S A N M AT E O C O U N T Y June 2014
I NS I D E
S A N M AT E O C O U N T Y M E D I C A L A S S O C I AT I O N
Volume 3 Issue 6
Physician
ROBOTIC SURGERY: The cutting edge
ROBOT PATIENTS
The new SMCMA website
A ďŹ nancial safety net for you—
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10- AND 20-YEAR LEVEL TERM LIFE No matter where you are in life, SMCMA Group Level Term Life Insurance beneďŹ ts can be an affordable solution to help meet your family’s ďŹ nancial protection needs. Mercer and SMCMA leveraged the buying power of your fellow members to secure dependable and affordable life insurance beneďŹ ts at competitive premiums from ReliaStar Life Insurance Company, a member of the Voya family of companies.
With quality life insurance beneďŹ ts extended at competitive rates, you’ll rest easy knowing you’ve provided coverage for your loved ones through the Group 10-Year and 20-Year Level Term Life Plans.
As a member, you can conveniently help protect your family’s ďŹ nancial future with the Group 10-Year and 20-Year Level Term Life Plan. It features: t BeneďŹ ts up to $1,000,000 t Rates designed to be level for 10 or 20 full years* t BeneďŹ t amounts that never change provided premiums are paid when due
See for Yourself: Get more information about your Group 10-Year and 20-Year Level Term Life Plans, including eligibility, benefits, premium rates, exclusions and limitations, and termination provisions by visiting www.CountyCMAMemberInsurance.com or by calling 800-842-3761. Underwritten by:
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ReliaStar Life Insurance Company, a member of the Voya family of companies.
67150 (7/14) Copyright 2014 Mercer LLC. All rights reserved.
.FSDFS )FBMUI #FOFmUT *OTVSBODF 4FSWJDFT --$ t $" *OT -JD ( 4PVUI 'JHVFSPB 4USFFU -PT "OHFMFT $" t t $."$PVOUZ *OTVSBODF TFSWJDF!NFSDFS DPN t XXX $PVOUZ$.".FNCFS*OTVSBODF DPN * The initial premium will not change for the ďŹ rst 10 or 20 years unless the insurance company exercises its right to change premium rates for all insureds covered under the group policy with 60 days’ advance written notice. The County Medical Associations and Societies/NORCAP/CMA receive sponsorship fees for insurance programs that offset the cost of program oversight and support member beneďŹ ts and services.
S A N M AT E O C O U N T Y
Physician Editorial Committee Russ Granich, MD, Chair Sharon Clark, MD Edward Morhauser, MD Gurpreet Padam, MD Sue U. Malone, Executive Director Shannon Goecke, Managing Editor
SMCMA Leadership Amita Saxena,, MD, President; Vincent Mason, MD, President-Elect; Michael Norris, MD; SecretaryTreasurer; Gregory C. Lukaszewicz, MD, Immediate Past President Alexander Ding, MD; Manjul Dixit, MD; Russ Granich, MD; Edward Koo, MD; C.J. Kunnappilly, MD; Susan Nguyen, MD; Michael O’Holleran, MD; Chris Threatt, MD; Kristen Willison, MD; David Goldschmid, MD, CMA Trustee; Scott A. Morrow, MD, Health Officer, County of San Mateo; Dirk Baumann, MD, AMA Alternate Delegate
Editorial/Advertising Inquiries San Mateo County Physician is published ten times per year by the San Mateo County Medical Association. Opinions expressed by authors are their own and not necessarily those of the SMCMA. San Mateo County Physician reserves the right to edit contributions for clarity and length, as well as to reject any material submitted. Acceptance and publication of advertising does not constitute approval or endorsement by the San Mateo County Medical Association of products or services advertised. For more information, contact the managing editor at (650) 312-1663 or sgoecke@smcma.org. Visit our website at smcma.org, like us at facebook.com/smcma, and follow us at twitter.com/SMCMedAssoc.
© 2014 San Mateo County Medical Association
June 2014 / Volume 3, Issue 6 Columns President’s Message: The fine art of teamwork ...............................4 Niki Saxena, MD
Executive Report: SMCMA partners with ACO to offer participation in Medicare shared savings program .........................6 Sue U. Malone
Feature Articles Robotic surgery: The cutting edge ....................................................8 Ori Melamud, MD
Robot patients ..................................................................................10 Ann Gerhardt, MD
The new SMCMA website .................................................................13 SMCMA Staff
Of Interest Member Updates, Index of Advertisers ........................................ 14
President’s Message by Niki Saxena, MD
The fine art of teamwork
On
June 19 the San Mateo County Medical Association held its Annual Meeting of Members at the Peninsula Golf and Country Club. Our keynote speaker was someone who has carved a unique path in medicine, Dr. Zubin Damania, aka ZDoggMD. He has roots in the Bay Area (trained at UCSF and Stanford, worked at
PAMF) and was an early presence on social media. Two years ago he moved to Las Vegas to start up a primary care clinic called Turntable health. His presentation was funny and entertaining, but his frustrations with the current system of medicine hit home for many of us in the audience. “I went into medicine to help people” he said at one point, “but when my daughter told me she wanted to be a doctor just like me because she wanted to help people, I could not support her.” He is not alone in this-more and more polls show that a declining percentage of physicians would recommend medicine as a
career to their children, or to other young people starting out on their own career paths. Physician burnout is a growing concern. How do we stay engaged in your work and connected with our patients? How can we take care of ourselves and support our colleagues? Many of us survived incredibly competitive educational environments where the last thing one would do is to lend a hand to a “rival.” Teamwork may be clear as a concept, and it makes sense in the context of sports, but at our core how many of us carry those principles with us in our day-to-day professional lives? The traditional doctor-patient relationship is a binary one, and many of us are struggling with how to wrap our minds around a more inclusive model that would bring in many more layers. And if healthcare is headed the way of a team-based model, who is the “captain”? Is it even politically correct to assume there should be one?
“
I had the chance to experience a crash course in team building
“
4 SAN MATEO COUNTY PHYSICIAN | JUNE 2014
recently as I participated in a twoday “learn to row” camp in Redwood City. I’ve always wanted to learn how to row…I’ve seen the movies where boats glide poetically across the river as the sun breaks over the horizon….all oars flashing in unison as a crew of people seem to paddle effortlessly across water as still as glass. Well, after two days I can tell you it is a LOT harder than it looks! Taken individually each step seems simple enough, but when you try to synchronize them in a very long and skinny boat on top of deep and cold water, it becomes imperative to learn to work as a team. There is a clear chain of command: the coxswain “steers” the boat and functions as the captain. He or she counts out strokes, determines who rows and who works on balancing the boat, and is the only person who faces “forward” and can see the entire course. The crew faces “backward,” looking at the coxswain and trusting in his or her ability to steer them safely to their destination. Port and starboard, bow and stern, all these areas have their own “subspecialties” and areas of focus.
You may not control all the events that happen to you, but you can decide not to be reduced by them. — Maya Angelou
But each person concentrates on the task at hand, there is a clear delineation of duties, and timing is key. You can seriously undermine a race by being off-rhythm from your teammates by even a few seconds. When it is not clear who is in charge, or what the commands are, that is when an element of chaos can set in. Being a novice I felt a little overwhelmed learning a new jargon and a new muscle memory skill set. But every once in a while, when my oar would “catch” at just the right time and match the rhythm of the team, it felt like I was flying across the surface of the water…and that felt magical! A good day at work feels just like that: all the pieces come together, the timing is right, and the entire
healthcare team connects in a positive way. I think patients get better care, and physicians like me are happier, when that happens. Speaking of teams, this past year I had the honor and privilege to serve as your president for the SMCMA. Sue Malone and her staff function as an incredible team, they are a hardworking and dedicated group of professionals who work hard to help support the physicians in our county. I appreciate the strength and diversity of the medical community we have here in San Mateo, and I look forward to seeing many of you at future events. Thank you. ■
SMCMA Family Picnic Join us for family-friendly food and fun under the California sun! This event is FREE to SMCMA members and their families.
Sunday, August 24, 2014 11:30 A . M . - 3:00 P . M .
Huddart County Park Woodside
For reservations and information, please contact us at (650) 312-1663 or visit our website at smcma.org.
JUNE 2014 | SAN MATEO COUNTY PHYSICIAN 5
Executive Report by Sue U. Malone
SMCMA partners with ACO to offer participation in Medicare shared savings program
In
an attempt to address the unsustainable growth in health care expenditures and inconsistent quality of care, Congress passed legislation for the creation of the Medicare Shared Savings Program. The Shared Savings Program has a three-pronged aim:
solo to large multi-specialty group practices • Guarantees local clinical control and brand—the SMCMA initiative will be led by SMCMA and participants • Offers centralized data and compliance, deployed securely over the internet • Employs proven care and quality coordination methods • Offers proven provider education, audits and feedback
to deliver better care for individuals, improve the health of populations, and lower growth in Medicare Parts A and B expenditures. A new national Medicare Shared Savings Program ACO, developed by Physicians Accountable Care Solutions, L.L.C. (PACS), is slated to start January 1, 2015. PACS provides an affordable way for physicians to maintain their current practices. In addition, physicians retain responsibility and leadership in the design, operations and delivery of medical services in their communities using PACS’ clinical support tools and systems. The SMCMA/PACS ACO is unique in many ways: • Enables “virtual” practice integration, allowing physicians to remain in their current practice settings, from
• Gives physicians access to CareScreen™ software and care management tools (licensed, developed, and owned by Quality Health Ideas, LLC.), which will work on any EMR. • Meets NCQA, CMS and state requirements • Satisfies PQRS requirements for all physicians who participate • Assists practices in maximizing revenue from the new transition payments (CPT Codes 99495 and 99496) • Provides opportunity to become adept at managing patient populations and successfully transitioning to value-based payment systems There are no start-up costs to the individual practices, so there is no need to invest in expensive EHRs or other technology. There is also no downside risk, Physicians still receive their Medicare fee-for-service payments,
6 SAN MATEO COUNTY PHYSICIAN | JUNE 2014
with no loss potential as the ACO operates under a shared savings only model. A bonus payment is awarded if there is lower growth in medical costs for SMCMA’s local initiative’s ACO-assigned patient population while meeting performance standards on quality. Our own local committee craft the distribution of bonus payments. Our SMCMA ACO and Physician Accountable Care Solutions (PACS) and its service providers only get paid if there are bonus funds —that is, only if the data, tools and analytics provided the ACO participants lead to success. We are operating under significant time constraints in order to credential each of you wishing to participate in this ACO, which has a January 1, 2015 start date. Applications are due in July 2014, as each application must be credentialed before being sent by the ACO to CMS to accept and assign Medicare beneficiaries to each participant practice. SMCMA has extensive information for you to review, as well as the ACO Participation Agreement. The materials are posted on our website at www.smcma.org/acoinformation. We can also fax or mail you the materials, as well as answer questions you may have. Contact the SMCMA at (650) 312-1663. We are extremely pleased to have the opportunity to offer members participation in this program and hope it will bring real value to you, your practice and your patients. ■
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Pictured left to right: John M. Knight, M.D.; George J. Tischenko, M.D.; Charles F. Preston, M.D.; Joseph X. Kou, M.D.
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JUNE 2014 | SAN MATEO COUNTY PHYSICIAN 7
ROBOTIC SURGERY: THE CUT TING EDGE
Medicine and technology are advancing at a dizzying pace. Even ten years ago we would not have believed what we are capable of today, treating diseases more effectively and with less morbidity. Obviously, advancement always comes with a cost. Robotic surgery is one of those amazing advancements of modern medicine with great benefit when used properly, but also with inherent costs that should be considered. by Ori Melamud, MD Robotic surgery as we know it today was originally an endeavor funded by NASA and DARPA at SRI International in Menlo Park. It was intended initially to allow for remote battlefield surgery so soldiers could be treated more effectively. Unfortunately that never came to fruition, but the work led directly to the robotic technology we use today. The da Vinci Robotic system by Intuitive Surgery (Sunnyvale, California) is the most widely used robotic surgical system. It is a master-slave system where the robotic surgeon sits at a console connected to the instruments in the patient, and the surgeon’s hand movements are mimicked by those instruments. It has binocular 3-D magnified vision and the instruments have wrists, allowing for greater dexterity than traditional laparoscopy. Procedures widely performed with this system include prostatectomy, hysterectomy, cholecystectomy, colectomy, partial nephrectomy and many more. There 8 SAN MATEO COUNTY PHYSICIAN | JUNE 2014
are centers performing cardiac procedures (valves, bypass), pulmonary procedures, radical cystectomies and other complex procedures as well. There is a great deal of controversy surrounding robotics. Much of it is focused on the costs of the procedures and the equipment, as well as concerns about adverse outcomes when used improperly or with inadequate training. This has to be balanced with the potential clinical benefits and careful evaluation of whether those benefits are borne out in prospective studies. The system alone can cost a hospital between $1.5 and $2.2 million dollars, with an additional annual service contract and expensive disposable instruments. Yet many of the procedures performed robotically lead to shorter length of stay and fewer complications, which drive down overall cost. Insurers do not currently pay any differently for a laparoscopic or robotic case, so hospitals hope these factors will help make up the cost difference. The patient may also return to productivity sooner, leading to global economic benefits.
Not all procedures show these kinds of benefits over the non-robotic alternative. Those with the greatest benefit would be the procedures that would otherwise be traditional open surgeries, or those with great complexity such as prostatectomies, colectomies, cystectomies, gastric bypasses, large hysterectomies, and many others. High-volume centers focused on those procedures with clear clinical benefit will have the most cost-effective programs. Surgeon training has become another area of focus. As with any new surgical technology, there is a learning curve and many hours of training are needed to perform the procedures safely, and further hours are needed to become more and more proficient. Reports of tragic complications have certainly occurred, and each robotic program must take pains to ensure their surgeons are being properly trained, proctored and evaluated for continued safety and quality. This technology is somewhat unique in that the industry is heavily involved in the training, leading to some concerns of ethical conflict. It is imperative that each hospital monitor this process and ensure that their patients are properly cared for and protected. I believe our local hospitals are doing a fantastic job in this regard. Despite all the above concerns, robotic surgery continues to grow in popularity. In 2011, 360,000 robotic procedures were performed; in 2012, that number was 450,000. The technology continues to change to allow for more advanced procedures. Singlesite techniques are now available to allow for better cosmesis and possibly less pain.
Data continues to be accrued suggesting that robotic surgeries often have fewer complications, shorter hospital stays, less pain, fewer blood transfusions and overall improved outcomes. One of the first and best studied procedures done robotically is the radical prostatectomy for prostate cancer. Open surgeons have long argued that robotics would be inferior as it lacks the tactile feedback they use to facilitate the identification of structures
and abnormalities. It has now been well established that patients having robotic prostate surgery had shorter hospital stays (1.8 days vs. 2.9 days), less blood loss (207cc vs. 852cc), fewer transfusions (4.3% vs. 30.3%) and fewer short-term complications, but long-term outcomes were in doubt. Recently a population-based study out of UCLA and the University of Montreal Health Center has suggested that robotic prostatectomies, when compared to open prostatectomies, show a 30% or more reduction in positive margins and a 25% or more reduction in the need for additional cancer treatment. Further studies certainly will be needed to confirm that, but these results are very reassuring. Robotic surgery is growing rapidly and, as with any new technology, has led to some concerns. However, the benefits seem to be real when used properly and by experienced well-trained hands. The questions mainly surround the cost and whether these costs justify the benefits. The answer is certainly complex, and is different for each procedure, each hospital, and each community. Those of us performing these procedures whole-heartedly believe our patients benefit greatly from it. â–
About the Author Ori Melamud, MD, is a board-certified urologist with Melamud Urology Group in Burlingame. He has lead the charge in bringing advanced minimally invasive surgery to the peninsula, including robotic, laparoscopic, and endoscopic urology and was appointed Director of Robotic Surgery at Peninsula Hospital when they purchased their robot in November 2012.
JUNE 2014 | SAN MATEO COUNTY PHYSICIAN 9
ROBOT PATIENTS
by Ann Gerhardt, MD
ENOUGH ALREADY WITH ROBOT doctors, computer-assisted diagnosis and EMRs to keep us from forgetting to order an HgbA1c. OK, so we’re imperfect—we’re human— What about the other side of the equation—The Patient? Some days I crave a robot patient. We’ll call him Hal. Hal exercises five days a week, 45 minutes per day. He eats a totally prudent, plant-rich diet every day, with no more calories than necessary to maintain his ideal body weight. He has never smoked or used recreational drugs, and minimal alcohol. He agrees to recommended vaccinations, washes his hands frequently and wears a mask during cold season. Hal is on time for his appointments. He maintains a current insurance policy and budgets money for his medical co-pays. He knows his medications and takes them precisely as described, every day. He calls in advance for refills When he has a new problem, he presents it in logical order, describing onset, quality, frequency, intensity and duration in concrete terms, without histrionics or editorializing. He uses unambiguous terms common in medical parlance, since he’s been programmed with medical textbooks. He leaves out extraneous data, like his little sister’s reaction to his sputum. He provides a complete relevant review of systems, family history and social updates. He mentions his concerns, but allows you to generate a differential diagnosis and plan that addresses his concerns but is independent of his bias. He doesn’t demand testing or the latest Internet remedy. He does prescribed testing and sees referrals as soon as possible. He follows the plan and gives an update in a pre-designated
10 SAN MATEO COUNTY PHYSICIAN | JUNE 2014
amount of time. If he’s not happy with your plan, he notifies you and requests a revised plan, which he then follows. Hal knows you work hard on his behalf, but are often screwed by the insurance companies. He discovers your favorite restaurant and gives you a gift card during a holiday season appropriate for your heritage. (OK, so this is a bit extreme.)
BUT…if all patients were like Hal, most would stay healthy into old age, without hypertension, diabetes, heart disease, and lifestyle-related cancers. This would eliminate the need for probably a third of all doctors. Another third would need to switch to geriatrics (for
the arthritis, infections and vascular disease that would finally appear) and orthopedics (to deal with injuries incurred during bocce ball and skydiving). A significant number of the last third would be BORED. It’s the non-robot behaviors that make medicine interesting, entertaining and challenging. I would really miss the English majors and artists who describe systems in graphic metaphors. And those who act out their symptoms. And those whose personalities are revealed in the stories they tell. And the main patients who are downright entertaining, even if they don’t want to hear what I say and refuse to take medication (don’t you envy Robin Williams’ doctor?) Patients whose bodies and diseases don’t follow the textbooks remind us that we don’t know everything. We LEARN from them, as we discover new disease presentations, behavior types and reactions to substances and drugs. A tough diagnosis is more fulfilling when I have to dig deep in the history and physical exam and creatively address testing, rather than have it handed on a platter of totally relevant history. Treatment decisions that consider genetic differences, personality types and co-existent disease, rather than blindly follow an algorithm (oh, my, such heresy!) have a better chance of working.
Eating disorder patients, who withhold information and are non-compliant because they need their disordered behavior to psychologically cope, are terribly frustrating. But when they actually recover, each, in their own, predictable way, I remember why I’m a doctor, and not a technician. The same is true for other addictions and challenging personality types. I doubt that any human is a Hal-type patient. I’ve never taken medication for times a day in my life, and three a day is a stretch. But too many of us brand patients as “difficult” or “non-compliant,” as if to rid us of the responsibility of dealing with our patients’ human side. Herein lies the “art” of medicine. ■
About the Author Ann Gerhardt, MD, is a physician in Sacramento. Boardcertified in Internal Medicine and Clinical Nutrition, she is a private medical and nutrition consultant, Medical Director for the Sutter Community Hospital’s heart transplant program and a part-time hospitalist. She is also a member of the Board of Directors of the Sierra Sacramento Valley Medical Association. This article was originally published in the March/April 2014 issue of Sierra Sacramento Valley Medicine.
JUNE 2014 | SAN MATEO COUNTY PHYSICIAN 11
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12 SAN MATEO COUNTY PHYSICIAN | JUNE 2014
WELCOME TO THE NEW SMCMA WEBSITE
The San Mateo County Medical Association is pleased to announce it has a new website at smcma.org. SMCMA staff and consultants worked hard to develop an attractive, intuitive interface with relevant content and helpful resources for all of our constituents. Our new website’s features include: •
•
•
•
The ability to join or renew your membership and securely pay your dues online. There is also online registration and payment for SMCMA events, including CME programs. The Practice Resource Center includes information on working with Covered California, staying compliant with HIPAA and other regulations, and the member services offered by SMCMA, such as reimbursement advocacy assistance.
information for their legislators, as well as sample messages that can be customized before sending. •
Our Featured Member profile now includes a thoughtful interview with the physician, asking questions such as “Who are your heroes?” and “What is something that people might be surprised to learn about you?” And there’s more yet to come. We are currently working on a password-protected job board where members can view employment opportunities and post positions they need to fill.
Please take a moment to cruise by smcma.org and check it out. Please note that the site was built to perform well, well into the future. Scan the QR code above with Therefore, it should be viewed in your smartphone or table to see the most current version of your the mobile version of the new chosen web browser whenever SMCMA website. The Patient Resources has possible. Internet Explorer (IE) been enhanced, including users should be using IE 9 or straightforward information on above. Mozilla Firefox users should make sure they have health insurance and health care reform, as well Firefox 30.0. Chrome users should be using Chrome 35.0. as links to numerous health-related resources The site will not display properly on Internet Explorer within San Mateo County. 8. If you are still on Windows XP (which Microsoft stopped supporting in April 2014), you will not be able We have added an exciting feature to our to upgrade from IE 8, but you can still see the site by Advocacy section called Take Action Now. When downloading the latest version of Firefox from there is an initiative that impacts physicians mozilla.org or the lates version of Chrome from and the practice of medicine in our county, individuals can visit our website to find contact
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JUNE 2014 | SAN MATEO COUNTY PHYSICIAN 13
NEW SMCMA MEMBERS
THE NEW SMCMA WEBSITE (continued from previous page) google.com/chrome. Both browsers are secure, easy to use, and free.
Melissa Braveman, MD *PD/Menlo Park
Those users who have eschewed the “traditional” desktop and laptop computers in favor of tablets and smartphones will be pleased to know that the new SMCMA website uses responsive web design to to provide an optimal viewing experience—easy reading and navigation with a minimum of resizing, panning, and scrolling—across a wide range of devices.
Beth Haynes, MD EM/Half Moon Bay
Please note that the new site was built from the ground up; any user names and passwords that members used on the previous SMCMA website are no longer valid. In a few weeks, the SMCMA will be emailing all of our members for whom we have email addresses, with their individual user name, password, and instructions for logging into their member profile. If you don’t hear from us, or if you don’t have an email address, simply contact the SMCMA and we will be happy to help you.
Sara Whitehead, MD D/Palo Alto
Please call Shannon Goecke at (650) 312-1663, fax (650) 312-1664, or email sgoecke@smcma.org with your questions and comments. ■ * Board-certified by the American Board of Medical Specialties
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A
REGISTRY
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FIRM
Physicians Nurse Practitioners Physician Assistants
The following SMCMA members have recently retired from practice: George Bulloch, MD Ned Grove, MD Amon Liu, MD
In Memoriam Eldon Ellis, MD
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June 15, 2014
May 27, 2014
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