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Western Health Care Leadership Academy PLUS: Autism Rising Multidisciplinary Treatments for Fibromyalgia
You have to pay for workers' compensation insurance. But...
YOU DON'T HAVE TO In California, rates for workers' compensation insurance are soaring. In the second half of 2013, rates increased by an average of 8.7%.1 That's after a 10% increase in the first half of 2013.2 Source: Workers Compensation Insurance Rating Bureau of California, http://www.wcirb.com/sites/default/files/documents/132023_010114_ amended_ppr_filing_complete.pdf
SCCMA/MCMS members, call 800-842-3761 to see if you can save!
Are you paying too much for your workers' compensation coverage? Finding out is easy. Just call 800-842-3761 to compare your current policy with workers' compensation insurance available through the Association/Society. This members-only program is available through Mercer. As the world's leading insurance broker, Mercer can provide the outstanding service and expertise you deserve. Call Mercer at 800-842-3761 today to get your free, no-obligation quote.
Source: Business Insurance, https://www.businessinsurance.com/ article/20130925/NEWS08/130929901 2
Mercer Health & Benefits Insurance Services LLC • CA Ins. Lic. #0G39709 67132 (5/14) Copyright 2014 Mercer LLC. All rights reserved. 777 South Figueroa Street, Los Angeles, CA 90017 • 800-842-3761 email@example.com • www.CountyCMAMemberInsurance.com 2 | THE BULLETIN | MAY/JUNE 2014
Official magazine of the Santa Clara County Medical Association and the Monterey County Medical Society
700 Empey Way • San Jose, CA 95128 • 408/998-8850 • www.sccma-mcms.org
Feature Articles
8 Autism Rising – Part 1
CME Tracking
14 2014 Western Health Care Leadership Academy
Discounted Insurance
22 GPCI Victory
Financial Services
22 TB Screening Policy Changes
Health Information Technology Resources
26 MICRA Update
House of Delegates
32 Tips for Lowering Ambulatory-Care Risks
Representation Human Resources Services Legal Services/On-Call Library Legislative Advocacy/MICRA Membership Directory iAPP for the iPhone Physicians' Confidential Line Practice Management Resources and Education Professional Development
34 The Dental Effects and Associated Properties of Natural Sugars, Sugar Substitutes, and Artificial Sweeteners 44 Multidisciplinary Treatments for Fibromyalgia
Departments 5 From the Editor's Desk 6 Message From the SCCMA President
21 Membership News
Referral Services With
28 Choosing Wisely
Membership Directory/Website Reimbursement Advocacy/ Coding Services Verizon Discount
30 Medical Times From the Past 36 MEDICO News 42 Classified Ads MAY/JUNE 2014 | THE BULLETIN | 3
THE SANTA CLARA COUNTY MEDICAL ASSOCIATION OFFICERS President Sameer Awsare, MD President-Elect James Crotty, MD VP-Community Health Cindy Russell, MD VP-External Affairs Kenneth Blumenfeld, MD VP-Member Services Peter Cassini, MD VP-Professional Conduct Seham El-Diwany, MD Secretary Eleanor Martinez, MD Treasurer Scott Benninghoven, MD
William C. Parrish, Jr.
El Camino Hospital of Los Gatos: Arthur Basham, MD El Camino Hospital: Imtiaz Qureshi, MD Good Samaritan Hospital: David Feldman, MD Kaiser Foundation Hospital - San Jose: Seema Sidhu, MD Kaiser Permanente Hospital: Anh Nguyen, MD O'Connor Hospital: Michael Charney, MD Regional Med. Center of San Jose: Richard Kline, MD Saint Louise Regional Hospital: Diane Sanchez, MD Stanford Hospital & Clinics: Michael Champeau, MD Santa Clara Valley Medical Center: Richard Kramer, MD
AMA TRUSTEE - SCCMA James G. Hinsdale, MD
CMA TRUSTEES - SCCMA Thomas M. Dailey, MD (District VII) Martin L. Fishman, MD (District VII) Randal Pham, MD (Ethnic Member Organization Societies) Tanya Spirtos, MD (District VII)
Printed in U.S.A.
President Kelly O'Keefe, MD President-Elect Jeffrey Keating, MD Past President John F. Clark, MD Secretary Patricia Ruckle, MD Treasurer Steven Vetter, MD
Official magazine of the Santa Clara County Medical Association and the Monterey County Medical Society
Joseph S. Andresen, MD
Managing Editor Pam Jensen
Opinions expressed by authors are their own, and not necessarily those of The Bulletin, SCCMA, or MCMS. The Bulletin reserves the right to edit all contributions for clarity and length, as well as to reject any material submitted in whole or in part. Acceptance of advertising in The Bulletin in no way constitutes approval or endorsement by SCCMA/ MCMS of products or services advertised. The Bulletin and SCCMA/MCMS reserve the right to reject any advertising. Address all editorial communication, reprint requests, and advertising to: Pam Jensen, Managing Editor 700 Empey Way San Jose, CA 95128 408/998-8850, ext. 3012 Fax: 408/289-1064 email@example.com © Copyright 2014 by the Santa Clara County Medical Association.
CHIEF EXECUTIVE OFFICER William C. Parrish, Jr.
DIRECTORS Paul Anderson, MD
John Jameson, MD
E. Valerie Barnes, MD
Jeff Keating, MD
Ronald Fuerstner, MD
Eliot Light, MD
James Hlavacek, MD
R. Kurt Lofgren, MD
David Holley, MD
AMA TRUSTEE - MCMS David Holley, MD
JOSEPH S. ANDRESEN, MD Editor, The Bulletin
Bringing You Up-to-Date On A Number of Important Topics By Joseph S. Andresen, MD Editor, The Bulletin
ver and was recognized as the state capitol. Eiffel of the Eiffel Tower designed a tower that still stands in the town center. However, many of the town's inhabitants died, leaving it a virtual ghost town. Thousands died from mercury and arsenic poisoning that was found in the ore and also used in the extraction process of both gold and silver. Today, El Triunfo has only a population of a few hundred and is beginning to slowly rebound with tourism and its remarkable history. Dr. Shea describes a similar event in the 1800s just south of San Jose, CA. Maybe in the future we won't need to think about ICD codes. However, for the present time, they remain an integral part of our medical lives in describing proper diagnosis, treatment, and billing. Learn more about ICD-10!
Health Care
2 015
April showers bring May flowers! Rain, rain, and more rain for all of us in California, these past few weeks, and snow in the Sierras for a brief but much-appreciated ski season. As summer approaches, we look forward to longer days, warmer nights, and a bit of respite from our busy schedules. Our May-June Bulletin will bring you up-to-date on a number of important topics. I was disappointed to miss the 2014 Western Health Care Leadership Academy this past month. However, the next best thing to being there is to read the excellent article describing the enthusiasm of the 700 attendees, former Secretary of State Hillary Clinton's ideas on the broken reimbursement system for physicians, and hear Covered California Director Peter Lee's bumpy ride during the introduction of the Affordable Care Act. Joseph S. Andresen, MD, is the editor of The Bulletin. He is board Dental care is as integral to good health as is medical care. And as we certified in anesthesiology and is currently practicing in the Santa all know, sugar tastes good, but isn't the best for our dental health. It's not Clara Valley area. often that we get an update from our dental colleagues. This month, we include an update on the dental effects and comparison of 18th natural sugars and sugar subAnnuAl stitutes. A number of years ago, my father, afflicted with bothersome hip pain, was diagnosed as having fibromyalgia. This chronic pain syndrome was an enigma to me, until I learned more about it. Dr. Davidson, a retired rheumatologist, has just written May 29 - 31, 2015 • Hollywood, CA • Loews Hollywood Hotel a book on the topic and he shares his knowledge with us REGISTER ONLINE @ WESTERNLEADERSHIPACADEMY.COM in an illuminating excerpt. During a recent trip to Baja, Mexico, I visited El Triunfo, a small town two hours north of Cabo San Lucas. In the 1800s, it was a bustling city of thousands seeking their fortune in gold and sil-
SAMEER V. AWSARE, MD, FACP President, Santa Clara County Medical Association
Your Voice is Key to Our Success By Sameer V. Awsare, MD, FACP President, Santa Clara County Medical Association Critical issues affecting physicians in our state are being decided by our legislature. Health care reform, medical liability and insurance reform are just a few of the issues that are being debated and voted on in Sacramento. April 21st was CMA's 40th Annual Legislative Leadership Conference. In our county, this means that physicians from various modes of practice – solo, group, academic, county and specialty – arrive at our Santa Clara County Medical Association at 6:00 AM to take the bus to Sacramento. This is an opportunity for us to meet as colleagues, and to speak to our legislators with the single voice of the house of medicine. And speak we did, on behalf of all the physicians in our county and our state. Below, I will highlight some of the issues that we discussed on your behalf. Before I discuss the specific issues, it is important to understand that elected officials have very little time to meet with us and appointments with them have to be made in advance. It is important to state things concisely, and personal stories are very useful. If possible, it is important to try and get a commitment from the elected official and to also let them know that you will be following up. It is also important to understand how elected officials think. They consider if a particular issue is good public policy, whether it affects their district or them politically. They also consider who else supports or opposes the particular issue. Finally, in today's fiscal environment, they always want to know if it will cost money. Following are some of the key issues that we discussed with our elected officials in the Assembly and Senate. Restoring the 10% Cut to Medi-Cal Provider Rates: If you recall, Medi-Cal rates were cut by 10% in 2011, hence, California's Medicaid reimbursement currently ranks at 47th in the nation. With Covered California, many of our uninsured citizens now have access to Medi-Cal, yet the cuts in reimbursement have forced many physicians and health care centers to close their doors. One of our colleagues recalled that he was on Medi-Cal as a child. Since he became a physician, almost 20 years ago, he has always cared for Medi-Cal patients. Recently he had to make the sad decision to not accept Medi-Cal patients since he was losing money on every patient he saw (his reimbursement is now less than the price of the delivery of a large pizza to your house). As California's economy improves, AB 1805 authorizes the director of the Department of Health Care Services to restore the 10% cut in Medi-Cal provider reimbursement rates. All Product Clauses: These are provisions in physician contracts that require them to participate in all of a health insurer's products, sometimes even extending to future products without the physician's express knowledge. An SCCMA surgical colleague reported that his recent Blue Shield 6 | THE BULLETIN | MAY/JUNE 2014
contract included a 70% reduction in reimbursement for Covered California patients. They were trying to force him to sign the contract by telling him that he would not get to see his Blue Shield PPO patients if he did not sign. Physicians should not be forced to assume such obligations as a condition for maintaining access to their patients covered by commercial plans, hence, we asked our legislators to support AB 2400, which allows physicians to affirmatively participate in each of an insurer's or health plan's network or product. Reimbursement for Telephone/Electronic Patient Management: This requires insurance companies licensed in the state of California to pay contracted physicians for telephone and electronic patient management services. This lets our patients have faster and more convenient access to treatment, while reducing their lost time from work. It is simply the right thing to do in the 21st century, and we lobbied our legislators to support AB 1771. Sugar-Sweetened Beverages Safety Warning Label: Obesity now riSameer V. Awsare, MD, FACP, is the 2013-2014 president of the Santa Clara County Medical Association. He is a board certified internist and is currently practicing with The Permanente Medical Group in Campbell.
vals smoking as the largest cause of preventable disease and death. 40% of California's children are now obese, and daily servings of sugary drinks and sodas significantly contribute to this. SB 1000 would require beverages containing over 75 calories per 12-ounce serving to be sold with a safety warning, so that consumers can make informed decisions. Self-Referral: In general, physicians are prohibited from referring a patient to another medical professional in which a physician or their family has a financial interest or receives a referral fee. However, there is an "in-office exception" which allows our patients to receive integrated care if a physician and the medical equipment are located at one facility. This is consistent with federal law as well. Senator Hernandez's SB 1215 attempted to prevent this. So, if a patient came to me for a suspected pneumonia, I would not be able to send the patient for an x-ray in our office to make a timely diagnosis. I would be forced to send this patient to an outside radiology office to get their x-ray. This would delay their diagnosis and treatment. Similarly, if a pregnant woman came in to see her OB/GYN, a fetal ultrasound could not been done in the office and the worried mother would then have to be sent outside to get her study. This bill simply did not make sense and we worked to oppose it. I am happy to report that this bill was just defeated and did not make it out of committee. Medical Residency Training Programs: Medicare has frozen residency training funding since 1997. Since then, the population of California has grown 20% and medical students graduating from our medical schools are forced to look for residency slots outside our state. These residents then often live and practice close to where they trained. California is experiencing a shortage of primary care physicians and AB 2458 provides funding for primary care residency programs in medically underserved areas of our state. Finally, no trip this year to Sacramento would be complete without highlighting MICRA. The trial lawyers have enough signatures to put their anti-MICRA initiative on the ballot. The coalition to defeat the anti-MICRA measure continues to grow and includes physicians, community health clinics, hospitals, family-planning organizations, unions, local leaders, public
safety officials, businesses, and the ACLU. It is imperative that we defeat the anti-MICRA initiative, otherwise, malpractice insurance costs for all physicians in the state will skyrocket. Although the California Medical Association (CMA) and its allies have raised several million dollars to protect MICRA on your behalf, we need the help of individual physicians like yourself. I urge you to learn more about MICRA and how you can help in the fight by visiting www.cmanet.org/micra and then making a contribution to either SACPAC or CALPAC to protect MICRA. In conclusion, although the CMA has some of the best lobbyists, lawyers, and advocates in the state capitol, our most powerful weapon is you. A physician dressed in their white coat, speaking with frontline experience and on behalf of their patients, is a powerful voice that can make all the difference for a legislator facing a complicated health care issue. Our strength is in our numbers and we are strongest when each of you speaks up and is heard. I want to thank all the medical students, residents, and physicians who took the time out of their busy schedules and practices to take the bus trip to Sacramento this year to speak on your behalf. I want to encourage all of you to get on the bus in April 2015, and to join us at the CMA House of Delegates, this year, from December 5 – 7 in San Diego.
Pandemic Rates of Autism Cannot Be Explained by Genetics or Diagnosis Alone RATES SKYROCKET By Cindy L. Russell, MD AUTISM Do you have a sense there are more children who have learning dis-
VP - Community Health, Santa Clara County Medical Association
April was Autism Awareness Month, but if you are a parent of an autistic child you are aware of autism every day of every month. The individual and societal implications of the burgeoning autism rate are staggering. Caring for and educating an autistic child can be overwhelming. Parents are forever concerned about their child's future independence and happiness. Economic losses are also significant. In 2012, Autism Speaks, the world's leading autism science and advocacy organization, estimated autism costs society an astounding $126 billion per year in the U.S. That number has more than tripled since 2006. The lifetime cost of caring for an individual who is not impacted by intellectual disability is estimated at $1.4 million in the U.S. (19)
Part 1 8 | THE BULLETIN | MAY/JUNE 2014
abilities, attention deficit disorder, or just behavior problems with more aggression and less focus? Studies would confirm your impressions and, in fact, neuroscientists are now warning of a "silent pandemic" of neurologic developmental disorders, some of which are obvious, and others so subtle they fall under the research radar. Disorders of neurobehavioral development affect 10%-15% of all births. (4) According to a March 2014 report from CDC's Autism and Developmental Disabilities Monitoring (ADDM) Network, about 1 in 68 children are now identified with autism spectrum disorder (ASD). (1) This is a 30% increase from the last report, just two years ago, when it was 1 in 88 children. The CDC has used the same method to
"Our very great concern is that children worldwide are being exposed to unrecognized toxic chemicals that are silently eroding intelligence, disrupting behaviors, truncating future achievements, and damaging societies.�(2)
Dr. Phil Landrigan Dr. Phillipe Grandjean
Autism Rising, from page 9 determine autism prevalence every two years since 2000. Autism historically has been rare throughout the world. The first reported case was in 1943 in the U.S. by Dr. Leo Kanner, a psychiatrist from Johns Hopkins Hospital. In 1981, the U.S. autism rate was 1 in 10,000. In 2007, it was 1 in 150. In 2009, it was 1 in 100. At this rate, it is estimated that by 2025 it will be 1 in 2 or 50% – very bad news indeed. What is causing the increase in autism prevalence? Is it just better diagnosis and funding? That large an increase can't be dismissed as just improved diagnosis, however convenient that explanation is. Autism is a tragedy for families and our society. Experts advise that we shift our attention to environmental factors that have changed since the 1990s when the steep curve began. Is it a single toxin or a combination of factors that is driving this alarming trend both here and abroad? (2)
"Autism costs society an astounding $126 billion per year in the U.S." (19) A GROWING LIST OF NEUROTOXIC CHEMICALS
As the shocking news of rising autism rates came out this year, another major article on developmental neurotoxins was published in the Lancet by pediatrician and epidemiologist Dr. Phil Landrigan, a professor of preventative medicine and director of the Children's Environmental Health Center at Mount Sinai School of Medicine, and Dr. Philippe Grandjean, adjunct professor of environmental health at Harvard University School of Public Health. They have spent decades working to identify environmental threats to children and the unborn fetus, where key development occurs. They conclude that a growing list of chemicals in our environment contributes to this rise and that genetics or improved diagnosis cannot account for the steep increase. (2) Their original review in 2006 identified 201 adult neurotoxins as well as five developmental neurotoxicants – lead, methylmercury, polychlorinated biphenyls (industrial lubricants, carbonless paper), arsenic (semiconductors, pesticides, coal combustion, food), and toluene (solvent in glues, paints, nail polish, printing ink). (3) A recent update of epidemiological studies have documented six additional developmental neurotoxins – manganese (gasoline additive, batteries, steel and aluminum manufacturing), fluoride, chlorpyrifos (pesticide), dichlorodiphenyltrichloroethane (DDT pesticide), tetrachloroethylene (Perc dry cleaning fluid), and the polybrominated diphenyl ethers (flame retardants). Unfortunately, the article notes that there are many more chemicals commercially released that have not been studied for harm to the developing brain. (2)
"Inhibition of neurite outgrowth was found at concentrations of additives theoretically achievable in plasma by ingestion of a typical snack and drink." Liverpool study (6)
A big problem in identifying chemicals causing any disease is that we are not exposed to just one chemical at a time, but this is how they are tested in the laboratory for toxicity. In our kitchens, cars, living rooms, offices, and on the highway, breathing fumes, we have chronic low-dose daily exposure to chemicals causing cancer, pulmonary disease, renal toxicity, asthma, in addition to neurotoxicity. Biomonitoring studies have documented these chemicals and metals of concern brewing in our bodies for decades. (5) In 2009, studies of newborn umbilical cord blood revealed more than 200 chemicals that were circulating through the babies' brains prior to birth. (17)(18) Some of these toxins are persistent pollutants and do not easily break down in our bodies or in nature, such as DDT or flame retardants (PBDE). Others such as triclosan (antibacterial additive) or Bisphenol A (BPA), have a half life of less than a week in our bodies, but are found in the vast majority of those tested because of constant exposure in consumer products. Chemicals in combination can give a one-two punch to the developing brain. It has been demonstrated that food dyes and additives can cause adverse behavioral effects such as hyperactivity.(19)(20) Scientists have studied deleterious effects of food additives on the developing brain as well. In a study from the University of Liverpool, scientists examined the neurotoxic effects of four common food additives in combinations of two (Brilliant Blue and L-glutamic acid, Quinoline Yellow and aspartame) to assess potential interactions. They found "Inhibition of neurite outgrowth was found at concentrations of additives theoretically achievable in plasma by ingestion of a typical snack and drink….and both combinations had a straightforward additive effect on cytotoxicity."(6)
The most critical developmental window in humans extends from early gestation to the first two years of life. That is when the majority of cells and synapses are settled in place. The brain does not complete development until the early 20s however. The billions of brain cells that form a functioning brain require a very complex and fragile dance between DNA, RNA, proteins, cells, and circulating hormones that occurs in a defined sequence. Many mechanisms can be responsible for harming a growing brain at many points in the process. Thyroid hormone is one factor that plays an essential role in brain development. Environmental operatives that disrupt its production or function will cause irreversible neurologic harm. It is well known that iodine given to pregnant women is necessary for thyroid hormone production in the first trimester to prevent cretinism. However, if given in the second trimester, iodine supplementation does not prevent neurological damage. The fetus begins to produce its own thyroid hormone from 10-12 weeks, but still uses maternal thyroid hormone. (10) Cindy Russell, MD, is the Vice-President of Community Health, Chair of the Environmental Health Committee, and a CMA Delegate with the Santa Clara County Medical Association. She is board certified in plastic surgery and is currently practicing with the Palo Alto Medical Foundation Group.
"During these sensitive life stages, chemical exposure can cause permanent brain injury at low levels that would have little or no adverse effect in an adult." Dr. Grandjean, Dr. Landrigan (2) EVERYDAY ENDOCRINE DISRUPTORS AFFECT THYROID HORMONE
R. Thomas Zoeller from the University of Massachusetts has extensively studied the effects of industrial toxins on thyroid function and found that PCBs can reduce the circulating levels of thyroid hormone, although the TSH levels were not altered. There is strong scientific evidence that exposure to polychlorinated biphenyls (PCBs) – global pollutants found in transformers, old fluorescent lights and fish – is associated with negative effects on cognitive development and IQ. (9)(10) Many commonly used chemicals have been found to interfere with thyroid hormone. 1. PBDEs , which are ubiquitous flame retardants, reduce circulating levels of thyroid hormone. PBDE's have also been shown in several animal studies to lower circulating levels of vitamin A, which is a co-regulator of gene expression with thyroid hormone signaling. 2. Perchlorate is a stable compound found in fireworks, rocket fuel, and is now a widespread water contaminant. It is found in breast milk. Perchlorate has been shown to interfere with thyroid function by reducing iodide uptake and thus thyroid hormone synthesis. 3. Bisphenol-A (BPA) is one of the highest volume chemicals produced worldwide with over six billion pounds produced each year. Over 100 tons are released into the atmosphere each year. It is found in the lining of tin and aluminum cans, on cash register receipts, dental sealants. 93% of humans tested had BPA in their bloodstream, although the half-life is about a week. BPA has a complex, but harmful interaction with thyroid signaling and has been shown to bind to thyroid receptors. 4. Phthalates are ubiquitous chemicals found in plastic water bottles, pharmaceutical drug and vitamin coatings, PVC products, IV bags, flexible plastic toys, paints, printing inks, as a food contaminant in milk and meats, and in drinking water. Most Americans test positive for phthalates in their urine. Phthalates were found to have thyroid receptor antagonistic activity. (12)(13) 5. Perfluorinated compounds found in Teflon, lining of pizza boxes and takeout cups, fire fighting foam, water/stain proofing on clothing and shoes are bioaccumulative and are found in most people and animals in biomonitoring studies. Perfluorinates can cross the placenta and compete with thyroxine (T4, i.e., the transport form of thyroid hormone) for binding to the human thyroid hormone transport protein transthyretin (TTR). They can thus inhibit and adversely affect the thyroid hormone system in animals and humans. (15) Considering there are over 80,000 synthetic chemicals being produced and a mere 200 have been tested for neurotoxicity alone, it would take geologic time to test all of these in combination. Experts agree it is time for action. We should not have absolute proof of harm before removing a chemical from consumer or environmental exposure. A
precautionary approach is called for to reduce/eliminate chemicals in consumer products once harm is discovered. (2) New and old chemicals need to be fully tested before commercial release or we will eventually find them in our coffee and our cake.
Several emerging commercial practices of concern for public and environmental health that have been proliferating since the early 1990s are below. These are added to the chemical/heavy metal blends previously described and which may contribute to the rise in autism and other neurobehavioral disorders. • Genetically modified foods with built-in pesticides along with much higher levels of pesticide applications, especially glyphosate. • Flame retardant use continues to rise in furniture and electronics. MAY/JUNE 2014 | THE BULLETIN | 11
Autism Rising, from page 11 • Electromagnetic wireless microwave radiation in cell towers, cell phones, cordless phones, routers, smart meters. • Nanoparticles in consumer products. Autism Rising: Part 2 will discuss some of these issues.
1. CDC Autism Spectrum Disorder Data and Statistics http://www. cdc.gov/ncbddd/autism/data.html2 2. Neurobehavioural effects of developmental toxicity. Grandjean P1, Landrigan PJ Lancet Neurol. 2014 Mar; 13(3):330-8 http:// www.ncbi.nlm.nih.gov/pubmed/245560103 3. Developmental neurotoxicity of industrial chemicals. Grandjean P1, Landrigan PJ Lancet. 2006 Dec 16; 368(9553):2167-78. http:// www.ncbi.nlm.nih.gov/pubmed/171747094 4. Summary Health Statistics U.S. Children: National Health Interview Survey, 2012 http://www.cdc.gov/nchs/data/series/ sr_10/sr10_258.pdf5 5. CDC National Biomonitoring Program. http://www.cdc.gov/ biomonitoring/6 Synergistic Interactions between Commonly Used Food Additives in a Developmental Neurotoxicity Test. Lau, K. Toxicol. Sci. (March 2006) 90 (1): 178-187. http://toxsci. oxfordjournals.org/content/90/1/178.long7 6. Body Burden The Pollution in Newborns . July 14, 2005. http:// noharm-europe.org/sites/default/files/documents-files/51/Body_ Burden_in_Newborns.pdf http://noharm-europe.org/sites/ default/files/documents-files/51/Body_Burden_in_Newborns. pdf 7. Tests Find More Than 200 Chemicals in Newborn Umbilical Cord Blood. Scientific American. Dec 2, 2009. http://www. scientificamerican.com/article/newborn-babies-chemicalsexposure-bpa/ 8. Biomonitoring of bisphenol A concentrations in maternal and umbilical cord blood in regard to birth outcomes and adipokine expression: a birth cohort study in Taiwan. Chou WC. Environ Health. 2011 Nov 3;10:94. http://www.ncbi.nlm.nih.gov/ pubmed/2205096710 9. Thyroid Hormone Action in Fetal Brain Development and Potential for Disruption by Environmental Chemicals. R. THOMAS ZOELLER. NeuroToxicology® 21(6) 2000.11) 10. Environmental chemicals targeting thyroid. Zoeller. Hormones 2010, 9(1):2_-40 http://www.umass.edu/cns/Zoeller2.pdf12 11. Phthalates residues in plastic bottled waters. Al-Saleh I, J Toxicol Sci. 2011 Aug;36(4):469-78. http://www.ncbi.nlm.nih.gov/ pubmed/2180431113 12. Dibutyl Phthalate Contributes to the Thyroid Receptor Antagonistic Activity in Drinking Water Processes. Na Li. Environ. Sci. Technol., 2010, 44 (17), pp 6863–6868. http://pubs. acs.org/doi/abs/10.1021/es101254c14 13. Thyroid effects of endocrine disrupting chemicals. Boas M. Mol Cell Endocrinol. 2012 May 22;355(2):240-8. http://www.ncbi. nlm.nih.gov/pubmed/2193973115 14. Competitive Binding of Poly- and Perfluorinated Compounds to the Thyroid Hormone Transport Protein Transthyretin. Jana M. Weiss, Toxicol. Sci. (2009) 109 (2): 206-216 15. New Study: Autism Linked to Environment. Scientific America. Jan 9, 2009. http://www.scientificamerican.com/article/autismrise-driven-by-environment/ 16. Aluminum toxicity to the brain. Krishnan SS. Sci Total Environ. 1988 Apr;71(1):59-64. http://www.ncbi.nlm.nih.gov/
pubmed/3358118 17. Would decreased aluminum ingestion reduce the incidence of Alzheimer's disease?, McLachlan DR CMAJ. 1991 Oct 1;145(7):793804. http://www.ncbi.nlm.nih.gov/ pubmed/1822096 18. New Research Finds Annual Cost of Autism Has More Than Tripled to $126 Billion in the U.S. and Reached £34 Billion in the U.K. http:// www.autismspeaks.org/about-us/press-releases/annual-cost-ofautism-triples 19. Synthetic Food Colors and Neurobehavioral Hazards: The View from Environmental Health Research. Environ Health Perspect. Jan 2012; 120(1): 1–5. Bernard Weiss http://www.ncbi.nlm.nih. gov/pmc/articles/PMC3261946/ 20. Food additives and hyperactive behavior in 3-year-old and 8/9-year-old children in the community: a randomized, doubleblinded, placebo-controlled trial. McCann, D The Lancet, Volume 370, Issue 9598, Pages 1560 - 1567, 3 November 2007 21. Neurotoxins and neurotoxicity mechanisms. An overview. Segura-Aguilar J1Neurotox Res. 2006 Dec;10(3-4):26387. http://www.ncbi.nlm.nih.gov/pubmed/17197375 22. Neurodegenerative memory disorders: a potential role of environmental toxins. Caban-Holt A. Neurol Clin. 2005 May;23(2):485-521 http://www.ncbi.nlm.nih.gov/ pubmed/15757794 23. Developmental Fluoride Neurotoxicity: A Systematic Review and Meta-Analysis. Environmental Health Perspectives. Volume 120 | number 10 | October 2012. Anna L. Choi,1 Guifan Sun,2 Ying Zhang,3 and Philippe Grandjean1,4 24. The Toxins That Threaten Our Brains. Atlantic Monthly. James Hamblin. March 18, 2014. http://www.theatlantic.com/features/ archive/2014/03/the-toxins-that-threaten-our-brains/284466/ www.
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For 16 years, the California Medical Association hosted the California Health Care Leadership Academy, which earned a reputation as one of the West Coast's premier health policy and leadership development conferences. This year, the 17th annual conference was rebranded the Western Health Care Leadership Conference and welcomed physicians and practice managers from many of the western states. This year's conference – with more than 700 attendees – was a huge success. >>
Among our high powered presenters was keynote speaker Hillary Rodham Clinton, Former Secretary of State and Former U.S. Senator from New York. Clinton, who addressed the attendees live via satellite, joined many other big-name thinkers and doers who shared strategies and resources for accelerating the shift to a more integrated, high performing and sustainable health care system. The conference examined the most significant challenges facing health care today and presented proven models and innovative approaches to transform health care delivery and business practices. Below are highlights from this year's conference, which was April 11-13, 2014, at the San Diego Convention Center.
Former Secretary of State Hillary Rodham Clinton addressed the 700 physicians, practice managers, medical students and others at the Western Health Care Leadership Academy in San Diego.
Delivering the keynote address live via satellite, Secretary Clinton urged the California Medical Association to work with other like-minded organizations to help advance meaningful health care
delivery and payment reform, instead of continuing to "rejigger" a broken system. "At some point, we have to move away from fee for service payment for medical care," said Secretary Clinton. "It is not serving physicians well, or any other health care providers, and I don't believe it's serving patients well." Secretary Clinton told attendees that she shares physicians' frustration with Congress's inability to make any progress on fixing the current broken payment system. She said she would like to see more systemic reform so that physicians are fully reimbursed for everything that
goes into the care of patients. "It is deeply bothersome to me that it is still not accepted that a lot of what constitutes wellness—things that a physician can be promoting with his or her patients— should be reimbursed by Medicare," Clinton said. "When a physician sits down with a patient and says 'I'm going to give you a nutrition regimen. I'm going to have my nurse or my PA check in on you to make sure that you're walking every day.' These are all things that would keep that patient out of the operating room for a bypass or a stent or some other expensive intervention."
"We're never going to resolve the injustice, the unpredictability, the unfairness that unfortunately permeates the current system," she said. "We need to move away from this very narrow approach to reimbursing physicians." "At some point, I hope we're going to be able to take a look at the broad base of funding streams, both public and private, that go into funding health care– particularly physicians' pay—and look more at who the patient is and what the doctor is providing that patient, instead of what the program is and how we can keep trying to put square pegs in a round hole."
Western HealthCare Leadership > 2014
Secretary Clinton also held up California's implementation of the Affordable Care Act as a model for the nation. "We're going to be watching closely what happens in California. Seeing what works, and what doesn't. States like California, intent on covering more citizens and fostering bold experimentation to improve outcomes and reduce costs, will not only lead the way, but help everyone else find the way." Secretary Clinton also urged all stakeholders to work together to keep pushing for improvements to the health care system. "The transparency called for under the Affordable Care act is going to reveal a lot of information. Some of it may be surprising. And some of it may even be quite troubling," said Clinton. "But
for the first time, we're going to see information. And everyone will be able to look at the same information. We can then try and figure out 'Is there a problem that needs to be fixed?'" The data collected under the Affordable Care act will, according to Clinton, will allow us to ask questions that will give us much better insight into how we can move towards a more efficient, quality driven health care system. "I think this is a great opportunity, if we do it with that kind of open attitude of 'let's learn what works, let's make this better.' Let's hear from physicians and nurses and pharmacists, you name it. Everyone come to the table. What do you think needs to be changed?"
Attendees also heard from a diverse panel of health care industry experts who discussed the changing dynamics of the health care marketplace and how we can work together to contain health care costs through innovation and integration. "How do we offer something that is affordable to patients and still allow physicians to be financially whole? It's a very fine needle we need to thread," said panelist Paul Markovich, CEO of Blue Shield of California. According to Markovich, two key elements will be attracting younger, healthier patients into the risk pool and redefining "primary care." "If there's a way for us to look at the scope of primary care more broadly, shift to a system where we can understand that it's not just the services provided in the office," said Markovich. "If we can understand it, manage it, and pay for it, we'll be far more successful together."
is secure and safe. We're going to see an explosion of new apps and technologies to connect with people. But the single source of truth should always be the same." Integration is going to be key, agreed Dustin Corcoran, CEO of the California Medical Association. But he warned not to mistake consolidation for integration. "We have to find a way for small and medium practices to have that same level of integration [as large groups and hospitals] without consolidation and without driving prices up," said Corcoran. "We need to find a way for small practices to bind together, share data, share analytics, so they can better coordinate care at a lower cost."
COVERED CALIFORNIA Markovich predicts that if we don't get a handle on rising health care costs, we'll end up with a single payer system. "We must all work together. Everyone is a cost center. Even me. Everyone is a part of the problem, and everyone needs to be a part of the solution." The panelists agreed that advances in technology and changing patient expectations are going to push the health care industry to think very differently than it does today. "Technology is a tool that we have not even begun to leverage to its real potential," said Susan Turney, M.D., President and CEO of the Medical Group Management Association. According to Craig Sammitt, M.D., President of DaVita Healthcare Partners, electronic health records will play a critical role. But in order to truly revolutionize health care, he says, "we need a single source of truth about our patients that
On the closing day of the conference, Covered California Executive Director Peter Lee told attendees that he recognizes that the roll out of the Affordable Care Act (ACA) has been a "bumpy ride," but that he looks forward to working with the physicians of California during this "new era" of health care. "This is beginning the new era of health care – an era where health care is a right, not a privilege," said Lee. "That is what will make the ACA truly historic." Lee urged the hundreds of physicians, practice managers and other health care stakeholders in attendance to remember that the ACA is the biggest change in health care since the launch of Medicare over 50 years go. "If we go back 50 years ago, the launch of Medicare was not smooth, it was not without controversy, it was not without calls
Western HealthCare Leadership > 2014
for boycotts from some in the physician community," said Lee. "And yet today, it's something we all take for granted – the fact that we have a Medicare system to make sure that our seniors get access to high quality care." According to Lee, Covered California and the contracted health plans could have definitely benefited from another 6 months to a year of lead time, but such a delay would have also meant a delay in getting literally millions of people insured. "We're continuing to work to build and improve a system that we think is going to be here for many, many years to come, and I look forward to us working together to improve a system that will be historic in changing what health care is for California and the nation," said Lee. Lee admits that there is still a lot of work to do, particularly in the area of network adequacy. "We're going to be relying on the regulatory standards of network adequacy and see how those work – do we need to lean in and do more? That's what we're looking at right now," said Lee. "We are looking to plans to keep updated their provider directory information. This is an area where, without a doubt, plans are stumbling. This is an area where the plans could have used more time and they doing fixes." Lee insists Covered California recognizes and takes to heart that the ACA is not just about coverage. It's about getting people the care they need. "We need to make sure that once people are covered, that people are actually getting care. Again, this isn't about coverage, it's about addressing disparities in care, about addressing wellness and prevention, and getting people the care they need." Part of this will be done by looking at claims data and using consumer surveys, says Lee. "We have in process a long-term set of analytics and methodologies to understand what consumers are really facing – looking at the clinical information on what care are people getting, and on a timely basis, are they getting the care as needed?" Lee told attendees that Covered California will be 20 | THE BULLETIN | MAY/JUNE 2014
reviewing very substantial clinical analytics for all the care that is being provided to Covered California enrollees. Through the analytics, Lee hopes that we can ensure that the promise of coverage isn't an empty one, and that patients' needs are being met. "This is a moving process, a process that we are learning and we appreciate learning from you what's working and what's not working," said Lee. "But also we look forward in many ways to making history with you."
Visit the California Medical Association Flickr page at www.flickr.com/californiamedicalassociation to see the photographs from this year's conference!
Mark your calendars and plan to join us for the 18th Annual Western Health Care Leadership Academy, planned for May 29-31, 2015, at the Loews Hollywood Hotel. Additional information will be posted at www. westernleadershipacademy.com when available. Our keynote speaker will be Malcolm Gladwell, international bestselling author whose books have changed the way we think about sociological changes and the factors that contribute to high levels of success.
Thank You to SCCMA Alliance CALPAC Donors In the March/April edition of The Bulletin, SCCMA acknowledged our member CALPAC donors. We would also like to acknowledge and extend a huge "thank you" to the Alliance members, listed below, who have made contributions to CALPAC for the 2013-2014 fiscal year. SCCMA genuinely appreciates your commitment to defending and protecting MICRA as well.
Alliance Rosemary Adamson ........................................ $25 Heather Goodman........................................... $25 Suzanne Jackson............................................. $125 Steve Jackson, MD.......................................... $100 Carolyn Miller................................................... $25 Sally Normington............................................. $25 Debbi Ricks........................................................ $25 Siggie Stillman.................................................. $25
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County of Santa Clara Public Health Department Administration 976 Lenzen Avenue, 2nd Floor San José, CA 95126
Date: April 15, 2014 To:
DATE: April 15, 2014 District Superintendents School Nurses TO: Care Providers District Superintendents Health School Nurses
From: Sara H. Cody, MD, Health Officer Health Care Providers Teeb Al-Samarrai, MD, Tuberculosis Controller Re:
Sara H. Cody, MD
Change in the Tuberculosis (TB) School Mandate: Health Officer From Universal Testing to Universal Risk Assessment and Targeted Testing
Teeb Al-Samarrai, MD Controller Beginning June 1, 2014, the Tuberculosis Santa Clara County Tuberculosis (TB) School Mandate will change from a requirement for universal
TB testing to a requirement for universal TB risk assessment. RE: County has required Change the Tuberculosis (TB) School Mandate: Santa Clara TBin testing for students entering school since 1989. This Health Officer Mandate was impleFrom Universal Testing to Universal Risk Assessment Testing early and mented at that time because TB rates rapidly increased. It was intended to ensure that childrenand withTargeted TB were diagnosed treated appropriately when the infection was latent or "silent." The California Health and Safety Code, § 121515, gives the county Beginning June 1, 2014, the Clara County Tuberculosis (TB) School Mandate will change from Health Officer authority to implement suchSanta mandates. As TBarates have declined the US and Centers for Disease Control TB and risk Prevention (CDC), the American Acadrequirement for in universal TBCalifornia, testing tothe a requirement for universal assessment. emy of Pediatrics (AAP) and the California Tuberculosis Controller's Association (CTCA) have revised their recommendations. In place of universal TB testing, these now TB recommend thatstudents healthcare providers ask a series questions assess a child's risk Santa Clara County hasbodies required testing for entering school since of 1989. This to Health of exposure to TB and target TB testing for children at increased risk for TB exposure or developing TB disease. Although Officer Mandate was implemented at that time because TB rates rapidly increased. It was intended to rates of TB have declined Santa Clara County since thediagnosed Mandate was put in place, we continue to have when one of the the highest rates of TB in the ensureinthat children with TB were early and treated appropriately infection was US. Santa Clara County has very few cases of active TB among children, however, children remain vulnerable to being exposed latent or "silent." The California Health and Safety Code, § 121515, gives the county Health Officer to TB from others and are attogreater risk of progressing to active TB disease if latent or "silent" TB infection is not detected and treated early. authority implement such mandates. In February 2014, the Public Health Department convened a School Mandate Review Task Force — including school representatives and pediatricians community — US to review our local TBthe data, the AAP/CDC/CTCA recommendations, the academic As TB ratesfrom havethe declined in the and California, Centers for Disease Control and Prevention literature, the policies of similar jurisdictions across California and the US, as well as challenges and advantages of different policy (CDC), the American Academy of Pediatrics (AAP) and the California Tuberculosis Controller's changes. Based on this review and discussion, Santa Clara County will no longer require universal testing but will transition to a Association (CTCA) have revised their recommendations. In place of universal TB testing, these mandate for universal risk assessment and targeted testing. bodies now recommend that healthcare providers ask a series of questions to assess a child's risk of The new Santa Clara County Public Health Department Risk Assessment for School Entry form will be required for school exposure to TB and target TB testing for children at increased risk for TB exposure or developing TB registration effective June 1, 2014 for all children enrolling in kindergarten or transferring, at any grade level, from outside of disease. Santa Clara County.Although rates of TB have declined in Santa Clara County since the Mandate was put in to have oneTB of School the highest rates ofreplace TB inwith the US. Santa Clara County has very few Please place, discardwe all continue prior references to the Mandate and the following documents: cases of active TB among children, however, children remain vulnerable to being • NEW: TB Risk Assessment for School Entry form (to be completed by healthcare providers) exposed to TB from othersGuidelines and are attogreater risktooftheprogressing to active TB disease if latent or "silent" TB infection is • Revised: Revisions School Mandate and Requirements not detected and treated early. • Revised: Frequently Asked Questions • Revised: Dear Parent Letter In February 2014,County the Public Department • Revised: Santa Clara SchoolHealth Mandate Flow Chartconvened a School Mandate Review Task Force — including school representatives and pediatricians from the community — to review our local TB • Revised: IGRA Fact Sheet data,List theofAAP/CDC/CTCA academic • NEW: school health clinicsrecommendations, and FQHCs in Santathe Clara County literature, the policies of similar California andschool the US, as well as challenges andlocation advantages differentregistration policy is done Please jurisdictions reproduce thisacross entire packet for each in your district as well as any where of centralized for new and transfer students. Please also feel free to post on District or School websites. These materials will also be available at www. Board of Supervisors: Mike Wasserman, Cindy Chavez, Dave Cortese, Ken Yeager, S. Joseph Simitian sccphd.org/tb. County Executive: V. Smith If you have questionsJeffrey about these changes, please contact the TB Prevention and Control Program at (408) 885-4214. Thank you for helping us protect the health of children in Santa Clara County. 22 | THE BULLETIN | MAY/JUNE 2014
Child's Name: ________________________ Birthdate: _______________ Last,
School: ____________________
Address________________________________________________________ Phone: ______________ Street City Zip
Grade: __________
Santa Clara County Public Health Department TB Risk Assessment for School Entry
This form must be completed by a licensed health professional and returned to the child's school. 1. Was your child born in Africa, Asia, Latin America, or Eastern Europe?
! Yes
! No
2. Has your child traveled to a country with a high TB rate* (for more than a week)?
! Yes
! No
! Yes
! No
4. Has a family member or someone your child has been in contact with had a positive TB test or received medications for TB?
! Yes
! No
5. Was a parent, household member or someone your child has been in close contact with, born in or traveled to a country with a high TB rate?*
! Yes
! No
6. Has another risk factor for TB (i.e. one of those listed on the back of this page)?
! Yes
! No
3. Has your child been exposed to anyone with tuberculosis (TB) disease?
* This includes countries in Africa, Asia, Latin America or Eastern Europe. For travel, the risk of TB exposure is higher if a child stayed with friends or family members for a cumulative total of 1 week or more. If YES, to any of the above, the child has an increased risk of TB infection and should have a TST/ IGRA. All children with a positive TST/IGRA result must have a medical evaluation, including a chest X-ray. Treatment for latent TB infection should be initiated if the chest X-ray is normal and there are no signs of active TB. If testing was done, please attach or enter results below. Tuberculin Skin Test (TST/Mantoux/PPD)
Induration _____ mm
Date given:
Impression: ! Negative
! Positive
Impression: ! Negative
! Positive ! Indeterminate
Impression: ! Normal
! Abnormal finding
" LTBI treatment (Rx & start date):
" Prior TB/LTBI treatment (Rx & duration):
" Contraindications to INH or rifampin for LTBI
" Offered but refused LTBI treatment
Date read:
Interferon Gamma Release Assay (IGRA) Date: Chest X-Ray (required with positive TST or IGRA)
Providers, please check one of the boxes below and sign: " Child has no TB symptoms, none of the above or other risk factors for TB and does not require a TB test. " Child has a risk factor, has been evaluated for TB and is free of active TB disease. _______________________________________ Health Provider Signature, Title
_____________ Date
Name/Title of Health Provider: Facility/Address: Phone number:
Fax number: Rev 4/15/2014 Santa Clara County TB Assessment Form MAY/JUNE 2014 | THE BULLETIN | 23
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Increased costs. Losing trusted doctors. Threatened privacy. That's what happens when lawyers play doctor You may have heard that the trial lawyer-sponsored ballot measure that aims to undermine the protections of the Medical Injury Compensation Reform Act (MICRA) has officially qualified for the November ballot. In less than six months, on November 4, 2014, these trial lawyers will ask voters to weigh in on "The Troy and Alana Pack Patient Safety Act," an initiative that was carelessly thrown together without any concern for taxpayer pocketbooks, privacy, patients or health care. If trial lawyers get their way, our state will be saddled with a costly threat to privacy that California simply cannot afford. If this measure is approved by voters, malpractice lawsuits and payouts will skyrocket, adding "hundreds of millions of dollars" in new costs to state and local governments, according to an impartial analysis conducted by the state's Legislative Analyst. Someone will have to pay, and that someone is providers, taxpayers and consumers. The California Medical Association (CMA) has joined a campaign coalition to oppose the measure, because it will be costly for consumers and taxpayers, endanger patient access to quality health care and jeopardize the privacy of our personal health information. This group, "Patients and Providers to Protect Access and Contain Health Costs," is a diverse and growing coalition of trusted doctors, community health clinics, hospitals, family-planning organizations, local leaders, public safety officials, businesses, and working men and women formed to oppose this costly, dangerous ballot proposition that would make it easier and more profitable for lawyers to sue doctors and hospitals. This measure would also have devastating effects on access to care for patients everywhere, but especially in rural and already underserved areas. Community health care clinics like Planned Parenthood and the Central Valley Health Network are already warning that this measure will cause specialists like OB/GYNs to reduce or eliminate services to their patients. This measure could also cause doctors to leave the state, meaning thousands of Californians could lose access to their trusted doctors. Over the next few months, you'll hear a lot of rhetoric from the proponents of the measure – but really, this is another example of special interest politics trying to fool the voters into thinking this is something that it's not. Authors purposely added doctor drug testing to disguise their real intent behind the ballot measure: to increase law26 | THE BULLETIN | MAY/JUNE 2014
suits against health care providers, which will increase our health care costs and reduce access to quality health care. According to the Los Angeles Times: "The drug rules are in the initiative because they poll well, and the backers figure that's the way to get the public to support the measure. 'It's the ultimate sweetener,' says Jamie Court, the head of Consumer Watchdog." (December 10, 2013) This proposal also forces doctors and pharmacists to use a massive statewide database known as the Controlled Utilization Review and Evaluation System, or CURES, filled with Californians' personal medical prescription information – a mandate our government will find impossible to implement, and a database with no increased security standards to protect your personal prescription information from hacking and theft. Though the database already exists, it is underfunded, understaffed and technologically incapable of handling the massively increased demands this ballot measure will place on it. This ballot measure will force the CURES database to respond to tens of millions of inquiries each year– something the database simply cannot do in its current form or functionality. A non-functioning database system will put physicians and pharmacists in the untenable position of having to break the law to treat their patients, or break their oath by refusing needed medications to patients. Most concerning, the massive ramp up of this database will significantly put patients' private medical information at risk. The ballot measure contains no provisions and no funding to upgrade the database with increased security standards to protect personal prescription information from government intrusion, hacking, theft or improper access by non-medical professionals. The initiative is bad for patients, taxpayers and health care as a whole, and there has never been a greater need for physicians to band together and fight for our patients. As you can see, this initiative is fraught with problems and would prove detrimental to California's health care system. I'm asking each of you to join the effort to defeat this costly threat to our state, and in doing so, protecting access to care and preventing higher costs for all California. Together, I'm sure we will be victorious. As we forge ahead to Election Day, it is more important than ever to make sure we are speaking as a unified, coordinated voice. If you haven't done so already, please visit CMA's website at www.cmanet.
org/micra for the latest information, handouts and to sign up as a campaign coordinator in your area. Please also visit the campaign website at www.stophigherhealthcarecosts.com to sign up to become an official opponent of this badly flawed measure. From the website you can: • Sign up to add your name to the growing list of individuals and groups opposed to the MICRA ballot measure. • Get important facts, downloads and information that will help you spread the word about this costly measure. • Be part of our outreach team. If you have direct patient contact, become part of our outreach team. Visit CMA's
MICRA resource page to sign up as a campaign coordinator at http://www.cmanet.org/issues-and-advocacy/cmas-topissues/micra/join-the-fight/. • Participate in message/media training. The campaign is also looking for physicians interested in taking on a more public role speaking to community groups about why this ballot measure should be defeated. Contact Molly Weedn at firstname.lastname@example.com for more information.
Choosing Wisely An initiative of the American Board of Internal Medicine (ABIM) Foundation SCCMA-MCMS is publishing various Choosing Wisely® lists of "Things Physicians and Patients Should Question." Choosing Wisely - see next page - is an initiative of the ABIM Foundation to help physicians and patients engage in conversations to reduce overuse of tests and procedures, and support physician efforts to help patients make smart and effective care choices.
Originally conceived and piloted by the National Physicians Alliance through a Putting the Charter into Practice grant, leading medical specialty societies along with Consumer Reports, have identified tests or procedures commonly used in their fields whose necessity should be questioned and discussed. The resulting lists of "Things Physicians and Patients Should Question" will spark discussion and the need - or lack thereof - for many frequently ordered tests or treatments.
The American Gastroenterological Association (AGA) convened a work group that included members from the Clinical Practice and Quality Management Committee (CPQMC), chair of the Practice Management and Economics Committee (PMEC), the chief medical officer for the AGA Digestive Health Outcomes Registry® and members of the AGA Institute Governing Board. Ideas for the "five things" were solicited from the workgroup for review by the CPQMC, which developed additional topics, resulting in six draft items. The workgroup continued to pare down and refine the list, before submitting a final draft to both the CPQMC and the PMEC for approval. After final refinements were made to simplify language and avoid complex clinical terminology, the final list was submitted to and approved by the AGA Institute Governing Board. AGA's disclosure and conflict of interest policy can be found at www.gastro.org. For more information or to see other lists of Five Things Physicians and Patients should question, visit www.choosingwisely.org.
American Gastroenterological Association
Five Things Physicians and Patients Should Question
For pharmacological treatment of patients with gastroesophageal reflux disease (GERD), long-term acid suppression therapy (proton pump inhibitors or histamine2 receptor antagonists) should be titrated to the lowest effective dose needed to achieve therapeutic goals. The main identifiable risk associated with reducing or discontinuing acid suppression therapy is an increased symptom burden. It follows that the decision regarding the need for (and dosage of) maintenance therapy is driven by the impact of those residual symptoms on the patient's quality of life rather than as a disease control measure.
Do not repeat colorectal cancer screening (by any method) for 10 years after a high-quality colonoscopy is negative in average-risk individuals. A screening colonoscopy every 10 years is the recommended interval for adults without increased risk for colorectal cancer, beginning at age 50 years. Published studies indicate the risk of cancer is low for 10 years after a high-quality colonoscopy fails to detect neoplasia in this population. Therefore, following a high-quality colonoscopy with normal results the next interval for any colorectal screening should be 10 years following that normal colonoscopy.
Do not repeat colonoscopy for at least five years for patients who have one or two small (< 1 cm) adenomatous polyps, without highgrade dysplasia, completely removed via a high-quality colonoscopy. The timing of a follow-up surveillance colonoscopy should be determined based on the results of a previous high-quality colonoscopy. Evidencebased (published) guidelines provide recommendations that patients with one or two small tubular adenomas with low grade dysplasia have surveillance colonoscopy five to 10 years after initial polypectomy. "The precise timing within this interval should be based on other clinical factors (such as prior colonoscopy findings, family history, and the preferences of the patient and judgment of the physician)."
For a patient who is diagnosed with Barrett's esophagus, who has undergone a second endoscopy that confirms the absence of dysplasia on biopsy, a follow-up surveillance examination should not be performed in less than three years as per published guidelines. In patients with Barrett's esophagus without dysplasia (cellular changes) the risk of cancer is very low. In these patients, it is appropriate and safe to exam the esophagus and check for dysplasia no more often than every three years because if these cellular changes occur, they do so very slowly.
For a patient with functional abdominal pain syndrome (as per ROME III criteria) computed tomography (CT) scans should not be repeated unless there is a major change in clinical findings or symptoms. There is a small, but measurable increase in one's cancer risk from x-ray exposure. An abdominal CT scan is one of the higher radiation exposure x-rays — equivalent to three years of natural background radiation. Due to this risk and the high costs of this procedure, CT scans should be performed only when they are likely to provide useful information that changes patient management.
These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.
Mines, Mercury, and Medicine By Michael A. Shea, MD Leon P. Fox Medical History Committee
Twelve miles south of San Jose lies a 3,500 acre site that was once known as the Almaden Quicksilver Mine. Time and nature have covered up much of the operative equipment of the once thriving mercury mine. Founded in 1845, the mine produced over one million flasks of mercury in its more than 100 years of operation. It was the second most productive mercury mine in the world. The number one ranking belongs to the mine in Almaden, Spain. Andres Castillero, a Mexican cavalry officer, was the first non-native to discover that the mine contained mercury. He did this with the help of the Ohlone Indians in 1845. He was looking for financial gain, as mercury was needed to mine silver in Mexico. This proved impossible for him, due to his military obligation in Mexico. Future owners of the mine knew that mercury was necessary to recover gold in the United States. This was the basis for Almaden's success and the high price that mercury commanded. A virtual city soon grew up around the quicksilver mine. It consisted of three sections: Spanishtown, Englishtown, and the Hacienda. Miners from Mexico, Chile, and California lived in Spanishtown. Cornish miners, known as "cousin jacks" (from Cornwall, England) lived in Englishtown. The Hacienda contained the reduction works for recovering mercury from the ore (cinnabar). The company manager also lived in this area, along with other administrators and even some of the miners who worked the reduction plant. At its peak, over 3,000 people lived in this community. There were Catholic and Protestant churches, a school consisting of eight grades, a general merchandise store, a firehouse, and an apothecary shop where medicines were sold at cost. Other facilities included: a barber shop, a cantina for billiards and card games, a bakery, shoemaker, a second hand store, library, and social hall. Miners rented their homes for five dollars a month and paid fifty cents a month for water. They worked 10-hour shifts, six days a week, and received $40-$75 per month. The process of mercury extraction was a simple procedure and took advantage of it being a liquid at room temperature. Cinnabar (mercurous sulfide) was heated until the mercury vaporized. After it was condensed by cooling, it was collected in eight-by-eighteen-inch iron flasks. Each flask contained 75 pounds of mercury. It was shipped by rail to the Alviso port and from there, across the United States and the world.
Mercury, in any form, is poisonous. It can affect the central nervous system, the gastrointestinal system, and the renal system. It exists in three forms: (1) elemental mercury, (2) inorganic salts, and (3) organic compounds (methylmercury). Absorption from the gastrointestinal tract is zero with elemental mercury, low with mercury compounds, but 90% from organic mercury. Absorption can also be from inhalation of mercury vapors via the lungs 30 | THE BULLETIN | MAY/JUNE 2014
and even from chronic epidermal contact. Acute exposure symptoms include: metallic taste, excess salivation, thirst, burning around the mouth, nausea and vomiting, abdominal pain, and diarrhea. Chronic exposure symptoms consist of ataxia, tremors, convulsions, depression, and weakness. It is to be noted that these forms of mercury exposure can have overlapping symptoms. For example, the body can convert part of the vaporized elemental mercury into inorganic mercury in red blood cells, thus giving symptoms of each form. Vaporized mercury absorbed through the lungs can enter the central nervous system with corresponding side affects. The Ohlone Indians used the vermillion form of cinnabar (ground powder mixed with water) and applied it to their skin for ceremonies and rituals. Absorption over time led to symptoms of tremors, personality changes, and ataxia. They warned Castillero of these occurrences when guiding him to the cinnabar in 1845. For the miners, the exposure came mainly from the inhalation of the mercury vapor. A miner with increased salivation was temporarily removed from the reduction works until his body could clear itself of the mercury.
Dr. S. W. Winn
Dr. Underwood Hall, Jr.
In 1871, General Manager James B. Randal established the first industrial medicine department in California. A miners' fund was the source of the finances. Each miner paid one dollar per month into the fund. This covered the salaries of the resident physician and the pharmacist. The only extra cost to the miner was prescription medication. Doctor calls started slowly because of the tendency of the miners to treat ailments with home remedies. Some examples were: (1) sulfur and molasses to all members of the family as a blood tonic and purifier, (2) asafetida (stinking gum) used orally to treat coughs and influenzas. It was also made into a paste and hung around a child's neck for treatment and as a preventive measure for the common cold. It may have worked in the latter capacity as it had a terrible odor and certainly could have kept people from coming in contact with the child, (3) mustard plaster was applied to the chest of someone with a cold and cough. This was left on until the skin became hot and red; and (4) garlic, brown sugar, vinegar, and honey added
to a cup of warm water was taken to treat a cough. In 1876, Dr. A. R. Randal, brother of the manager, became the first company M.D. Resigning after only a few months, he was succeeded by F. V. Hopkins, MD, who carried on the work until 1879. Dr. S. W. Winn arrived in the fall of 1879 and established residence at Englishtown. He received $400 per month, plus a horse and buggy. A dispensary with an office was built in Englishtown and a smaller one in the Hacienda. The doctor's time was divided between the office and home visits. An average of 5,000 calls a year is an estimate of Dr. Winn's early practice. Along with common ailments (aches, pains, and trauma) were the following more serious disorders: tuberculosis, cholera, meningitis, bronchitis, peritonitis, erysipelas, tetanus, nephritis, diphtheria, grippe, cancer, and measles. There is not found in the records any mention of some of the more serious toxic effects of mercury. The assumption here is that miners with acute and early symptoms of toxicity, such as excess salivation, were treated early by removal from the reduction works. These miners would recover and could even be returned to work at a later date. With his cheerful eyes, prominent nose, and a beard that made him seem older than his 31-odd years, this quiet man was loved and respected long after his cures had done their work. Photography was his favorite hobby and he worked with Robert Bulmore, the company accountant, to record the mine's history and operations as fully as possible. Together, they developed a system of flash illumination, using magnesium powder in pill boxes, to take some of the first underground pictures. In 1889, Dr. Winn suffered a nervous breakdown and was replaced by a new graduate from medical school, Dr. Underwood Hall, Jr. Dr. Hall was born at Gold Hill, Nevada, in 1868. He first attended Cooper Medical College, in San Francisco, and then transferred to Jefferson Medical College of Philadelphia, where he graduated in 1889. Dr.
Hall's first year at the mine consisted of 2,040 office visits, 3,499 home visits, and 25 home deliveries. After five years as the company doctor, he left and moved to San Jose. The following statistics show the death and birth rates at New Almaden for 1890.
Death rate per thousand • Spanish-American - 30.8 • Anglo-American and other nationalities - 8.1 Birth rate per thousand • Spanish-American - 45.4 • Anglo-American and other nationalities - 27.1 Total population in 1890 - 1,413 With new methods of mining gold and emerging toxicity data on mercury, the price of mercury fell, causing the Almaden Mine to close in 1970. In 100-plus years of operation, the mine produced enough mercury to make it the richest mine in California. In addition, families were raised, children were schooled, doctors made house calls, babies were born, church services were held, people lived, and people died. Rusting equipment, shafts partially open, a tall brick chimney against the skyline, a Catholic Church saying weekly mass, a refurbished Casa Grande (home of the manager), even a few of the original homes in the Hacienda – these are some of the historical landmarks still remaining in New Almaden that keep the past in our present, and, hopefully, in our future.
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Tips for
Lowering NORCAL Managing Professional Risk is a quarterly feature of NORCAL Mutual Insurance Company and the NORCAL Group. More information on this topic, with continuing medical education (CME) credit, is available to NORCAL Mutual insureds. To learn more, visit www. norcalmutual. com/cme.
Risks Risk Management, PMSLIC Insurance Company and the NORCAL Group Karen D. Davis, MA, CPHRM
Among the factors that influence the safety of ambulatory care and the liability risk levels of office-based physicians, three of the main ones are: The level of communication with other healthcare providers about patients' care; the effectiveness of office follow-up processes; and the attention given to documentation of telephone calls. The following tips may help physicians and office staff members increase patient safety and lower liability exposure related to these factors. >>
Communication with Other Healthcare Providers
When you refer a patient to another physician, have some mechanism in place to determine whether your referral recommendation has been carried out and the patient has been seen by the recommended consultant (or another physician of the patient's choice). Communicate in writing with the consultant about the requested consultation.
An effective way to convey significant details to another physician is to prepare a "fact sheet" with the patient's clinical information and your impression. After your patient is seen by a consultant, you and the consultant should establish who is responsible for which aspects of the patient's care and who will order further testing and consultations if necessary. If there is a question about what you or the consultant will do, you should take the time to communicate physicianto-physician and to document the understanding you reach in your discussion. Effectiveness of Follow-up Processes
Systematically monitor compliance with appointments. Establish a process whereby a designated staff member reviews all no-show appointments to determine which patients must be called and rescheduled. Document no-shows, along with the steps taken to contact the patient and reschedule the visit. When a patient is advised to undergo a test, three areas of concern require follow-up:
Has the patient complied with the recommendation? Have test results been
received and reviewed by the ordering physician? Has the patient been notified about the results? An appropriate followup system provides answers to these questions. Patients should not be solely responsible for making appointments for tests, to see consultants or for calling the office to obtain results.
You should assist patients in making appointments in order to be assured that the appointment has been made. It is also prudent to notify all patients of all test results (rather than just reporting abnormal results). Such a policy helps close each testing loop and reduces the possibility of patient information "falling through the cracks." Your follow-up system for tests should not only confirm receipt of test results but also ensure that you review the results.
The review should be timely. A test result should never be filed until you (as the ordering physician) have personally reviewed, dated, and initialed it. Without such a method, a positive result can be accidentally misplaced or filed away before you review it or the patient is notified. If the patient later alleges that harm occurred as a result of a delay in diagnosis and treatment, the mishandled test result may well be viewed as concrete evidence of negligence. Documentation of Telephone Calls
Generally, the types of telephone calls from patients that should be documented include: clinical questions and what advice was given, calls for prescriptions or renewals, after-hours calls, and calls to an oncall physician. Calls to patients that should be documented include: calls to share test results, calls to contact no-show patients, calls to give patients
instructions or to advise about further access to care, and unsuccessful attempts to contact patients. Telephone contacts should be documented in the appropriate medical record.
If your office simply keeps a call log, information about a specific call can be difficult to retrieve. The facts surrounding a call are not readily available if they are recorded in a call log; thus, using a log can be detrimental if a malpractice claim is filed and your office must produce information about the patient's interactions with the practice. You should have a system for documenting all after-hours phone calls.
You can use telephone call forms or a tape recorder or dictation machine to record patient name, time of and reason for the call, and your advice or action. When the call is from a patient, the information should be added to the patient's chart as soon as possible. Giving clinical or medical advice over the telephone without timely, face-to-face follow-up increases your liability exposure.
Prescribing over the phone is also risky, as it requires you to assess the patient sight unseen. You should not prescribe for a patient unknown to you without seeing the patient. It is also prudent to have established parameters as to when prescriptions will be renewed by phone. Consider developing the preceding suggestions as policy and including them in a policy manual.
Make sure all employees review your policy and consider asking them to sign off yearly that they have been advised of the policy and understand it.
The Dental Effects and Associated Properties of Natural Sugars, Sugar Substitutes, and Artificial Sweeteners Randy Ligh, DDS SUGAR AND ITS MANY FORMS Sucrose, glucose, lactose, fructose, and dextrose are some of the chemClaire Saxton, MS, RD, CNSC ical names of what we call "sugar." Simple sugars are monosaccharide and Joe Fridgen, DDS disaccharide forms of carbohydrate, while complex carbohydrates such as There appears to be a lot of misconceptions in the health care arena surrounding sugars. We would like to clarify and bring to light the information that exists surrounding sugars as related to dentistry. Health care professionals will find this information useful to guide patients in making appropriate choices about food, beverages, and chewing gums. Sugar has long had a reputation as a culprit in contributing to dental decay. Dental caries (decay) is a disease with a multifactorial etiology. It is an infectious process during which carbohydrates (sugar) are fermented by oral bacteria and the acid production causes enamel dissolution at the tooth enamel surface.
We know that a number of oral microorganisms can produce enough acid to demineralize tooth structure. Streptococcus mutans have demonstrated to be one of the major and most virulent caries-producing microorganisms.1 The acids produced by the microorganisms are metabolic by-products of the consumption of carbohydrate.2 Extended periods of low (acidic) pH in the mouth provide a supportive environment for the proliferation of cavity-causing bacteria. The low pH is also responsible for the demineralization and net mineral loss of the teeth leading to irreversible breakdown. Caries requires both the presence of the microorganisms and the availability of carbohydrate.3 Other contributing risk factors include oral hygiene habits, presence of oral appliances or braces, medical conditions, salivary flow and content, medications, and dietary habits.
TABLE 1: OTHER LABELS FOR SUGARS barley malt
fruit juice concentrate
malt syrup
beet sugar
corn syrup solids
brown sugar
date sugar
cane sugar
grape sugar
evaporated cane juice
high-fructose corn syrup
carob syrup
invert sugar
corn syrup
fruit juice
sorghum syrup turbinado sugar
starch and glycogen are made up of longer chains called polysaccharides. These complex carbohydrates have less of a cariogenic effect. Numerous forms of the simple sugars are used in food manufacturing, and labeling for sugar can be overwhelmingly complex. All forms of sugar can be found in the ingredient lists, but there are many names for sugars that may be difficult to recognize by the consumer. See Table (1) for
TABLE 2: PROPERTIES OF SUGARS AND SUGAR SUBSTITUTES Nutritive value (calories/g)
Natural sugars
Sugar substitutes Sugar alcohols/polyols Sorbitol
Aspartame (NutraSweet, Equal)
Saccharin (Sweet 'N Low)
Sucralose (Splenda)
Acesulfame potassium (Sunett)
Non-nutritive artificial sweeteners
Natural Chrysanthemum Family Herb Stevia (Truvia, PureVia)
*Sucrose (table sugar) is the standard for sweetness comparison and is given the sweetness value of "1."
a detailed list. Ultimately, these are all forms of sugar that do have a cariogenic insult potential on the teeth.
The sugar alcohols or polyols (such as xylitol, sorbitol, mannitol, and maltitol) are used in foods as sweeteners and thickeners. They can be found as a sugar substitute in some "diabetic" foods because they have less of an effect on blood sugar than other sugars. As they are not extremely sweet and as they can cause stomach upset (bloating, diarrhea) when consumed in large amounts, artificial sweeteners are often used and included in the product as well. Sugar alcohols have been demonstrated to be noncariogenic. Polyols used in combination can reduce caries, but xylitol appears to take the lead in effectiveness.4 Most of our dietary sugars and polyols consist of a 6-carbon monosaccharide unit, but xylitol has a unique 5-carbon structure.5 Xylitol disrupts the processes of energy production by Streptococcus mutans, leading to bacterial cell death. With adequate consumption levels of xylitol (6-10 grams daily), bacterial levels are reduced.6 The resulting bacteria exhibit reduced adhesion to the teeth and other reduced virulence properties such as less acid protection. Dosing frequency of xylitol should be a minimum of two times a day. Xylitol can be found in some brands of chewing gum. Thus, xylitol can be beneficial and other sugar alcohols do not promote a cariogenic insult on the teeth.
Artificial sweeteners are food additives that add a sweet flavor to foods, but have minimal calories. The artificial sweeteners that are approved for use in the United States are aspartame, sucralose, neotame, acesulfame potassium, and saccharine. Stevia is an approved non-caloric sweetener that is derived naturally. They are used in diet drinks, cereals, sugar-free products such as ice creams and yogurts. Artificial sweeteners also do not promote a cariogenic insult on the teeth. See Table (2) for summary.
educated choices. Our role as health care professionals is to perpetuate accurate information to our patients, colleagues, and friends. A "sweet" treat does not have to cause negative dental consequences.
1. Marshall, TA. Preventing dental caries associated with sugarsweetened beverages JOURNAL OF THE AMERICAN DENTAL ASSOC> 144(10):1148-1152, 2013. 2. Loesche, WJ. Role of Streptococcus mutans in human dental decay MICROBIOL. REV 50: 353-380, 1986. 3. Orland, FJ. Bacteriology of dental caries:formal discussion, JOURNAL OF DENTAL RESEARCH 43:1045-1047, 1964. 4. LY, K; Milgrom, P; and Rothen, M. Xylitol, Sweeteners and Dental Caries PEDIATRIC DENTISTRY 28: 2 :154-163, 2006. 5. Trahan, L. Xylitol: a review of its action on mutans streptocci and dental plaque –its clinical significance. INT DENT JOURNAL 1995;45 (suppl1): 77-92. 6. Dean, J; Avery, D; and Mcdonald, R. DENTISTRY FOR THE CHILD AND ADOLESCENT (MOSBY ELSEVIER , Missouri, 2011) 177-181. 7. Guideline on xylitol use in caries prevention PEDIATRIC DENTISTRY REFERENCE MANUAL Volume 35, Number 6, 171-173, 2014. 8. Position of the Academy of Nutrition and Dietetics: Use of Nutritive and Nonnutritive Sweeteners. J Acad Nutr Diet. 2102;112:739-758.
AUTHORS Randy Ligh is a private practitioner for Pediatric Dentistry in San Jose, CA, 408/286-6308. Claire Saxton is a clinical dietician at Kaiser Santa Clara Medical Center in Santa Clara, CA, 408/569-1551. Joe Fridgen is a private practitioner for Pediatric Dentistry in San Jose, CA, 408/286-6315.
The choices for something "sweet" are varied and complex. The effects of different types of sweeteners on our dental health have been discussed and, hopefully, this knowledge will lead us to make informed and
What does the ICD-10 delay mean for physicians? The ICD-10 compliance date will be delayed by at least one year, based on a provision in a federal law signed in April that pushes the date to no sooner than October 1, 2015. It is unclear at this time how this unexpected delay will impact the health care industry, which has been feverishly working to prepare for the transition to the new code sets, previously scheduled for October 1, 2014. The International Classification of Disease tenth revision (ICD-10) is a system of coding created in 1992 as the successor to the previous ICD-9 system. ICD-10 will include new procedures and diagnoses, which United States Department of Health and Human Services (HHS) hopes will improve the quality of information available for quality improvement and payment purposes. For many, particularly smaller physician practices who were struggling to meet the October 2014 deadline, the delay is a welcome one. Some industry stakeholders, however, have already invested a lot of time and
money to prepare for the transition and are worried that the delay will make an already costly and complicated transition even more so. What everyone does agree on is that HHS needs to provide more clarity about the new law. Among the questions the California Medical Association (CMA) is hearing are: • Will the Centers for Medicare and Medicaid Services (CMS) offer a dual use period during which either code set can be used? • Is CMS considering skipping ICD-10 and instead implementing ICD-11, which is scheduled to be released in 2017? • Should practices continue training and testing as planned? Or should they suspend all such activities until they receive further guidance from CMS? CMA is closely monitoring the situation and will provide additional information as it becomes available. (CMA Alert, April 7, 2014 issue)
Are you using Windows XP? You may need to upgrade Physician offices using Windows XP should be aware that Microsoft will no longer be providing support for Windows XP after April 8, 2014. This means that updates, bug fixes, security patches, and troubleshooting will not be available for systems operating Windows XP, making such systems vulnerable to security risks. While the California Medical Association (CMA) has received concerns from physicians who are being told that they will be in "automatic violation of the Health Information Portability and Accountability Act (HIPAA)" for using Windows XP after April 8, the HIPAA security
rule does not specifically mandate any minimum operating system requirements. Physician offices using Windows XP, however, should be aware that continuing to use an unsupported operating system without the proper maintenance in place to protect electronic patient health information (PHI) increases their risk of security breaches. The HIPAA security rule requires a security management process, which means the development and implementation of policies and procedures to prevent, detect, and correct potential risks and vulnerabilities to electronic PHI. An unsupported operating system should
be identified as a risk and physician practices using Windows XP should conduct a risk assessment to determine the appropriate measures to reduce any risks to electronic PHI, including upgrading to a more current, supported operating system. For more information, see CMA On-Call document #4102, "HIPAA Security Rule." OnCall documents are available free to members in CMA's online health law library at www.cmanet.org/cma-on-call. (CMA Alert, April 7, 2014 issue)
Paid family leave coverage expanded Beginning on July 1, California's paid family leave (PFL) program will be expanded to provide benefits to workers who take time off of work to care for a seriously ill parent-in-law, grandparent, grandchild or sibling. This change was prompted by the passage of Senate Bill 770, which was signed into law by Governor Brown on September 24, 2013. Currently, PFL is only available to workers who take time off of work to care for a seriously ill child, parent, spouse or registered domestic partner, or to bond with a minor child. Eligible individuals can receive up to six weeks of PFL within a 12-month period. 36 | THE BULLETIN | MAY/JUNE 2014
Physicians are also reminded that they can now certify claims for PFL and disability insurance online via the state's new electronic claim filing system, State Disability Insurance (SDI) Online. The system allows physicians, claimants, and voluntary plan administrators to submit claims and other supporting documents online. For more information on PFL, see California Medical Association On-Call document #6203, "Family and Medical Leave." On-Call documents are available free to members in CMA's online health law library. (CMA Alert, April 7, 2014 issue)
HHS develops toolkit to help physicians prepare for online communication with patients The California Health and Human Services Agency (HHS) has developed a toolkit to help medical practices prepare for online patient communications through an electronic health record (EHR) portal, personal health record, mobile app, secure messaging, or other electronic means. Data indicates that patients who use health information technologies may be more efficient users of health care resources, better managers
of their health behaviors, and feel more satisfied with the health care system. The free toolkit, "Preparing for Online Communication with Your Patients," provides checklists and worksheets to help offices collect and organize information needed to create an effective plan for online patient communications. It also provides materials that can be given directly to patients including, a letter that can be customized to explain the medical
practice's electronic communication services; a brochure about electronic communication with physicians; and a video explaining the benefits of communicating online with their health care providers. Go to http://www.ohii.ca.gov/calohi/content.aspx?id=162 to download the toolkit. (CMA Alert, April 7, 2014 issue)
HHS releases security risk assessment tool to help providers with HIPAA compliance The U.S. Department of Health and Human Services (HHS) has released a new tool to help guide health care providers in small- to mediumsized practices conduct information security risk assessments of their organizations. The tool, available at www.HealthIT.gov, is the result of a collaborative effort by the HHS Office of the National Coordinator for Health Information Technology (ONC) and Office for Civil Rights (OCR). It is designed to help practices conduct and document a risk assessment in a thorough, organized fashion at their own pace by allowing them to assess the information security risks in their organizations under the Health Insurance Portability and Accountability Act (HIPAA) Security Rule. The tool also produces a report that can be provided to auditors. HIPAA requires organizations that handle protected health information to regularly review the administrative, physical, and technical safeguards they have in place to protect the security of the information. By conducting these risk assessments, health care providers can uncover po-
tential weaknesses in their security policies, processes, and systems. Risk assessments also help providers address vulnerabilities, potentially preventing health data breaches or other adverse security events. A vigorous risk assessment process supports improved security of patient health data. Conducting a security risk assessment is a key requirement of the HIPAA Security Rule and a core requirement for providers seeking payment through the Medicare and Medicaid EHR Incentive Program, commonly known as the Meaningful Use Program. The tool is available for both Windows operating systems and iPad. Download the Windows version at http://www.healthit.gov/providersprofessionals/security-risk-assessment. The iPad version is available from the iTunes App Store (search "HHS SRA tool"). For more information, see CMA On-Call document #4102, "HIPAA Security Rule." On-Call documents are available free to members in CMA's online health law library at www.cmanet.org/cma-on-call. (CMA Alert, April 7, 2014 issue)
Medicare Advantage plans to see a modest increase in payments The Centers for Medicare and Medicaid Services (CMS) announced in April that Medicare Advantage plans would see a 0.4% boost in payment rates for 2015. This small payment boost is a change from CMS's February proposal that would have reduced Medicare Advantage plans' payment rates by 1.9%. This announcement comes on the heels of new data that predicts falling Medicare costs due to healthier baby boomers aging into the system. Healthier beneficiaries in Medicare have led to a downward drop in risk adjustment for the program. CMS has also proposed an improved risk adjustment methodology to account for patient's health status (severity of illness) and demographics. Plan bids will be based on these criteria. Along with this modest payment increase for Medicare Advantage
plans, CMS announced that it plans to discontinue a three-year quality bonus demonstration project that shielded some plans from cuts required by the Affordable Care Act. CMS also said it will limit how much Medicare Advantage plans are allowed to increase beneficiaries' premiums in 2015. This proposal limits these increases to the equivalent of $32 per month annually in 2015, down from $34 in 2014. With Congress's recent passage of a bill that will update California's outdated Medicare localities, the Medicare Advantage rates in the 14 affected counties will see an even greater increase because the rates are partially built on the Medicare fee-for-service rates. (CMA Alert, April 21, 2014 issue) MAY/JUNE 2014 | THE BULLETIN | 37
Anthem accidentally overpays some physicians Anthem Blue Cross recently notified almost 8,500 practices of a claims pricing error that caused some physicians to be paid for services provided to individual/exchange patients at Anthem's higher Prudent Buyer PPO rates. In the April 9 notice to physicians, Anthem states it had been applying "discounted rates inconsistently" on claims for dates of service January 1 through March 31, 2014. According to the payor, the error was cor-
rected effective for dates of service on or after April 1, 2014. While not mentioned in the notice, Anthem has advised the California Medical Association that it will not attempt to recoup the overpayments that resulted from this error. Questions can be directed to Anthem Blue Cross Network Relations at 855/238-0095 or email@example.com. (CMA Alert, April 21, 2014 issue)
Study: California physicians account for $160+ billion in economic impact and almost 1 million jobs California's 85,943 patient care physicians fulfill a vital role in the state's economy by supporting 983,990 jobs and generating $162.6 billion in economic activity, according to a new report by the American Medical Association (AMA). The report notes that given the changing health care environment, it is paramount to quantify the economic impact physicians have on society. To provide lawmakers, regulators and policymakers with reliable information, the report measured the economic impact of California physicians according to four key eco-
nomic barometers. • Jobs: Each physician supported an average of 11.45 jobs and contributed to a total of 983,990 jobs statewide. • Output: Each physician supported an average of $1.9 million in economic output and contributed to a total of $162.6 billion in economic output statewide. • Wages and Benefits: Each physician supported an average of $1.03 million in total wages and benefits and contributed to a total of $88.071 billion
in wages and benefits statewide. • Tax Revenues: Each physician supported $90,814 in local and state tax revenues and contributed to a total of $7.81 billion in local and state tax revenues statewide. The AMA study looked at physicians who engage in patient care activities, as opposed to those who focus on research or teaching. To view the full report and an interactive map of the United States, please visit www.amaassn.org/go/eis. (CMA Alert, April 21, 2014 issue)
Anthem mistakenly lists almost 1,000 physicians as participating in individual/ exchange network Anthem Blue Cross recently notified 965 physicians that they were erroneously listed as participating in the payor's individual/exchange network. The April 9 notice states that affected physicians were "inadvertently" listed for "a certain period of time" during open enrollment. After receiving a number of complaints from physicians who believed they were listed inaccurately as participating in the Anthem Blue Cross individual/exchange network provider directory, the California Medical Association (CMA) contacted Anthem to discuss the matter. At that time, Anthem acknowledged the error and said that affected patients had already been notified. At CMA's urging, Anthem agreed to also notify affected physicians. According to Anthem, affected physicians were paid at 100% of Pru38 | THE BULLETIN | MAY/JUNE 2014
dent Buyer PPO rates for affected dates of service between January 1 and March 31, 2014. However, claims for dates of service on or after April 1, 2014, will be reimbursed as out-of-network. Anthem notified affected patients who had seen an out-of-network physician that they would need, by March 31, to either select a new innetwork physician or change to a different plan in which that physician participates or face higher out-of-pocket costs. The patient notice also advised them of their right to request continuity of care with the out-ofnetwork physician. Questions about the error can be directed to Anthem's Network Relations Department at 855/238-0095 or firstname.lastname@example.com. (CMA Alert, April 21, 2014 issue)
Pledge your commitment to protect MICRA With less than 200 days left until the 2014 general election, the California Medical Association (CMA) is working hard to educate every physician in California about the efforts underway to defeat the trial lawyer-backed anti-MICRA ballot measure. Ensuring that each and every California physician understands the importance of our state's landmark Medical Injury Compensation Reform Act (MICRA) remains one of CMA's top priorities. The ballot measure being pushed by trial lawyers would increase health care costs for everyone in California and decrease access to care – which is why such a broad coalition of doctors, community clinics, health centers, hospitals, and other health care providers are opposed to the initiative. The effect on our health care system would be devastating, limiting access to care for those who need it most, at a time when millions of newly insured patients are entering the health care system. CMA and the campaign to defeat the anti-MICRA measure need each and every one of you to help spread the word and educate your colleagues about the critical importance of MICRA. To that end, CMA has developed a MICRA Commitment Card.
In addition to asking physicians to pledge their "no" vote on the antiMICRA measure, the cards also provide physicians with the opportunity to volunteer as "Hospital Coordinator," a position which will prove instrumental to the campaign by helping organize and educate fellow physicians about the ballot measure. The commitment card can be completed online at www.cmanet.org/ micra (click on "Join the Fight" in the left sidebar). You may also request hard copies of the cards to distribute to your colleagues, by contacting CMA at 916/551-2567 or email@example.com. With less than 200 days until the election, every day must be viewed as a new opportunity to defeat this dangerous, costly ballot measure. We already know that our opponents will spend these next 200 days attempting to further deceive the public about their measure's true intentions. We must continue to inform voters that this initiative would be costly to taxpayers and hugely detrimental to health care in California. For more information about MICRA and what you can do to help in the fight, visit www.cmanet.org/micra. (CMA Alert, April 21, 2014 issue)
CMA supports medical board efforts to address prescription opioid misuse In an effort to support the Medical Board of California's current review and update of the board's Guidelines for Prescribing Controlled Substances for Pain, the California Medical Association (CMA) Council on Scientific and Clinical Affairs recently completed an extensive review of existing opioid prescribing guidelines and has published a white paper that summarizes their findings, titled Prescribing Opioids: Care amid Controversy. The paper was produced by a panel of physician experts, who conducted a review of current literature, existing clinical guidelines, and expert opinion in order to present an up-to-date, clinically relevant overview of opioid prescribing practice. The paper is written by physicians
for prescribers to provide a balanced clinical perspective and updated guidance, as the medical board considers revisions to its guidelines. The paper addresses a variety of topics related to pain management, but is focused on the use of opioid analgesics to treat chronic pain. It is intended neither as an exhaustive review nor a standard of care, but rather summarizes established methods for appropriately prescribing opioid analgesics. "The California Medical Association appreciates the Medical Board of California's recent efforts to address issues related to prescription drug misuse. We agree that now is an important time to review the board's Guidelines for Prescribing Controlled Substances for Pain and
have been involved in the discussion led by the board's Prescribing Task Force," said Richard Thorp, MD, CMA president. "We hope that the board and the Prescribing Task Force will find Prescribing Opioids: Care amid Controversy to be a useful resource, as we believe the information will help ensure appropriate controlled substance prescribing in California." Prescribing Opioids: Care Amid Controversy complements the June 2013 CMA report, "Opioid Analgesics in California: Relieving Pain, Preventing Abuse, Finding Balance," which focused on legislative and policy aspects of opioid prescribing. Both resources are available in CMA's online resource library at no charge. (CMA Alert, April 21, 2014 issue)
IMQ Judicial Review Service Announcement IMQ has introduced a new Judicial Review Service to refer credentialed physicians for service on judicial review panels. In the case of certain disciplinary actions, physicians are entitled by California law to a fair hearing by their peers, and this service helps hospitals meet that requirement by providing qualified, independent panelists to hear evidence regarding the quality of care provided by particular physicians. Hear-
ings are scheduled in a variety of California locations and typically last three to five consecutive days. Additionally, IMQ is recruiting physicians to serve as panelists. The physicians selected by IMQ as possible candidates to serve on Judicial Review panels must hold an unrestricted California medical license and be either in active practice in California or retired from active
medical practice for no more than two years. Physician panelists will be paid an hourly rate of $250, plus travel and meals. For additional information on IMQ's Judicial Review Service or on becoming a physician panelist, please contact Leslie Iacopi (liacopi@ imq.org or 415/882-5167).
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2395 Montpelier Dr #5, San Jose 95116. Rent $2,000 per month. Lease required. Owner pays triple net and monthly H/O dues. Two doctors set up. Three examination rooms. Approximately 1,100 sq. ft., furnished or unfurnished, adequate parking, walk to Regional Med Ctr. Close to X-Ray and lab. Previous tenant doctor retired. Call Marie at 408/268-2040.
Beautiful medical office across from Palo Alto Medical Foundation. Professional office with vaulted ceilings, new interior, digital x-ray, natural light, and Wi-Fi. Trained receptionist to
schedule patients, make reminder calls, collect paperwork and insurance info. Rent exam room one to five days per week, excellent office – low overhead. Call 650/814-8506.
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Rent/Buy/or Option to purchase 2,000 sq. ft. office with minor surgical suite in first class building within walking distance of El Camino Hospital. Full service lease, with or without furnishings. Call 650/961-2652.
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Our occupational medical facilities offer a challenging environment with minimal stress, without weekend, evening, or "on call" coverage. We are currently looking for several knowledgeable and progressive primary care and specialty physicians (orthopedist and physiatrist) interested in joining our team of professionals in providing high quality occupational medical services to Silicon Valley firms and their injured employees. We can provide either an employment relationship including full benefits or an independent contractor relationship. Please contact Rick Flovin, CEO at 408/228-0454 or e-mail email@example.com for additional information.
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Midmark Power 100. Very good condition; little used. Tan/dark brown. Includes stirrups, 30 cloth exam gowns and drapes. $195. Pick up in Palo Alto. Contact Alan Brauer, MD at 650/329-8001 or email at drbrauer@ totalcare.org.
2014 Physician Membership Resource Directory ORDER YOUR COPIES TODAY! There are a lot of updates and changes in the new 2014 edition. Make sure to order enough copies for you and your staff! Contact Maureen Yrigoyen at 408/998-8850 today!
Help Create an AIDS-Free Generation Include routine HIV testing for all patients, regardless of their risk status, starting at age 13. HIV screening is recommended for all patients in all healthcare settings. Persons at high risk for HIV infection should be tested at least annually. For more information and to view a video on how to incorporate routine testing into your practice, please scan the QR code or visit http://bitly.com/bundles/prxinc/2.
Multidisciplinary Treatments for Fibromyalgia By Paul Davidson, MD, FACR Dr. Davidson, a retired rheumatologist, is the author of Chronic Muscle Pain Syndrome, a bestselling book on fibromyalgia. Reprinted by Permission of the Marin Medical Society My interest in fibromyalgia syndrome (FMS) began when I was a fellow at the Mayo Clinic training in internal medicine and rheumatology from 1957 to 1960. At that time, FMS was generally known as fibrositis, but the syndrome was later named fibromyalgia because of the lack of any findings of inflammation. Most physicians at the time (and many to this date) considered it a "wastebasket diagnosis." My perspective is that FMS is not really a disease (manifested by both signs and symptoms), but rather a somatoform disorder (manifested only by symptoms). As of this writing, there are no physical or laboratory findings that allow us to make a firm diagnosis of FMS. The syndrome is diagnosed almost entirely by symptoms and a tender-point examination, which is often inconsistent. Whatever you wish to call FMS – a disease, a somatoform disorder, or a psychosomatic disorder – it can vary from a mild to a very debilitating condition. Empathetic physicians can be quite helpful in treating this enigmatic disorder. Let me address some basic questions regarding FMS.
A typical case may be illuminating. The patient, B.J., was a 26-year-
old newly married secretary working in a law firm. She complained of generalized muscle pains and stiffness, neck and low back pain, chronic fatigue, poor sleep, paresthesias, headaches, frequent urination, and irritable bowel symptoms – all increasing for the past six months. She was depressed and anxious "because of my pain." She had formerly been a trainer at a gym, but was now working hard in the law office for up to 50 hours a week. She had no time to get any significant exercise. B.J. had an extensive workup with her internist, including a history, a physical exam, an arthritis panel, muscle enzymes, thyroid studies, Lyme and parvovirus titers, and MRIs of the cervical and lumbar spines. The results were all negative, except for a minimally positive RA factor and normal ESR and anti-CCP tests. She seemed unusually tender in many body points, but her muscle strength was good. She was referred to specialists in neurology, neurosurgery, gastroenterology, endocrinology, urology, and rheumatology. None found any pathology to account for her symptoms. Despite the lack of any joint swelling, the rheumatologist's diagnosis was "probable early rheumatoid arthritis." She was treated with Plaquenil, NSAIDs, analgesics, muscle relaxants, antidepressants, narcotics, and even a brief course of prednisone. She did not improve. In fact, she felt worse. B.J.'s first physical therapy visit increased her pain, and she had to go to bed for three days. Her medical bills were mounting; she took more time off work; she was getting depressed; she asked to be put on disability. Meanwhile, her internist was becoming very, very frustrated. Her pains
were considered to be an "industrial injury" and were reported as such. Her internist then became embroiled in an endless round of paperwork with the workers' comp carrier and her attorney. The internist's thoughts began drifting to taking a long vacation in Hawaii. Spurred by these thoughts, he got another rheumatology opinion. The second rheumatologist got more history from B.J. and learned that she hated her boss and her job. She had no time to exercise. Her major concerns, beside her symptoms, were the specter of permanent disability and the effects on her marriage. Her joint examination was normal. Her new diagnosis was classical and early FMS. She was given information on FMS and a two-month medical leave from work. She was also told to stop all medications, gradually get back to her previous exercises, and return in a month. B.J. called back three weeks later, laughing, and cancelled the appointment. Asked why, she said she was back to normal, had quit her job, was getting more exercise, and might go back to being a physical trainer. B.J.'s case is illustrative in many aspects. First, the excessive number of referrals to other physicians and the delay in diagnosis is not unusual. Second, not getting a history of her lack of exercise and the stress of her work situation played major roles in the delay in diagnosis. Third, her unusually rapid recovery was most surely due to her understanding of the basis of her illness plus the resolution of her legitimate concerns regarding chronic disability and the subsequent strains on her marriage.
Any physician who has a basic knowledge of the symptoms of FMS and is a good listener should do fine, whether it's a family physician, an internist, or a rheumatologist. A referral to a rheumatologist can be helpful if the primary care physician is concerned about another disorder, such as rheumatoid arthritis, lupus, polymyalgia rheumatica, or Lyme disease. If the rheumatologist does not "believe" in FMS, avoid him or her. Too often, the non-believer will not recognize FMS developing in a patient with an associated rheumatic disease and will treat every symptom with potent medications that can make things worse.
I firmly believe that a family physician or internist who has the disposition to work with the patient could do as well or better than a rheumatologist. The primary care physicians probably have a better understanding than the specialist of the total physical and emotional state of the patient.
A multidisciplinary approach to treatment has been the most effective and is now generally accepted. In my book Chronic Muscle Pain Syn-
drome (1989), I advocated a program that I named RETRAIN, as summarized below. R is for Rest and Relaxation. Most FMS patients are under stress from a number of causes, such as family, work, and poor health. The method of R&R (they are two different things) will depend on understanding what stresses exist. E is for Education. There are many good (and bad) basic books and articles that can offer the patient understanding and guidance. My guideline is that if a patient feels worse after reading certain information, they should ignore it. The same goes for support groups. Some are excellent. Others, as one patient told me, are just "pity parties" and should be avoided. T is for Therapeutic Muscle Training. Many studies have shown that the muscles are normal in FMS. A good physical therapist can guide a patient through exercises that start slowly and gradually increase without creating additional discomfort. R is for Responding to Stress. First, the origins of the stress must be uncovered, since the patient may be unaware of the origins or loath to discuss them with you. If the patient is not responding, a referral to a psychologist or psychiatrist is probably in order. Psychotherapy or cognitive behavioral therapy may be of benefit and can serve as a key to improvement. A is for Analgesics and Other Medications. Medications such as acetaminophen and NSAIDs generally do not help FMS, and narcotics should be avoided. Trazodone or amitriptyline (may cause weight gain) in small doses at bedtime should be the first choice since they have relatively few side effects and are inexpensive. A host of other medications have also been used for FMS, the most popular being the SSRIs and the SSNRIs. They are more expensive and generally have more side effects, including weight gain. In my experience, the incidence of positive results is pretty similar with all of these medications – about 30%. I is for Involvement and Alternative Therapies. If the patient is not personally involved in his or her therapy, you are probably fighting a losing battle. Many alternative therapies can be very helpful and do not require a doctor's prescription. Choices include tai chi, Feldenkrais, yoga, and meditation. See the sidebar for more information on tai chi, which has become one of my favorite alternative movement therapies. N is for Never Give Up Hope. No matter how severe your patients' symptoms are, there are many paths to relief. Many patients have informed me that their FMS is "cured," despite some naysayers who are convinced that it never goes away. If these patients have no symptoms, they are presumably cured. You may find that your FMS patients are some of the most grateful in your practice! Email: email@example.com
Tai chi for fibromyalgia Tai chi is a Chinese body-mind movement exercise, based on the martial arts, that goes back hundreds of years. Research has shown that it promotes balance control, flexibility, and cardiovascular fitness. It also lessens the risk of falls in elderly patients and in those recovering from stroke and other conditions. According to estimates, tai chi's gentle, low-impact movements burn more calories than surfing and nearly as many as downhill skiing. A recent study published in the New Eng-
land Journal of Medicine found that "tai chi may be a useful treatment in the multidisciplinary management of fibromyalgia. Longerterm studies involving larger clinical samples are warranted." [Wang C, et al, "A randomized trial of tai chi for fibromyalgia," NEJM, 363:743754 (2010).] In my opinion – which is probably shared by many millions of people around the world –I doubt if further studies of tai chi are needed before trying the technique. Tai chi has been
shown over the centuries to be helpful in many patients, so why not just try it? It is non-invasive and harmless, with no apparent side effects, and the cost to learn is relatively inexpensive compared to the cost of many medications. The most popular form of tai chi is the Yang style. YouTube has many great videos of this particular style; they are a pleasure just to watch. A superb and widely available DVD is "Simplified Tai Chi Chuan" by Master Liang, Shou-Yu. MAY/JUNE 2014 | THE BULLETIN | 45
We Celebrate Excellence – Corey S. Maas, MD, FACS CAP member and founder of "Books for Botox®" community outreach program, benefitting the libraries of underfunded public schools
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