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Home Medical Society of the 17th United States Surgeon-General


The ‘war on doctors’


Banner to acquire UAHN Tenet to acquire Ascension/CHN

Arizona: Grape Canyon State

Cameron Javid MD, April Harris MD, Egbert Saavedra MD, Mark Walsh MD One of the
Cameron Javid MD, April Harris MD, Egbert Saavedra MD, Mark Walsh MD One of the
Cameron Javid MD, April Harris MD, Egbert Saavedra MD, Mark Walsh MD One of the
Cameron Javid MD, April Harris MD, Egbert Saavedra MD, Mark Walsh MD One of the

Cameron Javid MD,

April Harris MD,

Egbert Saavedra MD,

Mark Walsh MD

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SOMBRERO – August/September 2014


Official Publication of the Pima County Medical Society

Vol. 47

No. 7


Pima County Medical Society Officers

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) Jeffrey Brown (Student) Jamie Fleming (Student)

Members at Large

At Large ArMA Board

Donald Green, MD Veronica Pimienta, MD

R. Screven Farmer, MD

President Timothy Marshall, MD President-Elect Melissa Levine, MD Vice President Steve Cohen, MD Secretary-Treasurer Guruprasad Raju, MD Past-President Charles Katzenberg, MD

Pima Directors to ArMA

Board of Mediation

Timothy C. Fagan, MD Timothy Marshall, MD

Delegates to AMA

Timothy Fagan, MD Thomas Griffin, MD George Makol, MD Mark Mecikalski, MD Edward Schwager, MD

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

Arizona Medical


Association Officers


PCMS Board of Directors

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


Eric Barrett, MD Diana Benenati, MD Neil Clements, MD

Executive Director


Bill Fearneyhough













Editor Stuart Faxon Phone: 883-0408 E-mail: Please do not submit PDFs as editorial copy.

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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 repre- sent 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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Letters: Drug war is really pain patient war.


Dr. Timothy Marshall: Our president knows when enough enforcement becomes too much.


Milestones: Recognitions and achievements of our members.


Mix At Six: Members and student members meet informally.


Behind the Lens: Dr. Hal Tretbar and Dorothy tour and sample Arizona wineries and wines.


PCMS News: If rising healthcare costs never hit a ceiling, will big local healthcare organization buyouts change anything?


Arizona Medical Association News: Dr. Tom Rothe’s year as ArMA president, plus annual meeting report.


CME: Pima County Medical Foundation has your most-local credits.






Home Medical Society of the 17th United States Surgeon-General



The ‘war on doctors’ Banner to acquire UAHN Tenet to acquire Ascension/CHN Arizona: Grape Canyon
The ‘war on doctors’
Banner to acquire UAHN
Tenet to acquire Ascension/CHN
Arizona: Grape
Canyon State

On the Cover

Sonoita Vineyards and Winery south of Elgin, founded by Gordon Dutt in 1983, began statewide development of Arizona as a locale for quality wineries and product. Gordon is still active in management. For your virtual tour of the Grape Canyon State, see this issue’s Behind the Lens (Dr. Hal Tretbar photo).

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Le ers

Pain patients casualties of ‘War on Drugs’

To the Editor:

The actions of the Drug Enforcement Administration to eliminate diversion of Oxycodone is working to decrease its legitimate manufacture and availability in pharmacies. It has become difficult for patients to fill their prescriptions for appropriate use as well as for the one to two percent who don’t use them appropriately.

Patients have been forced to go to multiple pharmacies because of the limited supply. They are often turned away by pharmacists who are fearful to dispense, having been intimidated by the DEA. Often their poorly substantiated rationale is the patient does not fit their “good faith dispensing profile.”

The paradox is that Oxycodone is affordable (covered by AHCCCS), an effective pain reliever with few side effects,* but at the same time the easily crushable favorite of abusers. Besides, not being able to obtain a medication which may have worked well for them to increase their function in the past, patients face prejudice from poorly informed friends, families, and health professionals. All this adds to the chronic pain and disability which brought them to seek treatment in the first place.

There is also the irony that government actions have doubled the street price of Oxycodone. Overdoses seen in our ERs are now more frequently from black tar heroin. The profit for the black market has also been aided by the threats and actions that have frightened off medically licensed competitors who might consider prescribing.

These actions have been effective strategies to create negative publicity and misinformation for not only the medical professions, but for politicians and the public. The often-quoted statistic, that anyone who dies and has an opiate in their blood is counted as a opiate death no matter what other disease they may have or medications they may take, fuels the fire with scientific misinformation.

The visibility and sometimes budgets of state medical boards, the Justice Department, local police, the militarized border patrol, the prison industry, and the courts have increased. This is a reflection of political and public sentiment that patients on drugs must be abusers and physicians who prescribe them “drug pushers.” Both are seen as making a profit and being a threat to taxpayers who feel, “I don’t need those drugs, why do they?’ Maricopa County Sheriff Joe Arpaio, on the other hand, has been reported to say—and which was reported to be echoed by Pima County Attorney Barbara LaWall—that we need prescribed medication for pain patients or they’ll become their clients.

We advise our patients to act to protect their legitimate access to the appropriate use of prescribed controlled medications. They are the real victims of these confused policies. We suggest first, that they call on their federal representatives to re-examine DEA’s marching orders and state licensing boards. Second, that they explain that they are not diverters or addicts, but rather that controlled medication allows them to better function. Third, that they record their experiences at pharmacies and with physicians and complain when they are treated with prejudice and disrespect. Fourth, that they participate, in their own self-

interest, in a “community watch” to identify those who are misusing these medications, so that they may either be treated for their problems or eliminated from their unintended consequence of their actions that upend prescriber’s practices.

Developing better approaches to these issues of prescription and non-prescription medication and drug abuse, decreasing the need for and expense of more prisons for patients and non- patients (and for more Suburbans for those who fight the war), depends on evolution of public understanding and our law. The issues for education include:

That these medications provide legitimate pain relief to many who have a legal right to access to them via the Americans With Disabilities Act;

that misuse becomes less socially acceptable and tolerated by a society that is willing to recognize regulated access to medication and treatment;

and that physicians are in the best position and have a responsibility to lead this process.

*Oxycontin is costly and its new non-crushable formulation is difficult for many to digest. Continent or Morphine ER causes intolerable side effects for many. The Fentanyl Patch causes irritation for many and is costly as is the long-acting Hydrocodone. Affordable Methadone has the potential for arrythmias as well as other undesirable features especially when used in combination with other opiates.

Sincerely, David A. Ruben, M.D., M.B.A.

Dr. Ruben is a diplomate in adult and child psychiatry, addiction, and pain medicine. He writes and speaks on issues of medical practice and consults with lawyers and doctors on regulatory interactions. He can be reached at


and doctors on regulatory interactions. He can be reached at n SOMBRERO – August/September 2014
and doctors on regulatory interactions. He can be reached at n SOMBRERO – August/September 2014
and doctors on regulatory interactions. He can be reached at n SOMBRERO – August/September 2014
and doctors on regulatory interactions. He can be reached at n SOMBRERO – August/September 2014
and doctors on regulatory interactions. He can be reached at n SOMBRERO – August/September 2014
Sutton’s Law and the war against doctors By Timothy Marshall, M.D. PCMS President W hy

Sutton’s Law and the war against doctors

By Timothy Marshall, M.D. PCMS President

W hy is it that every time I order home oxygen for a

patient I need to sign a form that threatens me with criminal liability? Can I actually go to jail for prescribing someone oxygen? It seems the answer is yes.

convicted on two counts of making “false statements” in his operative reports. The term “false statement” suggests a deliberate lie, but it could be a simple mistake. The prosecutor does not need to prove that a doctor “knowingly and willfully” lied in order to pad his fee, but only to show that an incorrect AMA code or incorrect description to an incorrect AMA code was used and that the doctor intended to get paid for his work. The implications of the case are profound, the judge noted: Any error in any medical record related to a health program could be a federal crime. And just when you think coding errors are getting a little out of hand, the government imposes ICD 10.

Are there other ways to save money in healthcare? Lets look at malpractice reform and defensive medicine. Defensive medicine refers to the practice of recommending a diagnostic test or treatment that mainly serves to protect the physician against the patient as potential plaintiff. Defensive medicine is said to be a reaction to the rising costs of malpractice insurance premiums. I don’t practice defensive medicine because my insurance premiums rise. I practice defensive medicine because one lawsuit could erase 30 years of hard work, take away all my assets, my home, and my future.

As you’d expect, the medical literature and the trial lawyers have a very different take on the extent of defensive medicine. Clearly accurate measurement of defensive medicine is extremely difficult. A survey of 300 physicians found that more than 76 percent of the physicians responded that malpractice litigation had hurt their ability to provide quality care to patients. Because of their fear of the excesses of the litigation system:

79 percent said they had ordered more tests than they would have based only on professional judgment.

74 percent had referred patients to specialists more often than they believed was medically necessary.

51 percent had recommended invasive procedures such as biopsies to confirm diagnoses more often than they believed were medically necessary.

41 percent said they had prescribed more medications, such as antibiotics, than they would have based only on their professional judgment, and 73 percent had noticed other doctors prescribing medications similarly.

The American Association for Justice (Formerly Association of Trial Lawyers of America) not surprisingly has a different opinion:

“To the extent that defensive medicine does exist, research has found that the motivation behind it is not liability but rather a desire to simply help a patient or, in some cases, boost physician income. One government agency found that doctors chose not to order any tests or diagnostic procedures 95 percent of the time. Doctors who ordered tests almost always did so because of medical indications, and only one half of one percent of all cases involved doctors who ordered tests due solely to medical negligence concerns.” Of all the diagnostic tests I order here in Tucson that I would not have done in Canada, I can tell you it’s far greater than half of one percent! In my opinion the lawyers’ assertion is ludicrous.

When asked why he robbed banks, bank robber Willie Sutton replied, “Because that’s where the money is.” Federal attorneys are aggressively prosecuting physicians for the same reason. They think that’s where the money is. My argument is that only part of the solution to the high cost of healthcare lies with preventing fraud. The fact that this administration does nothing to allow tort reform, has reduced the burden of proof necessary to convict physicians for fraud, while piling on regulations, the burden of EHR, ICD 10, PQRI, it all amounts to a war against physicians.

According to the FBI, “Rooting out healthcare fraud is central to the well-being of both our citizens and the overall economy. Healthcare fraud costs the country an estimated $80 billion a year. And it’s a rising threat, with national healthcare spending topping $2.7 trillion and expenses continuing to outpace inflation. Recent cases also show that medical professionals are more willing to risk patient harm in their schemes.” [] The government’s healthcare fraud prevention and enforcement

efforts recovered a record $4.2 billion in taxpayer dollars in Fiscal Year 2012. This is a result of President Obama making the elimination of fraud, waste, and abuse, particularly in healthcare,

a top priority for the administration. 1

I’m sure all physicians would agree with prosecuting cases of actual premeditated fraud, such as performing bypass graft surgery in the absence of coronary disease, or providing home healthcare for patients who don’t exist, is very reasonable and necessary. We do not, however, want to be persecuted, or prosecuted, for practicing medicine to the best of our ability in good faith.

After researching this article I have discovered that any of us could be jailed for a coding error! Congress has created new crimes specifically addressing healthcare fraud. Under this statute, any healthcare provider who presents a false or fictitious claim or demand to the government, seeking reimbursement for medical goods or services, can be liable. The long-standing requirement of proof of criminal intent in connection with the federal prosecution of physicians has been eliminated. The False Claims Act may be applied to physicians providing services that were not provided, or were not “medically necessary.” The punishment for a criminal conviction under the act is up to five years’ imprisonment and a fine of $250,000.00 for each infraction. Civil penalties can be up to $11,000 per incident, plus three times the amount claimed.

A continuing example is the case of Dr. John Natale, a cardiovascular surgeon who spent 10 months in a federal prison even though

the jury found him not guilty on all fraud charges. But he was

How much does defensive medicine cost? Not surprisingly, the true cost of defensive medicine is hard to discern. Kessler and McClellan noted that limits on noneconomic damage awards, such as those California has had in effect for 25 years, can reduce healthcare costs by between 5 percent and 9 percent without “substantial effects on mortality or medical complications.” Applying non-economic damage limits to the country as a whole, with its national healthcare expenditure of $1.4 trillion, would reduce healthcare costs by as much as $126 billion, and reduce the federal government’s share of such costs by as much as $50 billion, according to McClellan’s 2003 estimate. Imagine what we could save based upon more recent healthcare expense estimates. These cost savings would be dwarfed by what we could actually achieve by removing defensive medicine altogether.

So it would stand to reason that if you want to reduce healthcare cost, all aspects would be implemented, not just those that protect your election donors. The criminalization of medicine has to be stopped. The government’s burden of proof requirement of criminal intent must be reinstituted. Criminalizing speech, without requiring proof of intent to defraud, creates a new risk of imprisonment for anyone who is less than perfect in what he or she documents or codes.

Some of these financial numbers and references may be old, but are useful for illustration. The more I researched for this article, the more I felt as Hamlet, besieged by the slings and arrows of our outrageous government, justice system, and malpractice attorneys.

The war on physicians is fully underway on many levels. Watch your coding!


 1. U.S. Department of Justice. Departments of Justice and Health and Human Services Announce Record-Breaking Recoveries Resulting from Joint Efforts to

Combat Health Care Fraud, Department of Justice. Office of Public Affairs, Feb 11,


 2. Hellinger FJ, Encinosa WE. The Impact of State Laws Limiting Malpractice Damage Awards on Health Care Expenditures. Am J Public Health 2006


 3. Kessler D, McClellan M. Do Doctors Practice Defensive Medicine? Quarterly Journal of Economics 1996; 111(2): 353-390.

 4. Studdert DM, Mello MM, Sage WM, et al. Defensive medicine among high- risk specialist physicians in a volatile malpractice environment. JAMA 2005 Jun


 5. U.S Congress, Congressional Budget Office, The Economics of U.S. Tort Liability: A Primer. Washington, DC: US Government Printing Office Oct 2003.  6. U.S Congress, Congressional Budget Office, Medical Malpractice Tort Limits and Health Care Spending. Washington, DC: US Government Printing Office, April


 7. The Factors Fueling Rising Healthcare Costs. Prepared for America’s Health Insurance Plans. Price Waterhouse Cooper, America’s Health Insurance Plans, 2006.  8. U.S. Department of Justice. Departments of Justice and Health and Human Services Announce Record-Breaking Recoveries Resulting from Joint Efforts to Combat Health Care Fraud. Office of Public Affairs, Feb 11, 2013.  9. Hellinger FJ, Encinosa, WE. The Impact of State Laws Limiting Malpractice Damage Awards on Health Care Expenditures. Am J Public Health 2006


10. Kessler D. McClellan M. Do Doctors Practice Defensive Medicine? Quarterly Journal of Economics 1996; 111(2): 353-390. 11. Studdert DM, Mello MM, Sage WM, et al. Defensive medicine among high- risk specialist physicians in a volatile malpractice environment. JAMA 2005 Jun


12. U.S Congress, Congressional Budget Office, The Economics of U.S. Tort Liability: A Primer. Washington, DC: US Government Printing Office Oct 2003. 13. U.S Congress, Congressional Budget Office, Medical Malpractice Tort Limits and Health Care Spending. Washington, DC: US Government Printing Office, April 2006. 14. The Factors Fueling Rising Healthcare Costs. Prepared for America’s Health Insurance Plans, Price Waterhouse Cooper. America’s Health Insurance Plans, 2006. n

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Dr. Lavor retires

“Dear friends and colleagues,” Dr. Michael Lavor wrote in July, “it is with mixed emotions that I write to tell you of my future plans.

“After more than 23 years as a surgeon, I will be retiring from active surgical practice. I will, however, be continuing as Saguaro Surgical’s medical director. In addition, I will be continuing as medical director at The Wound Center where,

through state-of-the-art treatments, we remain available to provide specialized therapy for chronic or non-healing wounds.

“First and foremost, I want to assure you that each member of the Saguaro Surgical medical team remains strong, committed to excellence, and able to offer your patients the full range of general and vascular surgical services you’ve come to expect.

“In a few weeks Saguaro Surgical welcomes the newest general surgeon to our team, Dawn Elliott, M.D., a native of Arizona who received her M.D. at The University of Arizona. Dr. Elliott, along with Saguaro Surgical’s four other surgeons, will continue to meet all the surgical needs of your patients.

“Our staff remains committed to assisting your office and making certain you receive detailed

updates on each patient you trust to our care. As medical director I will focus not only on assuring our high medical standards are maintained, but also that all of the latest technologies and services are available here for you and your patients.

“I have valued our relationship as medical colleagues and feel both fortunate and grateful to have had the opportunity to meet your patients’ surgical needs over the years. I sincerely hope you will develop new and strong relationships with my colleagues at Saguaro Surgical, allowing us to continue to provide general and vascular surgical care for your patients even after I step back from my role as a surgeon.

“Although I will, obviously, remain active in our community, my retirement from active practice as a surgeon is something to be noted— and for my wife, Irene, and me—something to celebrate.

“Sincerely, Michael Lavor, M.D., Saguaro Surgical”

“Sincerely, Michael Lavor, M.D., Saguaro Surgical” Dr. Lavor is an Ohioan born in 1949. He earned
“Sincerely, Michael Lavor, M.D., Saguaro Surgical” Dr. Lavor is an Ohioan born in 1949. He earned

Dr. Lavor is an Ohioan born in 1949. He earned his M.D. in 1985 at University of New Mexico Medical School. He interned at University of Chicago’s Michael Reese Hospital, and did his residency and chief year at University of Illinois’ Metropolitan Group Hospitals, Chicago. He was a U.S. Navy Corpsman with the Marines 1967-69. He is American Board of Surgery certified.

Dr. Elliott earned her bachelor’s degree in microbiology at NAU, and then her M.D. at The University of Arizona College of Medicine, with a post-sophomore Fellowship in pathology. She did her GS residency and internship with Grand Rapids (Mich.) Medical Education Partners at Spectrum Health and Mercy

Health hospitals.

She has a special interest in complex hernia repair and advanced laparoscopy including inguinal and ventral hernia repair, anti- refulx procedures, hiatal and paraesophageal hernis repair, splenectomy, adrenalectomy, and colectomy.

Physiatry Associates adds Dr. Lipson

and colectomy. Physiatry Associates adds Dr. Lipson Physiatry Associates, Ltd. Recently announced that the

Physiatry Associates, Ltd. Recently announced that the practice is pleased to have added Nancy Lipson, M.D.

She joins Charles Blake, M.D., John Larson, M.D., and Michael Goodman, D.O. at the practice at 2102 N. Country Club Rd. Building B.

Dr. Lipson graduated from Wayne State University School of Medicine in Detroit, and completed her PM&R residency at The Ohio State University. She practiced for 25 years in Indianapolis, Ind. before moving to Tucson in June 2014.

Dr. Lipson has expertise in all areas of general rehabilitation, and is subspecialty board-certified in Spinal Cord Injury Medicine. She is currently accepting new patients.

Chicanos Por La Causa honors Dr. López

Ana Maria López, M.D., M.P.H., F.A.C.P., medical director of the Arizona Telemedicine Program, professor of medicine and pathology at The University of Arizona College of Medicine– Tucson, and member of University of Arizona Cancer Center, was one of three women recently honored for being a “cornerstone of our community” by Chicanos Por La Causa (CPLC) at its 34th Annual

of our community” by Chicanos Por La Causa (CPLC) at its 34th Annual 8 SOMBRERO –

Southern Arizona Dinner celebration, “The Art of Being a Woman.”

An internationally recognized oncologist, Dr. López’s work focuses on patient-centered care of women with cancer that includes the family and community, and on enhancing equity and access to healthcare through innovative technology. She also is a leader in

addressing disparities and diversity in the health professions. She is

a principal investigator for several breast and ovarian cancer clinical trials focused on quality-of-life care and innovative treatments.

A native of La Paz, Bolivia, she holds a bachelor’s degree in

philosophy from Bryn Mawr (Pa.) College; a medical degree from Jefferson Medical College, Philadelphia; and a master’s in public health with a concentration in health administration and policy from the UA Mel and Enid Zuckerman College of Public Health.

Dr. Doraiswamy joins UA College of Medicine

Public Health. Dr. Doraiswamy joins UA College of Medicine residency at Cedars Sinai Medical Center, he

residency at Cedars Sinai Medical Center, he was a Senior Fellow in Health Care Studies at Pacific Research Institute, and president of the Docs4PatientCare California Chapter. He has completed a Graduate Health Policy Fellowship at the Heritage Foundation.

In addition to these pages his work has appeared in the Washington Examiner, Arizona Republic, National Review Online, and The Washington Times. He is studying for an M.B.A. at the UofA. He holds an M.D. from Albert Einstein College of Medicine at Yeshiva University, and a B.A. in economics from The Johns Hopkins University.

Carondelet St. Mary’s, St. Joseph’s awarded for stroke care

“Being honored for providing excellent care is the best recognition a hospital can get,” Carondelet Health Network says, “and Carondelet’s Tucson hospitals continue to receive valuable recognition each year from the American Heart Association/ American Stroke Association.

the American Heart Association/ American Stroke Association. Dr. Vijay A. Doraiswamy , a resident member of

Dr. Vijay A. Doraiswamy, a resident member of PCMS, is one of the UofA Cardiology Fellows preparing for the next phase of their careers, the university reports.

In June UofA Sarver Heart

Center celebrated graduation of five Fellows from the Cardiovascular Medicine Fellowship Program,

and two







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from the Interventional Cardiology Fellowship Program. Dr. Doraiswamy is joining the UA College of Medicine, Division of Cardiology as an assistant professor, primarily practicing

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Dr. Fodeman 2014 Claremont Lincoln Fellow

The Claremont Institute, a center for political philosophy and statesmanship dedicated to “recovering the American idea,” reported in June that it had named Dr. Jason Fodeman as a 2014 Lincoln Fellow.

An occasional Sombrero columnist, Dr. Fodeman is a board-certified IM physician and currently an Assistant Professor of Medicine at The University of Arizona, and medical director of the University of Arizona Medical Center Home Health.

He previously studied as an adjunct scholar at the James Madison Institute. During his

“The ‘Get With The Guidelines® Stroke Gold Plus Quality Achievement Award’ was” recently “bestowed on St. Mary’s Hospital for the third consecutive year, and St. Joseph’s Hospital, home of Carondelet Neurological Institute, for the fourth consecutive year.

“The two hospitals, both Joint Commission-certified Primary Stroke Centers, also earned the Target: Stroke Honor Roll Award for the third consecutive year. Both awards are historically given to the highest performing Stroke Centers in the country. These awards recognize Carondelet hospitals’ commitment to exceptional care for their stroke patients by the adherence to the latest evidence- based guidelines based on the latest scientific research.

“Guidelines were established by AHA/ASA in 2003 and were designed to improve ‘stroke care by promoting consistent adherence to the latest scientific treatment guidelines,’” according to AHA/ASA. “Participating hospitals enroll in the program and submit data through a Web-based Patient Management Tool™ provided by AHA/ASA, which is then evaluated to determine both the hospital’s baseline and improvements. Hospitals receive these quality awards based on adherence to the quality metrics for a designated time. Carondelet Tucson hospitals have received the Gold Plus and Target Stroke Honor Roll recognition for their ongoing focus on quality stroke care.”

College of Medicine welcomes 2018 class

The University of Arizona College of Medicine–Tucson welcomed its newest class of medical students with free iPads and three-

days of community-building activities beginning July 30, the university reported. One hundred fifteen students began three days of orientation on their “four-year, hands-on training commitment to learn leading-edge patient care under the mentorship of distinguished clinician-educators at the University of Arizona College of Medicine–Tucson.”

Students were welcomed by campus leaders including Joe G.N. “Skip” Garcia, M.D., UA senior vice president for health sciences and interim dean of the UA College of Medicine–Tucson; Francisco Moreno, M.D.,deputy dean for diversity and inclusion and professor of psychiatry; and Kevin Moynahan, M.D., deputy dean for education, director of the UA College of Medicine– Tucson Societies Program and associate professor of medicine.

Included was a “community service-learning day, during which the medical students will volunteer with local community organizations to build a sense of community and to gain an understanding of some of the social issues the Tucson community faces.”

“The goal of orientation” the university says, is to “develop a sense of professional identity, community and collegiality among a diverse group of future physicians. The College of Medicine– Tucson Class of 2018 includes 33 students who graduated from the UA, 40 percent of the students are Arizona residents, 25 hold graduate or professional degrees, a little more than half are female and two are student-veterans.”


degrees, a little more than half are female and two are student-veterans.” n 10 SOMBRERO –
degrees, a little more than half are female and two are student-veterans.” n 10 SOMBRERO –
degrees, a little more than half are female and two are student-veterans.” n 10 SOMBRERO –
degrees, a little more than half are female and two are student-veterans.” n 10 SOMBRERO –
degrees, a little more than half are female and two are student-veterans.” n 10 SOMBRERO –
degrees, a little more than half are female and two are student-veterans.” n 10 SOMBRERO –
degrees, a little more than half are female and two are student-veterans.” n 10 SOMBRERO –
degrees, a little more than half are female and two are student-veterans.” n 10 SOMBRERO –
degrees, a little more than half are female and two are student-veterans.” n 10 SOMBRERO –
SOMBRERO – August/September 2014 11

Mix At Six

By Dennis Carey

Society welcomes students, interns at Mix

P CMS had its latest a Mix At Six social July 25 at La Paloma Country Club’s 19 th Hole, with former PCMS and ArMA President Thomas, Rothe, M.D., serving as host.

Society members welcomed several medical students and interns to the local medical community, providing an opportunity for them to meet practicing physicians and other students in an informal setting.

“Students and interns have been very enthusiastic about the Mix

At Six events,” PCMS Executive Director Bill Fearneyhough said. “It’s a great opportunity for them to network with colleagues and introduce themselves to practicing physicians. We look forward to their participation in the Society, and in the medical community.”

More Mix At Sixes will be given throughout the year. Watch for notifices of coming events here in Sombrero, on the Society website, and in e-mail. As the cliché goes, be there or be square!


and in e-mail. As the cliché goes, be there or be square! n New PCMS student

New PCMS student members Sean Behan, Edwin Telemei and Jack Rusing enjoy their first Mix At Six social.

and Jack Rusing enjoy their first Mix At Six social. Former PCMS presidents Michael Hamant, M.D.

Former PCMS presidents Michael Hamant, M.D. and Timothy Fagan, M.D. sample the guacamole and appetizers while relaxing at La Paloma Country Club’s 19th Hole.

while relaxing at La Paloma Country Club’s 19th Hole . Dr. Basil Skeif and his wife,
while relaxing at La Paloma Country Club’s 19th Hole . Dr. Basil Skeif and his wife,

Dr. Basil Skeif and his wife, Allison, and Dr. Ken Sandock enjoy refreshments and conversation in Mix At Six’s relaxed atmosphere.

Dr. Steve Cohen and med student Jeff Brown fill out nametags at the mix.

and med student Jeff Brown fill out nametags at the mix. New PCMS student members Pooja

New PCMS student members Pooja Rajguru, Carolyn Sleeth, Jared Brock and Joelle Wang were among Mix At Six’s early arrivals.

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Behind the Lens Arizona: Grape Canyon State By Hal Tretbar, M.D. A rizona is beginning

Behind the Lens

Arizona: Grape Canyon State

By Hal Tretbar, M.D.

A rizona is beginning to be recognized for the fine

M.D. A rizona is beginning to be recognized for the fine Tasting Room Associate Tim Godin

Tasting Room Associate Tim Godin at Page Springs Cellars is ready to pour a splash of a Rhone Valley-type blend.

were wiped out by Pierce disease, transmitted by the glassy- winged leafhopper. As often happens with limited partnerships, there was insufficient funding to replant.

In spite of aging tastebuds and possibly early anosmia (loss of smell ability), I still enjoy stopping at tasting rooms to chat with the locals and sip what they are passionate about. I tend to go with the whites because my cardiologist said red wine might aggravate an arrhythmia. I can tell you what appeals to my taste, but I can’t depict it as a Chenin Blanc has been described at Javelina Leap. “There are honeysuckle aromas followed by layers of apple, honey, mango, and pineapple with hints of butterscotch and lemon curd.”

There was activity in the yard next to the Javelina Leap Vineyard entrance when we stopped by in mid-August. A forklift was moving large empty plastic containers and the driver said, “We are about ready to harvest, and the crush should be good this year.”

Annie Jones was behind the bar in the tasting room and gave us the vineyard history as we tasted several varietals. Rod, a chef, and Cynthia Snapp started from the ground up nine years ago and have been open for eight years. They have developed a number of outstanding varietals including a pink Pinot Grigio, Chenin Blanc, and a Tempranillo. Most of the grapes are from 20 acres

wines coming from our wineries. It all started in the Sonoita-Elgin area when UofA professor Gordon Dutt recognized that soil and weather conditions were similar to noted French Burgundy vineyards. More recently excellent vineyards have become established in Santa Cruz, Cochise, and Graham counties.

Where there are vineyards there are wineries. In the Elgin region two of the oldtimers, Dutt’s Sonoita Vineyards (1983) and Callaghan Vineyards (1990), have had their best served in the White House on numerous presidential occasions.

Then it was determined that the Verde Valley along lower Oak Creek south of Sedona near Cornville has the climate and soil similar to the Rhone region of Southern France. Mediterranean and Spanish varietals such as Mourverde, Roussanne, Grenache, Syrah, Viognier, and Connoise now flourish there.

Recently Dorothy and I drove the Verde Valley Wine Trail. If you start from Sedona, go south 12 miles on 89A and turn left of Page Springs Road. If you are coming off of Interstate 17, turn west at exit 293. Go 9 miles to Cornville to reach Page Springs Road, and 3.5 miles in either direction brings you to three of the five wineries in the Verde Valley. Oak Creek, Javelina Leap, and Page Springs Cellars are just down the road from each other. Echo Canyon is near Sedona, while Alcantara is closer to Camp Verde.

I certainly am not a wine connoisseur; maybe a sometime

aficionado. We watched a family friend give up his hobby store business in Tucson to become a vintner. Robert “Bob” Webb was

a pioneer in Cochise County when he planted 20 acres of

Cabernet Sauvignon, Merlot, and Riesling, at Kansas Settlement in1983. This was at the at the same time Gordon Dutt started in Santa Cruz County. Bob built the nice Mediterranean- style R.W.Webb Winery on I-10 just east of Tucson. In spite of quality wines, the winery failed because of manage- ment problems, poor location, and lack of ambience.

I was in a limited partnership for Terra Rosa Vineyards, located a few miles west of Elgin. We planted 20 acres of Merlot and other popular varietals. After four years of increasing production and some excellent vintages, we

of increasing production and some excellent vintages, we At the Javelina Leap tasting room, Annie Jones

At the Javelina Leap tasting room, Annie Jones says that a Zinfandel would go well with the pizza snack.

Danielle and Barry of Gilbert enjoy the cool Page Springs Cellars Vineyard. The Chardonnay was

Danielle and Barry of Gilbert enjoy the cool Page Springs Cellars Vineyard.

The Chardonnay was fresh and spirited. It is 100 percent varietal, combining Chardonnay grapes from both Bonita Springs and Arizona Stronghold. Dorothy enjoyed the Serrano, the flagship blend from Page Springs Cellars. This is their 10 th year of blending 42 percent Mourvedre, 41 percent Syrah and 17 percent Petite Sirah, all from Arizona.

The owner, inspiration, driving force, and vintner for the cellars is Eric Glomski, who comes from a California winemaking background. He briefly worked at Echo Canyon Winery before a prime property became available on Oak Creek near Cornville. The first vines were planted in 2004, and Eric planned to have a small “boutique” affair.

In 2007 he partnered with Maynard James Keenan, a well-known rock singer who came from an Italian winemaking family.

Together that had big plans. They wanted to put the best wines at

a fair price all across the country. They bought the 80-acre Dos Cabezas vineyard at Kansas Settlement from Don Buel. Don had expanded the original 20 acres planted by Bob Webb. They renamed it Arizona Stronghold. Later they added the Bonita

Springs Vineyard 20 miles north of Wilcox. The Stronghold winery

is in Camp Verde and the tasting room is in Cottonwood.

After an intense cross-country tour and advertising campaign, they were ready to sell in 38 states as well as in Canada, Australia, and New Zealand. In 2012 Arizona Stronghold produced 12,000 cases of wine.

Soon there was a clash of personalities and in the spring of this year the divorce happened. The Arizona Republic reported on May 12, 2014 that Keenan would take possession of the Stronghold vineyard in Kansas Settlement and change the name

in the Verde and Skull valleys.

Javelina Leap has become well known for its Zinfandels. Their 2012 AZ Zinfandel comes from their Dragoon Vineyard. The 2012 Estate Legacy Zinfandel is from the 4.5 acres of seven-year-old vines outside the front door. They offer only one blend, made with Arizona Zinfandel, Merlot, and Petite Sirah.

The Page Springs Cellars tasting room was busy with a hum of relaxed conversation. Beyond the sunlit room with its traditional bar and wine bottle racks was an inviting alcove. Subdued lighting and soft music tempts one to sink into a soft leather sofa and linger over a glass of wine.

We chose to have a “Flight” that combined both reds and whites. A Flight gives you a chance to try four or five of the winery’s favorites, usually all red, white, or specialty. A splash of each can be sniffed and rolled on the tongue for about $8 to $10. Tim Godin was our very knowledgeable Tasting Room associate. Some that we chose to sample were the Rhone style 2011 La Serrana ($26), the 2012 Arizona Chardonnay ($24) and a red 2012 El Serrano ($32).

The Serrana is a pleasant blend of 75 percent Viognier and 25 percent Roussanne from the Stronghold vineyard at Kansas Settlement.

and 25 percent Roussanne from the Stronghold vineyard at Kansas Settlement. SOMBRERO – August/September 2014 15
and 25 percent Roussanne from the Stronghold vineyard at Kansas Settlement. SOMBRERO – August/September 2014 15
and 25 percent Roussanne from the Stronghold vineyard at Kansas Settlement. SOMBRERO – August/September 2014 15
and 25 percent Roussanne from the Stronghold vineyard at Kansas Settlement. SOMBRERO – August/September 2014 15
The cozy, inviting alcove off the main Page Springs Cellars tasting room. to the Al

The cozy, inviting alcove off the main Page Springs Cellars tasting room.

to the Al Buhl Memorial Vineyard. Glomski would keep the Arizona Stronghold name and retain the winery.

A press release from Arizona Stronghold on May 24, 2014 stated that Eric Glomski had now gained full control of all Stronghold activities. He will retain the name, winery, current inventory, and the Bonita Springs property. He has a five-year contract on key blocks of Keenan’s Al Buhl Memorial Vineyard.

As Dorothy and I tasted our Flight at Page Springs Cellars, I asked Tim Godin what was new. He said they had just released a vintage that was something different for them. “A year ago we agreed to ferment a few hundred gallons of an apple-pear juice blend for a

a few hundred gallons of an apple-pear juice blend for a Doug and Heidi Ruff of

Doug and Heidi Ruff of Jacksonville, Fla. took a wine tour from Sedona. They are beside shady Oak Creek at Page Springs Cellars.

guy known as Apple Bob Mertis. We are so impressed with it that we are selling a 2013 Mertis as a desert wine. It is 80 percent apple and 20 percent pear juice.” I sniffed and tasted it not knowing what to expect. I found it to be attractive, palatable, and not too sweet.

Before we left Page Springs Cellars we ambled down under a vine-covered trellis through the vineyards to a lovely picnic deck beside gently flowing Oak Creek. I chatted with a couple having lunch. Doug and Heidi Ruff were from Jacksonville, Fla. and were on a wine tour out of Sedona. Doug said, “I like trying new wines.

I’m not really into red wines. I really like this white that we bought here. It is smooth, mellow, and very slightly sweet. It is this one

called Mertis.”


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Sellout Summer? Buyout Binge?

Within a month of each other, two large local healthcare organizations, that reportedly lost more than $30 million each last year, made agreements to be fully or partly bought.

In June, University of Arizona Health Network and Banner Health entered what they called a long-term agreement.

In July, Ascension (formerly Ascension Health) and Carondelet Health Network signed a letter of intent to form a partnership with Tenet Healthcare and Dignity Health, exploring a joint venture that would aquire Carondelet.

UAHN, Banner

In announcing the move, UAHN and Phoenix-based Banner Health called it “an “historic” effort to “create a statewide organization to transform and advance healthcare in Arizona.” The university press release called plans a “comprehensive new model for academic medicine. This ground-breaking agreement will formalize discussions and is intended to lead to final definitive agreements sometime in Fall.”

The proposed transaction is “anticipated to generate approximately $1 billion in new capital, academic investments, and other consideration and value beneficial to UA and the community,” the university reported. “The anticipated transition of 6,300 employees working at UAHN’s two hospitals, the health plan, and the medical group into Banner will create Arizona’s largest private employer with more than 37,000 employees.”

The action followed votes from the UAHN and Banner boards of directors “in support of proceeding with negotiations, as well as a vote by the Arizona Board of Regents (ABOR) to authorize the UofA to also move forward with UAHN and Banner. The parties will now work together towards final definitive agreements, anticipated to be completed and signed in September. The definitive agreements must also be approved by ABOR and the boards of directors of UAHN and Banner. The proposed transaction is expected to close a few months following the signing of the definitive agreements.”

They stated these proposed key transition elements:

 To create an Arizona-based, statewide health system that improves care for all the state’s citizens by reliably and compassionately delivering superior care to all who turn to this system;  To create a nationally leading health system that provides better care and improved patient and member experiences at lower costs through valued-based or accountable care organizations that utilize population health management models that emphasize wellness;  To expand University of Arizona Medical Center capabilities for complex academic/clinical programs such as transplantations, neurosciences, genomics-driven precision health, geriatrics, and pediatrics while providing for investment opportunities in other areas;

 To bolster fiscal sustainability, eliminating persistent shortfalls and low operating margins currently experienced by UAHN.

In addition to solving the immediate financial needs, they said, the proposed agreement will:

 Eliminate the debt burdening UAHN (currently projected to be $146 million);  Provide resources for improved hospital infrastructure, including the $21 million purchase of land currently leased to UAMC and $500 million within five years to expand and renovate the medical center, and build new facilities as appropriate, such as a major, multi-specialty outpatient center to be constructed in Tucson;  Create a $300 million endowment which will provide a $20-million-per-year revenue stream to advance the UA’s clinical and translational research mission;  Preserve historic funding levels between the clinical and academic partners in addition to a $20 million per year enhancement;  Allow additional funding support based on growth in revenues generated by the clinical and academic partnership;  Improve operational efficiencies;  Secure and sustain a lasting relationship with, and commitment to, the University of Arizona, anchored by an Academic Division within Banner. The Academic Medical Centers:

The University of Arizona Medical Center—University and South Campuses and Banner Good Samaritan Medical Center and the faculty practice plan, will support the growing needs of the Colleges of Medicine in Phoenix and Tucson and create a value- based delivery system;  The Phoenix and Tucson academic medical centers will be infused with operational strength through the proposed transition and rapidly evolve into major economic drivers that will attract highly skilled, trained and paid professionals, elevating Arizona as a bioscience destination;  Train more physician specialists and allied health professionals, including pharmacists and advanced practice nurses for Arizona;  Provide a comprehensive platform for the development of physician-scientists who will drive discovery across basic science studies, patient-oriented clinical research, health services research, and population health;  Enhance and elevate academic medical excellence across Arizona to national leadership levels; and  Secure and sustain an operational foundation for the Colleges of Medicine in Tucson and Phoenix that will maximize the value of the ongoing state funding received annually through legislative appropriations.

“When these respected organizations unite, the potential for delivering top-tier academic medicine throughout the state, recognized nationally, becomes a reality,” UAHN Board Chairman Steve Lynn said.

Added UAHN President and CEO Michael Waldrum, M.D., “I’m especially pleased that this proposed transition will infuse stability and energy into our organization. This will benefit our patients, faculty, staff and students as we pursue excellence. Ultimately, we’re moving from a situation in which we can only maintain status quo, to a situation in which we can create a premier Academic Medical Center.”

“With healthcare here in Arizona and across the nation facing new challenges and opportunities every day, this agreement will allow the Arizona Health Sciences Center and the entire UA to advance our mission to provide education, conduct research and enhance patient care that will transform healthcare at the state and national level,” said UofA President Ann Weaver Hart. “Combining the world-class care at UAHN and Banner will better meet the needs of patients in Arizona and throughout the region, while also providing tremendous learning experiences for students at the University of Arizona. By forming this collaboration we will accomplish more for Arizona’s residents and for the advancement of medical knowledge and practice than we could do in isolation.”

Added Banner Presidient and CEO Peter S. Fine, “We’re honored that the UAHN Board of Directors strategically sought Banner to create Arizona’s first statewide health system to help strengthen medical education. Banner’s vision is to sustain a position of national leadership. This opportunity to join with a premier academic organization significantly advances Banner towards this vision. In addition, we’re especially mindful of UAHN’s legacy of excellence in Tucson and throughout the state, which must be maintained, nourished and strengthened.”

The press release said that The University of Arizona Colleges of Medicine and Banner Health have a “long history of successful affiliation through the Graduate Medical Education program at Banner Good Samaritan Medical Center in Phoenix. Each year, Banner and the UA Colleges of Medicine

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collaborate in the training of nearly 260 physicians in five residency programs and in numerous fellowships.”

Ascension & CHN, Tenet & Dignity

In a July 22 press release datelined St. Louis, Mo. and Tucson, involved parties announced that Ascension and Carondelet Health Network had signed a letter of intent to form a partnership with Tenet Healthcare and Dignity Health, and that they will “ex-plore” a joint venture that would acquire Carondelet. Ascension is the parent of CHN. They called the letter with a Tenet subsidiary “exclusive” and “non-binding.”

“Upon closing,” they said, “it is anticipated that Ascension would retain a minority interest in such a joint venture. The parties have launched a period of due diligence which they expect will result in a definitive agreement.

“Under the proposed agreement, Tenet would be the majority partner in the joint venture with management responsibility for all operations of Carondelet’s assets, including St. Joseph’s and St. Mary’s Hospitals in Tucson … Holy Cross Hospital in Nogales … Carondelet Medical Group, Carondelet Specialist Group, and Carondelet’s ancillary businesses. Once the acquisition is complete, the joint venture would maintain Carondelet’s heritage and identity, continuing Carondelet’s Catholic sponsorship.

“Tenet and Dignity Health both own and operate hospitals in the Phoenix area. Their participation in a Tucson–based joint venture will connect Carondelet to a regional healthcare system, including Tenet’s and Dignity Health’s growing accountable care organization, Arizona

Care Network; strengthen and grow Carondelet’s relationships with physicians; and fund strategic growth initiatives in Southern Arizona.”

“We are excited to pursue this relationship with Tenet and Dignity Health,” Carondelet President and CEO James K. Beckmann said. “Like Carondelet, Tenet and Dignity Health are committed to providing high quality, low cost, person-centered care. This relationship is an opportunity to strengthen those efforts, enhance healthcare across Arizona, and continue Catholic sponsorship of Carondelet. The people of Tucson and Southern Arizona will continue to benefit from the tremendous dedication and talent of Carondelet’s associates and physician partners.”

The parties said they do not plan to provide any further detail “until such point as a definitive agreement is reached.”

Tenet Healthcare Corp. described itself as “a leading healthcare services company, through its subsidiaries operates 79 hospitals, 193 outpatient centers, including six hospitals and four outpatient centers in Arizona, and Conifer Health Solutions, a leader in business process solutions for healthcare providers serving more than 700 hospital and other clients nationwide. []

Dignity Health in Arizona said it includes “four outstanding hospitals: Chandler Regional Medical Center, Mercy Gilbert Medical Center, St. Joseph’s Hospital and Medical Center, which includes Barrow Neurological Institute and St. Joseph’s Westgate Hospital. From this foundation, Dignity Health in Arizona has expanded into a comprehensive health care system, which includes imaging centers, clinics, specialty hospitals, urgent cares, an insurance provider, an accountable care organization and

other clinical partnerships. The Dignity Health Medical Group employs more than 250 physicians, who cover a wide range of specialties. Dignity Health, Arizona Service Area, is part of Dignity Health, one of the nation’s five largest health care systems.

Ascension reported that last year it provided $1.5 billion in care of persons living in poverty and in community benefit programs, and that it employs more than 155,000 associates serving in more than 1,900 sites in 23 states and the District of Columbia. “Ascension’s direct subsidiaries provide services that include healthcare delivery, medical equipment management, treasury management, resource and supply management, venture capital investing, physician practice management, and risk management.”

CMS: Open Payments ‘Sunshine’ program means more transparency

By Betsy Thompson, M.D., DrPH, Region 9 CMO

As part of the Open Payments program, the Centers for Medicare & Medicaid Services will soon make data about the financial relationships between the health care industry and physicians (e.g. including medical doctors, doctors of osteopathy, dentists, chiropractors, and others) and teaching hospitals available to the public. Offering this data will create more transparency and allow those interested to use, analyze and monitor it.

Open Payments, previously known as the Sunshine Act, is a federal transparency program enacted by Congress in 2010. Under this program, CMS collects and publicly reports data about

Congress in 2010. Under this program, CMS collects and publicly reports data about SOMBRERO – August/September
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payments (“transfers of value”), ownership, or investment interests between drug and device manufacturers and physicians and teaching hospitals. Beginning with the last five months of 2013, CMS will collect this data annually from industry and make it publicly available, downloadable, and searchable. Every year CMS will continue to release this financial information as it becomes available about the prior year (e.g. by June 30, 2015 for 2014 data).

These financial interactions can happen for many reasons: research, conference travel and lodging, gifts, and consulting. They can foster collaboration among physicians, teaching hospitals, and industry manufacturers that may contribute to the design and delivery of life-saving drugs and devices. However, they also can potentially lead to conflicts of interest in how health care providers prescribe medications or give medical care.

While CMS doesn’t make assumptions or draw conclusions about the reported information, the Agency will take steps to ensure that only accurate information is made public. For example, as part of this initial data collection process, CMS has

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engaged stakeholders as pilot users to ensure that reporting systems are user-friendly and performing properly.

In addition, CMS will give physicians and teaching hospitals an

opportunity to be sure that information reported about them is accurate. In order to review the data and make corrections if necessary, physicians and teaching hospitals must first register in CMS’ Enterprise Portal starting on June 1, 2014. Then, starting in July, they must register in the Open Payments system (via CMS’ Enterprise Portal). This voluntary review and dispute period is open for 45 days.

CMS strongly encourages physicians and teaching hospitals to register in our Enterprise Portal and Open Payments systems so they can review their specific data. Any data that physicians or teaching hospital dispute, but is not corrected by industry within the dispute resolution period, will be included when the data is made public and marked as disputed.

It is important that physicians or teaching hospitals know about this program, how and what financial relationships are reported, and how to answer questions from patients. Visit openpayments to get more information about Open Payments (the Sunshine Act) and the resources available to understand the program. Health care providers and others with questions and concerns can be e-mailed to

This information was provided by the United States Department of Health and Human Services.

Hyperbaric ambulance:

fast HBOT treatment saves brains

By Carol L Henricks, M.D.

A hyperbaric oxygen therapy (HBOT) equipped ambulance is being

developed in North Carolina through a collaborative effort of the FDA, Wake Forest University Hospital system, and the UHMS.

The hyperbaric ambulance will prolong the therapeutic window to allow TPA therapy (tissue plasminogen activator or “clot buster”) to be given to patients who have suffered an acute stroke and have a long travel time to a hospital.[1] TPA improves stroke outcome=less disability.

HBOT intervention, preferably within three hours of rescue, also improves the outcome in acute anoxic brain injury caused by near-drowning and cardiopulmonary arrest. Hyperbaric ambulances and/or acute HBOT treatment would change the associated disability of these injuries forever! The research of French physician Dr. Mathieu suggests a mechanism by which you interrupt the cascade of intracellular injury caused by acute anoxia under hyperbaric conditions at 2.0 ata 100% medical


In the worldwide literature we know that Japan has been using hyperbaric ambulances since the 1970s. In Japan, if you call “911” and may have a heart or brain related emergency, EMS will arrive in a hyperbaric ambulance to minimize the loss of heart and brain


Oxygen under pressure provides physiological benefits that are

not present when a patient is breathing oxygen under atmospheric pressure conditions. HBOT creates oxygen radicals in a hyperoxic environment and triggers healing mechanisms including acute arrest of the cascade of intracellular injury, release of stem cells, induced healing, bacteriostatic effects, and modification of gene expression.

All physicians should get to know the benefits of hyperbaric oxygen therapy.[4]

REFERENCES 1. Membership Newsletter of the Undersea & Hyperbaric Medical Society (UHMS ). Stroke Ambulance in Development. Pressure: 23. Nov/Dec 2013. 2. Mathieu D et al. Hyperbaric oxygenation in acute ischemic encephalopathy (near-hanging). Eur J Neurol 7(Suppl3);151. 3. Discussed at the Third International Symposium for Hyperbaric Oxygen Therapy in 2003, Fort Lauderdale, Fla. 4. Henricks C. HBOT activates healing mechanisms. Sombrero Feb 2014.

AMA: Prevent diabetes before it starts

Given that 86 million Americans have pre-diabetes, you likely have patients with this common but treatable condition.

To help these patients and improve outcomes for your practice, you can refer people who have prediabetes to an evidence-based diabetes prevention program at the YMCA of Southern Arizona. This program can have a positive impact on patients, providers, and communities such as ours seeking to reduce the incidence of type 2 diabetes.

In the Tucson area, a grant covers the cost for people over age 65 with pre-diabetes to attend the YMCA’s Diabetes Prevention Program. Adults under 65 who have pre-diabetes can still participate by paying out-of-pocket or by having a health plan that covers participation.

The YMCA’s Diabetes Prevention Program is based on the Centers for Disease Control and Prevention’s National Diabetes Prevention Program. AMA and the YMCA of the USA are collaborating to increase the number of Medicare participants in the YMCA’s Diabetes Prevention Program. Additionally, YMCA of the USA is participating in a Center for Medicare & Medicaid Innovation grant that pays for at-risk people older than 65 to attend its diabetes prevention program in 17 communities across the country, including Tucson and Phoenix.

Physician referral tools

While physician practices can already refer patients with pre- diabetes to the YMCA’s Diabetes Prevention Program, AMA is seeking to enhance a referral process that works well across different types of practices. It has created tools to:

 Increase education and awareness of pre-diabetes by promoting physician screening of those at risk.  Increase physician referrals of people with prediabetes to the diabetes prevention program offered by the YMCA.  Create a feedback loop linking the patient’s progress in the program to the physician’s practice so that information can be integrated into the patient’s care plan.

These easy-to-use tools, created as part of a pilot project with physician practices in Delaware, Indianapolis and Minneapolis/St.

Paul, are available to physician practices at no cost and can be adapted to meet a practice’s specific needs. Check out and download the tools at, and/or contact Janet Williams at to receive them.

AMA is also engaging insurers to collaborate on strategies for expanded coverage of evidence-based services shown to prevent type 2 diabetes, including services delivered through YMCA.

YMCA’s Diabetes Prevention Program

This program is a one-year, community-based program led by a trained lifestyle coach. Participants and the coach gather in a relaxed classroom setting, at a local YMCA or elsewhere in the community, and work together in small groups for 16 weekly sessions, then eight monthly sessions to incorporate healthier eating and moderate physical activity into their daily lives.

The program is based on research funded by the National Institutes of Health and published in the New England Journal of Medicine in 2002. The research showed that among people with pre-diabetes who enrolled in a diabetes prevention program, there was a 58 percent reduction in the total number of new diabetes cases, and a 71 percent reduction in new cases among those 60 or older.

Reserve Corps works on civilian casualty care training, more

Medical Reserve Corps of Southern Arizona reports that it has undertaken three significant projects this summer:

The MRCSA Nurses Task Force, together with Tucson Electric Power, will host a high-level Emergency Power Outage Roundtable on Friday Sept. 19, bringing together “key stakeholders” to discuss the functional and access needs of community members who are homebound or have conditions requiring durable medical equipment during an extended power outage.

Participating organizations will be asked to summarize their current emergency plans that address needs of the target population during a power outage of more than three days. Similarities and gaps will be identified and next steps will be proposed. Those interested in attending the roundtable should contact MRC for more information or to join up: 520.445.7035;

Emergency Civilian Casualty Care (E3C) training, established in February of this year, has provided life-saving instruction to more than 300 medical professionals, business leaders, security personnel and students.

Created by Dr. Sheldon Marks and Capt. Kris Blume for civilian

training, E3C is based on the military’s Tactical Combat Casualty

Care (TCCC). The program teaches the newest advances in

saving trauma care including the proper use of tourniquets, traumatic and life-threatening wound treatment, triage, violent encounters, situational awareness and community resilience. Goals are to train 1,500 people within the first year, develop a train-the-trainer program, and enlist a cadre of individuals who will provide E3C training throughout Southern Arizona.


Individuals interested in becoming a trainer are encouraged to contact the MRCSA office at 520.445.7035.

MRCSA is also working to better address the needs of the Southern Arizona community through Community Needs Assessment surveys. Focus is on jointly establishing priorities and planning efforts with Tucson metro hospitals, community clinics and emergency response agencies.

Surveys are designed to provide a current snapshot of community preparedness and awareness of available resources for emergency and disaster response and recovery. MRCSA will use the information it gets to create a volunteer corps of physicians, nurses, pharmacists, mental health professionals and others that most effectively addresses the needs of the community.

“Our objective is to be stronger and better prepared in the event of any emergency situation through an investment in long-term community resiliency,” MRCSA said in a release. Project partners include University of Arizona Medical Center, Northwest Medical Center, Tucson Medical Center, Carondelet Medical Group,

Kindred Hospital, Tucson Fire

Arizona College of Nursing, Arizona HOSA–Future Health Professionals, and Pima County Public Health Nurses.

Department, the University of

PCOA: Reach nutrition out to elders

By Debra Adams

Access to an adequate amount of nutritious food is important for everyone, but can be even more critical as you age. Good nutrition plays a critical role in preventing and managing chronic conditions, maintaining energy levels, aiding in recovery and promoting overall health.

Many physiological and socio-economic factors affect the nutritional status of our communities’ elders, leading to food insecurity. For some, limitations on physical mobility interfere with the independent performance of daily living activities including shopping for and preparing healthy, well-balanced meals.

For others, depression and social isolation lead to inadequate consumption of enough calories because many seniors do not eat regularly when having to dine alone. Still others cannot afford to buy nutritious food because they live on very limited fixed incomes. If not addressed, these factors can lead to poor health and eventual loss of independence.

Every three years Pima Council On Aging conducts a Community Needs Assessment to identify the needs and concerns of Pima County’s older adults. Preparing nutritious meals moved into the top eight serious problems for the first time in the 2012 Community Survey. In prior years this problem has been noted as a serious concern for survey respondents 85+ years of age, but has now been identified as a serious problem for all 60+ age groups combined.

PCOA’s Nutrition Program for the Elderly, and its component services of Congregate Meals and Home-Delivered Meals, has for the last 34 years been a reliable source for nutritious, prepared meals for many of Pima County’s older adults. These programs

decrease social isolation and assist many frail older adults in remaining safely and comfortably in their own homes.

Ten Congregate Meal Centers in Tucson have been strategically placed to be accessible to older individuals across the community, while also targeting the most vulnerable—those in greatest economic need, minority elders, and individuals with limited means for transportation. The City of Tucson Parks & Recreation Dept. administers programs at Armory Park, Archer, Donna Liggins, William Clements, Freedom and El Rio centers. The Tucson Urban League operates at the Quincie Douglas Neighborhood Center. Catholic Social Services administers sites at El Pueblo Neighborhood Center, Flowing Wells/Ellie Towne Neighborhood Center and the Eastside/El Dorado Center. Three additional sites are available in Robles Ranch, Ajo, and Green Valley.

For those who are unable to attend a Congregate Meal site, PCOA contracts with two agencies to deliver nutritious, prepared home-delivered meals throughout the metropolitan Tucson area and select areas of Pima County.

Both the Congregate and Home-Delivered Meals meet one third of the Daily Reference Intake. Meals are provided on a donation basis with individuals contributing what they can afford toward the cost of the meal.

Of the 1,237 nutrition program participants who completed the program evaluation survey in FY 13-14, 90 percent stated that the meals helped them maintain their health; 88 percent stated that the meals provided a larger variety of fruits, vegetables and meats than they would be able to prepare for themselves; and 84 percent stated that meals increased their daily intake of food.

Please help PCOA in reaching out to those older individuals who find themselves unable to prepare or access the foods necessary to maintain good health. Assistance is available. Encourage your patients to call the PCOA Help Line at (520) 790.7262 or visit

Debra Adams is PCOA chief operating officer.

PCOA, Carondelet partner in post-hospital patient support

Carondelet Health Network reported Aug. 13 that with the goal of of improving patient care quality and safety, and reducing hospital readmissions, they are collaborating with Pima Council On Aging.

“The Centers for Medicaid and Medicare Services (CMS) recognized the Tucson program as a ‘Best Practice’ and says this community-based Care Transitions Program is a valuable model for other communities to consider,” CHN reported.

“The program focuses on Medicare patients with multiple chronic illnesses who have been discharged recently from the hospital. Carondelet nurses and PCOA care coordinators partner on making regular visits to the homes of these patients, providing much-needed medical follow-up care and a variety of other kinds

of social support to help the patient manage their recuperation and maintain their health after they leave the hospital.”

“We’ve seen some real success with this program,’ said CHN CMO Donald Denmark, M.D. “Patients are improving their health … and their well-being simply by receiving the support necessary to remain healthy and stay out of the hospital.”

“The program is an outgrowth of the Affordable Care Act,” CHN said. “The federal government reached out to healthcare providers in 2011, challenging them to design programs that provide high quality care and cut costs to the overall healthcare system. Carondelet took up the charge, and in doing so, recognized that medical care is only part of what patients need after they leave the hospital. Carondelet partnered with Pima Council on Aging, a well-respected organization providing important in-home and community-based services and social support to older adults and family caregivers.”

CHN quoted PCOA President and CEO W. Mark Clark: “The Care Transitions Program works because of the unique partnership of Carondelet nurses and PCOA coaches and navigators. Each of us brings our medical and social service skills to the focused care of these patients in their homes, providing medical follow-up and specific social supports that can improve the health outcome for the patient.”


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Arizona Medical Associa on News

A year at ArMA’s megaphone

By Dr. Thomas C. Rothe

In May I finished my one-year term as Arizona Medical Association president. Fortunately, it was an “easy” year for healthcare in Arizona, as Gov. Jan Brewer got the Medicaid expansion passed in early 2013.

Legislators were so burned out by the prolonged fight over this issue that they had little energy left for anything related to healthcare. As such, I was able to escape frequent trips to Phoenix since the skirmishes were few!

ArMA has a threefold mission: patient advocacy, physician advocacy, and scope of practice oversight. This year ArMA has stepped up to protect patients from non-physicians purporting to deliver healthcare services (non-nurse mid-wives wanting to do VBACs at home, psychologists requesting prescribing privileges, chiropractors asking to deliver hormone therapy, etc.) I would not call this turf protection as some do.

ArMA follows more than 175 bills each year introduced into the Arizona Legislature, and prides itself, and is widely respected for, making sure we separate fact from opinion: legislators know if we

give them a fact, even if they do not agree with our opinion, the fact has been vetted and is reliable. Our credibility is surpassed by no one at the Capitol, and our support is considered essential when it comes to healthcare and physician services. The governor and staff are in close

communication with ArMA as the voice of physicians. They know politically we can drive an issue, and we speak with credibility and honesty.

In addition, your state medical society has worked closely with the Mutual Insurance Company of Arizona (MICA) to cut down on frivolous lawsuits. This has resulted in stabilization, and rebates in malpractice insurance premiums. Likewise, ArMA works to protect these reforms and diligently watches for legal-system end- runs around them.

diligently watches for legal-system end- runs around them. New ArMA President Jeffrey Mueller, M.D., left, accepts
diligently watches for legal-system end- runs around them. New ArMA President Jeffrey Mueller, M.D., left, accepts

New ArMA President Jeffrey Mueller, M.D., left, accepts the gavel from outgoing President Thomas C. Rothe, M.D. May 31 at the ArMA Annual Meeting.

The biggest frustration of my ArMA tenure was going to Washington, D.C. to fight for the permanent repeal of the SGR, only to have it postponed once again. In both the House and Senate, Republicans and Democrats overwhelmingly agreed that this problem should be fixed. Docs from all backgrounds and the AMA vigorously fought for this, but legislators said they “could not come up with a way to pay for it.” The take-home message is crystal clear:

national politicians do not care about physician interests because of fragmentation and differences within the physician community. They know that, sense that, docs will eventually go along with whatever legislation is passed, and frankly would just as soon see docs fight it out themselves. Their only interest is to maintain power and give lip-service to everything else.

Statewide is another matter. Like medical care, all politics is local and the representatives seem to be more interested in physician opinions, perhaps because it relates specifically to their constituents more directly. Passage of the Medicaid expansion by

a Republican governor in a right-wing-crazy state like Arizona was a major accomplishment!

This was good for both the citizens of Arizona as well as the physicians. Regardless of your political feelings on this matter, having money to pay for medical care for those who need it most

is paramount to a healthy and more productive Arizona.

Dr. Rothe, a PCMS past-president and member since 1982, practices with La Cholla Family Practice.

Annual ArMA meeting report

By Bill Fearneyhough PCMS Executive Director

It was early morning coffee, rolls, fresh fruit, and cloistered

conversations as delegates from across the state gathered in Phoenix May 30 and June 1 for the Arizona Medical Association’s annual meeting.

Along with election of new officers and general business, delegates had a full agenda of resolutions to discuss, including two divisive proposals for establishment of a single-payer healthcare insurance system, and a moratorium on the medicalization of capital punishment.

As in the past PCMS was well represented. Attending were PCMS President Timothy Marshall, M.D., and PCMS Board members

doctors Timothy Fagan, Screven Farmer, Gary Figge, Michael Hamant, William Mangold, and Thomas Rothe. Doctors Richard Dale and Thomas Hicks also attended. Doctors Farmer, Figge, and Hicks served on the Reports and Resolutions Committees.

President’s Address Friday’s afternoon session saw Immediate Past-President Thomas Rothe, M.D. introduce Dr. Jeff Mueller as the 123 rd ArMA President. Dr. Mueller is Associate Dean of Hospital Practice for Mayo Clinic’s 23 hospitals, and medical director and a staff anesthesiologist at Mayo Clinic Hospital, Phoenix.

Dr. Mueller spoke on the numerous challenges facing physicians, including increased hospital, clinic and physician group consolidations; increasing practice administrative costs; new payment models; the politically-driven substitution of non- physicians for physicians; and the ever-increasing reductions in reimbursement as demand for healthcare services escalate.

To answer these challenges and more effectively use ArMA resources, Dr. Mueller said the association should focus more on state-based advocacy, called for physicians to actively seek and assume formal leadership positions within hospitals and health systems, and recommended that the state organization more closely coordinate its advocacy activities with county and state specialty societies. Currently ArMA leadership meets with these societies once a year, but Dr. Mueller suggested meetings be held at least twice a year to discuss how all could work together more efficiently and effectively on behalf of Arizona physicians.

Elections Tucson family practitioner Timothy Fagan, M.D. was voted AMA Alternate Delegate and continues to serve as a PCMS Director; Michael Hamant, M.D. was elected ArMA Secretary; Screven Farmer, M.D. will serve as At-Large Director and Thomas Hicks, M.D. as a delegate to AMA. Dr. Timothy Marshall was elected PCMS Director, replacing Dr. Charles Katzenberg who resigned the post earlier in the year. All join fellow ArMA Board members doctors Gary Figge, William Mangold, and Thomas Rothe.

Resolutions The House of Delegates debated a multitude of significant resolutions. Uncharacteristically, PCMS sponsored a single resolution, dealing with GME funding.

Resolutions receiving delegate support:

✓  Transferral of authority to establish membership dues from the ArMA House to the ArMA Board of Directors. ✓  Join with the University of Arizona’s Valley Fever Center for Excellence, public health departments, and other organizations to promote coccidioidomycosis awareness and/or actively seek funding resources for cocci awareness and education. ✓  Support increased GME funding in Arizona and oppose funding cuts. The PCMS Board-approved resolution was adopted from a position paper submitted by PCMS Board student members Jamie Fleming and Jeffrey Brown. ✓  Propose that AMA petition the U.S. government and the National Institute of Health (NIH) requiring publication of all NIH- National Center for Complementary and Alternative Medicine- funded studies without regard to results. ArMA would also propose to AMA and the Association of American Medical Colleges that medical student education be limited to scientifically sound medical practice that adheres to evidence-based physics,

chemistry, pharmacology, and biology. It also calls for teaching of Complementary and Alternative Medicine to follow the same rigorous requirements of research and published studies showing efficacy before being included in medical school curricula. ✓  Encourage appropriate healthcare providers to review the American Endocrine Society guidelines for testosterone replacement therapy in adult men with Androgen Deficiency Syndrome, and urge a thorough discussion of the risk vs. benefit of the therapy be discussed between the provider and patient. ✓  Educate ArMA members, as prescribed by the Agency for Healthcare Research and Quality guidelines, that allergen immunotherapy be administered in a setting allowing prompt recognition and management of adverse reactions unless withholding such therapy would seriously jeopardize a patient’s health. ✓  Have ArMA participate in the Arizona Prescription Drug Misuse and Abuse Initiative and urge state legislators to adequately fund efforts to adequately fund initiative efforts; encourage voluntary CME regarding use and management of controlled substances; encourage licensed prescribers to enroll and use, where appropriate, the Arizona Controlled Substances Monitoring Program; endorse ongoing efforts by the Arizona Department of Health to develop Opioid Prescribing Guidelines.

Resolutions referred back to ArMA committees for further study:

✓  Calls to renew federal CDC funding for gun violence research, and support legislation directing the Arizona Department of Public Safety to notify the National Instant Criminal Background Check System when an individual has been adjudicated for court- ordered psychiatric treatment. Delegates voted to send the resolution back to the Public Health Committee for further study and recommendations. ✓  Calls for ArMA to propose to the Association of American Medical Colleges and the American Medical College Application Service that they adopt a similar matching service for residencies as provided by the National Residency Matching Program. The resolution would streamline the application process, saving medical school applicants time and expenses associated with applying to a multitude of medicals schools. It also offers rejected applicants time to make alternate plans for a coming academic year. Delegates voted to send the resolution to ArMA’s Executive Committee with the recommendation that the committee seek input from medical schools. ✓  Direct the state association to seek legislation that would lift the cap on the number of patients physicians may treat for opioid dependence and eliminate the lengthy certification process for physicians using buprenorphine to treat such patients. Delegates voted to send the resolution to the Executive Committee for further action and study. It was noted that past efforts to change Drug Addiction Treatment Act language have failed to get action from the state legislature.

Failed Resolutions:

✓  Directed ArMA to support the adoption of a single-payer financing mechanism for health insurance. ✓  Ask the state medical association to urge AMA request all states with active capital punishment statutes enforce a moratorium on all future executions until resolution of the problems associated with medicalization of the death penalty.

Highlighting Friday evening’s President’s Awards Banquet was Gov. Jan Brewer’s keynote address.



Local CME from Pima County Medical Foundation

PCMF has scheduled these CME events for its Tuesday Evening Speaker series. Dinner is served at 6:30 p.m. presentation follows at 7.

Sept. 9: New Medical and Surgical Treatments for Prostate Cancer presented by UA medical oncologist Frederick Ahmann, M.D., and UA radiation oncologist Shona Dougherty, M.D.

Oct. 14: Dermal Fillers and Fat Stem Cells in Plastic Surgery presented by plastic surgeon John Pierce, M.D.

Nov. 11: Newer Anticoagulants and their Role in A-Fib, DVT, and Pulmonary Embolism presented by Timothy Fagan, M.D.


Sept. 4-6: The Association of American Physicians and Surgeons 71 st Annual Meeting: Rescuing Patient Care from Failed Policy and Flawed Science is at the DoubleTree by Hilton in the Historic District of Charleston at 181 Church St., Charleston, S.C. 29401.

Up to 16 AMA PRA Category 1 CME credits are available in accordance with accreditation requirements of the New Mexico Medical Society through joint providership of Rehoboth McKinley Christian Health Care Services and AAPS.

“Doctors must lead the charge to stop the subjugation of patient care to the interests of the government, third parties, and so-called

interests of the government, third parties, and so-called ‘guidelines,’” AAPS says. This meeting “will arm you

‘guidelines,’” AAPS says. This meeting “will arm you with the tools you’ll need to help in this fight. Learn how you can make a difference, including steps you can take now to free your practice and your patients from ‘ObamaCare’ while others wait around for politicians to ‘fix’ American medicine, and much more.”

Speakers include AAPS President Tom Kendall, M.D.; Kris Held, M.D. of; Avik Roy of; Citizens Council for Health Freedom founder Twila Brase, R.N.; Physicians Declaration of Independence author and AAPS President-Elect Richard Amerling, M.D.; Paul Kempen, M.D., Ph.D. of ChangeBoard Recert. com; Parvez Dara, M.D. of Jedis Medicine; AAPS Executive Director Jane Orient, M.D.; and Charles Sauer of The Market Institute.

Learn more and register online at You may register for full meeting or individual sessions. For hotel reservations call 877.408.8733 and mention AAPS to receive group rate of $149 per night. Cost as of Aug. 4 is $475 AAPS members, $625 non-members, $625 new members including first year’s dues, and $250 spouse/guest registration. Partial registration options available.

Sept. 6: The Future of Heart and Vascular Care: An Update for the Practitioner is a Carondelet Heart & Vascular Institute syposium at Loews Ventana Canyon Resort, 7000 N. Resort Drive, Tucson, 85750. Register at CME: Up to 7.5 AMA PRA Cateogory 1 credits.

Event targets primary care physicians, cardiologists, cardiothoracic surgeons, vascular surgeons, PAs, NPs, RNs and radiologic technologists. Symposium highlights recent advances and best practices in heart and vascular medicine, and new treatments to improve patient outcomes for those with heart failure, valve disease, or A-fib. Presentations emphasize emerging and changing concepts that influence guidelines for cholesterol and diseases affecting the heart’s valves.

CHVI is a new 92,000-square-foot facility based at Carondelet St. Mary’s Hospital. It includes a dedicated Cardiovascular ICU, all- private bed Progressive Care Unit, three cardiac cath labs, electrophysiology suite, three dedicated Ors, and a unique hybrid operating suite.

CHN is a ministry of Ascension Health, the nation’s largest Catholic, not-for-profit healthcare system. In Fiscal Year 2013, Carondelet reported nearly $69 million in Community Benefit to improve community health and access to healthcare.

Sept. 13: Acute and Chronic Leukemias 2014: A Case-Based Discussion is at Mayo Clinic Education Center, 5665 E. Mayo Blvd., Phoenix 85054. Accreditation is to be determined.

Activity is designed to provide “up-to-date information on practical, current and evolving therapies using real-case-based scenarios.” Attendees will be able to discuss practical cases with faculty knowledgeable in specific specialties. Course has breakout sessions for one-on-one interaction between faculty and learners.

One-day comprehensive symposium targets hematologist and oncologist physicians, NPs, RNs, PAs and pharmacists. Full program details, including schedule, faculty, accommodations, and registration will be available prior to event.



Contact: Lilia Murray, Mayo School of Continuous Professional Development, 13400 E. Shea Blvd., Scottsdale 85259; phone 480.301.4580; fax 480.301.8323.

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Did you know? MICA members are eligible for retirement tail when they retire completely from
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MICA members are eligible
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completely from the practice
of medicine at age 55 or older,
with one year of MICA coverage
immediately preceding retirement.
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