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Sombrero

Pima County Medical Society


Home Medical Society of the 17th United States Surgeon General

M AY 2 0 1 3

I survived a Medicare audit

Our interim executive director Remembering Dr. Vincent Fulginiti

D DIIS SA AB BIIL LIIT TY YL LIIM MIIT TS SO ON NT TH HE ER RIIS SE E


YOU YOUEXAMINE EXAMINEYOUR YOURPATIENTS PATIENTSEVERY EVERYDAY, DAY,OFTEN OFTENDISCOVERING DISCOVERINGRISKS RISKSNOT NOTOUTWARDLY OUTWARDLYAPPARENT. APPARENT. BUT BUT HOW HOWOFTEN OFTENDO DOYOU YOUEXAMINE EXAMINEYOUR YOUROWN OWNRISKS? RISKS? IT ITMIGHT MIGHTBE BETIME TIMETO TOTAKE TAKEA ACLOSER CLOSERLOOK. LOOK.
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SOMBRERO May 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 Members at Large


Richard Dale, MD Anant Pathak, MD

Vol. 46 No. 5

PCMS Board of Directors


Diana V. Benenati, MD R. Mark Blew, MD Neil Clements, MD Interim 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

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

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

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

At Large ArMA Board


Ana Maria Lopez, MD,

Pima Directors to ArMA Timothy C. Fagan, MD R. Screven Farmer, MD Delegates to AMA


William J. Mangold, MD Thomas H. Hicks, MD Gary Figge, MD (alternate)

Arizona Medical Association Ofcers


Gary Figge, MD, immediate past-president

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

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.

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SOMBRERO May 2013

Inside
5 Letters: More on AHCCCS expansion. 6 Bill Fearneyhough: Our interim executive director
introduces himself. Mega Raffle.

8 PCMS News: Go ahead, you cant escape the TMC 13 Medicare: Dr. Tamra Whiteley Myers tells how she
survived a RAC audit. Fulginiti.

20 In Memoriam: Remembering Dr. Vincent A. 21 Pima County Medical Foundation News: PCMF
education awards and coming CMEvents.

22 Perspective: Dr. Michael F. Hamant on the politics


of contraception. patients.

25 Makols Call: Eurocare and American impatient


On the Cover
Soft light after sunset gives a relaxing glow to Saguaro National Park East (Dr. Hal Tretbar photo).

24 CME: Coming events for Continuing Medical


Education credits.

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Leers

Comparing choices on AHCCCS expansion


To the Editor: [Response to Dr. Jane Orient on AHCCCS, Letters, April Sombrero] Dear Dr. Orient, I read your opinion pieces in the Arizona Daily Star and Sombrero, and I would like to hear your response to some follow-up questions I have. As fellow Tucson physicians, I think we agree that Arizona legislators depend on our professional voices for accurate information and guidance on the issue of AHCCCS expansion. We are obligated to outline for them the facts, and the predictable consequences of a yes-or-no vote. It is hoped that physicians with different points of view can respectfully debate the issue, and in the process shed some light on the matter for policy makers to consider. Im not a left-wing ideologue. I am conservative with respect to many issues. For instance, I believe that the federal budget is hugely and disproportionately bloated, and that this is largely due to irresponsible federal spending on Medicare and Social Security. I think it is immoral to have a national debt in the range of 100 percent of GDP, as it guarantees excess taxation andausterity upon future generations. I think there should be means testing for Social Security benefits, as there is no rational reason to federally support people who are perfectly capable of providing for themselves.I think Social Security Disability benefits are abused, and granted to individuals who are indeed not physically disabled. I think Medicare covers goods and services that the federal government has no business spending money on, such as drugs for erectile dysfunction, duplicate electric scooters (yes duplicate!) for individual patients, certain brand medications, prohibition of volumediscounts on meds, organ transplantation in patients with incurable terminal conditions, bariatric surgery, etc. But when it comes to allowing citizens at or near poverty status access to basic medically necessary healthcare, such as treatment of fractures, gallbladder surgery, cancer, and so on, it is immoral to deny humans this type of care under threat of bankruptcy and loss of home. You mentioned that one reason to oppose expansion of AHCCCS is the policy of estate recovery (i.e. liens against property owned by patients). However, my understanding is that estate recovery only applies to individuals in AHCCCS who are requiring long term care services, so this is small subset.Also, the estate recovered is limited to $3,800/month, which is far less than the value of the care.As onerous as this is, isnt this policy far superior than the alternative of not expanding AHCCCS, which applies the equivalent of estate recovery (i.e. collections) to all patients whether they are in long term care or not, and which applies estate recovery exceeding the contracted value of provided services, with the additional burdens of bankruptcy, destroyed credit, and denied services due to inability to pay?At least under the AHCCCS system, it is retroactive and orderly; under the uninsured scenario, it is proactive and much more destructive.
SOMBRERO May 2013

You mentioned that one reason to oppose expansion of AHCCCS is the historically low reimbursement rates to physicians, resulting in physician restricting their AHCCCS panels. It turns out that the ObamaCare Affordable Care Act requires AHCCCS reimbursement to be raised to 100 percent of Medicare, so this concern is no longer valid. You also mentioned that the circuit breaker provision (automatic cancellation of expansion of AHCCCS if the federal government reduces its subsidy to the state) should be a reason to oppose the plan.I agree with you that the circuit breaker provision is horrible. But rather than killing the expansion outright, wouldnt it be far superior to modify the circuit breaker provision to automatically raise the necessary funding for the program from the corporate beneficiaries of the program, such as the participating health plans that you mentioned are receiving an unfair windfall from the program just by participating? I welcome your comments on these specific points, as I think they are crucial to a rational debate. Sincerely, Chuck Kaplan, M.D. Internal Medicine Tucson n

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A change at the office


By William C. Fearneyhough PCMS Interim Executive Director

n May 1 Bill Fearneyhough became Interim Executive Director for the Society, replacing Steve Nash who is now Executive Director at the Tucson Osteopathic Medical Foundation. These changes meant it was time to talk with Fearneyhough about the transition, what will be different as he assumes administrative leadership, and what the remainder of 2013 has in store for the Society. When did you find out Steve was leaving and were you surprised? I found out shortly after our board of directors was notified. I believe that was in February. Was I surprised? Yes and no. Over the years Steve and I have occasionally been approached by headhunters and other organizations. But to make such a major move it must be right for you, your family, make financial sense and for a lot of other reasons. Taking the TOMF position made a lot of sense for Steve and for the foundation. From what Ive learned, TOMF has a full agenda laid out for him and hes going to be very busy. When you work with someone for more than 20 years, you really get to know him as a colleague and a person. Steve has the ideal professional and personal qualifications and experience for his new job, just as he did for this one. Hell do a fantastic job. How do you replace someone whos been with one organization most of his adult career? You dont. Twenty-one years is a long time to run anything, which means you know everything about everything, even things nobody wants you to know. Theres no way I can replace someone that valuable right out of the box. You cant download the information from Steves brain into mine like a computer hard-drive. Im facing a huge learning curve, but in time Ill gain my footing. Meanwhile Ill be turning to the PCMS Board and all our members for support and help along the way. Im a quick learner. Ive faced a lot of challenges during my career. This is just one more. What qualifies you to be Interim ED? For the past 15 years Ive served as the Societys Director of Services and Membership, so I bring a lot to the table. Then
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again, I made it clear to our board that I was willing to remain as director if they wanted me to. I was flattered when the announcement was made. What other jobs have you held? For 10 years I was Carondelet Healthcares corporate director of public relations. I was also vice-president for marketing and PR at Introspect Healthcare for several years before starting my own firm. Before venturing into the corporate world, I was a reporter for print and electronic media. What is your educational background? Thanks to the GI Bill Ive been able to attend each of our state universities. I received my MA in journalism from the University of Arizona and my undergraduate, double-major degree in journalism and radio/TV broadcasting from Northern Arizona University. I also attended classes at the College of Business at Arizona State University. I never did finish my business degree, but it was time to put the books down and start a career. What changes will the transition mean? Other than learning my responsibilities as Interim ED, my first priority is to hire someone for the office. Ive been surprised to learn many of our members are unaware that for years now Steve and I have been the only full-time staff at PCMS. It has been just the two of us. Because of our complimentary skills weve been able to accomplish quite a bit during the years without the need for more full-timers. As for changes, I dont see any coming immediately other than I have already started re-negotiating vendor contracts to cut our overhead. The board and I have also discussed other proposals for cutting overhead and possible collaborative efforts with other Tucson health organizations, all of which are too preliminary to discuss here. But if we can realize them, PCMS will benefit. Whats in store for the rest of the year? The PCMS Board has made a major commitment to increase membership. That still remains the most important goal for 2013. About every five years we find ourselves needing to make a major push for new members. The simple answer to increase our rolls is to have every active members sign up just one non-member
SOMBRERO May 2013

physician and we would immediately double our membership. Sounds simple. I wish it worked that way. The board has set a goal of 75 new members in the next quarter. We are also considering a permanent committee to recruit membership. We have long needed such a committee. There are very valuable benefits associated with being a PCMS member but we need to do a much better job of getting that word out. Im also excited to say that by the end of the year the Society will have an online physician search site. We provide hundreds of referrals each year over the phone but the new site will allow the public to search our member physician database for specific specialties and office location. Each physician profile will include his or her photo, contact information, education background, sub-specialties, areas of interest, whether theyre taking new patients and a host of other information. We will also include a link to the physicians own website if they wish. These are exciting changes and they will be a big plus for our members and the community. Any final thoughts? I appreciate the confidence the PCMS Board has shown me through this new appointment. To our membership, please be patient because Ill be asking some dumb questions of you. Just remember, as in your medical education, its a learning process! n

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PCMS News

Exec Steve Nash exits PCMS; award created in his honor


As we went to composition a week before the event, we were about to celebrate with our Stars on the Avenue April 27, with part of the spotlight on PCMS Executve Director Steve Nash. Nash has served PCMS for more than 25 years. He was set to leave the Society May 1 to become executive director of Tucson Osteopathic Medical Foundation. To recognize Steves commitment to PCMS, the Board of Directors established the Steve Nash Award for commitment to the health of the Tucson community. Steve is the awards first recipient and it was set to be presented at Stars on the AvenueSaturday, April 27, to honor and celebrate Steve for his decades of unwavering loyalty and service to the Society and Tucson/Pima physicians.

vacations, and an array of the latest in electronics, jewelry, and home accessories. Tickets purchased by May 1 were entered in the Early Bird drawing on May 8, and re-entered for the final draw on May 29. Three Early Bird prizes and two grand prizes were to be awarded along with more than 2,800 other prizes. Mega Raffle coordinator and spokesperson Kathy Rice handselected each of the more than 2,800 prizes, many of which were purchased locally in Tucson to ensure the raffle not only benefits Tucson Medical Center, but also the Southern Arizona economy. I look for prizes with a real wow factorthings people dream about, Rice said. The real goal here is to create a winning proposition for all involvedTMC, its patients, and the community. Tickets were priced at $100 each with a limited number of three-ticket packages available for $250. We are Southern Arizonasnot-for-profit community hospital that is locally governed, said TMC Foundation Vice-President and Chief Development Officer Michael Duran, J.D. I am always interested in identifying new ways for TMC to generate funding that will support patient care. The big raffle fund-raising concept has been done in other locations nationally, and Barrow Neurological Institute in Phoenix pioneered it in Arizona in 2003. I saw that other hospitals were having success with the raffle format, and began looking at how we might be able to do the same. Duran said. One of the appeals about a raffle is it allows us to generate unrestricted dollars and generate support for programs from people in the community that may not give a traditional donation. I hope they feel good about buying a ticket that will help the hospital and give them the chance to win an amazing prize. The raffle is not just a first for TMC, but its a first for Southern Arizona, and we are excited to be the ones to introduce it to the community. Funds raised from the raffle are for programs and services that directly impact patient care, Duran said. These can include things like our Hospital to Home Program, our Breast Screening Program, therapies, and much more. In the first year we expect to do a better-than-break-even after covering our initial start-up costs, and then we expect to raise close to $1 million per year. Tucson/Pimas traditionally lower comparative economics present no obstacle, mega or otherwise, Duran said. People who like to participate in raffles come from all income levels and all ages and like the opportunity to win prizes.As a community hospital we have a unique advantage, as many people in Tucson were born at our hospital, had their children at TMC, and may have received care of some kind at TMC. We are uniquely positioned to offer residents statewide the opportunity to participate in the TMC Mega Raffle. By the time you get your Sombrero, Mega will be between its several deadlines. Our June-July issue will be devoted to TMC and we plan to include some results then. Two top Grand Prize winners will be drawn on May 29. First Grand Prize is an A.F. Sterling Home equipped with a brand-new Mercedes-Benz and $100,000 with a total value of $625,000 (winner may also opt. to take cash instead of home). Grand Prize No. 2 was being kept secret, so we hope no one from Wikileaks finds out. Participants who purchased their tickets before May 1 are eligible
SOMBRERO May 2013

TMC Mega Raffle has wow factor


By Stuart Faxon
It probably crept up on you as it did us. First was a radio interview with Kathy Rice. Then the TV ads blanketed your screen. Finally you got it smack in the face along with your USPS junk mail in 16 pages of full color. Even if youd tried, you could not escape the media attack of the Tucson Medical Center Mega Raffle. But escape was no ones plan. The plan was for one look at those prizes to send donors running for their wallets and purses with dreams of sugarplum rewards dancing in their imaginations. Mega is not an overstatement. Even the lesser of 2,800 prizes are fabulous and a participant has a one in 20 chance of winning one. TMC announced what it calls Southern Arizonas first-ever mega raffle in late March and made tickets available right away. Net proceeds from the raffle will benefit the hospital and its commitment to providing the highest standard of patient care to those in Southern Arizona. This is very exciting for the hospital and we are thrilled to introduce the TMC Mega Raffle to Southern Arizona, said Michael Duran, vice-president and chief development officer of TMC Foundation. The raffle gives Tucson Medical Center the opportunity to expand on innovative healthcare programs and services with unrestricted dollars available to invest in patient care. Raffle participants have a one in 20 chance of winning prizes, including a luxury home package, a variety of new cars, dream
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to win an Early Bird prize, the first of which is a 2013 Audi A5 and $14,000. EBP No. 2 is a six-night vacation to Banff and Lake Louise, plus a 2013 Honda Accord and $9,000. EBP No. 3 is the winners choice to a championship sports event in the U.S., plus $4,000. Early Bird winners were scheduled to be drawn May 8. TMC has been a not-for-profit community hospital since 1943. It is licensed for 629 adult, pediatric, and behavioral health beds. The hospital serves more than 30,000 inpatients and 122,000 outpatients yearly and has several emphasis areas, including maternal and child health, cardiac care, hospice care, neuroscience, orthopedics, diagnostic services, behavioral health, and senior services. TMC also created the regions first pediatric emergency department. For more information, please visit www.tmcaz.com.

AAP: Same-sex marriage in kids best interests


The New York Times reported March 21 in a story by Catherine Saint Louis that the American Academy of Pediatrics had declared its support for same-sex marriage for the first time, saying that allowing gay and lesbian parents to marry if they so choose is in the best interests of their children. The story was immediately picked up nationally. The academys new policy statement says same-sex marriage helps guarantee rights, benefits, and long-term security for children, while acknowledging that it does not now ensure access to federal benefits, the story said. When marriage is not an option, the academy said, children should not be deprived of foster care or adoption by single parents or couples, whatever their sexual orientation. AAPs review of the scientific literature began more than four years ago, and the result is a 10-page report with 60 citations. If the studies are different in their design and sample but the results continue to be similar, that gives scientists and consumers more faith in the result, said Dr. Ellen Perrin, a co-author of the new policy and a professor of pediatrics at Tufts University School of Medicine. Other scientists called the evidence lackluster and said the academys endorsement was premature, the story said. Loren Marks, an associate professor of child and family studies at Louisiana State University in Baton Rouge, said there was not enough national data to support the pediatric associations position on same-sex marriage. National policy should be informed by nationally representative data, he said. We are moving in the direction of higher-quality national data, but its slow. The academy cited research finding that a childs well being is much more affected by the strength of relationships among family members and a familys social and economic resources than by the sexual orientation of the parents, the story said. There is an emerging consensus, based on extensive review of the scientific literature, that children growing up in households headed by gay men or lesbians are not disadvantaged in any significant respect relative to children of heterosexual parents, the academy said. A large body of evidence demonstrates that children raised by gay or lesbian parents fare as well in emotional, cognitive and social functioning as peers raised by heterosexuals, the academy said.
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One study in England compared 39 families with lesbian mothers to 74 heterosexual parents and 60 families headed by single heterosexual women. No difference was found between the groups in emotional involvement, abnormal behaviors in children as reported by parents or teachers, or psychiatric disorders in them. Both mothers and teachers reported more behavioral problems among children in single-parent families than twoparent ones, whatever their sexual orientation. A 2010 study of children born to 154 lesbian parents in the United States compared mothers reports of their 17-year-olds to a national sample of age-matched peers. The mothers reports indicated that their sons and daughters had high levels of competence and fewer social problems, compared with their peers. Marriage strengthens families and benefits child development, and it also increases a parents sense of competence and security when they are able to raise children without stigma, said Dr. Nanette Gartrell, lead author of the study and a visiting scholar at UCLA School of Law. The research on same-sex marriage has limitations, experts note, including the relatively small sample sizes of gay or lesbian parents even in long-term studies. Many studies have relied on parental assessments of their childrens well being, and there is relatively little data about the well being of children raised by gay men compared with lesbians. Many studies compare wealthy, well-educated lesbian mothers to single heterosexual mothers instead of married couples, Dr. Marks said. This matters, because children from married families do better on numerous outcomes including psychological and physical health and avoidance of high-risk behaviors than children of single-parent families.

UA surgery dept. announces new ENT residency program


The Department of Surgery at the UofA College of Medicine has received American Council on Graduate Medical Education (ACGME) accreditation for an OtolaryngologyHead and Neck Surgery Residency Program, the university reported March 28. Scheduled to begin July 1, the program will be the second otolaryngology training program in Arizona and the sole training program for Southern Arizona. The five-year residency training program in head and neck surgery will be based at The University of Arizona Medical CenterUniversity Campus. One physician-resident will be added each year until the program is full with five residents. The otolaryngology training program provides residents with education in comprehensive evaluation, as well as medical and surgical management, of patients of all ages with diseases and disorders of the ears, upper respiratory, upper digestive system and the head and neck. Led by Alexander Chiu, M.D., professor and chief of the Division of Otolaryngology Head and Neck Surgery, and Audrey Erman, M.D., assistant professor of surgery and codirector of Head and Neck Oncology, the new program will follow ACGME program standards. In addition to the new program, the Department of Surgery has ACGME-accredited residency training programs in general surgery, neurosurgery, urology and vascular surgery. Our emphasis is on top-notch education for the new generation of otolaryngologists for Arizona, Dr. Chiu said. Dr. Chiu has built an extremely successful otolaryngology division in only two years, said Rainer W.G. Gruessner, M.D., surgery department chairman. The approval for the Department of Surgerys fifth accredited residency program demonstrates the success and growth of the division and the facultys commitment to training future ENT surgeons.

Only two openings left for THMEPing downriver


As we went to press, Dr. Richard Dale told us he was pleased to report that there were only two spots left for the Tucson Hospitals Medical Education Programs 4th Bi-Annual Colorado River Medical Conference is scheduled for July 16-21 to go down the river through the Grand Canyon. Please call Dr. Dale at 721.8505 or e-mail him at rdale9136@aol.com if you would like to be one of the people who fill it out. Significant others and children age 8 and older are invited, Dr. Dale said. We leave Lees Ferry Tuesday July 16 at 8 a.m. and return there Sunday July 21. This trip is mildly strenuous, potentially dangerous (large rapids) but extremely fun and educational. Conference topics include general and vascular surgery, plastic surgery, orthopedics, and internal medicine. About 12 AMA Category 1 CME credits are pending. Registration is $200 for physicians and affiliated dentists, and $100 for RNs, residents, allied health professionals and medical retirees. Deposit is $500 per person. Cost is $2,400 for the full trip plus the registration fee, exclusive of one nights lodging at Marble Canyon.
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Dr. Weinstein fights health illiteracy


A University of Arizona College of Medicine Pilot Project is introducing med school coursework to middle- and high-school students in an effort to combat health illiteracy, the university reported in March. Health illiteracy is rampant in the U.S., as practicing physicians know all too well, they said. This problem is fueled in part by the severe lack of a suitable curriculum on common human diseases in K-12 education in U.S. schools. Two nationally noted professors at the UofA CofM in Tucson have implemented whats being called an innovative pilot project to
SOMBRERO May 2013

introduce high school, and now middle school, students to graduate-level medical science coursework. Ronald S. Weinstein, M.D., a national award-winning medical educator and innovator and founding director of the Arizona Telemedicine Program, said, We are not adequately preparing U.S. students to take lifelong responsibility for their own healthcare. Dr. Weinstein and Anna R. Graham, M.D., professor emeritus of pathology, recently introduced two medical science courses for K-12 students, one for 12th-grade students at BASIS Tucson North School, and the second for eighth- and ninth-grade students at BASIS Oro Valley School. Both professors are College of Medicine Basic Science Teacher-of-the-Year Lifetime Award winners. Lack of standardized K-12 coursework on our most-common lifethreatening diseases, such as heart disease, cancer, stroke and diabetes, in our K-12 schools, is at cross purposes with the Affordable Care Acts assumption that patients will take more responsibility for their own healthcare, Dr. Weinstein said. I think were headed for a national crisis generated by misconceptions about what American patients currently know about their own diseases. Small numbers of K-12 students are getting a smattering of exposure to medical science, but its not nearly enough. Since 2008 the Arizona Telemedicine Programs T-Health Institute in Phoenix has been offering components of a medical science curriculum to high- school students. Early versions of the curriculum were offered in Phoenix and Tucson as a six-week Sir William Osler Summer Fellowship Program at the T-Health Institutes videoconferencing facilities at the UA College of MedicinePhoenix. The following year, this medical science curriculum was delivered as a yearlong lecture series for students at the Phoenix Union Bioscience High School. This year, the curriculum is being incorporated as a one-trimester course into the curriculum of two BASIS schools in the Tucson area. Our decision to offer our T-Health Institutes Sir William Osler medical science course as a regular school course at BASIS Tucson North was easy, Dr. Graham said. We found BASIS teachers receptive to innovation and they cut through red tape. The BASIS students we work with have a wonderful work ethic and they are fully engaged in classroom activities. They know how to ask great questions and they want to learn everything we can teach them. The Osler medical science course was introduced as a 12th-grade capstone course at BASIS Tucson North last fall. All of the students passed this single-trimester course. Currently, the medical science course is being given as an eighth- and ninthgrade course at BASIS Oro Valley. Dr. Weinstein has been wrestling with the health literacy issue since 1975 when he was named Harriet Blair Borland Professor and chairman of pathology at Rush Medical College in Chicago. At Rush, he established an open-door policy and encouraged families of deceased patients to come to Rush-Presbyterian St. Lukes Medical Center, Rushs flagship teaching hospital, to discuss autopsy results of any deceased family member with him. Dr. Weinstein had intensive training in autopsy pathology in Boston and knew the potential benefits that could come from discussing autopsy findings directly with family members. Although many families took him up on his offer over the years, Dr. Weinstein found that patients family members often lacked a rudimentary understanding of the mechanisms of diseases,
SOMBRERO May 2013

Mohammed H. Nomaan, M.D. has been named as a Leading Physician of the World & Top Pediatrician in Tucson by the International Association of Pediatricians. Dr. Nomaan was also honored as PCMS Volunteer of the Year during Stars on the Avenue April 27 (Steve Nash photo).

despite its coverage in newspapers and magazines. Therefore, he began to explore the root causes of the low level of health literacy among patients in the United States. Dr. Weinstein traced this low level of U.S. health literacy back to recommendations made years earlier, in the highly influential 1910 Flexner Report. Although unknowable at the time, the Flexner Reports recommendations inadvertently discouraged teaching U.S. high-school and college students about human diseases years later, by encouraging that courses on human disease, including pathology, be taught exclusively in medical schools. Today, a college journalism student would be hard-pressed to find coursework on human diseases on our state university campuses, despite an interest in medical reporting, Dr. Weinstein said. Throughout the U.S., pre-med students can graduate from college knowing little about disease processes.

Med students get scholarships for aging research


The Arizona Center on Aging at The University of Arizona announced in April that four College of Medicine students have won scholarship awards for the prestigious Medical Student Training in Aging Research (MSTAR) program, administered by the American Federation for Aging Research (AFAR) and the National Institute on Aging (NIA).
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The highly competitive MSTAR award was established to encourage medical students, particularly budding researchers, to consider careers in academic geriatrics and, ultimately, to assist in meeting the growing demand for physicians and scientists with special knowledge and skills in aging. Applicants compete for 110 national scholarships at NIA-funded training centers and/or partner sites, including the UofA. Chosen on the basis of their academic excellence, interest in geriatrics and potential for success, students participate in an eight-totwelve-week, structured research, clinical and didactic program in geriatrics and are mentored by national leaders in the field. The 2013 MSTAR award winners from the UA College of MedicineTucson are Stewart Dandorf, Johns Hopkins University (HIV, aging, immunity and frailty); Sarah Daley, UCLA (dementia); Melissa Ludgate, University of North Carolina (geriatric emergency medicine); and Kirandeep Sumra, UCLA (emergency medicine). The 2013 MSTAR award winner from the UA College of MedicinePhoenix is Carmel Moazez, Johns Hopkins University Wilmer Eye Institute (geriatric ophthalmology). Each MSTAR awardee will spend eight to 12 weeks at the assigned research facility and get a stipend of up to $5,400. Program participation includes submitting a journal-style paper within three months of completing the program and presenting a poster at the annual meeting of the American Geriatrics Society in May 2014. During the annual meeting, they also will participate in a roundtable discussion with prominent aging and geriatric research scholars. Since its inception in 1994, the MSTAR program has trained nearly 1,500 students from more than 100 medical schools and has led many physicians-in-training to pursue academic careers in aging, contributing to the ultimate goal of improving the health and wellness of seniors nationwide. The programs major sponsors are the John A. Hartford Foundation, MetLife Foundation, and NIA. Mindy Fain, M.D., co-director of the ACOA, professor of medicine at the UA College of MedicineTucson and co-director of the Arizona Center on Aging said, We are building a cohort of students with aging-research interest, as well as a great national reputation. This award is recognition of the skills and motivation of these exceptional students, as well as the successes of the UA students who came before them. Faculty sponsors of UA applicants for the AFAR/MSTAR awards are Dr. Fain and Jane Mohler, Ph.D., M.P.H., N.P. and co-director of the Arizona Geriatric Education Center. Doctors Fain and Mohler will continue to mentor the awardees in academic geriatric career development throughout their med school experiences.

nonsurgical technique is used in angioplasty procedures called percutaneous coronary interventions to unblock clogged arteries. Candidates for this procedure often have had a heart attack, have heart disease, or experience unstable angina, a type of chest discomfort caused by poor blood flow to the heart. Today, nearly three years after Carondelet started offering the procedure, the healthcare system proudly announces that nearly all 200+ patients who have received a transradial cardiac catheterization at one of its hospitals have experienced procedural success with a near-zero percent complication rate. Before this procedure was available, a patients principle option was standard catheterization. The transradial approach can successfully unblock arteries using a catheter inserted into the patients wrist instead of in the femoral artery in the groin. They said that benefits of transradial cardiac catheterization to patients are: Equally successful to femoral (groin) catheterization. Less procedure-related bleeding, lower risk of complications. More comfort, allowing patient to immediately sit upright. Same-day discharge for low-risk patients, as opposed to an overnight stay. Freckle-sized scarring. Procedure is much less expensive. Transradial cardiac catheterization has enjoyed much success in Europe since the early 1990s. Although this approach has steadily increased in Europe and Asia, adoption in the U.S. has been slow. Of the nearly 600,000 procedures performed in the U.S. in 2010, less than 2 percent were performed with this approach. Carondelet has been very instrumental in bringing this state-of-the-art procedure to Tucson, says Joseph Chambers, M.D., F.A.C.C., F.C.C.P., F.S.C.A.I., an interventional cardiologist at Carondelet St. Josephs Hospital. There are relatively few physicians in Southern Arizona who perform elective transradial cardiac procedures. There are even fewer who opt for this approach emergently. Cardiologists who perform angiograms with this technique do them almost exclusively because this procedure offers the same results as standard femoral approach catheterization with two significant advantages to patientscost and comfort. Around the same time as the CHVI announcement, Carondelet St. Marys Hospital announced that Healthgrades had honored the Westside campus as among the nations top five percent of hospitals for the third year in row. Healthgrades examines thousands of hospitals on mortality and medical complication rates in up to 27 areas, including critical care, heart failure, surgeries and joint replacement, they said. Out of the more than 5,000 hospitals reviewed, only 262 received this prestigious award. Carondelet St. Marys was one of only eight Arizona hospitals, and the only one in Tucson, to receive the designation of 2013 Healthgrades Distinguished Hospital Award for Clinical Excellence. Carondelet St. Marys President & CEO Amy Beiter, M.D. said this recognition always provides a wonderful feeling of accomplishment to the hundreds of physicians and more than one thousand associates who call St. Marys home and treat their patients like family. It speaks to the deep commitment of our physicians, nurses and associates who make St. Marys one of the finest acute care facilities in Southern Arizona. n
SOMBRERO May 2013

CHVI trumpets arterial procedure


Carondelet Heart & Vascular Institute recently claimed lower complication rates and lower costs to patients for its state-ofthe-art procedure for blocked arteries. Carondelet Health Network has been instrumental in making an internationally leading surgical procedure called transradial cardiac catheterization available in Southern Arizona, they said. The

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Medicare
By Tamra Whiteley Myers, M.D.

How I survived a Medicare audit


Its May 2011, four days before I am to leave on a trip to Ireland to celebrate my 25th wedding anniversary. It is a day like any other in my dermatology office until the mail comes, and with it a rather fat envelope from a company called HDI: Health Data Insights. When my staff brings me a piece of mail with a shellshocked look on their faces, the news is never good. HDI is the Recovery Audit Contractor for my Medicare carrier. I am now the subject of a RAC audit. Each Medicare carrier nationwide is contracted with a company to review paid claims for processing errors as well as fraud and abuse. Each company is paid a portion of the proceeds they recover on Medicares behalf. The letter I received is called a demand letter, and I cant believe what Im reading. This company tells me that I never performed Mohs surgery on 10 patients for which I billed and was paid by Medicare. Since I billed these services without actually having provided them, I must return all the money ASAP. Before I can finish packing my suitcase, I have two additional letters covering the surgeries of seven more patientsa demand letter can include one patient or manyall with the same message: Pay up, or appeal if I think the letters are in error, because I if I dont pay up or prevail on appeal, I will owe the money plus 10.75 percent interest. I put in an anxious call to HDI, and they confirm that this is a computer- generated audit, and say that surely I have done something to warrant this scrutiny. Mohs surgery is a microscopically controlled surgical removal technique for complex skin cancers. I have done Mohs surgery for almost 30 years, and no entity has ever tried to tell me I didnt do it by the book. Because Mohs surgery is labor intensive, it pays well. Taking advantage of these heftier fees, some dermatologists and non-dermatologists in
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the past billed for Mohs, but actually had a pathologist evaluate the surgical tissue for residual tumor. That was and is against the rules, so it is now codified that the doctor billing for Mohs must be both the surgeon and the pathologist. You have to surgically remove layers of skin for processing, and you must also do the processing of frozen sections to evaluate for residual tumor. I have my own CLIA-certified in-office lab to do just that. At this point, I cant get a straight answer from HDI about how I became ensnared in the audit, but I have an idea. On days that I performed Mohs and let the surgical defect close on its own by second intention, or I referred the patient to a plastic surgeon for closure, I am not an audit candidate. On days I performed Mohs and reconstructed the defect with a linear closure, removing some extra tissue at the ends of the closure called redundancies, I have an audit on my hands. HDI wont tell me directly why this is the case, but using the 20 questions of the is it bigger than a bread box variety, they confirm that the hang-up is the redundant tissue I removed and sent for permanent processing for storage. I send this tissue to my local histopathology lab for processing (I do frozen sections for Mohs, not fixed tissue processing), and when the lab sends in

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a bill for that service on the same date of service as my Mohs, the Medicare computer is not at all happy. I have sent redundant tissue for processing for many years on the theory that if these tumors were complex, why would I throw away any tissue related to their removal, even if it was part of the reconstruction after Mohs? That approach always appealed to my Midwestern sense of caution, and a notquite-compulsive urge to save everything that might be important someday. I have used Pathology Biomedical Consultants Labs run by Dr. Paul Sagerman for my pathology needs for decades. Paul was completely correct to bill for his service. However, the computer saw his processing fee for the reconstruction redundancy, and assumed incorrectly that PBC Labs did the Mohs work as well. It is an absurd notion, since a Mohs surgery cant be done with one permanent tissue section, but the apparent conflict was sufficient to give the RAC cause to doubt me. There are three different ways to appeal a demand letter: discussion, rebuttal and redetermination. For discussion, your appeal paperwork goes back to the audit company and must be delivered and adjudicated in 40 days. The rebuttal option is only available for those who plead financial hardship, and though I am not there yet, I have a premonition that I might be someday soon. This option for now is closed to me, so I settle for re-determination. This option gives you plenty of time to put together an appeal which goes to the Medicare carrier, Noridian, and not the RAC people, but they have 60 days to get back to you which means you are in the for long haul. Before leaving on my trip, I spend long hours putting together a thick packet of information for each patient in dispute for re-determination, including a four- page letter outlining my reason for appealing. I include clinic notes, surgical notes, reconstruction reports, and billing and payment information. Its a yeomans job for me and my staff to pull it all together in just a few days, but by the time I leave, every patients appeal packet has been sent by certified mail. As far as the money goes, Medicare will take a check for what they say you owe them, or they will recoup the funds you owe from the payments you are getting in real time. You can also just wait out the whole process, and be assessed the total you owe plus that outrageous interest rate if you dont prevail.
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SOMBRERO May 2013

I believe that where the government is concerned, you can be right but still not prevail, so I elect to have Medicare recoup the money in real time. So from that first fateful week of May 2011, my Medicare explanation of benefits come with lots of data on patients seen and services provided, but the dollars paid at the bottom of the form is always 0. Fast forward to the end of my anniversary celebration, and six new demand letters have arrived, bumping up my disputed patient totals dramatically. The dollar amount involved is rising quickly, so with an equally rising sense of panic, I contact a healthcare regulatory attorney to give me some advice and moral support. I speak with Julie Nelson who practices medical regulatory law in Phoenix, and after hearing my story, she asks if I work for a clinic or hospital. When I tell her that I am in solo practice, she responds that she thinks I am the first individual physician in the state to be the subject of a RAC audit. Wonderful. Who doesnt want to be first? Right from the beginning, Julie thinks my case is strong and that I will ultimately be vindicated, but she warns me that it is unlikely that my first level of appeal will have a favorable outcome. That is when I discover there are three levels of appeal, and that I might need to run through them all to get that favorable decision.

expert in regulatory medicine. Our cash flow is relentlessly ticking downward, and worst of all, we are collectively dispirited. In succession, the 17 letters trickle in. All 17 patient appeals are judged UNFAVORABLE. I thought nothing could cause me more despair than the audit itself, but now I find that a copy of each unfavorable decision letter is sent to the patients involved, informing them that not only did their doctor not do their Mohs surgery, but she has lost her appeal to convince Medicare otherwise. Medicare acknowledges the dollar amounts owed in these letters, so soon the phone calls start coming in from anxious patients. Most of them misinterpret the letter, and think that they owe money to someone. Many are incredulous about the allegation that I did not do their surgery. Of course I did, because they were there and have the scar as proof. Their concern touches me, and along with Julies confidence, I feel better. I want these patients to know my side of the story, so with Julies blessing I draft a letter explaining the audit and the appeal. I send the draft to Julie to review, and she scraps the entire thing as too complicated, too defensive and too angry. But it is complicated, and I am more than defensive and angry. Cooler heads prevail, and a one-paragraph Its all going to be O.K. letter goes to each patient. The anxious phone calls stop.

She reviews the letter I prepared and Nearing the end of summer 2011 I am sent for my initial batch of patients, and awash in demand letters. Tens of believe that where government thousands of dollars are at stake. reworks it for clarity and better legalese. She also encourages me to is concerned, you can be right but Medicare is recouping all those funds, so add to my appeal packet anything that because Medicare patients make up still not prevail. would support my contention that I was slightly more than half of my patient load, acting in my pathologist role during my my cash flow is plummeting. I am not a surgeries. So to my original packet of information I add my new cosmetic dermatologist, so there is no cash-on-the-barrelhead selling of Botox or fillers to make up the difference. My MBA-educated and improved appeal letter, a copy of my CLIA license and husband helps me make contingency plans for meeting payroll. manual, which alone runs more than 30 pages, and a letter from Paul Sagerman explaining the role of his lab in processing the In August 2011 the miracle I have been hoping for arrives in a redundant tissue following my surgical reconstructions. letter from HDI, the recovery audit contractor. Starting with At this time I have another phone conversation with a RAC patient No. 18, they issue a FAVORABLE decision. I call HDI in representative who is willing to explain at length what their agency great anticipation. Since I have a favorable decision in my hand, is looking for: doctors doing Mohs surgery who arent processing and all the demand letters involve the same Mohs issue, wont their own frozen sections. When I explain my situation, she says in the demand letters stop coming? Of course not, they reply. As essence that HDI isnt looking for people like me. With that long as the computer is finding conflicts in billing, more demand encouragement in mind, I switch from re-determination as my letters will be issued, up to a three-year statute of limitation. appeal option, to the discussion option. If someone at HDI thinks I I am incredulous, but resigned. The favorable letters for the am not a deadbeat, then I should let this agency pass judgment on remaining patients slowly roll in over the next three months, me, instead of my Medicare carrier. So off to HDI by certified mail alongside new demand letters. By October 2011 when the goes another raft of appeal packets, each one more than 50 pages. demand letters stop, I have 62 patient surgeries under audit. But I wont forget the day when that first decision envelope arrives the favorable results of those numbered 18 to 62 have halted the from Noridian for my first batch of audit patients, the ones I sent recoupment. My previously confiscated funds are returning to before I collaborated with Julie. In that five-page letter they put me, and I feel absolutely flush. the decision in the second paragraph in capital letters, so you can An oddity of the audit crops up. I had made an error in the see it immediately. And just as Julie anticipates, it is UNFAVORABLE. original billing of one patients Mohs surgery on the date of I remind myself, this batch of appeals went without the revised surgery, which required a corrected submission, so the claim was appeal letter, the CLIA manual, and Dr. Sagermans eloquent paid in two parts. Because the demand letters roughly sort letter. But that doesnt help me feel better. patients by date of payment, the two parts of this one mans By now my staff and I are spending hundreds of hours creating surgery appeared on different demand letters. Part of his surgery letters, copying and collating and mailing documents, all the is among the first 17 patients, and is awarded an unfavorable while trying to deliver care to the hundreds of patients we see decision. The other part of his surgery is given a favorable each month. I feel like I have two jobs0: my old doctor job during decision. The illogic of this is striking, and I am hopeful this bizarre the day, and my new one at night and on weekends as an evolving inconsistency will help me later.

SOMBRERO May 2013

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Buoyed by our success, my staff and I prepare for the second level of appeal to protest the unfavorable decision for our first 17 patients. This time there are no choices to be made, as all the paperwork we sent to Noridian for round one goes to a RAC contractor for a different Medicare region. In our case the company is called C2C and is based in Jacksonville, Fla. I am allowed to send additional documents, so I draft yet another cover letter that Julie very skillfully edits, and add in the CLIA manual and Dr. Sagermans letter. If I dont prevail on appeal this second time, the next level of appeal is to appear before an administrative law judge. The judge will only consider documents submitted through Level Two, so the warning is clear: this is the last chance to get it right.

The judge then warns me that he is not bound by any decision made by any other adjudicator to date. My little smug feeling dissipates. He questions me about my other favorably argued cases. He questions me about Paul Sagermans letter, and I have an inkling that this is a key document for him. Paul and I are either wholly ethical, or were not. Before we conclude, the RAC representative asks why the man with half a surgery is on our list, because her data shows his claim has been settled. I explain at the judges request how this patient came to life on two different demand letters, one half resolved, the other half before us in limbo. I told him she would have to explain why this half was still being adjudicated, because I certainly couldnt. Everyone is quiet for a bit, digesting this. I think the HDI representative is irritated, as she has no answer. The hearing takes 20 to 30 minutes. I am informed that the judge will have a written decision to me in a few months. Ive nearly lapped a year, so what are a few more months?

The months roll by again, and by mid-winter I am dumbfounded to learn that three of my 17 patients have favorable decisions from C2C, but 14 of them are unfavorable, again. This time there is a signed, written opinion from the adjudicator for each patient. I look at the signatures, and the same adjudicators that found in Im now thinking that the end is in sight. But Im truly myopic, my favor for some patients found against me for others. How can because within weeks of the hearing that be possible when there is only and before the judges opinion is one issue at stake? The written rendered, two new demand letters y staff and I spent hundreds of opinions are all largely rambling with 11 additional patients arrive by essays, full of bureaucratese and hours creating letters, copying and mail. I think my offended sparring legalese, and devoid of coherent, mailing documents, all the while partner at the hearing is surely logically developed argument. The trying to deliver care to the hundreds behind these new letters, but these inconsistency of the adjudication are from Noridian, not HDI. process is a torment, but I am of patients we see each month ... our letters Because of this, I can no longer use determined to appeal for the third cash flow was ticking downward... the discussion mode as my appeal time for these 14 cases. route. I am back to a re-determination Level Three appeals require meeting with an administrative law route instead, the one that led me through the maze of appeals judge. Arranging this process is lengthy, and my appeal is finally to the hearing in the first place. My weary staff and I copy, collate, set for April 4, 2012, nearly one year after receiving my first and mail again, though this time I include in my revised letter the demand letter. The administrative law judge is part of the Social fact that 48 of my prior Mohs cases have been adjudicated in my Security system, and mine is in Irvine, Calif. My well-traveled favor. For emphasis, I italicize the paragraph. appeal packets are sent there from C2C, but no additional In June 2012 the judges decision arrives by mail. My 14 cases information or documentation is allowed. I dont have to go to before him have been adjudicated in my favor. Within days that California, as my appearance will be by telephone. I ask Julie if I chunk of recouped money is returned to me. Now I have to wait need her to be with me. Shes willing to attend, but doesnt on the 11 new cases to be decided by Noridian, hoping that no believe that it is necessary in my case. I decide to proceed on my new demand letters are churning through the mail to my door. own. Julie tells me that I am the best doctor lawyer she has ever worked with. It is flattering, but not a compliment I really want. By December 2012, the last favorable decision has reached me and my last dollar returned. Time elapsed since receiving my first On the appointed day of my hearing, I sit at my desk in my office, demand letter is one year and seven months, almost to the day. nervously wondering if administrative law judges are old, retired guys with bad hearing. I am truly ignorant on this point, because I You would think that is an appropriate end to this story. I was can tell when my assigned judge comes on the phone that he is vindicated 73 times. But I have learned just before going to press young and smart. He explains the process that will follow, and not that on Jan. 1, 2013, Congress passed a law allowing Medicare to only am I sworn in, so is the head of Noridians RAC. This initially change its statute of limitation on RAC audits from three years to surprises me, but then why wouldnt the opposition have a five years to make up for funds lost due to the two percent representative at this hearing? across-the-board sequester imposed on March 1, 2013.

The judge stipulates to a few things, then presents a crisp synopsis of the issue at stake: Did I, or did I not do Mohs surgery for these 14 patients? I am impressed at his preparation. He questions the HDI administrator first, but she mostly parrots the billing rules for Mohs surgery. He cuts her off, acknowledging he is well aware of the rules. I start to feel a little smug. She knows her rules, but she apparently doesnt know anything about my personal situation with the audit.
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I will be watching the mail for those fat envelopes. Tamra Whitley Myers, M.D. has practiced dermatology in Tucson for 27 years, 23 of them in solo practice.She practiced IM first, and then went back for specialty training. She is a University of Arizona graduate in both undergrad and med school, and did her dermatology training at the University of Iowa. She is married and has two grown children. n

SOMBRERO May 2013

SOMBRERO May 2013

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In Memoriam
By Stuart Faxon

Dr. Vincent A. Fulginiti, 1931-2013


Dr. Vincent A. Fulginiti, founding chairman of the UofA College of Medicine Department of Pediatrics, former CofM acting dean, former dean of Tulane University Medical School, and former chancellor of University of Colorado Health Sciences Ccnter, who joined PCMS in 1968, died March 19 after losing his battle with stomach cancer. He was 81. Vince was recognized internationally for his professionalism, leadership, and innovation Dr. Vincent A. Fulginiti in 1984 in medical education and biomedical ethics, the family told the Arizona Daily Star. UofA College of Medicine Dean Steve Goldschmid, M.D. called Dr. Fulginiti a visionary leader in medicine and the health sciences. Vincent Anthony Fulginiti was born Aug. 8, 1931 in Philadelphia, where he graduated from Temple University in 1953. He continued at Temple for med school, earning his M.D. in 1957. He interned at Philadelphia General Hospital and did his pediatric residency at St. Christophers Hospital for Children in Philadelphia, where he specialized in pediatric infectious disease and was a member of research teams working on eradicating polio in the U.S. and smallpox worldwide. In 1961-62 he did a fellowship in virology and infectious diseases at the University of Colorado. He was American Board of Pediatrics-certified and a fellow of the American Academy of Pediatrics. In 2001 he returned to Tucson, the family told the Star, where he was an active member of the medical community, serving as writer, lecturer, and innovator for organizations including the UMC Board of Governors, CDC, American Pediatric Society, medical journal Medscape, and the federal response to bioterrorism. An internationally respected expert in pediatric infectious diseases, Dr. Fulginiti authored four books and more than 200 scholarly articles. He pioneered digital multimedia and websites for evidence-based patient care and medical education.
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He was chief editor of the American Journal of Diseases of Children for 11 years, and served on editorial boards of several other medical journals. He was named chairman of the AAPs Red Book Committee, and served on the National Vaccine Advisory Committee of the U.S. Public Health Service. Vince and his wife of 56 years, Shirley, held a lifelong interest in biomedical ethics, and in 2012 the University 9f Colorado honored their commitment with dedication of the Fulginiti Pavilion for Bioethics and Humanities at UCs Anschutz Medical Campus in Denver. Vince was awarded many honors in his career, including AOA, Fulbright, and Markle scholarships. He received teaching awards from the University of Arizona, Tulane Medical School and University of Colorado. He was most recently honored with University of Colorados First Annual Veritas Award and last year the Pima County Medical Foundation Award for Exemplary Lifetime Achievement in Furtherance of Medical Education. Vince was an inveterate doodler, his family said, and he loved his family, opera, chess, Oriental cooking, and global travel. His wife, Shirley; sister Elizabeth Cherry; sons John and Paul; daughter Laura; and three grandchildren survive him. Dr. Fulginitis son Jeffrey Thomas Fulginiti predeceased him in 1984. n

Dr. Vincent Fulginiti and Shirley flank their daughter Laura Fulginiti, Ph.D., a forensic anthropologist, at PCMS Jan. 31, 2006 (Stuart Faxon photo). SOMBRERO May 2013

Pima County Medical Foundaon News


By Stuart Faxon

PCMF awards four MDs for education distinction


On April 9 Pima County Medical Foundation, in a tradition going back to 1997, awarded four PCMS physicians with its Foundation Award for Exemplary Lifetime Achievement in Furtherance of Medical Education. North Dakota native Dr. Richard Dale came to Arizona as a youngster. He was PCMS 2005 Physician of the Year, PCMF president in 2005-06, and 1977 PCMS president, and served as St. Josephs Hospital chief of staff in the early 1980s. He has coordinated seasonal Tucson Hospitals Medical Education Programs for 30 years. Upstate New York native Dr. James Dunn came to Tucson in 1977 and since then has taught surgical anatomy at The University of Arizona College of Medicine. Over 55 years he has taughtsurgical anatomy to several thousand medical students while maintaining a private practice in general surgery. Dr. Frank Marcus is a native of the Town of Haverstraw, N.Y. in northern Rockland County on the Hudson Rivers west bank. He came to Tucson in 1969 and became founding chief of cardiology at The University of Arizona College of Medicine. He served as a Distinguished Professor of Medicine there 1982-99, and since 1999 has been a Professor Emeritus. Rocky Ford, Colo. native Dr. John Wilson came to Tucson in 1952 and joined a small group of radiologists who later organized as Radiology Ltd., now the dominant Tucson radiology practice. Dr. Wilson worked at several local hospitals but mainly at Tucson Medical Center, where for many years he conducted teaching sessions for the house staff. He was TMC chief of staff 1963-64 and PCMS president in 1969. Founded in 1990, Pima County Medical Foundation, Inc. is an allvolunteer 501 (c) 3 non-profit foundation whose mission is dissemination of medical knowledge and health-related information to the broad medical community and the general public, including sponsorship of dinner meetings with Continuing Medical Education programs presented by individuals and groups expert in their fields. PCMF also provides small grants to local organizations such as the Southern Arizona Research, Science and Engineering Fair. Tucson Alliamce for Autism, and AIDSWalk.
Dr. James Dunn and his wife, Smithie.

Dr. Richard Dale, PCMF Board of Directors member.

Coming CMEvents

Dr. John Wilson with Dr. James Klein, PCMF chairman.

Coming CME events in the Pima County Medical Foundation Tuesday Evening Speaker Series are: May 14: Healthcare Reform: Where Are We Now? with doctors William Mangold, Marc Leib, and Timothy Fagan. June 11: Breast Cancer Treatment with Dr. Ana Maria Lopez, medical oncologist; Dr. Eric Whitacre, surgeon; and Dr. Marilyn Croghan, radiation oncologist. Sept. 10: Newer Antibiotics: How They Work and Why and When We Use Them with Assistant Professor of Medicine Anca Georgescu, M.D., Department of Infectious Disease, UofA College of Medicine. Oct. 8: Ocular Signs of Systemic Disease with Dr. Robert Snyder. Nov. 12: Robotic Surgery: What It Means for the Future with the UofAs Dr. Robert Poston, cardiothoracic surgeon, and Dr. Sanjay Ramakumar of Urological Associates of Southern Arizona.
SOMBRERO May 2013 Dr. Frank Marcus and his wife, Janet. 21

Perspecve
By Dr. Michael F. Hamant

Our freedoms are both of, and from religion


Recent regulation proposed by the Obama Administration would extend contraceptive insurance benefits to all employer groups. The exemption for employees of religious organizations (churches) would continue, but would not include organizations run by religious groups that do not have religious activity as their primary focus (for instance, Catholic hospitals and universities). This prompted a backlash from Roman Catholic and other religious organizations that choose to not provide contraceptive insurance coverage as a matter of religious principal. They argue that the religious freedom of their organization is violated by forcing them to pay for something they morally oppose. In my opinion, this argument is based on several incorrect assumptions. First of all, the assumption that the religious/moral view of the employer supersedes that of the employees individual rights is incorrect. Second, the employer, regardless of religious affiliation, must abide by all contract law and all other federal and state regulation. The exemption for contraception then assumes that the employer has the right to control the employees religious/moral choices in regard to contraception, but does not allow the employer to violate contract law or federal regulation in any other instance. Of course the basis of the controversy is the interpretation of the First Amendment to the U.S. Constitution. The First Amendment reads in part: Congress shall make no law respecting an establishment of religion, or prohibiting the free exercise thereof This has often been re-stated as separation of church and state. This term was used in an 1802 letter from President Thomas Jefferson to the Danbury Baptist Association: Believing with you that religion is a matter which lies solely between man and his god, (the people in the First Amendment) declared that their legislature should make no law respecting an establishment of religion, or prohibiting the free exercise thereof, thus building a wall of separation between church and state. Jefferson had previously written in 1785 in support of legislation for a freedom from religion clause in the Virginia House: no man shall be compelled to frequent or support any religious worship, place, or ministry whatsoever, nor shall be enforced, restrained, molested, or burdened in his body or goods, nor shall otherwise suffer, on account of his religious opinions or belief; but that all men shall be free to profess, and by argument to maintain, their opinions in matters of religion, and that the same shall in no wise diminish, enlarge, of affect their civil capacities. The First Amendment has had several important Supreme Court rulings that further delineated the ability of the government to regulate religion. In 1978 in Reynolds v United States it was established that the state could regulate religion in that the ruling outlawed bigamy in Utah. So the government could define what religious freedom encompasses. In other words, the freedom to believe is unlimited, but the freedom to act on ones religious beliefs can be regulated. More modern rulings have allowed for the Pledge of Allegiance to contain the phrase one nation, under God, and for the phrase In God We Trust to remain on the currency. However, other rulings have required removal of the Ten Commandments from display on state property. So although there is a wall between the church and state, it is not absolute and has been subject to interpretation and regulation by the government. The crux of the argument opposing the Obama Administrations ruling on the provision of contraceptives by religious affiliated organizations is that this is a violation of the principal of separation of church and state. But as I have shown, the state in many instances does regulate religious acts as opposed to religious belief. One cannot smoke peyote and claim it as a religious act. One cannot marry multiple wives. One cannot claim a religious pretext for performing illegal acts. In the regulation of insurance, the government has decided that contraceptives should be offered as a standard benefit. The efficacy and safety of contraceptives are beyond refuting. Since all current prescription contraceptives are for females, the denial of contraceptive benefits
SOMBRERO May 2013

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constitutes sexual discrimination and would result in un-funded healthcare costs disproportionately effecting female employees. The government also has an interest in reducing unwanted/unplanned pregnancy, and therefore has an interest in allowing for the widespread availability of contraception. So the government has the proper role of ensuring equal access to contraception for anyone who chooses to use the technology. It seems to me that the separation of church and state argument has been turned upside down by the organizations opposed to the ruling. Religious freedom is an individual right. The individual chooses his own belief system and may join a like-minded religious organization. But the individual may or may not adhere to every single creed or belief that the group espouses. The data show that the vast majority of American Catholics use contraception despite their churchs opposition. The government may not interfere with the teachings of the Roman Catholic Church about contraception, but the government has the responsibility to ensure that the church does not infringe on the religious beliefs of those individuals who are employed by Roman Catholic institutions. The other major argument used in opposition to the proposed ruling is that it forces the religious organizations to pay for something they find objectionable. The key objection is the requirement to pay. However, in reality, the employer is not paying for the healthcare benefit; the employee earns it. Employee benefits are non-wage compensation provided to employees in addition to wages or salary. The term fringe benefits was coined during World War II by the War Labor Board when indirect benefits were used to attract and retain labor when direct wage increases were prohibited. Over time, standard employee benefits have included health, dental, and disability insurance, retirement or pension plans, sick leave, vacation, profit sharing, education funding, relocation allowances, and more modern benefits such as child care and gym memberships have been added. The important concept is that these benefits are a contractual relationship between employer and employee. The employee agrees to accept the benefit in lieu of wages. In any case, the employee earns the benefit; it is not a gift from the employer. (As an aside, this is an argument in favor of singlepayer healthcare. Roman Catholic Western European countries with single-payer systems do not have this conflict with religious employers and moral issues with contraception since employers are out of the system in providing healthcare.) If the employee earns her insurance benefit, what right does the employer have in dictating to the employee what her insurance will or will not cover? Many non-Catholic individuals work at Catholic hospitals or study at Catholic universities. Why do they need to abide by Catholic teaching about contraception when their work or their tuition payments and fees are paying for the health insurance coverage? Why should Catholic employees have their individual religious freedom dictated by the Roman Catholic Church when they personally choose to use contraception? Again, does the employers right supersede the employees right? Do corporations have the freedom of religion or is this right limited to an individuals freedom of religion? I think it is nonsensical to discuss corpora-tions having a belief or freedom. These are qualities that human beings can possess, but not an artificial legal entity like a corporation.
SOMBRERO May 2013

It would be absurd for an employer to dictate to an employee how he uses his vacation benefit. It would be equally ridiculous for a Mormon employer to dictate that its employees could not drink caffeine while not on the job. (Mormon- owned Marriott Corp. certainly sells caffeine and alcohol.) It would be equally illegal for a Baptist university to insist that the janitorial staff completely abstain from alcohol while off duty. So why is it acceptable for a Roman Catholic hospital to insist that a non-Catholic nurse it employs not choose a health insurance plan with a contraceptive benefit? Again, the argument about the Catholic hospital paying for the benefit is not accurate, but the hospital is certainly dictating its corporate contraception policy on the nurses individual religious freedom. The concept of the right of the employer to dictate religious belief to its employees has spread from Roman Catholic-owned hospitals and universities to private corporations. If one were to follow the logical conclusion that an employer has the right to decide on providing a contraceptive benefit based on the employers religious belief notwithstanding the individual employees beliefwhere does one then draw the line on the employers control over his employee? There are thousands of regulations that protect employees from excesses from the employer (40-hour work week, safety rules) or discrimination (based on age, gender, or race). These are all designed to protect the rights of the employee. The contraception exemption for religious institutions presumes that the employers right supersedes the employees right, but the entirety of employment law is to protect the employees rights. The First Amendment and subsequent Supreme Court rulings have enshrined in American law the freedom of religion, and the freedom from religion. The individual citizen has these protections. Nowhere has the law applied these freedoms to corporations. To again quote Jefferson: Religion is a matter which lies solely between man and his god. Churches, hospitals, universities, and corporations were not mentioned. A PCMS past-president, Dr. Hamant is a Family Practitioner, and Society member since 1989.

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SOMBRERO May 2013

Makols Call
By Dr. George J. Makol

Eurocare
My wife and I were walking down the center aisle of our first-class Eurail car looking for our comfortably cushioned seats. We had just left Paris after I attended the weeklong World Asthma Meeting, and we were to spend the rest of a month touring around Europe, mostly by train. On this particular leg of our journey there was a $100-per-person additional charge on top of our First Class Eurail Pass, I guess because this was some kind of special train with luxury cars. I really didnt mind that, as the car was comfortable, air conditioned, and we were even served complimentary coffee at the start of our journey. That is about the last positive thing I can say about this eight-hour train ride, as one hour outside of Paris, the temperature in our car began to climb, from 75 degrees to 80, then to 90-plus. We were casually clothed in shorts and T-shirts, but the rest of the passengers were European businessmen in wool three-piece suits, I suppose headed for meetings in Zurich, our destination. In a flash I was at the back of the car prying open the thermostat box with my penknife (one can still carry these on a train without being arrested). That did little good, as it was marked in centigrade, and all I could remember was that 0 degrees was freezing. I slammed it to the lowest reading, but to no avail! I attempted to open the car windows, but they were all sealed shut. I rang for the conductor, who came running, and read him the riot act; unfortunately I was yelling in English, and he was listening in French. He went off in a huff, and I found myself sweating and standing in the middle of the car, the only person upset. The rest of the European businessmen were sitting quietly in their wool suits, sweating profusely, and drinking from their warm bottles of water. I sat back down and said to my wife, What is wrong with these people, anyway? We all paid a small fortune for this first-class ride, and its miserable. Just then the passenger directly in front of us turned, smiled, and said in pretty good English, You must be Americans. I dont know if it was my Miami Dolphins T-shirt that gave me away, or my American flag pen, or maybe just that I was jumping up and down and not speaking French. This gentleman went on to explain that he worked for Coca Cola, and though he was a French citizen, he had lived in Atlanta for three years, accounting for his excellent English. He smiled and
SOMBRERO May 2013

began to explain. These people are Europeans, and they are used to putting up with state-run trains that may not always function well. They are used to standing in long lines, and tolerating long waits for access to doctors, basic dental care, and just about everything else. They do not find this situation unusual. I then told him what would have happened if this were back home and a luxury train had faulty air conditioning. If this train were in the U.S. the passengers would have kidnapped the conductor, forced the train to stop for repairs at the next station, and then we would have demanded double our money back! He found this hilarious, and my wife and I bid him adieu then went back to a tourist-class car, which would have been free, and sat on a wooden bench next to a womans crated live chicken in glorious 75-degree heaven for the rest of the journey. Im telling this tale at this moment because there is lots of talk going on in the face of the insanely complex Patient Protection Actnow that Nancy Pelosi and the rest of us know what is in it. Single-payer systems are looking better and better, and some pundits have written that the ObamaCare PPACA was deliberately written to fail, to set the stage for a then-muchmore-acceptable national healthcare system. I dont know if there is any truth in this theory, and I dont care. The fact is Americans demand a certain level of service, and as customers we like to be treated with dignity and respect. Our time is valuable, as is our health and welfare. I read last year that the wait for a non-emergency CT scan in Canada could be more than one year. My patients are upset if I tell them they have chronic sinusitis and I can get the CT done next Tuesday. The most common response I get is What about Monday? Good for them. Coming in second is not an option in March Madness Sweet 16, and almost not dying is not good enough. Doctors who will do anything that the government will pay for to save your spouses life just does not cut it for Americans. Recall the case of the Abdelbaset al-Megrahi, convicted of bombing Pan Am Flight 103 and crashing it into Lockerbie, Scotland in 1998, killing 259 people in the largest attack on U.S. civilians to that date. The Scots released the convict in 2009 on grounds of compassion, as he had terminal prostate cancer and his Scottish physicians gave him three months to live. Unfortunately, he was being treated under the U.K. healthcare system, in which modern anti-cancer drugs like abiraterone, cabazitaxel, and alpharadin were not widely available. His physician, Dr. Sikora, noted in a Wall Street Journal op-ed on Aug. 23, 2009, that the patient did not even receive the then-standard treatment with docetaxel because it was not available. Libya, then the dictatorship of the late loony Muammar Gaddafi, took responsibility for al-Megrahis crime. The criminal was transferred to Libya, where he received the best of Western medicine and chemotherapy, embarrassingly absent in the British national healthcare system at the time. He lived relatively comfortably for the next three years until succumbing to cancer, but spent lots of quality time with his family. Libya is a third-world country. If the Westernstyle Libyan healthcare system trumps a national healthcare system like Britains, its time to watch what we wish for. George J. Makol, M.D. practices with Alvernon Allergy and Asthma, 2902 E. Grant Rd., and has been a PCMS member since 1980. n
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CME

May
May 23: Trauma Update 2013 is at Sierra Vista Fire Dept. Registration: Carmen Martinez at 520.694.4806 or Carmen. martinez@uahealth.com. (TNCC registration is through Arizona ENA website.) For more information on trauma education opportunities, contact Dan Judkins at UAMC Trauma: daniel.judkins@uahealth. com or call 520.490.7770. ABIM/ABFM Recertification modules offered. Website: http:// www.mayo.edu/cme/cardiovascular-diseases-2013s955 Contact: Cassandra Skomer, Mayo School of Continuous Professional Development, 13400 E. Shea Blvd., Scottsdale 85259; phone 480.301.4580, 480.301.8323 mca.cme@ mayo.edu http://www.mayo.edu/cme Aug. 23-24: ATLS Provider course (open) + ATLS Refresher course (open) + ATCN (open) at Abrams Public Health Building. Registration as above.

June
June 29-30: Upcoming trauma education in Southern Arizona: ATLS Provider course (closed) + ATLS Refresher course (open) +ATCN (open) at University Campus room 5403. Registration as above.

November
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-of-the-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 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

July
July 25-26: Trauma education: ATLS Provider course (closed) + ATLS Refresher course (open) +ATCN (open) at Abrams Public Health Building. Registration as above.

August
Aug. 1-2: Southwest Regional Trauma Conference at Starr Pass resort, Tucson. Aug. 2-4: Mayo Clinic Cardiology Update 2013: The Heart of the Matter is at Enchantment Resort 525 Boynton Canyon Rd., Sedona; phone 928.282.2900. CME: AMA Category 1 credits. Program covers a wide spectrum of topics in CHF/heart transplant, coronary artery diseases, cardiac arrhythmias, preventive cardiology, and valvular heart disease among others.

Members Classieds
To advertise in Sombrero classifieds, call Bill Fearneyhough, 795-7985.
MEDICAL INVESTMENT/USER OPPORTUNITY: 3,522 leased medical ofce at $23 psf NNN with increases $916,000 with 8.8% annual investment return. Located in premier Northwest Center across from Foothills Mall. Built 2007 / reserved covered parking. Contact Jordan Simon 722-9292 X103 or jsimon@venturewestaz.com. You may also email pgcarter@aol.com. (5-13) EQUIPMENT FOR SALE: Two standard examining tables, one professional scale, and eight neutral-colored waiting room chairs. Joanie, 298-6324. (5-13) PART TIME OBGYN NEEDED: The University of Arizona, Campus Health Service (CHS) is seeking a Part-Time, .50 FTE, Board Certied OB-GYN Physician for the Womens Health Clinic. This is a year round position in an interesting and rewarding medical practice that provides health care to a population that includes a wide range of ages, cultures, clinical presentations and needs. Duties will include compassionate and excellent OB-GYN patient care; early diagnosis and referral for pregnancy; pre-conception counseling; family planning; screening and treatment of STIs; pap screening and follow up; and providing technical direction for the RN and MA support staff. Procedures include LEEP, colposcopy, IUDs, I and D of abscesses. The ability to practice in a harmonious and collegial fashion with the four experienced NPs in the department is essential. (3-13) Outstanding UA benets include health, dental, vision, and life insurance; sick leave and holidays; UA/ASU/NAU tuition reduction for employee and qualied family members; access to campus cultural and recreational activities; retirement; malpractice insurance coverage and more! For more information, please go to www.uacareertrack.com/ applicants/Central?quickFind=207193 OFFICE FOR LEASE: Medical or Professional Ofce Space for Lease or Sale. 1,806 sq.ft. near St. Josephs Hospital on Carondelet Drive. Five exam rooms and two physician ofces. Favorable lease rate and terms. Call 749- 1454 or 885- 6701 (Dr. Wood). OFFICE SPACE AVAILABLE: New Ofce Space available for rent in Northwest Tucson off of Oracle Rd adjacent to a busy rheumatology practice. Up to 2,000 sq ft available. Can be built to suit for ofces, physical therapy or other medical needs. For information, contact Sue Haeger 382-4795. OFFICE SPACE: Professional/Medical Ofce Space for Lease. Central location, tenant friendly rates, move-in ready. See details & photos at: www.space-4-lease.com http://www.space-4-lease.com/

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SOMBRERO May 2013

SOMBRERO May 2013


Y EA R S
O F CA R E

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MICA_Sombrero05'13ad_MICA_Sombrero05'04ad 4/15/13 2:24 PM Page 1

Ranjani Panithi, MD MICA Member Since 2010 MICAs online CME is interesting and easy to complete. The panel of experts in the CME video were interesting and provided great ideas.

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SOMBRERO May 2013