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SOMBRERO

Pima County Medical Society


Home Medical Society of the 17th United States Surgeon General

OCTOBER 2013

Light and dark: The ACA arrives The Crisis Response Center Tucson and the Ericksons

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SOMBRERO October 2013

SOMBRERO
Pima County Medical Society Ofcers
President Charles Katzenberg, MD President-Elect Timothy Marshall, MD Vice President Melissa Levine, MD Secretary-Treasurer Steve Cohen, MD Past-President Alan K. Rogers, MD

Official Publication of the Pima County Medical Society


Soheila Nouri, MD Jane M. Orient, MD Guruprasad Raju, MD Scott Weiss, MD Victor Sanders, MD (resident)

Vol. 46 No. 8

PCMS Board of Directors


Diana V. Benenati, MD R. Mark Blew, MD Neil Clements, MD Michael Connolly, DO Bruce Coull, MD (UA College of Medicine) Stewart Dandorf, MS, MPH (student) Howard Eisenberg, MD Afshin Emami, MD Randall Fehr, MD Jamie M. Fleming (student) Alton Hank Hallum, MD Evan Kligman, MD Melissa D. Levine, MD Clifford Martin, MD Kevin Moynahan, MD Editor Stuart Faxon Phone: 883-0408 E-mail: tjjackal@comcast.net Please do not submit PDFs as editorial copy. Art Director Alene Randklev, Commercial Printers, Inc. Phone: 623-4775 Fax: 622-8321 E-mail: alene@cptucson.com

Arizona Medical Association Ofcers


Thomas Rothe, MD president Michael F. Hamant, MD secretary

Members at Large
Richard Dale, MD Anant Pathak, MD

At Large ArMA Board

Ana Maria Lopez, MD R. Screven Farmer, MD

Board of Mediation
Bennet E. Davis, MD Thomas F. Griffin, MD Charles L. Krone, MD Edward J. Schwager, MD Eric B. Whitacre, MD

Pima Directors to ArMA Timothy C. Fagan, MD Charles Katzenberg, MD Delegates to AMA


William J. Mangold, MD Thomas H. Hicks, MD Gary Figge, MD (alternate)
SOMBRERO (ISSN 0279-909X) is published monthly except bimonthly June/July and August/September by the Pima County Medical Society, 5199 E. Farness, Tucson, Ariz. 85712. Annual subscription price is $30. Periodicals paid at Tucson, AZ. POSTMASTER: Send address changes to Pima County Medical Society, 5199 E. Farness Drive, Tucson, Arizona 85712-2134. Opinions expressed are those of the individuals and do not necessarily represent the opinions or policies of the publisher or the PCMS Board of Directors, Executive Ofcers or the members at large, nor does any product or service advertised carry the endorsement of the society unless expressly stated. Paid advertisements are accepted subject to the approval of the Board of Directors, which retains the right to reject any advertising submitted. Copyright 2013, Pima County Medical Society. All rights reserved. Reproduction in whole or in part without permission is prohibited.

Executive Director Bill Fearneyhough Phone: 795-7985 Fax: 323-9559 E-mail: billf 5199@gmail.com Advertising Phone: 795-7985 Fax: 323-9559 E-mail: billf 5199@gmail.com

Printing Commercial Printers, Inc. Phone: 623-4775 E-mail: andy@cptucson.com Publisher Pima County Medical Society 5199 E. Farness Dr., Tucson, AZ 85712 Phone: (520) 795-7985 Fax: (520) 323-9559 Website: pimamedicalsociety.org

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SOMBRERO October 2013

Inside
6 Dr. Charles Katzenberg: The Patient Protection and Affordable Care Act arrives. 8 Milestones: Dr. Lavor in Afghanistan. 10 PCMS News: Free gun locks are available. 12 Public Health: The Crisis Response Center; civil commitment in Pima County. 17 Time Capsule: Dr. Kenneth R. Scooter Johnson of the PCMS History Committee on the Ericksons, whose Desert Sanatorium morphed into Tucson Medical Center. 22 Makols Call: Testing is testing our mettle. 24 Financial Management: Dr. John Stephens on 2013 tax, income, and investment planning. 26 CME: Coming events from Mayo Clinic, others.
On the Cover
From Oak Creek Canyon north to Sedona, late October is prime time to see the foliages brilliant color changes (Dr. Hal Tretbar photo).

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ObamaCare: The ACA arrives


By Charles Katzenberg, M.D. PCMS President
poor quality and/or expensive (greater than 9.5% of your income) insurance, giving you the option of going to an Exchange. As in the past, benefits and costs will vary year to year. Ninety-five percent of employers with more than 50 employees currently offer insurance. [1] 2) Small businesses, defined as fewer than 50 employees, can go to www.healthcare.gov and use the Marketplace to find insurance. Tax credits to employers, up to 50% of the premium cost, will be available to firms with fewer than 25 employees. Over the 11 years of 2000 to 2011, the percent of small businesses offering insurance fell from 47% to 38%. [2] Today, almost half of Americas uninsured are small business owners, employees, or their dependents. The ACA will provide subsidized healthcare to 83% of small business owners currently uninsured. Small businesses with fewer than 25 employees benefit most. Small-business employees make up more than half of the workforce and are the main drivers of job creation. 3) The unemployed, self-employed, or no insurance offered by employer, and income above 138% Federal Poverty Level (FPL is $15,856 if you are single or $21,404 for married couples), can access the Health Insurance Marketplace and receive tax credits and/or tax subsidies if their income is between 138-400% of FPL www.healthcare.gov

y the time you read this, the Patient Protection and Affordable Care Acts Insurance Exchanges or Marketplaces will be up and running. Nineteen will be run by their respective states. Twenty-five, including Arizonas, will be run by the federal government. Seven states will be doing joint-partnership Exchanges with the feds. The Exchanges will be resources for those who do not receive insurance through their employer. I suspect that a lot of PCMS members and their office staffs will be looking into the Marketplaces. What groups are out there and how will they be affected? 1) If you are employed and receive insurance through employer, probably there will be no changes, unless the employer offers

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SOMBRERO October 2013

4) The unemployed, self-employed, or with no insurance offered by employer and income less than 138% of the FPL will be directed to the AHCCCS exchange www.azahcccs.gov. In 2014 an estimated 350,000 uninsured Arizonans could be added to the 1.3 million (one of five Arizonans) already on the AHCCCS roles. 5) Medicare enrollment will not change. Medicare will add some benefits, such as preventive care without co-pays. Private insurance Medicare Advantage Plans will receive fewer tax dollars because they have historically been paid more by the federal government than it cost to care for their patient populations. www.medicare.gov. No employer is required to offer insurance, but in 2015 large businessesthose with more than 50 employeeswill face the employer mandate, called the Employer Shared Responsibility Payment, which is a requirement that all businesses with more than 50 full-time employees provide health insurance for their employees or face a tax penalty. [3] Penalties for individuals failing to purchase insurance in 2014 will be the greater of one percent of taxable income or $95 per adult, $47.50 per child, up to a maximum of $285 per family. This amount will increase each year. In 2016 the penalty will be at the greater of 2.5% of taxable income, or $695 per adult and $347.50 per child (up to a maximum $2,085 per family). What are the consequences of the ACA? Intended consequences: 1) 20 -30 million people will now have access to health insurance. 2) Insurance companies cannot cancel policies or put lifetime or annual limits on coverage. 3) Young adults can stay on their parents policies until they are 26. 4) Pre-existing conditions will no longer be a factor in obtaining insurance. 5) Some preventive services will be covered without copay or deductible 6) Women will no longer be charged more than men. 7) The Medicare Part D doughnut hole will be closed by 2020. 8) No waiting period. Insurance is in effect from the moment of purchase. Unintended consequences: 1) Massive public confusion about the ACA. 2) If the law fails, the only current fallback is to return to pre-ACA healthcare. This may push us toward the type of system currently in place in almost all industrialized countries. Not socialized medicine, but a single-payer or Medicare-for-all

system. This may not be such a far stretch, as our tax dollars currently pay more than 50 percent of healthcare costs (Medicare, Medicaid, military, VA, government employees, teachers, firemen, police). 3) Large companies may opt to pay the penalty rather than offer health insurance to their employees. This would result in more people purchasing insurance through the Marketplaces. 4) Small companies will not be penalized for not offering insurance but, like large companies, they may also find it more cost-effective to direct their employees to the Exchanges rather than offering insurance. 5) Large companies are starting to play games to avoid the employer mandate penalty. They are reducing employees hours to fewer than 30 so they will not be considered full-time. The promise, If you like your health plan, you can keep it, may not play out if a workers hours are cut to less than full time. 6) Small companies may avoid hiring and/or keep the full-time numbers below 50 so as not to enter the employer mandate/ penalty zone. 7) Choice of insurance carriers and plans will depend on which ones show up in your Marketplace. This may result in better or worse choice. 8) Some physicians may close practices and/or choose not to join provider networks of Insurance Companies offering products on the Exchanges. 9) The relentless increases in healthcare costs are not directly addressed. Between 1980 and 2010 the average healthcare insurance premium increased seven percent per year, while average wages increased one to two percent per year. Since the recession began in 2008, healthcare cost inflation has slowed to about four percent. This good sign lacks a compelling explanation, and we lack compelling evidence that the ACA will significantly bend the cost curve downward. The ACA offers hopeful and encouraging changes as well as potential threats and challenges. [4] My bottom line is that the law is a step in the right direction. It is not the final destination. It is simply a part of our journey to create the best healthcare system for our patients.
REFERENCES 1. http://kff.org/health-costs/report/employer-health-benefits-2012annual-survey/ 2. http://money.cnn.com/2013/04/15/smallbusiness/health-insurance/ index.html#sthash.IxzhD0c7.dpuf 3. http://www.obamacarefacts.com 4. http://npalliance.org/wp-content/uploads/NPA-ACA.Quick_.Guide_. for_.Physicians.041311.pdf n

Questions:

SOMBRERO October 2013

B. In 2012 the U.S. spent about 50 percent more on healthcare per person than Switzerland, the country with the second highest per capita costs. U.S. is $8,233, Switzerland $5,270. A. The U.S. spends more than 17% of GDP on healthcare, the highest percentage of any country.

Answers:
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A. What percent of our GDP is spent on healthcare? 1) 11 2) 15 3) 17 4) 19 B. What do we spend per capita on healthcare costs? 1) $5,000 2) $6,000 3) $7,000 4) $8,000

Milestones

Dr. Farmer new Carondelet Foundation trustee


R. Screven Farmer, M.D. was recently elected as a new trustee on Carondelet Foundations Board of Trustees for the 2013-2014 fiscal year, the foundation announced. Dr. Farmer, president of Southern Arizona Anesthesia Services, joined PCMS in 1986. He served on our board of directors 20062010, and is a past-president of ArMA who also served as a delegate starting in 2004. He has served as a Pima Director to ArMA, and currently he serves at-large on the ArMA Board. Another PCMS member, Christine Donnelly, M.D., family practice physician with Carondelet Medical Group, also serves on the Carondelet Foundation Board of Trustees. Comprised of area business and community leaders, the Carondelet Foundation Board is responsible for generating charitable support and community awareness to advance the mission of Carondelet Health Network, Southern Arizonas only faith-based, not-for-profit healthcare system, the foundation said in a news release. Carondelet Health Network is a ministry of Ascension Health, the nations largest Catholic, not-for-profit healthcare system.

Dr. Lavor finds Afghan experience positive


By TMC Communications
Dr. Michael A. Lavor, 64, summarizes his medical stint in Afghanistan for the U.S. Navy over the past year as the Good, the Bad and the Ugly. Deployed from the Navy Operational Support Center in Tucson, he spent September 2012 through April 2013 directing medical operations at the base at Tarin Kowt, in southern Afghanistan. The Good included the fact that we were operating at a coalition base: a Dutch base with an Australian commander, Australian special forces, Slovakian security personnel, Singaporean surveillance, he said. It was amazing how so many people from so many places worked so well together. We did a lot of valuable training with Afghan personnel, educating them in medical procedures. Dr. Lavor was considerably older than most of his colleagues. He has long years of experience in vascular and trauma surgery in Tucson, and his medical record dates all the way back to military service as a corpsman during the Vietnam War. On the Bad side of this new experience, the environment was desolate, rocky, dusty and hot. And the Ugly obviously included the loss of life. But he said the experience was generallypositive, even in the face of such adversity. We were staying in temporary shelters, Dr. Lavor said. The isolation was especially difficult for the young troops.We managed to bring sanity back into our lives during downtime. We used things such as basketball, ping-pong, Christmas parties, and barbecues. We even made our own golf course, good for chipping and putting, with some help. He thanks Tucson golf pro Don Pooley and Southwest Greens of Tucson for providing the valuable golfing diversion. Dr. Lavor noted that the medical team served a vital function in treating anyone injured in the conflict whether coalition military personnel, Afghan civilians, or wounded insurgents. We were proud that 100 percent of wounded personnel brought into our base were treated successfully, and were able to leave the base alive. Continuing presence in Afghanistan is beneficial to the U.S., Dr. Lavor said. Our team did a phenomenal job in training Afghan medical and military personnel, and its certainly a positive situation for the Afghan people. There were many positive interactions. We saw the Australians bringing Afghan teens and other civilians in for training in construction and other skills. At 64, Dr. Lavor obviously finds age no obstacle to service.I would encourage physicians, even near the end of their careers, to consider volunteering, to give back.My being older helped provide stability for the junior officers and enlisted personnel. I had direct responsibility for the wellbeing of my crew as a senior leader. It helps to be in shape, he added. Older personnel generally face lower fitness mandates than the younger folks do, but Dr. Lavor
SOMBRERO October 2013

Dr. Gordon co-chairs national exam committee


Paul Gordon, M.D., M.P.H. was recently selected to serve as national co-chairman of the Test Materials Development Committee (TMDC) for the United States Medical Licensing Examination (USMLE) Step 2 Clinical Skills Exam, the University of Arizona reports. The USMLE assesses a physicians ability to apply knowledge, concepts, and principles, and to demonstrate fundamental patient-centered skills, that are important in health and disease and that constitute the basis of safe and effective patient care. Each of the three Steps of the USMLE complements the others; no step can stand alone in the assessment of readiness for medical licensure. Dr. Gordon is director of the Doctor and Patient Block and professor of Family and Community Medicine at the UA College of MedicineTucson. He has continuously served as a member of the Step 2 Clinical Skills Test Materials Development Committee and the Step 2 Clinical Skills Interdisciplinary Review Committee since 2005. A board-certified family practice physician, Dr. Gordons research interests include womens health, delivering medical services to under-served populations, and education. His practice includes care of hospitalized patients and provision of maternity care including delivery. In addition to his clinical practice, Dr. Gordon is a faculty member at the College of Medicine in Tucson, where he teaches and supervises family practice resident physicians and medical students, and directs the Doctor and Patient Block, which contains the Societies program at the college.
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noted that he managed to meet the physical qualifications of those 17-to-20-year-olds. Now, the bigger challenge for him, he admits, may be getting back to the workday routine at Saguaro Surgical P.C., treating patients at facilities such as Tucson Medical Center and the TMC Wound Care Center, and re-learning all those computer systems involved in practicing modern medicine in the U.S.

Dr. Chiu recruited national experts to the program, which now has seven surgeons including head and neck cancer experts specializing in reconstructive surgery. We have faculty here that can practice anywhere in the country, and we are so lucky to have them in Tucson, Dr. Chiu said. The UofA reported that the department is equipped to handle the most difficult cases, including that of Aundrea Aragon who made international headlines in 2012 when Dr. Chiu and Michael Lemole, M.D., chief of the Division of Neurosurgery, teamed up to repair cracks in the back wall of Aragons sphenoid sinus that allowed brain fluid to leak out of her nose. He and Dr. Lemole also partner to remove brain tumors through the nose. The department is drawing patients from throughout Arizona, New Mexico and Southern California. n

When sinus gets tough, Dr. Chiu gets going

The University of Arizona College of MedicineTucson was recently crowing about its nationally recognized ENT Division providing relief for patients with complex chronix sinusitis, inflammation of the nasal sinuses from which millions suffer and which can be debilitating and life-threatening. Alexander Chiu, M.D., professor of surgery and chief of the Division of Otolaryngology Head and Neck Surgery in the University of Arizona Department of Surgery and his team at UAMC are specializing in these challenging complex cases, helping the division to earn recognition as one of the nations top programs. Out of about 5,000 U.S. hospitals, UAMC was ranked No. 30 in ENT by U.S. News & World Report in its Best Hospitals list of 2013-14. Dr. Chiu was named one of the 2013 Best Doctors in America. Although we think of sinusitis as a fairly benign problem, its location can make it potentially a very serious problem, said Dr. Chiu, who specializes in endoscopic surgery. Your sinuses are right next to your eyeballs and your brain. You can have a serious eye or brain condition that started with a sinus infection. Instead of opening his skull, Dr. Chiu may treat by going through the patient;s nose and drilling open the frontal sinus, removing polyps and allowing it to drain. Thus, the patient is safe from having a brain infection. Recovery from the three-hour outpatient surgery is fairly simple. Endoscopic surgery results in no facial scars, less pain, and easier recovery. Dr. Chiu, author of the textbooks Atlas of Endoscopic Sinus and Skull Base Surgery and Sinonasal Tumor, is also the editor-in-chief of the leading journal on sinus disease, American Journal of Rhinology and Allergy. He came from the University of Pennsylvania three years ago to start the UofA otolaryngology division. I was tasked with building something from scratch, he said. I came in with a very determined plan to make this one of the best programs in the country. What I wanted to do was to focus on the tough ENT cases and these tend to focus around head and neck cancer, revision surgeries (surgeries that have been done two and three times) and complex ear surgeries.
SOMBRERO October 2013

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PCMS News

Stopping diabetes before it starts

The county attorneys office says that providing the free gun locks to parents is a common sense, practical way to promote firearm safety in our homes, and that through education and proper use of free gun locks, we can help prevent unnecessary violence and accidental shootings. Framed promotional posters in English and Spanish are also available for hanging in practice lobbies and information on the proper way to secure and handle firearms is provided. Dr. Norman Epstein of the PCMS Public Health Committee says getting the locks is simple. I called the phone number and within a week had four boxes of locks for the four physicians in our office. People see the signs, and I have already given out about a dozen locks. If you are interested in participating in the program, call the Pima County Attorneys Office at 740.5529.

The YMCA of Southern Arizona is participating in the Centers for Medicare and Medicaid Innovation (CMMI) grant that pays for atrisk, age 65+ people to attend an evidence-based diabetes prevention program in their community. (Adults under 65 can participate, but need to pay out-of-pocket or be in a health plan that covers participation.) The YMCA program is based on the CDC-led National Diabetes Prevention Program (DPP), which is designed to bring evidencebased lifestyle coaching programs for preventing type 2 diabetes into local communities nationwide. The AMAsAmerican Medical News recently published an article illuminating the positive impact the DPP has on patients, providers, and communities such as ours seeking to reduce the incidence of Type 2 diabetes. AMA has partnered with YMCA of the USA to raise awareness about prediabetes and to assist physicians and care teams in identifying and referring individuals at risk for Type 2 diabetes to the DPP at their local Y. If you are interested in more information about AMAs work with the YMCA, please contact Janet Williams at janet.willliams@ ama-assn.org.

OPTN/UNOS Board revises deceased-donor kidney allocation policy

The Organ Procurement and Transplantation Network and the United Network for Organ Sharing Board of Directors, meeting June 24 and 25 in Richmond, Va., approved substantial amendments to OPTN policy for deceased- donor kidney allocation. The policy will maintain access to kidney transplantation for all groups of candidates while seeking to improve outcomes for kidney transplant recipients, increase the years recipients may have a functioning transplant, and increase use of available kidneys. Implementation date of the policy was not immediately established, but is expected to occur in 2014. OPTN operates under contract with the U.S. Department of Health and Human Services, Health Resources and Services Administration, Division of Transplantation by the United Network for Organ Sharing (UNOS). OPTN brings together medical professionals, transplant recipients and donor families to develop organ transplantation policy. These changes will result in better long-term kidney survival and more balanced waiting times for transplant candidates, OPTN/ UNOS President John Roberts, M.D. said. Matching to increase benefit and use More than 96,000 people are listed for kidney transplantation nationwide. About 10 percent of kidney candidates die each year while waiting. Because there are not enough kidneys donated to meet the need, it is important to improve benefit by matching recipients according to the potential function of the kidney and ensure as many kidneys as possible are transplanted. The newly approved policy includes new factors not used in the current policy. Their use is recommended to enhance survival benefit and use of available kidneys. Existing policy definitions of standard criteria and extended criteria donors will be replaced with the Kidney Donor Profile Index (KDPI), a clinical formula that classifies donor kidneys based upon how long they are likely to function once transplanted. Kidney transplant professionals already have access to this index as an informational resource. The policy will also include a clinical formula to estimate the number of years each specific candidate on the waiting list would be likely to benefit from a kidney transplant. This score is called the Estimated Post-transplant Survival formula (EPTS).
SOMBRERO October 2013

Gun locks free for the asking

More than 144 physician offices and clinics are participating in a program through the Pima County Attorneys Office that provides free gun locks to physicians, clinics, and hospitals for distribution to patients with adolescents or children in the home. Last year PCAOs Community Addressing Responsible Gun Ownership program distributed more than 2,700 gun locks to the community. Since the program started in 2000, more than 35,000 have been given away. Using a cable-based design, the lock can secure the vast majority of pistols, shotguns, and rifles. The program is underwritten with funds seized from criminal enterprises.
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Under the new policy, when a kidney donor is entered into the matching system, that individual donors KDPI score will be considered along with the individual EPTS for compatible candidates. A limited number of kidneys expected to function the very longest will be considered first for the candidates expected to need them for the longest amount of time, said John Friedewald, M.D., chairman of the OPTN/UNOS Kidney Transplantation Committee. The policy is expected to increase overall life-years, or time that recipients retain kidney function after the transplant. It may also reduce recipients future need for repeat transplants, thus allowing more transplants among candidates awaiting their first opportunity. The kidney matching process would not change for the majority of kidney transplant candidates unless they receive additional priority based on other considerations addressed below. Promoting greater use The 15 percent of kidney offers estimated to have the shortest potential length of function based on KDPI score will be offered on a wider geographic basis. Transplant programs may be most likely to consider these offers for candidates who would have a better life expectancy with a timely transplant than they would remaining on dialysis. This feature is expected to increase utilization of donated kidneys currently available for transplant. It may also help minimize differences in local transplant waiting times across different regions of the country. The policy does not affect the decision-making process between an individual candidate and his or her transplant team regarding kidney offers they would be willing to accept for a transplant. The use of KDPI will provide the candidate and transplant team a clearer understanding of the potential function of the kidney to allow for more informed treatment decisions. Wait-time calculation As in the current kidney allocation system, the longer a candidate has waited for a transplant, the more priority he or she will have compared to others who have waited less time.

The current national default policy assigns waiting time when the candidate is listed with a program, even if he or she had begun dialysis or met other criteria for end-stage kidney failure before being listed. Under the amended policy, once a person is accepted as a transplant candidate, waiting time will be calculated from the date the person first had a GFR score (a standard clinical measure of kidney function) less than or equal to 20 ml/minute, or when the candidate began dialysis or other renal replacement therapy, even if that date preceded the transplant listing. n

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Public Health

Crisis Response Center provides much-needed services


By Jim Marten Communications Manager Community Partnership of Southern Arizona Communities nationwide are struggling to meet the financial and operational challenges of behavioral health crises. The extraordinary burdens placed on first responders, courts, jails, and hospital emergency departments, have become considerable public costs. Yet, it is most concerning that individuals experiencing a behavioral health crisis are unable to receive critical care, or are forced to endure significant wait-times, traumatically accentuating and perpetuating an illness. The Community Partnership of Southern Arizona collaborated with the community at large to establish a Crisis Response Center in August 2011, and CRC could not have been created without this support. Pima County voters approved bonds for the Crisis Response Center in 2006. CPSA immediately recognized that community response was needed to effectively identify needs, risks, and solutions. Participants included Pima County government, the University of Arizona Health Network, the UofA College of Medicine, law enforcement, courts, advocacy and peer-run organizations, and CPSA members and their families. The result is a welcoming, supportive facility to help individuals and their families stabilize from a crisis and return safely to the community. The CRC is noteworthy not only because it is the only one of its kind in the country, but because its working. Furthermore, individuals who receive behavioral health treatment earlier are more likely to recover and less likely to relapse. The CRC has demonstrated that providing quality and expedient care is the most meaningful and efficient method of addressing behavioral health crises. Simply put, the CRC reduces the burden on community resources, cultivates savings, and gets treatment to those who need it, when they need it. Its working. The CRC is just south of Ajo Way and Country Club Road, and is operated by the non-profit Crisis Response Network of Southern Arizona. As the Regional Behavioral Health Authority, CPSA provides oversight for the CRC and more than $15 million in annual funding for services. For further information about the CRC, please visit the CPSA website at www.cpsaArizona.org/CRC or call the CRC information line at 520.301.2400. If a patient is experiencing a behavioral health crisis, or is building toward a crisis, the Community-Wide Crisis Line can be reached at 520.622.6000. The trained staff will calmly request information, assess the situation, and work with the caller to determine the best course of action. Please call 911 for immediate or life- threatening emergencies. Editors note: Our Public Health Committee had some questions. Those and their answers follow.

CRC Crisis Line 622.6000

The CRC provides 24-hour services for anyone in Pima County experiencing a mental health or substance use crisis, regardless of insurance coverage. The control center for the crisis-care network, coordinating resources, responding to requests for hospital transfers, court-ordered evaluations, and dispatching Mobile Acute Crisis (MAC) teams, is a state-of-the-art call center. To ensure a safe environment, individuals also experiencing a chronic or significant medical situation may require treatment outside of the CRC. The crisis-care network and call center work with many medical and behavioral health professionals to coordinate care. Physicians, individuals, and community members can always reach out to the CRC because no one is turned away. At the CRC, law enforcement and other first responders transfer individuals using a specially designed one-stop drop-off point, providing expedient care and allowing first responders to quickly return to the street. The 60,000-square-foot center houses an expansive 24-hour observation area, and 36 beds for stays of 24 hours or longer. The CRC fosters recovery by providing members and their families access to advocacy, peer support, and CPSA providers to coordinate continuing care. CRC serves more than 12,000 adults and children annually; the on-site Community-Wide Crisis Line answers more than 15,000 calls every month; and first responders make 12 to 15 drop-offs daily. In addition, CRC has reduced demand on crowded emergency rooms and diverted offenders who have a mental illness from jail into treatment, when treatment is a more appropriate option for them.
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Integrating treatments for behavioral health crisis and significant medical needs currently presents safety and licensure challenges. CPSA is addressing the challenges, and has established integration as a goal. Please note that the CRC is not a medical facility, a medical urgent care, or medical emergency department.However, if an individual has chronic or significant medical needs and is experiencing a behavioral health crisis, the individual should still contact the community-wide crisis line at the CRC.The crisis line staff can direct the caller to the best location for the person in need. Generally, the CRC is currently unable to accept patients requiring medical services that are beyond the scope of an acute behavioral health facility. Nevertheless, patients will not be turned away. If a patient presents to CRC and has needs that are beyond its scope, the patient will be directed to a facility better equipped to meet the patients needs. CRC staff will coordinate the transfer and provide immediate crisis intervention until the transfer is completed. UAMCSouth Campus is in the same complex as the CRC, and houses ED beds specifically designed for patients who have psychiatric crises and major medical needs beyond the scope of a behavioral health facility.
SOMBRERO October 2013

A:

What about restrictions a physician may encounter, such as that the unit apparently cannot take patients who need certain medical support, like oxygen therapy? Are there additional restrictions, such as pts on home IV antibiotics? PEG tubes? Or other medical conditions? We need to know what the restrictions are in order to avoid sending a patient there who will ultimately be sent away rather than being admitted.

Q:

Q: When should a physician call the CRC, and what happens if A: Anyone can call the community-wide crisis line if an
you do? individual is experiencing a behavioral health crisis, or is building toward a crisis. Individuals can call for themselves or for a friend, family member, or patient.Trained staff will calmly request information, assess the situation, and work with the caller to determine the best course of action. The CRC call center maintains open connections to many medical and behavioral health professionals to best coordinate care. Anyone can call the CRC with confidence, because no one will be turned away.

Q: What options do physicians have when they encounter a

treatment: when the person is Persistently or Acutely Disabled (PAD); and when the person is Gravely Disabled (GD). PAD is typically for those suffering from chronic mental illness who are experiencing an increase in their symptoms acuity, or whose mental illness impairs their judgment to the point at which they are not able to consistently make safe and appropriate decisions for themselves. This kind of person does not necessarily have suicidal or homicidal ideas, but mental illness impairs his or her judgment, ability to reason and ability to control behaviors, or distorts perceptions of reality. A GD persons mental illness must so substantially interfere with their thought process that they are unable to attend to their daily needs such as feeding and dressing themselves, or even getting out of bed. What counts as a mental illness? Mental illness is a substantial disorder of a persons emotional processes, thought, cognition, or memory. Behaviors resulting from alcoholism, substance abuse, anti-social personality disorders, or intellectual disability are excluded from the T36 process unless the person also has a mental disorder. Who can initiate the process? Any responsible individual can initiate the process with an application. Often the applicant is a family member or member of law enforcement, but the applicant can be anyone with a concern for the persons mental health needs, such as a caregiver, case manager, neighbor, co-worker, doctor, or clergy. How do I get someone evaluated? There are two ways to begin the evaluation process: an emergent route (Emergency Application); and a non-emergent route (Involuntary Application or Pre-Petition Screening).

any other means of immediate harm, call 911. If otherwise, the CRC staff will gather information, may choose to call 911, or dispatch a mobile acute crisis (MAC) team to the location. They may also speak directly with the person, family member, or friend, and circumstances permitting, ask that the person come to the CRC.

A: If a person is threatening himself or others with a weapon, or

patient or family member they feel represents a real threat to themselves or others? What happens if we call the hotline?

Civil Commitment in Pima County


By Paula J. Perrera Deputy Pima County Attorney Incidents of mass murder across America, involving perpetrators who were diagnosed with mental illness, have sparked discussion about what mental illness looks like, and how to get treatment sooner for those in need. Most mentally ill people will never be involved in violent incidents such as those that made national news. They are fully able and willing to participate in voluntary treatment. The nature of mental illness, however, sometimes prevents individuals from having insight into the signs and symptoms of their illness, and it prevents them from fully embracing treatment and recovery. This is a concise overview of the involuntary commitment (often referred to as the Title 36 or Petitioning) process in Pima County for use in those instances when a person is in need of evaluation and treatment, but is unable or unwilling to seek or engage in appropriate treatment voluntarily. Who can be committed? An adult can be committed who, because of mental illness, is either unable or unwilling to participate in treatment on a voluntary basis and meets one of four standards. In Arizona the ability to have a person involuntarily evaluated and treated is not limited to situations where the individual is an immediate danger to him/herself or others (DTS or DTO). In addition to the traditional DTS or DTO processes, there are two other situations when a person may be involuntarily subject to evaluation and
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The process always starts with a phone call to 622.6000, the number for the Crisis Hotline staffed 24/7 by the Crisis Response Network, the agency that serves as traffic control for emergent or urgent behavioral healthcare. The CRN will walk the caller through the process and coordinate with the various agencies necessary to arrange the persons evaluation. Which one do I use? If the person is more likely than not to harm him/herself or another within the next 48 hoursthe time necessary for the Southern Arizona Mental Health Corporation (SAMHC) to perform a Pre-Petition Screening evaluationthe Emergency Application should be used and may be made by phone if necessary. If the person can remain safe for the next 48 to 72 hours, the Involuntary Application process is more appropriate. The decision to use an Emergency Application or an Involuntary Application is also influenced by the applicants knowledge of the persons behaviors. An Emergency Application requires that the applicant have firsthand knowledge of the facts requiring emergency evaluation. An Involuntary Application must be used if the applicant has not personally observed the behaviors in question, and concludes that the person has a mental disorder and is in need of evaluation based on second- or third-hand information. What happens next? When an Involuntary Application is completed, SAMHC will, within 48 hours (excluding weekends and holidays), perform a PrePetition Screening of the person at whichever location the person can be foundhome, nursing home, park, hotel, airport, etc. The person is not taken into custody, and may refuse to participate in

the screening interview. SAMHC then compiles a report based on interaction with the person and whatever other historical information they may have, and submits the matter to the medical director who then makes a determination if more evaluation is appropriate. If so, a Petition for Court Ordered Evaluation is prepared and submitted to the Pima County Attorneys Office for review and filing with the Pima County Superior Court. If the Court, upon review of the request for evaluation, agrees that an evaluation is appropriate, it issues an order requiring the person to submit to evaluation and another order directing law enforcement to retrieve the person from the community and transport him or her to an evaluation agency. If the person has not already gone to an evaluation agency, law enforcement has 14 days before the Order for Evaluation expires to locate the person and transport him/her to an evaluation agency. When an Emergency Application is initiated, SAMHC will send a Mobile Acute Crisis (MAC) Team to the persons location. The MAC team will contact law enforcement officials if they are not already involved. Once the MAC team assesses the person, they assist the applicant and law enforcement in securing an authorization from an evaluation agency to transport the person to an appropriate facility. Once at the evaluation agency, a psychiatrist examines the person and a determination is made about whether further evaluation is appropriate, and whether the person is able to submit to that evaluation on a voluntary basis. If the evaluation agency thinks further evaluation is warranted and the person is unable or unwilling to agree to it, the evaluating agency submits a Petition for Court Ordered Evaluation with the Pima County Attorneys Office, which reviews it and files it with Superior Court. The person is released if the evaluation agency determines further evaluation is unwarranted. Regardless of the type of application filed, once a court order authorizing an involuntary evaluation is issued, and the person arrives at an evaluation agency, that facility has 72 hours (excluding weekends and holidays) to perform a formal evaluation. A formal evaluation involves at least two physicians who are typically psychiatrists, and two other members of an evaluation team. During the evaluation period, the person is provided with an attorney and maintains a right to refuse treatment unless his or her behavior poses an immediate physical danger. The person also has the right to an independent evaluation, or to request release from the evaluation agency pending the evaluation, although requests for release are rarely granted. If upon evaluation the evaluating agency determines that the person is not able to accept and follow through with treatment on a voluntary basis, a Petition for Court Ordered Treatment is filed, at which point a hearing is set. Otherwise, the person must be admitted on a voluntary basis or released. What happens at the hearing? A hearing must be held within six business days of the filing of the Petition for Court Ordered Treatment. The county attorney is required by statute to elicit testimony from a minimum of four witnesses: the two evaluating physicians, and two other witnesses who are familiar with the person. The Rules of Civil Procedure apply, and the need for the court order
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must be proven by a clear and convincing standard of evidence rather than the less stringent preponderance of the evidence standard typically applicable to civil proceedings. The patient is provided with an attorney and has the right to call, examine, and cross-examine witnesses. The existence of a civil commitment case and all associated court filings are confidential. Hearings, however, are open to the public. What happens if the Court orders someone to participate in treatment? If the Court determines that an order requiring a person to participate in treatment is appropriate, it may order inpatient, outpatient, or a combination of inpatient and outpatient treatment. The number of days that a person can be placed in a Level 1 locked inpatient setting under a court order for treatment varies with the court findings: DTS 90 days; DTO 180 days; PAD 180 days; and GD 365 days. A court order for treatment is in effect for a period of up to one year. Persons who are found to be PAD or GD may have their orders extended at the expiration of the year upon a showing that the order is still necessary. Once a person is placed under a court order they have the right, every 60 days, to request that the court terminate its order early. The person is often discharged the same day or shortly after the hearing, and may return to residence or, based on their acuity level, to a step-down facility. Persons under a court order for treatment are subject to some supervision and restriction in treatment compliance, but are not subject to the same level of supervision that someone who is on probation or parole would expect. While under a court order for treatment, if a person experiences an increase in the acuity of their symptoms or becomes non-compliant with the treatment recommendations of their assigned treatment agency, they can be administered medications involuntarily and may be returned to a locked inpatient setting against their will. Important considerations In Arizona, involuntary evaluations and treatment may only be conducted by specially licensed entities. In Pima County there are currently three appropriately licensed evaluation agencies: University of Arizona Medical CenterSouth Campus (UAMC South); Tucson Medical CenterPalo Verde; and Sonora Behavioral Health. Additionally, in order for a person to receive court-ordered treatment on an outpatient basis, an appropriately licensed treatment agency must accept responsibility for that person. There are no private pay treatment agencies. Rather, a person must either qualify as Seriously Mentally Ill (SMI) or be Medicaid (AHCCCS)-eligible to be enrolled with Pima Countys Regional Behavioral Health Authority (RBHA), the Community Partnership of Southern Arizona (CPSA), the entity responsible for administering publicly funded behavioral health services in Pima County. Crisis services at the Crisis Response Center (CRC), at UAMCSouth Campus, are available to everyone regardless of ability to pay. n
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SOMBRERO October 2013

Time Capsule
By Dr. Kenneth R. Johnson

Alfred and Edith Erickson, TMCs founding benefactors


housewife. Her brother Ed was three years older and her sister Grace a year younger. The family lived at 3881 W. 18th St. in New York City. Early in the marriage, Alfred started his own advertising agency at 127 Duane St. in NYC. His first client was McCutcheons Department Store. Other early clients included Fiat Automobiles, Crawford Shoes, Bon Ami Cleanser and the Barrett Company. Newcomb Cleveland (of the Cleveland Baking Powder Company) joined him as his financial manager. In 1910 Erickson moved his office to a larger space at 381 4th Ave., by which time he had 50 employees. He was not merely the advertising agent for products he believed in; he would purchase stock, sit on boards of directors, and play an active part in sales strategies and management of companies including Bon Ami (Hasnt scratched yet.) and Valspar (The varnish that wont turn white.) Dr. Herbert Kalmus invented Technicolor in 1914. Starting in 1920, Erickson began investing in color movies and was a major owner of the Technicolor process. Erickson was chairman of the board for Congoleum-Nairn, a merger of Congoleum Co. and Nairn Linoleum Co. Stocks were good to Erickson, and his market investments made him very wealthy. His estimated wealth at one point was more than $48 million, equivalent to about $625 million in todays money. Descriptions of him at this time invariably note that he was short and squat, and neatly but not fashionably dressed. His friends called him Eric. He always seemed to be in a hurry, speaking in a

Many know that Tucson Medical Center, spotlighted in the JuneJuly Sombero, rose from the sturdy framework of the Desert Sanatorium, a treatment and research center dedicated to heliotherapy. Many also know that the Desert San was the brainchild of Bernard Wyatt, M.D. who had noticed during World War I that soldiers from Arizona had the lowest incidence of arthritis. Later, Wyatt was influenced by the research of August Rollier, M.D., who was Bernard Langdon Wyatt, M.D. founded the Desert Sanatorium using heliotherapy to treat in 1925 to further his interest in tuberculosis. In the early 1900s the concept potential of sunlight. of heliotherapy consisted of exposure to the sun on a daily basis, and even magnified with large lenses. Not only advocated as preventive and cure for diseases such as TB, the craze spread across the world and suntanning became looked upon as healthy. [curiouseh. wordpress.com] Even though it was discredited around 1940 as erroneous, having a suntan remained popular, which may be the origin of our current popular beliefs about suntanning. In Tucson the San had a pair of financial benefactors named Erickson. Alfred William Erickson is the American dream personified. Despite a lack of educational opportunity, influential contacts, or family capital, Erickson went on to become an advertising titan and philanthropist who collected paintings by old masters. Erickson was born in 1876 at Farmers Mills, N.Y. of Swedish descent. His only schooling was grammar school in Brooklyn. He never went to high school or college. His first job was handling packing cases at a grocery warehouse. Tired of manual labor, he applied for and got a job as an office boy at age 14. He worked his way up to advertising manager at the Cleveland Baking Powder Company. When Royal Baking Powder bought it, Erickson went to work for McCutcheons Department Store in Manhattan in 1900, and became advertising manager there. That was not the only change for him at the turn of the century. He also married Anna Edith McGrann that same year in New York City. Anna Edith McGrann was born in 1877 in New York City. Her father, Bernard, was a plumber who had been born in Ireland and was 34 when she was born. Her Welsh mother, Anna, was a
SOMBRERO October 2013 heliotherapythe healing

Anna Erickson on the patio of her home, Erickson House, now being renovated in the shadow of the new Orthopaedic and Surgical Tower. 17

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SOMBRERO October 2013

The Patio Building, built in 1928, was called the Desert Sanatorium Institute of Research and Diagnostic Clinic.

The Desert Sanatorium Administration Building was built along the road that evolved to todays Beverly entrance to TMC.

rapid staccato. He was given to snap judgments. He never owned a car and used Carey Cadillac Service when he needed transportation. He was known to be generous, but not wasteful. He endowed graduate study courses in advertising at Harvards Graduate School of Business Administration. Daily he would read classics or books on history and art criticism. He invested in antiques and in fine art, owning paintings worth millions, including works by Rembrandt (Aristotle Contemplating the Bust of Homer), Van Dyke, and Gainesborough. Theodore Roosevelt was among Ericksons friends. Erickson backed TR politically and even went hunting with him. Minnie and Dr. Bernard Wyatt were also friends. Anna Erickson and Minnie Wyatt were especially close. The Ericksons, in addition to their New York City residence at 110 W. 35th St., had a game lodge in New England. It was their tradition to invite friends to spend Christmas at the lodge, and the Wyatts were invited in 1924. It was there that Alfred Erickson agreed to put up the initial $25,000 for the Desert Sanatorium project, which was codenamed Tiny Tim, perhaps because the Dickens tale was always read aloud during an Erickson Christmas. Few other backers were found for the Tiny Tim project in Tucson. By 1927, Alfred and Anna had sunk $137,951 into the project (their eventual aggregate contributions to the Desert San topped $1.5 million). In March 1927, Alfred Erickson became sole owner of the San, holding the mortgage for the place, including 60 acres south of Grant Road. He was added to the board of directors. Construction on the Erickson home on the San grounds started on April 4, 1927. The architect was Henry Jaastad. Anna Erickson took to spending winters in Tucson, with her husband joining her when he could. Her companion in Tucson was Virginia Jean Markel. Anna was said to have had poor eyesight and was subject to severe headaches. Her friends called her Nancy or Miss Nancy. In 1930 Erickson merged his agency with Harrison King McCann (1880-1962), who had started with Rockefellers Standard Oil in 1911, and formed the McCann-Erickson Advertising agency, which became one of the largest in the world. It was the first to bill $100 million in TV and radio sales and has more than $20 billion in annual sales today. The agency is the source of such
SOMBRERO October 2013

The Desert San entrance in 1929. Over the decades, the TMC entrance on Grant Road at Beverly has been the hospital campus main entryway.

slogans as Put a tiger in your tank for Exxon, Id like to teach the world to sing for Coca- Cola, Army Strong for the U.S. Army, and There are some things money just cant buy for MasterCard. They also developed the Rice-a-Roni San Francisco treat jingle, and Things go better with Coke. Eventually McCann-Erickson had offices on Madison Avenue and in 130 countries around the world. Their motto became, The truth well told. Although he was the original chairman of the board, much of this came without Alfred Erickson. He had a stroke in 1935 and died on Nov. 3, 1936 in a hotel in Pasadena, Calif. where he had been living for six months. He was buried in Kings, New York. The crash and the Depression had reduced his fortune, but he was still worth $8 million at his death, or about $100 million in todays dollars. Anna took Alfreds place on the Desert Sanatorium Board of Directors. The 1940 U.S. Census lists her as widowed, living with her cook, Teresa Duffy, age 36, in New York City. World War II workforce shortages and travel restrictions made it difficult to keep the Desert Sans doors open. Yet war work and flight training had filled Tucsons hospital beds, and the San increasingly resembled a community hospital.
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In another Christmas financing, the community raised money in December 1943 to pay for needed remodeling. In March 1944 the San property was formally transformed into Tucson Medical Center, with the provision that if TMC failed to operate as a nonprofit community hospital at any time in the ensuing five years, the property would be returned to the Erickson Trust. TMC has met those terms to this day. Anna died on Feb. 7, 1961 at age 87 in her downtown New York City home. Her home and other land holdings were willed to TMC. Parke-Bernet Galleries sold the Erickson art collection. A Rembrandt went to the Metropolitan Museum of Art for $2.3 million. Tucson and the world have slowly forgotten the Ericksons. Even those who park in the garage next to their residence and work at TMC think only Erickson house and really dont remember why it is called that or who lived there. In 2012 McCann-Erickson dropped Erickson from the company name and is now known as McCann Worldwide. But these people, who believed in the Christmas dream that arthritis and TB could be conquered in the Arizona desert, put their money, time, and energy into a promising effort. The Ericksons should be remembered for that alone. But when the sun cure could not be realized, generosity from Anna gave us, in Tucson Medical Center, one of our enduring community institutions and landmarks. Recall that next time you pass by on Grant Road. Dr. Kenneth R. Scooter Johnson, general surgeon who recently retired, is a graduate of TMCs surgical residency program. He is a member of the PCMS History Committee whose interests include genealogical sleuthing and the health histories of American presidents.

TMC nurses 1964. When TMC was about 20 years old, ashtrays were still in the break rooms for nurses. By 2008, the whole campus was declared smoke-free.

Patient rooms in the Desert Sanatorium in the 1920s and 30s featured sunlight and fresh desert air.

Erickson building receives historic preservation award


Just days after the new TMC Orthopaedic and Surgical Tower opened its doors, the historic Erickson Building on the TMC campus was recognized with a local Historic Preservation Award From the Tucson Pima County Historical Commission, the hospital reported in July. The award recognizes organizations and individuals that make a commitment to restoring historic structures in Pima County. The Erickson Building is n the west side of the TMC campus, adjacent to the new Orthopaedic and Surgical Tower. It was designed and built in the 1920s for Anna and Alfred Erickson. The Erickson House also became home to TMC President Emeritus Don Shropshire and his wife during his team as chief executive beginning in the 1960s. The awards ceremony was at St. Philips in the Hills Episcopal Church. Richard Prevallet, TMC vice-president of facilities, attended the event with Mike Waters, TMC manager of facilities and construction, and Jon Daugherty, TMC facility project leader.
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It was excellent to see partners Mike and Jon publicly rewarded for their involvement in this project, Prevallet said. They were the driving force behind the Erickson House restoration. TMC conducted an assessment of structures on the TMC campus as part of the planned area development, and the Erickson Building was one of those identified as having historical significance and recommended for restoration. When we started this renovation project, the condition of the building showed definite signs of wear, Prevallet said. Restoration consisted of replacement of stucco, repairing walls and the roof, and extensive preservation of the exterior in order to protect the structure of the building. The Erickson, Patio, and Arizona buildings have been submitted for placement on the National Registry of Historical Places. Now that the Erickson Building is done, a study is moving forward on restoring the Patio Building and then the Arizona Building. n
SOMBRERO October 2013

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Associates Associatesof ofWealth WealthManagement ManagementStrategies Strategieso o er ersecuri securi titi es esthrough throughAXA AXAAdvisors, Advisors,LLC LLC(NY, (NY,NY NY212-314-4600), 212-314-4600),member memberFINRA, FINRA,SIPC. SIPC. Investment Investmentadvisory advisoryproducts productsand and services ered ered serviceso o eredthrough throughAXA AXAAdvisors, Advisors,LLC, LLC,an aninvestment investmentadvisor advisorregistered registeredwith withthe theSEC. SEC. Annuity Annuityand andinsurance insuranceproducts productso o eredthough thoughAXA AXANetwork, Network,LLC. LLC. Wealth Wealth Management ManagementStrategies Strategiesisisnot notaaregistered registeredinvestment investmentadvisor advisorand andisisnot notowned ownedor oroperated operatedby byAXA AXAAdvisors Advisorsor orAXA AXANetwork. Network. AXA AXAAdvisors Advisorsand andAXA AXANetwork Networkare arenot not a liated with Pima County Medical Society. PPG 69384 (07/12) a liated with Pima County Medical Society. PPG 69384 (07/12)

SOMBRERO October 2013

21

Makols Call
By Dr. George J. Makol

cardiologist, but I bet between the new patient consultation and the various cardiac tests, hundreds to thousands of dollars were charged. Maybe the provider payments should have been swapped. Maybe then I could trade in my Ford for a Mercedes! I dont mean to pick on cardiologists. Some of my best friends are cardiologists. Okay, so one of my friends is a cardiologist. Well, actually I once ran into a cardiologist in the parking lot as he was leaving a fancy five-star restaurant here in town; I was on my way in, having mistaken it for a Chinese takeout joint. We did talk for a while, which is kind of like being friends. You might well ask, have I seen such overzealous workups performed by allergists? I am sorry to admit, I have such a story. I had a difficult chronic urticaria patient (are there any easy ones?) and she was under control with antihistamine therapy. She asked if I minded if she consult a newly minted allergist/immunologist in Phoenix whom she had heard was brilliant. I knew the fellow, and he was well trained, so I gave her my blessing. In 2011 Lang et al. published a well circulated study on urticaria workups at Parkland Memorial Hospital in Dallas. Out of 1,872 lab tests ordered by the housestaff on 187 chronic urticaria patients, 1.6 percent of the tests were abnormal, and only one test out of the 1,872 ordered lead to changes in the patients management resulting in clinical improvement. The brilliant Phoenix doctor ordered approximately all 1,872 lab tests on my patient, and made her drive back up to Phoenix for another visit to tell her the labs were all normal. Of course, I had already called the Sonora Quest lab in Phoenix, and called her with all the normal results weeks before she went back up there to try to save her another co-pay and gas money. After all, we are in an energy crisis, and you all know what an environmentalist I am. And now I will probably have to treat her for anemia after all those blood draws. Every specialist I talked to before taking on this subject immediately said not to write about this controversial topic. But amazingly, as soon as they said that, they went on to tell me about some unnamed doctor in their specialty who orders far too many unnecessary tests, most performed in their own offices. And these guys are apparently among the highest-paid in town in each of their specialties. How does this do harm? Well, Medicare and private insurers have a treasure-trove of data, and they can tell you which doctors are costeffective, and which are profligate with testing. However, they refuse to use this data. They just wait and see which procedures are overused, and they cut reimbursement for all providers. So if you are like most doctors and play it straight, doing a good history and physical exam before ordering tests, you are getting the short end of the stick. Physicians charges make up only 20 percent of medical care costs in this county, but according to recent statistics, doctors control 80 percent of medical spending. Unfortunately I do not have an answer for this obvious but seldom discussed problem. The Accountable Care Organizations have been promoted as a cost-saving strategy, but the AMAs American Medical News recently reported that among ACOs that actually saved money for Medicare last year, more than 20 percent of the participating doctors refused to sign up for the next year. And as regular Sombrero readers know, I love my Ford and was just kidding about the Mercedes. Sombrero columnist George J. Makol, M.D. practices with Alvernon Allergy and Asthma, 2902 E. Grant Rd., and has been a PCMS member since 1980. n
SOMBRERO October 2013

This is only a test


Did you ever stop to think that how we are paid makes little or no sense? I think this is the reason that physician salaries have fallen far behind those of dentists, who have half our training; lawyers, who have one third of our training; and politicians, who have no training. Cutbacks in reimbursement are the main reason for our falling behind, so let us explore what may be driving such cutbacks. Im reminded of a story. Not long ago a female patient came in for her return visit for her mild asthma. She said right off, Doctor, my chest pain is still there and really no better. I have seen my primary doctor, and a cardiologist, and had every heart scan and test in the book, and no one knows why I have this pain. I quickly scanned the chart and found no mention in my prior history of chest pain. When I pointed this out, she said, I must not have mentioned it to you because you are just an allergist. I replied, Well, I am actually a real doctor, so why dont you tell me about your chest pain? She shrugged, and then touched her finger to her chest in the area of the third chostochrondral junction on the right, and then jumped up in pain in her chair. I asked if I could touch her there and she said O.K., and when I did she jumped in pain. I asked, Mary, is that the chest pain that you went to your primary care doctor and then a cardiologist for? She replied yes, that was the exact pain. I then said, Mary, you have Tietzes syndrome, and she quickly replied, Doctor, thats impossible, Ive never been to Africa. I patiently explained that Tietzes syndrome is an inflammation of the joint where the rib meets the sternum, and the pain can be reproduced by pushing on this joint. Frankly, any doctor who has ever been in an ER would check for this condition, and any third- year medical student could easily diagnosis this. In fact, I am pretty sure that the pizza delivery guy who came daily to our emergency room at Jackson Memorial Hospital in Miami could make this diagnosis merely from being around the medical staff. So I prescribed local heat and ibuprofen for 10 days, and the pain that she had for eight months disappeared. So why this story? After all, everyone including me misses a diagnosis now and then. Isnt that why the return visit was invented by Hippocrates, or was it Maimonides? Marcus Welby, M.D.? Whomever! I bring this up because I was reimbursed about $60 for this curative visit. Im not sure how much the primary doctor was paid, or the
22

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23

Financial Management
By John Stephens, M.D., M.B.A., C.F.A., C.F.P.

Lines in the sand: 2013 tax, income, and investment planning


Physicians and their advisers need to be aware of major changes affecting their financial planning as a result of the recent passage of the American Taxpayer Relief Act of 2012the fiscal cliff dealand stepped-up implementation of the Affordable Care Act. In this and a following article I will outline changes that are significant, define income lines in the sand, and most importantly outline steps taxpayers can take to limit this impact. This article addresses new rules and the tools for tax and investment planning related to adjusted gross income (AGI) for higher wage earners. The next will focus on more complicated planning issues related to changing your AGI to take advantage of lower tax thresholds. As a result of changes from passage of the 2012 tax act: 1) Tax rates for all but the highest income earners were left unchanged. 2) The Alternative Minimum temporary patch was made permanent and indexed for inflation. 3) The estate tax limits were set at $5.25 million, indexed for inflation, and remained portable. 4) The doctor Medicare patch was renewed for 2013 only. 5) Dividend and capital gains will remain at the same 15 percent for all but the highest income earners. 6) Personal exemptions will be phased out for higher income earners. 7) Itemized deductions will phase out for high earners. Coming into effect because of the Patient Protection and Affordable Care Act: 1) Increase in payroll taxes on high-income employees. 2) Medicare surcharge of 3.8% on certain investment income for high earners. Because many of the tax changes were for higher income brackets, there are three distinct divisions for income: 1. $200,000 Individual/$250,000 Joint Above this threshold, payroll tax is increased by 0.9% and an additional 3.8% Medicare tax is applied on unearned net investment income. Unearned net investment income includes rental income, dividends, taxable interest, capital gains, royalties, passive income, and annuity payments. 2.$250,000 Individual/$300,000 Joint In addition, personal exemptions and itemized deductions are phased out. Two percent of the personal exemptions are phased out for each $2,500 above the limit until they are completely phased out at $372,500 for singles and $422,500 for marrieds filing jointly. Itemized deductions are reduced by three percent of the amount by which AGI exceeds the threshold up to a limit of 80% reduction. 3.$400k Individual/$450k Joint In addition, the top federal tax rate increases to 39.6% and dividends and capital gains are taxed at 20 instead of 15 percent. Lets look at six impact-planning strategies: 1.Asset location If your income is greater than $200k Individual/$250k Joint, you are required to pay 3.8% Medicare tax on dividends, interest, and capital gains. Therefore it makes sense to

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SOMBRERO October 2013

hold the assets with income from those categories in your taxdeferred accounts. For example, if you have a $1 million IRA and a $1 million Trust and wanted a 60- percent equity and 40- percent fixed-income portfolio, the holdings that pay out ordinary interest, dividends, or generate capital gains, routinely should be held in the IRA. Taxefficient growth assets are preferred in the Trust. The same strategy applies to non-qualified dividend real estate investment trusts or REITs. At these AGI levels, they should always be held in a deferred account. 2. Active vs. passive Changing from a passive to an active partner/investor may be to your advantage. Active participants in partnerships and investments are not subject to the Affordable Care Act 3.8% surcharge. Check with your CPA and proceed cautiously; other issues such as liability and time available for active management are in this option. 3. K1 distribution vs. wages Because of the additional 0.9% payroll tax it may be even more important to limit W-2 wages and maximize K-1 distribution. Of course, you and your CPA will need to make sure your W-2 salary is appropriate, and there might be reasons relating to retirement plan funding that warrant higher wages. 4. Municipal bonds Because municipal bond interest is not subject to the 3.8% surcharge, consider municipal bonds if there is a purpose to hold bonds in a taxable account. Remember, well planned asset allocation would have taxable bonds in the deferred accounts. 5. Fill the tax bracket Any given year you find yourself in a lower tax bracket, and you expect to be moving into a higher bracket the next year, fill the lower bracket year with additional income. Filling the bracket might include harvesting capital gains, doing Roth conversions or taking IRA/annuity withdrawals. Note that IRA/annuity withdrawals prior to age 59-and-a-half are subject to penalties. The same strategy might be pertinent if you and your CPA find that you are subject to AMT tax. Because AMT is a 28% tax, you might want to add more AMT income that year if you will be in a higher bracket in the future. 6. Income shifting You may gift low-basis assets to low-income-bracket adult children (>26 years) or relatives, and they can sell those assets at a lower capital gains rate. As with all tax planning suggestions, it is important to consult with your CPA. In a subsequent article I will focus on more complex planning issues and strategies for lowering Adjusted Gross Income. Dr. Stephens is an Associate PCMS member. He specializes in helping physicians and senior-level execs build and maintain wealth, independent of their businesses. In 2010 he was named one of the countrys 150 best financial advisers for doctors by Medical Economics magazine. He can be reached at TCI Wealth Advisors, Inc., 733.1477 or www.tciwealth.com. n

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CME

October

Nov. 6-9: Mayo Clinic Hospital Medicine: Managing Complex Patients is at Loews Ventana Canyon Resort, 700 N. Resort Drive, Tucson 85750; phone 520.299.2020; reservations 1800.234.5117. Complexity and managemnent of hospitalized patients grows as hospital medicine continues to grow. Course addresses many of the challenges experienced by hospital-based healthcare professionals and provides a forum for exchange of clinical and practice ideas. Course uses an interactive, case-based format. Key highlights from most major areas of internal medicine and its subspecialties will be presented. CME to be announced. Website: www.mayo.edu/cme/internalmedicine-and-subspecialties-2013s964. Contact: Mayo School of Continuous Professional Development, Mayo Clinic, 13400 E. Shea Blvd, Scottsdale 85259; phone 480.301.4580; fax 480.301.8323 mca.cme@mayo.edu www.mayo.edu/cme. Nov. 13-16: Mayo Clinics Multidisciplinary Update in Breast Disease is at Westin Kierland Resort and Spa, 6902 E. Greenway Pkwy.,Scottsdale 85254; phone 480.624.1244; fax 480.624.1001. CME: AMA, AAFP, Nursing. info@kierlandresort.com http://www.kierlandresort.com/ Symposium provides a multidisciplinary overview of the diagnosis and treatment of benign and malignant breast disease with state-ofthe-art management. Faculty include experts in the fields of surgery, oncology, pathology, radiology, genetics and internal medicine. Website: http://www.mayo.edu/cme/internal-medicine-andsubspecialties-2013s846 Contact: Mayo School of Continuous Professional Development, Lilia Murray, 13400 E. Shea Blvd., Scottsdale 85259; phone 480.301.4580; fax 480.301.8323. mca.cme@mayo.edu http://www.mayo.edu/cme

Oct. 10-13: 16th Annual Mayo Clinic Internal Medicine Update: 2013 Session 1 is at Hilton Sedona Resort, 90 Ridge Trail Drive, Sedona 86531; phone 928.284.4040. CME accreditation to be determined. Course is practical update for primary care physicians, NPs, and PAs on subspecialty topics including allergy, cardiovascular disease, dermatology, endocrinology, gastroenterology, hematology, infectious diseases, integrative medicine, neurology, psychiatry, pulmonary, renal disease, rheumatology, and others applicable to todays practice and patients. It is also offered on Oct. 24-27. Website: http://www.mayo.edu/cme/internal-medicine-andsubspecialties-2013s898 Contact: Registrar, Mayo School of Continuous Professional Development, 13400 E. Shea Blvd., Scottsdale 85259; phone 480.301.4580; fax 480.301.8323 mca.cme@mayo.edu http://www.mayo.edu/cme Oct. 24-27: 16th Annual Mayo Clinic Internal Medicine Update: 2013 Session 2. Details as above.

November

Nov. 2-3: Southern Arizona Trauma Education: Sat/Sun TNCC at UAMC. Registration at Arizona ENA website. Thursday/Friday ATLS Provider course (open) + ATLS Refresher course (open) +ATCN (open) at Abrams Public Health Building. Registration: Carmen Martinez, 520.694.4806, or Carmen.martinez@uahealth.com. For more information on trauma education opportunities, contact Dan Judkins at UAMC Trauma: daniel.judkins@uahealth.com or call 520.490.7770.

Members Classieds
SEEKING NP FOR PAIN MANAGEMENT PRACTICE: The Integrative Pain Center of Arizona is currently recruiting a Nurse Practioner. We are Arizonas only pain clinic to be designated by our specialty society as a Center of Excellence. If you are interested in working in a patient centered environment where the goal is to help patients nd their way to wellness, whatever it takes, this is for you. Candidates are urged to review the IPCA website www.ipcaz.org. Job duties include intake evaluation; assessment of physical activity, diet, health risk factors and screening for mental health/behavioral risk factors; ongoing management of patients that includes pain treatment, diet and exercise, oversight of the integration of behavioral health treatment into the careplan, use of complementary and alternative medicine consultants, use of procedures to treat pain including routine injections, minimally invasive techniques and referral for surgical evaluation, and more. You will be working closely with experienced pain medicine practitioners. Successful candidates must have a current Arizona license and unrestricted prescribing privileges. Interested applicants please send resumes to bdavis@ipcaz.org. (10-13) PAIN MANAGEMENT PHYSICIAN NEEDED: Physician needed to join our Pain Management group practice that is expanding to meet current demand in our community. Full-time/parttime. Previous experience in a clinic setting is a plus, however, we are willing to train the qualied candidate that has the ability to work and collaborate in a team-effort environment with providers, supervisor, and ancillary staff. Patient care to include physical assessment, exam, formulation of care plans, new patient intakes, patient follow-ups, ordering, performing and interpreting diagnostic tests such as UDS, labs, imaging, etc., review and maintenance of records, patient education, and medication management with prescription writing and appropriate referrals. We offer competitive pay and benets, including PTO, medical/dental insurance with a discount vision plan available, & paid holidays. Will share on-call approximately 2 - 3 times per month with 1 weekend approximately every 5 - 6 weeks. Send Resume to karla@desertpainandrehabspecialists.com or fax: 602-331-2499 ATTN: Karla (9-13) MEDICAL OFFICE SPACE AVAILABLE: Modern, professional ofce space is available at Swan and Pima. Easy accessibility for patients and conveniently located near TMC and St. Josephs Hospital. Space is available immediately. Number of exam rooms, space, terms and rent is negotiable. Please contact Susan Wolff at 520-546-2420. (6-17) CABIN FOR SALE: Idyllic Mt. Lemmon retreat, with breathtaking view of Marshall Gulch. Arguably the best view on the Mountain. Located on deeded land in Sabino Loma Pines subdivision with the largest individual lots on the mountain. Extremely private with year round access. For details contact: Philip Fleishman M.D. at 444-8226 (10-13) OFFICE EQUIPMENT FOR SALE: Professional ofce reception desk. More than $4,000 new, but willing to sacrice for $1,500. Datum classic stack letter le holder. Perfect for medical or legal ofces or any ofce with lots of records that need to be organized. Retailed for more than $8,000 but only asking $4,000. Contact mmoran@retinacenterspc.com. (7-13)

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