November-December 2013

PhysicianS a n M a t e o C o u n t y

November/December 2013 | Volume 2, Issue 10

A publication of the San Mateo County Medical Association

Hypertension Control Over Two Decades

MICRA Under AttackHouse of Delegates

2013 Recap

Google Glass and the Surgeon

It’s Open Enrollment time for the San Mateo County Medical Association sponsored Group Dental program. This plan is designed to help you, your family and your

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Annual Benefi ts of $2,000 per person for dental care, using network providers ($1,500 if you use non-network providers).

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Low, calendar year deductible of $50 per person ($100 per calendar year maximum for families).

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Remember, the open enrollment period is available once per year. To be eligible for coverage, applications must be received during the special open enrollment period ending on

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This issue of San Mateo County Physician includes an update on the latest attack against MICRA, California’s landmark Medical Injury Compensation Reform Act, by CMA President Richard Thorpe, MD. Also inside, my Kaiser Permanente colleague, endocrinologist Marc Jaffe, MD, reflects on his two decades of experience working to keep patients’ blood pressure under control. Burlingame plastic surgeon Lorne Rosenfield, MD, writes about his

recent experience performing surgery using Google Glass, which is essentially an eyeglasses-like, Internet-connected, wearable computer. Finally, we include an update from the 2013 House of Delegates, which met in October and resulted in the adoption of 63 resolutions related to health care policy, medicine and patient care.

Editorial CommitteeRuss Granich, MD, Chair; Sharon Clark, MD; Edward Morhauser, MD; Gurpreet Padam, MD; Sue U. Malone, SMCMA Executive Director; Shannon Goecke, Managing Editor

Editorial and Advertising Inquiries

San Mateo County Physician is published ten times per year by the San Mateo County Medical Association. Members are encouraged to submit articles, commentary and letters to the editor. Opinions expressed by authors are their own and not necessarily those of the SMCMA. San Mateo County Physician reserves the right to edit contributions for clarity and length, as well as to reject any material submitted.

Advertising in San Mateo County Physician is a great way to reach out to the San Mateo County medical community. Classified ads begin at $40 (for up to five lines) for members. Acceptance and publication of advertising does not constitute approval or endorsement by the San Mateo County Medical Association of products or services advertised.

For more information, contact managing editor Shannon Goecke at (650) 312-1663 or [email protected].

Visit our website at smcma.org, like us at-facebook.com/smcma, and follow us at twitter.com/SMCMedAssoc.

SMCMA LeadershipAmita Saxena,, MD .....................................................................PresidentVincent Mason, MD ........................................................ President-ElectMichael Norris, MD............................................. Secretary- TreasurerGregory C. Lukaszewicz, MD........................... Immediate Past President

Alexander Ding, MD; Manjul Dixit, MD; Russ Granich, MD; Edward Koo, MD; C.J. Kunnappilly, MD; Susan Nguyen, MD; Michael O’Holleran, MD; Chris Threatt, MD; Kristen Willison, MD; David Goldschmid, MD, CMA Trustee; Scott A. Morrow, MD, Health Officer, County of San Mateo; Dirk Baumann, MD, AMA Alternate Delegate

Introduction | Russ Granich, MD

Physician

President’s Message | Issues Impacting Physicians in 2014 ......... 5

Amita Saxena, MD

MICRA Under Attack ........................................................................ 7

Richard Thorp, MD

Hypertension Control Over Two Decades: Perspectives from a Kaiser Permanente Physicians .................... 10

Marc Jaffe, MD

Google Glass and the Surgeon ..................................................... 13

Lorne Rosenfield, MD

House of Delegates Recap Recap ................................................. 15

CMA Staff

New SMCMA Members .................................................................. 17

Upcoming Events, Membership Updates, Classified Ads, ndex of Advertisers .............................................. 18

S a n M a t e o C o u n t y

n o v e M b e r / D e C e M b e r 2 0 1 3

© 2013 San Mateo County Medical Association

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NOvEMbER/DECEMbER 2013 | SAN MATEO COUNTY PHYSICIAN 5

President’s Message | Amita Saxena, MD

It’s almost 2014, and here in no particular order are the issues that I think will have an impact on all physicians, regardless of whether you may be a SMCMA member or not. They also represent areas in which the SMCMA and CMA are actively working on your behalf.

Threats to the Independent Practice Model

How do I count the many ways that independent and small group practices are under siege? Changing reimbursement models, healthcare exchanges, a lack of negotiating power with insurance companies, the high cost of providing services in urban areas such as San Mateo County, staffing problems, the high cost of EHR implementation, difficulty maintaining a robust primary care network outside of the large group setting, cash flow pressures…the list just keeps growing. SMCMA is working hard to compile a comprehensive list of resources to help independent and small group physicians navigate the storms ahead. Stay tuned for more details.

The Changing Role of Hospitals

Quality improvement and clinical integration are the buzzwords of the day, and the goal of insurers and physicians often center on keeping patients out of the hospital. If patients have fewer and shorter hospital stays, this will impact hospital finances, which in turn will effect hospital-based specialties first. And ultimately, the effect on hospital-based providers can trickle down to ambulatory care providers as well. Since no one seems to know exactly how all of this will play out, or how best to brace for all those changes, we will just have to wait and see how things unfold in 2014.

UHC Dropping about 2,250 Physicians, both Primary Care and Specialists

Medical Economics has been reporting on this story and its implications for physicians everywhere: United Healthcare was one of the first insurance companies to start dropping physicians from its network. UHC is dropping 15% of

physicians in 10 states by the end of 2014 due to “significant changes and pressures in the healthcare industry.” Most of the cuts target physicians in the Medicare Advantage Program. UnitedHealth chief executive officer Jack Larsen stated that “We are working to collaborate with a more focused network of physicians to help us provide higher quality and more affordable healthcare coverage to meet the needs of our members, and help them get more from their health plan benefits.” Two Connecticut medical associations won a temporary injunctive order against UnitedHealth hours before the insurer was set to drop thousands of physicians and patients from its rolls. The actions of UHC have the potential to impact physicians across the country if other insurers follow suit.

Enrollment in Healthcare Exchanges

We all know how bumpy the much-anticipated rollout of healthcare.gov has been, and as of this writing it’s still not clear whether the website’s problems have been resolved. Covered California, our state’s healthcare exchange, has been up and running and being billed as a success as of this writing. Covered California’s Board of Directors also declined to allow a one-year postponement of cancellation of insurance plans that do not conform to ACA guidelines. It will be interesting to see how many people actually sign up for insurance through the exchange.

ACA and Healthcare Reform

Most of us agree that the healthcare system in America needs to be fixed, but the problem is that most solutions bring their own set of unintended consequences. UHC has tried to drop more 2,000 physicians in 10 states, commercial insurers are raising rates in anticipation of increased utilization of resources, and states that declined Medicaid expansion may face hospital closures that will leave patients without any access to care….the ACA has set some unintended consequences in motion. As of this writing, the meaningful use Stage 2 attestation deadline has been pushed back for a year, the small business mandate has been pushed back, and the White House has suggested

Issues Impacting Physicians in 2014

6 SAN MATEO COUNTY PHYSICIAN | NOvEMbER/DECEMbER 2013

insurers delay cancelling existing policies for a year. All of this has created uncertainty in the healthcare marketplace, and I am sure that will bring its own set of consequences as well. Next year should be an interesting year indeed.

ICD-10 Implementation

What is ICD-10, you ask? The official definition is: the 10th revision of the International Statistical Classification of Diseases and Related Health Problems, a medical classification list by the World Health Organization. It seems that just when I finally figured out how to drive the old model of ICD-9, there is a new system with a lot more bells and whistles. I’m told this will allow for a great deal of specificity when billing and coding and describing what I do, and that the rest of the world already uses this system. I’m already stocking up on some ibuprofen for the headaches I’m going to get as I learn this brave new medical nomenclature.

Changing Reimbursement Models: Quality Initiatives, value based Purchasing

See “ACA and Healthcare Reform,” above. Unintended consequences…enough said.

Physician Shortage/Scope of Practice

There is a perfect storm brewing of changing healthcare payments, evolving healthcare delivery systems, and a shrinking pool of physicians. Some legislators have proposed increasing the scope of practice for physician extenders [such as PA’s, NP’s] as a solution. See earlier sections on “unintended consequences” and stay tuned to future SMCMA publications for updates.

MICRA Threat

The trial lawyers have put MICRA in their crosshairs, and the results are not pretty. They are mounting a campaign that is designed to obscure the truth while taking cheap shots against physicians. If there is only one issue you track in 2014, make it this one. We will need all hands on deck to repel this threat against MICRA. Don’t know the significance of MICRA? This is what Wikipedia says about MICRA: en.wikipedia.org/wiki/Medical_Injury_Compensation_Reform_Act.

I am one of the lucky physicians who have not had to deal with the pre-MICRA malpractice landscape. Looking at states that don’t have similar legislation, you can see a landscape that is not pretty for physicians, and many physicians have left those states because they couldn’t afford the malpractice insurance required to practice medicine in those states. None of us want to see anything close to that happen here in California. I urge you to read our updates, and consider contributing to SMPAC and CALPAC that is actively fighting this threat on behalf of all physicians in California.

But I don’t want to end on a negative note...it is the holiday season, after all! I wish all of you a very happy and healthy holiday and a very prosperous 2014. ■

President’s Message | Amita Saxena, MD

San Mateo Co. Medical Association06-18-09

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The fifth health plan accepting Covered California patients in San Mateo County is Kaiser Permanente.

Blue Shield of Calfiornia916-350-6738

Anthem Blue Cross855-238-0095

HealthNet800-641-7761

Chinese Community Health Plan415-956-8800, x3289


When trial lawyers announced earlier this year that they were working to scrap California’s Medical Injury Compensation Reform Act (MICRA), the California Medical Association (CMA) warned that the campaign would be riddled with lies, misdirection and below-the-belt shots designed to fool the public into thinking the trial lawyers’ efforts were anything more than an outright money grab.

Unfortunately, we didn’t know how right that warning would prove to be.

Since its passage, MICRA has been under near-constant attack from those who place the prospect of a higher payday above the overall health and well-being of California residents. While MICRA has repeatedly weathered the storm, the law is under siege once again. This time MICRA is facing the greatest threat yet, as trial lawyers aim to put more money in their own pockets at the expense of patients across the state.

Driven by greed and the promise of inflated attorney fees, California trial lawyers have renewed their fight to lift MICRA’s cap on speculative, non-economic damages, presenting ballot language that seeks to more than quadruple the maximum award for non-economic damages to roughly $1.1 million.

While trial lawyers have postured and threatened major action on MICRA before, this latest effort is made credible by the nearly $1 million the lawyers recently put into a ballot measure committee. The proposed ballot language, put forward by a trial lawyer front group inappropriately named Consumer Watchdog, was cleared by the Attorney General for MICRA opponents to begin collecting signatures to place the measure on the November 2014 ballot. Trial lawyers and their allies are bankrolling the proposed initiative.

With money on the table and signature gatherers on the street, it’s clear that MICRA opponents are serious about overturning the law in 2014.

If successful, these efforts would be devastating to California’s healthcare system. More meritless lawsuits will lead to

reduced patient access to our healthcare professionals--and fewer options for affordable, quality healthcare--especially in rural and underserved communities. With federal healthcare reform expanding coverage for millions of additional patients, California is already struggling to provide access to care for the neediest and most vulnerable patients. If this ballot initiative is successful, it will only make the situation worse: even longer lines in emergency rooms, extended waits for appointments with specialists and reduced access to women’s services. This measure will make healthcare professionals, including doctors, nurses and other providers, less accessible--not more accountable, as claimed by the trial lawyers.

A broad-based coalition of nearly 1,000 groups and organizations led by CMA--including doctors, nurses, dentists, hospitals, Planned Parenthood and community health centers and clinics, among others--has emerged to protect access to care across the state.

While the latest fight over MICRA has now taken its first steps toward the ballot box, CMA and its allies have already notched several key victories in this fight, and remain committed to defeating the initiative push in its entirety.

The Threat Emerges

The central intent of the proposed ballot language is nothing more than a thinly veiled money grab by California’s trial attorneys, who stand to make hundreds of thousands of additional dollars on every malpractice case should the cap be changed. However since most voters would not support that provision, the ballot language also calls for physician drug testing and a bolstering of the state’s Controlled Substance Utilization Review and Evaluation System (CURES).

Currently, MICRA protects patients involved in medical liability lawsuits by allowing unlimited economic compensation for any and all economic or out-of-pocket costs, including past and future lost income and earning capacity, all necessary medical care, as well as unlimited

MICRA UNDER ATTACKby RichaRd ThoRp, Md


punitive damages. Under MICRA, patients can also receive up to $250,000 for non-economic pain and suffering damages. This allows legitimate medical liability cases to move forward while discouraging lawyers from filing frivolous suits. MICRA also limits how much lawyers can take as payment, ensuring more money goes to patients, not lawyers.

The trial lawyers’ measure would not only nearly quadruple MICRA’s non-economic damages cap from $250,000 to $1.1 million--it would also triple the legal fees that lawyers receive.

While the trial lawyers get rich, everyone else pays. More lawsuits mean higher healthcare costs for everyone. An analysis by California’s former independent legislative analyst found that this measure would increase healthcare costs for consumers and taxpayers in California by nearly $10 billion annually.

Pandering in the Capitol

This fall, MICRA opponents also attacked the Capitol, where members of the Legislature were returning from their summer recess and preparing to begin the final legislative push for the 2013 session.

Knowing that legislation attempting to scrap MICRA would never survive the vetting process typical of a full session, opponents sought to find an author willing to use the so-called “gut-and-amend” action to avoid public scrutiny provided through the regular legislative process to push an anti-MICRA bill through the Legislature in the final days, or even hours, before the Assembly and Senate adjourned for the year.

In its effort to locate an author, as well as drum up opposition to MICRA, Consumer Watchdog began conducting daily mail drops featuring their “38 is too late” campaign to legislative offices. The canvassing project targeted physicians as being unsympathetic to their patients’ needs, and portrayed MICRA as a barrier to victims seeking restitution for medical malpractice. Nowhere in Consumer Watchdog’s literature did it mention that medical malpractice victims are entitled to unlimited economic damages--such as lost wages, earning capacity and medical expenses--under California law. Nor

did it mention that lawyers would stand to make more money should MICRA be overturned.

To combat this effort, CMA and a host of allies--including labor groups, public safety entities, allied healthcare professionals and municipal interests--inundated members of the Legislature with facts supporting MICRA’s efficacy, warning that altering the cap would adversely impact local governments, community clinics and insurance premiums for all Californians.

In the end, MICRA’s supporters emerged victorious, as trial attorneys were unsuccessful in getting anti-MICRA legislation introduced during the most recent session.

Cheap Shots and Scare Tactics

Shortly after being defeated in the state Capitol, MICRA opponents decided it was time to start playing dirty.

In late September, Consumer Watchdog distributed a mail piece featuring the names of hundreds of California physicians who it claims are afraid to “pee in a cup,” while also personally targeting CMA Past President Dr. Paul Phinney, asking what he had to hide by opposing the trial attorneys’ greed-fueled initiative to gut MICRA. Oddly enough, the trial attorneys’ mailer makes no mention of the proposed initiative’s attempt to nearly quadruple MICRA’s cap on non-economic damages and exponentially increase their fees, and sticks to the more voter-friendly provisions regarding substance abuse in the workplace.

The attack was a brazen one, illustrating that the state’s trial lawyers and their puppet organization, Consumer Watchdog, will stop at nothing to line their pockets through the inflated attorney fees that would be generated from MICRA’s cap being lifted.

These cheap shots continued, however, when representatives from Consumer Watchdog crashed CMA’s annual House of Delegates conference in Anaheim, hosting a press conference outside of the conference center before circling the streets with a video truck broadcasting the message that “doctors should pee in a cup.”

While these attacks may sting for those who are personally targeted, they also illustrate one fact--MICRA opponents are desperate.


In the months since trial lawyers launched their latest assault against MICRA, California physicians and other allies have rallied to MICRA’s defense at a near-historic rate. Funds are being raised at record numbers, and physician engagement with the issue grows every day. As a result, Consumer Watchdog and other MICRA opponents are stooping to new lows in an attempt to intimidate those who have come to MICRA’s defense.

These deceitful attacks by MICRA opponents will continue, and will get worse as the November 2014 election cycle ramps up. Physicians, however, must continue to advocate for MICRA and ensure that our patients and practices are not jeopardized by the greed of those who would like to see MICRA fall.

Rest assured, CMA will win this fight, but will need all physicians in order to do so. To find out how you can help, visit www.cmanet.org/micra today. ■

About the Author

Richard Thorp, MD, fACP, is the president of the California Medical Association, and has spent the past 38 years practicing General Internal Medicine in Paradise, California. He is the President/CEO of Paradise Medical Group, Inc., a physician owned multi-specialty primary care group incorporated in 2001.

TAlK TO YOUR PATIENTS AbOUT MICRA

Under the current law called MICRA, trial attorneys can sue for unlimited economic damages, unlimited punitive damages, and unlimited medical compensation in medical malpractice cases.

In addition to the jury awards for unlimited economic, punitive, and medical damages, MIRCA allows for jury awards up to a quarter million dollars in pain and suffering.

MICRA also sets limited on what attorneys can take as payment in lawsuits, so that more money can go to the patient and pay for medical bills instead of legal bills.

Now, special interests and trial attorney lobbyists are trying to change the law to increase the amount of money lawyers can take as payment in these cases, and make it easier to file more lawsuits.

More lawsuits and bigger payouts for a small group of trial attorneys means higher health care and insurance costs for patients, doctors, health clinics, hospitals and health care providers.

The Independent Nonpartisan Legislative Analyst states that if this effort passes, it would increase costs for California taxpayers by hundreds of millions of dollars annually.

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The CMA-led collation working to protect MICRA has published a patient education brochure to help inform California voters about the ballot initiative being pushed by trial attorneys. To win this fight, patients must also understand the fact that protecting MICRA goes hand-in-hand with protecting access to quality health care in California. The pamphlet can be distributed to patients during office visits and will be accompanied by talking points for physicians to ensure that any conversation regarding MICRA is about educating patients on the real impacts of the proposed ballot measure. If you would like copies of this brochure, contact the SMCMA at (650) 312-1663, or email [email protected] to request 50 free copies be sent to your office.


I remember when I first began my practice of medicine in 1993 in South San Francisco at The Kaiser Permanente Medical Group. Like many other new doctors, I was excited about my new job (my first real job), and I was eager to help my patients take better care of their health.

I was practicing in the early nineties, which was a time when we had many tools to take care of high blood pressure and we had dozens of medications to offer to our patients. I tried very hard to encourage my patients to make healthy lifestyle changes. Yet, like most other doctors in the United States, I was not very effective at getting my patients under good blood pressure control. In 1993, the national average was below 50% and that’s what I witnessed in my own practice - when a person with hypertension came to the office for any reason, more often than not the blood pressure was not controlled.

How could this be? We had the evidence from many large clinical trials demonstrating that high rates of blood pressure control were possible in a research setting. We had dozens of pills that could lower blood pressure. We knew what could (and too often did) happen when blood pressure was uncontrolled over many years, and we knew that many strokes and heart attacks were preventable. And yet despite this, and despite the efforts of many dedicated and devoted clinicians all over the country, most people in the United States had uncontrolled blood pressure.

So in 1999 I met with several other physicians in Northern California who also practiced in my medical group, Kaiser Permanente. We had several meetings and investigated the challenges that our patients and clinicians faced as we tried to control blood pressure. In 2000, we started a four part program to improve the care of people with hypertension, as we felt we could offer our patients a more effective way to manage their hypertension.

1 Hypertension Registry

In order to help our patients to get their blood pressure under control, we had to determine who these patients were. So a registry (a master list) was created by identifying hypertensive individuals using outpatient visit diagnosis codes, pharmacy data and hospitalization records. We validated the accuracy of the registry inclusion criteria through chart review of random samples of registry members. The registry started with 350,000 people and has grown to 650,000 today.

2 Evidence-based Hypertension Guidelines

Once we had identified the patients who needed help with blood pressure control, we felt we needed to determine the most appropriate treatment for them. We created and maintained a hypertension guideline based on current clinical evidence and updated it every 2 years. The

HyPERTENSION CONTROL OVER TWO DECADES

Perspective from a Kaiser Permanente Physician

by MaRc Jaffe, Md


guideline development team included primary care and specialty physicians as well as pharmacists and evidence-based methodologists. The guidelines were distributed in many forms, such as printed guideline documents, email updates, pocket cards, televised videoconferences, and in-person lectures.

3 Quality Performance Metrics

After we created a registry and had developed guidelines, we developed quality reports containing clinical information describing blood pressure control for everyone in the hypertension registry. We had a challenge before 2005 when we were not yet using an electronic health record. We felt that we could not wait for its arrival and implementation (the electronic health record was implemented starting in 2005 and completed in 2008), so we developed a temporary solution that allowed us to access our blood pressure data. We recognized that all clinic visits were associated with a paper coding form and doctors were in the habit of marking the “bubbles” for diagnostic and procedure-related codes. We modified the bottom of the form to include two new rows, one with six systolic blood pressure ranges and another with 6 diastolic blood pressure ranges. We used this “temporary” solution from 2001 until 2008, until we had a fully implemented electronic health record. After 2008, we used the blood pressure data compiled from the electronic record and no longer had to send in the paper forms, and that was the end of “blood pressure bubbles.”

We collected the blood pressure measurements and added other information (addresses, medications, laboratory results, other diagnoses, visit information, etc.). Medical center directors (with strict processes to assure confidentiality and data integrity) used the data to generate work plans for quality improvement processes.

A physician-led management team reviewed the quality performance of the medical centers and identified medical centers with superior performance. We contacted the teams at those sites in order to understand why these teams were successful, and helped these teams share their successful processes with the other medical centers using training sessions and email communications.

4. Practice effectiveness and practice efficiencies

After we had created a registry of patients, agreed on an evidence-based treatment plan, and developed a way to track our progress using quality improvement data, we went to work on helping doctors use these tools more effectively and efficiently.

In 2007 we created new type of follow-up visit as an alternative to the traditional visit with a physician. These visits were with a medical assistant, usually located on the primary care doctors’ medical station. Visits were usually scheduled two to four weeks after a blood pressure medication adjustment. Patients were not charged a co-payment for these visits. Typically, a medical assistant measured blood pressure and informed the primary care physician, who then directed treatment intensification and follow-up

care as needed. Medical assistants were trained using standardized materials and blood pressure competency assessments.

In 2005, we incorporated a single combination pill blood pressure medication (lisinopril-hydrochlorothiazide) into our evidence-based guidelines. This therapy was promoted by developing both patient and physician education materials such as email communications, printed materials, pocket card clinician tools, and highlighting this medication in the practice improvement regional meetings. From 2001 to 2009, the rate of lisinopril-hydrochlorothiazide prescriptions increased from less

I think back on those days in the late 1990s when uncontrolled blood pressure was the norm. At that time, blood pressure control rates of nearly 90% were unimaginable, yet now control rates like this seem within reach.

ContinueD...


About the Author

Marc Jaffe, MD, is an endocrinologist at the Kaiser Permanente Medical Group in South San Francisco. A graduate of Baylor College of Medicine, he is board-certified in Internal Medicine and Endocrinology, Diabetes and Metabolism by the American Board of Medical Specialties. Currently, he is Subchief of Endocrinology, Kaiser Permanente South San Francisco Medical Center; Clinical Leader, Kaiser Permanente Northern California Cardiovascular Risk Reduction and Program (PHASE Program); and Clinical Leader, Kaiser Permanente National Integrated Cardiovascular Health (ICVH) Guideline Development Group. He was the recipient of the SMCMA’s Distinguished Service Award in 2013.

than 20 to over 23,000 prescriptions per month. During this period, the percentage of angiotensin-converting enzyme (ACE) inhibitor prescriptions (dispensed as lisinopril-hydrochlorothiazide) increased from less than 1% to 27%.

In 2013, 20 years after I first started to practice in South San Francisco and a decade after implementing the hypertension program, the changes in hypertension care are easy to see. From 2001 to 2011, hypertension control in Kaiser Permanente Northern California has increased from 44% to 87%. Over approximately the same period of time, the rate of heart attacks have fallen 24% and death from stroke has fallen 42%. And in my own personal practice, I see the difference in hypertension control every day. Now when I see patients in my office, more than 4 out 5 have controlled blood pressure. I think back on those days back in the late 1990s when uncontrolled blood pressure was the norm. At that time, blood pressure control rates of nearly 90% were unimaginable, yet now control rates like this seem within reach. This was, and continues to be, a team effort - with thousands of physicians, pharmacists, nurses, mangers, data analysts, and others who work tirelessly to help our patients maintain healthy blood pressure levels. How far we’ve come in the past 20 years! ■

References

Jaffe MG, Lee GA, Young JD, Sidney S, Go AS. Improved blood pressure control associated with a large-scale hypertension program. JAMA. 2013;310(7):699-705.

Sidney S, Jaffe M, Nguyen-Hyunh M, Kushi L, Young J, Sorel M, Selby J, Go A. AHA 2012 Abstract 13610: Closing the Gap Between Cardiovascular and Cancer Mortality in an Integrated Health Care Delivery System, 2000-2008: The Kaiser Permanente Experience.

Yeh RW, Sidney S, Chandra M, Sorel M, Go AS. Population trends in the incidence and outcomes of acute myocardial infarction. N Eng J Med. 2010:;362(23):2155-65.

Physicians, Are You Submitting PQRS Measures?

Physician Quality Reporting System (PQRS) is a reporting program that uses a combination of incentive payments and payment adjustments to promote reporting of quality information by eligible professionals.

If you have not yet started reporting, the deadline to avoid a 1.5% fee schedule penalty in 2015 is fast approaching. There is still time to report at least one valid individual measure via claims for dates of service in 2013. There are many measures that only need to be reported once per reporting period (January 1 through December 31, 2013) that meet the requirement.

The Centers for Medicare and Medicaid (CMS) website serves as the primary and authoritative source for all publicly available information and CMS-supported educational and implementation support materials for PQRS: www.cms.gov/pqrs.

Remember, you cannot go back and add a measure code to claims already submitted.


“If you want something new, you have to stop doing something old.” This challenge by Peter Drucker has certainly been the battle cry of plastic surgery. In surgery, in order to “stop doing something old,” there usually needs to be a marriage of old surgical habits with technological innovation. One such innovation, Google Glass, could truly impact some of our age-old dynamics in the operating room.

This technological wonder is simple in concept but a powerhouse of potential. Google Glass is essentially a wearable computer, with an optical head-mounted display. Think of your car’s rear-view mirror, but instead of seeing what’s behind you, you see a computer screen, which you control with your voice. To continue the analogy, think of your car’s windshield, and imagine that everything you see can be transmitted wirelessly to anyone else, on any device, anywhere in the world.

When my son Michael, a student at Case Western Reserve University, applied and became one of only a few thousand Google Glass “Explorers” to receive the device this summer, I knew I would be testing it in my operating room at some point. When I started reading about the first European and American surgeons transmitting their surgery through Google Glass, I was prodded into action: I informed my son that, on his way back to college, his Google Glass would be “missing” from his backpack.

I chose an upcoming blepharoplasty as the prototype case because its seminal step, the pinch, could be completed within minutes and thus not strain this very beta technology. Michael and I made many a practice run in my operating room, simulating the transmission of a surgery through the online video conferencing application called Google Hangout. Although the dress rehearsal was successful, it did reveal some of the device’s shortcomings Because the camera’s angle of view is fixed at a decidedly anterior orientation, the surgeon must unnaturally hyper flex his or her neck in order to ensure the spectator sees

what the surgeon sees. Also, the video is of lower quality and can freeze up intermittently, regardless of the upload bandwidth. Despite these limitations I felt it would still be worth testing in vivo.

A patient was chosen and consented, and the residents at both UCSF and Stanford plastic surgery programs were invited to observe the world’s first Google Glass-streamed plastic surgery at precisely 3:00 p.m. Pacific Time on October 29th, 2013. Parenthetically, as we do with our patients, I ensured that the resident participants’ expectations were properly adjusted: this live stream would not be the high definition video we have all become accustomed to at our live surgery meetings.

As is so often the case with any “live” performance, on the day of the surgery, the AT&T internet went down in our town and the office computer failed to connect to the Google Glass. But, as with any well-planned surgery, my son and I had embedded redundancies in our plans: a back up hotspot using my mobile phone and an extra computer were at the ready in the operating room.

I conducted the facelift and upper eyelid portions of the surgery, leaving the lower eyelids for the appointed time of transmission. Meanwhile, my son, from his dorm room in Ohio, was primed to invite all the participants from his

GOOGLE GLASS AND THE SURGEON

Old Surgical Habits Meet Technological Innovation

by LoRne K. RosenfieLd Md

ContinueD...


HOD 2013Google Glass account and run tech mission control during this veritable “lunar launch.” When the hour arrived, the Glasses were carefully fitted over my readers, since there is actually no prescription “glass” within the device yet. With voice activation, the “rear-view mirror” computer screen sprung to life, hovering before me. I had placed a piece of a sterile 10/10 drape on the device’s side to allow me to utilize some additional touch-sensitive controls on its side arm, and wore a pair of noise cancelling Bose headphones to amplify my hearing since the Glass transmits sound by bone conduction. Then once all the participants’ images assembled one by one at the bottom of the Google Hangout screen, I torqued my neck into the extreme hyperextended position and proceeded to conduct the pinch portion of the surgery. I was informed, with great relief, that all systems were working flawlessly: the “Eagle had landed”!

To reflect on the potential medical benefits of this technology one can easily see that they will be myriad: Google Glass will break down the cost and logistical barriers to real-time transmission of surgery, which will benefit students and fellow surgeons alike anywhere in the world. Beyond this core utility, with the proper software, the surgeon will be able to use Google Glass, with its primarily hands-free attributes, to call up valuable information on the spot: the patient’s medical record, vital signs, laboratory results, scan and x-ray results, relevant anatomy/technical consideration, and so on. Additionally, the anesthesiologists and nurses in the room will be using the glass for similar purposes, accomplishing many tasks more efficiently and accurately, such as completing safety checklists, monitoring the patient’s vitals, and searching the patient’s medical record. Clearly, many of these benefits and more could benefit the physicians and other medical staff in the rest of the hospital, whether it be the patient ward, the ICU, or the emergency room.

As I write this, there are already several forward-thinking companies working on medical/surgical applications for Google Glass. Birmingham plastic surgeon Dr. Jim Grotting recently made me aware of an augmented reality two-way conferencing software for Glass developed by the University of Alabama. The technology is called VIPAAR,

or Virtual Interactive Presence in Augmented Reality. This software recently allowed a surgeon in Atlanta to “place” his hands within the wound of a patient at UAB and guide the surgeons as though he were assisting in person. Several other emerging companies are similarly on the road to developing health care applications for the device.

Obviously, as with all revolutionary information technologies, the great challenge will be to harness its enormous benefits while still respecting the privacy of both our patients and ourselves. On this point, I have great confidence that, as with other innovations in medical history, whether it was the first clandestine

anatomical dissections of cadavers or the initially very wary adoption of sterile techniques in the operating room, this advance will be similarly integrated into our medical system for the benefit of all. In fact, at the American Society for Aesthetic Plastic Surger (ASAPS) meeting in San Francisco in the spring, there will be an exciting panel, Innovation and Google Glass, to discuss these very issues.

In the meantime, more importantly, it is projected that

Google Glass will be for sale to the public for several hundred dollars by early next year. This imperfect technology is clearly “bleeding edge,” but I encourage all of us, as Drucker advised, to “want something new,” don a pair of these glasses, and help peer into our collective future. ■

As with all revolutionary information technologies, the great challenge will be to harness its enormous benefits while still respecting the privacy of both our patients and ourselves.

About the Author

lorne K. Rosenfield, MD, fACS is a plastic and cosmetic surgeon at Peninsula Plastic Surgery Medical Group in Burlingame. He is also an active clinical professor of plastic surgery at UCSF and Stanford University Medical Centers. He has published numerous articles on aesthetic surgery. For a video of Dr. Rosenfield’s surgery using Google Glass, please visit his website at www.drrosenfield.com.


More than 500 California physicians convened in Anaheim October 11-13 for the 2013 House of Delegates (HOD), the annual meeting of the California Medical Association (CMA). Each year, physicians from all 53 California counties, representing all modes of practice, meet to discuss issues related to health care policy, medicine and patient care and to elect CMA officers.

More than 90 resolutions were introduced and debated in reference committees on Friday, October 11. Over the next two days, the complete house met again to debate and vote on reference committee recommendations. A total of 63 resolutions were adopted. The following are summaries of some of the resolutions that were adopted as policy. (The full actions of the HOD are available to members at www.cmanet.org/hod.)

Increased reporting of immunizationsResolution 104-13

The delegates approved a resolution that encourages increased reporting of patient immunizations to the California Department of Public Health for purposes of vaccination, disease control and prevention.

HIv and STDs: Consent requirements for testingResolution 109-13

The delegates voted to support revision of HIV consent requirements to allow all health care providers to order a test for HIV when appropriate and to encourage routine HIV testing for all patients that are evaluated for other sexually transmitted diseases.

Graphic health warnings on tobacco productsResolution 115-13

Delegates called on CMA to support the use of graphic image labeling on cigarette and other tobacco packaging that warns of the health impact of smoking.

legal blood alcohol limit for driversResolution 118-13

Delegates endorsed the National Transportation Safety Board’s 2013 recommendation that the legal blood alcohol limit for operating a motor vehicle be decreased from .08 percent to .05 percent or lower.

HOD 2013

CMA delegates set policy at annual meeting


food insecurity screeningResolution 122-13

The delegates directed CMA to promote that providers need to identify children and adults who are food insecure to avoid detrimental development and co-morbidities and to refer them to appropriate programs and services.

Elimination of CMS outpatient observation statusResolution 211-13

The delegates directed CMA to request that the Centers for Medicare and Medicaid Services eliminate its “outpatient patient observation” status, which is placed upon patients whose anticipated hospital stay is 48 hours or less. Delegates noted that this practice places undue financial burden on patients and creates administrative hassles for physicians.

Health exchange benefit designs and tax deductibility of out-of-pocket expensesResolution 401-13The delegates called on CMA to support efforts to develop benefit designs in the health benefit exchange that appeal

to the young and healthy to boost the risk pool; and to support legislation allowing federal and state income tax deductibility of all out-of-pocket health care expenses.

Reimbursement for telephone/electronic patient managementResolution 407-13

The delegates asked that CMA support legislation requiring health insurance companies to pay physicians for telephone or other electronic patient management services.

National health information exchange Resolution 501-13

The delegates called on CMA to support the development of a secure, interoperable, nationwide health information exchange network.

Graphic Image labeling on Cigarettes

Delegates overwhelmingly voted to support graphic image warning labels on tobacco packaging that depict the very real health impact of smoking.

The U.S. Centers for Disease Control and Prevention rolled out a series of graphic advertisements in 2012, which featured startling photos of the health consequences of smoking. National smoking cessation hotlines and websites saw a doubling of calls and a fivefold increase in web visits while the ads were running.

The FDA has also proposed placing such images on cigarette packaging as a deterrent to smoking and a stimulus to cessation, but was stopped by legal challenges from the tobacco industry.

The resolution also directs CMA to urge courts to also support such labeling.

Reduced blood Alcohol limit for Drivers

Delegates voted to endorse the National Transportation Safety Board’s 2013 recommendation that the legal blood alcohol limit for operating a motor vehicle be decreased from .08 percent to .05 percent or lower.

According to NTSB, each year in the U.S., nearly 10,000 people are killed in crashes involving alcohol-impaired drivers and more than 173,000 are injured, with 27,000 suffering incapacitating injuries. Since the mid-1990s, even as total highway fatalities have fallen, the proportion of deaths from accidents involving an alcohol-impaired driver has remained constant at around 30 percent.

Research shows that although impairment begins with the first drink, by .05 percent blood alcohol content most drivers experience a decline in both cognitive and visual functions, which significantly increases the risk of a serious crash. Currently, more than 100 countries on six continents have limits set at 0.05 percent or lower. The NTSB has asked all 50 states to do the same.

Reference Committee D was chaired by SMCMA member

and former president John Hoff, MD, Ph.D.


neW SMCMa MeMberS

Kara Kerns, MDIM/Redwood City

Angelika Deloa, MDFM*/Belmont

Adam Harmon, MDTS*/Redwood City

David Jackosn, MDSPIN/Daly City

Emily Crozier, MD OTO/San Mateo

Jenna Hansen, MDAN/Redwood City

Dennis Hughes, MDIM*/Belmont

Edwin Cheng, MD AN/Redwood City

Erinn Hama, MDEM/South San Francisco

Tyken Hsieh, MD AN/Redwood City

Amy Atwood, MD*OBG/Daly City

Gary Greensweig, MD*FM/Belmont

Jolly Philip, MD FM*/Daly City

Timothy Litwin, MDIM/Daly City

Susan Larson, MDPRE*/San Mateo

Shaun Kunnavatana, MDAN/Redwood City

Jesus Saucedo, MDFM*/Burlingame * Board-certified

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The Stepping Up to Leadership program was created by the Institute for Medical Quality and the PACE Program at the University of California at San Diego in response to a commonly expressed need for better, more practical hands-on training for medical staff leaders. “For years, physicians asked for a program that would empower them to take on leadership roles,” said William Norcross, MD, founder of the PACE Program and an originator of the conference. A grant from The Physicians Foundation helped the conference’s organizers meet their goal of making the program accessible to a broad spectrum of medical staff leaders.

The Stepping Up to Leadership program made its debut in 2011 with a program emphasizing communications skills and addressing issues of disruptive and impaired professionals. Now in its third year, the 2014 conference will cover all of the original content, with an added emphasis on aligning the needs of medical staffs and hospitals and helping both work together effectively.

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This webinar will focus on final rules from the Medicare Physician Fee Schedule rules, including PQRS and Value Based Modifier changes that will affect physician practices during 2014 and beyond. 1.0 CEU credit.

Update on Medicare Physician Incentives: what’s New for 2014

January 22, 2014 | 12:15 - 1:15 p.m.

Attendees will learn the rationale for CMS incentives and payment adjustments that affect physicians, including the Physician Quality Reporting System, the ePrescribing Incentive Program, the Electronic Health Record Incentive Program, and the new Value Modifier program; and be able to define what actions they need to take to receive each incentive and avoid payment adjustments.

These webinars are FREE to CMA members and staff, $99 for non-members. To register, please contact the CMA Member Help Center at or [email protected] or (800) 786-4262. Please register at least one hour before the webinar to guarantee your place.

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November-December 2013

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Transcript of November-December 2013