July/August 2012

A Publication of the San Mateo County Medical Association

July/August 2012 | Volume I /No. 6

56582 (7/12) ©Seabury & Smith, Inc. 2012

AR Ins. Lic. #245544 • CA Ins. Lic. #0633005 • d/b/a in CA Seabury & Smith Insurance Program Management777 South Figueroa Street, Los Angeles, CA 90017 • 800-842-3761 • [email protected] • www.CountyCMAMemberInsurance.com

Marsh is sponsored by: Underwritten by:

id you know that CMA/San Mateo County Medical

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Please call a Client Service Representative at 800-842-3761 today. The process is simple and fast.

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“My premium savings was over $1,900! What a great member benefit. All Society members with employees should get a quote. It was so easy to do.”

Philip R. Delio, M.D. Neurology Associates of Santa Barbara

SAN MATEO COUNTY PHYSICIAN | PAgE 3

The San Mateo County Medical Association’s newest community service program, Walk with a Doc, still needs your help in terms of promoting this free physical activity opportunity among your patients or taking part in the walks themselves.

As you may know, the Walk with a Doc program gives members of the general public an opportunity to walk with physicians and ask general questions about health and the benefits of physical activity. We have now hosted two walks and are specifically looking for physicians who may be willing to further promote this program among their patients through posting flyers about the upcoming walks in your office/exam rooms or emailing information about the walks to your patient email database.

You can also still volunteer as a physician walker! We conduct Walk with a Doc every other Saturday, with walks coming up on September 8th and 22nd as well as October 6th and 20th. Physician Walk with a Doc volunteers will walk with participants for approximately an hour at a pace determined by the community residents.

To learn more about helping SMCMA with Walk with a Doc promotion or becoming a Walk with a Doc volunteer, contact Whitney Wood at (650) 312-1663 or [email protected].

The walks have been taking place at the Sawyer Camp Trail (Crystal Springs Rd & Skline Blvd entrance), but future walks are scheduled in such sites as downtown Half Moon Bay, Bay Trail, Long Ridge and Coal Creek as well as downtown Redwood City, starting at the Historical Museum.

We look forward to additional SMCMA members helping out with this great program! Happy Walking!

SMCMA SErvICES

San MateoCounty PhysicianJuly/August 2012

Vol. I / No. 6

Table of Contents

President’s Message..........................5

Executive Report................................7

Distinguished Service Award Recipient.................................8

Embrace the Natural Color of Your Skin...............................9

For Better or For Worse....................10

Mandated Disease Reporting Requirements...................12

Travelling with Diabetes.....................13

Membership Update and Classified Ads..................................18

Walk with a Doc Program Still Needs Your Help...

56582 (7/12) ©Seabury & Smith, Inc. 2012

AR Ins. Lic. #245544 • CA Ins. Lic. #0633005 • d/b/a in CA Seabury & Smith Insurance Program Management777 South Figueroa Street, Los Angeles, CA 90017 • 800-842-3761 • [email protected] • www.CountyCMAMemberInsurance.com

Marsh is sponsored by: Underwritten by:

id you know that CMA/San Mateo County Medical

Association members can save 5% on their workers’

compensation insurance? And, they may save even more than

that, up to 15%, depending upon their group medical carrier.

It’s true. CMA/SMCMA members receive a 5% discount on

workers’ compensation insurance policies provided through

Employers Compensation Insurance Company. This discount is

available exclusively through Marsh/Seabury & Smith Insurance

Program Management, the CMA/SMCMA sponsored broker

and administrator.

Rather than guess what your savings can be, take a moment to

contact Marsh and let us show you how we can deliver a quality

insurance program and exceptional savings to you.

Please call a Client Service Representative at 800-842-3761 today. The process is simple and fast.

Let us show you...how your membership in the CMA/San Mateo County Medical Association can save you money.

Visit: www.MarshAffinity.com/download/59778.pdf

D

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“My premium savings was over $1,900! What a great member benefit. All Society members with employees should get a quote. It was so easy to do.”

Philip R. Delio, M.D. Neurology Associates of Santa Barbara

About the Cover: The photo was taken by Poppy Richie. Poppy is the wife of SMCMA’s Controller, Jim Richie. It was taken at Filoli.

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Campaign Financing

PrESIdENT’S MESSAgE

BY gREgORY LUkASzEWICz, MD

In our political system, money has always talked. And now, since the Supreme Court’s 2010 landmark ruling in Citizens United v. Federal Election Commission, money is speaking louder than ever. The Court’s ruling has essentially overturned the McCain Feingold campaign finance reform regulations. It now allows unlimited political expenditures by groups and organizations such as unions and corporations to be protected as free speech, which cannot be restricted by the federal government under the First Amendment. In fact, the Supreme Court reinforced this ruling this June by striking down a century old Montana state campaign finance law. We are seeing the results of the Citizen United ruling most commonly in political attack ads, whether aimed at a candidate or a specific issue, often supported by an anonymous donor or group of donors. Unfortunately, the opportunity for individuals or groups with deep pockets to flood the public with truths, half-truths and even lies threatens to undermine the democratic process as individuals will have difficulty discerning reality from fiction in the onslaught of mailings, television and radio advertisements and billboards.

Nowhere has this been more apparent than here in California in the case of Proposition 29, the $1 a pack proposed cigarette tax. On June 21st, approximately two weeks after Prop 29 came before the voters, the Yes on Prop

29 campaign conceded that they had lost by a margin of 50.3 to 49.7 percent of the votes counted to date. What is most telling is that Prop 29 went down to defeat despite the fact that 67 percent of the likely voters who were polled in May prior to the election supported the cigarette tax. However, opponents of Prop 29, supported by big tobacco companies and led by Philip Morris, spent over $47 million dollars (compared to $12 million raised by supporters of the proposition and led mainly by public health groups). These funds were spent on radio and television ads as well as an onslaught of mailings that were able to erode support for Prop 29 over the course of a month before the election, eventually defeating it in the polls.

What does this mean for physicians? I would suspect that for many physicians the role of money in the political process is extremely distasteful. We have prided ourselves on the use of facts, scientific data and clinical evidence to treat our patients. We naturally assume that the truth should prevail. Unfortunately, this does not appear to be enough. It means that to remain relevant in the political process and to make our voice heard, we need to stay organized. Though we may find the role of money and wealth in the political process disheartening, the reality is that physician organizations have played this game at the very highest levels. Between 1998 and 2012, the American Medical Association spent $269,507,500 on its lobbying efforts,

second only to the US Chamber of Commerce, which spent $857,015,680. In terms of donations to the two political parties, the AMA was 17th on the list of top donors to the Democratic and Republican parties between 1998-2012 as well, spending $28,200,557 over 15 years. To put things into perspective, other major donors include the American Federation of Teachers, goldman Sachs, Citigroup, the National Association of Realtors, ActBlue (an independent political action committee, which acts to bundle donations for Democratic candidates and committees), Microsoft and the Teamsters - to name just a few examples. I would recommend checking out the lists of donors at Opensecrets.org. It makes for some very fascinating, surprising and enlightening reading.

How to reconcile our highest ideals about our profession and caring for patients with the reality of modern politics, is the question. While we should not ignore the role that money plays in the political system (and has been used by our organizations to promote our interests), we also need to recognize that our profession still has great moral authority. By maintaining a common voice, focused on the larger issues of individual health, as well as the health of our community and society as a whole, we make ourselves heard - not because we pour more money into the debate but rather because we seek to do what is right and just.

PAgE 6| SAN MATEO COUNTY PHYSICIAN

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EXECUTIvE rEPOrT

One-Half Cent County Tax InitiativeBY SUE U. MALONE

In July, the SMCMA Board of Directors met with Seton Medical Center representatives’ Sister Arthur gordon, Vice President of Mission Services, and Jim Schuessler, Interim CEO, to discuss a proposed San Mateo County one-half cent sales tax Initiative. Seton Medical Center is particularly interested in this initiative as they hope to receive revenue derived from passage of the initiative in order to fund Seton’s retrofit due to the state mandated seismic upgrades that must be made to the hospital by 2020.

The SMCMA Board was asked to support placing the tax initiative on the ballot. The Board was not asked at this time to support the tax initiative itself. The SMCMA Board voted to support placing this initiative on the ballot for the electorate to decide. On July 24 I spoke at a Board of Supervisors hearing expressing SMCMA support for placement of the initiative on the ballot.

The private hospital’s closure would have a huge impact on the San Mateo Medical Center since Seton provides a significant amount of care for the no and low-income population that lives in the northern portion of the county. Seton has been faced with the challenge to continue serving its patient population, of which 35 percent are Medi-Cal/Heath Plan of San Mateo recipients, with Medicare patients

representing a large percentage of the remaining number. Without outside financial assistance Seton states that they will not be able to continue their inpatient facility. It is primarily for this reason that the county is willing to entertain providing financial support for the seismic upgrade.

The county Board of Supervisors voted to place this 10-year sales tax initiative on the November ballot by a 4-1 vote. Supervisor Dave Pine voted against the initiative countering with a quarter-cent increase which was not favorably received by the other Board members. If passed, the sales tax is expected to generate $60 million annually.

The ordinance passed by the county Board of Supervisors identifies “general fund purposes” as beneficiaries of the new tax. The Board resolution identities a litany of potential facilities/services that could benefit from passage of the one-half tax initiative, such as child abuse prevention, 911 dispatch, fire prevention, after-school programs, library reading/homework programs, keeping parks open, and maintaining seismically safe hospital/emergency departments (which includes anticipated funding to replace Seton Hospital/emergency department).

While we believe the sales tax initiative to support, among other things, the seismic update at Seton Medical Center

is worthy of a decision by the voters, I am concerned that the county Board of Supervisors is required to identify the tax increase as a tax for general fund purposes. Obviously, this leaves an opportunity for the Board (which will not be composed of the same members that just voted to place the measure on the ballot) an opportunity to fund programs that were not even discussed during the Board hearings when the vote was taken to place the measure on the ballot. I am in no way disparaging the county Board of Supervisors, but no one knows what may befall the county by the time the “new” money is available.

There is also the issue of Ascension Health Alliance, the nation’s largest Catholic and nonprofit health system, that in March entered into a Memorandum of Understanding (MOU) with the Daughters of Charity Health System (DCHS), for the Daughters to become part of Ascension Health. The Daughters is a regional health system that includes Seton Medical Center. Ascension is the Nation’s largest Catholic and nonprofit health system. It is expected that a definitive agreement between the two health systems will be finalized by year end. When that happens, one would assume that Ascension would be asked to help fund the Seton retrofit.


attorney, Bill Ingram, who asked him to take over 78 malpractice cases that he could not address, being newly appointed as a Superior Court Judge. It was in taking over cases for Mr. Ingram when his career fully transitioned to defending doctors.

Ed handled 150 to 200 cases that were tried to verdict and worked on thousands that were settled outside of a trial. When asked what motivated him to continue this type of work, he stated, “The challenge of the work kept me going and that I knew I was assisting fellow professionals. Helping balance the scales has meant a lot to me, personally.”

He was also extensively involved in the passage of MICRA legislation and helping to establish two doctor-owned insurance companies, deeming these professional experiences as his most challenging. “There were so many divergent viewpoints and there weren’t that many examples of doctor-owned insurance companies at that time,” he explained.

Ed also earned a reputation for representing physicians before the Medical Board of California and in hospital staff issues.

Additionally, Ed mentioned the number one piece of advice that he would give to physicians, after decades of medical legal work, “To sum it all up, document, document, document.” Physicians live and die by what is in the medical record,” he adamantly explained. He also reminds doctors of the issues that are arising with documentation in the electronic medical record (EMR) age.

The Association honored Edward A. Hinshaw, J.D. with its 2012 Distinguished Service Award, recognizing his 40+ years of service defending physicians who have called on him to assist them in governmental entity defense, administrative defense, and medical malpractice defense.

He retired on July 1 from his post as senior and managing partner of Hinshaw, Marsh, Still & Hinshaw.

“A friend to doctors,” as many call him, was born in 1937. He attended the College of the Pacific (now University of the Pacific) on an athletic scholarship for competitive swimming and water polo. He pursued a degree in Physical Education, also coached other athletes and took numerous science and human anatomy classes. This scientific education later assisted him in understanding the thousands of medical record charts in his work with physicians.

His law education began at the University of California, Hastings College of the Law in 1959, but was interrupted during his second year when he was drafted into the military. After he got out of the service, he moved back to the Bay Area and continued his legal education at Santa Clara University School of Law, graduating in 1963.

There were influential mentors along the way that guided Ed towards a legal career in the medical field. He first obtained an internship during his third year of law school with an attorney named Austin Warberg. This internship provided his initial experience in the medical legal field with a practice that represented hospitals in the Bay Area. He helped Mr. Warberg prepared 23 cases for trial. A little later on, Ed had the opportunity to work with another

Edward A. Hinshaw Receives Distinguished Service Award

“Physicians have a tendency to use pre-programmed language that the EMR provides. It is crucial that doctors be extremely diligent to add unique information to a patient’s electronic record, not using template or copying and pasting information from another medical record.”

Along with the impending electronic medical record challenges, Ed offered other hurdles that can obstruct the future of health care. He explained that many health care stakeholders are attempting to address health care issues one at a time. “We have to have an intelligent conversation as to how these complex issues influence each other, rather than attempting to address issues in isolation,” he added.

With these many impressive years of service to physicians, Ed humbly explained that his biggest accomplishment is receiving a simple “thank you” from the doctors he has worked with. Upon receiving the Distinguished Service Award, Ed respectfully added, “I see this award as a way of the Association saying thank you to me and that means a great deal.”

Left to right: Edward A Hinshaw, JD, SMCMA President Gregory Lukaszewicz, MD and Past President, James Missett, MD

SAN MATEO COUNTY PHYSICIAN | PAgE 9SAN MATEO COUNTY PHYSICIAN | PAgE 9

New Seton CEO, Jim Schuessler, with David Goldschmid, MD and Robert Tseng, MD.

SMCMA Board Member, Amita Saxena, MD (left) takes some time to connect with Mills-Peninsula’s Chief of Staff, Lorraine Massa, MD

New SMCMA Secretary-Treasurer, Vincent Mason, MD poses with SMCMA Board Member, Kristen WIllison, MD.

John Hoff, MD (left) chats with San Mateo County Supervisor, Dave Pine (right).

SMCMA President, Gregory Lukaszewicz, MD presents Alberto Bolanos, MD with an acknowledgement of his tenure as a member of 2011-12 SMCMA Board.

Robert Benner, MD catches up with Michael Norris, MD.

Celebrating SMCMA Events2012 Annual Meeting of Members

A Special Thank You to our Annual Meeting Sponsors: NORCAL, Mutual Insurance Company, MARSH, Gilead Sciences, Palo Alto Medical Foundation, Mills-Peninsula Health Services, Sequoia Hospital, Seton Medical Center/ Seton Coastside, The Permanente Medical Group, Redwood City, The Permanente Medical Group, S. San Francisco, Hill Physicians Medical Group


use of tanning beds increases melanoma risk by 75% and just four visits increase the risk by 11%. Melanoma rates are up across the board, but especially among women under forty. They are eight times more likely to get skin cancer now than they were in 1970.

Many people who use tanning beds say that they do so to obtain a ‘base tan’ prior to the summer or a vacation. Dark skin provides greater protection from UV damage than light skin due to a higher constitutive pigmentation but what photoprotective benefit, if any, is afforded by a tan induced by UV exposure? Tanning beds emit predominantly UVA which causes DNA damage through the formation of free radical mediated oxidative injury. One study repetitively exposed human skin to suberythemal doses of UVA and/or UVB over 2 weeks, after which a challenge dose of UVA and UVB was given. The skin that had been exposed to UVB had mild protection from DNA damage but no protective effects were seen in UVA tanned skin. UVA-induced tans seem to result from the photooxidation of existing melanin with redistribution of pigment granules, while UVB stimulates melanocytes to produce more melanin and increases pigmentation coverage. Thus, UVA tanning contributes essentially no photoprotection. Exposure to all types of UV light, however, result in DNA damage, which can eventually lead to photocarcinogenesis and photoaging.

Fortunately, the state of California recently banned the use of tanning devices by minors and other states are following suit. Recent investigations have shown that even spray tans composed mostly of DHA may pose

More than half of all people still believe they look healthier and more attractive with a tan, according to a recent study conducted by the American Academy of Dermatology (AAD). While the sun has been worshipped since the beginning of time as a source of visibility, warmth, health and vitality, ancient civilizations also appreciated the adverse effects that too much sunlight could have on their skin. Tanned skin looked weathered and became associated with the poor who had to work outdoors. The sun was shunned by the gentry of ancient Rome, who used lead based paste to whiten their faces. Porcelain white skin was desired until the end of the Victorian era and women routinely wore elaborate hats and carried parasols to protect themselves. In the 20th century as people moved from the farm to the factory, being tan meant one could afford oceanside vacations and engage in outdoor sports. The term “healthy tan” was born when lack of sunlight was linked to rickets. Coco Chanel popularized tans in 1923, when she returned to Paris with golden brown skin after a Riviera vacation on the Duke of Westminster’s yacht. By the 1970s an entire generation was turning to vegetable shortening, baby oil and aluminum foil to literally fry themselves during the summer months. The indoor tanning industry took off in 1978 when people discovered they could have this “healthy” glow all year round. Currently, more than 30 million people visit tanning salons each year and there are more tanning salons than Starbucks in many large cities.

In 2009, the WHO elevated tanning beds to the highest risk category--carcinogenic to humans--alongside arsenic, asbestos, and nitrogen mustard. Recent data show the regular

BY JANET MALDONADO, MD

Embrace the Natural Color of Your Skin

some carcinogenic health risk, especially if inhaled.

Here are some tips to protect you and your patients’ skin this summer: 1) Wear a wide brimmed hat and UV protective sunglasses. 2) Wear broad spectrum UVA/UVB protective sunscreen that is labeled waterproof if you plan to be in and out of water. 3) Seek shade during peak hours of sun. 4) Apply sunscreen 30 minutes prior to sun exposure although sunscreens containing zinc and titanium do provide immediate protection. 5) Reapply sunscreen every two hours.

Choosing a sunscreen can be confusing, but help is on the way. The FDA has created new regulations for sunscreen manufacturers that should go into effect by the end of 2012. To briefly summarize, sunscreens with an SPF of 15 or higher will be able to claim protection against skin cancer and photoaging, while anything less can only help prevent sunburn. Sunscreens will not be able to use the terms ‘waterproof’ or ‘sunblock’ as these claims overstate the effectiveness of the products. A water resistant sunscreen will now have to indicate whether it remains effective either 40 or 80 minutes after water exposure. Sunscreens can not claim to provide sun protection for more than two hours without reapplication. Most importantly, sunscreens can only be labeled broad spectrum if they have passed the FDA’s ‘broad spectrum test’ ensuring adequate UVA protection.

Hopefully with the recent pushes made by the FDA and California to protect and educate the public, we will begin to embrace the natural color of our skin.

Dr. Maldonado is a Dermatologist and practices in

Burlingame.

SAN MATEO COUNTY PHYSICIAN | PAgE 11SAN MATEO COUNTY PHYSICIAN | PAgE 11

Almost every physician attended two four-hour sessions of communication training. The topics included how to listen to patients and demonstrate empathy, how to include patients in decision making, how to deal with difficult patients (e.g. “be curious and not furious”), and how to be efficient. We hired actors so physicians could practice by role-playing. The administration at SSF kaiser was extremely supportive to physicians so that these trainings could be done during office hours.

Other early projects of the Health and Wellness Committee included establishing physician support groups, finding space and equipment for a mini-gym in the hospital, launching reward and recognition programs, designating a photo display wall for retired physicians, inaugurating an annual dinner for physicians and spouses, and setting up a doctors’ dining room. (The dining room perished quickly because physicians had little time to utilize it so it became converted to a storeroom.)

As the SSF Physician Health and Wellness Committee evolved over time, additional activities have been added to help physicians create balance in their lives. We have roving massage therapists, Sunday basketball games, lunchtime yoga and tai chi, physician diversity and communication skill training, family baseball games, self defense for women physicians, luncheons for physician moms of young children, docent-led museum tours, physician-led hikes, a program to encourage volunteering, and lunch time lectures devoted to physician health on topics such as physicians as patients

“To be a good doctor, you need to be married to medicine.” So began one of my instructors in the first year of medical school. If I understood him correctly, there were to be no other competing passions if one were to be a successful physician. A personal relationship might be considered polygamy. Maybe this is why I observed so many divorces and broken relationships among physicians who tried to balance work/life demands.

When I began my career at South San Francisco kaiser Permanente in 1981, I was not sure what to expect in terms balancing work and raising a family. My twin daughters were born just three weeks before I began my first day of work. I was disconcerted when I learned that no physician from the Department of Medicine had retired alive – and this was before the days of electronic records. It became one of my goals to be conscientious of my own health as well as to improve the well-being of my colleagues. After significant negotiation with the Physician in Chief, I organized a Well Being committee for physicians in 1982, followed by a Physician Health and Wellness Committee a few years later. The Well Being Committee dealt with Physician Impairment, and the Health and Wellness Committee attempted to help prevent burnout and to sustain physicians in their careers.

One of our initial projects of the Health and Wellness Committee in the early 1990’s was to improve the communication skills of physicians. Since doctors spend countless hours talking to patients, we felt this would improve the daily work experience.

BY JERRY SALIMAN, MD

For Better of For Worse

and how to deal with adverse outcomes. This summer there is also a wellness retreat for physicians and their families at Costanoa Lodge. As an organizer and participant in many of these activities, it has been rewarding to see my colleagues outside the clinical setting enjoying the camaraderie of the experience.

When physicians are healthier physically and emotionally, their patients receive better care and are more likely to pursue a healthy lifestyle. It seems that every successive year there are new demands and expectations placed upon us physicians – newer quality goals, Medicare coding requirements, keeping up with new medical information, and medical license requirements. Maintaining our own emotional and physical health is the only way to cope up with these demands. This needs to be a priority for ourselves so that we can deliver optimal care to our patients. My first year medical professor should have said, “To be a good doctor, you should be married to medicine AND strive for a balanced healthy life.”Jerry Saliman, MD, is a volunteer physician at Samaritan House in San Mateo. He founded the Physician Well Being and Physician Health Wellness Committees at SSF Kaiser Permanente, and recently retired. He can be reached at [email protected]

The current chair of the Physician Health and Wellness Committee at SSF Kaiser is Dr. Yvonne Ong. She can be reached at [email protected]


“every patient 14 years of age or older, when a physician and surgeon has diagnosed a disorder characterized by lapses of consciousness in a patient,” (dmv.ca.gov/pubs/vctop/appndxa/hlthsaf/hs103900.htm) Title 17, section 2806, describes lapses of consciousness (LOC) as those conditions that involve:

• Marked reduction of alertness or responsiveness to external stimuli

• Inability to perform one or more activities of daily living, or

• Impaired sensory motor functions used to operate a motor vehicle.

• Examples of these conditions include:

• Loss of consciousness (e.g., syncope, hypoglycemia)

• Seizures

• Dementia, including Alzheimer’s disease and other dementias (e.g., post-CVA, brain neoplasm)

• Conditions such as sleep apnea and narcolepsy where they interfere with driving.

Physicians are protected from liability with good-faith reporting for these and other conditions they feel interfere with safe driving. In fact, physicians have had judgments against them for failure to report when drivers with these conditions had subsequent motor vehicle crashes. Physicians do not need to report former drivers who are unlikely to drive again (admitted to long-term care facility, severely impaired, coma, etc.), or when there is documentation in the chart that the patient has been reported previously and you believe they no longer operate a motor vehicle.

Practicing physicians are mandated to report a number of conditions to their local Department of Health Services (DHS); the list of reportable conditions in California has been recently updated and can be found at www.cdph.ca.gov/HealthInfo/Pages/ReportableDiseases.aspx. Compliance is less than ideal, despite potential sanctions against physicians for not reporting. Of importance to note is that some of the conditions must be reported within the hour of diagnosis, others within a day, and the rest within a week. guidance is provided by the icons (phone, fax, etc.) that precede the diagnosis on the list.

The California Department of Public Health provides forms by County for reporting communicable and noncommunicable diseases, and a separate form for tuberculosis use: http://www.cdph.ca.gov/HealthInfo/Documents/LHD_CD_Contact_Info.pdf. Do not assume that your laboratory will report for you; it remains the responsibility of the physician to report these diseases to the County. The DHS would rather have duplicates than lapses in reporting.

The noninfectious diseases that must be reported to DHS include lapses of consciousness, cancers, and pesticide-related illnesses. Lead poisoning is reported by laboratories, but DHS would welcome physician reporting as well. Compliance with reporting of noncommunicable disease has been even more problematic. This is at least partially due to the impaired understanding of the mandate and (unfounded) concerns about the protections afforded to reporting physicians.

The California Department of Motor Vehicles’ (DMV) reporting requirement,

BY LINDA LOUISE HILL, MD, MPH

Mandated Disease Reporting Requirements - A Roadmap

As stated above, noncommunicable disease including, lapses of consciousness, can also be reported on the CMR form. . The reported cases of lapses of consciousness are forwarded by the DHS to the DMV; however, simultaneous direct reporting to the DMV will result in timelier follow-up by the DMV. To report directly to the DMV, it is best to use the DMV’s Request for Driver Reexamination (DS699), which can be found at: dmv.ca.gov/forms/ds/ds699.pdf, but faxing the CMR form, or even using office letterhead, is acceptable.

Lapses in consciousness should be reported only when associated with an event in a patient who has an underlying condition likely to impair driving. Therefore, while a loss of consciousness due to diabetes-associated hypoglycemia is reportable, the loss of consciousness from an injury-induced mild concussion is not. Narcolepsy associated with somnolence during driving is reportable, but recumbent-only associated sleep apnea is not. Even mild dementia is reportable, but confusion post-operative is not.

The development of a reporting system and written protocols will improve compliance in your institution. The physician making the diagnosis is responsible for the reporting, whether in the emergency department or office. However, do not assume that another physician has reported, unless there is written documentation in the chart. Again, the DHS and DMV would rather have duplicate reporting than none at all. For example, if your epileptic patient had a seizure, was brought to the emergency department, and follows up

continued on page 15


the use of their meters and strips on board aircraft. Furthermore, not every airline has blood glucose testing equipment in the aircraft cabin medical bag. At altitude, there is reduced partial pressure of oxygen, with reduced oxygen availability. For blood glucose monitoring devices using glucose oxidase (gOX) as the strip enzyme, these systems are sensitive to the prevailing oxygen concentration while glucose dehydrogenase (gDH) based systems theoretically should be less affected as oxygen is not involved in the reaction pathway. Recently, we evaluated the performance of four new generation blood glucose meters at sea level and at a simulated altitude equivalent to that used in the cabin of commercial aircrafts and found that, overall, at simulated altitude, there were no differences in meter performance between gDH and gOX meters. Overestimation of blood glucose concentration was seen among individual meters evaluated but none of the results obtained would have resulted in dangerous failure to detect and treat blood glucose errors or resulted in giving treatment that was actually contradictory to that required. Others have also reported that the effect of altitude on blood glucose meter precision is less significant when temperature and relative humidity are adjusted for (3).

For insulin pump users, there are suggestions that the effect of travelling in a commercial airplane, per se can impact on safe travel. Following anecdotal reports of changes in insulin delivery using an insulin pump as cabin pressure falls following take off, king et

In 2010, nearly 37 million US citizens travelled abroad. Assuming a prevalence of diabetes of 8%, this equates to more than 3 million overseas travellers with diabetes (1). Unfortunately about 10% of travellers with diabetes may encounter significant problems during travel, mostly due to hypoglycaemia. Also delays causing late meals have also been identified as being a particular problem (2). Although concerns about maintaining safe and acceptable levels of blood glucose control during a trip should not prevent people with diabetes from travelling, in routine clinical practice a requirement for insulin can influence a traveller’s choice of holiday destination. Unfortunately, advice given by health care providers can be conflicting and often lacks specific details for the individual asking for help. For example, for travellers with diabetes wishing to travel overseas by air there are potential hazards to consider:

• Preparation for the journey (e.g. what to pack, having appropriate insurance and the need to take medical authorisation letters)

• Dealing with the demands of modern airport security

• The impact of crossing time zones

• Unfamiliar environments and food at the destination

• Concerns about becoming unwell far away from home or the loss of essential diabetes-related equipment and medicines.

As an example, most manufacturers of blood glucose monitoring equipment do not provide specific advice regarding

BY DAVID kERR, MD

Travelling with Diabetes

al reported that on ascent 1.0-1.4 extra units are delivered and gas bubbles appeared when pressure fell by 50 mmHg (4). Whether this change in insulin delivery is sufficient to cause hypoglycaemia is, however, debatable but warrants further investigation.

Several societies have published guidelines regarding the do’s and don’ts around travel and diabetes. The author has also created a free on-line service for travellers with diabetes including a “flight calculator” which contains guidance on the frequency and timing of blood glucose testing and insulin injections (www.VoyageMD.com). A particular challenge for travellers with diabetes and those using insulin in particular is dealing with the nuances of airport security. The advice provided on VoyageMD.com is from the United States Transport Security Administration, but is suitable for airport security in most countries.

Travelling across time zones and insulin

As a basic rule of thumb, travellers with diabetes should be encouraged to test blood glucose levels every 4-6 hours. For short trips where the time difference is 3 hours they should stay on their insulin regimen. In contrast, long-haul journeys need to think about the time zones, the effects of journey fatigue and how long they are away.

Flying East to West

• If the traveller takes fast-acting insulin with each meal they should continue to do so on board the aircraft and once they arrive at their destination.

continued on page 17


with you the next week, you should report the incident if you don’t see documentation of reporting in the emergency department records. Similarly, if a patient with dementia transfers to your care, you must report them to the DHS unless the prior records reflect notification in your state.

As mandated reporters, we are required to report lapses of consciousness, but we can reassure our patients that this does not equal the loss of one’s driving privilege, as only the DMV is authorized to make this determination. The DMV wants to hear about all reportable LOC, but makes a decision on each driver after conducting a thorough investigation that will include additional medical information, usually obtained through DMV form DS 326 (dmv.ca.gov/forms/ds/ds326.pdf), and may include interviews, vision and written exams, and on-the-road testing. In patients with mild dementia, for example, the DMV may determine that they are safe to continue driving for an abbreviated period of time, with close monitoring.

Identification of age-related driving disorders includes the screening and diagnosis of lapses of consciousness, frailty, vision deficits, and other medical conditions (e.g., use of medications that impair cognition) that influence driving abilities. AMA has provided guidelines for screening at www.ama-assn.org/ama/pub/physician-resources/public-health/promoting-healthy-lifestyles/geriatric-health/older-driver-safety/assessing-counseling-older-drivers.page. Of the disorders identified through this screening, only lapses of consciousness require reporting. keeping our patients and the public safe requires attention to driving safety, including compliance with noncommunicable-disease mandated reporting laws. More information on the physician’s role in older driver safety can be found on the TREDS website - treds.ucsd.edu.Dr. Hill is a member of the San Diego County Medical Society and is a Professor in the Department of Family and Preventive Medicine at UCSD, Director of the UCSD/SDSU General Preventive Medicine Residency, and the Director of TREDS (Training, Research, and Education for Driving Safety).

continued from page 12

Reporting Requirements

bonus by virtue of meeting the reporting requirements in 2013 to avoid the penalties in 2015.

• Multiple reporting options – Physicians have several reporting options under PQRS, including claims-based reporting, electronic medical records reporting, or registry reporting. Some physicians may also be able to choose between individual measures (more frequently reporting a smaller number of measures) and measure-groups (less frequent reporting of a greater number of measures).

• No enrollment required to participate – All physicians who accept Medicare Part B (fee-for-service) can participate in PQRS, and no enrollment is required. Simply transmit quality data to CMS through one of the three reporting options and Medicare will consider your transmission of such data as an indication of your participation.

• Reporting period is January 1st through December 31st – Physicians must meet PQRS reporting thresholds over a 12 month reporting period that begins on January 1st. While it may be possible to meet these thresholds by starting to report after January 1st, you will increase your chances of avoiding future penalties if you get started before the end of 2012.

Participating in PQRS

For details on how to start participating in PQRS, visit www.cms.hhs.gov/PQRS under their “Educational Resources” Section.

Other PQRS Information

Group Practice Reporting Option

For 2012, the group Practice Reporting Option (gPRO) is open to medical groups with 25 or more eligible professionals. group practices will report 29 quality measures on a certain number of consecutive patients, such as 218 for

Physicians who do not meet reporting requirements under the Physician Quality Reporting System (PQRS) in 2013 will be subject to a 1.5% Medicare reimbursement penalty in 2015. The 2013 reporting period begins on January 1st, so to avoid this penalty physicians are encouraged to begin participating in PQRS as soon as possible to familiarize themselves with the reporting process and increase the probability that they meet the reporting requirements in 2013.

There may be some slight changes for the 2013 reporting period that are not reflected in this article, but the core structure of the program will remain the same: physician practices report quality data to Medicare through claims, a registry, or an EMR system, and must meet certain reporting thresholds to avoid penalties and obtain incentives. In fact, for most physicians, the reporting process in 2013 will be no different from 2012.

PQRS in Brief

PQRS is a program of the Centers for Medicare and Medicaid Services (CMS) that began in 2007 (under the name Physician Quality Reporting Initiative). Some of the key aspects of PQRS that physicians should be aware of include:

• It’s no longer a voluntary program. Successful reporting in 2013 is required to avoid penalties in 2015 – CMS will begin imposing penalties in 2015 on physicians not meeting the reporting requirements in 2013.

• Financial incentives for reporting remain in place through 2014 – Physicians may earn a financial incentive of 0.5% of their total allowed Medicare charges for successfully reporting in 2012, 2013 and/or 2014. Bonuses earned for successful reporting in a given calendar year are paid in one lump sum the following calendar year. This means that physicians will simultaneously qualify for a 0.5%

Penalties for Not Participating in Medicare Quality Reporting Begin Soon

a group practice with 25-99 professionals, or 411 consecutive patients for group practices with 100 or more professionals. CMS will allow the “skipping” of patients for valid reasons, such as a beneficiary’s medical records not being found or not being able to confirm diagnosis. While this opportunity has passed for 2012, groups with 25 or more eligible professionals may wish to keep this option in mind for 2013.

Informal Appeals Process

For 2012, an eligible professional electing to utilize the informal appeals process must request an informal review within 90 days (used to be 60 days) of the release of his or her feedback report, irrespective of when the participant actually accesses their feedback report.

Validation Process if Less Than Three Measures Are Reported

For physician practices reporting fewer than three quality measures, CMS uses a “measure-applicability validation process” to verify whether a physician could have reported on additional measures before determining whether reporting requirements have been met. If CMS finds that 30 or more patients/encounters during the reporting period were eligible for quality reporting, then the physician practice will not have met the reporting requirements.

Financial Incentive Paid to TIN

PQRS payment will be made to the Taxpayer Identification Number (TIN) used by the reporting physician. Participating physicians within the same practice (using a common TIN) should expect to receive the physicians’ incentives in a lump sum. Likewise, physicians who see patients on behalf of more than one practice (and, therefore, use more than one TIN when submitting Medicare claims) should expect their PQRS payment to be made to the respective TIN under which the services were reported.This article has been reprinted with permission from the Alameda-Contra Costa Medical Association.


continued from page 13

Diabetes

• If they take background (basal) insulin twice a day they may need to swap round the morning and evening doses in the new time zone at their destination.

• If they are on once a day background (basal) insulin and the trip is short (3-4 days) they should take their insulin at the same time as at home or as near as possible. For longer trips travellers will need to move the timing of this injection to bedtime in the new destination.

Flying West to East

• If traveller takes fast-acting insulin with each meal they should continue to do so on board the aircraft and once they arrive at their destination.

• If they take background (basal) insulin twice a day simply swap round the morning and evening doses in the new time zone at their destination.

Using a once a day basal insulin

If the regimen is a once a day background (basal) insulin and the trip is short (3-4 days) travellers need to inject insulin at the same time as at home. For longer trips move the timing of this injection to bedtime in the new destination but they may need to reduce the dose as the day is shorter.

Using an insulin pump

Insulin pump users can simply change the clock on arrival at their destination for short trips with a time difference of less than 4 hours. For journeys with time zone changes of more than 4 hours adjust the pump clock by up to 4 hours towards the new time zone on departure and within 1-2 days set the pump clock to the new local time.

Using twice-daily pre-mixed insulin

If the traveller uses twice-daily pre-mixed insulin they should take their usual insulin before departure at the normal time. It makes sense to prescribe an insulin pen/vial ofrapid-acting insulin. If glucose levels rise above target values the traveller can give a small amount of this rapid-acting insulin every 4-6 hours (preferably with a meal) until it is time for their usual second injection of pre-mixed insulin in the new time zone after arrival.

Conclusions

Being prepared for a journey by planning ahead is likely to reduce the risk of serious events for any traveller with diabetes. Travel is never completely risk free but it should always be possible to for any person living with diabetes to enjoy the personal benefits of overseas travel without avoiding trips because of concerns about the risks involved.Dr. kerr is a physician and endocrinologist at the Bournemouth Diabetes and Endocrine Centre in South U.k.

1. U.S. Dept of Commerce Office of Travel and Tourism Industries. http://tinet.ita.doc.gov/tinews/archive/tinews2011/20110927.html

2. Burnett J. Long and short haul travel by air: Issues for people with diabetes on insulin. J Travel med 2006; 13: 255-260.

3. Olateju T, Begley J, Flanagan D and kerr D. Effects of simulated altitude of blood glucose meter performance. J Diabetes Science Technology 2012; July: (In Press)

4. Hirsch I. Hitting the dartboard from 40, 000 feet. Diabetes technology & therapeutics 2011; 13: 1-2

Save the Date - September 15, 2012

Membership BBQ

Come join the San Mateo County Medical Association for a

Membership Appreciation Barbeque

Bring your whole family for food, fun and games! This is a complimentary event.

Contact [email protected] for details and to register

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For Lease in San Mateo 34 N San Mateo Drive492’, 709’, 1637’, 1754’, or 2200’ available.Build to suitEmail: [email protected]

Russ granich, M.D., Chair Sharon Clark, M.D.Edward g. Morhauser, M.D gurpreet k. Padam, M.D.Michael Stevens, M.D

Sue U. Malone ............................................Executive Director Reina O’Beck .................................................Managing Editor

2011-2012 Officers & Board of Directors

gregory C. Lukaszewicz, M.D...................................PresidentAmita Saxena, M.D..........................................President-ElectVincent Mason, M.D.................................Secretary-TreasurerJohn D. Hoff, M.D...........................Immediate Past President

Raymond gaeta, M.D. Michael O’Holleran, M.D.Russ granich, M.D. Irwin Shelub, M.D.Edward koo, M.D. kristen Willison, M.D. C.J. kunnappilly, M.D. Chris Threatt, M.D.Michael Norris, M.D.

David goldschmid, M.D. ......................................CMA TrusteeScott A. Morrow..............Health Officer, County of San MateoDirk Baumann, M.D. .............................AMA Alternate Delegate

Article Submission

Members are always encouraged to submit articles, commentary and Letters to the Editor. Email your submission to the SMCMA Editorial Committee at [email protected] for consideration for publication in San Mateo County Physician.

For editorial or advertising inquiries, please use the contact information provided below.

Editorial and Advertising Offices

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Acceptance and publication of advertising in San Mateo County Physician does not constitute approval or endorsement by the San Mateo County Medical Association of products or services advertised. SMCMA reserves the right to reject any advertising.

Opinions expressed by authors are their own and not necessarily those of the SMCMA. San Mateo County Physician reserves the right to edit all contributions for clarity and length, as well as to reject any material submitted.

© Copyright 2012 San Mateo County Medical Association

Editorial CommitteeNew Members

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Jan Horn/ *gSSan Mateo

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Winnie kwan/ *PDS. San Francisco

Jin Lee/ *FMRedwood City

Sandra Lee/ *PMRS. San Francisco

Jennifer Lin/*IM, *NEPRedwood City

Sapan Mody/ *FMRedwood City

Divya Namburi/ *IMS. San Francisco

Susan Nguyen/ *IMBurlingame

Place a classified ad for $40 for up to five lines for members and $75 for up to five lines for non-members. Contact SMCMA at (650) 312-1663 or [email protected].


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