March 2012

SAN MATEO COUNTY PHYSICIAN | PAgE 1

A Publication of the San Mateo County Medical Association

March 2012 | Volume I No 2

Marsh and the Association do not provide tax investment or legal advice Please consult with your professional advisors for guidance on these issues

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significant premium savings that can help fund your HSA account With individual-

only coverage you are eligible to contribute up to $3100 to your account or $6250 with family

coverage on a tax-deductible basis (members age 55ndash64 are eligible to

contribute another $1000)

bull Investigate RAF Sales Health plans offer incentives through discounts off their risk adjustment factors (RAFs) for you to change health

Please call Marsh at 800-842-3761

56568 (312) copySeabury amp Smith Inc 2012

dba in CA Seabury amp Smith Insurance Program Management bull 777 South Figueroa Street Los Angeles CA 90017

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We serve members who want assistance in evaluating the medical insurance choices before them We can assist you with the information you need to make the critical choices on the road ahead

plans Instead of your medical rates increasing this year we might be able to help you offset some of that increase

bull Mercer Select HRKnowHow If you play a role

in your medical grouprsquos health care and benefit plan decisions stay current on challenging issues Access is included at no charge for all members who purchase group health insurance through Marsh

Includes bull Newsandanalysisofimportantbenefitissuesbull ComplianceLinktooltoassistwithhealthcare

and group benefit plan administration

So what can you do

Sponsored by Administered by

You still need to make important decisions now about rising health insurance premiums

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2012


The San Mateo County Medical Assocation can serve as the first point of

contact for any practice management questions you may have on the day-to-day

functions of a medical office We can help with ways to improve practice

efficiency coding issues or inquiries EHR implementation assistance and

navigating governmental regulations such as HIPAA Our goal is to provide you

with the resources you need to keep your practice running smoothly

Did you also know that the San Mateo County Medical Association and the

California Medical Association will work directly with commerical and

government payers to resolve reimbursement or other disputes on your behalf

Call us regarding untimely payment unreasonable requests for medical records

claim denials despite prior authorizationseligibility verifications and other

matters Let us focus on handling these hassles so that you can pay attention to

what matters most - your patients

In addition the SMCMA offers a variety of educational programs that address

the above issues We have hosted customer servicepatient relations seminars

coding classes as well as a variety of programs to improve your practicersquos

bottom line Be sure to take a look at the events section of our website at

wwwsmcmaorg for upcoming courses You may also have an idea for an

educational program that we should offer We would love to hear your

suggestions so please contact us

To utilize these services and get the practice help you need contact Reina

OrsquoBeck Director of Economic Services at (650) 312-1663 or

robecksmcmaorg

SMCMA SErvICES

San MateoCounty PhysicianMarch 2012

Vol I No 2

Table of Content

Presidentrsquos Message5

Executive Report7

Alzheimerrsquos Disease - Updates on Symptoms Diagnosis and Treatment9

San Mateo Hep B Free Campaign11

In Memoriam - Charles Geraci MD12

Genetics and Epidemiology of Melanoma13

Membership Update and Classified Ads18

About the Cover The photo was taken by Christopher White MD an Emergency Medicine physician practicing in Burlingame It is titled Hints of Spring and captures the ice receding off of Mirror Lake in Yosemite Valley

SMCMA Offers Solutions to Improve Your Practice


















So what can you do



Scan tolearn more

2012

PAgE 4| SAN MATEO COUNTY PHYSICIAN

A vibrant lifestyle like no other Every detail is anticipated to reflect your personal style and zest for life Enjoy a healthy lifestyle Stay active Keep learning Discover engaging experiences and relationships Pool spa social activities transportation fine dining itrsquos all here We surround you on the inside with what you need so you can concentrate on whatrsquos outside that rejuvenates your life

(888) 860-6915(650) 697-7700

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Because you deserve the best

T H E P E N I N S U L Arsquo S P R E M I E R R E T I R E M E N T C O M M U N I T YRCFE 415600154

D I S T I N C T I V E L Y U N I Q U E


Recently I saw a copy of Outside magazine with the caption ldquoHow Getting Outside Makes You Smarter Happier and Want to Fix the Planetrdquo Automatically my brain added the word ldquohealthierrdquo Looking at my patients those who seem both the happiest and healthiest are certainly the most active continuing to hike walk bike golf play tennis garden etc well into their 70s and 80s - things they have been doing most of their lives This headline also led me to consider the general level of health of those living in San Mateo County We have a number of opportunities that allow for improved health which include a relatively mild climate that permits frequent outdoor activity vast open space areas - 40 percent of San Mateo Countyrsquos area is considered protected open space compared to 29 percent of Santa Clara and 60 percent of Marin Counties easy access to beaches hiking trails mountains and parks numerous farmersrsquo markets that feature local healthy foods and increasing use of public transportation Have all of these opportunities for improved health really lead to a more healthy population Unfortunately the answer is not cause for optimism

According to the 2011 Community Assessment sponsored by the Healthy Community Collaborative of San Mateo County and our public health officer Scott Morrow MD the County is doing fairly well overall Deaths due to cancer the leading cause of death among our population and heart disease are currently

on the decline in the County However we are unfortunately seeing a rise in conditions such as diabetes hypertension and elevated levels of cholesterol As a result we may see a reversal in the trends related to cardiovascular disease In fact the number of people with diabetes (almost entirely Type II diabetes as in the rest of the country) has grown from almost four percent in 1998 to over eight percent by 2008 In addition we know that these conditions are in part related to personal behavior and practicing a healthy lifestyle Yet many in our community do not follow the basic guidelines for a healthy life such as refraining from tobacco drug and excessive alcohol use exercising 30 minutes a day and maintaining a healthy weight and diet Arthritis and asthma are the most common chronic illnesses in the County The rate of arthritis is relatively stable and particularly important as we consider what services with be needed as our population ages as falls are a major cause of morbidity and mortality for the elderly Conversely the rate of asthma has increased from eight percent in 1998 to 14 percent in 2008

One additional very important and disturbing statistic that the report sites is years of potential life lost (YPLL) which is the difference between the average life expectancy in a population and the number of years a population would be expected to live without dying prematurely This statistic is used to measure the

impact of premature death on a given population Though the overall YPLL has decreased in the County from 631 potential years per 10000 residents between 1992-1994 to 420 years between 2006-2008 the YPLL for African American residents was a markedly elevated at 853 per 10000 residents in 2006-2008 compared to 394 for Asian 3787 for Caucasian and 4078 for Hispanic residents Looking at a number of markers (cancer deaths cardiovascular deaths etc) African Americans are fairing much worse than other ethnic groups in the County

The community health data represents very clear disparities but also provides an opportunity to address these gaps As physicians we play only a part in the health of our patients Many factors come together that include geneticsfamily history personal health behavior the surrounding environment and education - just to name a few But in order to care for our patients and understand the barriers they may face regarding their health I would recommend taking a look both at the 2011 Community Assessment (httptinyurlcom6wvlhmy) and the 2011 Sustainable San Mateo County report (httptinyurlcom83mros4) which provides a broad array of data regarding our County These reports make for sobering reading but help shed light on ways to intervene with regard to some of the disturbing trends that we are now seeing

A Look at the Countyrsquos Health

PrESIdENTrsquoS MESSAgE

BY GREGORY LUkASzEWICz MD


LIF

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INS

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DISABILITY

Long-Term Care

Protecting the rights of all policyholders to be treated fairly and in good faith

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EXECUTIvE rEPOrT

Billing Service ContractsBY SUE U MALONE

This monthrsquos column is written by SMCMArsquos legal counsel Phillip Goldberg Esq The Association has been receiving quite a few calls from our members regarding billing service contracts We hope that this information can provide clarification on this area of practice management

Although physicians are often attentive to the terms and conditions of their contracts with third party payors my experience has been that many physicians give little time or attention to their billing service contracts The lack of concern or interest in billing service contracts is surprising considering the potential significance to the medical practice This article will describe what should and should not be in the billing service contract

Who is Working for Whom

In my experience many billing service contracts are written backwards That is they are written so it appears the physician is working for the billing service as opposed to the other way around The billing service contract is first and foremost a service contract with the billing company acting as the service provider and the physician as the service recipient As such the terms should focus on the services the billing company provides to you and not on your obligations to the billing company Indeed your obligation should be limited to working cooperatively with the billing service in

submitting complete and accurate information for bill preparation and paying the companyrsquos fees

The Scope of Services

Although the scope of services from one billing service contract to another can vary significantly and many companies provide what might be more appropriately described as consulting or practice management services it is essential that the basic billing services be set forth clearly in the contract The services might be described as ldquoappropriate bill preparation transmittal to responsible payors follow up as commercially reasonable and posting and deposit as collections are receivedrdquo Beyond these basic billing services physicians often contract for credentialing services even if they do not get more comprehensive (and costly) consulting or management services In all events the contract should clarify that it extends to billings to patients and third party payors defined broadly to include any and all payors In deference to the billing company details on the complete and accurate information you are to provide may be included as well The hours during which the billing company will be in operation should be stated clearly in the contract This is important not only for communications from you but also for the convenience of patients and third party payorsBeyond generating and following up

bills and posting and depositing collections the billing company should also generate reports These reports give the physician an understanding of what type of job the billing company is doing keep the physician informed about cash flow and help identify problems with specific payors At a minimum the reports specified in the billing service contract should include aged accounts receivables which may be sorted by payor service location or other classification The billing company should provide reports on a periodic basis as stated in the contract but they should also be available as ldquoreasonably requestedrdquo for which an additional fee may apply

The Standard of Care

Physicians are well aware that a certain standard applies to the services they perform and that there are consequences if they fall below that standard The same should be true for billing services Accordingly an essential element of every billing service contract is a statement of the standard applicable to the billing companyrsquos services with references to both expertise and care For instance the billing company might be required to utilize ldquostaff qualified to furnish the billing services with appropriate levels of education training and experiencerdquo The volume and depth of services

continued on page 14

Get more information at wwwHillPhysicianscomProviders or contact

Bay area Jennifer Willson regional director (925) 327-6759 JenniferWillsonhpmgcomSan Joaquin area Paula Friend regional director (209) 762-5002 PaulaFriendhpmgcom

Sacramento area Doug Robertson regional director (916) 286-7048 DougRobertsonhpmgcom

Practices affiliated with Hill Physicians Medical Group retain their independence while enjoying the support of a large well-integrated network of providers Hillrsquos advantages include bull Fast accurate claims payments bull Free eReferrals ePrescribing and secure online doctor-patient communications bull Experienced RN case management for complex time-intensive cases bull Deep discounts on EPM and EHR solutions to help you meet the federal mandate bull Easy preventive care and disease management reminders for patients bull Extensive health resources that boost patient engagement bull High consumer awareness that builds practice volume Thatrsquos why 3700 independent primary care physicians specialists and healthcare professionals have made Hill Physicians one of the nationrsquos leading Independent Physician Associations Get more for your practice and your patients by affiliating with Hill Physicians Medical Group

Hill Physiciansrsquo 3700 healthcare providers accept commercial HMOs from Aetna Alliance CompleteCare (Alameda County) Anthem Blue Cross Blue Shield CIGNA Health Administrators (San Joaquin) Health Net United Healthcare WEST and Western Health Advantage Medicare Advantage plans in all regions Medi-Cal in some regions for physicians who opt-in

Cynthia Carsolin-Chang MDHill Physicians provider since 2010Uses Hill inSite RelayHealth and Ascender for eligibility eClaims processing secure online communications ePrescribing eReferrals and preventive care reminders

Get MoreSupport








Get MoreSupport

of conversations or events misplacing objects or disorientation to time Other early symptoms can include trouble with navigating problem solving and completing familiar tasks As the disease progresses the personrsquos cognitive abilities decline leading to increasing problems with usual and daily activities In the later stages of disease the person develops problems with ambulation mobility swallowing and continence

The diagnosis of AD is based on a clinical evaluation that includes a history physical examination and cognitive assessment Laboratory studies and brain imaging are used to exclude other possible causes to the personrsquos cognitive symptoms At this time there are no specific tests that makes a pre-mortem diagnosis of AD with 100 certainty or accuracy

The neuropathology of AD is abnormal accumulation of beta-amyloid protein outside of neurons and tau protein within neurons leading to plaques and tangles respectively As the proteins accumulate neurons become increasingly dysfunctional which then causes selective brain regions atrophy This leads to progressive decline in the personrsquos cognitive abilities and function

There are several approved medications for AD The two classes of medications are the cholinesterase inhibitors and an NMDA-receptor antagonist The cholinesterase inhibitors are donepezil (Aricept) rivastigmine (Exelon) and galantamine (Reminyl) These work by increasing brain levels of acetylcholine which is important for cognitive function Memantine (Namenda) blocks the N-methyl-D-aspartate (NMDA) receptor

Alzheimerrsquos disease (AD) is becoming a major health issue as the population of the United States ages The Alzheimerrsquos Association estimates 54 million Americans have AD Not only does AD affect the patient but the impact is also felt by the family caregivers and the society as a whole The total cost of health care long-term care and hospice care for AD and other dementias is estimated to be $183 billion dollars in 2011 This cost does not include unpaid caregiving and the loss of productivity as the personrsquos cognition and function decline

This article will first provide an overview of dementia and AD with a focus on AD symptoms diagnosis pathology and treatment The next section will be a review of mild cognitive impairment (MCI) which is viewed by many dementia experts to be ldquoincipient ADrdquo This will be followed by the emerging technology of amyloid imaging with positron emission tomography (PET) that may assist in diagnosis The final topic will be the theory of immunotherapy for AD

AD is the most common cause of dementia Dementia is defined as decline in memory or other cognitive abilities such as language visual processing judgment reasoning and behavior In dementia the decline is sufficient enough to affect daily life and usual activities Other neurodegenerative causes of dementia are vascular dementia dementia with Lewy bodies Parkinsonrsquos disease dementia and frontotemporal lobar degeneration

The most common presenting symptom of AD is trouble with short term memory This often manifests as repetitive questioning rapid forgetting

BY CRAIG HOU MD

Alzheimerrsquos Disease - Updates onSymptoms Diagnosis and Treatment

which when activated contributes to the degeneration of neurons It is important to note that these medications are symptomatic therapies In other words they only temporarily improve or stabilize the personrsquos cognitive and functional abilities They do not affect the pathology of AD so the person will eventually decline as the disease progresses There are no disease-modifying drugs that are approved and clinically available at this time but such therapies are in clinical trials as will be discussed later

Mild cognitive impairment (MCI) is defined as cognitive changes most often short term memory problems that are noticed by the person or informant and that are detectable by cognitive testing However the cognitive decline in MCI is not enough to affect the personrsquos daily life or usual activities thus not meeting the criterion for a diagnosis of dementia In several longitudinal studies individuals with MCI are at higher risk for developing dementia with AD being the most likely diagnosis Those with amnestic MCI (those with prominent memory deficits relate to other cognitive deficits) very likely have AD pathology within the brain even during the MCI stage This supports the concept that there is a pre-clinical stage of AD where a person can have normal or mildly impaired cognition yet have AD pathology on post-mortem analysis At this time there are no approved or effective medications for MCI Recommended interventions for those with MCI are aerobic exercise mental stimulation and addressing vascular risk factors



1st Annual

Spring Gala To Benefit the

San Mateo Hep B Free Campaign

DINNER COCKTAILS RAFFLE GIVEAWAYS SILENT AUCTION GUEST OF HONOR ASSEMBLYWOMAN FIONA MA LIVE ENTERTAINMENT

SPECIAL GUEST PROFESSIONAL BOXER ANA JULATON $100 per person

San Mateo Hep B FreemdashA Community Service Program of San Mateo County Medical Association

Thursday April 26 2012 600mdash900 PM

South San Francisco Conference Center 255 S Airport Blvd

The SMCMA Community Service Foundation invites you to attend the

Please submit payment with this registration form and mail to 777 Mariners Island Blvd Ste 100 San Mateo CA 94404 or fax to (650) 312-1664

Name ____________________________________ Guest Name _______________________________

Address ___________________________________ CityZip ___________________________________

Phone ____________________________________ Email ___________________________________

I am unable to attend but please accept my tax-deductible donation in the amount of $________ I would like to purchase a table at the event for $800 (8 people at a table)

Payment Information (We accept Visa MasterCard Discover and Checks) Card Number ____________________________________ Exp _________ CCV_____

Billing Address ____________________________________ CityZip __________________________

Signature ____________________________________ Date __________ Amount $_______ (Make Checks Payable to SMCMA Community Service Foundation)

Meal Selection (please select item amp quantity) ______ NY Steak ______ Chicken Parmigiana ______ Salmon Provencale

For questions regarding the event please contact Whitney Wood at 650-312-1623 or wwoodsmcmaorg


of cancer death in certain Asian populations For this reason hepatitis B is often referred to as the ldquosilent killerrdquo Establishing a community-wide program like San Mateo Hep B Free is necessary to raise awareness of hepatitis B and liver cancer and to offer potentially life-saving services for at risk populations in San Mateo County

The collaboration behind this program is comprised of four vital parts including San Mateo County Medical Association the Hospital Consortium of San Mateo County (in which Mills Peninsula Health Services participates) San Mateo County Health System and Asian Liver Center at Stanford University Recently both the Mills Peninsula Community Benefits Foundation and the Peninsula Health Care District have agreed to continue to support San Mateo Hep B Free financially with grants The San Mateo County Medical Association provides administrative and financial support utilizing its members to serve as advocates and educators of basic hepatitis B prevention and treatment SM Hep B Free has already gained the support of legislative representatives such as Assemblywoman Fiona Ma Congresswomen Jackie Speier and Anna Eschoo and City of Millbrae Councilman Wayne Lee SM Hep B Free has garnered backing from community organizations such as the San Francisco and Millbrae Lions and Leos Clubs Self Help for the Elderly the San Francisco State and Canada College of Nursing as well as community leaders like Ted Fang In 2009 the San Mateo Hep B Free

In 2009 the San Mateo County Medical Associationrsquos Community Service Foundation along with a strong steering committee pooled their resources to begin a program called San Mateo Hep B Free Campaign Modeled after the highly successful San Francisco Hep B Free program its goal is to raise awareness about the severity of hepatitis B in San Mateo County San Mateo County has an incredibly diverse population of which 26 percent (176000) are Asian and Pacific Islander (API) Approximately 17600 APIs in San Mateo County are chronically infected with Hep B and two-thirds do not know it Liver cancer rates are 23 times higher in API men versus non-API men and 33 times higher in API women versus non-API women Since its founding San Mateo Hep B Free has sponsored dozens of educational screening and vaccination events Additionally San Mateo Hep B Free has published several informational articles and held educational forums on Hepatitis B for the public and healthcare providers

Hepatitis B is a serious disease of the liver caused by the hepatitis B virus which can lead to cirrhosis liver failure and liver cancer The API populations bear a disproportionately higher incidence of chronic hepatitis B as ten percent are infected versus less than one percent of Caucasian Americans according to the CDC There are often no symptoms and most of the chronically infected are unaware that they have the virus until it is too late One quarter of infected patients die of liver failure or cancer the leading cause

BY DIRk BAUMANN MD


Campaign was awarded a Certificate of Special Congressional Recognition from the US Congress for outstanding and invaluable service to the community of San Mateo County

San Mateo Hep B Free seeks to unite community and medical stakeholders to promote awareness of hepatitis B This goal is being accomplished by

San Mateo Hep B Free is comprehensive and includes education for the community and health care providers awareness campaigns and clinical services The educational aspect seeks to raise public awareness about the threats of hepatitis B in the API population The clinical components include routine screening and vaccination of API adults as well as assisting those who tested positive for chronic hepatitis B in obtaining further treatment Joining efforts with the San Mateo County Medical Association San Mateo Hep B Free has arranged for specialty physician management of these identified patients irrespective of insurance coverage

On the evening of April 26 2012 the 1st Annual San Mateo Hep B Free Spring Gala will be held at the South San Francisco Convention Center All interested are encouraged to attend this gala RSVP to Director Whitney Wood at wwoodsmcmaorg If you require any additional information about the San Mateo Hep B Free campaign or are interested in participating please visit our website at SMHepBFreeorg or do not hesitate to contact meDr Baumann is a Vascular Surgeon and practices in Burlingame and is the Chairman of the Hep B Free Campaign


Sequoia Hospital when there were no cardiac surgeons and covered the Emergency Room before emergency doctors existed He also volunteered for Project Hope serving in Peru Ceylon and an Indian reservation in Arizona

One of Charliersquos greatest assets was his technical ability in the operating room He was able to write with both hands simultaneously and used this ambidextrous skill when operating If another surgeon had a difficult case Charlie was the one they would call for assistance Fellow physicians nurses and co-workers always referred themselves and their family and friends to Charlie

After an automobile accident limited Charliersquos ability to perform primary surgery he would cherish the chance to be in the operating room His assistance made other surgeons better due to his calm demeanor that instilled confidence in those around him Charlie was never flustered by events in or out of the operating room and his clinical judgment was second to none

Charliersquos ability to communicate with his patients was exceptional and his calm caring nature that instilled absolute confidence in his patients separated him from others Patients believed ldquoDr Grdquo would get them through anything He could explain complicated problems in easy to understand terms His gentle manner made hearing difficult news of cancer or a terminal illness much more acceptable and patients felt that they were not alone Charlie would sit at the

Charles Geraci was the modern day Renaissance man His title states MD however his life tells much more How does one summarize a lifetime in a few paragraphs

Charlie graduated from Bellarmine High School in 1940 and from Stanford University in 1944 He then continued on to medical school at Stanford and upon completion he joined the Air Force and served at the Veterans Hospital in San Francisco After his military commitment he returned to Stanford to complete his surgical residency He worked under such notable surgeons as Roy Cohn who rarely gave out praise However when I informed Roy that I was joining Charlie in practice he told me how lucky I was as Charlie was truly a great surgeon Charlie finished his training at Stanford and started a private surgical practice at Sequoia Hospital in 1953 until he retired in 2008

Throughout Charliersquos career there were many situations that showed not only demonstrated his excellent surgical skills but also the compassion and understanding he portrayed to each and every patient His very first case at Sequoia Hospital was a burn patient that he would take to the operating room every night to change and debride their wounds When Charlie described this patient and their progress even fifty years later he would light up with excitement This was truly the definition of a surgeon who was passionate about his work and treatment of patients He performed the first heart surgery at

BY MICHAEL OrsquoHOLLERAN MD

In Memoriam - Charles Geraci MD

bedside and hold a patientrsquos hand and then explain what was going on and answer any questions they might have This made the patient feel that they were his only concern

Charlie was also extremely active in the political arena of medicine He served two terms as president of Sequoia Hospital was president of the San Mateo County Medical Association was on the California Medical Association Board of Directors and was the first Medical Director of Sequoia Hospital

In addition to his medical skills Charlie was a pianist and an artist He also enjoyed hiking skiing traveling and San Francisco fine arts events He was a skilled craftsman who built grandfather clocks which I was lucky enough to be gifted He was a devoted brother husband father and grandfather

Not a week goes by in the office that a former patient or family of a patient doesnrsquot ask about ldquoDr Grdquo Each patient has a different experience however the story line is the same They describe Charlie as a person who provided confidence during the most difficult time had exceptional bedside manner a sense of humor and was the ldquobest doctor everrdquo

Charlie was the ultimate role model for me He was a father confessor and tutor With the loss of Charlie Geraci the mold was broken This has been said many times however this time it is trueDr OrsquoHolleran is a General Surgeon and practices in San Carlos


BY JANET MALDONADO MD

Genetics and Epidemiology of MelanomaMelanoma is the most frequent cause of death from skin cancer and the most common overall cancer in men over the age of 50 (more prevalent than colon prostate and lung) It is also the second most common cancer in women aged 20 to 29 One in 51 people will be diagnosed with melanoma during their lifetime -- up from one in 65 just eight years ago This is thought to be due not only to increased detection but also to a shift from outdoor to indoor occupations leading to more intermittent sun exposure and increased tanning bed use

Melanoma most commonly presents on the back in men and the back of the legs in women which leads to much confusion about how the sun exactly causes melanoma Much of the uncertainty stems from the implicit assumption that all cutaneous melanomas arise through the same pathologic pathway There is a dramatic variation in incidence and anatomical distribution of melanoma in light and dark skinned people Melanoma is much more common in light skinned individuals who tend to get them on sites that receive more sun exposure Dark skinned people get melanomas on relatively sun protected areas such as the palms soles and mucosal sites more frequently than anywhere else on their body These phenotypic differences already speak to the question of whether there are different genetic pathways to melanoma The development of melanomas on sun shielded areas is probably less related to sun exposure and instead more to

genetic pathways unaffected by UV exposure

The MAP-kinase pathway is activated in the majority of melanomas BRAF is a critical serinethreonine kinase in this pathway that was found to have a high frequency of mutations in melanoma It was found that BRAF mutations are highly unevenly distributed among the four major subgroups of melanomas--melanomas on intermittently sun damaged skin such as the trunk and extremities melanomas on chronically sun damaged skin such as the face acral melanomas and mucosal melanomas BRAF mutations were found in 59 of the melanomas on the trunk and extremities but in only 11 of the melanomas on chronically sun damaged skin Individuals who develop melanomas on intermittently exposed skin tend to be younger as compared to individuals who develop melanomas on chronically sun damaged skin This supports the existence of at least two distinct genetic pathways to melanomamdashone that is BRAF dependent in susceptible individuals who need less UV exposure are younger and develop their melanomas on intermittently sun exposed sites and the other that is BRAF independent in resistant individuals who need more UV exposure are older and develop their melanomas on sites that are chronically sun-exposed

The goal of anti-cancer therapies now is to target causative proteins in a specific manner to minimize side-effects The innovation of Vemurafenib a small molecule inhibitor of BRAF has been

revolutionary in treating melanoma Although many patients eventually build a resistance to it Vemurafenib has been shown to prolong overall survival in patients with BRAF mutated metastatic melanoma

It has also become clear that uncontrolled activity of c-kit contributes to the formation of melanoma Melanomas on the head and neck mucosal and acral melanomas have a higher percentage of c-kit mutations than those arising on the arms and trunk Multiple case series have been published of metastatic melanoma containing kit-activating mutations being successfully treated with c-kit blockers such as imatinib

The newest of the genetic discoveries concerns the rare but often fatal ocular melanoma 80 of all uveal melanomas have been found to contain mutations in the alpha subunit of the G proteins GNAQ or GNA11 which result in MAP kinase pathway activation Clinical trials are underway for targeted therapies

It is exciting that we are finally moving away from traditional chemo to finding the silver bullet for a patientrsquos particular condition A continued effort towards the precise determination of the molecular and genetic mechanisms underlying melanoma pathogenesis is crucial However it is important to remember that metastatic melanoma is still virtually always fatal Early detection screening and counseling on sun protection will always remain paramountDr Maldonado is a Dermatologist and practices in Burlingame


continued from page 7

Executive Report

should be that ldquoreasonably required and customary for similar medical practicesrdquo Additionally the billing services should be provided with ldquodue care prudence and judgmentrdquo and ldquoin compliance with all applicable third party payor rules and regulations both commercial and governmentalrdquo Ideally the service should be rendered to the physicianrsquos ldquoreasonable satisfactionrdquo Most disputes between physicians and their billing services involve circumstances where the physician is unhappy with the service and the billing company asserts it has complied fully with the contract The reasonable satisfaction standard can be very helpful in such cases

Ownership and Custody of Records

The billing company should take responsibility for maintaining custody of all documentation relating to the services it provides and the bills it generates as well as its communications with patients and third party payors More importantly the billing service contract should specify that all such records ldquoare and will remain the sole property of physicianrdquo Disputes over ownership of records can be particularly frustrating If you have not clearly established your ownership of records along with the billing companyrsquos obligation to maintain them and make them available to you on request you may run into problems when the relationship with your billing company terminates Although you may not want to take custody of what may be a substantial volume of records this is far preferable to being denied access to those records For similar reasons the billing service contract should cover what protocols the billing company employs to preserve and back up electronic data

Related to ownership and control of records is the physicianrsquos right to audit those records The billing service contract should specify that the physician has the right to review and audit through an agent hired by physician if desired ldquoall billing and collection information in the custody or control of the billing companyrdquo It is reasonable to require you give advance notice to the billing company not disrupt the billing companyrsquos operations and conduct the audit during regular business hours The billing company may have legitimate concerns if the audit is conducted by a competing service may reasonably request that a direct competitor not conduct the audit and require a confidentiality agreement from any auditor Conversely the billing company should offer its full cooperation with any audit The right of audit is essential to ensure the billing company has performed up to the standard set forth in the billing service contract

Collections and Payment of the Billing Company Fee

The billing service contract should not include a provision on the billing company paying the physician because the collections are (or certainly should be) the exclusive property of the physician The accounts receivables before they are collected the checks by which payments are made and the account into which the checks are deposited are the property of the physician and the billing service contract should make this perfectly clear The contract should also indicate that funds received by the billing company should be immediately deposited into your account Clarifying ownership of accounts receivables checks and deposits would be a good idea in all events but it also helps ensure compliance with Medicare rules on billing services Under Medicare rules a ldquolockboxrdquo account into which

payments are deposited and over which you have exclusive access should be established

A review of the Medicare rules on billing service arrangements could lead to the conclusion that the commonplace ldquopercentage of collectionsrdquo fee arrangement is not allowed However the Center for Medicare and Medicaid Services indicates (rather cryptically) that percentage of collections fee arrangements are acceptable when a lockbox account is used The billing company should not have access to the lockbox account and should receive payment of its fee from the physician as opposed to taking it out of collections

Although fees based upon a percentage of collections are not the only means for calculating compensation they are by far the most common The billing service contract should specify the percentage of collections (and not billings) on which the fee is calculated as well as specifying the time for payment Ideally the billing company should generate a ldquotrue and correctrdquo invoice because it has information available on collections Monthly calculation and payment of the fee is common but a more or less frequent basis is allowed It is also a good idea to specify the collection on which the percentage fee is based For instance capitation payments may be excluded or may be subject to a lower rate since they involve less effort on the part of the billing service

Confidentiality and HIPAA Compliance

The billing service contract should make clear that all information provided to the billing company is to be considered and maintained as confidential and not just that information which constitutes


ldquoprotected health informationrdquo or ldquoPHIrdquo under HIPAA The billing service contract should include standard ldquobusiness associaterdquo language to ensure compliance with your obligations under HIPAA The billing company should be well aware of these requirements and familiar with the obligations imposed under the law on its use of PHI In addition to the HIPAA Privacy Rule the billing must also comply with the HIPAA Electronic Transaction Rule

Term and Termination

Whether or not there is any express term to the billing service contract it should allow you to terminate the relationship without cause on a reasonable period of notice The right to terminate without cause may not be exercisable during the first year when the billing company is getting ldquoup to speedrdquo and has a legitimate interest in recovering start-up costs When you are terminating the relationship you probably want the notice period to be as short as possible Thirty to 60 days might be appropriate Conversely if it is the billing company terminating the relationship you may want a longer period of notice to find a substitute In this case 90 to 120 days might be more appropriate There is no legal requirement that the notice period for termination by one party be the same as the notice period for termination by the other party but this is the most common arrangement The billing service contract should specify a much shorter notice period for termination for cause Typically a notice of default giving rise to termination would be given and the defaulting party afforded an opportunity to cure within a relatively brief period of time If the physicianrsquos obligations are properly limited to reasonable cooperation and paying the fee it is much more likely that the physician will be the one terminating for cause Accordingly the

cure period might be as brief as five to ten days

The billing service contract should specify the causes for termination which most importantly include breach of the contract The breach by the billing company will almost always involve some degree of subjectivity Including a standard for the services rendered helps to establish a basis for termination for cause by the physician when the services have not been as expected The failure to meet that standard will constitute a breach giving you the right to provide notice of the default which will result in termination if not cured in short order

Except in the case where the billing service contract is terminated because of a breach by the physician he or she should have the option of having the billing company continue to provide services after the effective date of termination That is you may require the billing company to ldquorun offrdquo the receivables for dates of service prior to the date of termination On the other hand you should be free to collect information on your accounts receivables from the old billing company and transfer it to the new billing company if you do not exercise your option to have the old billing company run off the receivables In most circumstances you will want the run off performed by the old billing company since payors would have received instructions to deliver payment (or at least payment information) to the old billing companyrsquos address It is important to clarify the special compensation arrangements if any that apply during the run off period and on termination

No matter how or when the relationship with the billing company is terminated you should expect some collections will be lost when moving from one company to another In order to help diminish this inevitable loss the

billing service contract should specify that the old company shall cooperate in good faith with any new company This cooperation should include at a minimum the ldquotransmittal of accounts receivable and other information to the replacement service in such form and format as the replacement service may reasonably requestrdquo This language is intended to facilitate an electronic transfer of data to avoid the need for the new service to input information manually into its system given the time and inaccuracy associated with this exercise It does not mean the old company has to incur unreasonable expenses to transfer data electronically from one system to the other but it certainly means that the old billing company cannot refuse to make an electronic transfer that only involves in a few keystrokes HIPAArsquos Electronic Transaction Rule should make electronic transmission from one company to another relatively simple

Conclusion

Many physicians comparing their current billing service contracts with the comments in this article may find little connection between the two Obviously some of the provisions I suggest are more important than others Similarly some of the provisions will be easier for a billing company to accept than others Nevertheless there are good reasons for each of the provisions suggested What may be more important than the terms of your billing service contract is the strength and quality of your relationship with the billing company When that relationship deteriorates you will want billing service contract terms that protect your interests


That Means They Receive The Profit Distributions $30000000 Dividend Declared in 2011 - A Company Record

MIEC Belongs to Our Policyholders

For more information or to apply contact

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(On premiums at $13 million limits Future dividends cannot be guaranteed)

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SMCMA_ad_122011

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SMCMA_ad_122011indd 1 122111 1114 AM


Since the diagnosis of MCI and AD is a clinical diagnosis there is increasing attention on ways to identify amyloid and tau deposits in vivo at the earliest stages of disease or even before clinical symptoms appear ldquoAmyloid imagingrdquo utilizies radiolabelled compounds that bind amyloid deposits within the brain and create an abnormal signal on a PET scan This field has reached the point where a company applied for FDA approval of their compound for clinical use The FDA denied approval over concern about inter-rater reliability of the interpretation of the scans

Concern about the clinical use of amyloid imaging comes from the fact that there are no disease-modifying therapies available A dilemma arises when someone has an abnormal amyloid imaging study but is cognitively normal or has MCI but these individuals may never develop or have a long time before they reach the point of a clinical diagnosis of AD These false-positive diagnoses could have a major impact on the person and their families

The current focus of research in disease-modifying therapy for AD is on immunotherapy directed against the amyloid protein that accumulates in the brain and causes AD Early trials involved infusing fragments of the amyloid protein to trigger an immune response that would target and lower the amyloid burden This worked well in mice models of AD But in 2002 a clinical trial of an amyloid vaccine was stopped when some patients developed meningoencephalitis Drugs in on-going clinical trials do not use an active vaccine theory but rather involve passive immunization where monoclonal antibodies directed against the AD-causing amyloid proten are infused Results of these clinical trials should be forthcomingDr Hou is a Neurologist and practices in S San

Francisco

San Mateo Co Medical Association06-18-09

Tracy Zweig AssociatesA R E G I S T R Y amp P L A C E M E N T F I R M

INC

tzweigtracyzweigcomwwwtracyzweigcom

Voice 800-919-9141 or 805-641-9141FAX 805-641-9143

Locum Tenens Permanent Placement

Physicians Nurse Practitioners

Physician Assistants







SMCMA_ad_122011







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Upcoming Event

2012 Physician Art Exhibit at

Hillsdale Mall

from May 3 through May 10

Join Us for an

Opening Reception on May 3 at 600 pm

For more details call Gina Cromosini

at (650) 312-1663 or gcromosinismcmaorg

PAgE 18 | SAN MATEO COUNTY PHYSICIAN

New Members

Aifa Ahmed IMRedwood City

Manjita Bhaumik OBGRedwood City

David Chou PSY GPSYS San Francisco

Henry Chun IM GERedwood City

Sean Cullen DR NR Redwood City

kimberly Dalal GSBurlingame

Garrett Eggers EMRedwood City

Patricia Fung PDRedwood City

Gary Heit NSRedwood City

Mamatha Hiregoudar IMRedwood City

Sawsan kara PDSan Carlos

Lorin kreitzer IMRedwood City

Eric kwon URedwood City

Membership Update

Classified Ads

Burlingame Medical BuildingLocation on El Camino Burlingame across from Mills-Peninsula Hospital Two office suites 800+ square feet and 1700+square feet Call Alipate Sanft SC Properties 650-342-3030 x212

Medical Office Space Available for SubletFour exam rooms with running water and one MD office available for up to four days weekly May be able to provide office staff if needed Excellent location opposite Peninsula Hospital For details please contact Bonnie McGuire Bon-nileeaolcom or 650-259-1480

Place a classified ad for $40 for up to five lines for mem-bers and $75 for up to five lines for non-members Contact SMCMA at (650) 312-1663 or smcmasmcmaorg

Barry B Sheppard MD Chair Sharon Clark MDRuss Granich MD Gurpreet k Padam MDEdward G Morhauser MD Michael Stevens MD

Sue U Malone Executive Director Reina OrsquoBeck Managing Editor

2011-2012 Officers amp Board of Directors

Gregory C Lukaszewicz MDPresidentMary Giammona MDPresident-ElectAmita Saxena MDSecretary-TreasurerJohn D Hoff MDImmediate Past President

Alberto Bolanos MD Raymond Gaeta MDRuss Granich MD Robert Jasmer MDEdward koo MD CJ kunnappilly MDVincent Mason MD Michael Norris MDkristen Willison MD

David Goldschmid MD CMA TrusteeScott A MorrowHealth Officer San Mateo CoBarry B Sheppard MD 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 smcmasmcmaorg 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

777 Mariners Island Boulevard Suite 100 San Mateo CA 94404Tel (650) 312-1663Fax (650) 312-1664smcmasmcmaorgwwwsmcmaorg

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

copy Copyright 2012 San Mateo County Medical Association

Editorial Committee

Jonathan Lam ORSRedwood City

Linda LeungIMRedwood City

Stephanie Lin GS VSBurlingame

Amon LiuDRRedwood City

Raghu MiddePUDRedwood City

John Ngai GSRedwood City

Andrew Nguyen PMRRedwood City

Stephen Nguyen IM GERedwood City

Tina Nguyen NRedwood City

Jamie Nuwer FM SMBurlingame

Rujeko Nyachoto FMRedwood City

Olga Onay PDRedwood City

Todd Osinski DRRedwood City


777 Mariners Island BoulevardSuite 100San Mateo California 94404

ADDRESS SERVICE REQUESTED

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robecksmcmaorg

SMCMA SErvICES


Vol I No 2

Table of Content


Executive Report7

























So what can you do



Scan tolearn more

2012



(888) 860-6915(650) 697-7700
















LIF

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INS

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DISABILITY

Long-Term Care



















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Get MoreSupport









BY CRAIG HOU MD






1st Annual










Name ____________________________________ Guest Name _______________________________

Address ___________________________________ CityZip ___________________________________

Phone ____________________________________ Email ___________________________________












BY DIRk BAUMANN MD


































Executive Report





















Conclusion









SMCMA_ad_122011







SMCMA_ad_122011indd 1 122111 1114 AM





Francisco



INC


Voice 800-919-9141 or 805-641-9141FAX 805-641-9143










SMCMA_ad_122011







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Upcoming Event


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New Members














Membership Update

Classified Ads










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1


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PHOneCall

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robecksmcmaorg

SMCMA SErvICES


Vol I No 2

Table of Content


Executive Report7

























So what can you do



Scan tolearn more

2012



(888) 860-6915(650) 697-7700
















LIF

E

INS

UR

AN

CE

DISABILITY

Long-Term Care



















EXECUTIvE rEPOrT



















Get MoreSupport








Get MoreSupport









BY CRAIG HOU MD






1st Annual










Name ____________________________________ Guest Name _______________________________

Address ___________________________________ CityZip ___________________________________

Phone ____________________________________ Email ___________________________________












BY DIRk BAUMANN MD


































Executive Report





















Conclusion









SMCMA_ad_122011







SMCMA_ad_122011indd 1 122111 1114 AM





Francisco



INC


Voice 800-919-9141 or 805-641-9141FAX 805-641-9143










SMCMA_ad_122011







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Upcoming Event


Hillsdale Mall


Join Us for an





New Members














Membership Update

Classified Ads










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| SAN MATEO COUNTY PHYSICIAN


(888) 860-6915(650) 697-7700
















LIF

E

INS

UR

AN

CE

DISABILITY

Long-Term Care



















EXECUTIvE rEPOrT



















Get MoreSupport








Get MoreSupport









BY CRAIG HOU MD






1st Annual










Name ____________________________________ Guest Name _______________________________

Address ___________________________________ CityZip ___________________________________

Phone ____________________________________ Email ___________________________________












BY DIRk BAUMANN MD


































Executive Report





















Conclusion









SMCMA_ad_122011







SMCMA_ad_122011indd 1 122111 1114 AM





Francisco



INC


Voice 800-919-9141 or 805-641-9141FAX 805-641-9143










SMCMA_ad_122011







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New Members














Membership Update

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Editorial Committee



























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LIF

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DISABILITY

Long-Term Care



















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Get MoreSupport








Get MoreSupport









BY CRAIG HOU MD






1st Annual










Name ____________________________________ Guest Name _______________________________

Address ___________________________________ CityZip ___________________________________

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BY DIRk BAUMANN MD


































Executive Report





















Conclusion









SMCMA_ad_122011







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Francisco



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Voice 800-919-9141 or 805-641-9141FAX 805-641-9143










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Membership Update

Classified Ads










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Editorial Committee



























1


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ss

iste

d in

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1

is all it takes


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xper


AS YOU DO

PHOneCall

25 000


EXECUTIvE rEPOrT



















Get MoreSupport








Get MoreSupport









BY CRAIG HOU MD






1st Annual










Name ____________________________________ Guest Name _______________________________

Address ___________________________________ CityZip ___________________________________

Phone ____________________________________ Email ___________________________________












BY DIRk BAUMANN MD


































Executive Report





















Conclusion









SMCMA_ad_122011







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Francisco



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Voice 800-919-9141 or 805-641-9141FAX 805-641-9143










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Upcoming Event


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New Members














Membership Update

Classified Ads










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Editorial Committee



























1


00C

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iste

d in

201

1

is all it takes


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xper


AS YOU DO

PHOneCall

25 000







Get MoreSupport








Get MoreSupport









BY CRAIG HOU MD






1st Annual










Name ____________________________________ Guest Name _______________________________

Address ___________________________________ CityZip ___________________________________

Phone ____________________________________ Email ___________________________________












BY DIRk BAUMANN MD


































Executive Report





















Conclusion









SMCMA_ad_122011







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Francisco



INC


Voice 800-919-9141 or 805-641-9141FAX 805-641-9143










SMCMA_ad_122011







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Alzheimerrsquos

Upcoming Event


Hillsdale Mall


Join Us for an





New Members














Membership Update

Classified Ads










Article Submission








Editorial Committee



























1


00C

all

er

s a

ss

iste

d in

201

1

is all it takes


ve e

xper


AS YOU DO

PHOneCall

25 000








Get MoreSupport









BY CRAIG HOU MD






1st Annual










Name ____________________________________ Guest Name _______________________________

Address ___________________________________ CityZip ___________________________________

Phone ____________________________________ Email ___________________________________












BY DIRk BAUMANN MD


































Executive Report





















Conclusion









SMCMA_ad_122011







SMCMA_ad_122011indd 1 122111 1114 AM





Francisco



INC


Voice 800-919-9141 or 805-641-9141FAX 805-641-9143










SMCMA_ad_122011







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Alzheimerrsquos

Upcoming Event


Hillsdale Mall


Join Us for an





New Members














Membership Update

Classified Ads










Article Submission








Editorial Committee



























1


00C

all

er

s a

ss

iste

d in

201

1

is all it takes


ve e

xper


AS YOU DO

PHOneCall

25 000

1st Annual










Name ____________________________________ Guest Name _______________________________

Address ___________________________________ CityZip ___________________________________

Phone ____________________________________ Email ___________________________________












BY DIRk BAUMANN MD


































Executive Report





















Conclusion









SMCMA_ad_122011







SMCMA_ad_122011indd 1 122111 1114 AM





Francisco



INC


Voice 800-919-9141 or 805-641-9141FAX 805-641-9143










SMCMA_ad_122011







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Alzheimerrsquos

Upcoming Event


Hillsdale Mall


Join Us for an





New Members














Membership Update

Classified Ads










Article Submission








Editorial Committee



























1


00C

all

er

s a

ss

iste

d in

201

1

is all it takes


ve e

xper


AS YOU DO

PHOneCall

25 000






BY DIRk BAUMANN MD


































Executive Report





















Conclusion









SMCMA_ad_122011







SMCMA_ad_122011indd 1 122111 1114 AM





Francisco



INC


Voice 800-919-9141 or 805-641-9141FAX 805-641-9143










SMCMA_ad_122011







SMCMA_ad_122011indd 1 122111 1114 AM


Alzheimerrsquos

Upcoming Event


Hillsdale Mall


Join Us for an





New Members














Membership Update

Classified Ads










Article Submission








Editorial Committee



























1


00C

all

er

s a

ss

iste

d in

201

1

is all it takes


ve e

xper


AS YOU DO

PHOneCall

25 000





























Executive Report





















Conclusion









SMCMA_ad_122011







SMCMA_ad_122011indd 1 122111 1114 AM





Francisco



INC


Voice 800-919-9141 or 805-641-9141FAX 805-641-9143










SMCMA_ad_122011







SMCMA_ad_122011indd 1 122111 1114 AM


Alzheimerrsquos

Upcoming Event


Hillsdale Mall


Join Us for an





New Members














Membership Update

Classified Ads










Article Submission








Editorial Committee



























1


00C

all

er

s a

ss

iste

d in

201

1

is all it takes


ve e

xper


AS YOU DO

PHOneCall

25 000










Conclusion









SMCMA_ad_122011







SMCMA_ad_122011indd 1 122111 1114 AM





Francisco



INC


Voice 800-919-9141 or 805-641-9141FAX 805-641-9143










SMCMA_ad_122011







SMCMA_ad_122011indd 1 122111 1114 AM


Alzheimerrsquos

Upcoming Event


Hillsdale Mall


Join Us for an





New Members














Membership Update

Classified Ads










Article Submission








Editorial Committee



























1


00C

all

er

s a

ss

iste

d in

201

1

is all it takes


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xper


AS YOU DO

PHOneCall

25 000








SMCMA_ad_122011







SMCMA_ad_122011indd 1 122111 1114 AM





Francisco



INC


Voice 800-919-9141 or 805-641-9141FAX 805-641-9143










SMCMA_ad_122011







SMCMA_ad_122011indd 1 122111 1114 AM


Alzheimerrsquos

Upcoming Event


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Join Us for an





New Members














Membership Update

Classified Ads










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Editorial Committee



























1


00C

all

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s a

ss

iste

d in

201

1

is all it takes


ve e

xper


AS YOU DO

PHOneCall

25 000





Francisco



INC


Voice 800-919-9141 or 805-641-9141FAX 805-641-9143










SMCMA_ad_122011







SMCMA_ad_122011indd 1 122111 1114 AM


Alzheimerrsquos

Upcoming Event


Hillsdale Mall


Join Us for an





New Members














Membership Update

Classified Ads










Article Submission








Editorial Committee



























1


00C

all

er

s a

ss

iste

d in

201

1

is all it takes


ve e

xper


AS YOU DO

PHOneCall

25 000


New Members














Membership Update

Classified Ads










Article Submission








Editorial Committee



























1


00C

all

er

s a

ss

iste

d in

201

1

is all it takes


ve e

xper


AS YOU DO

PHOneCall

25 000














1


00C

all

er

s a

ss

iste

d in

201

1

is all it takes


ve e

xper


AS YOU DO

PHOneCall

25 000

March 2012

Documents

Transcript of March 2012