • Identifying systems that help prevent patient injury. • Current and evolving risks in medicine.

Free of charge for Medical Society members and NORCAL Mutual Insurance Company policyholders. All physicians should come to this exciting risk management CME presentation that will present real closed claims scenarios and present risk management recommendations and materials. Educational Objectives: By analyzing closed malpractice claims (i.e. reviewing the causes of the errors and strategies to prevent those errors from happening again), this educational activity will support your ability to: • Apply documentation practices that support the continuity of care and increase defensibility of that care in the event of a claim. • Implement follow up systems to consistently track laboratory results and medications, as well as increase communication with other providers. • Facilitate and document informed consent/refusal.

Space is limited and reservations are required. To RSVP, please contact Elizabeth Gomez at 213-473-8729 or egomez@cap-mpt.com The Cooperative of American Physicians, Inc. is accredited by the Institute for Medical Quality/California Medical Association (IMQ/CMA) to provide continuing medical education for physicians. The Cooperative of American Physicians, Inc. takes responsibility for the content, quality and scientific integrity of this CME activity. The Cooperative of American Physicians, Inc. designates this educational activity for a maximum of 3 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity. This credit may also be applied to the CMA Certification in Continuing Medical Education.

Using Tele-Medicine to Improve Acute Stroke Care with David Tong, MD Medical Director, CPMC Comprehensive Stroke Care Center

To Register simply call the San Joaquin Medical Society at (209) 952-5299 Course Faculty : Mike Mordaunt, Esq. , Riggio, Mordaunt and Kelly Law Firm Jane Mock, Risk Management Specialist, NORCAL Mutual Insurance Co. CME Information and Disclosure: This activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of NORCAL Mutual Insurance Company and San Joaquin Medical Society. NORCAL Mutual Insurance Company is accredited by the ACCME to provide continuing medical education for physicians. NORCAL Mutual Insurance Company designates this educational activity for a maximum of 2 AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with the extent of their participation in the activity. The faculty members—Mike Mordaunt, Esq. and Jane Mock—have no relevant financial relationships to disclose. Planners from NORCAL include Jo Townson (Supervisor, CME), Christina Cassady (Supervisor, Risk Management) and Katey Bonderud (Supervisor, Claims)—all of whom have no relevant financial interests to disclose. The planner from San Joaquin Medical Society—Michael Steenburgh (Executive Director)—has no relevant financial interests to disclose.

Presented by:

Thursday, September 23, 2010 Cocktail Reception 6:30pm and Dinner Presentation 7:00pm Full Dinner Served with choice Selections. Wine & Roses Restaurant in Lodi

Aortic Thoracic Disease: Endovascular and Open Surgeries with Glen Egrie, MD Presented by:

Join Dr. Tong and CPMCs Central Valley Tertiary Care Coordinator Brad Studabaker for an exciting evening on this fascinating topic which will feature: • Learn the benefits of telemedicine for acute stroke care • Understand the logistics of establishing a telemedicine program for stroke • Understand the pros, cons, and costs of such a program

Wednesday, November 10, 2010 Cocktail Reception 6:30pm and Dinner Presentation 7:00pm Full Dinner Served with choice Selections. Stockton Golf & Country Club

To Register simply call the San Joaquin Medical Society at (209) 952-5299 All attendees will receive 1.0 hour of Category 1 CME

To Register simply call the San Joaquin Medical Society at (209) 952-5299 All attendees will receive 1.0 hour of Category 1 CME

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GILL & GYNECOLOGY 75,000 HEALTHY GILL OBSTETRICS OBSTETRICS & MEDICAL GROUP, GYNECOLOGY INC. MEDICAL GROUP, INC.

BABIES DELIVERED GILL OBSTETRICS & GYNECOLOGY MEDICAL GROUP, INC.

BOARD CERTIFIED OB/GYN • MEMBER OF THE AMERICAN SOCIETY OF LASERS IN MEDICINE BOARD CERTIFIED OB/GYN • MEMBER OF THE AMERICAN SOCIETY OF LASERS IN MEDICINEParam K. Gill, M.D.

Experience Matters

75,000 HEALTHY 75,000 HEALTHY BOARD CERTIFIED OB/GYN • MEMBER OF THE AMERICAN SOCIETY OF LASERS IN MEDICINE BABIES DELIVERED BABIES DELIVERED

With 50 years of experience and roots dating back to 1953, Gill Obstetrics has a rich history of serving generations of women throughout San Joaquin County. We offer clinical expertise and compassionate care in a welcoming environment where women can feel comfortable and secure, knowing that we put our patients’ needs first. With With 50 50 years years of of experience experience and and roots roots dating dating back back to to 1953, 1953, Gill Obstetrics has a rich history of serving generations ofneeds are unique and After all… each woman's Gill Obstetrics has a rich history of serving generations of women throughout throughout San San Joaquin Joaquin County. County. you We deserve offer clinical clinical special care! women We offer expertise and compassionate care in a welcoming environment where expertise and compassionate care in a welcoming environment where women can can feel feel comfortable comfortable and and secure, secure, knowing that women knowing that PRENATAL & POSTPARTUM CARE we put our patients’ needs fi rst. we put our patients’ needs first. HIGH RISK PREGNANCY

Experience Matters

Param K. Gill, M.D.

Peter G. Hickox, M.D.

Peter G.

Peter G. Hickox, M.D. Jasbir S. Gill, M.D. Catherine Mathis, M.D.

Charnpal

David Eibling, M.D.M.D Patricia A. Hatton, Darrell R. Burns, M.D.

Thomas

Thomas Vincent P.Streeter, Pennisi,M.D. M.D. Ramneet K. Mangat, M.D.

Harjit Sud

Catherine Mathis, M.D.

75,000 HEALTHY BABIES DELIVERED

Param K. Gill, M.D.

Jasbir S. Gill, M.D.

Charnpal S. Mangat, M.D.

Darrell R. Burns, M.D. Jasbir S. Gill, M.D.

INFERTILITY, INVITRO FERTILIZATION After all… all… each each woman's woman's needs needs are are unique unique and and After GYNECOLOGY you deserve deserve special special care! care! you Patricia A. Hatton, M.D ENDOMETRIOSIS Thomas Streeter, M.D. URINARY INCONTINENCE Peter G. Hickox, M.D. PRENATAL && POSTPARTUM POSTPARTUM CARE CARE PRENATAL Tonja Harris-Stansil, M.D HIGH RISK RISK PREGNANCY PREGNANCYOVARIAN CYSTIC DISORDER HIGH Patricia A. Hatton, M.D INFERTILITY, INVITRO INVITRO FERTILIZATION FERTILIZATIONLAPAROSCOPY INFERTILITY, HYSTEROSCOPY GYNECOLOGY GYNECOLOGY DIAGNOSIS & TREATMENT OF CERVICAL, Vincent P. Pennisi, M.D. ENDOMETRIOSIS ENDOMETRIOSIS Harjit Sud, M.D. UTERINE & OVARIAN CANCERS URINARY INCONTINENCE INCONTINENCE Param K. Gill, M.D. URINARY Madhavi Ravipati, M.D. OVARIAN CYSTIC DISORDER OVARIAN CYSTIC DISORDER Vincent P. Pennisi, M.D. LAPAROSCOPY LAPAROSCOPY OSTEOPOROSIS DETECTION CENTER HYSTEROSCOPY HYSTEROSCOPY We are proud to announce the opening of The Osteoporosis Detection Center using state of the art DEXA DIAGNOSISimaging. TREATMENT OF CERVICAL, DEXA scanning is now recognized to be the most accurate predictor ofM.Dfracture risk in women. Mala Ashok, DIAGNOSIS && TREATMENT OF CERVICAL, Meena Shankar, M.D. UTERINE & OVARIAN CANCERS UTERINE & OVARIAN CANCERS Stockton: 1617 N. California St., Ste. 2-A (209) 466-8546 • 435 E. Harding Way (209) 464-4796

With 50 years of experience and roots dating back to 1953, Gill Obstetrics has a rich history of serving generations of women throughout San Joaquin County. We offer clinical expertise and compassionate care in a welcoming environment where women can feel comfortable and secure, knowing that we put our patients’ needs first.

Catherine Mathis, M.D.

Vijaya Sud, Bansal, M.D. Harjit M.D.

Meena S

Madhavi Ravipati, M.D.

Meena Shankar, M.D. Jennifer Phung, M.D.

Lynette B

Linda Bouchard, M.D.

2509 W. March Ln., Ste. 250 (209) 957-1000 • 10200 Trinity Parkway, Ste. 206 (209) 474-7800 Linda Bouchard, M.D.

Lodi: 999 S. Fairmont Ave., Ste. 225 &230 – Ph. (209)Charnpal 334-4924 S. Mangat, M.D. Manteca: 1234 E. North St., Ste. 102 – Ph. (209) 824-2202

visit(209) our website atofwww.gillobgyn.com We areStockton proud to announce openingParkway, of The Osteoporosis Center using state the art DEXA 10200the Trinity Ste. 206Detection – Ph. 957-1000 Jennifer Phung, M.D. imaging. DEXA scanning is now recognized to be the most accurate predictor of fracture risk in women. Stockton 1617 N. California St., Ste. 2-A – Ph. (209) 466-8546

Stockton E. Harding Way Ph. (209) 464-4796 Stockton: 1617435 N. California St., Ste. 2-A–(209) 466-8546 • 435 E. Harding Way (209) 464-4796

Darrell R. Burns, M.D.

Kevin E. Rine, M.D. Dr. Rine Vicki Patterson-Lambert, R.N.P.C.

Beth Fragilde, R.N., C.N.P

2509 W. March Ln., Ste. 250 (209) 957-1000 • 10200 Trinity Parkway, Ste. 206 (209) 474-7800

Stockton 2509 W. March Ln., Ste. 250 – Ph. (209) 957-1000 Lodi: S. FairmontAve., Ave.,Ste. Ste. 225 225 &230 (209) 334-4924 Lodi 999 S.999 Fairmont &230– Ph. – Ph. (209) 334-4924 Manteca 1234 E. North Ste. 102 – Ph. 824-2202 Manteca: 1234St., E. North St., Ste. 102(209) – Ph. (209) 824-2202

Vijaya Bansal, M.D.

Vicki Patterson-Lambert, R.N.P.C.

Jasbir S. Gill, M.D.

Lynette Bird, R.N., B.S.N.

visit visit our our website at at www.gillobgyn.com website www.gillobgyn.com

After all… each woman's needs are unique and

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Lynette Bird, R.N., B.S.N.

Denise Morgan, M.S.N. - N.P.

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SAN JOAQUIN PHYSICIAN FALL 2009 Denise Morgan, M.S.N. - N.P. Jennifer Phung

Denise M


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“ We listen to policyholders. We provide solid advice and offer real-time solutions to real-time problems.” Loss Prevention Representative Kathy Kenady

Unparalleled Service and Value • Another large dividend - $20 million back to MIEC policyholders

For 35 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 our policyholders to keep premiums low. Added value: At MIEC we have a history of dividend distributions. Because we are a zero-profit carrier with low overhead, MIEC has been able to return dividends to our California policyholders 17 of the last 20 years with an average savings on premiums of 25.5%. For more information or to apply contact: n www.miec.com or call 800.227.4527 n Email questions to underwriting@miec.com * (On premiums at $1/3 million limits. Future dividends cannot be guaranteed.)

6250 Claremont Avenue, Oakland, California 94618 800-227-4527 • www.miec.com SJMS_07.19.10 FALL 2010

MIEC Owned the policyholders we protect. SANby JOAQUIN PHYSICIAN 45


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Membership > Benefits

Is Your Office Manager or Staff Utilizing CPR?

CMA provides valuable monthly Bulletin at no Cost The maiden issue of CMA Practice Resources (CPR) was launched several months ago to rave reviews and is available on a monthly basis, but surprisingly only a handful of members are utilizing it on a monthly basis. Our normal Q & A section often features material from “CPR” and for this issue we simply decided to insert the entire September Bulletin so you could see an actual copy.   This free monthly e-mail bulletin from the reimbursement experts in CMA’s Center for Economic Services is full of tips and tools to help physicians and their staff improve practice efficiency and viability.   If you or your staff would like to subscribe, you can do so at http://www.cmanet.org/ news/cpr or go to our own website at www.sjcms.org and you will find the subscription links there as well (There is also a PDF subscription form attached, if you would prefer to print/fax.)   If you have any questions or comments, contact San Joaquin Medical Society’s very own Membership Coordinator Gena Welch, who is here to assist you, your staff in any capacity we can. We receive calls every week regarding reimbursements challenges, coding issues, contract negotiation, etc. and are eager to help find you the support and assistance in a timely manner. Gena can be reached at (209) 952-5299 or via email at gena@sjcms.org For specific questions about CMA’s new CPR Bulletin, contact Aileen Wetzel, at (916) 551-2037 or awetzel@cmanet.org.

Gena Welch Membership Coordinator (209) 952-5299 gena@sjcms.org

Briefly Noted Unreasonable requests for medical records Blue Cross provides clarification on upcoming policy change Claim your share of the $350 million UnitedHealth settlement Medicare audits find improper use of new patient codes Underpayment of TriWest vaccines

OFFICE MANAGERS FORUM: Join Gena Welch each month at Valley Brew for a lively seminar attended by dozens of other office managers who enjoy a complimentary lunch and some great networking as well. For more info or next month’s topic, call Gena at 952-5299 to be added to our guest list. Every second Wednesday from 11:00 - 1:00

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September 2010

In this issue:

CMA Practice Resources (CPR) is a free monthly bulletin from the California Medical Association’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.

Unfair Payment Practice: Unreasonable requests for medical records

1

Report unfair payment practices

2

Blue Cross provides clarification on upcoming policy change

2

Claim your share of the $350 million UnitedHealth settlement

SPREAD THE WORD: Please forward this bulletin to your coworkers and colleagues.

2

CMA Advocacy at Work

BREAKING NEWS: For breaking news, subscribe to CMA’s biweekly member

2

Problems getting paid?

2

Medicare audits find improper use of new patient codes

3

Ask the Expert: Fee schedule disclosure

3

Health plan provider newsletters

3

Data entry error results in underpayment of TriWest vaccines

4

Payor updates

4

Got questions?

4

Tell us what you think

4

Save the Date

4

CMA resources

When you see this icon, that means there are additional resources available free to California Medical Association (CMA) members at the CMA website. To access any of these resources, visit www.cmanet.org/ces.

CMA On-Call

Throughout this publication, you will find references to “CMA On-Call” documents. On-Call is an online library that contains over 4,500 pages of medical-legal, regulatory, and reimbursement information. On-Call documents are available free to CMA members at www.cmanet.org/member. Nonmembers can purchase On-Call documents for $2 per page in the CMA bookstore, www. cmanet.org/bookstore.

SUBSCRIBE NOW: Sign up for a free subscription at www.cmanet.org/news/cpr.

newsletter at www.cmanet.org/news.

Unfair Payment Practice: Unreasonable requests for medical records California law prohibits health plans from requesting from physicians more information than is reasonably necessary to determine whether services are covered and medically necessary. With regards to prior authorizations, a plan may only request information that is reasonably necessary in order to determine whether to approve, modify, or deny a request for authorization. “Reasonably relevant information” means the minimum amount of information generated by or in the possession of a provider related to the billed services that enables a claims adjudicator with appropriate training in accurate claims processing to determine the plan’s liability for the claim (28 C.C.R. §1300.71(a)(10).). Payors that request more than the minimum information reasonably necessary to adjudicate a claim or that make unreasonable demands for documentation, including duplicate requests for information previously provided by the physician, should be reported to both the appropriate regulator and to the California Medical Association. For more information on filing a formal complaint with a regulator, see the May 2010 issue of CPR. TIP: Health plan requests for medical records should be documented and tracked in your practice management system and reviewed on a regular basis to identify medical records requests that are not consistent with state and federal laws. CMA RESOURCE: CMA On-Call document #1170, “Health Plan Access

to Medical Records,” #1070, “Managed Care Contractual Protections,” #1051, “Physician Complaints About Managed Care Plans.”

Report unfair payment practices The California Medical Association (CMA) is fighting on your behalf to curb abusive practices by third party payors. Our goal is to not only enact meaningful laws, but to make sure that these laws are enforced by state regulators.

CMA Center for Economic Services 1201 J Street, #200, Sacramento, CA 95814 economicservices@cmanet.org • 916/551-2061

FALL 2010

continued on page 2

CPR • September 2010 • Page 1 of 4

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Membership > Benefits Unfair payment practices include, but are not limited to: • • • • • •

Improper denial or delay in payment of a claim Failure to acknowledge receipt of a claim Underpayment Dispute resolution difficulties Untimely requests for refunds Unilateral contract amendments

For a list of prohibited unfair payment practices, see “Know Your Rights: Identify and Report Unfair Payment Practices,” which can be downloaded from CMA’s members-only website at www.cmanet.org/ces.

Blue Cross provides clarification on upcoming policy change As previously reported in the July 2010 issue of CPR, Anthem Blue Cross notified contracting physicians in May of impending changes to its Prudent Buyer Participating Physician Agreement. Physicians are reminded to carefully assess the impact these contract changes will have on their practices. One of the changes announced in the notice addresses how Blue Cross will reimburse certain services when performed during the global surgical period. Specifically, the notice stated CPT codes 10060, 10061, 10140, 10160, and 10180 would no longer be eligible for separate reimbursement when performed during the global post operative period of the related surgical procedure (page 2 of the notice). Previously, appending modifier -78 to these codes would bypass the edit. After receiving questions from physicians, the California Medical Association (CMA) inquired further with Blue Cross’ medical director and learned that the new edit only applies when these services are performed in the physician’s office (place of service 11). At CMA’s request, Blue Cross has provided written clarification on the matter. A copy of the letter can be downloaded at www.cmanet.org/ces.

Claim your share of the $350 million UnitedHealth settlement Don’t miss the chance to claim your share of the $350 million UnitedHealth Group settlement. The settlement is the result of a class action lawsuit, initially filed in 2000 by the American Medical Association (AMA), and other health care provider and patient groups, alleging that United conspired to defraud consumers by manipulating out-of-network reimbursement rates, and shortchanging physicians and patients by hundreds of millions of dollars, over the past 15 years. The deadline to submit claims for payment from the settlement fund is October 5, 2010. Physicians are eligible to file for damages if they provided covered out-of-network services or supplies between March 15, 1994, and Nov. 18, 2009, to patients covered by UnitedHealth or its subsidiaries, including PacifiCare. Physicians may recoup underpayments for out-ofnetwork services provided to PacifiCare subscribers at any time during the class period, even before PacifiCare became a subsidiary of United. Physicians will be paid based on their total “recognized loss” between 1994 and 2009, which is calculated based on the difference between a physician’s billed amount and the continued on page 3

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CMA Advocacy at Work

“The CMA provides critical resources to small private practice providers that would otherwise be too costly or difficult to obtain. Exceptional client service, dedicated “provider advocates” and outstanding results is just the beginning when it comes to describing the team at the CMA Center for Economic Services. Running a specialty eating disorder facility in Southern California, we are often confronted with insurance companies that seem to have limited knowledge regarding their clients’ benefits relating to mental health but have proven knowledge when it comes to denying, delaying, and avoiding provisions and payments for medically necessary services. The CMA team has demonstrated time and time again that they possess the skills and talents to facilitate the insurance companies addressing claims payment oversights (from unintentional practices to AB1455 abusive payment practices) while preserving the professional and clinical relationship between the patient and physician. In the current health care system, it is frequently not enough for the provider to have the paperwork in order (contracts, authorizations, clean claims, etc.) The CMA can provide an avenue to resolution even when it seems all but impossible. That is why we are so appreciative of the CMA team and their exceptional performance. Thank you all.”

Jeffrey Mar, M.D., FAAP CMA member since 2007

Problems getting paid?

The California Medical Association’s Center for Economic Services provides direct reimbursement assistance to CMA physician members and their office staff.

• REIMBURSEMENT HELP LINE 888/401-5911 °

One-on-one educational and reimbursement assistance to physician members and their staff

• PRACTICE EMPOWERMENT

° °

Tools and resources to empower physician practices Seminars and toolkits for physicians and their staff

• EXPERIENCED STAFF °

Staffed by practice management experts with a combined experience of over 125 years in medical practice operations

To access our reimbursement advocates, your physician must be a CMA member. For membership information, contact CMA Member Services at 800/786-4CMA (4262) or memberservice@cmanet.org.

CPR • September 2010 • Page 2 of 4

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“allowed amount” that United actually paid for covered outof-network services. If the total amount of submitted claims exceeds the settlement fund, physicians will receive a pro rata share based on their total recognized loss. United has submitted data to the claims administrator showing all the payments it made (i.e., the allowed amounts) for covered out-of-network services during the timeframe covered by the settlement. Physicians can request a copy of their own claims data from the claims administrator by completing a “Claims Information Request Authorization Form,” which can be downloaded at www.cmanet.org/settlements. A hearing to determine final approval of the settlement is scheduled for September 13, 2010, in U.S. District Court in New York. For more information about the settlement, and what physicians need to do to claim their share, visit the California Medical Association’s settlement resource center at www.cmanet.org/settlements. There physicians can find CMA’s United Healthcare/Ingenix Settlement Guide, claim forms, and a number of other helpful resources. Contact: Samantha Pellon, 916/551-2872 or spellon@cmanet.org.

Medicare audits find improper use of new patient codes The Center for Medicare & Medicaid Services (CMS) Recovery Audit Contractor (RAC) program was designed to identify fraud and waste in the Medicare system by identifying improper payments made for health care services provided to Medicare beneficiaries. The California Medical Association (CMA) has learned that many RAC overpayments are being assessed because new patient office visit codes are being used instead of established patient office visit codes. A “new patient” is someone who has not within the previous three years received any face-to-face professional services from the same physician or a physician in the same group practice with the same specialty. An interpretation of a diagnostic test, such as the reading of an x-ray or EKG, in the absence of another face-to-face service with the patient does not affect the designation of a new patient. For more information, see CMS IOM Manual 100-4, Chapter 12, Section 30.6.7 (http://www.cms.gov/manuals/downloads/clm104c12.pdf). CMA RESOURCE: CMA On-Call document #0629,

“The Medicare Recovery Audit Contractor Program.”

Data entry error results in underpayment of TriWest vaccines In early July, the California Medical Association (CMA) began receiving reports from physicians about a sudden decrease in payments for the RotaTeq vaccine (CPT 90680). Physicians reported that beginning with May 1 dates of service they saw their rates drop from $70/dose to $35/dose, which didn’t cover the cost of the vaccine. CMA reached out to our contacts at TriWest and asked them to investigate. continued on page 4

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Ask the Expert: Health plan requests for medical records QUESTION: My office called a health plan to obtain priorauthorization for a specific procedure and was told I would need to submit the patient’s medical records for the past 10 years. Is this lawful? ANSWER: Under California law, health plans are authorized to request “only the information reasonably necessary” to determine whether to approve, modify, or deny requests for authorization (Health & Safety Code §1367.01; Insurance code §10123.135.). In other words, plans are prohibited from requesting voluminous copies of medical records that are not related to the services for which authorization is being requested.

Health plan provider newsletters

To make sure that you are aware of important news from your contracting health plans, we encourage you to regularly read plans’ provider newsletters and bulletins. Follow the links below to access the current issues. AETNA: www.aetna.com. Click on “Health Care Professionals” in the main menu, then on “News for Providers” in the left sidebar. CIGNA: www.cigna.com. Click on “Health Professionals” under “Customer Care” in the main menu. Then, scroll down and click on “Newsletters.” ANTHEM BLUE CROSS: www.anthem.com/ca. Click on “Providers” in the main menu, then on “Professional Network Update” under “Spotlight.” BLUE SHIELD: www.blueshieldca.com. Click on “I’m a Provider,” then on “Announcements” under “News and Features.” HEALTH NET: www.healthnet.com. click on “I’m a Provider” and then “California.” Enter username and password, and then click “Online News.” MEDI-CAL: www.medi-cal.ca.gov. Click on “Publications” in the main menu, then on “Provider Bulletins.” MEDICARE/PALMETTO GBA: www.palmettogba.com/ j1b. Click on “Publications” in the left sidebar, then on “Medicare Advisory.” UNITED HEALTHCARE: www.unitedhealthcareonline.com. Click on “Tools & Resources” in the main menu, then on “Network Bulletin.” CMA RESOURCE: Find up-to-date profiles on each of the major payors in California at www.cmanet.org/ces.

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Membership > Benefits TriWest has since advised CMA that there was a clerical error with the way the reimbursement rates were entered into the system not only for RotaTeq, but several other vaccines that do not have a set CHAMPUS Maximum Allowable Charge rate. The vaccines had been entered into the TriWest system as two-unit vaccines rather than 2 ml vaccines, thus reducing the payment by 50 percent. TriWest corrected the error with July 1 dates of service and, at CMA’s request, agreed to automatically reprocess all affected claims from May 1 through June 30. CMA is working to obtain a comprehensive list of all affected vaccines from TriWest and will publish the list as soon as it’s available.

Payor updates As payors continue to make changes to fee schedules and contracts, physicians are reminded to regularly read health plan provider newsletters and bulletins for important updates, including changes to contract terms and reimbursement, or medical policies. ANTHEM BLUE CROSS: As announced in the July 2010 issue of CPR, Anthem Blue Cross’ revised PPO reimbursement policies on global surgery and anesthesia became effective August 23. Additional policies including but not limited to global surgery, multiple surgery reductions, modifier -59, sleep studies and bundled services became effective August 29. A copy of the notice can be viewed at www.cmanet.org/ces. HEALTH NET: Health Net notified contracting physicians in its June 2010 Provider Update of revisions to the plan’s prior authorization requirements for PPO, Medicare Advantage PPO, and Flex Net products, effective October 1, 2010. Participating physicians can access Health Net’s prior authorization requirements at www.healthnet.com/provider, click on “Manage My Authorizations,” then “Services Requiring Authorization.” UNITED: UnitedHealthcare recently notified physicians of the plan’s

new Preterm Labor Medical Policy, effective October 1, 2010. According to the new policy, the following services will no longer be covered: tocolytic therapy beyond seven days, subcutaneous terbutaline pump maintenance, tocolytic therapy, and home uterine activity monitoring. The new policy can be viewed at www.unitedhealthcareonline.com by going to “Tools & Resources” at the top of the page then “Policies & Protocols” and clicking on “Medical & Drug Policies and Coverage Determination Guidelines” on the right hand column titled “Policies, ” and scroll down to “Preterm Labor: Identification and Treatment.”

Tell us what you think The California Medical Association (CMA) is interested in your feedback. Let us know which topics you would like to see addressed in future issues. Contact CMA’s Center for Economic Services at 916/551-2061 or economicservices@cmanet.org.

Got questions? If you have questions related to any articles, please contact the California Medical Association’s (CMA) reimbursement help line, 888/401-5911 or economicservices@cmanet.org.

Save the Date: Upcoming CMA events The California Medical Association offers our members programs to educate physicians and staff on a range of practice management issues. Space is limited, so register soon. Events marked with an asterisk (*) are PMI CEU Credit Approved.

October: Become a Certified Medical Coder in 5 Days San Diego County Medical Association Course Classes: Oct 1, 8, 15, 22, 29 (9 am – 4 pm)

Certified coders have never been in greater demand. More physicians need Certified Medical Coders who are capable of understanding the complexities of the reimbursement process. Improve your practice’s financial health. Your skills will help guard against improper claim submissions and contribute to a higher rate of paid claims for your physician’s practice. For more information, see www.sdcms.org/event/certified-medical-coder-class.

9/2: Addressing an Epidemic: Clinicians’ Role in Preventing Pertussis (12:15 - 1:15 pm)

In this webinar hosted by the California Department of Public Health, Mark Sawyer, MD, pediatric infectious disease specialist and professor of clinical pediatrics, UC San Diego School of Medicine, will provide the latest information on California’s 2010 pertussis epidemic.

9/22: Practical steps to ensure HIPAA compliance Members-only webinar (12:15 - 1:15 pm)

In this member’s only webinar, David Ginsberg of PrivaPlan presents on the practical steps you can take to ensure HIPAA Compliance.

10/13: Successful preparation for and implementation of an electronic health records system Members-only webinar (12:15 -1:15 pm)

In this member’s only webinar, David Ginsberg of PrivaPlan Associates presents explains how you can prepare your practice for the successful implementation of an Electronic Health Records System.

For more information or to register for any of these events, visit www.cmanet.org/calendar.

Education and networking opportunities There are numerous educational and networking opportunities for office managers and administrators throughout California. Many county medical societies host forums for practice managers and are an excellent resource. The California Chapter of the Medical Group Management Association (CAMGMA) also offers a broad range of practice leadership, professional development, educational opportunities, and networking activities. For more information or to register for upcoming CAMGMA events, visit www.camgma.com/calendar.cfm.

CPR • September 2010 • Page 4 of 4

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Dr. Senegor’s Memoir:

Science and a Royal Visit

I

n one of the more surreal events of my years in the English High School of Istanbul, I came face-to-face with Princess Anne, the daughter of Queen Elizabeth II of Great Britain. The year was 1971, and it happened, of all places, in a chemistry lab at the school, located on the very top floor. For most of the 20th century the English High School stood as a bright beacon of British colonialism in the exotic lands of the Muslim Turks. The Brits, of course never actually colonialised the heart of the Ottoman Empire, as they did India or Egypt, or large chunks of the Middle East which they captured from the Turks in the Great War. . They merely exerted varying amounts of influence over the centuries, increasing greatly by the time of the First World War. After the disintegration of the Ottomans a new, secular Turkish Republic followed its own course, and by the end of the Second World War, was more in alignment with the U.S. and NATO. Our little elite High School occupied a tiny role

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in British-Turkish relations, in proportion with the by then decreased influence of Great Britain as a world power. By the 1970’s the school was in serious decline. It had long since lost subsidies from the British, and was badly struggling financially. Later in the same decade it was to fail completely, be taken over by the Turks and change its name to Istanbul Anadolu Lisesi. In other words it would cease to exist. At this peculiar moment in time, with our school in its deathbed, Queen Elizabeth happened to be pay a state visit to Turkey, and decided to visit EHS. Why, I don’t know! The school was meaningless to all parties involved except, perhaps, as a symbol of old, more glorious days. This was, to our knowledge, the first time ever that a British monarch visited our school. We were informed of this historic visit months in advance, and a general excitement swept through the school. Preparations began to make this momentous occasion in the history of the school as perfect and auspicious as possible. Why? Again, in retrospect I don’t

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know. But But “the “the Queen Queen was was coming”! coming”! What What other other reason reason did did know. we need? need? we As the the school school became became more more impoverished, impoverished, the the small small   As building in in Nishantash Nishantash which which housed housed us us was was becoming becoming building more and and more more dilapidated. dilapidated. We We didn’t didn’t mind mind this. this. But But we we did did more mind that that the the school school did did not not have have proper proper funds funds to to furnish furnish mind us with with suitable, suitable, state state of of the the art art science science labs. labs. In In aa society society that that us valued aa technical technical education education more more than than anything anything else, else, the the valued lack of of proper proper physics, physics, chemistry chemistry and and biology biology laboratories laboratories lack to supplement supplement the the lecture lecture courses courses in in these these fields, fields, which which to incidentally were were obligatory obligatory for for all, all, was was conspicuous conspicuous and and aa incidentally source of of much much consternation. consternation. By By contrast contrast many many other other private private source Lycee’s including including the the wealthy wealthy Robert Robert College, College, an an American American Lycee’s school located located in in aa gorgeous gorgeous campus campus on on the the hills hills overlying overlying the the school Bosphorus, seemed seemed to to have have Bosphorus, everything, including including those those everything, much coveted coveted laboratories. laboratories. much Half of of the the class class that that   Half started at at EHS EHS with with us us back started back in Ortaokul in Ortaokul (grade(grade school) school) had recently in 1967, in had1967, recently defected to to Robert Robert College College defected in the the transitional transitional summer summer in from grade grade school school to to high high from school. Many Many of of them them were were school. intellectually the the best best and and intellectually brightest. Those Those of of us us left left brightest. behind felt felt aa bit bit abandoned abandoned behind and bewildered bewildered by by this this mass mass and move to to Robert Robert College, College, move in effect effect an an overt overt act act of of in recognition that that EHS EHS was was in in decline and a better education recognition was to be had elsewhere. We felt to our American decline and a better education wasinferior to be had elsewhere. We counterpart, and wealthier than us. larger In a funny way, the felt inferior tolarger our American counterpart, and wealthier two schools now, inway, retrospect, likenow, a microcosm of the than us. In a funny the two seem schools in retrospect, post World War II reality of the two parent countries seem like a microcosm of the post World War II realitythey of the represented. We werethey toorepresented. young to appreciate two parent countries We werethe toometaphor young that our schools become. Allour weschools knew was there were to appreciate the had metaphor that hadthat become. All inadequacies and there gaps in ourinadequacies education and wegaps wondered we knew was that were and in our how muchand better education if these filled. education we our wondered howwould muchbe better ourwere education As the approached however, the powers that would be ifroyal thesevisit were filled. at EHS set out sweep thesehowever, inadequacies underthat the  be As the royal visittoapproached the powers rug,atand schoolthese to the inadequacies monarch as a under perfect,the well be EHSpresent set outthe to sweep rounded, up-to-date prep school, injectingas ostentatious rug, and present the school to the monarch a perfect, well British culture to the progeny of the Istanbulostentatious elite. Thus they rounded, up-to-date prep school, injecting came toculture include chemistry asThus part ofthey British toathe progenylab of demonstration the Istanbul elite. the show they put on for her,lab as ifdemonstration the school regularly came to include a chemistry as parthad of chemistry lab in curriculum. theschool visit approached, the show they putitson for her, as As if the regularly had preparations an increasingly more furious chemistry labtook in itson curriculum. As theurgent, visit approached, pace. It was no different staging urgent, a schoolmore play.furious We preparations took on an than increasingly rehearsed frequently with higher intensity. pace. It wasmore no different thanand staging a school play. We rehearsed more frequently and with higher intensity.

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Our chemistry teacher that was to lead the royal lab demonstration was a young Turk, as it turned outlabin more Our chemistry teacher that was to lead the royal ways than one. was He was a relatively recent alumnus EHS demonstration a young Turk, as it turned out inofmore himself, had graduated fromalumnus the University. ways thanand one. Heonly wasjust a relatively recent of EHS This wasand anhad interim him on the way bigger and himself, onlyjob justfor graduated from thetoUniversity. betterwas things, and hejob wasfor a breath fresh air,tobringing This an interim him onofthe way bigger and energythings, and enthusiasm subject previously languishing better and he wastoa this breath of fresh air, bringing under and lugubrious British His namelanguishing was energy enthusiasm to predecessors. this subject previously Mehmet Ipekci. HeBritish cut a dashing figureHis in the school, under lugubrious predecessors. name was tall and handsome with aHe grand andinthe of Mehmet Ipekci. cut amoustache, dashing figure thetemperament school, tall and a young Ottoman officer. He was formal andtemperament abrupt, and aof bit handsome with a grand moustache, and the He was, in allHe appearances Ataturkand to be. aintimidating. young Ottoman officer. was formal new and abrupt, a bit Mehmet Bey to an illustrious family fromto be. intimidating. He belonged was, in all appearances new Ataturk who were saidtotoanbeillustrious “donme”family ( “conversos”  Thessaloniki Mehmet Bey belonged from in Spanish), whichwho means Thessaloniki wereJews said who had converted to Islam in to be “donme” ( “conversos” some prior generation. Such in Spanish), which means families, regardless of how Jews who had converted much success theyprior sought, to Islam in some were viewed with generation. Suchsuspicion families, byregardless higher echelons Turkish of how of much society and were morewere likely success they sought, toviewed encounter ceilings withglass suspicion by inhigher their rise through echelons of the Turkish ranks, especially in more military society and were likely ortopolitical careers. uncle encounter glassHis ceilings was a famous journalist in their rise through thefor the well especially read Istanbul daily ranks, in military Milliyet, Abdicareers. Ipekci,His who,uncle or political before decade was over, was athe famous journalist for was be read assassinated none thetowell Istanbulby daily other than the infamous Mehmet Ali Agca, who subsequently Milliyet, Abdi Ipekci, who, attempted to slay Pope Johnwas Paul young Ipekci, before the decade was over, toIIbe. The assassinated by none fearless, ambitious and full of vigor,Aliseemed oriented to other than the infamous Mehmet Agca, who subsequently overcome to hisslay family curse and destined shatterIpekci, any ceilings attempted Pope John Paul II . Thetoyoung placed inambitious his way. and full of vigor, seemed oriented to fearless, He washis alsofamily a proud man did nottotake to any overcome curse andwho destined shatter anyhumor ceilings at his expense. Once, a classmate named Selim, a science geek placed in his way. strong theoretical physics andtochemistry,  with Hea was alsointerest a proudinman who did not take any humor who greata ambitions, that of Selim, becoming the geek at hishimself expense.had Once, classmate named a science next aEinstein, had leftinhim a message on a blackboard. This with strong interest theoretical physics and chemistry, happened Bey abruptly off histhe imposing who himselfafter hadMehmet great ambitions, that ofshaved becoming moustache in the schoolonyear, shocking us all next Einstein, hadmiddle left himofa the message a blackboard. This with a new,after more childishBey andabruptly thus lessshaved respectable happened Mehmet off hisimage. imposing In those days put inyear, a given classroom moustache in the students middle ofstayed the school shocking us all all day, and more every childish hour a new to giveimage. a new with a new, andteacher thus lessentered respectable lesson. wasstudents always astayed 5 or 10put minute breakclassroom in between. In thoseThere days the in a given Justday, before chemistry delighted all and every hourclass, a newSelim teacher enteredustowith givehoots a newand laughterThere with was a poetic linea on blackboard: “biyiksiz lesson. always 5 orthe 10class minute break in between. Mehmet This translates “Mehmet Just beforekuyruksuz chemistryesege class,benzer”. Selim delighted us withtohoots and without awith moustache donkey without a“biyiksiz tail”. In laughter a poetic resembles line on theaclass blackboard: Turkey “donkey” is aesege mildbenzer”. swear word. the timetoour teacher Mehmet kuyruksuz ThisBy translates “Mehmet

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without a moustache resembles a donkey without a tail”. In Turkey “donkey” is a mild swear word. By the time our teacher entered we were all mum, our amusement suppressed and replaced by curiosity about his reaction. Our self-important young teacher did not take to having his visage compared to that of a donkey’s ass - sans moustache or tail - very well. He hit the roof, insisted on knowing who had written that message and gave Selim hell for the rest of the schoolyear, starting with a call to his parents to complain about their irreverent son.   When assigned the important task of a chemistry-show for the Kralice (“queen” in Turkish), Mehmet Bey came up with a simple, easy to perform demonstration that was least likely to blow up the lab – and the royal visitors – and most likely to impress. It was an acid-base titration experiment, where as the pH of the reactants changed so did their color in magical, almost artistic transition. I was a science geek in those days, a fact well known to the teacher staff, and got quickly assigned to this lab. My mate Selim, much to his disappointment was excluded; that tailless donkey was to hound him for many months to come. Those of us assigned to the royal demonstration found ourselves in the chemistry lab at the very top of the school building, right under the roof, repeatedly practicing this simple experiment to acquire facility with it. Thus the occasion of this visit gave us students who cared about science, a rare chance to experience that much coveted laboratory that was deficient in our lives.   After months of anticipation the much awaited day arrived. The Queen showed up with an entourage that included her then rather young, unmarried daughter Princess Anne. The majority of the student body greeted her in the dusty schoolyard outside the main entrance, lined up in as perfect a military formation as the school could muster. This they had practiced countless times, as we had with our acid-base titrations. Those of us assigned to the lab were happy to be excluded from this tedium and abide in a less constrained world. On the day of the visit we found ourselves crowding the few windows of the lab that overlooked that part of the yard, to observe the upcoming royal inspection of our fellow students. When she finally entered the yard, accompanied by the Mayor of Istanbul Vefa Poyraz, and other dignitaries, all we saw was the top of Her Royal Highness’ hat, walking slowly, observing the student body, with God knows what demeanor.   Queen Elizabeth did not come to our chemistry lab. Maybe the four story climb to the attic was too much for her; the school had no elevators. Instead, she sent her young daughter for whom those stairs were, I suppose, no trouble. And thus, one day in 1972, at age 15, I witnessed the grand entrance of Her Royal Highness Princess Anne of Great Britain into our humble lab, where, with a well timed cue from an advance observer we had initiated our titration some minutes earlier. We were attempting to time that all important, and much theatrical pH change with her royal arrival, so that she did

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not experience much ennui in the few minutes it takes for the reagents to mix in the beakers and flasks. This we managed to do with much flair. The students were in groups on a rectangular bench arrangement, akin to a large board-table with a missing center, and the Princess circled on the outside of the groups, observing the proceedings with obvious disinterest.   She was much prettier in person face-to-face, than in countless newspaper and magazine photos I had seen of her, where she appeared plain and horse-faced. I distinctly remember thinking that if she stayed in the room maybe a few minutes longer I could develop a crush on her. My surprise at how pretty I found her is now indelibly etched in my memory of that day. But was I just a horny, hormone crazed teenager who would have found any woman her age attractive? I will never know, for I have never seen her again in person. She rounded the benches as fast as she could courteously do, and then muttered something under her breath, soft but distinctly audible, about how much she disliked chemistry. Within seconds she was gone. We immediately rushed the windows to catch a glimpse of her mother, still at the dusty school yard engaging in some ceremony or speech with the dignitaries, school officials and the still stiff, immobile geometric lines of our fellow students standing at attention. We stared at the top of their heads, and Her Royal Hat, trying to make out what was being said, but high atop the building so far away, with the regular noise of the busy city around us, this was impossible.   That’s when the second most memorable impression of the day unexpectedly occurred, and nearly wiped out my budding romantic impression of the formerly plain, now pretty Princess. In the safety of the lab, for all practical purposes hermetically sealed from the rest of the ceremonious world honoring Her Highness, Mehmet Bey, our teacher, went on an uncontrolled tirade about what a useless woman Queen Elizabeth was, and how anachronistic the British Monarchy had become in our age. This he did with all the passion of a Young Turk properly educated in the tenets of Ataturk, the relatively recent “father” of our nation, displacing his hatred of the Ottoman Monarchy, a central tenet of the modern Republic, on this hapless woman which for us was nothing but a round red hat viewed from the fourth floor. His emotions, raw with youthful zeal, were not just his. They belonged to the new intelligentsia of the lucky few with higher education in this yet newly Westernized nation. The Ottoman Monarchy was a symbol of Medieval backwardness, illiteracy, and dogmatic tenacious attachment to the Kuran, itself a major impediment to the enlightenment of the potentially powerful new Turkish nation. For Mehmet Bey the Queen was nothing but a fellowfelon, a sister to the Abdulhamits, and Abdulmecits of the past. I did not understand all this then. All I remember was how shocked I was at this overt display of utmost disrespect towards, of all people, a Queen, “Queen of England” for

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Heaven’s sake! That the words were uttered by none other than a teacher, an authority figure who commanded automatic and obligatory respect in our society made the occasion all the more shocking.   It was clear to me then, as it is now, that if Mehmet Bey had been within earshot of the school’s higher up powers, he would never have made such a disrespectful statement to us students. Despite his arrogance, he was still too young to dare such an act. The conflict he created between the official school “party-line” and his personal opinions expressed so bluntly left me much bewildered. Was the Queen really a superfluous, useless, anachronistic figure? Did she deserve respect from us, people foreign to her? Did she even deserve respect from her own subjects, as Mehmet Bey seemed to question? I was to ponder these questions through decades to come as I lived and studied medicine in England, and as I observed England go through wars in the Falklands and Iraq. When the tragic death of Princess Diana occurred in 1997, to my surprise, Mehmet Bey’s passionate opinions, uttered by the open windows on the top of the EHS building, were in the mouths of the whole world including England, and in the front pages of newspapers everywhere. The question he posed that day remains unanswered.   A few years after the royal visit, I found myself at the University of Chicago as a freshman college student, performing the exact same acid-base titration in a chemistry lab. I was now in one of the great Universities of the world, one with no financial problems, a dynamic institution that clearly was not resting on its laurels as did my former high school. As a pre-medical student I was engaged in a heavy science oriented curriculum in my first two years, with memories of EHS still fresh in my mind. To my surprise and amusement I discovered that the Chemistry, Physics, Calculus and Biology I took in Chicago was nearly a verbatim repetition of the curriculum we were taught at EHS. In Chicago straight A’s came to me easily in these subjects, for this was material I already knew well. Wouldn’t you know it? That EHS education that we denigrated and suspected for being inferior, as it turned out, was actually top notch, laboratories notwithstanding. In fact those much coveted labs were, in reality, overrated.   We now fast forward to 1989. I was living in Cincinnati, Ohio at the time, and my wife was pregnant with our first baby. I was a young attending physician practicing neurosurgery, and her, she was a seasoned nurse. We both had been through obstetrics and gynecology in our training and encountered births and deliveries. I myself had delivered quite a few babies. I was thus surprised when my wife dragged me to La Maz classes. “What do we need this for”, I kept asking myself. But I was a newlywed, and wanted to indulge my young wife whom I loved at the time. The classes were held in a fancy retirement home tastefully decorated with reproductions of British hunting scenes. I found the classes incredibly boring, and took to frequent mental distractions during seemingly interminable sessions.   In the middle of one such class Julie turned to me and found me in a contemplative gesture staring at one of those English paintings. Thinking that I was daydreaming about the upcoming blessed event, the birth of our first child, she asked me with excitement in her voice, “honey, what are you thinking about?”. “The decline of the British Empire”, I laconically answered, and then turned to face her anguished, disappointed expression. I stared at her blankly as Mehmet Bey, fully moustached, made a lightning pass through my disinterested mind. Then I snapped out of it and tried, as best as I could, to rectify my gaffe.

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In Memoriam < COMMUNITY

Mehernosh E. Dah, MD June 30, 1941 - May 24, 2010

Mehernosh E. Dah, MD of Stockton passed away on Monday, May 24, 2010 in a Stockton hospital. He was born June 30, 1941 in Bombay, India and was a respected member of the community. Dr. Dah practiced medicine in Stockton since 1977.   His wife Dr. Naju M. Dah of Stockton, three children, Anita Dah of San Francisco, Eric Dah of Stockton and Zubin Dah of Orange County, LA, as well as two brothers, Cyrus and Darius Dah both of Stockton, survive him.   (Following are selected portions of writings about Dr. Dah by Morris Senegor, M.D.)   In every medical community there are a handful of doctors who transcend barriers that subdivide physicians into smaller groups, and assume prominence or popularity among all. Often they tend to feature colorful, eccentric personae. There are many adjectives that can be attributed to Dr. Dah, but the one that best described him was “colorful”, in more ways than one. He was loud and boisterous, and charming. He was the only physician I have ever known who got away with calling women, patients

FALL 2010

and ancillary personnel alike, “darling”, and exuded exotic elegance in the act, always flattering them. In a profession accustomed to stiff shirts and ties, or scrubs, Dr. Dah wore colorful T-shirts and slacks to work, and an occasional scarf thrown around just so, carried with much panache. My wife once told him that she needed sunglasses to look at the color combination he had chosen for rounds one day. They laughed together, of course. Dr. Dah was full of animated laughs. Always upbeat, always curious, and always friendly, Dr. Dah roamed about the halls and ICU’s of his hospitals at all hours of the day and night, and on weekends. He was tireless, and carried a huge practice, not to mention a massive call schedule, never refusing any patient or referral, regardless of insurance or social class. Moris Senegor M.D. Editor

Dr. Guey Mark Feb. 22, 1928 - August 4, 2010

Dr. Guey Mark was born in 1928 in a village in the southern Chinese province of Guangdong. He was one of six children. Though it is now one of the most productive parts of China, at that time poverty was the rule in the fertile sub-tropical province. Most survived by subsistence farming.

In the early 1930s, his father went to Canada and then to Chicago, eventually bringing Guey’s older brothers to South Bend, Indiana, where they opened a popular Cantonese restaurant.   His father, who was a well-known Taoist priest in China, would return periodically from America to bring a son back to the West. During those years women weren’t allowed to immigrate. In 1938, at age ten, Guey Mark boarded a ship with his father for the journey across the Pacific to join his brothers. He was seasick every day.   In the ninth grade, his class was assigned to write a paper about their career goals. He wrote that he wanted to become a physician as a way to help people. Dr. Mark followed through on the dream that he formulated in that middle-school paper.   He went to University of Michigan, University of Notre Dame, and received his M.D. from Indiana University. He returned to Asia with the U.S. Army Medical Corps in Korea. He was honorably discharge with the rank of Captain.   After his military service he and his wife, Clara, whom he married in 1953, visited a distant relative in Stockton named Bing Mark. Bing owned a restaurant on the corner of Weber and California. Guey and Clara were looking for a place to start a practice and Stockton was about the right size town because it was about the same population as South Bend.   Intrigued with the climate, he also learned that there was a large Chinese community in Stockton. He visited the administrators of St. Joseph’s Hospital and Dameron Hospital. He felt comfortable with each of them and in 1958 opened an office in the 540 North California Building. He moved his office twice, eventually residing in the 2800 California Street Building before he retired in 2008. Dr. Mark began his practice as a family practitioner, which in those days also meant delivering babies. He had to

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COMMUNITY > In Memoriam stop delivering because he wasn’t getting enough sleep to take care of his office practice during the day. He and Clara raised three children; together built his practice when Clara stayed to manage the office after initially helping part-time; and became involved in the Chinese and greater Stockton communities. Dr. Mark’s ability to speak Chinese was a boon to the many Chinese-only speakers in the area. Dr. Mark’s desire to help people spurred him to contribute to many community organizations, such as the Jene Wah multipurpose center, the Senior Service Agency and the Chinese Benevolent Association. The Chinese Cultural Society of Stockton named him Chinese Citizen of the Year in 2002. He was a member of the San Joaquin Medical Society, chapter president of American Board of Family Practice (1973-74), chairman of Stockton Parks and Recreation Commission (1978), president of the Stockton Chinese Golf Club (2002), member of Stockton Kiwanis Club (for 49 years), and lifelong member of Cathay Club. Volunteered medical services to migrant farm worker community, taught resident physicians at the San Joaquin County Hospital, and practiced family medicine in Stockton for fifty years. He received the lifetime achievement award from the San Joaquin Medical Society in 2009.   He is survived by the love of his life, Clara, daughter Kathleen, sons Nelson (Shirley) and Kelvin

Calvin James Wegner, M.D. December 23, 1923 May 6, 2010

Magretta and Henry Wegner, was born in Madison, Wisconsin. He graduated from the University of Wisconsin Medical School and

Weldon Wallace West, M.D. 1921-2010

Weldon Wallace West was a child of the Depression whose self-reliance and determination were relentless. He was a member of the Greatest Generation that transformed America into a modern powerhouse. Like the rest of his generation, he did all this with humility and gratitude. He loved his family more than anything else, and above all, his extraordinary wife, Pearl.

served in WWII and the Korean War, ending with the rank of Major. He taught at Harvard Medical School. He met his wife, Barbara, while skiing in New Hampshire. He moved to Stockton in 1957. He practiced Pathology for more than 50 years. In the early years he was the pathologist for both Dameron Hospital and St. Joseph’s Medical Center. He established a practice with Dr. A. C. Armanini, whom Dr. Wegner had known at Barnes Hospital in St. Louis. They did residency together and then served in Korea together.   Survived by his wife Barbara Lenehan Wegner, Brother William Wegner of New Jersey, Children Allison Wegner, Meredith McMindes (Matt), Mark Wegner (Julie), Grant Wegner (Stephanie), and Neal Wegner (Joni). Grandchildren Laurel, Elise, Mariel McMindes, Jacob, Cody, Cole, Cade, Finn, Patrick, Michael Wegner.

Weldon was born in Modesto in 1921 to Wirt Mercer West, a master carpenter and homebuilder from Lakeport, and Ada May McCoy, a striking Scotts Valley girl. Weldon grew up in Stockton where his father built many of the homes surrounding the University of the Pacific. He graduated from Stockton High School.   Weldon earned a Chemistry degree from UOP and was accepted to Harvard Medical School during the last years of World War II. While at UOP he met a brilliant and beautiful San Francisco woman named Pearl Steiner. They were married in 1945.   After graduation from Harvard, where he trained as a surgeon, he had a residency at Massachusetts General Hospital. He served a total of six years

Calvin James Wegner, the son of

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COMMUNITY > In Memoriam in the Navy and Army, including two years at Fort Hood, Texas.   Weldon and Pearl had four sons: Donald Wells West, William Eric West, James Lowell West, and Robert McCoy West. Returning to Stockton in the early 1950s, he opened a medical practice on an upper floor of the historic Medico-Dental building. His sons recall climbing with him to the roof and gazing at the farmlands stretching west toward Mr. Diablo and east to the Sierra Nevada Mountains.   The Sierras held a special place for Weldon. During his teens he hiked the John Muir trail. As an adult he vacationed at Silver Lake in a cabin he co-owned with Dr. Edward Caul and Dr. John Morizumi and their families. Hiking the mountain slopes and shores of the lake, he shared his love for the high country.   He specialized in Cardio-Vascular surgery and had privileges at many valley and foothill hospitals but St.

Joseph’s Hospital was the primary venue for his surgeries. He moved his practice to a California Street location north of St. Joseph’s. He shared the office with Dr. Robert K. Salter.   He was very active in the San Joaquin Medical Society, serving on various committees or as a member of the Board of Directors beginning in 1958.   As if the demands of medical practice weren’t enough mental exercise, during moments between cases the busy doctors played a running game of chess on a magnetic chessboard affixed to a wall in the office’s lab.   Though a quiet and serious person, he had lighter moments. He could lob a deadly pun. He could roller skate backwards. He loved clever antic humor ala Danny Kaye. Combining his sense of humor and his athleticism, he was the Watermelon Seed Spitting Champion of Harvard, (there are photos of the athlete in action),

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a singular moment in Ivy League history when the Halls of Academe resounded with the sounds of “patooey”.   He was a photographer with his own dark room equipment. He used the carpentry skills he learned from his father to build household projects ranging from a complex patio roof to a whimsical racecar bed for young Robert.   He and Pearl supported UOP, St. Joseph’s, Stockton Symphony, Habitat for Humanity, and many other causes. Quietly, he directly helped several individuals and wished only that they pay it forward. During the Depression his family had to take in boarders, thus he understood hard times.    He built an office on Alpine Avenue in the late 1970s. Dr. L. Buscaglia was part of that office. He served as Chief of Staff at St. Joseph’s. He was passionate and resolute in advancing the quality of medicine. He worked closely with Sister Gabriel, the moving force behind that era’s growth of St. Joseph’s. He retired in 1986 at the age of 65.   A grandson, Alexander Weldon West, was born in 1988 to James (Deborah). A granddaughter, Kari Jasmine West, was born to Robert (Diane) in 2002.   He continued to read scientific and medical journals during his retirement. He loved the life of the mind and never stopped learning. He built a stereo system from the board level up, purchased one of the early generation computers, learned some very basic programming, read and re-read the works of Charles Darwin and other scientific giants.   He was a gardener and, like his own father, grew roses and backyard tomatoes until late into his eighties. In St. Joseph’s Hospital, a place where he had lived the life of a physician, Weldon West died on January 25, 2010

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SPRING 2010

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H E A LT H C A R E H A P P E N I N G S

Annual Membership Dinner in Recognition of our 2010 Lifetime Achievement and Young Physician Recipients

Top left photo: Young Physician Award Recipient Dr. Ramin Manshadi and his family. Top right photo: Lodi Memorial Hospital CEO Joe Harrington enjoys the event. Second row, right photo: Drs. Tom Streeter and Harjit Sud pose with their children. Bottom left photo: St. Josephâ&#x20AC;&#x2122;s Medical Center CEO Don Wiley visits with Dr. Venkata Emani and Dr. George and Rae Charos.

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Bottom right photo: Assemblywoman Cathleen Galgianai made several presentations to both of our awardeeâ&#x20AC;&#x2122;s on behalf of herself and her esteemed colleagues at the state capital.

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H E A LT H C A R E H A P P E N I N G S

Stockton Golf and Country Club Sunday, June 27, 2010

Top left photo: Incoming medical society President Jim Halderman accepts the gavel and in return offers outgoing President Lawrence Frank a cut glass award in honor of his year of service. Center left photo: Dr. Joe Serra accepted Dr. Stanley Clarkâ&#x20AC;&#x2122;s Lifetime Achievement Award on his behalf and is here pictured with former NFL player Mike Merriweather and his wife Sandra who presented a poem on behalf of Dr. Manshadi. Second row, right photo: Past-President Dr. Robin Wong presented Dr. Ramin Manshadi his award. Bottom left photo: Drs. Guey Mark, Mas Kamigaki, and Ed Schneider share a laugh during the reception. Sadly, this would be Dr. Marks last society event before his untimely passing in early August. Bottom right photo: Dr. John Irish and Fran Meredith are always smiling.

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HEALTHCARE HAPPENINGS is now a regular feature in San Joaquin Physician Magazine and requests your photo submissions for publication consideration. All photos must be submitted as JPG files electronically and contain appropriate captions. Email your submissions to submissions@sjcms.org

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

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Fall 2010