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Pima County Medical Society
Home Medical Society of the 17th United States Surgeon General


Meet our new president

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SOMBRERO – January 2014

Pima County Medical Society Officers
President Timothy Marshall, MD President-Elect Melissa Levine, MD Vice President Steve Cohen, MD Secretary-Treasurer Guruprasad Raju, MD Past-President Charles Katzenberg, MD

Official Publication of the Pima County Medical Society Members at Large
Donald Green, MD Veronica Pimienta, MD

Vol. 47 No. 1

PCMS Board of Directors
Eric Barrett, MD Diana Benenati, MD

Neil Clements, MD Michael Connolly, DO Michael Dean, MD Howard Eisenberg, MD Afshin Emami, MD Randall Fehr, MD Alton Hallum, MD Evan Kligman, MD Kevin Moynahan, MD Soheila Nouri, MD Wayne Peate, MD Scott Weiss, MD Leslie Willingham, MD Gustavo Ortega, MD (Resident) Snehal Patel, DO (Resident) Joanna Holstein, DO (Resident) Editor Stuart Faxon Phone: 883-0408 E-mail: Please do not submit PDFs as editorial copy. Art Director Alene Randklev, Commercial Printers, Inc. Phone: 623-4775 Fax: 622-8321 E-mail:

At Large ArMA Board

Ana Maria Lopez, MD R. Screven Farmer, MD

Board of Mediation
Timothy Fagan, MD Thomas Griffin, MD George Makol, MD Mark Mecikalski, MD Edward Schwager, 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)

Arizona Medical Association Officers
Thomas Rothe, MD   president Michael F. Hamant, MD   secretary Printing Commercial Printers, Inc. Phone: 623-4775 E-mail:

Executive Director Bill Fearneyhough Phone: 795-7985 Fax: 323-9559 E-mail: billf Advertising Phone: 795-7985 Fax: 323-9559 E-mail: billf

Publisher Pima County Medical Society 5199 E. Farness Dr., Tucson, AZ 85712 Phone: (520) 795-7985 Fax: (520) 323-9559 Website:

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 Officers 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 © 2014, Pima County Medical Society. All rights reserved. Reproduction in whole or in part without permission is prohibited.

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SOMBRERO – January 2014


 5 Dr. Timothy Marshall: Our 2014 president says
educate, advocate, communicate. address.

 8 PCMS News: We very much need your e-mail 10 In Memoriam: Dr. Charles W. Needham died in
November 2013.

11 Behind the Lens: Time to grab that camera and 15 Meet the President: We interview Dr. Timothy
M. Marshall.

get your wildlife photos without leaving the Santa Cruz Valley.

16 Perspective: Dr. Jason Fodeman’s ACA forecast. 18 Time Capsule: Our History Committee’s Dr.
Kenneth Johnson recounts PimaCare, Tucson’s first HMO. Benz.

20 Makol’s Call: Paying for the ACA is like getting the 22 CME: Coming events from THMEP and Mayo
Clinic Scottsdale.

On the Cover
Solo-practitioner cardiologist Dr. Tiomothy M. Marshall is 2014 PCMS president. Golden retriever father-and-son Nitro and Cypher help out in the office (Bill Fearneyhough photo).

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4 SOMBRERO – January 2014


Established 1971

‘May you live in interesting times’
By Timothy Marshall, M.D. PCMS President


o goes the old Chinese curse, which, as with many misquotations, happens to have no foundation in Chinese. The original quote was probably, “It is better to be a dog in a peaceful time than a man in a chaotic period.” Judging by the life of my dogs, I suspect this to be true. For those of us engaged in the practice of medicine, we are entering a period of accelerating chaos. The government is implementing a monumental and wide-ranging healthcare law that, we are told, no one took the time to read. This plan means different things to different people and has contributed to polarization of our politicians, our patients, and ourselves. It is causing great uncertainty for our members. Pima County Medical Society can contribute in three main ways as we navigate these political waters: education, advocacy, and promoting communication amongst our members. Education often helps comfort our patients fearful of a new diagnosis or symptom. Knowledge is easier to deal with than uncertainty. I hope as we learn about the ACA, we will become less fearful. I am not optimistic. When politicians enact hurried laws with the goal of becoming re-elected, ignoring common sense and balanced input, the results are certain. PCMS will help to keep you informed of important ACA facts as they become apparent. Did you know that under the ACA, the insurance exchanges can recoup payments they have made to doctors if the patient does not pay his premiums after three months? PCMS has striven over the last year to discuss the implications of this act as it unravels, or is enacted, depending on your perspective. Please let us know any new issues you encounter. Sombrero, published 10 months each year, is an excellent sounding board and I encourage you to share your experiences on how the ACA has affected you. We need someone to speak for physicians as we go through this process. PCMS is here to advocate for changes in legislation as we uncover the “gems” hidden within the ACA. It is difficult for us and our patients to live through a political experiment that affects our lives. As a Canadian I have experienced socialized healthcare and major policy shifts. A good example is the impact of the Stoddard Report on the Canadian medical system. Thirty years ago the Canadian government commissioned an accountant named Stoddard to find out why providing universal healthcare was so expensive. Stoddard deduced that medical care was expensive because of doctors. If there
SOMBRERO – January 2014

were fewer doctors, they would provide less medical care and thus reduce expense. The Canadian government wholeheartedly agreed and reduced enrollment in medical and nursing schools. The result of this policy was predictable. Within 10 years there was a huge shortage of physicians and nurses. Physicians and nurses were once again highly valued with a commensurate improvement in reimbursement and working conditions. Is our current situation in America a pendulum that will swing back, or a new trend towards socialized medicine and employed physicians? The coming years will be interesting indeed. To the contrary, these social experiments such as Medicare may look good to us 30 years later. In the 1950s in Canada, physicians went on strike when socialized medicine was introduced. Planeloads of British physicians flew in as strike breakers. Now Canadians are proud of their healthcare system. My younger brother is very happy he will get a new knee in three months, having been only six months on the waiting list. The last straw for me was a 39-year-old man who died after a week of post- infarction angina for lack of an angioplasty that I could have been done in 20 minutes with the right facilities. When I complained to the minister of health, he said, “Doctor, that is your fault because you did not triage him adequately.” Oh, the joys of having politicians run healthcare! I predict it will take at least two generations to alter the expectations of American citizens regarding waiting lists and limitations on treatment. Meanwhile, the physician remains most at risk in the struggle to balance cost- effective care and defensive medicine.

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Advocacy is not something we think about as we struggle to provide quality care for our patients and stay up late completing our electronic paperwork. Thankfully someone is thinking about this. At PCMS Board meetings and ArMA annual meetings I have heard incredible and threatening concepts being floated by our legislators, including criminalizing portions of healthcare. They proposed laws that I thought completely insane. Many nights I actually lay awake worried for the future of medicine. Happily, we are effective advocates and are positioned to provide some balance and clarity to these lawmakers. Most of these ominous proposals never reach the floor. For this reason I decided to continue actively supporting PCMS and agreed to be president this year. The American Medical Association is an example of governmental impact on organized medicine. The AMA was formed in 1847 to improve the legitimacy of medicine. It supported physician education, a standardized medical curriculum, and opposed lay ownership of physician practices. In 1975 the Federal Trade Commission stripped AMA of many powers, citing antitrust law, and this led to a much less powerful AMA. We must be ever vigilant in navigating these political waters. The future of medicine must be led by organized medicine, not by politicians and lawyers. Their motivation is clearly getting re-elected, not implementing effective policy. For example, passing a massive healthcare law without one iota of tort reform to reduce expense because the trial lawyers donate to the Democrats. Communication is the third pillar of my discourse here. We need to get together and share our opinions. What continually amazes me is how different our views and opinions are, and how powerfully we hold these opinions. We learn an incredible amount when we listen to one another, particularly to those who disagree with us. It improves my awareness of how others think. I am perpetually astounded by the authoritarian opinions of uninformed Americans about the Canadian healthcare system. As we have seen in these pages, these opposing views can be eloquently expressed, and I encourage you to send us your thoughts and opinions. PCMS has instituted a new social gathering called Mix at 6. We can all get together without the burden of a meeting to have an appetizer and get re-acquainted. Ever since hospitalists reduced our hospital burden, we never see each other in the doctors’ lounge over a low-fat yogurt. This is a great opportunity to meet your peers. I hope many will make the time to attend. Thank you, Dr. Alan Rogers and Dr. Chuck Katzenberg, who preceded me as president. You have both committed many hours and worked diligently with the society to further our purpose. In conclusion, I believe some of the goals or organized medicine are: to allow physicians to practice independently; to be fairly compensated for our work and education; to have influence with legislators in healthcare issues; to maintain patient choice; and to promote collective bargaining. We need organized medicine on a larger scale than our specialty societies provide. It will require the concerted effort of all physicians and societies to work for major changes, such as repealing the SGR and promoting tort reform. It may be “better to be a dog in a peaceful time than a man in a chaotic period,” but from chaos comes opportunity. The future of medicine must be led by physicians. We can be rendered obsolete by politicians and bureaucrats, or decide to lead. I vote we lead. I wish you all a happy, healthy, and prosperous New Year! n


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SOMBRERO – January 2014

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SOMBRERO – January 2014

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THMEP heads for Telluride
The 36th Annual Tucson Hospitals Medical Education Program Winter Conference is Feb. 20-22 during Rodeo Week in Telluride, Colo. The program features speakers from Tucson on a variety of topic relevant to practicing physicians. “This is an excellent way to get CME credits in a beautiful mountain setting with excellent skiing,” said course organizer Robert Berens, M.D. “Kids will enjoy the winter sports and activities, so be sure to bring the whole family.” The conference is at The Peaks hotel on the mountain at Telluride, featuring first-class facilities with deluxe accommodations. Please check the meeting website for meeting details and sign-up. Register now to get exclusive meeting room rates at The Peaks. Contact Sue Corcoran at, or meeting organizers Robert Berens, M.D. at, Richard Dale, M.D. at, or Alan Rogers, M.D. at We look forward to seeing you there!

Members must send PCMS their e-mail addresses
As of this month, the Society transitions to e-mail, a speedier, low-cost means of distributing our bulletin, legislative news and alerts, social announcements, and educational opportunities for physicians and staff. Other than mailings required by Society bylaws, including Sombrero magazine, ballots, bylaws changes, etc., we are going strictly electronic. For our physician e-community to work, each member must provide the Society an e-mail address to add to our membership e-distribution list. So, please email your address to Assistant Director Dennis Carey at Once we’ve verified or added your address, you’ll start to receive all our announcements and news via your iPhone, iPad, laptop, or desktop computer.

PCMF schedules CME dinnermeets
Pime County Medical Foundation has scheduled these CME events for its Tuesday Evening Speaker series. Dinner is served at 6:30 p.m. and the presentation is at 7. Feb. 11: Medical Marijuana presented by Sue Sisley, M.D. This is our annual physician homecoming event. March 11: Treatments of Obesity presented by Jeffrey Monash, M.D. April 8: Alzheimers and Other Degenerative Brain Diseases presented by Geoffrey Ahern, M.D. Also at this meeting, Timothy Fagan, M.D., Hector L. Garcia, M.D., and Jane Orient, M.D. will receive the Foundation Award for Lifetime Achievement in the Furtherance of Medical Education. May 13: Healthcare Update 2014 presented by Timothy Fagan, M.D. Other likely speakers are Marc Leib, M.D. and Bill Mangold, M.D. June 10: Rheumatoid Arthritis presented by Michael Maricic, M.D. Sept. 9: Dermal fillers and Fat Stem Cells in Plastic Surgery presented by plastic surgeon Dr. John Pierce. Oct. 7: New Medical and Surgical Treatments for Prostate Cancer presented by Rick Ahmano, M.D. and Mitch Sokoloff, M.D. Nov. 11: Newer Anticoagulants and Their Role in A-Fib, DVT, and Pulmonary Embolism presented by Tmothy Fagan, M.D. n


SOMBRERO – January 2014

SOMBRERO – January 2014


In Memoriam
By Stuart Faxon

Dr. Charles W. Needham, 1936-2013


r. Charles W. Needham, who in his 50-year career practiced neurosurgery in Montreal, Los Angeles, Tucson, and Connecticut, and who joined PCMS in 1971, died Nov. 15 in Tucson. He was 77. Charles William “Charlie” Needham was born Oct. 14, 1936 in Brooklyn, New York, where he graduated from Adelphi Academy cum laude in 1953. He earned the same honor graduating in 1957 from Wagner College, Staten Island, N.Y. The physician path led him north to Albany Medical College, where he earned his M.D. in 1961. He interned at Albany Medical Center Hospital and did his general surgery residency there. He did his neurosurgery residency at McGill University’s Montreal Neurological Institute. Dr. Needham was a post-doctoral Fellow 1967-69 with the National Institute of Neurological Diseases and Blindness. He was a stereotaxic research Fellow with Montreal Neurological Institute 1968 while earning an M.S. in neurophysiology at McGill. He also served as assistant professor of neurosurgery at UCLA School of Medicine and Harbor General Hospital 1969-71. He was a Fellow of the American College of Surgeons. “Over a career spaning 50 years,” the family told the Arizona Daily Star, “Charlie practiced as a neurosurgeon in Montreal, Los Angeles, Tucson, and Connecticut. He held acadmic positions at the David Geffen School of Medicine at UCLA, Yale School of Medicine, and The University of Arizona College of Medicine, and taught medical students and residents throughout his career. “He authored four medical textsbooks and was extensively published in regional and national medical journals. He also invented a morphine-based analgesic paste to provide sustained relief from post-operative pain.” With Neurological Associates of Tucson, Dr. Needham practiced with neurosurgeons Thomas F. Norton and Joseph C. Mirabile, and neurologists Harvey W. Buchsbaum, William S. Masland, Francisco R. Valdivia, Robert A. Foote, and Michael S. Smith. Not long after he joined PCMS, Dr. Needham was part of the Tucson community effort to temporarily house 230 refugee South Vietnamese children, including arrangements for their medical care and transportation from San Francisco, the Star reported. In 1982 he advocated humanism against the “mad extremism of the global nuclear arms race,” which has hardly diminished since. Noting the slim protection offered by the 18 Titan ICBMs around Tucson then, Dr. Needham said in a letter to the Star that “building weapons that invite mass suicide and global homicide by human or machine error renders no one ‘secure’ and no nation ‘superior.’

“In order to remain human, we must now substitute sanity for madness, decency for cruelty, hope for fear, and action for despair. Being human is what the current anti-nuclear passion is all about. American needs to rediscover her enormous capacity to inspire all the world’s people as a bright beacon of light in an age of darkness.” Dr. Needham’s analytical and critical writing also appeared in this magazine. “Charlie loved philosophy, as well as history, teaching, and writing,” the family told the Star. “Charlie was a kind and generous man. He will be deeply missed by the many hundreds of people whose lives he touched, including his patients, colleagues, students, friends, and family. Although Charlie is no longer with us, he will remain forever in our hearts.” Dr. Needham’s wife, Constance T. Needham; sister Marion Krupp; sons Andrew and Benjamin; daughters Susan, Jennifer, and Sarah; cousin Michael Fallabala; and 10 grandchildren survive him. Private memorial services for the family were scheduled. n

SOMBRERO – January 2014

Behind the Lens

Your subjects are waiting
By Hal Tretbar, M.D.


t’s that time of year again. Time to get out and enjoy our Sonoran Desert climate. Time to visit the Arizona-Sonora Desert Museum and Tucson’s Reid Park Zoo—and to bring your camera along. I recently had the pleasure of working with wildlife photographer Kathleen Reeder on an Arizona Highways Photo Workshop at the desert museum. She has gained a lot of recognition recently for wildlife images published in the European press. Kathleen is an outstanding instructor. She gave an hour-long interactive instructional program over the Internet to our 15 participants before the workshop. Several informational handouts at the museum detailed the best time and angles for the various animals and birds. She arranged the best place for the group to stand for the Raptor Free Flight program, the twice-daily show of free-flying ravens, owls, and hawks. The birds fly from perch to perch where handlers place bits of food. It’s a rare chance for close-up images. The hawks show off by spiraling high on thermals, and then diving down to zoom just above the crowd’s heads. Kathleen emphasizes that animal photos are more impressive when shot at eye level, and to be sure that the eyes are in focus. Most of the participants had telephoto lenses of 300 to 400mm for the caged animals. She noted that the best time to shoot is with the sweet light early or late in the day. Overcast days work well to avoid the deep shadows in the dens where the animals tend to hang out. On the other end of the spectrum, a number of the students used macro lenses to shoot through the windows of the reptile room. Some used flash with the camera against the glass to avoid reflections and others used high ISO and tripods for a more natural lit image of a creepy crawly. Participants seemed thrilled with their results. They gave Kathleen one of the best
SOMBRERO – January 2014

Great Horned Owl, ISO 1000, 1/160, f.8, 240mm

evaluations that have been given to an instructor at a Highways workshop. She is doing another one-day desert museum workshop on Feb. 22. For anyone interested in outdoor closeups of rattlesnakes, gila monsters, and scorpions, I will helping with the Creepy NG Crawly









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SOMBRERO – January 2014

Prairie falcon, ISO 1000, 1/1600, f.13, 210mm

Sidewinder rattlesnake, ISO 6400, 1/20, f.11, 100mm macro

Harris hawk, ISO 1600, 1/1250, f.13, 220mm

Grand Canyon rattlesnake, ISO 6400, 1/60, f.8, 100mm macro

Critters workshop in Phoenix on April 12. Outstanding wildlife photographer Bruce Taubert will be the instructor. You can look up and contact Arizona Highways Photo Workshops at . The Arizona-Sonora Desert Museum is in Tucson Mountain Park in the Tucson Mountain foothills just west of downtown, reachable by Gates Pass, or Kinney Road north from Ajo Way. But if staying in town for your animal experience is more convenient, don’t forget Tucson-owned-and-operated Reid Park Zoo, bordered by 22nd Street, Country Club Road, and Alvernon Way. The zoo now has more than 500 animals whose habitats range from the mountains of South America to the Asian rainforest to the African savanna. December through May is peak season and hours are 9 a.m. to 4 p.m. Admission is $9 for adults aged 15-62; $7 seniors 62+; and $5 children 2-14. Here are some of my desert museum images using a Nikon D600 that has a fullsize 24 MP sensor. The lenses were a 24-85 mm Nikkor, a 100-300mm Nikkor, and an ancient Vivitar 100mm macro lens. There has been some Photoshop cropping in order to get a portrait rendition. n
SOMBRERO – January 2014

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SOMBRERO – January 2014

Meet the President

Medicine vs. politics
By Stuart Faxon


hat should politics have to do with medicine? Nothing, really. But that would be in an ideal world, which is not what we have. What we have is the “Affordable Care Act.” That’s the flavor of what you hear talking with the 2014 PCMS president, solo-practice cardiologist Timothy M. Marshall, M.D., F.A.C.C., F.R.C.P.(C), F.S.C.A.I. Born in 1955 in Maple Creek, Saskatchewan, to a family that emigrated directly from England to the Canadian West, he earned his M.D. in 1979 at the University of Saskatchewan at Saskatoon. He interned at Royal Jubilee Hospital, Victoria, B.C. He did his IM residency at Vancouver General Hospital, and his cardiology residency at the University of British Columbia, Vancouver. He was fellowship-trained in angioplasty at University of Calgary, Alberta, and that is his specialty along with hypercholesterolemia. He is board-certified in IM and cardiology. “My goal is to involve more people” in PCMS, he said, “It’s a very political time. We need to talk with each other more in order to find out what we need to do. If our members talked to each other more, they would become more interesed and more involved.” Toward that end, Dr. Marshall will be leading “Mix @ 6” events, as done by the Maricopa County Medical Society. The first one is in the works for Feburary. “No one wants to go to a long meeting after they’ve worked a whole day,” he said. “These events will be for people to get together at a venue, and invite all members and their colleagues.” We should also be doing “meaningful activities for organized medicine,” Dr. Marshall said. “I don’t know what those are yet, but we need to get some resolutions out there to deal with this new politicized medicine.” Though the politics are detrimental to medicine, “We’re going to have to take part in the process, or become victims of the process,” he said. “The ACA has so many unknowns,” Dr, Marshall said. “For example, in the insurance exchanges, they’re not going to let insurance companies ‘fire’ patients until patients are three months delinqent in payment, at which point the companies come back to the physicians and anyone else they paid, to get back the money they paid out. That’s going to place a huge burden on physicians.” It’s now common knowledge that the ACA was a one-party bill passed without even its advocates reading it. “The ACA is such a behemoth,” Dr. Marshall said, “and as parts get implemented, they keep politically manipulating the equation.” Like medicine itself, organized medicine is a learning process. “I was never really interested in organized medicine until I got involved in it,” Dr. Marshall said. “After being invited to run for the board, I went to a few board meetings, and I became aware of how important it is for physicians to have a voice in the political process.”
SOMBRERO – January 2014

His CV easily shows Dr. Marshall to be “a boat” as Canadian as one gets, and that helps him understand what’s happening here. “Since I’m Canadian, I was raised under socialized medicine, so I know what politicians can do to medicine,” he said. For an aggravating example, “The politicians have exempted themselves from the system” they create for everyone else “and restricted others’ access to healthcare in order to save money. Canadians and Americians are no different in this. They’ve devalued their human populations. They say you can wait eight months for a hip operation because you’re just not important enough.” Dr. Marshall recalled that his mother used to drive into the U.S. to Bellingham, Wash. to get MRI scans because she would have had to wait two years in Canada because the equipment had simply gone missing. “Their way to not spend money is to not build hospitals,” Dr. Marshall said, “and to not buy the MRI machine, and presumably people will learn to live without it.” Dr. Marshall notes that another area for examination, also noted in these pages by Dr. George Makol, is too much testing. “Too much of testing has become standard-of-care,” he said, “and doctors keep doing it because of the threat of lawsuits if they don’t. Defensive medicine is not cost-effective.” Like tort reform, “It’s going to be long-term and take re-training because medically, you don’t do a lot of tests for no medical reason.” Dr. Marshall has been in solo practice in Tucson for eight years, one of only two or three solo cardiologists in the city, he says, adding that this kind of practice gives him a regular, controlled life and helps him concentrate on the primary tasks—and get enough sleep. Helping invaluably at the office are his wife, Denise, who is a nurse, and two big purebred golden retrievers, Nitro and his offspring Cypher. “The Boys,” as he calls the friendly, attentionseeking dogs, “are so good for people. They so much help to put people at ease.” Indeed, they wanted us to attend to them rather than writing these notes! In all the daily media blah about healthcare, have you noticed that you hear lots about government, and insurance, and even lawsuits, but nothing about doctors, where healthcare actually comes from? At PCMS that seems bassackwards to us, and it sums up Dr. Marshall’s concern: “They—the politicians, the insurance corporations and even the hospitalss—devalue physicians by making us employees or commodities, and taking our decision process out of the loop.” n


The forecast calls for pain
By Dr. Jason Fodeman


ith the healthcare reform rollout plagued by technical glitches, low enrollment, and consumer frustration, President Obama has recently enlisted the help of Google and other technology companies to fix the exchange website. But these highly-publicized problems are mere sideshows to the real issue: what is happening to medical care in this country under the Patient Protection and Affordable Care Act. The president has now called in computer engineers and programmers to make the site work. Wasn’t the website made with the wisdom of technology experts? And if they could not get it right in three-and-a-half years, how are they supposed to get it right in one month as the administration has promised? Alas, whether they do or not, it’s irrelevant. Unfortunately, for those seeking healthcare, the problems with “ObamaCare” transcend website outages and error messages. A recent CBS News story found that more than 2 million people have already lost their health insurance policies. This directly contradicts multiple promises from the president that, “If you like your health plan, you can keep it.” The White House has now taken the offensive, blaming “bad apple” insurance companies. We’ve seen this movie before. The real estate debacle wasn’t caused by Fannie or Freddie, or misguided legislation. It was caused by the big bad banks, even though they were responding to said legislation. Now it’s the insurance companies’ fault for merely trying to stay afloat in the rough waters created by this law’s ripple effects. With the federal government telling exchange health plans who they can cover, what they can cover, and limiting how much they can charge, many of the same ideas that plague the Medicaid system will likely sink these plans as well. These perverse market forces could foster a race to the bottom, causing these quasiprivate plans to morph into “Medicaid lite” with limited access and poor- quality care. As the government compels “qualified health plans” in the exchanges to provide more services and limits premium increases, the successful business models for these companies are limited. The strategy for these exchanges—to soak young healthy patients with exorbitant premiums to subsidize older and sicker ones—is a gamble, betting young people will take the bait. As companies continue to raise premiums on this cohort, many are likely to jump ship, opting instead to pay the individual mandate penalty, which will be cheaper than the premium.

Another tactic is exchange health plans contracting with a narrow network of doctors, hospitals, and providers. As these patients become more consolidated among fewer doctors, these health plans will likely use their market share to bludgeon down reimbursements. This scenario will thwart patient choice and personal preference by hindering patients from seeing the primary care physician or specialist that they have been seeing, may want to see, or need to see. For patients with complicated medical comorbidities that “like their doctor,” this will be a major hassle to have to start over with a new physician. It will waste patient and doctor time as well as foster additional inefficiencies in a system with scarce resources. Most importantly, this could lead to delays and jeopardize patient care. A recent report featured in US News & World Report confirms that top hospitals are opting out of the ACA. According to the report, 11 of the top 18 hospitals are only accepting one or two health plans offered through the exchange. Cedars Sinai Medical Center and the Cleveland Clinic both only accept one exchange plan. A September 2013 survey from the Medical Group Management Association (MGMA) of more than 1,000 practices found that it’s not just the elite hospitals that are reluctant about the exchanges. Of the practices surveyed, only 29.2 percent planned to accept exchange products, while 14.4 percent had already decided that they would not. The rest were undecided. This early evidence suggests that patients in the exchanges will be left with limited choices, worse coverage, and deteriorating medical care. As the deadline for signing up approaches, get ready to see a high-tech version of the lifeboat scene from Titanic. The formerly insured will be flooding the digital pathways, desperately trying to get covered, even by an inferior insurance product forced upon them. With time, the hiccups with will no doubt be resolved, but the deeply-rooted problems with “ObamaCare” are beyond the expertise of Silicon Valley. PCMS member Jason D. Fodeman, M.D. is an IM assistant professor at the University of Arizona College of Medicine and frequent healthcare columnist for Daily Caller and other web and print publications. As a former Graduate Health Policy Fellow at the Heritage Foundation, he has appeared on various cable news programs as a healthcare commentator. This column was posted on Daily Caller Nov. 20, 2013. n


SOMBRERO – January 2014

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SOMBRERO – January 2014


Time Capsule

PimaCare, Tucson’s first HMO
By Dr. Kenneth R. Johnson


an. 1 marked the 40th anniversary of Tucson’s first Health Maintenance Organization, PimaCare.

Prepaid health plans debuted in Tucson in 1871, when 25 of the city’s finest citizens paid $100 each to bring Dr. John C. Handy to the Old Pueblo. Still, the current concept of HMO medicine began in our town with PimaCare. Paul M. Elwood, Jr., M.D. coined the term Health Maintenance Organization in a 1970 Fortune article. Dr. Elwood was a pediatric neurologist out of the University of Minnesota who worked with the Nixon Administration to re-shape national healthcare policy, the outcome of which was the HMO Act of 1973. Dr. Elwood argued that a system of competing HMOs would give doctors an incentive to keep their patients well, while driving healthcare costs down. Doctors would promote preventive medicine and be less inclined to order expensive tests and procedures that had not been proven to improve health outcomes. The HMO Act of 1973 provided grants and loans to provide, start, or expand a Health Maintenance Organization; removed certain state restrictions for federally qualified HMOs; and required employers with 25 or more employees to offer federally certified HMO options if they offered traditional health insurance to

employees. The Act did not require employers to offer health insurance, but it solidified the term HMO and gave HMOs greater access to the employer-based market. In Tucson in 1971, George Rosenberg and Gary Buck created Pima Health Systems. George, a native of Rochester, N.Y., had been in the Air Force stationed at Davis-Monthan. When he was discharged from the service in 1946, he decided to remain in the Old Pueblo. He ended up working for the Tucson Citizen and was its managing editor for about 20 years, retiring in 1967. While at the Citizen, he became interested in healthcare delivery systems and for many years he was on the Board of Directors at Tucson Medical Center, chairing the board 1962-1964. He was executive director of Tucson’s Health Planning Council from 1969 to 1971. Gary Buck, Ph.D. was a sociologist associated with the University of Arizona, and head of the Arizona Institute of Research. Pima Health Systems worked with Tucson’s hospitals to try to get them to cooperate and to avoid duplicating services, thus keeping costs down. Buck and Rosenberg wrote a grant proposal and submitted it to the Department of Health, Education, and Welfare (HEW, now Health and Human Services), seeking money to study alternative healthcare delivery systems for Tucson. They went to Washington, D.C. to plead their case, meeting with Sen. Ted Kennedy and his staff. Future Indiana senator, Richard Lugar, assisted them in writing the grant. With the grant of $560,000, the Health Systems Management Program was born. A board of directors was created with Dave Minter, M.D. as chairman and George Rosenberg as executive director. The program was charged with studying adequacy of local healthcare, analyzing and studying more than 70 Tucson groups and agencies. This community board then launched PimaCare as its proposal to improve Tucson healthcare delivery. Group Health of Arizona came into existence and a community board of directors was created to oversee PimaCare. A business office was procured on Speedway between Campbell Avenue and Tucson Boulevard. Richard Katchmeister was brought in from Kaiser Group in California to be the executive director and the insurance product began to be marketed to employers. David Minter, M.D. was contacted about starting a medical group to provide medical services for PimaCare enrollees. The original contract for hospital services was with Tucson Medical Center and a pharmacy system was initiated by Bill Fink. Dr. Minter, along with Samuel Goldfein, M.D. and William Nevin, M.D. founded Group Health Medical Associates as the provider group. An office at 2430 E. 6th St. was made ready and opened its doors for their first


SOMBRERO – January 2014

patients on Jan. 1, 1974. This building had previously been used by the Holbrook-Hill Medical Group. Within a few months several new providers joined the group, among them were doctors Pete Planting, Chuck Swetnam, Jim Beach, Steve Moore, Terry Vondrak, Ron Blumenfeld, Maybelle Cremer, Vince McKenzie, and Sandra Smith. An additional office on Wetmore was opened. GHMA was responsible for all doctor services. For orthopedics, urology, neurology, and other services not provided by GHMA doctors, these were paid for out of GHMA’s budget. PimaCare paid for hospital services, pharmacy costs, physical therapy, and other services. Initial successes were immediate. HEW actually wrote a glowing report about PimaCare, praising its innovative methods of providing HMO care to citizens of Tucson. The HMO grew rapidly. By May 1975 PimaCare had 11,000 members. This became alarming to many members of Tucson’s medical community. This was a closed-panel HMO, meaning patients with PimaCare insurance were required to see the doctors at GHMA. Community physicians saw this as a threat to their patient base. Patients they had seen for many years were now leaving their practices for the HMO option of care. Some community physicians accused the HMO doctors of withholding necessary care and preventing services. The HMO doctors accused fee-for-service doctors of ordering unnecessary tests and procedures to line their pockets. Some specialist physicians, unhappy with this new form of delivering healthcare, even refused to see PimaCare patients in consultation. Tension in the medical community was palpable. Primary care physicians weren’t the only doctors to suffer the loss of patients. Cardiology, pulmonology, pediatrics, and OB-GYN services were already being provided by GHMA, but soon general surgery services were added with the hiring of surgeons Sam Joseph and Kenneth Johnson. Dermatologist Paul Lichtenstein and radiologist Mike Strober soon joined. Other early additions were doctors Winston Warr, Sandy Mesel, Walt Goodwille, Charles Gideon, John Ey, Chuck Sawyer, John Curtis, Jon Long, and Lee Milton. Several nurse practitioners were also hired, including Julie Waters, Manny Bracamonte, and Micky Birchard. Facilities for the GHMA doctors expanded with the opening of offices on St. Mary’s Road. In 1976 an office was opened at 899 N. Wilmot Rd., followed in a couple of years by larger offices on Carondelet Drive. Eventually there would be additional offices on Ina Road, 22nd Street, Bellevue, Valencia Road, and in Green Valley. GHMA served the membership of PimaCare and also saw fee-forservice patients. Most often, the doctors didn’t know which patient had which type of insurance and treated all of them alike. In 1981, GHMA introduced the idea of a 24-hour “urgent care” facility to Tucson with the opening of an urgent care center at its Bellevue office. Pioneered by GHMA physicians Woody McGinnis and Bob Cairns, this concept took patients out of expensive and overcrowded ERs and provided them with same- day services when they couldn’t get appointments with their regular physicians. This resulted in cost savings for the insurance plan in addition to convenience for the patients. But corporate medicine was not without problems and changes of its own. In the autumn of 1974, PimaCare was having financial problems with unpaid claims and lack of reserves. Insurance revenues were not keeping up with the costs of providing
SOMBRERO – January 2014

services to the members. Multiple consultants were brought in to try to correct the financial problems. Eventually in May of 1975, Blue Cross of Arizona stepped in with an infusion of cash and management skills to take over PimaCare. Saul “Skip” Honigstein was brought on board from where he was working at the Arizona Department of Public Safety to become executive director of PimaCare and GHMA. Rick Barrett was added as marketing director and Bill Leimbach was HMO director for Blue Cross. Within a short time PimaCare was employing more than 100 Tucsonans, GHMA had expanded to more than 50 providers, and patient membership had grown past 15,000. After about two years, the health plan was purchased from Blue Cross by Health Plans, Inc. for cash considerations. Health Plans, Inc. was a Nashville, Tenn. company started by Phil Bredesen. By 1982 this company was known as HealthAmerica and the health plan in Tucson dropped the name PimaCare in favor of its new name, HealthAmerica. HealthAmerica was an expanding, publicly traded corporation with dreams of creating a nationwide HMO, and it quickly expanded into a multimillion-dollar corporation. In Tucson, HealthAmerica continued the early successes of PimaCare and GHMA continued to provide medical services for its members. In 1984, CEO Skip Honigstein moved on to Nashville and Mike Harris became CEO in Tucson. In 1986 Bredesen would sell HealthAmerica to MaxiCare, another nationwide HMO, for $47 million. He was elected mayor of Nashville in 1991 and governor of Tennessee in 2002. Maxicare was founded by Fred Wasserman and his wife Pamela K. Anderson in 1973 in California with an initial investment of $37,000. It would grow to an organization of 2.3 million members, with annual revenues of $1.8 billion. Again, GHMA continued to be the provider group for the HMO members in Tucson now insured by MaxiCare. As membership grew, so did GHMA, which now had more than 100 doctors in its employ. But despite these early successes, MaxiCare was forced to file for bankruptcy protection in April of 1989, a victim of rising medical care costs and over-expansion. In Tucson, this meant the dissolution of MaxiCare. With intervention by the Arizona Department of Insurance, the members who had Maxicare insurance were transferred to insurance coverage by Partners Insurance, begun in 1987. GHMA continued to provide service to the Partners members. Partners would eventually be sold to UnitedHealthcare in 1997. Group Health Medical Associates provided care for thousands of Tucsonans until April 1998 when the group disbanded. Between 1974 and 1998, GHMA employed hundreds of Tucsonans as doctors, nurses, medical assistants, receptionists, secretaries, clerks, technicians, and others providing high-quality care and touching the lives of countless patients. The face of medicine in Tucson is ever-changing. As each new system arises, it provides some solutions, and some new problems. Now we await the full arrival of the Patient Protection and Affordable Care Act as we strive to provide a payment s ystem that matches the excellence in medical care that Americans enjoy today. Surgeon Kenneth R. Johnson, M.D., F.A.C.S. is a member of the PCMS History Committee. n

Makol’s Call

Getting the Benz
By Dr. George J. Makol


suggest that the United States Congress immediately enact a law requiring all families in our country to purchase a new Mercedes Benz S550 sedan, a car characterized by AutoWeek magazine as “the best car in the world.” It’s certainly an immodest proposal, but hear me out. This car is a great performer. With a 4.6 liter, 455hp twinturbocharged engine and sevenspeed automatic transmission, it goes zero to 60 in 4.8 seconds. One could save so much time going to the store and back, or to pick up an EBT card at the Department of Economic Security. The S550 sedan is equipped with a perfume atomizer, heated armrests (so that in Arizona your arms can be as hot as the rest of you), a six-way seat massager that includes a “hot stone” setting, executive class rear seats that recline 43 degrees and have builtin footrests, LCD screens and Internet service, and cup holders

that keep any drink cold or hot. This car is further equipped with Stop & Go Pilot, a system that allows for hands- and feet-free driving, following a car ahead at speeds of up to 37mph even on gentle bends in the road. This is terrific as long as you are not following two gals named Thelma and Louise in a Thunderbird. This car does have a base price of $98,000, perhaps out of the range of some families, but Congress could provide a subsidy to any family that makes less than $95,000 annually, making the car more affordable. Now, I ask you, does your car have all those features? I bet if I asked the president of the United States to assess my current car using the S550 as a benchmark, he would characterize my current automobile as “sub-standard.” By now you are probably asking yourself, though likely not for the first time, “Has Makol lost his mind?” But three years ago your Congress passed a law equally ridiculous as my Mercedes-Benz proposal. They called it the Patient Protection and Affordable Care Act, and it requires everyone to carry Mercedes-Benz-level insurance, when they might easily get by with Chevy-level. When the ACA was passed in 2010, within weeks I received a new bill for my then-19-year-old daughter’s health insurance. Her premium went from $179/month to $479/month. I called my insurance agent, who informed me that the ACA had a clause that only allowed health insurance companies to charge a 60-year-old man three times the premium charged a 19-year-old woman. However, it costs on the average five to six times as much to provide healthcare to a 60-year-old, for obvious reasons. Since even the dumbest insurance company CEO is smarter than the smartest congressman, the industry responded by tripling the premium for the 19-year-old. At the time, I had the option of slightly changing her coverage (an option that no longer exists because all policies have to be ACA-compatible), so I customized her policy to cover somewhat less but still provide the major coverage we needed, and the premium only went up to a monthly $325! My business partner’s two sons also had their individual insurance canceled. With all policies—individual and business—forced to become ACA- compatible, my agent warned me to be ready for another 50-100 percent increase next year, which all individual policy holders in the U.S. will experience. You may have been told that only individuals’ policies have been canceled. One week after the ACA rollout began, my office policy for myself, my business partner, and my employees was canceled as of fall of next year. And, mark my words, all small business policies will be canceled over the next 10 to 12 months. What will replacement insurance look like? First, as I pointed out in a column more than a year ago, all state and federal exchange policies must meet all previously passed insurance mandates of


SOMBRERO – January 2014

the respective states. Arizona has 18 such mandates. In addition, required coverage for everyone includes ambulatory care, emergency care, hospitalization, maternity care (even if you are a single male), mental health and substance abuse care, prescription drugs, rehabilitative services, laboratory services, preventative services, chronic disease management, and children’s dental and vision care (required even for childless adults). Not only are these services included in each policy, but also provided are “free” mammograms and colonoscopies, wellness visits, gestational diabetes screening, HPV testing, STI counseling, HIV screening and counseling, FDA-approved contraceptive methods, breastfeeding support and supplies, and domestic violence screening and counseling. Your parents presumably taught you that there is no “free lunch,” no matter how tasty it may seem. So how is all this to be paid for, aside from the $2.7 trillion estimated federal price tag? You the currently insured, are going to pay two to three times what you were paying before the Affordable Care Act rollout in late 2013, and the insurance companies whose lobbyists wrote most of the ACA will now sell only luxury policies. Consider that if all car dealerships in America had their whole inventory of cars disappear, and only Mercedes Benz S550s were available, even at Ford and Chevy dealers. The margin on bloated luxury cars is two to three times the margin on more commonly purchased vehicles, so the insurers and their lobbyists just struck pure gold; their profits will be profligate, and government guaranteed. But where does this leave the doctors and the patients? A McKinsey and Company analysis reported on in the Dec. 1 Wall Street Journal revealed that nearly half of the ACA plans in many states are using tightly controlled HMO-type networks, 40 percent of the size of networks offered for normal commercial coverage. Recent news reports say United Healthcare has already, cut reimbursements to doctors on the new networks in New York to 20 percent below Medicare levels. Re-check visits are being reimbursed at $40, and since this is below most physician’s overhead costs, it is going to be hard to make it up in volume! Tertiary academic centers are being left out of such networks. To paraphrase the Dec. 1 WSJ editorial, childless couples can now enjoy pediatric vision services, but parents can not take their seriously ill child to an expensive children’s hospital of their choice. Even more ridiculous is that a 25-year-old male will find that the cheapest policy covers everything imaginable, but with a $2,000 deductible, and $6,200 out-of-pocket. If he declines coverage, he will pay a $95 tax penalty—if they can find him. If he gets sick
SOMBRERO – January 2014

later, he can simply sign up at any time. I can see young people, who feel they are immortal, rushing to sign up for “free” preventative care. Without the healthy 25-year-olds, the whole plan collapses, even according to the president. As for the botched, handled 3.5 million orders on Black Friday alone, without a hitch, but they are obviously not a government operation. Everyone got taken for a ride on this one, but if you have to ride, it may as well be in a 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

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“Kids will enjoy the winter sports and activities, so be sure to bring the whole family.” The Peaks features first-class facilities with deluxe accommodations. Please check the meeting website for meeting details and sign-up. Register now to get exclusive meeting room rates at The Peaks. Contact Sue Corcoran at, or meeting organizers Robert Berens, M.D. at, Richard Dale, M.D. at, or Alan Rogers, M.D. at

Jan. 24-26: Mayo CME’s Clinical and Multidisciplinary Hematology and Oncology 2014, 11th Annual Review is at Westin Kierland Resort, 6902 E. Greenway Pkwy., Scottsdale 85254; phone 480.624.1000 or 1800.354.5892. Accreditation: TBD. Course is comprehensive update and management strategies for hematologic and oncologic malignancies, presenting new disease classification, treatment, and challenging cases. Topics include updates from the American Society of Hematology (ASH) annual meeting and in medical oncology, focusing on key hematologic diseases (dysproteinemias, acute and chronic leukemias, lymphomas), key solid tumors (breast, thoracic, GI, GU), and overlap topics of supportive, ancillary, and diagnostic care. Interactive sessions are on patient care issues. Website: Contact: CME Dept., Mayo Clinic Scottsdale, 13400 E. Shea Blvd., Scottsdale; phone 480.301.4580; fax 480.301.8323 .

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Feb. 16-21: The Mayo Interactive Surgery Symposium is at Wailea Beach Marriott Resort, 3700 Wailea Alanui, Wailea-Maui, Hawaii; phone 877.622.3140. Accreditation AMA and MOC. “Trends in management of general surgical patients are constantly changing. As technical advances progress, options of surgical treatments continue to expand. This symposium for general surgeons assists in decision-making for multiple aspects of surgical practice.” Website: Contact:Mayo School of Continuous Professional Development Registrar, 13400 E. Shea Blvd., Scottsdale 85259; phone 480.301.4580; fax 480.301.9176 Feb. 20-22: The 36th Annual Tucson Hospitals Medical Education Program Winter Conference is at The Peaks hotel during Rodeo Week in Telluride, Colo. Program features speakers from Tucson on a variety of topics relevant to practicing physicians. “This is an excellent way to get CME credits in a beautiful mountain setting with excellent skiing,” said course organizer Robert Berens, M.D.

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SOMBRERO – January 2014


MICA_Sombrero01'14ad_MICA_Sombrero05'04ad 12/19/13 12:06 PM Page 1

MICA’s Board of Trustees Announces a $30 Million Dividend
At its December Board Meeting, MICA’s Board of Trustees approved a $30 million dividend to be paid to qualifying members as of December 31, 2013. The dividend will be processed in February. This is MICA’s ninth consecutive year of dividends. The 2013 dividend represents approximately 25% of MICA’s 2013 written premium.
Dividends declared for a policy year reflect the Company’s financial performance during that year. Past performance does not guarantee future dividends.

(602) 956-5276 (800) 352-0402


SOMBRERO – January 2014