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



Our old HQ= Tucson Concussion Center

Full ahead in reverse with Dr. Sheldon Marks

A ‘sunrise application’ and you

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For maps of office locations, visit the contact us page.


Official Publication of the Pima County Medical Society

Vol. 49

No. 1


Pima County Medical Society Officers

PCMS Board of Directors

Snehal Patel, DO (Alt. Resident) Joanna Holstein, DO (Alt. Resident) Jeffrey Brown (Student) Juhyung Sun (Alt. Student)

Members at Large

Arizona Medical

Association Officers

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

Eric Barrett, MD David Burgess, MD Michael Connolly, DO Jason Fodeman, MD Howard Eisenberg, MD Afshin Emami, MD Randall Fehr, MD G. Mason Garcia, MD Jerry Hutchinson, DO Kevin Moynahan, MD Wayne Peate, MD Sarah Sullivan, DO Salvatore Tirrito, MD Scott Weiss, MD Leslie Willingham, MD Gustavo Ortega, MD (Resident)

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

Richard Dale, MD Charles Krone, MD Jane Orient, MD

At Large ArMA Board

R. Screven Farmer, MD

Pima Directors to ArMA

Board of Mediation

Timothy C. Fagan, MD Timothy Marshall, MD

Delegates to AMA

Timothy Fagan, MD Thomas Griffin, MD Evan Kligman, MD George Makol, MD Mark Mecikalski, MD


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

Executive Director



West Press


Bill Fearneyhough


(520) 795-7985


(520) 323-9559

E-mail: billf



(520) 795-7985


(520) 323-9559


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

Art Director

Alene Randklev


(520) 624-4939


(520) 624-2715




(520) 624-4939

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 © 2015, Pima County Medical Society. All rights reserved. Reproduction in whole or in part without permission is prohibited.

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Milestones: Honors for three of our members.


Membership: The International Center for Vasectomy Reversals is right here at home, and another of our past-presidents takes on a new job.


PCMS Alliance News: Holiday Luncheon raises approximately $8,000 for Mobile Meals of Tucson.


Legal Medicine: Dr. Timothy Fagan explains what a certain Sunrise Application means to you.


Behind the Lens: The very term ‘fallout shelter’ raises a whiff of Cold War. Evidence may be in your neighborhood.


Makol’s Call: John Mayer raises the Dead.


Affordable Care Act: An analyst examines ‘ObamaCare’ mysteries, how they came to be, and what they portend.

mysteries, how they came to be, and what they portend. On the Cover The Grand Canyon’s

On the Cover

The Grand Canyon’s Toroweap Overlook is at the end of a poorly maintained 61-mile-long dirt road on the North Rim. It gives the observer a dizzying 3,000-foot view down to the Colorado River. This was shot on Velvia film with Nikon F100 (Dr. Hal Tretbar photo).

the Colorado River. This was shot on Velvia film with Nikon F100 (Dr. Hal Tretbar photo).


Dr. Barker honored twice

Milestones Dr. Barker honored twice Steven J. Barker, M.D., Ph.D. , University of Arizona Health Sciences

Steven J. Barker, M.D., Ph.D., University of Arizona Health Sciences professor emeritus and former head of the UofA College of Medicine Department of Anesthesiology, was recently honored with two lifetime achievement technology awards “for his dedication and innovation in anesthesiology,” the university reported.

Two professional organizations,

the Society for Technology in Anesthesia, and the international symposium Innovations and Applications of Monitoring Perfusion, Oxygenation and Ventilation, honored Dr. Barker with the awards.

Dr. Barker was also honored as a top educator among awardees at the 36 th Annual Faculty Teaching Awards and the Vernon and Virginia Furrow Awards honoring faculty members’ outstanding achievements and excellence in teaching.

The Furrow Awards were established by Virginia Mann Sugg Furrow, M.D., who in 1942 was one of only two women in Baylor College of Medicine’s graduating class. The Furrow Awards are the College’s primary system for peer recognition of excellence in education and are presented by the College’s Academy of Medical Education Scholars (AMES).

Review: Dr. Beiter among top 100

Amy Beiter, M.D. was recently named among the top 100 physician hospital leaders nationwide by Becker’s Hospital Review for a third consecutive year, Carondelet Health Network, reports.

Dr. Beiter is president and CEO of Carondelet St. Mary’s Hospital. The recognition was “based on each leader’s healthcare experience, accolades, and commitment to quality care. Dr. Beiter is the only physician hospital or health system leader in Arizona on the list.

“Under Dr. Beiter’s leadership Carondelet St. Mary’s, a Joint Commission-certified Primary Stroke Center, is also one of the American Heart Association/American Stroke Association’s Gold Plus and Target Honor Roll Hospitals for Stroke Care.”

Plus and Target Honor Roll Hospitals for Stroke Care.” “We have grown from a community hospital

“We have grown from a community hospital to a facility that provides tertiary referral care for the entire city and surrounding region,” Dr. Beiter said. “Year after year, St. Mary’s is recognized for its quality and safety. But it’s the compassion and warmth of our staff that so often makes the biggest difference to our patients and their families. I’m really proud of the care we provide here.”

Dr. Beiter is board-certified in IM and pediatrics. She moved to Tucson in 1992 and began her medical practice at El Rio Community Health Center where she served as chief of staff and developed and managed a free clinic for teens. That same year she joined the medical staff at Carondelet St. Mary’s Hospital. After leaving El Rio in 1999, Dr. Beiter worked as a hospitalist at Carondelet Health Network. Seven years later, she became medical director of utilization management at St. Mary’s, soon followed by a position as Chief Medical Officer in 2008. She was promoted to CEO in 2012.

Dr. Gordon honored in education research

Paul Gordon, M.D., M.P.H., PCMS member since 2010, was among those recently recognized in education-related research at the UA College of Medicine—Tucson for his research contribution to “Novel Use of Ultrasound to Aid in Medical Student Reproductive Physical Examination Skills and Pelvic Anatomy.”

The university reports that “as part of its commitment to

excellence and innovation in medical education, Academy of Medical Education Scholars (AMES) funds grants to support education-related research at the Ua College of Medicine— Tucson. Eligibility includes faculty members, fellows, residents

and medical students who are sponsored by a faculty member.”

Dr. Gordon has been an ABFM-certified FP physician in Arizona since 1986. His research interests include women’s health, delivering medical services to under-served populations, and education. He practices full spectrum family practice including care of hospitalized patients and provision of maternity together with delivering babies.

In addition to his clinical practice, Dr. Gordon is a faculty member at the College of Medicine–Tucson, where he teaches and supervises family practice resident physicians and medical students.

Dr. Gordon earned his M.D. at Mount Sinai School of Medicine in New York. His internship and residency in family medicine were at the University of Rochester.

York. His internship and residency in family medicine were at the University of Rochester. n SOMBRERO




Forward in reverse with the Niche Guy

Story and photos by Stuart Faxon

R emember the budding sociopath nearsighted nerd kid in your neighborhood, the one who used to take apart dead

animals to see how they worked? O.K., maybe you lived in a different neighborhood, but what if the kid went good instead of bad? What if he actually didn’t graduate to killing animals and people, but instead became a doctor? Would that we all could channel weird that well.

Sheldon Harris Feiler Marks, M.D. was the guy. He became the niche-market go-to guy for micro-surgical vasectomy reversals.

Raised in Phoenix, he graduated from the University of Arizona College of Medicine in 1982, did his general surgery residency at the Mayo School of Graduate Education in Rochester, Minn., and did his residency in urology at Tufts University’s New England Medical Center Hospital in Boston.

“I was always fascinated with how the body works,” Dr. Marks says. “If I found a dead cat, snake, or lizard, I’d always dissect it to understand how it worked.” If neighborhood folks came across a dead animal, they knew they’d better hide it before Sheldon got hold of it, he said. “As a kid I even tried to understand anatomy books.”

“As a kid I even tried to understand anatomy books.” ICVR’s operating suite is ‘designed, built,

ICVR’s operating suite is ‘designed, built, and equipped specifically for reversals,’ Dr. Marks says. ‘It’s the only one in the country at this level.’

‘It’s the only one in the country at this level.’ Dr. Sheldon Marks with his son,

Dr. Sheldon Marks with his son, Matthew, a masters-level specialist who runs the andrology lab for male fertility and sperm banking at ICVR.

Sheldon had no family history of career medicine, though his father was an attorney who often had physician contacts, he said. “First I wanted to be a forensic pathologist,” Dr. Marks said. “I was obsessed with what we don’t normally see. I was very nearsighted. Anything micro is what seemed to draw me.” He said he once inscribed the Gettysburg Address on the back of a postage stamp. On his plastic models of airplanes, he’d even paint the dashboard instruments. “I didn’t know it yet, but that had me primed for later in life.”

While in general surgery, “I was having a great time, loving everything,” he said, when another surgeon suggested that Sheldon was “too nice to be a surgeon.” That subject would seem to be for a whole ‘nother article! But the further suggestion was urology, as a general practice of one organ system. Dr. Marks took the suggestion. “It has everything from small office-procedures to 12-hour cancer surgeries,” he said. “It includes pediatric, geriatric, infectious disease, oncology, stones, psych, endocrinology—it’s almost all of medicine in one organ system.”

The path was nearly built. “The urologists I worked with at Mayo were world-class leaders,” he said, “I did a rotation in tubal reversal and excelled at it.” After residency, Dr. Marks returned to the Southwest, and to Tucson because “it has the best Mexican food. You just can’t get it anywhere else!” Isn’t that what New Yorkers are always saying about their bagels? Here, Dr. Marks partnered in oncology at the Thomas-Davis Clinic and then with doctors Del Steinbronn, Joel Childers, and Earl Surwit.

In 1990 we went into solo urology practice. “It was mostly prostate cancer and reversals,” he said. In 1995 he wrote a book on prostate cancer, Prostate Cancer—A Family Guide to Diagnosis, Treatment, and Survival, a best-seller now in a fourth edition and translated into eight languages. That led to plenty of travel and lecturing as a visiting professor. Then “at some point,” he said. “the reversal practice just took off.”

‘Dads again’ begin with sperm, and Dr. Marks shows how ICVR can bank the little
‘Dads again’ begin with sperm, and Dr. Marks shows how ICVR can bank the little

‘Dads again’ begin with sperm, and Dr. Marks shows how ICVR can bank the little swimmers.

That many men had ill-considered vasectomies? It’s more about the variable human psychology of it all—relationships, family planning, life itself. “One out of 20 men changes his mind,” Dr. Marks said., “It can be as soon as a month, or as much as 40 years later.” That calls for physician sub-sub-specialization. “Any urologist can do a vasectomy, but it doesn’t mean they can do a reversal,” Dr. Marks says. “It takes a unique skill set that has a very long learning curve—and it’s a really perishable skill set.”

When he started doing lots of reversals, “I was getting very high

success, and now this is what I do,” he said. “This is a full-time, reversal-only practice. It’s unlike anything in the


It’s been frequently noted that his patients come from Arizona, the rest of the nation, and the rest of the world, and for anyone who doubts it, Dr. Marks has wall maps of the U.S. and the world pinpointing exactly where. Around the maps on almost every

wall are photos of kids, often with the fathers who wanted and caused them. That’s why the practice’s slogan is “We Make Men Dads Again.”

Procedures are done on site, in the practice’s special O.R. “I chose to limit myself to one reversal per day,” Dr. Marks said. “It gives me time, and gives the patient the best chance for success.” The procedure takes two to three-and-a-half hours. “We fix other people’s failed reversals, too,” he said. “About one in seven is a re- do.” Peter J. Burrows, M.D., F.A.C.S., another PCMS member, does

It’s not just for Christmas. The teddy bear in ICVR’s foyer is so big and heavy, he lives there all the time as an oversized symbol of the kids who may not even exist yet. Besides, what else would you do with a bear this big?

reversals at ICVR. Both men have done nearly 6,000 reversals combined in their many years in practice, claiming a success rate up to 99.5%.

In vasectomy reversals, you’d actually have to work to avoid the Niche Guy. For the past eight years Dr. Marks has been the only urologist in the country teaching a postgraduate course on reversal at the annual American Urological Association meeting. “I wrote the teaching module on reversals for the American Society of Reproductive Medicine, and I

recently wrote a textbook chapter on reversals. I write for Dr. Andrew Weil’s website, and I’m the urologist for WebMD.”

Having done this kind of microsurgery for so long led Dr. Marks to design the ASSI Marks Vas

Cutting Forceps, with Accurate Surgical & Scientific Instruments Corp. of Westbury, N.Y. The instrument’s 15-degree angle “provides larger lumenal area” and “allows for easier anastomosis and improves opportunity for patency. Even if inflammation and/or scarring are present at the anastomotic site, the [instrument’s] larger area provides greater chances for successful reversals.” Its technique and results were discussed in the March 2014 Fertility and Sterility, and in Andrology, showing

“success is high in skilled hands, even in men 15 to 40 years from vasectomy,” Dr. Marks said.

‘I always wanted to be better than anybody at what I do—whatever one thing it is.’

–Dr. Sheldon Marks

There isn’t an American state that has not been home to some of Dr. Marks’

There isn’t an American state that has not been home to some of Dr. Marks’ and Dr. Burrows’ patients, and this is only the U.S. Map.

Oh but there’s more. Niche Guy has also been a local SWAT team guy for 14 years. He co-chairs the Medical Reserve Corps of Southern Arizona, teaching physicians in disaster preparedness and active shooter/violent encounter and security training, and civilians in trauma training. He’s taught wilderness medicine courses to Special Operations Command soldiers in Virginia, and he’s taught trauma training to people being deployed to high- threat areas in Afghanistan.

Since 2008 he has been married to Page, a personal injury attorney, in a second marriage. From his first, 28-year marriage

in a second marriage. From his first, 28-year marriage Kids a-plenty and parents decorate ICVR’s walls
in a second marriage. From his first, 28-year marriage Kids a-plenty and parents decorate ICVR’s walls
in a second marriage. From his first, 28-year marriage Kids a-plenty and parents decorate ICVR’s walls
in a second marriage. From his first, 28-year marriage Kids a-plenty and parents decorate ICVR’s walls
in a second marriage. From his first, 28-year marriage Kids a-plenty and parents decorate ICVR’s walls
in a second marriage. From his first, 28-year marriage Kids a-plenty and parents decorate ICVR’s walls

Kids a-plenty and parents decorate ICVR’s walls in photo after cute photo.

have come Matthew Marks, who runs the ICVR andrology lab; Jordan, a writer living in L.A.; and Ally, a comedian and writer who also lives in L.A.

“Every day the world should be a better place,” Dr. Marks said, quoting a concept he got from his mother. His question for himself and everyone else is, “What are you going to do today to make the world a better place?”

If that includes making dads again, Sheldon H.F. Marks, M.D. is doing it daily.


place?” If that includes making dads again, Sheldon H.F. Marks, M.D. is doing it daily. n


What’s new in the old neighborhood

Story and photos by Dennis Carey

PCMS past-president Michael Hamant, M.D., has not made a specific New Year’s resolution, but change is certainly in the works.

Dr. Hamant has been selected as medical director for the new Tucson Concussion Center, set to open at the site of the former Pima County Medical Society building at 5199 E. Farness Drive in Tucson Medical Park. The opening date has not been set, but it could be as early as the end of this month. PCMS offices will share space with the new center. Dr. Hamant will add this responsibility to continuing his primary care and sports medicine practice at 6761 E. Tanque Verde.

“I really don’t have a definite plan at this point,” Dr. Hamant said. “We will see what happens with the concussion center before I decide how much I need to change my primary care practice. Eventually, I do expect to spend less time with the practice. I might need to hire an associate or nurse practitioner, depending on the response we have.”

With the recent rise in attention to head injuries as the result of participation in sports, Dr. Hamant acknowledges business at the Tucson Concussion Center could take off quickly. “We are hoping to hit the ground running,” he said. “It should be a welcome addition to the Tucson medical community.”

Dr. Hamant became interested in becoming part of Tucson Concussion Center in summer 2014, after talking with long-time colleague Tom Sanderson at Momentum Physical Therapy. Sanderson had been to a meeting in Scottsdale with Hirsch Handmaker, M.D. at the Banner Concussion Center. Sanderson and Dr. Handmaker thought it might be a good idea to open a similar facility in Tucson. Dr. Handmaker worked at getting the financial backing for the center. Sanderson thought Dr. Hamant’s background in sports medicine would make him an excellent choice to manage the Tucson Concussion Center and made the connection.

“There have been a few delays along the way,” Dr. Hamant said. “But once we cleared the way, things got moving pretty fast.”

The center will have all the expected services for diagnosing and treating head injuries, while adding some of the newest innovations in this area. There will be baseline concussion testing for athletes of all ages. A neuro-optometrist will be available help diagnose and treat visual problems related to head injuries. A neuro-psychologist will also help with the cognitive and balance issues.

Dr. Hamant said the center will address most of the non-surgical areas of head injuries. There will be an advisory group of experts, from audiology to occupational therapy, to help with any situation. Athletes will be able to get baseline tests before participating in sports to help determine how serious their condition is after suffering an injury, and how recovery has progressed.

after suffering an injury, and how recovery has progressed. PCMS past-president Michael Hamant, M.D. at his

PCMS past-president Michael Hamant, M.D. at his primary care and sports medicine practice. He will be medical director for the new Tucson Concussion Center, which will open soon in the former PCMS building.

“Baseline testing will be an important part of the center,” Dr. Hamant said. “Each person is different and may respond to treatment or recover differently. Young children are different from teens or adults. A high-level athlete is different than the weekend athlete. Without that baseline evaluation, it will be difficult to determine how a patient is progressing.”

“Heading” into treating concussion is a natural step for Dr. Hamant. After getting his bachelor’s degree in zoology and chemistry, and master’s in physiology from Northern Arizona University, he graduated from University of Arizona College of Medicine in 1983. He completed his internship at Rutgers University Medical School Hospital in New Brunswick, N.J. 983- 84, and an internship at University of Oklahoma’s University Medical Center in Tulsa 1986-89, specializing in family practice. There were no sports medicine fellowships at that time.

“In graduate school I was interested in muscle physiology, having played sports as a kid,” he said, “and I was interested in staying close to sports in some way as part of my practice. I was not able

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866.467.3611 fax Workers were in the final stages of building out the Tucson

Workers were in the final stages of building out the Tucson Concussion Center at 5199 E. Farness Drive. Our former offices will be again, sharing space with the new center.

to get a fellowship, but I was lucky enough to be grandfathered into a program to get a Certificate of Added Qualification in sports medicine.

“For a long time, team doctors for sports teams at schools and in communities have been the local family doctor. Opportunities in sports medicine, especially for primary care physicians, are a very recent development. Now being a team doctor for a sports team is a very competitive business. Sports medicine has so many aspects now. In the past it used to be focused on treatment of injuries, and orthopedics dominated the field. There is still a lot of that, but you have nutrition, the effects of diseases such as diabetes, injury prevention, and now the focus on the effects of head injuries.”

Dr. Hamant and his wife, Lynnell Gardner, M.D., have been PCMS members since they opened their Tucson practice in 1989. Dr. Gardner is an OB-GYN specialist who is now focusing on the gynecology part of her practice. She will continue her practice in the office they share.

The extensive resume Dr. Hamant has built in organized medicine continues to grow. His PCMS service includes president in 2008, serving on our board of directors from 2004 to present, and serving on our Executive Committee from 2005 through 2009.

He started as a member of the Health Partners Physician Network Board of Directors from 1991-1995. He chaired of the Board of Directors of Southwest Physicians Network from 1995-2002. At TMC he was a board member 1996 to 2001 and still serves on the TMC Quality Committee.

His current commitment to service includes being vice-president of ArMA after serving three terms as secretary. He has also been named an alternatee delegate to AMA for 2015-17.

“It keeps me out of trouble,” Dr. Hamant says with a smile. “I don’t plan to slow down in that area, either. As I see it, if we (physicians) don’t advocate for ourselves, who will? This is an important time to make our voices heard.”


MembershipPCMS Alliance News

Mobile Meals, Alliance partnership continues

Story and photos by Dennis Carey

F lemings Prime Steakhouse and Wine Bar hosted the 2015 PCMS Alliance Holiday Luncheon on

Dec. 9, with about 115 attendees. They raised approximately $8,000 for Mobile Meals of Tucson, Inc.

Attendees included Alliance members, guests, and board members from Mobile Meals of Tucson. This year’s luncheon included the tradition of selling Mrs. A’s Apples and caramel nut bars. The giant caramel apples and nut bars are from the recipe of Alliance member Kathy “Mrs. A” Armbruster.

Attendees also put in bids on silent auction items such as spa packages, wine gift baskets, artwork, and other donations from local businesses and restaurants. Each table was decorated with an elegant centerpiece, and the centerpieces were sold as part of the auction.

Mobile Meals of Tucson delivers more than 100,000 meals to home-bound adults each year.

u n d a d u l t s e a c h y e a

Putting together the 2015 PCMS Alliance Holiday Luncheon was the work of many, including the organizers, from left, Co-Chair Anastasha Lynn, Mobile Meals of Tucson Executive Director Priscilla Altuna, Co-Chair Reem Aussy Hanna, Lupita Barboa, and Allison Duffy.

Co-Chair Reem Aussy Hanna, Lupita Barboa, and Allison Duffy. Artwork, gift cards, wine baskets, and spa

Artwork, gift cards, wine baskets, and spa packages were among the items at the Alliance’s silent auction to raise money for Mobile Meals of Tucson.

silent auction to raise money for Mobile Meals of Tucson. Alliance volunteers Kay Dean, Neda Kiarash,

Alliance volunteers Kay Dean, Neda Kiarash, and Anastasha Lynn help attendees check in, buy raffle tickets, and collect nametags.

check in, buy raffle tickets, and collect nametags. Just ogle that inviting display of the justly

Just ogle that inviting display of the justly famous Mrs. A’s Apples! Lupita Barboa and Allison Duffy help a customer sort out the variety of caramel apples for sale. Sales of the apples and caramel nut bars are a traditional part of the event’s fund-raising.

Legal Medicine

An important Sunrise Application

Legal Medicine An important Sunrise Application By Dr. Timothy C. Fagan Most Arizona physicians know little

By Dr. Timothy C. Fagan

Most Arizona physicians know little or nothing about Sunrise Applications, but they are extremely important to us.

Arizona Revised Statutes 32-104 requires any group of medical professionals to file a sunrise application before the next legislative session if they wish to expand their scope of practice. The sunrise application then has a hearing before the Committee of Reference (COR), comprised of all of the members of the Arizona House and Senate health committees.

Testimony by the applicant organization and witnesses is heard, as well as testimony from other interested parties. If the application is approved, the applicant entity is free to have scope- of-practice legislation introduced at the next legislative session. If the application is not approved, increased scope-of-practice legislation may not be introduced.

The Arizona Nurses Association (AzNA) filed a sweeping sunrise application in 2015. The intent of the application is to extensively expand the scope of practice of Advanced Practice Registered Nurses (APRNs); Nurse Practitioners (NPs); Certified Nurse Midwives (CNMs); Certified Registered Nurse Anesthetists (CRNAs); and Clinical Nurse Specialists (CNS’s).

Rationale The primary rationale stated in this application is to increase access to care, particularly in medically under-served areas of Arizona. Not stated, but implicit in the application, is the desire of APRNs for fewer limitations on practice and responsibility only to the Arizona Board of Nursing (BON).

Dr. Raymond Woosley, internist and clinical pharmacologist is a former dean and vice-president for health sciences at the University of Arizona. He testified that the less extensive pharmacology and clinical training of APRNs make it important, for patient safety, that APRNS work as part of a team with physicians.

Changes applicable to all APRNs Currently, all APRNs are licensed as RNs by the BON and certified in their APRN specialty, based on national certifying exams. Although not directly specified, and only briefly alluded to in the AzNA Sunrise Application, but clearly stated in the draft legislation, is establishment of a new category of licensure, Advanced Practice Registered Nurse, with specialization in one of the four areas, e.g. Advanced Practice Registered Nurse—Nurse Practitioner. This is analogous to a physician being licensed as an M.D.—Internal Medicine, or D.O.—Family Practice. The rationale for this is unclear and appears unnecessary.

This Sunrise Application seeks to have prescribing authority, for the four classes of APRN, to be determined solely by the BON “after consultation with the Arizona Medical Board, Arizona Board of Osteopathic Medical Examiners and Arizona Board of Pharmacy.” These determinations should be made by legislation, not by the BON.

Changes applicable to NPs and CNMs In the application, AzNA states that insurance companies have argued that NPs and CNMs are not “Independent Practitioners” due to “collaboration” language in the statutes, and therefore they are not entitled to inclusion in provider panels, or to compensation for services performed. This may also limit the ability of NPs and CNMs to practice in medically under-served areas.

This is a misinterpretation, by the insurance companies, of the terminology “collaboration with a physician.” According to Arizona statute, the legal meaning is “to establish a relationship for consultation or referral with one or more licensed physicians on an as-needed basis.” However, Arizona law does not require any specific designation of a collaborating physician or documentation of the collaborator. Substitution of the correct definition for the collaboration language should solve this problem, rather than deleting any reference to NPs and CNMs “collaborating” with physicians. However, insurance companies will always be able to find an excuse not to pay for services, so neither elimination of “collaboration” nor substitution of more accurate language is likely to solve the provider panel and reimbursement problems.

of more accurate language is likely to solve the provider panel and reimbursement problems. 12 SOMBRERO

Changes applicable to CRNAs CRNAs are the primary or sole providers of anesthesia care in many rural parts of Arizona. Current Arizona law limits administration of anesthesia by a CRNA to “under direction and in the presence of a licensed physician or surgeon…”. AzNA proposes repealing this language.

ArMA’s witness, Dr. Ross Goldberg, a general surgeon, made an excellent case that, while the CRNA knows more about anesthesia, the surgeon is responsible for, and knows more about the whole patient, and therefore should be the individual directing activity in the O.R. rather than the anesthesiologist or CRNA.

Dr. Jane Fitch, a nationally prominent anesthesiologist, practiced as a CRNA before attending medical school and becoming an anesthesiologist. She testified that the broader and more extensive education of anesthesiologists makes it important for patient safety that CRNAs function in a team with anesthesiologists.

The CRNAs are also seeking prescribing authority and the ability to practice pain medicine independently. Dr. Patrick Hogan, a pain management specialist, gave a brief history of the development of pain medicine as a specialty, and made an excellent case that the broad educational background and clinical experience outside the specific area of pain management are essential for provision of optimal pain management.

Changes applicable to Clinical Nurse Specialists

Although there are approximately 70,000 CNSs practicing nationally, there are only 182 licensed in Arizona. Training of a

CNS is similar to that of an NP, but they usually have a practice limited to particular patient populations or disease categories, such as geriatrics or psychiatry. They usually

practice in clinics, hospitals, or outpatient facilities. Many CNSs primarily work on processes and protocols to improve clinical outcomes, such as wound management or prevention of hospital readmissions.

For a CNS to be paid by Medicare, there must be a collaborative relationship with a physician. In Arizona, CNSs do not have prescriptive authority. AzNA is seeking this authority. This would be unrestricted for a Psychiatric CNS, but limited to the patients of the facility or clinic in which the other CNS specialists practice. How prescribing could be monitored and limited to these patients is problematic.

The hearing

This COR hearing was an outstanding example of our democracy in action. The proceedings lasted five hours and 20 minutes without a break. Both sides were heard and many excellent questions were asked. Committee members were knowledgeable, prepared, and attentive for the whole time.

Rep. Randall Friese, M.D. (D-9 th ) and Sen. Kelli Ward, D.O. (R-5 th ) provided the benefits of their medical backgrounds. Heather Carter, chairperson of the House Health Committee, was particularly knowledgeable

and had clearly spent many days reading the proposal and background documents.

The COR voted five to four to allow the application to go forward. Each committee member explained his or her vote. Virtually all were concerned about the extent and complexity of the application.

Organized medicine’s position

After making it perfectly clear that physicians respect and appreciate all categories of APRNs, working as a team with physicians, testimony on behalf of ArMA and nine other statewide specialty societies opposed the entire AzNA Sunrise Application.

The rationale is that these expansions of practice without physician involvement, would jeopardize patient safety. ArMA will continue to oppose legislation furthering the requests in the Sunrise Application. However, this does not rule out negotiation between AzNA and organized medicine, which could lead to compromises regarding some of the proposals in the application.

REFERENCES The entire Sunrise Application and hundreds of supporting documents and publications are available at .

IM physician and pharmacologist Timothy C. Fagan, 2011 PCMS president, has long been active in organized medicine and education. He is vice-governor and treasurer of the Arizona Chapter of the American College of Physicians, and serves as an ArMA alternate delegate to AMA. He is a University of Arizona Professor of Medicine Emeritus.






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Behind the Lens

Living with ‘the bomb’

By Hal Tretbar, M.D.

the Lens Living with ‘the bomb’ By Hal Tretbar, M.D. R ecently a house in our

R ecently a house in our neighborhood, built in

1961, went up for sale. The description of the property pointed out that it had a fallout shelter that could be used as a wine cellar. That mention of a bomb shelter brought back lots of Cold War memories with the nuclear anxiety of Mutually Assured Destruction.

In the late ‘50s Dorothy and I had been in the army in Germany, facing large numbers

of Russian troops in the Eastern bloc countries, but we didn’t feel any true tension. We came to Cleveland in July 1961 and began to worry about possible conflict. In May of 1960 Gary Powers in a Lockheed U2 spy plane

had been shot down by a rocket over Russia. Cleveland had many Nike anti-aircraft rocket sites for protection.

Then the international situation rapidly changed. In July 1961 the tension between

West and East over the status of Berlin led President Kennedy to ask Congress to increase the strength of the military and provide funds for civil defense. Overnight, building of the Berlin Wall began, on Aug. 13, 1961.

Kennedy wrote a letter to Life maga- zine in the September 1961 issue asking for establishment of fallout shelters in public buildings. A month later Kennedy advised American families to build bomb shelters to protect themselves from atomic fallout in the event of a nuclear exchange with the Soviet Union.

in the event of a nuclear exchange with the Soviet Union. My neighbor opens the heavy
in the event of a nuclear exchange with the Soviet Union. My neighbor opens the heavy

My neighbor opens the heavy counter-balanced cover to her Whitaker- built shelter. The air intake is close by.

One year later in October 1962, Kennedy’s fears almost came true when our aerial photography revealed Soviet nuclear missiles in Cuba. During the 13-day Cuban Missile Crisis as it came to be known, many Americans prepared for nuclear war by buying up canned goods and completing last minute work on their backyard bomb shelters.

Dorothy and I were so worried about a conflict that we considered

and I were so worried about a conflict that we considered The John Stufflebean family in

The John Stufflebean family in their Tucson backyard fallout shelter in April 1961 (Tucson Citizen photo).

The basic neighborhood concrete block shelter, with the air intake fan on the right, and

The basic neighborhood concrete block shelter, with the air intake fan on the right, and the exhaust in the ceiling.

moving her and our three kids to live with her parents on their Kansas farm, but we decided against splitting up the family.

We moved to Tucson in July of 1965 and found that Tucson was a prime target in case of nuclear attack. We were then surrounded by 18 nuclear-tipped Titan ll ICBMs in hardened silos. Radio programs beeped interruptions for emergency announcements. Air-raid sirens were tested regularly, and schoolchildren were taught to “duck and cover” under their desks.

Fortunately, the U.S. and the Soviet Union sought a common ground. Kennedy backed the Soviets down on their missiles in

ground. Kennedy backed the Soviets down on their missiles in Apparently Whitaker shelters came in 12-

Apparently Whitaker shelters came in 12- and 16-foot diameters. My neighbor’s 16-foot-wide Fiberglas dome had been covered with acoustic tiles because of echoes. The room still has water and electricity supplies.

Cuba, and years later it was revealed that part of the removal deal was our trading away our listening posts in Turkey. In 1963 the U.S. and Soviets signed the Nuclear Test Ban Treaty, shifting all nuclear weapons testing to underground. The Strategic Arms Limitation Treaty (SALT 1) in 1972 limited proliferation of weapons including nuclear missiles. In 1987 President Reagan and Soviet President Mikhail Gorbachev, eighth and last leader of the USSR, signed the INF Treaty that further removed medium- and short-range nuclear missiles.

Reagan began de-commissioning Titan ll missiles in 1982, and the final one was deactivated in 1987. Tucson’s last missile in its silo,

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A steel door is the entrance hatch to a fallout shelter in my neighborhood. without

A steel door is the entrance hatch to a fallout shelter in my neighborhood.

without the nuclear tip, is now the Titan Missile Museum near Green Valley.

In 1989 the Berlin Wall fell, and in 1990, East and West Germany reunited.

President George H.W. Bush and Gorbachev signed the Strategic Arms Reduction Talk for additional disarmament of nuclear weapons in 1991. Later that year the Soviet Union broke apart and the Cold War ended.

During those turbulent times, many Tucson public buildings displayed the shelter sign with a yellow-orange three-bladed fan symbol on a black background. Public schools built in the ‘50s and ‘60s had fallout shelters. TUSD was not able to tell me how many have them, but I know that Rogers Elementary and Palo Verde High have shelters.

It’s unknown how many backyard bomb shelters were built in Tucson. Every now and then we hear about an old fallout shelter that comes to someone’s attention.

Not long ago John Sims bought a house in central Tucson. He was told there was a shelter somewhere on the property, and he found plans for it in Tucson city records. He used a metal detector to find the cover, under two feet of sod in his backyard. The spiral

the cover, under two feet of sod in his backyard. The spiral When inverted, the label

When inverted, the label reads: USA CBR (Chemical, Bacterial, Radiation) filter assembly. Made by the Mine Safety Appliances Company, Pittsburgh, Pa.

stairs lead down to the empty shelter that is in good shape, and now John is deciding what to do with it.

John’s plans show it was built by Whitaker Pools. Brack Whitaker was the premier swimming pool builder in Tucson in the 1950s. Bonnie Henry wrote about him in the Arizona Daily Star for June

Henry wrote about him in the Arizona Daily Star for June The circular stairs lead to

The circular stairs lead to an anti-chamber that blocks gamma rays and contains the heavily filtered air intake.

Wooden stairs lead down to the neighborhood shelter with its hand-cranked air fan. 22, 2009:

Wooden stairs lead down to the neighborhood shelter with its hand-cranked air fan.

22, 2009: “With digging equipment and gunite (cement machine) it seemed natural for Whitaker to get in the bomb-shelter business, which he did after 18 Titan missiles started ringing the city in the early 1960s.”

“We dug the hole, placed the forms, gunited them, and made a Fiberglas ceiling,” says Whitaker, who charged $3,500 for a shelter seven feet in height with a circular stairway. “We probably made about 15 or 20. They were selling like hotcakes. And then the emergency was over.”

Fallout shelters were designed to protect occupants from the initial deadly gamma rays of a nuclear explosion. To survive the radioactive fallout, people might have to stay sheltered for up to two weeks. A good shelter had emergency lighting and an adequate ventilation system. Air intake pipes had filters for any fallout particles, and a backup hand-operated air pump. Exhaust pipes were at the other end. Human waste disposal could use heavy trash bags in five-gallon buckets. Storage had to be kept in mind.

Water and food supplies were available in sealed containers, and

and food supplies were available in sealed containers, and Recently John Sims used a metal detector

Recently John Sims used a metal detector to locate the Whitaker-built bomb shelter under the sod in his Tucson back yard. Note the circular staircase and the cover counterweight that was placed inside (John Sims photo).

the amount depended on the number of people for an extended time. Many shelters had stacked sleeping platforms hung from the ceiling. Materials for entertainment were also considered important.

I have a neighbor across the street whose house was built in

1960, and Whitaker Pools built the original swimming pool. She has a fallout shelter in the backyard that appears to be one by Brack Whitaker. It still has the original above-ground entrance

with a very heavy circular steel door. It has a three-foot arm with

a counter-balance so it can be swung up more easily. The circular

stairs are sturdy and lead down to a side door into the domed shelter. It is 18 feet from wall to wall. The ceiling appears to have had acoustic tile at one time. Electricity and water are still turned on. A special filter is still on the air intake but the rest of the

shelter area is empty.

A story goes that the previous owner had cocaine parties in the shelter so as not to disturb the neighbors. I wonder if they could climb the stairs, or if they had to spend the night in an old, cold, fallout shelter.


Makol’s Call

The living Dead

By Dr. George J. Makol

Over the past couple of years many members have told me that they like to flip to the back pages of Sombrero to see what lively topic I’m taking on next. This month it is really not that lively a topic, as we are going to approach The Dead.

Not the dead-pan Hillary Clinton, nor the nearly-dead Sen. John McCain, and not even the Mexican El Dia de los Muertos. Nope, I’m talking about a cultural phenomenon of more than 40 years, the Grateful Dead.

If you are not a rock’n’roll fan, if you did not treasure Elvis and Chuck Berry in the ‘50s, the Beatles and an electrified Bob Dylan in the ‘60s, or Steely Dan in the ‘70s, you probably should read no further. If you can’t tell John Sebastian or Bachman Turner Overdrive from Johann Sebastian Bach, you will have no idea what I’m talking about!

This tale began when I read an article in the Nov. 5, 2015 Rolling Stone headlined, “The Dead Rise Again.” I already knew that the

“The Dead Rise Again.” I already knew that the four surviving Grateful Dead members had done

four surviving Grateful Dead members had done their final concert series at Soldier Field in Chicago for three consecutive nights last year. That was supposed to be it, but on CBS’s Late Late Show one night John Mayer, the singer, songwriter, and blues guitarist extraordinaire, got to jam with Bill Weir, one of the four surviving original Grateful Dead members. Their vibe was so instantaneous when they started to play together that they could not even end the soundcheck, and it just went on and on.

Mayer had been listening to the Sirius radio Grateful Dead Channel nonstop, and he attended all three of their final shows at Soldier Field. Soon they had planned their first tour with original members Bob Weir on guitar and vocals, and Bill Kreutzmann and Mickey Hart on drums and percussion.

I figured I had a snowball’s chance in hell of getting a chance to see them, as they certainly weren’t coming to Tucson, so I was surprised when my wife said to me just before Thanksgiving, “Did you know John Mayer is playing with Dead and Company at the MGM in Las Vegas this week?”

As far as I know, my wife thinks the Grateful Dead is the name of a funeral home in Poughkeepsie, but she certainly knew who John Mayer was. She transferred from an e-mail she had received from the MGM Grand Hotel’s casino club, of which we are members, directly to her to Ticketmaster with the offer of half-price good- seat tickets for the coming Saturday’s concert.

To beat the nine-minute deadline I jumped on the other computer, booked two round-trip tickets on Southwest, while simultaneously calling the MGM Grand on their 800 number and booking our room, and we bought the concert tickets with one minute to spare—and for 44 bucks yet! It may have cost us more than $1,000 to get there and book a room, but since I got the

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tickets half-price I thought that was quite a deal. Surely you can see why I became a physician and not a forensic accountant.

So almost before we knew it, we were miraculously whisking off on an airplane bound for Lost Wages, Nev., which you may know as just Vegas, Las Vegas, N.M. Notwithstanding. I say miraculously not because we were on an airplane, but because my wife managed to travel with just a carry-on luggage piece for a three- and-a-half-day visit. Normally she takes a container this large with wheels to the mall and tells me it’s a purse.

When we arrived at the MGM Grand, I noticed a clientele totally different from that I’m used to seeing there. First of all, there were ponytails everywhere—and even some of the girls were wearing them. There were so many prematurely balding 60-ish men with ponytails walking around that I thought I was at a Tesla owners convention. Of course, that would not be very likely, as they all would have to live within 220 miles of the MGM or they would have had to stop overnight to recharge to get there. Tuxedos were replaced with tie-dyed shirts, Manolo Blahniks with Birkenstocks, and common casino smells with incense.

Or I think it was incense.

At 7 p.m. Saturday we all started rolling into the concert venue, after practically being strip-searched on the way in. By the time of the Nov. 28 concert, the Paris jihadi restaurant and concert attacks had occurred just two weeks before. Many in the crowd were worried whether John Mayer could really replace the Dead’s founding guitarist and multi string-instrument player Jerry Garcia. You see, Jerry, originally known as “Captain Trips,” was a genius, but so drug- addicted that the band finally gave him a choice between music and the drugs. He chose the latter, and died 20 years ago at 54.

When Mayer came out and began to play, it was as if the souls of B.B. King and Chet Atkins had drifted down from heaven into his gorgeous red Paul Reed Smith guitar, and the crowd quickly forgot about Jerry.

The band played for three-and-a-half hours, and it was a concert experience I will never forget. First, the crowd at a Dead concert is a little different. The guy in front of me was so excited about seeing the Dead again that he spent $5,000 to bring some of his closest friends and their wives to the concert. Behind me people were continuously passing a joint. No, I didn’t partake; I went through the ‘60s once and that was enough, so I kept both hands on my Diet Coke. All was well until one of them dropped a burning joint into my wife’s hair, and that was about it for me. I turned around and whispered to them that I was a Republican, and they recoiled in fear and didn’t bother us at all from then on.

It has been stated that if you haven’t seen the Grateful Dead live, you can’t possibly understand what they were all about. This was my first time seeing the band live, but they were so much better than everything I’ve heard recorded by them throughout the years that it was astounding. I don’t know if it was the live experience, or just John Mayer. If the guy had just written “Dreaming with a Broken Heart,” the best breakup song ever written, and nothing else, he would be a genius in my book. The fact that he’s one of the best blues/rock guitar players alive was just the Cherry Garcia on the cake.

Sombrero columnist George J. Makol, M.D., PCMS member since 1980, practices at Alvernon Allergy and Asthma, 2902 E. Grant Rd.


PCMS member since 1980, practices at Alvernon Allergy and Asthma, 2902 E. Grant Rd. n SOMBRERO

Affordable Care Act

The mysteries of ‘ObamaCare’

or, building the infrastructure of the ACA: Hillary Clinton, United Health Group/Optum, and the Center for American Progress

By Katherine Tillman, R.N., M.A.

T he Patient Protection and Affordable Care Act (ACA) is made up of

patient independence, if they remain within the system. As a result, many physicians are no longer accepting Medicare or Medicaid patients or have opted out or turned to retainer-based or membership practices.

This structure of the ACA was not the plan of the American people, or all of the Congress that passed it in a reckless flurry without reading it. It is now, however, a new monopolistic policy system, led by many from the Clinton- era team, including executives from UnitedHealth Group and its substantially diverse group Optum. The administration has carefully designated individuals to high-level management positions within HHS, but these bureaucrats fall just under the public radar. It is a dangerous arrangement of government insiders, insurers, and data brokers. With some study, a tangible picture emerges: well planned by members, past and present, of the Center for American Progress and aided by President Obama to bring the country closer to their ideal of a single-payer, government-controlled, medical services delivery system.

HHS leadership includes individuals with a common commitment to:

• Reach the goal of economic, social, and cultural transformation of the country through regulation, policy change, and strategically placed personnel within the executive branch; • Use the state exchange “failures” and delays of 2013–2014 to form a monopolistic insurance scheme, confusing consumers and overseers with brand changes, subcontracting, and partial acquisitions; • Form a big-data infrastructure, built on aggregate and identifiable personal data, to stratify and manage the population; • Advance development of an incremental single- payer system through contracting entities such as UnitedHealth Group/Optum/Optum Labs and

Quality Software Services, Inc. (QSSI); and • Work with the post Clinton-era Progressives and the Center for American Progress (Lois Quam, John Podesta, Neera Tanden, Ezekiel “Zeke” Emanuel, Jonathan Gruber, and Topher Spiro) to expand global health initiatives.

Because of ACA’s complexity, neither the public nor most of Congress really knew “what was in it” when it was a bill. The 2013 public focus was on the “what-ifs” of increased insurance premiums, the number of people to be insured, cost to taxpayers, and potential physician shortages. In the background, insurance companies were busy with mergers and acquisitions, and lobbying heavily.

With the much-anticipated day for enrollment came the “disaster” of the national website. Huge companies known for their IT expertise fell short of success, but still collected millions owed on their federal or state health exchange contracts.

numerous moving parts surrounded by truth and fiction, promises and

deception—elements coming from both inside and outside government, and making congressional oversight nearly impossible.

The ACA is also the legal catalyst for a massive information technology (IT) infrastructure connecting, tracking, and exploiting economic, social, and cultural components of American society. Government departments may now arbitrarily structure thousands of regulations and policies from this poorly written legislation, all of which have an impact on the personal lives of citizens from prenatal exams to hospice.

But who is in charge?

The Obama Administration issued assurances that individuals would see lower premiums and continuity with their insurance plans and “providers.” Meanwhile, the same administration has aided a continuum of the Clinton attempt at creation of universal health reform by essentially “packing” the management of the U.S. Department of Health and Human Services (HHS) with forceful Progressives from the shadows of the Clinton era.

The regulatory infrastructure imbedded in government healthcare management has already caused irreparable damage to physician and

has already caused irreparable damage to physician and At the end of February 2014, the administration

At the end of February 2014, the administration had spent $834 million on developing the troubled website[1] HHS total spending to

support the federal “marketplace” is still to be determined, but projected in 2014 to exceed $2.2 billion with the new $535 million contract to IT consultant Accenture.[2] When added to federal spending on failed state exchanges, the numbers increase substantially and may never be accounted for because of a general lack of transparency in state contracting, waivers, and federal subsidies.

The focus on websites and legal battles allowed time for well-positioned companies to be contracted to “assess” the problems of troubled exchanges, and essentially to “save the day” by bringing in their own subsidiaries for better management. It may never be determined how incompetence or deception played into the delays, but the opportunity put UnitedHealth Group/Optum/QSSI on the contracting map. At the very least there is the appearance of a conflict of interest in the non- transparent, no-bid contracting.

Lobbying and government contracting involving select ACA “architects” and consultants, such as Gruber and Emanuel, who promoted one company over another and have ties

to leftist organizations such as the Center for American Progress, have been instrumental in putting in place a health services infrastructure large enough to exist as a quasi-government, single-payer system and to change many aspects of our culture.

Optum is hardly a household name, but it is the largest of UnitedHealth Group subsidiaries. UnitedHealth’s Optum includes a managed-care business, a software and consulting unit, and a pharmacy benefit management (PBM) service provider. They also tout a bank, financial services, data analysis, and a clinical analytics service to their customers. The platform is designed to help clients such as hospitals, employers, and government agencies lower health costs. The biggest growth came from its OptumRx PBM unit, which notched a 33 percent year-over-year revenue gain for all of 2014.[3]

Optum claims on its website

“We are 80,000 health care experts, turning years of medical data into smarter decision making.” Optum has established plans for all aspects of healthcare, bragging that “state and federals agencies rely on Optum™ to turn huge amounts of data into powerful insights that improve health outcomes.” It claims that “domain expertise and a deep understanding of how government works” is what “guides us as we work with you to improve the effectiveness of Health and Human Services programs for organizations and citizens.” Sophisticated data warehousing is not enough: it “has little impact without deep domain knowledge and a track record in the government sector.” Optum™ experts, the website claims, “understand the nuances. … We can help contain costs and improve outcomes for Health and Human Services agencies, program beneficiaries and taxpayers.”

All of this may be true, and the company’s website and annual report offer much insight into its plans for our future, but who put Optum executives in charge, and are they really transparent? Why is UnitedHealth Group/Optum’s senior executive, Andy Slavitt, now acting administrator of the Centers for Medicare and Medicaid Services? The ACA was sold to the public as a solution for the uninsured, but in actuality is a comprehensive

infiltration into all the healthcare and social services aspects of our lives.

More than four years after passage of the bill, there are only a few substantial insurance companies left, as Emanuel, acclaimed architect of the ACA and senior fellow at the Center for American Progress, who also serves as the center’s vice-provost for global initiatives, pointed out in his book Reinventing American Healthcare:

First, they can refuse to change, in which case they will eventually go out of business. Second, they can shift their business to focus on offering services they have expertise in, particularly analytics, actuarial modeling, risk management, and other management services. An example that foreshadows this evolutionary path is United Healthcare’s Optum subsidiary, which sells management services to ACOs, hospitals, physicians, and health plans. As these customers need more help with analytics, risk management, and disease management, Optum will grow.[4]

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Emanuel also proclaimed on NBC’s Meet the Press, on Dec 1, 2013: “For the first time we actually have effective management overseeing this. We have an integrator that is independent and that seems to be very effective in [UnitedHealth’s Optum] as opposed to having CMS run it.”

UnitedHealth has made a cottage industry out of the ACA through Optum, which has become the go-to fix-it company for troubled insurance exchanges. Optum has been a consultant for state-based exchanges in Minnesota, Maryland, Massachusetts, and Hawaii. Kyle McDowell, an Optum vice-president leading operations in Vermont, said the company “has a presence” in virtually every exchange.[5]

And while the press and the populace spent months looking at website failure, the largest of the country’s insurers, UnitedHealth, was quickly building up Optum. While not an insurer, it is where the action is, and is an exceedingly fast-growing and efficient company. Concurrently, the

executive branch was outpacing the impotent legislative branch, writing thousands of regulations and putting in place presidential appointees to implement them. The government has proven its unwillingness for oversight, and there promises to be increasingly diminished quality of medical care because the big government insurers and contractors are, first and foremost, responsible to their stockholders. The insurers cut expenses by limiting coverage and paying providers less, rendering many physicians and others unable to financially support their own hospitals or practices.

Former HHS Secretary Kathleen Sebelius finally resigned in April 2013. It is a fair question to ask why a former state insurance commissioner and governor of Kansas, while being assisted by two more state insurance commissioners (Steve Larson, former insurance commissioner of Maryland, and Jay Angoff, former insurance commissioner for Missouri) during her time as secretary, could not succeed, but perhaps she saw the outcome as a success. By the time Sylvia Burwell

took the reins as HHS secretary, an essentially overlooked transformation of the healthcare system had taken place through regulatory processes.

There is a huge shadowy healthcare infrastructure developed in part and now guided by the leftover Clinton Task Force of 1993, and strongly supported by the Center for American Progress and the Obama White House. Without much interest or scrutiny by the public, press, or medical community, the new healthcare scheme is in place. Because of this structure, revisions of portions of the ACA may be possible, but repeal or de-funding will be daunting in terms of finding able resources and creating legal challenges to existing complex regulations and contracts that involve multiple parties and their subcontractors.

To paraphrase James Carville, who in 1992 said, “It’s the economy, stupid,” perhaps Gruber was alerting the American people to the fact that it’s “the economy and the data, stupid.” Data collection and analyses performed by a single entity with financial interests (the insurer) has always been regarded as

a professional conflict of interest. Today, insurers

contracted by government reimburse data-driven care using inherently biased analysis. This suggests that the new analytics and actuarial modeling, touted by Emanuel for developing “evidence- based” algorithmic treatment directives for patients and doctors, lead us down a perilous path. Authority over the ACA lies with an administration that has the stated goal of a single-payer system.

MD Dr. Matthew Clavenna,
MD Dr. Matthew Clavenna,

Dr. Matthew Clavenna,

MD Dr. Matthew Clavenna,
MD Dr. Matthew Clavenna,
MD Dr. Matthew Clavenna, Dr. Clavenna was born in Texas but spent most of his childhood

Dr. Clavenna was born in Texas but spent most of his childhood in Baton Rouge, Louisiana. He attended Trinity University in San Antonio for his undergraduate work, receiving a B.S. in Biochemistry. Dr. Clavenna’s desire to personally

help those with ailments, led him into the field of medicine. He earned his medical degree from Louisiana State University Medical School in Shreveport in 2009, where he was elected into Alpha Omega Alpha Honor Society.

While in medical school, he was introduced to Otolaryngology (ear, nose, & throat), a wonderful field of complex anatomy, requiring surgical and medical expertise to treat those with problems of the head and neck. Dr. Clavenna completed a general surgery internship and otolaryngology surgical residency at Louisiana State University Health in Shreveport.

Following residency, Dr. Clavenna completed a Fellowship in sinus, allergy, and anterior skull base surgery at Vanderbilt University in Nashville, Tennessee. There he trained under internationally known surgeons, Drs. Rick Chandra, Paul Russell, and Justin Turner. During fellowship he focused on advanced sinus surgeries, including management of frontal sinus disease, nasal and skull base tumors, pituitary surgery approaches, ophthalmological related procedures and treatment of allergies. Many of these cases were performed in conjunction with neurosurgeons and ophthalmologists. One of his most fond memories from fellowship involved treating a patient emergently transferred to Vanderbilt for severe sinus disease encroaching on the vision of his right eye. Using his recently learned endoscopic sinus surgery techniques with the aid of image guidance, he was able to successfully treat and drain the infection and preserve the patient’s vision.

Dr. Clavenna moves to Tucson with the desire of helping those in the community with their ear, nose and throat related problems. He is the first fellowship trained sinus and anterior skull base surgeon to join a private practice group in Tucson. Though he has a passion for nasal, sinus, and allergy related disorders, he also enjoys treating the full gamut of ENT related issues, from neck masses to ear surgery.

Dr. Clavenna in his free time enjoys spending time with his wife, the outdoors, and looks forward to taking advantage of the wonderful surroundings Tucson and Arizona have to offer.

forward to taking advantage of the wonderful surroundings Tucson and Arizona have to offer. ww w.

ww w. C a rl s o nEN T. c o m

Unknown entities are collecting, processing, and analyzing data, and creating huge, growing data hubs. The population has virtually no knowledge of the credibility or integrity of the data, or of the analysis that will be used to determine personal health and economic issues. Those with oversight are now embedded in the executive branch. They have the power and the organization to direct the future, and it does not appear that patients will benefit.

The economic decline of individuals and businesses

is already apparent. But the potential loss of

physician and patient autonomy, due to “decision- based evidence determinations,” as opposed to evidence-based clinical practice, in crucial

healthcare situations is the most significant forfeiture of freedom influenced by this unproven data scheme. The Progressive momentum in place cannot be underestimated, and is potentially very destructive.

On Sept. 5, 2014, CMS issued a final rule (CMS-9941-F) enacting automatic re-enrollment in the federal marketplace.[6] A consumer who does not return to the federal website to enroll may be re-enrolled

automatically. While consumers are encouraged to re-evaluate their financial status and tax credit eligibility, they do not have to provide their permission for HHS to check updated tax information for annual eligibility redetermination purposes. This CMS action may appear to be streamlining

a process, but may in fact be a further indication that we are approaching

a de facto single-payer system. The government, UnitedHealth Group/ Optum, and perhaps another company in the depleted field of insurers, will have achieved their goal for a quasi-governmental entity that will direct U.S. medicine and our ability to pay for it.

With so many regulations in place, the structure now lies solely within the executive branch in a government without transparency. It is about the data brokerage, which leads to political supremacy, and the financial benefits of unrestrained use of data to stratify, manage, and manipulate the healthcare system and the populace. Data is knowledge, and knowledge is power. We fear and fight foreign powers over theft of personal information, but we are complacent with the information and privacy threats inherent in the ACA.

The future may find implementation of the ACA to be the permanent Clinton-Obama legacy.

Some key players The following individuals and corporate entities are now firmly embedded in the HHS hierarchy. Influenced by Progressive policy factions, they serve as a cooperative organizational power with limited restraint.

Lois Quam In 2011 Quam was appointed to lead the President’s Global Health Initiative under Secretary Hillary Clinton’s State Department. She also served as special adviser to Secretary of State John Kerry, with a focus on global health and public-private partnerships. Quam was senior advisor to Hillary Clinton’s 1993 White House Task Force on National Health Care Reform. She left to become founder and CEO of UnitedHealth’s Ovations subsidiary and in 1997 brokered a deal with AARP to become the underwriter of its supplemental coverage and pharmacy benefit plan. In 2013, Ovations reported it collected some $4.3 billion in such “Medigap”


That deal resulted in one of the largest transitions in insurance business history, and was noted for its operational success. In 2003 through 2006, Fortune magazine selected Quam as one of the “50 Most Powerful Women in American Business.” Quam was a member of Hillary Clinton for President in Minnesota in 2008 and a fellow with the Center for American Progress. Quam founded Tysvar, a privately held Minnesota strategy company with the mission of bringing about universal healthcare reform and a “new green economy.” She was appointed chief operating officer of the Nature Conservancy in March 2014, where she continues to actively promote global health. She married Arshad Azizali Mohammed on Dec. 7, 2014, in a Muslim ceremony. He is a State Department-based Reuters correspondent.

Nancy-Ann DeParle DeParle was deputy chief of staff for policy in the Obama Administration from January 2011 to January 2013. In 2009 she served as the director of the White House Office of Health Reform, leading the administration’s efforts on healthcare issues, including the passing of the ACA. She was a CMS administrator during the Clinton years and worked in the Office of Management and Budget (OMB). Before taking her White House job, she earned earned more than $6 million serving on the boards of Cerner, Medco Health Solutions, Boston Scientific, CareMore, and DaVita.[8] She

resigned from these boards while in the White House and now serves on the board of CVS. In 2013 she left the White House to work in the world of private equity, as partner with Consonance Capital Partners. In an interview with Richard Pizzi, posted Aug. 26, 2013, DeParle stated, “I was fortunate enough to be able to invest in good ideas in healthcare, but it’s not for the faint of heart.”[9] She is married to Jason DeParle, reporter for The New York Times.

Kathleen Sebelius Former HHS secretary and former governor (2004-2009) and insurance commissioner of Kansas, Sebelius was charged with oversight of the roll- out of She was heavily criticized for the failures in the mechanics of the public’s inability to enroll in “ObamaCare.” Congressional hearings produced little in contracting rationale or concrete information. As HHS secretary, she supported and promoted Optum. In early 2008, there was some speculation that she might become a vice-presidential candidate.

Sylvia Mathews Burwell Burwell became HHS secretary in 2014. She is a Rhodes Scholar and worked as associate at McKinsey. She joined the Clinton presidential campaign in 1992, and then led the Clinton transition team. She was White House staff director of the National Economic Council (NEC) in 1993 and was then chief of staff for Treasury Secretary Robert Ruben from 1995 to 1997. Later, she became one of Clinton’s two deputy chiefs of staff under Erskine Bowles, the other being John Podesta. She served the Gates Foundation from 2001 to 2011, where she was president of the Global Development Program for five years. She went to the Walmart Foundation and from there was appointed director of the Office of Management and Budget (OMB) in April 2013. She was confirmed as HHS secretary on June 6, 2014, and hired Andy Slavitt, executive of UnitedHealth (Optum), soon thereafter.

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Andy Slavitt Appointed principal deputy administrator at CMS on June 20, 2014, Slavitt was a former Goldman Sachs executive. Later, he was managing director of UnitedHealth Group’s Center for Affordable Consumer Health and CEO of Ingenix Consulting, Inc., a company embroiled in a New York scandal leading to a settlement of $50 million with New York State and $350 million with the AMA.[10] Since November 2006 Slavitt has served as CEO of OptumInsight (a re-branding of Ingenix), a subsidiary of UnitedHealth Group, and also served as its chief operating officer from January 2005 to November 2006. Slavitt served as the chairman of the board of QSSI, the controversial UnitedHealth Group/Optum contractor that was the general contractor for the federal website

Obama’s nomination of Andy Slavitt to replace Marilyn Tavenner as permanent administrator of CMS is controversial. Because of interests shared by private and public sectors, this nomination appears an indicator of the President’s ambitious goals for single-payer. The confirmation hearings should be intense. However, for the nomination to have gotten this far is an ominous state of affairs not only for CMS, but for all of American medicine.

Kevin Counihan Appointed the first Director & Marketplace CEO of, Counihan came from the Connecticut Exchange in August after a May 2014 public request for new management structure from the Center for American Progress.[11] He led Connecticut’s health insurance exchange, Access Health CT, a program being purchased by Maryland, and was chief marketing officer for the Commonwealth of Massachusetts Health Insurance Connector Authority until 2011. Jonathan Gruber served on the board of directors and as a consultant to the state during the same time. Counihan also will manage the Obama Administration’s

relationships with state-run exchanges and oversee the CMS Center for Consumer Information and Insurance Oversight.[12]

Lucia Savage Savage is chief privacy officer for the Office of the National Coordinator (ONC) for Health IT. She served as senior associate general counsel at UnitedHealthcare where she supervised a team that represented the organization in its work on large data transactions related to health information exchanges, healthcare transparency projects, and other data-driven healthcare innovation projects. According to the ONC, she has served on the Governance Board of CMS’s Multi-Payer Claims database project (2011-2013), and collaborated with health information exchanges and state agencies in their planning with payers.[13] The agency is planning a number of key privacy-related projects for 2016 regarding inter-operable electronic health records.

Kevin Thurm According to the HHS website, Thurm is senior counselor to the HHS secretary. He served as HHS deputy secretary and chief operating officer from 1996 to 2001 during the Clinton Administration. He also served as principal adviser January 1993-96. He worked on the Clinton for President and Clinton Gore ‘92 campaigns in 1992. He is a former Rhodes Scholar with a B.A. from Tufts University, a B.A. and M.A. from Oxford University, and a J.D. from Harvard Law in 1989.[14]

Leslie Dach Now senior counselor and adviser to HHS, Dach is a prominent Democratic Party donor who gave $23,900 in 2008 to help elect Obama. In his previous job as a top lobbyist and strategist for Walmart (2006-13), he partnered with the White House on high-profile projects, including Michelle Obama’s “Let’s Move!” campaign. (Note that Hillary Clinton also served on the Walmart board from 1982-1986.) Dach and Burwell have known each other for more than 20 years. They first worked together in the 1988 Dukakis presidential campaign, according to a senior HHS official, and in the Clinton Administration.

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Vivek Murthy, M.D. As a 36-year-old graduate of Harvard and Yale, Murthy was appointed surgeon-general by President Obama and confirmed by a 51-43 vote on Dec. 15, 2014. Dr. Murthy organized Doctors for America, a group that started as Doctors for Obama. He is a political activist and a fellow at the Center for American Progress. He is said to have an agenda focused on revisions to the Second Amendment.[16]

Steve Larson Former director of the Center of Consumer Information and Insurance Oversight (CCIIO) under CMS 2010-12, and the former insurance commissioner of Maryland, Larson left CMS/ CCIIO in June 2012 to become executive vice- president of government solution at the UnitedHealth Group subsidiary, Optum. (CCIIO is the center of “ObamaCare” and HealthCare. gov.) Larson’s move was made under a cloud of the controversial contracting with UnitedHealth Group/Optum/QSSI to run This particular contract came to the attention of Congress and prompted concerns from the House Energy and Commerce Committee. Rep.

Fred Upton (R-Mich.) and Sen. Chuck Grassley (R-Iowa) asked two healthcare companies for information on whether they would limit any potential conflicts of interest presented by their involvement in implementing and potentially providing services under the healthcare reform law. It was noted that QSSI holds a contract with CMS to erect the federal data services hub that will serve as the foundation for complex federal health insurance exchanges. According to media reports, UnitedHealth Group, through its subsidiary Optum, purchased QSSI in late September 2012. Thus, UnitedHealth Group now owns both Optum and QSSI. It also owns UnitedHealthcare, a major national provider of healthcare plans and competitor to other health plans expected to participate in a federal exchange.[17]

Anthony Welters Welters was appointed executive vice-president of UnitedHealth Group in December 2006 and served as president of the Public and Senior Markets Group from September 2007 to December 2010. In 2011 Welters joined the office of UnitedHealth Group’s CEO. He gained notice when QSSI was granted a contract to implement and then was purchased by UnitedHealth Group subsidiary, Optum.

Anthony and Beatrice Welters bundled donations totaling between $200,000 and $500,000 for Obama’s campaign during the 2008 election cycle, according to campaign finance data compiled by Center for Responsive Politics. President Obama appointed Beatrice Welters as U.S. ambassador to Trinidad and Tobago.[18] Anthony Welters is currently executive chairman for Black Ivy Group, LLC, started by Cheryl Mills, a consulting firm focused on sub-Saharan Africa.

Welters founded AmeriChoice Corporation in 1989 and served as president and CEO; it was acquired by UnitedHealth Group in 2002. He serves as chairman of the board of New York University Law and Morehouse School of Medicine. He is the recipient of the prestigious Horatio Alger Award. He serves on multiple boards, including Bard, West Pharmaceutical Services, and Carlyle, and has received numerous awards for philanthropic endeavors.[19]

UnitedHealth Group The largest single health carrier in the U.S. and the world, boasting services to 85 million people in 18 countries, UnitedHealth Group lists more than 15 pages of subsidiaries with the Securities and Exchange Commission (SEC), including OptumHealth, Ovations, and AmeriChoice.[20]

In the third quarter of 2015 UnitedHealth Group reported a revenue jump to $41.5 billion from $32.8 billion in 2014.[21]

OptumHealth Formerly Ingenix, OptumInsight was established in a brand unification action by UnitedHealth Group as a health services platform that focuses on healthcare systems, population health management, care delivery, and clinical and operating elements of the system. The company has grown to be the major entity in the evolving “ObamaCare” scheme, as noted above. Optum describes itself as a health services company with more than 35,000 employees. Numerous acquisitions, partnering, contracting, and rebranding since 2009 make tracking contracts and downstreaming difficult.

The company reported 2013 revenues of $37 billion, a growth of 26 percent, and an increase of 61 percent in operating earnings. [21]

AARP AARP, Inc., formerly the American Association of Retired Persons, was founded in 1958 and as of April 2014 had more than 37 million members. Lois Quam authored the company’s landmark proposal for supplemental health insurance. A 2008 Boston Globe article claimed that

“AARP collects hundreds of millions of dollars annually from insurers who pay for AARP’s endorsement of their policies,” and that “after the Medicare bill was signed into law by Bush in December 2003, AARP was able to expand its contract with Minnetonka, Minnesota-based UnitedHealth Group Inc., which underwrites AARP’s Medicare supplemental insurance plan.”[22]

More recently, on Oct. 15, 2013, UnitedHealth Group announced that it had reached an agreement in principle with AARP to extend and broaden their long-time relationship focused on “improving the health and well- being of Americans 50 and older.” The new AARP relationship with Optum Labs, according to Optum, will help drive far-reaching research to consumer health innovation.[23] However, referenced in the multiple Working Papers of the 2013 Annual Report for UnitedHealth Group under Optum/Health Reform, there are multiple opportunities for abuses as they outline legislative reform, clinical research, population management, and provider directives based on their own data collection and analysis.

The Center for American Progress This public policy research and advocacy organization describes itself as “dedicated to improving the lives of Americans through progressive ideas and action.” On May 17, 2014, the Center for American Progress submitted a commentary to HHS, suggesting a new management structure for the ACA. Its CEO would report directly to the President and the HHS secretary, and be empowered to make all decisions, or delegate them to the President and the secretary. HHS Secretary Burwell appointed Kevin Counihan the first director & marketplace CEO in August 2014.

The Center for American Progress supports Media Matters and Health Care for America Now.

The center’s founder is John Podesta. He was President Clinton’s White House chief of staff and also served the Obama White House, which he left in January 2015 to work on Hillary Rodham Clinton’s presidential campaign. Replacing Podesta as president and CEO of the Center is Neera Tanden. She was a former aide to Bill Clinton and served as policy director for Hillary Clinton’s presidential campaign. She was also a senior adviser for health reform at HHS, advising Secretary Kathleen Sebelius and working on President Obama’s health reform team in the White House to pass the bill, according to her biography at the center’s website,

Conclusion We have yet to understand the full scope of the ACA. Its execution is in the hands of powerful, interlocking individuals and organizations, many having been involved in designing “healthcare reform” since the Clinton Administration. A central part of the transformation is compiling and tracking our most sensitive data, from health records and tax returns, which can now be used in making coercive decisions about our medical care, to help achieve the “progressive” social goals of this elite, powerful group.

Katherine Tillman, R.N., M.A., is a health policy analyst and Medicare fraud investigator. She retired in 2013 from CMS after 14 years as a policy analyst and GS14 technical adviser in the Center for Clinical Standards and Quality. Previously she worked in medical review, medical malpractice defense, and insurance adjustment. Contact: tillmankk@

This piece is reprinted with permission from the Journal of American Physicians and Surgeons Winter 2015 issue. It is a publication of the Association of American Physicians and Surgeons, which advocates for private, no-third-party medical practice.



Pavlich K. Obama’s anti-Second Amendment nominee for Surgeon

 1. Burwell SM. Exhibit 17. Response to questions for the record. Committee on Health, Education, Labor, and Pensions; May 18,


 2. Bier J. Cost of exceeds $2.2 billion after latest contract award. Weekly Standard, Dec 30, 2014. Available at:

after-latest-contract-award_822554.html. Accessed Nov 5, 2015.

 3. Cariaga V. UnitedHealth tops views as Optum unit drives gains.

Investor’s Business Daily, Jan 21, 2015. Available at: news.investors.


earnings-top-views.htm#ixzz3Pl07yVOb. Accessed Nov 5, 2015.

 4. Emanuel EJ. Reinventing American Health Care: How the Affordable Care Act Will Improve Our Terribly Complex, Blatantly Unjust, Outrageously Expensive, Grossly Inefficient, Error Prone System. New York, N.Y.: Public Affairs; 2015.

 5. True M. State was unaware of Optum’s prior legal troubles before company was hired, Miller says. VTDigger, Aug 15, 2014. Available at: past-legal-problems-miller-says/. Accessed Nov 5, 2015.

 6. Department of Health and Human Services, Center for Medicare and Medicaid Services. Bulletin No. 14: Guidance for Issuers on 2015 Re- enrollment in the Federally-Facilitated Marketplace. 79FR 52994, Sept 5, 2014.

 7. Fitzgerald S. Ethical questions engulf Obama’s CMS nominee. NewsMax, Jul 13, 2015. Available at: Accessed Nov 5, 2015.

 8. Steinle M. The DeParle portfolio. Investigative Reporting Workshop; Jul 2, 2009. Available at:


connections/. Accessed Nov 5, 2009.

 9. Pizzi R. Obamacare architect Nancy-Ann DeParle returns to private equity. Healthcare Finance News, Aug 26, 2013. Available at: http://

private-equity. Accessed Nov 5, 2015.

10. Pollock R. Obama’s top health care nominee was once embroiled in medical fraud case. Daily Caller, Aug 2, 2015. Available at: http://

once-embroiled-in-medical-fraud-case/. Accessed Nov 6, 2015.

11. Tanden N, Emanuel Z, Spiro T. A new management structure for a new phase of the Affordable Care Act [report]. Center for American Progress; May 17, 2014.

12. Goodnough A. Leader of Connecticut’s health marketplace is named to run federal program. NY Times, Aug 26, 2014.

13. Hoffman M-L. Former Unitedhealthcare Attorney Lucia Savage

Named ONC Privacy Chief.; Oct 15, 2014. Available at:

attorney-lucia-savage-named-onc-privacy-chief/. Accessed Nov 11,


14. U.S. Department of Health and Human Services. Kevin Thurm. Available at: Accessed Nov 8, 2015.

15. Viebeck E. Burwell appoints new counselor from Walmart. The Hill, Jul 23, 2014. Available at:


Accessed Nov 8, 2015.

General: guns are a healthcare issue., Mar 11, 2014. Available at:


general-n1806895. Accessed Nov 10, 2015.

17. Energy & Commerce Committee, U.S. House of Representatives. Grassley, Upton seek details of potential conflicts of interest involved in implementation of health law. Press release, Dec 10, 2012.

18. Miller SA. Obama donors firm hired to fix web mess it helped make. New York Post, Nov 13, 2013. Available at:


Accessed Nov 8, 2015.

19. UnitedHealth Group. Executive profile: Anthony Welters. Bloomberg Business. Available at: people/person.asp?personId=502700&privcapId=104673. Accessed Nov 8, 2015.

20. Securities and Exchange Commission. Subsidiaries of the Company. Available at: data/731766/000119312510027229/dex211.htm. Accessed Nov 8,


21. Dow Jones Newswires. UnitedHealth Group’s 3Q Profit Beats

Estimates. Fox Business, Oct 15, 2015. Available at: http://www.

profit-beats-estimates/. Accessed Nov 12, 2015.

22. Cohn G, Preston D. AARP/UnitedHealth bait and switch. Boston Globe, Dec 5, 2008. Available at: december/aarpunitedhealth_ba.php. Accessed Nov 8, 2015.

23. UnitedHealth Group. UnitedHealth Group to extend, broaden its relationship with AARP to focus more than ever on improving Americans’ health and well-being. Newsroom. Available at: unitedhealth%20group/2013/1015broadenaarp.aspx?sc_lang=e n. Accessed Nov 8, 2015.


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2 0 1 5 , that now makes 11 in a row. MICA’s Board of

2 0 1 5 ,

that now makes 11 in a row.

MICA’s Board of Trustees is pleased to announce a $27 million dividend for the 2015 policy year. This is our 11th consecutive dividend and our 25th dividend since MICA’s founding.

dividend and our 25th dividend since MICA’s founding. Medical Professional Liability Insurance (602) 956-5276,

Medical Professional Liability Insurance

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

Dividends declared for a given policy year reflect the Company’s financial performance during that year. Past performance does not guarantee future dividends.