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Sombrero

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

JANUARY 2016

Our old HQ=
Tucson Concussion Center

Full ahead in reverse
with Dr. Sheldon Marks

A ‘sunrise application’
and you

Cameron
Cameron Javid
Javid MD
MD

April
April Harris
Harris MD
MD

Egbert
Egbert Saavedra
Saavedra MD
MD

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2

SOMBRERO – January 2016

Sombrero
Pima County Medical
Society Officers

Official Publication of the Pima County Medical Society

PCMS Board of Directors
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)

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

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

At Large ArMA Board

R. Screven Farmer, MD

Pima Directors to ArMA
Timothy C. Fagan, MD
Timothy Marshall, MD

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

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

Printing
West Press
Phone: (520) 624-4939
E-mail: andyc@westpress.com

Advertising
Phone: (520) 795-7985
Fax:
(520) 323-9559
E-mail: dcarey5199@gmail.com

Art Director
Alene Randklev
Phone: (520) 624-4939
Fax:
(520) 624-2715
E-mail: alener@westpress.com

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

$235,000

SOMBRERO – January 2016

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

Members at Large

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

Presidio at Williams Center

Arizona Medical
Association Officers

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

Executive Director
Bill Fearneyhough
Phone: (520) 795-7985
Fax:
(520) 323-9559
E-mail: billf 5199@gmail.com

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Vol. 49 No. 1

SOMBRERO (ISSN 0279-909X) is published monthly
except bimonthly June/July and August/September by the
Pima County Medical Society, 5199 E. Farness, Tucson,
Ariz. 85712. Annual subscription price is $30. Periodicals
paid at Tucson, AZ. POSTMASTER: Send address
changes to Pima County Medical Society, 5199 E. Farness
Drive, Tucson, Arizona 85712-2134. Opinions expressed
are those of the individuals and do not necessarily represent the opinions or policies of the publisher or the PCMS
Board of Directors, Executive Officers or the members at
large, nor does any product or service advertised carry the
endorsement of the society unless expressly stated. Paid
advertisements are accepted subject to the approval of the
Board of Directors, which retains the right to reject any
advertising submitted. Copyright © 2015, Pima County
Medical Society. All rights reserved. Reproduction in
whole or in part without permission is prohibited.

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3

Inside
 5 Milestones: Honors for three of our
members.

 6 Membership: The International Center for

Vasectomy Reversals is right here at home,
and another of our past-presidents takes on
a new job.

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

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

14 Behind the Lens: The very term ‘fallout

shelter’ raises a whiff of Cold War. Evidence
may be in your neighborhood.

18 Makol’s Call: John Mayer raises the Dead.
20 Affordable Care Act: An analyst examines

‘ObamaCare’ mysteries, how they came to
be, and what they portend.

4

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).

SOMBRERO – January 2016

Milestones

Dr. Barker honored twice
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 36th 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.”

SOMBRERO – January 2016

“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.
n

5

Membership

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.”

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.

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.’
6

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.”
SOMBRERO – January 2016

‘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.”

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
When he started doing lots of reversals, “I was getting very high
reversal at the annual American Urological Association meeting.
success, and now this is what I do,” he said. “This is a full-time,
“I wrote the teaching module on reversals for the American
reversal-only practice. It’s unlike anything in the
Society of Reproductive Medicine, and I
country.”
recently wrote a textbook chapter on reversals.
‘I always wanted to be
I write for Dr. Andrew Weil’s website, and I’m
better than anybody at
It’s been frequently noted that his patients come
the urologist for WebMD.”
from Arizona, the rest of the nation, and the rest of
what I do—whatever

the world, and for anyone who doubts it, Dr. Marks
Having done this kind of microsurgery for so
one thing it is.’
has wall maps of the U.S. and the world pinpointing
long led Dr. Marks to design the ASSI Marks Vas
–Dr. Sheldon Marks
exactly where. Around the maps on almost every
Cutting Forceps, with Accurate Surgical &
wall are photos of kids, often with the fathers who
Scientific Instruments Corp. of Westbury, N.Y. The instrument’s
wanted and caused them. That’s why the practice’s slogan is “We
15-degree angle “provides larger lumenal area” and “allows for
Make Men Dads Again.”
easier anastomosis and improves opportunity for patency. Even if
inflammation and/or scarring are present at the anastomotic site,
Procedures are done on site, in the practice’s special O.R. “I chose
the [instrument’s] larger area provides greater chances for
to limit myself to one reversal per day,” Dr. Marks said. “It gives
successful reversals.” Its technique and results were discussed in
me time, and gives the patient the best chance for success.” The
the March 2014 Fertility and Sterility, and in Andrology, showing
procedure takes two to three-and-a-half hours. “We fix other
“success is high in skilled hands, even in men 15 to 40 years from
people’s failed reversals, too,” he said. “About one in seven is a revasectomy,” Dr. Marks said.
do.” Peter J. Burrows, M.D., F.A.C.S., another PCMS member, does
SOMBRERO – January 2016

7

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.

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

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 highthreat areas in Afghanistan.

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.

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

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

8

“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?”

n

SOMBRERO – January 2016

Membership

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.
SOMBRERO – January 2016

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. 98384, 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
9

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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.

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“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.”

n

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SOMBRERO – January 2016

PCMS Alliance News
Membership

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.

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.

SOMBRERO – January 2016

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.

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

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.

11

Legal Medicine

An important Sunrise Application
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 scopeof-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.

12

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.

SOMBRERO – January 2016

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.

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.

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.

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.

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 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.

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.

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

Changes applicable to Clinical Nurse Specialists

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.
n

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,
TINNITU
such as geriatrics or psychiatry. They usually
S
practice in clinics, hospitals, or outpatient
facilities. Many CNSs primarily work on
processes and protocols to improve clinical
TINNITUS
outcomes, such as wound management or
BUZZING
prevention of hospital readmissions.

BUZZING

RING
BUZZ

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-9th) and Sen.
Kelli Ward, D.O. (R-5th) provided the benefits
of their medical backgrounds. Heather
Carter, chairperson of the House Health
Committee, was particularly knowledgeable
SOMBRERO – January 2016

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13

Behind the Lens

Living with ‘the bomb’
By Hal Tretbar, M.D.

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.

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

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 magazine 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.
14

The John Stufflebean family in their Tucson backyard fallout
shelter in April 1961 (Tucson Citizen photo).
SOMBRERO – January 2016

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

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.

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

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 mediumand short-range nuclear missiles.

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

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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SOMBRERO – January 2016

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15

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

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
16

The circular stairs lead to an anti-chamber that blocks gamma
rays and contains the heavily filtered air intake.
SOMBRERO – January 2016

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

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).

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.”

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.

“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.”

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.

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
SOMBRERO – January 2016

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.

n
17

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

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 goodseat 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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SOMBRERO – January 2016

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 threeand-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.

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.
n

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 drugaddicted 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.
SOMBRERO – January 2016

19

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
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

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

20

SOMBRERO – January 2016

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 nontransparent, no-bid contracting.

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]

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
e are Tucson’s homegrown, full-service law firm providing legal services for
system and to change many aspects of our culture.
Southern Arizona since 1969. We provide a wide array of legal services in business
Optum is hardly a household name, but it is the
and corporate transactions, litigation, estate planning, bankruptcy, creditors’
largest of UnitedHealth Group subsidiaries.
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UnitedHealth’s Optum includes a managed-care
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arry Kirschner professionally handles claims of persons who have become
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clients such as hospitals, employers, and
behalf of doctors, lawyers, and other professionals. Barry has handled ERISA
government agencies lower health costs. The
biggest growth came from its OptumRx PBM unit,
terminations administratively and in court, opposing every major disability
which notched a 33 percent year-over-year
insurance carrier. Barry continues to be selected by his peers for inclusion in
revenue gain for all of 2014.[3]
The Best Lawyers in America® in the field of Litigation — ERISA and continues
Optum claims on its website www.optum.com:
to receive the highest AV ranking for quality and ethics from Marindale Hubbell.
“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
For more info visit
“has little impact without deep domain knowledge
and a track record in the government sector.”
Optum™ experts, the website claims, “understand
An independent member of
the nuances. … We can help contain costs and
MERITAS LAW FIRMS WORLDWIDE
improve outcomes for Health and Human Services
agencies, program beneficiaries and taxpayers.”

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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
SOMBRERO – January 2016

Williams Centre | 8th Floor | t 520.790.5828
21

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

Dr. Matthew Clavenna,
MD

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.

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.

www.CarlsonENT.com
22

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 “evidencebased” 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.
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 “decisionbased evidence determinations,” as opposed to
evidence-based clinical practice, in crucial
SOMBRERO – January 2016

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 HealthCare.gov 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”
coverage.[7]
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
SOMBRERO – January 2016

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 rollout of HealthCare.gov. 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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23

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 HealthCare.gov.
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 HealthCare.gov,
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

The Faces of Casa are the

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.
[15]

James Nicolai, M.D.
Associate Medical Director

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Hospice services are paid for by Medicare

24

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 vicepresident 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 HealthCare.gov. This
particular contract came to the attention of
Congress and prompted concerns from the
House Energy and Commerce Committee. Rep.

SOMBRERO – January 2016

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 HealthCare.gov 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

SOMBRERO – January 2016

“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 wellbeing 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, www.americanprogress.org.
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@
ymail.com.
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.

25

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Accessed Nov 8, 2015.

26

16. Pavlich K. Obama’s anti-Second Amendment nominee for Surgeon
General: guns are a healthcare issue. Townhall.com, Mar 11, 2014.
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22. Cohn G, Preston D. AARP/UnitedHealth bait and switch. Boston
Globe, Dec 5, 2008. Available at: www.pnhp.org/news/2008/
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:
www.unitedhealthgroup.com/newsroom/articles/feed/
unitedhealth%20group/2013/1015broadenaarp.aspx?sc_lang=e n.
Accessed Nov 8, 2015.
n

Members’ Classifieds
MEDICAL OFFICE FOR LEASE - Well situated on
Northwest Medical Center campus with great visibility
on Orange Grove. Well designed, 4,300 square feet,
aesthetically-pleasing with high efficiency, suited for
4-6 providers, built in 2006. Features 12 exams rooms,
including 1 procedure room; 4 offices; and 1 large
reception area; spacious storage area for supplies;
at door parking. Available April 2016 (Current leaser
is merging with another practice) Competitive rates.
Contact Catherine Westerband, MD, 520-488-7515 or
cwesterband@genesisobgyn.net
FULL-TIME PEDIATRICIAN – Great family and golf
community. Full-time Pediatrician BC/BE to join
well established Pediatric practice in Tucson, Az.
Competitive salary with excellent benefit package,
including bonus compensation. Send CV to kolleenr@
comcast.net

SOMBRERO – January 2016

IMAGING 2016

Enhanced Care with
Advanced Imaging

You’re
Invited!
Marcus J. Dill-Macky, M.D.
Breast Cancer Screening:
What if I Do Nothing?

Saturday, February 20, 2016
7:00AM - 12:00PM
Breakfast Buffet Provided
Westin La Paloma
3800 E. Sunrise Drive
Tucson, AZ 85718

RSVP to Professional Relations
at 520-545-1836 or online at
www.radltd.com/cme2016
This symposium is free of charge
and is being held to educate
physicians and providers on updated
imaging modalities and techniques.

Chad A. Kohl, M.D.
What You Don’t See Can Hurt
You: MRI of Radiographically
Occult MSK Pathology

Mark S. Peterson, M.D.
Low-Dose CT Lung
Cancer Screening

Creed M. Rucker, M.D.
Treatment of Stroke

Jason E. Wright, M.D.
3T MRI: Current
Applications in Prostate
and Abdominal Imaging

Enter to win a
staycation at the
Westin La Paloma!
Must attend to win.

A TUCSON TRADITION FOR MORE THAN 80 YEARS

(520) 545-1836
SOMBRERO – January 2016

27

2015,
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.

Medical Professional Liability Insurance
(602) 956-5276, (800) 352-0402
www.mica-insurance.com
Dividends declared for a given policy year reflect the Company’s financial performance during that year.
Past performance does not guarantee future dividends.

28

SOMBRERO – January 2016