Central Valley Doctor Magazine

Think local. Act global.

When Volunteers return home from making a difference in another country, they bring back real-world skills and experience for their own community.

800.424.8580 www.peacecorps.gov

Life is calling. How far will you go?

JANUARY 2010 Volume 1 Issue 1

CONTENTS

10 COVER STORY NOVALIS VERSUS CYBERKNIFE Studies from all over the world have proven stereotactic radiosurgery to be an effective treatment of brain metastases, and competition to treat benign and malignant lesions has increased dramatically over the years. With many options available in the Central Valley, how do you know which is right for your patients?

16 RESPONSE THE STATE OF THE VALLEY Weigh-in on your experiences practicing medicine in the heart of California. This in-depth comparison of the Central Valley against State and National statistics on employment, poverty, insurance coverage, is an eye-opening look at the challenges we face serving our community.

10 INSIDE 5 Editor’s Note 6 Valley Recommendations for National Health Care Reform 9 Planning for Growth in 2010 15 Laboratory List 18 ‘Meaningful Use’ Defined

22 Calendar Go online to:

www.centralvalleydoctor.com for our interactive online edition!

16 January 2010 Central Valley Doctor

17359_full page ad

1/17/08

4:49 PM

Page 1

EDITOR’S NOTE

ALL CAPS HEADLINE

Sentence Case and Bolded Headline For Those Who Love Italics

Key #3: Partners close, competition closer

Trust patient education from Ahabem con te, tum quamdituidet tem maionsum, unicae ad imor the leading names in idheart and strokefectella health. locciena, efatam ci pra nine fuis bonerum peresen irmaio et, Castife confirt

uament?Heart iam tes aci cotiameand deserimod senterum, conferis, eortuam Krames is your source for American Association American Stroke Association patient it, vidfoundation achuid redo, Valis. Deri quem noniacciem nir ades utemei pris education. Built on an 80-year of C. research andse,science, these resources help hor healthcare inatiferum esim audestocenina ma,disease ut veroracivis; nocchui professionals reach patients, munulin caregivers, and at-risk groups promote management anddienam intrunt imandeto missi pere, que publiquo inclatum num et? prevention, create awareness, and inspire change.

Education and awareness products

Turnkey kits

Caregiver resources

And more‌

Ask us about custom publishing opportunities!

Call 800-333-3032 or visit www.krames.com/aha for our complete collection of patient education!

7072

Central Valley Doctor www.centralvalleydoctor.com

EDITOR’S NOTE

5730 N. First St. #105-151 Fresno, CA 93710 Phone: (559) 492-0463 Fax: (559) 347-9518 www.centralvalleydoctor.com An IMG Publication Senior Executive Officer: Ken Melchor Publisher: Donna Reeg Editorial Director: J. Evans Editor: James Ingram Contributing Writers: Jeanie Erwin Bob Hall Kelsey Warnock

As you might have suspected, and may intuitively know, the Central Valley is a very unique place to practice medicine.

We face many challenges daily: high poverty, high unemployment, high incidents of teen pregnancy, sexually transmitted diseases, drug use, obesity, and more. I could continue, but choose instead to focus on those things which make the Central Valley a great place to live: that in spite of bad air, hot summers, and dense winter fog, we have a very special community; and that although our numbers are large, we have been able to maintain our small-town, neighborly culture. The Central Valley is still a place where relationships are important, integrity is valued, and hard work does not go unappreciated.

This is the reason Central Valley Doctor magazine exists -- to honor you, the doctors of the Central Valley for your hard work, commitment, and dedication to serving our community. You keep the people of the Central Valley healthy, and you care for the people who fuel the California economy and feed the world.

Photographer: David Marshall

As we enter 2010, we stand at the threshold of several major changes in American medicine. Health care reform has passed both the House and Senate, and it is difficult to ascertain exactly what this reform will mean.

While we do not have all of the answers, we will do our part to address the major changes as they arise.

Central Valley Doctor magazine is distributed at no charge to licensed, practicing physicians and surgeons in Fresno, Madera, Kings, Kern, Tulare, and Merced Counties. Please send address changes or subscription requests to the address above or email subscribe@ centralvalleydoctor.com.

It is with much hard work and dedication that the team here at Central Valley Doctor magazine researches and assembles this publication for you.

It is with your continued input and service on our advisory board that we are able to keep this magazine relevant. Please call, write, or email, and let us know how we can serve you. We invite article submissions, cover story nominations, comments, critiques, and suggestions. It is our goal to provide you with the timely information and local perspective you want, need, and deserve to successfully practice medicine in the Central Valley.

If you are a medical vendor or service provider and would like to request a subscription please call (559) 492-0463.

Annual subscriptions are available for $49 per year.

From all of us at Central Valley Doctor magazine, HAPPY NEW YEAR! You have worked hard to earn the right to be called “Doctor” and your continued sacrifice for our community is valued and appreciated. We are on your side.

To contact a sales representative or to request a media kit, please call (559) 492-0463 or email ads@ centralvalleydoctor.com. Visit us online at www.centralvalleydoctor.com Central Valley Doctor magazine is published by IMG Publishing in Fresno, California. Although every precaution is taken to ensure accuracy of published materials, Central Valley Doctor cannot be held responsible for opinions expressed or facts supplied by its authors or advertisers.

NOT INTENDED FOR WAITING ROOM.

To your continued health and success,

J. Evans Editorial Director editor@centralvalleydoctor.com Advertise in Central Valley Doctor For more information on advertising in Central Valley Doctor magazine call Publisher Donna Reeg at (559) 492-0463 or email ads@centralvalleydoctor.com

Contact Information Email press releases, PSAs, and other information to news@centralvalleydoctor. com or fax to (559) 347-9518.

Mail materials to: Central Valley Doctor magazine ATTN: J. Evans 5730 N. First St. #105-151 Fresno, CA 93710 January 2010 Central Valley Doctor

POLITICS

Valley Recommendations for National Health Care Reform

N

is underway and moving fast.

Although it is currently difficult to translate how these changes will affect the Valley, several local organizations worked hard to make sure that our voice was heard. ational health care reform

and patient advocates. The result of this forum was the identification of seven key recommendations which

uninsurable. Most agreed there should be a sliding fee scale and that cosmetic and elective surgeries should be excluded. Participants wanted the public option to place special focus on health education, access to primary care, and prevention.

“Children should not suffer for their parents’ immigration status.”

On September 17, 2009 the Central Valley Health Policy Institute at California State University, Fresno held a public forum discussing national health care reform from a Central Valley perspective. The event was cosponsored by the Great Valley Center, the California Partnership for the San Joaquin Valley, and AARP and drew a diverse crowd of hospital executives, medical professionals, providers, insurance companies,

were sent to our Congress members prior to casting their votes. The seven recommendations were:

1. Cover Everyone, Not Just the Uninsured and Uninsurable.

Forum attendees desired a public insurance option that was open to all, not solely the uninsured and

Central Valley Doctor www.centralvalleydoctor.com

2. Impose New Regulations on Private Insurance Companies.

An overwhelming majority of forum participants wanted new regulations for private health insurance companies, including revised policies on pre-existing conditions. They held that pre-existing conditions and demographic factors should not be a determinant of eligibility or a reason to drop coverage.

POLITICS

3. Redefine Benefit Definitions and Reimbursement Rates.

There was a consensus that benefits definitions and reimbursement rates should follow the guidelines of evidence-based medicine. Participants agreed that health care reform should focus on system improvements, primary prevention and mental health.

They strongly supported Electronic Medical records and many wanted to see a provision for EMR incorporated into the reform bill.

with federal standards on Culturally and Linguistic Appropriate Services (CLAS).

7. Tort Reform

A strong majority wanted tort reform addressed and placed it high on the agenda as well.

As health reform forges ahead, these local recommendations can be used as a guide for comparing the national legislature against the priorities of the Central Valley.

More information is available online at www.cvhpi.org.

4. Cover Every Child Participants agreed almost unanimously that coverage should be provided for every child, regardless of immigration status. Recognizing that as many as one in six children in the Valley are undocumented or living with an undocumented adult, participants stated that children should not suffer for their parents’ immigration status. Participants also recommended children be educated in healthy living at earlier ages.

5. Increase Physician Reimbursements Participants recognized that our region faces dramatic physician shortages in all areas and agreed that reimbursement rates for the Central Valley and all underserved communities should be adjusted to attract physicians. The participants supported policies which would promote community health workers and increase the use of physician assistants and nurse practitioners.

They recommended federal support for post graduate medical training targeted to underserved areas.

6. Require Cultural Competence The forum recommended that cultural and language appropriate services be made available to San Joaquin Valley patients and felt all insurance plans should be required to comply January 2010 Central Valley Doctor

I can’t

cover my

shift.

Flu doesn’t fight fair. even if you’re healthy, you can get sick and spread the flu to your co-workers, patients, or even bring it home to your family.

Fight back. don’t get the flu. don’t spread the flu. get vaccinated.

For more inFormation

cS121615

800-CDC-INFO

BUSINESS

Preparing For Growth in 2010

By Bob A. Hall, MBA

W

my mother had a simple remedy Everyone has a way for you to spend your money, and for everything that ailed us. It was called every marketing method is the best thing since sliced castor oil. If you Google it you are most likely bread. How do you sift through what can be done to to pull up Castrol motor oil (its name sake), determine what should be done? but back in those days it it be nice to have was Mom’s generationallyEveryone has a way for you to spend your Wouldn’t a skilled communicator inspired, Southern cure-all.

It had the look and feel of money, and every marketing method is the running in front of you, able to identify your Liquid Plumber but it worked, “perfect world” patients and Mom applied it faithfully best thing since sliced bread. How do you in the crowd and share and generously when faced with not only cold and flu sift through what can be done to determine your many successes, accomplishments, and symptoms, but skin disorders, amazing skill set with bruises, broken bones, head what should be done? anyone who would listen? injuries and warts. There were Well you can. This skilled very few doctor visits in our household because usually, before you could say “Mom I’m communicator is your marketing plan, and when done not feeling so well,” you’d have a large teaspoon of castor correctly it can produce amazing results. Even better, oil shoved in your mouth. I’m not sure if the fluid’s forced your present and future patients do not have to fully deployment started out as an old wives’ tale but the Food understand your marketing strategy to be positively and Drug Administration (FDA) still recognizes it as safe affected by it.

Continued on page 21 for consumption. hen i was a kid

Marketing can seem like an oily, colorless liquid with mild to no odor or taste; and an expensive one at that. If left to our own devices, we simply would not do it. No one wants to be “sold” and most professionals would prefer not to sell.

Besides, in a perfect world you wouldn’t need to market.

Patients would automatically know about you and your practice. Even better, every patient would have the best insurance, be ready and willing to cover the cost of any co-payment, and follow their doctor’s orders. Your office staff would take care of the scheduling, billing and administration and there would never be any grumpy or disgruntled patients. You would be free to focus solely on patient care and healing.

Unfortunately we don’t live in a perfect world and even worse, you have two demanding jobs. Along with being a healer, you have to focus on finding new patients, building a reputation, cash-flow, referrals, new technologies, increasing revenues, reducing expenses, profitability, liability, competition, and more.

Reality dictates you find ways to keep employees paid and the lights on, despite constant cuts in reimbursements.

You know the clichés, and all of them end with “work smarter and not harder,” but how? You’ve already sacrificed vacation time and quality time with your family.

January 2010 Central Valley Doctor

COVER STORY

Novalis versus By:Jeanie Erwin

Cyberknife

A Look at Stereotactic Radiosurgery in the Valley

R

adiosurgery is a promising alternative to traditional

or “open” surgery, and studies show it results in superior outcomes compared to those of its predecessor. Contrary to what its name implies radiosurgery does not involve cutting. There are no scalpels

used. Instead, highly focused beams of radiation – delivered in a singe high dose (Stereotactic Radiosurgery, SRS), or sometimes in a series of smaller doses (Stereotactic Radiotherapy, SRT) – converge on the specific target where the tumor or abnormality resides, sparing healthy tissue and nerves. The recent advances in traditional imaging technologies such as tomography, CAT scans, PET scans, and MRI have expanded the possibilities of radiosurgery and its application for patients who formerly had limited treatment options.

Two Central Valley hospitals, Saint Agnes Medical Center and Community Regional Medical Center (both in Fresno), offer doctors and their patients the most advanced radiosurgical technology available in the world.

Saint Agnes has both the Novalis Shaped Beam and the Gammaknife, and Community Hospital has the Cyberknife. Knowing the differences between the technologies can help physicians assure their patients receive the best possible clinical outcomes.

SAINT AGNES MEDICAL CENTER

Dr. Li Liu, Medical Director of Saint Agnes Hospital, in front of the Novalis Shaped Beam.

10 Central Valley Doctor www.centralvalleydoctor.com

According to Dr. Li Liu, Medical Director of Saint Agnes Cancer Center in Fresno, both the Novalis and Cyberknife are linear accelerator based radiosurgery machines, and are similar devices having inherent advantages and disadvantages. The machines deliver one large radiation beam, which is redirected into many arcs, lessening the damage to the surrounding healthy tissue. These

COVER STORY

Douglas Wong, MD and Nurse Coordinator Laura Valenzuela, R.N. shown in the CyberKnife Center at Community Regional Medical Center.

machines move around the patient, and offer more flexibility with the ability to fractionate treatments over several days.

“The applications [of Novalis and Cyberknife] are very similar because you can use the devices to treat the patient from head all the way down to the pelvis for different cancerous or noncancerous conditions.”

These devices can treat lesions of various sizes and are capable of divided treatments to better preserve adjacent tissues.

cancerous or benign. Traditionally, without IMRT, you gave a shot of radiation that delivered the same dose, a uniform dose, to the entire tumor. But in some areas of the tumor are thinner, some are thicker. If you give the same dose to treat the thinner part as you did the thicker part then you are over treating the tissue in front of and behind the thinner part. You get a pretty uniform dose, but you are also over-treating a lot of healthy tissue” says Dr. Liu.

Knowing the differences can help physicians assure their patients receive the best possible outcomes.

“We are very fortunate here,” says Dr. Li Liu discussing Saint Agnes’ Gammaknife and Novalis Shaped Beam. “There is no better technology than we have here. We are one of a very small group of institutions which includes Duke, USC and USCF medical centers that offers two types of radiosurgery.” In fact, Saint Agnes is one of only three hospitals in California making the Novalis technology available to its patients.

Novalis When asked to discuss the differences between the Novalis and its competitor, the Cyberknife, Dr. Liu offers a detailed description of IMRT: Intensity Modulated Radiation Therapy.

“The availability of IMRT must be considered whenever you are treating an irregularly shaped target, whether it be

“To understand IMRT, it helps to think of the tumor as a digital picture composed of pixels.

With the IMRT technology, when the beam goes to the thinner part of the tumor, you can give a lower dose of radiation, and when the beam goes to the thicker part you give a higher dose. In the end you get a very tight dose distribution around the target with much better sparing of the surrounding healthy tissue. This is something Cyberknife cannot do easily and effectively.”

“Another advantage to the Novalis,” explains Dr. Liu, “is the time involved. It takes about twenty minutes from start to finish where Cyberknife takes an hour to an hour and a half. That is important when you have a patient who is already not feeling well and having to lay on a flat surface for some time.”

Continued on next page January 2010 Central Valley Doctor 11

COVER STORY Continued from previous page

It has also been noted that many patients experience significant improvement in their pain with Novalis. “I do not know if it is psychological or biological, but patients whom I treat with metastases to the spine, often come off the table reporting that they feel better already. This is not one or two patients, but many. We would never hear this with traditional treatments,” said Dr. Liu.

Gamma Knife Radiosurgery A cobalt-60 based machine, the Gamma knife has been considered the gold standard of treatment Dr. Liu standing beside the Gamma Knife. for brain lesions for over 40 years.

Due to this extensive history, the who are out of town can submit a brief history and imaging technology has a considerable amount of data backing its favorable outcomes. The Gamma studies for review by our team and every physician referring Knife offers the highest degree of accuracy available and to our program receives a consultation and procedure has proven to be a viable choice for many patients where report regarding the care and treatment of their patients.” traditional surgery is not an option. In general, the Gamma COMMUNITY REGIONAL MEDICAL CENTER Knife is used to treat lesions of 3 cm or less.

“The Gamma Knife is very different from the Novalis or Cyberknife. It is a stereotactic radiosurgical device for the brain only, not for the body, and has the highest accuracy rate of any machine in this type of application. It is beneficial for patients that do not have many small tumors all over, because one would have to assume that there may be more yet unseen. For them, this application is not advised and whole brain radiation is most appropriate.

There are many instances however, when the precise delivery of radiation with a Gamma Knife would be a better choice for the patient than whole brain radiation. Unfortunately whole brain radiotherapy is often used habitually. Whole brain radiation should be abandoned in favor of the Gamma Knife when a patient has only a few lesions.

Community’s Cyberknife program was established in 2005 and is the brain-child of Dr. Douglas Wong, a visionary who saw the need for such technology in the Valley and advocated for it. Dr. Wong recognized early on that stereotactic radiosurgery would become a crucial tool in the treatment of cancer, and in the field of radiation oncology, the Cyberknife Radiosurgery system was, and still is, universally recognized as the premier radiosurgery system .

For us, it is very important that the physicians in the Central Valley know we are here to offer support.

“For us, it is very important that the physicians in the Central Valley know we are here to offer support. We have multidisciplinary conferences with teams of experts available to work with referring physicians who suspect a patient may have cancer or who need assistance making a determination on the best course of treatment. Doctors 12 Central Valley Doctor www.centralvalleydoctor.com

One of the main differences between Cyberknife and other stereotactic radiosurgery platforms is the number and angle of radiation beams that can be delivered to match the exact shape of the tumor and spare the healthy tissue which surrounds it, capable of delivering high doses of radiation with sub-millimeter accuracy anywhere in the body.

The accuracy comes from the robotic arm and movable table which work to deliver radiation doses in all directions (over 1,300 angles using 100 – 400 beams) and with real time adaptive tracking to allow for the natural movements Continued on next page

COVER STORY of the patient (breathing, coughing, and the movement of body fluids or gas, for example). The tracking system allows the Cyberknife to modify the patient’s position without the need for rigid restraint .

Since other radiosurgical devices usually require rigid patient immobilization with the use of a head frame for treatment, the devices are restricted to treating only the immobilized area, namely cranial lesions. The Cyberknife dynamically tracks and corrects for patient motion during treatment, allowing it to be used precisely with any body site.

Community Regional Medical Center is the only facility offering this technology in Central California, and one of only five Cyberknife sites in the state of California. Physicians of potential Cyberknife candidates should contact the California Cancer Center at Community Regional Medical Center to determine if Cyberknife treatment is appropriate.

Weekly multidisciplinary conferences are held to evaluate patient cases and recommended courses of treatment.

Reviewing a patient’s pre- and post-op scans.

Novalis

Gamma Knife

CyberKnife

Targeting accuracy

<1 mm

Better than 0.3 mm

<1 millimeter for stationary tumors, <1.5 millimeters for moving tumors

Applications

Intracranial and Extracranial (whole body)

Intracranial only (limited spine capabilities)

Intracranial and Extracranial (whole body)

Ability to fractionate treatment?

Yes

Typically limited to a single fraction

Yes

Image Guidance

Determined pretreatment using a combination of CT scan (and sometimes MRI) and Digitally Reconstructed Radiograph.

Relies exclusively on target’s fixed relative position to the stereotactic frame

Possible placement of fiducials near tumor site; CT scan, possible MRI. Automatically tracks, detects and corrects for tumor and patient movement.

Type of Immobilization

A rigid head frame, custom face mask or custom foam cushion

A light-weight rigid head frame.

A soft face mask for head/neck or body mold

“Claim to Fame”

IMRT (Intensity Modulated Radiotherapy)

“Gold Standard” for intracranial lesions; most accurate

Real-time lesion tracking

January 2010 Central Valley Doctor 13

When you start with Rotary, good things happen.

Rotary is ordinary people around the world working together to protect the environment, improve our communities, end polio, and accomplish other extraordinary things.

Learn more at rotary.org.

Rotary. Humanity in motion.

THE LIST

LABORATORIES year established ______________

valley locations ______________

insurances accepted

counties served

Hadden Pathology 5151 N Palm Ave, Suite 200, Fresno, CA 93704 Telephone: 559-226-1200 www.haddenpath.com Comprehensive Medical Laboratories 1824 Norris Rd. Bakersfield, CA 93308 Phone: (661) 399-5301

company name

Services

turn-around

reporting

30 years ______________ Most insurances accepted

1 – Fresno _____________ Fresno, Madera Kings, Tulare Counties

Cervical cytology, Non-GYN cytology, out-of-the-vial HPV, GC/Chlamydia testing, Anatomical Surgical Pathology

24-48 hours on most tests

Online reporting, Courier service

2000 ______________ Most insurances accepted

1 – Bakersfield 1 – Delano ______________ Kern County

Blood draws

Less than 24 hours

No Information available

Pathology, Cytopathology, Cytology, Histology, Pre-Op and EKG Testing, Daily service calls and pick-ups, 24-hour emergency services

24/48 hours

Courier delivery

Bakersfield Pathology Medical Group 3000 Sillect Avenue Bakersfield, CA 93308 Phone: (661) 336-0622 www.bakersfieldpathology.com

1987 ______________ Most insurances accepted

Crestview Clinical Laboratory 518 N. Court St. Visalia, CA 93291 Phone: (559) 635-2938

1998 ______________ Most insurances accepted

No Information available

Toxicology, Microbiology, In-House Testing, Immunology, Hematology, Chemistry

24 Hr Turnaround

No Information available

Hunter Clinical Laboratory 1702 N. Fresno St. Suite 101 Fresno, CA Phone: (559) 431-0015 Fax: (559) 431-0016 www.hunterlabs.com

2003 ______________ Most inurances accepted.

Comprehensive list on website.

1 - Fresno ______________ Fresno County

Clinical reference laboratory, over 2,000 tests (comprehensive directory on website), Courier delivery

Most tests are turned around next day.

We use the most sophisticated computer system in the industry which offers a wide choice of personalized reporting options.

2007 ______________ Most insurances accepted

2 - Fresno ______________ Los Angeles through Modesto

Hematology, Toxicology, Microbiology, Urinalysis, Endocrinology, Chemistry, Virology, Immunology, Lead testing, Cytology, Courier pick-up

Most tests are turned around next day

Auto fax, E-mail, Internet, Courier

1964 ______________ Most insurances accepted

6 – Fresno 1 – Hanford 1 – Madera 1 – Visalia 1 – Bakersfield ______________ Fresno, Kings, Tulare, Kern

All areas of pathology (including Cytopathology, Surgical, Gynecological, Hematopathology, Dermapathology), Clinical Services, GC/ Chlamydia and HPV

24-72 hours on all pathology and cytology specimens

Various types of weekly, monthly, and annual statistical reporting (including abnormal case summary); custom reports and services available upon request

20 years in Fresno ______________ Nearly all PPO insurances and most HMO plans

1 – Fresno _____________ Fresno, Madera, Merced, Kings, Tulare

All aspects of Surgical and Clinical pathology, GYN-Non-GYN cytology, Fine needle aspiration, Bone Marrow biopsy, autopsy, Frozen sections, special stains

24-48 hours

Correlate results of abnormal PAP to cervical biopsy; AutoFax reporting available; monthly diagnosis statistic report upon request; Courier service

Maharlika Medical Lab Inc. 1350 “O” Street, Suite 101 Fresno, CA. 93721 Phone: (559) 233-6242 Fax: (559) 233-6243 www.mahamedlab.com Westcliff Medical Labs Laboratory Headquarters 1821 East Dyer Road, Suite 100 Santa Ana CA 92705 Phone: (800) 373-9505 www.westclifflabs.com Pathology Associates 305 Park Creek Drive Fresno, CA 93611 Office (559) 326-2800 Fax (559) 326-2801 www.pathology-associates.com

1 – Bakersfield ______________ Kern County

January 2010 Central Valley Doctor 15

RESPONSE

THE STATE OF THE VALLEY A Candid Picture of Our Valley and Its Unique Challenges In a recent interview with Stephen Schilling, CEO of Clinica Sierra Vista, we sat down to discuss the Central Valley and the unique challenges facing healthcare practitioners serving the patients of the community. The results of the discussion are grim, but not without hope. Central Valley Doctor magazine invites reader feedback as well as suggestions and solutions for improving our situation. Please email your responses to RESPOND@centralvalleydoctor.com or text them to (559) 4920463.

CVD: How do these challenges affect the doctors serving this community?

SS: Everyday our doctors face increased need with reduced resources. In particular, safety net providers are severely affected by: 1. Medi-Cal eliminating dental, optometric, optician, psychology, podiatry, and audiology reimbursement 2. California eliminating Rural Health and Seasonal Migrant Farmworker funding

Central Valley Doctor (CVD): What are the major health care challenges facing the Central Valley?

3. California reducing funding for Expanded Access to Health Care by 65%

Steve Schilling (SS): Reduced access to care. Most of the counties in the Central Valley are federally-designated Medically Underserved Areas (MUAs) and Health Professional Shortage Areas (HPSAs).

4. Newly uninsured patients due to high unemployment -- employees losing their health insurance when they lose their jobs

We have very high poverty, with 20% of the people in Kern and Fresno Counties living below the Federal Poverty Level compared to 14.6% of the population in California. We have a rising unemployment rate in Kern and Fresno a well. It was 36% in October, compared to the 12.3% state average and the 9.5% national average. A whopping 41% of the residents of this Congressional District are uninsured. The State uninsured rate is only 20%.

CVD: Are any of these challenges unique to the Central Valley or common throughout the Nation?

SS: The Central Valley is “ground zero” in the United States for poverty, poor health status, and negative social indicators such as teen pregnancy and low education attainment, prior to the recession. In 2008, Congressional District 20 was identified as having the lowest “human development index” in the Nation by the American Human Development Project. This index measures health, education, income, safety, and other indicators.

5. Employers reducing medical and dental coverage to save cost.

With inadequate or no insurance coverage at all, patients are delaying their primary and preventative care due to the cost.

CVD: How do we compare to the rest of the State?

SS: In the Central Valley we have higher rates of death by all causes. We have a higher incidence of Chlamydia and Gonorrhea, Infant mortality, births to adolescent mothers, obesity, breast cancer, oral health disease, hypertension, diabetes, and asthma. We have lower rates of breastfeeding initiation.

CVD: How does the Central Valley compare to the rest of the nation?

SS: The Central Valley is the new Appalachia. The San Joaquin Valley has higher rates of poverty than Appalachia Continued on page 20

16 Central Valley Doctor www.centralvalleydoctor.com

WE

RY DAY I N STE AD O F T H E I R S E VE E S C AL A E STA TO R E TH N D 3 0 M I N UTE S TAK ITH DI E T A OF DA TO I LY ASE W ES E X DI S E E RC CI D OF IS E DE I NG M OB B E D BY F E M A L E A D M ISK R OF BE IRER RS S R IS K U NS WR

LO

NO

TAKE A SMALL STEP TO GET HEALTHY. Get started at www.smallstep.gov NOTE TO PUB: DO NOT PRINT INFO BELOW, FOR ID ONLY. NO ALTERING OF AD COUNCIL PSAs. Healthy Lifestyles and Disease Prevention- Magazine - (7 x 10) 4/C - HLDYR1-M-12036-F “Mobbed” 120 line screen

digital files at Schawk: (212) 689-8585 Ref#:211088

TECHNOLOGY

Meaningful Use Defined, Public Comment Encouraged The Centers for Medicare & Medicare Services (CMS) and the Office of the National Coordinator for Health Information Technology (ONC) encourage public comment on the two regulations passed December 30, 2009 which lay the foundation for the implementation of the EHR incentive programs enacted under the American Recovery and Reinvestment Act of 2009 (Recovery Act). The regulations outline a definition of “meaningful use” of EHR technology and set initial standards, implementation specifications, and certification criteria for EHR technology.

during the specified reporting period, demonstrates meaningful use of certified EHR technology in a form and manner consistent with certain objectives and measures presented in the regulation. These objectives and measures would include use of certified EHR technology in a manner that improves quality, safety, and efficiency of health care delivery, reduces health care disparities, engages patients and families, improves care coordination, improves population and public health, and ensures adequate privacy and security protections for personal health information.

MEANINGFUL USE

The rule proposes one definition applicable to eligible professionals participating in the Medicare fee-forservice and the Medicare Advantage

The proposed rule defines the term “meaningful EHR user” as an eligible professional or eligible hospital that,

18 Central Valley Doctor www.centralvalleydoctor.com

EHR incentive programs as well as a proposed definition that would apply to eligible hospitals and critical access hospitals. These definitions also would serve as the minimum standard for eligible professionals and eligible hospitals participating in the Medicaid EHR incentive program.

The rule proposes that states could request CMS approval to implement additional meaningful use measures, as appropriate, but could not request approval of fewer or less rigorous meaningful use measures than required by the rule.

The proposed regulation suggests a phased approach to implement the new requirements for demonstrating meaningful use. This approach would initially establish reasonable

TECHNOLOGY

criteria for meaningful use based on currently available technological capabilities and providers’ practice experience. CMS will establish stricter and more extensive criteria for demonstrating meaningful use over time, as anticipated developments in technology and providers’ capabilities occur.

EHR CERTIFICATION CRITERIA The second of the proposed regulations describes the standards that must be met by certified EHR technology to exchange health care information among providers and between providers and patients. This initial set of standards begins to define a common language to ensure accurate and secure health information exchange across different EHR systems. The proposal calls for standard formats for clinical summaries and prescriptions; standard terms to describe clinical problems, procedures, laboratory tests, medications and allergies; and standards for the secure transportation of this information using the Internet.

The Department of Health and Human Services (HHS) was required to adopt an initial set of standards for EHR technology by December 31, 2009 These new provisions go

into effect 30 days after publication, with an opportunity for public comment and refinement over the next 60 days.

A final rule will be issued in 2010. Doctors, hospitals, and other stakeholders are encouraged to provide comments on these standards and specifications.

The Recovery Act established programs to provide incentive payments to eligible professionals and eligible hospitals participating in Medicare and Medicaid that adopt and make “meaningful use” of certified EHR technology.

Incentive payments may begin as soon as October 2010 to eligible hospitals. Incentive payments to other eligible providers may begin in January 2011.

More information: The CMS proposed rule and fact sheets may be viewed at http://www.cms.hhs.gov/Recovery/11_ HealthIT.asp ONC’s interim final rule may be viewed at http://healthit. hhs.gov/standardsandcertification. In early 2010 ONC intends to issue a notice of proposed rulemaking related to the certification of health information technology.

January 2010 Central Valley Doctor 19

RESPONSE Continued from page 16

and lower per capita income. Our households are more likely to receive public assistance than households in Appalachia, but in spite of this, we receive less federal funds per capita than both the State and the National average.

CVD: Is there anything Central Valley Doctor readers can do to improve the situation?

SS: Since we are in the midst of a doctor shortage, it is important that specialists implement programs for treating the less fortunate members of our population.

They may want to consider seeing uninsured individuals at significantly reduced costs or providing charity care.

CVD: What part, if any, does Clinical Sierra Vista play in alleviating the burdens of community doctors?

SS: We provide primary care and enabling services such as insurance enrollment assistance, case management and health education. Our mission is to provide high quality and comprehensive primary and preventative health care services at the most efficient cost to the underserved populations of Kern, Fresno and Inyo counties regardless of ability to pay.

20 Central Valley Doctor www.centralvalleydoctor.com

For more information on Health Professional Shortage Areas (HPSAs) visit the Office of Statewide Health Planning and Development at www.oshpd.ca.gov.

Designation criteria for HPSA and Medically Underserved Areas/Populations is available at the U.S. Department of Health and Human Services Health Resource and Services Administration website at http://bhpr.hrsa.gov/shortage .

More information on Clinica Sierra Vista and their services for uninsured/underinsured patients is available on their website at www.clinicasierravista.org.

Please email responses to this discussion, as well as suggestions for future columns to RESPOND@ centralvalleydoctor.com.

Continued from page 9

Each month I will focus on one business or marketing concept. This month’s strategy is very simple conceptually but complex in its implementation and execution. Let’s get started!

First, draw two circles of equal size on a piece of paper. The first circle represents all of the available patients in your geographic region and specialty. It encompasses all of the existing and potential patients available to you and every other doctor practicing in your specific field. This is your “market.”

Underneath the first circle write down two numbers: 1. your practice’s total yearly revenue and 2. your market’s annual spending on health care services in your field. This second number is your market’s total worth.

Do you know your market’s worth? If yes, continue. If not, this is your first homework assignment.

Next, divide the first number (your yearly revenue) by the second number (your market’s worth). This is your percentage or slice of the market pie (also called your “market share”). Draw your slice of the pie proportionately on the first circle (2%, 10%, 25%, etc.) and write your percentage inside of your slice.

The rest of the pie equals the rest of the market currently served by your competitors. Divide up the remaining pie, with each piece representative of your in-market competition. Give bigger competitors a bigger slice of the pie and add names and numbers to the slices. It should add up to 100%.

Bottom-line, in a down economy you have to take an additional slice of the market-pie to equal your existing dollars. If you were practicing comfortably with 2% before, it will probably take at least 4% to equal your billings from just a few years ago. You need a bigger slice of the pie, because the pie is smaller now: Continued on next page January 2010 Central Valley Doctor 21

Continued from previous page

reimbursements are lower, fewer patients are insured, and fewer people are going to the doctor. If your practice is going to grow you have to take an even larger percentage of the pie.

Finally, copy all of the information from your first pie into the second pie. Draw a larger circle around your second pie. Imagine the value of your existing slice if the lines (percentage) extended out to the second circle. Why are you being asked to draw circles and respond to questions you may or may not have answers to? Well, because you are a slice in someone else’s piecircle and all your existing patients are your competition’s new business.

Do you get it?

This new year could be your best year ever, however you will need to find new ways to differentiate yourself, create greater awareness of your services, and fully understand the two circles approach.

We will talk about goals in next month’s column and dig deeper into your competition and market concerns in future articles. This is just the first step in understanding what should be done and how to do it.

Robert A. Hall, MBA, The Doctor’s Marketer, is the President of Halran Consulting & Marketing. Hall’s marketing expertise was cultivated over his years of management and consulting for public and private companies, including Disney, ABC, Travelers Insurance and a national advisor for the Coleman Research Group. Hall has served on many boards of directors including Children’s Hospital Foundation. He can be reached at (559) 326-2505 or by emailing bhall@halranmarketing.com. Find more information on practice marketing at www. thedoctorsmarketer.com.

CALENDAR OF EVENTS JANUARY

31

Annual Health and Wellness Fair. January 31, 2010 10AM – 5PM Regency Event Center, 1600 N. Willow, Clovis, CA

FEBRUARY

1

Family Fitness at The Lifestyle Center. Monday, February 1, 5:30pm – 6:30pm | Kaweah Delta Lifestyle Center Where5105 W. Cypress Ave. Visalia, CA 93277. Family Fitness is an hour designated for kids ages 4-12 and their parents to exercise together through fun activities, play and Sports Wall Fun Cost: Free to TLC members, $5 for non-members.

10

Grand Rounds - Medical Education Program. Wednesday, February 10, 12:30 - 1:30 pm| Saint Agnes Medical Center, Fresno, CA in the North Wing’s Shehadey Pavilion. (For physicians and clinical staff ) Lunch is provided. For information, call (559) 450-7566.

27

It’s My Heart Fresno CHD Awareness Run/Walk & Family Fun Day Saturday, Feb 27, 9:30am to 2:00pm |Woodward Park, Fresno, CA Congenital Heart Defects is the #1 birth defect in America and more children die from CHD’s than all childhood cancers combined. IMH Fresno will be holding a CHD Awareness Run/Walk & Family Fun Day to raise community awareness and educate the public about CHD across the Central Valley. Funds raised will be used to continue the programs already in place for families going through open heart surgery at Children’s Hospital Central Ca, donation to CHD research and continuing CHD education.

ONGOING Central Valley’s Greatest Loser Registration ongoing January 1, 2010 through April 23, 2010 This is a 12 week weight loss competition beginning April 23, 2010.

Registration begins Jan 1. Register at www.cvgreatestloser.com. Contest is open to residents from Bakersfield all the way to Modesto and everywhere in between. Cost $100.00; Contact Angela at Get A Better Body Fitness for more information by calling 559-930-2312 or emailing gabbfitness@yahoo.com.

Submit events to the Calendar by emailing event details to calendar@ centralvalleydoctor.com. Events will be published according to available space.

ADVERTISER’S INDEX Peace Corp.................................................... 2 American Heart Association.................. 4 Attorney Theresa Petty............................. 6 CMI Radiology ............................................ 7 Flu.gov .......................................................... 8 Fresno County Federal Credit Union... 9 22 Central Valley Doctor www.centralvalleydoctor.com

Rotary Club ................................................................. 14 Hadden Pathology ....................................................18 Digidex ......................................................................... 19 Windows 7 ................................................................... 20 McCormick Barstow ................................................ 23 Saint Agnes Hospital ............................................... 24

McCORMICK BARSTOW’S BUSINESS ATTORNEYS INCLUDE: Kenneth A. Baldwin W. F. Docker Kenneth M. Klug Kristen Leib John J. McGregor Steven G. Rau Jeffrey M. Reid Robert L. Sullivan, Jr.

Great timing!

Every second counts when youâ&#x20AC;&#x2122;re having a heart attack.

No one understands that better than the skilled team of physicians and nurses at Saint Agnes.

The only Fresno area hospital rated 5 Stars for the Treatment of Heart Attack

by HealthGrades (2009-2010).

This is lifesaving news for Valley residents, and just one more example of our commitment to deliver high quality compassionate care. Thereâ&#x20AC;&#x2122;s never been a better time to choose Saint Agnes for cardiac care.

www.samc.com