Aug-Sept 2014 Sombrero

8/11/2019 Aug-Sept 2014 Sombrero

1/28

SOMBREROP i m a C o u n t y M e d i c a l S o c i e t y

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

A U G U S T / S E P T E M B E R 2 0 1 4

The war on doctors

Banner to acquire UAHN

Tenet to acquire Ascension/CHN

Arizona: Grape

Canyon State


2/282 SOMBRERO August/September 2014

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3/28SOMBRERO August/September 2014 3

Ofcial Publication of the Pima County Medical Society Vol. 47 No. 7

PrintingCommercial Printers, Inc.Phone: 623-4775

E-mail: [email protected]

PublisherPima County Medical Society5199 E. Farness Dr., Tucson, AZ 85712Phone: (520) 795-7985Fax: (520) 323-9559

Website: pimamedicalsociety.org

EditorStuart FaxonPhone: 883-0408

E-mail: [email protected] do not submit PDFs as editorial copy.

Art Director

Alene Randklev, Commerc ial Printers, Inc.Phone: 623-4775Fax: 622-8321E-mail: [email protected]

Pima County MedicalSociety Officers

PresidentTimothy Marshall, MD

President-ElectMelissa Levine, MD

Vice PresidentSteve Cohen, MD

Secretary-TreasurerGuruprasad Raju, MD

Past-PresidentCharles Katzenberg, MD

PCMS Board of DirectorsEric Barrett, MD

Diana Benenati, MD

Neil Clements, MD

Michael Connolly, DO

Michael Dean, MD

Howard Eisenberg, MD

Afshin Emami, MD

Randall Fehr, MD

Alton Hallum, MD

Evan Kligman, MDKevin Moynahan, MD

Soheila Nouri, MD

Wayne Peate, MD

Scott Weiss, MD

Leslie Willingham, MD

Gustavo Ortega, MD (Resident)

Snehal Patel, DO (Resident)

Joanna Holstein, DO (Resident)

Jeffrey Brown (Student)

Jamie Fleming (Student)

Members at Large

Donald Green, MD

Veronica Pimienta, MD

Board of Mediation

Timothy Fagan, MD

Thomas Grifn, MDGeorge Makol, MD

Mark Mecikalski, MD

Edward Schwager, MD

Arizona MedicalAssociation OfficersThomas Rothe, MD

immediate past president

Michael F. Hamant, MDsecretary

At Large ArMA BoardR. Screven Farmer, MD

Pima Directorsto ArMATimothy C. Fagan, MD

Timothy Marshall, MD

Delegates to AMAWilliam J. Mangold, MD

Thomas H. Hicks, MD

Gary Figge, MD (alternate)

SOMBRERO (ISSN 0279-909X) is published monthlyexcept bimonthly June/July and August/September by thePima County Medical Society, 5199 E. Farness, Tucson,

Ariz. 85712. Annual subscription price is $30. Periodicalspaid at Tucson, AZ. POSTMASTER: Send address

changes to Pima County Medical Society, 5199 E. FarnessDrive, Tucson, Arizona 85712-2134. Opinions expressedare those of the individuals and do not necessarily repre-sent the opinions or policies of the publisher or the PCMSBoard of Directors, Executive Officers or the members atlarge, nor does any product or service advertised carry theendorsement of the society unless expressly stated. Paidadvertisements are accepted subject to the approval of theBoard of Directors, which retains the right to reject anyadvertising submitted. Copyright 2014, Pima CountyMedical Society. All rights reserved. Reproduction inwhole or in part without permission is prohibited.

SOMBRERO

Executive DirectorBill FearneyhoughPhone: 795-7985

Fax: 323-9559E-mail: [email protected]

AdvertisingPhone: 795-7985Fax: 323-9559E-mail: [email protected]

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On the Cover

Sonoita Vineyards and Winery south of Elgin, founded by Gordon

Du in 1983, began statewide development of Arizona as a

locale for quality wineries and product. Gordon is sll acve in

management. For your virtual tour of the Grape Canyon State,

see this issues Behind the Lens (Dr. Hal Tretbar photo).

24 Hours 7 Days A Week

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SOCIETY SINCE 1981

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WE ANSWER FOR YOU!PagersVoice MailI.V.R. (InterActive Voice Response)

Message Delivery via Live Operator, Email, Text Messaging, Voice Mail or Fax

Live AnsweringRemote ReceptionistAppointment SchedulingOrder Taking

790-2121www.RinconCommunications.comwww.RinconCommunications.comwww.RinconCommunications.com

5 Leers: Drug war is really pain paent war.

6 Dr. Timothy Marshall: Our president knowswhen enough enforcement becomes toomuch.

8 Milestones: Recognions and achievementsof our members.

12 Mix At Six: Members and student membersmeet informally.

14 Behind the Lens: Dr. Hal Tretbar andDorothy tour and sample Arizona wineriesand wines.

17 PCMS News: If rising healthcare costs neverhit a ceiling, will big local healthcare

organizaon buyouts change anything?

24 Arizona Medical Associaon News: Dr. TomRothes year as ArMA president, plus annualmeeng report.

26 CME: Pima County Medical Foundaon hasyour most-local credits.

SOMBREROP i m a C o u n t y M e d i c a l S o c i e t y

HomeMedical Society ofthe 17th United States Surgeon-General

A U G U S T / S E P T E M B E R 2 0 1 4

The war o n doc tors

Banner to acquire UAHN

Tenet to ac quir e Ascens ion/ CHN

Arizona: Grape

Canyon State

Inside



Leers

Pain patients casualtiesof War on DrugsTo the Editor:

The acons of the Drug Enforcement Administraon to eliminatediversion of Oxycodone is working to decrease its legimatemanufacture and availability in pharmacies. It has become dicultfor paents to ll their prescripons for appropriate use as well asfor the one to two percent who dont use them appropriately.

Paents have been forced to go to mulple pharmacies because

of the limited supply. They are oen turned away by pharmacistswho are fearful to dispense, having been inmidated by the DEA.Oen their poorly substanated raonale is the paent does nott their good faith dispensing prole.

The paradox is that Oxycodone is aordable (covered by AHCCCS),

an eecve pain reliever with few side eects,* but at the sameme the easily crushable favorite of abusers. Besides, not beingable to obtain a medicaon which may have worked well forthem to increase their funcon in the past, paents faceprejudice from poorly informed friends, families, and healthprofessionals. All this adds to the chronic pain and disabilitywhich brought them to seek treatment in the rst place.

There is also the irony that government acons have doubledthe street price of Oxycodone. Overdoses seen in our ERs arenow more frequently from black tar heroin. The prot for theblack market has also been aided by the threats and acons thathave frightened o medically licensed competors who mightconsider prescribing.

These acons have been eecve strategies to create negave

publicity and misinformaon for not only the medical professions,

but for policians and the public. The oen-quoted stasc, thatanyone who dies and has an opiate in their blood is counted as a

opiate death no maer what other disease they may have ormedicaons they may take, fuels the re with sciencmisinformaon.

The visibility and somemes budgets of state medical boards, theJusce Department, local police, the militarized border patrol,the prison industry, and the courts have increased. This is areecon of polical and public senment that paents on drugsmust be abusers and physicians who prescribe them drugpushers. Both are seen as making a prot and being a threat totaxpayers who feel, I dont need those drugs, why do they?Maricopa County Sheri Joe Arpaio, on the other hand, has been

reported to sayand which was reported to be echoed by PimaCounty Aorney Barbara LaWallthat we need prescribed

medicaon for pain paents or theyll become their clients.

We advise our paents to act to protect their legimate access tothe appropriate use of prescribed controlled medicaons. Theyare the real vicms of these confused policies. We suggest rst,that they call on their federal representaves to re-examine DEAsmarching orders and state licensing boards. Second, that theyexplain that they are not diverters or addicts, but rather thatcontrolled medicaon allows them to beer funcon. Third, thatthey record their experiences at pharmacies and with physiciansand complain when they are treated with prejudice anddisrespect. Fourth, that they parcipate, in their own self-

interest, in a community watch to idenfy those who aremisusing these medicaons, so that they may either be treatedfor their problems or eliminated from their unintendedconsequence of their acons that upend prescribers pracces.

Developing beer approaches to these issues of prescripon and

non-prescripon medicaon and drug abuse, decreasing theneed for and expense of more prisons for paents and non-paents (and for more Suburbans for those who ght the war),depends on evoluon of public understanding and our law. Theissues for educaon include:

That these medicaons provide legimate pain relief to manywho have a legal right to access to them via the AmericansWith Disabilies Act;

that misuse becomes less socially acceptable and tolerated bya society that is willing to recognize regulated access tomedicaon and treatment;

and that physicians are in the best posion and have aresponsibility to lead this process.

*Oxyconn is costly and its new non-crushable formulaon isdicult for many to digest. Connent or Morphine ER causesintolerable side eects for many. The Fentanyl Patch causesirritaon for many and is costly as is the long-acng Hydrocodone.Aordable Methadone has the potenal for arrythmias as well as

other undesirable features especially when used in combinaonwith other opiates.

Sincerely

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

Dr. Ruben is a diplomate in adult and child psychiatry, addicon,

and pain medicine. He writes and speaks on issues of medical

pracce and consults with lawyers and doctors on regulatory

interacons. He can be reached at [email protected] n



Suttons Law and the war against doctorsBy Timothy Marshall, M.D.

PCMS President

Why is it that every me I

order home oxygen for a

paent I need to sign a form

that threatens me with criminal

liability? Can I actually go to jail

for prescribing someone oxygen?It seems the answer is yes.

When asked why he robbed

banks, bank robber Willie Suon replied, Because thats where

the money is. Federal aorneys are aggressively prosecung

physicians for the same reason. They think thats where the

money is. My argument is that only part of the soluon to the

high cost of healthcare lies with prevenng fraud. The fact that

this administraon does nothing to allow tort reform, has

reduced the burden of proof necessary to convict physicians for

fraud, while piling on regulaons, the burden of EHR, ICD 10,PQRI, it all amounts to a war against physicians.

According to the FBI, Roong out healthcare fraud is central to

the well-being of both our cizens and the overall economy.

Healthcare fraud costs the country an esmated $80 billion ayear. And its a rising threat, with naonal healthcare spending

topping $2.7 trillion and expenses connuing to outpace

inaon. Recent cases also show that medical professionals are

more willing to risk paent harm in their schemes. [FBI.gov] Thegovernments healthcare fraud prevenon and enforcement

eorts recovered a record $4.2 billion in taxpayer dollars in Fiscal

Year 2012. This is a result of President Obama making the

eliminaon of fraud, waste, and abuse, parcularly in healthcare,

a top priority for the administraon.1

Im sure all physicians would agree with prosecung cases of

actual premeditated fraud, such as performing bypass gra

surgery in the absence of coronary disease, or providing home

healthcare for paents who dont exist, is very reasonable andnecessary. We do not, however, want to be persecuted, or

prosecuted, for praccing medicine to the best of our ability in

good faith.

Aer researching this arcle I have discovered that any of us

could be jailed for a coding error! Congress has created new

crimes specically addressing healthcare fraud. Under this

statute, any healthcare provider who presents a false or cous

claim or demand to the government, seeking reimbursement formedical goods or services, can be liable. The long-standingrequirement of proof of criminal intent in connecon with the

federal prosecuon of physicians has been eliminated. The False

Claims Act may be applied to physicians providing services that

were not provided, or were not medically necessary. Thepunishment for a criminal convicon under the act is up to ve

years imprisonment and a ne of $250,000.00 for each

infracon. Civil penales can be up to $11,000 per incident, plus

three mes the amount claimed.

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

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

convicted on two counts of making false statements in his

operave reports. The term false statement suggests a

deliberate lie, but it could be a simple mistake. The prosecutor

does not need to prove that a doctor knowingly and willfully

lied in order to pad his fee, but only to show that an incorrect

AMA code or incorrect descripon to an incorrect AMA code was

used and that the doctor intended to get paid for his work. The

implicaons of the case are profound, the judge noted: Any error

in any medical record related to a health program could be a

federal crime. And just when you think coding errors are geng a

lile out of hand, the government imposes ICD 10.

Are there other ways to save money in healthcare? Lets look at

malpracce reform and defensive medicine. Defensive medicine

refers to the pracce of recommending a diagnosc test or

treatment that mainly serves to protect the physician against the

paent as potenal plain. Defensive medicine is said to be areacon to the rising costs of malpracce insurance premiums. I

dont pracce defensive medicine because my insurance

premiums rise. I pracce defensive medicine because one lawsuitcould erase 30 years of hard work, take away all my assets, my

home, and my future.

As youd expect, the medical literature and the trial lawyers have

a very dierent take on the extent of defensive medicine. Clearly

accurate measurement of defensive medicine is extremelydicult. A survey of 300 physicians found that more than 76

percent of the physicians responded that malpracce ligaon

had hurt their ability to provide quality care to paents. Because

of their fear of the excesses of the ligaon system:

79 percent said they had ordered more tests than they would

have based only on professional judgment.

74 percent had referred paents to specialists more oen

than they believed was medically necessary.51 percent had recommended invasive procedures such as

biopsies to conrm diagnoses more oen than they believed

were medically necessary.

41 percent said they had prescribed more medicaons, such

as anbiocs, than they would have based only on theirprofessional judgment, and 73 percent had noced other

doctors prescribing medicaons similarly.

The American Associaon for Jusce (Formerly Associaon of

Trial Lawyers of America) not surprisingly has a dierent opinion:To the extent that defensive medicine does exist, research hasfound that the movaon behind it is not liability but rather a

desire to simply help a paent or, in some cases, boost physician

income. One government agency found that doctors chose not to

order any tests or diagnosc procedures 95 percent of the me.

Doctors who ordered tests almost always did so because of

medical indicaons, and only one half of one percent of all cases

involved doctors who ordered tests due solely to medical

negligence concerns. Of all the diagnosc tests I order here inTucson that I would not have done in Canada, I can tell you its far

greater than half of one percent! In my opinion the lawyers

asseron is ludicrous.



How much does defensive medicine cost? Not surprisingly, thetrue cost of defensive medicine is hard to discern. Kessler andMcClellan noted that limits on noneconomic damage awards,

such as those California has had in eect for 25 years, can reducehealthcare costs by between 5 percent and 9 percent withoutsubstanal eects on mortality or medical complicaons.Applying non-economic damage limits to the country as a whole,

with its naonal healthcare expenditure of $1.4 trillion, wouldreduce healthcare costs by as much as $126 billion, and reducethe federal governments share of such costs by as much as $50

billion, according to McClellans 2003 esmate. Imagine what wecould save based upon more recent healthcare expenseesmates. These cost savings would be dwarfed by what we couldactually achieve by removing defensive medicine altogether.

So it would stand to reason that if you want to reduce healthcare

cost, all aspects would be implemented, not just those that

protect your elecon donors. The criminalizaon of medicine has

to be stopped. The governments burden of proof requirement of

criminal intent must be reinstuted. Criminalizing speech,

without requiring proof of intent to defraud, creates a new risk of

imprisonment for anyone who is less than perfect in what he or

she documents or codes.

Some of these nancial numbers and references may be old, butare useful for illustraon. The more I researched for this arcle, themore I felt as Hamlet, besieged by the slings and arrows of our

outrageous government, jusce system, and malpracce aorneys.

The war on physicians is fully underway on many levels. Watch

your coding!

REFERENCES

1. U.S. Department of Jusce. Departments of Jusce and Health and HumanServices Announce Record-Breaking Recoveries Resulng from Joint Eorts toCombat Health Care Fraud, Department of Jusce. Oce of Public Aairs, Feb 11,2013.

2. Hellinger FJ, Encinosa WE. The Impact of State Laws Liming MalpracceDamage Awards on Health Care Expenditures.Am J Public Health2006

Aug;96(8):1375-81.3. Kessler D, McClellan M. Do Doctors Pracce Defensive Medicine? Quarterly

Journal of Economics1996; 111(2): 353-390.

4. Studdert DM, Mello MM, Sage WM, et al. Defensive medicine among high-risk specialist physicians in a volale malpracce environment.JAMA2005 Jun1;293(21):2609-17.

5. U.S Congress, Congressional Budget Oce, The Economics of U.S. TortLiability: A Primer. Washington, DC: US Government Prinng Oce Oct 2003.

6. U.S Congress, Congressional Budget Oce, Medical Malpracce Tort Limitsand Health Care Spending. Washington, DC: US Government Prinng Oce, April2006.

7. The Factors Fueling Rising Healthcare Costs. Prepared for Americas HealthInsurance Plans. Price Waterhouse Cooper, Americas Health Insurance Plans, 2006.

8. U.S. Department of Jusce. Departments of Jusce and Health and HumanServices Announce Record-Breaking Recoveries Resulng from Joint Eorts to

Combat Health Care Fraud. Oce of Public Aairs, Feb 11, 2013. 9. Hellinger FJ, Encinosa, WE. The Impact of State Laws Liming MalpracceDamage Awards on Health Care Expenditures.Am J Public Health2006Aug;96(8):1375-81.

10. Kessler D. McClellan M. Do Doctors Pracce Defensive Medicine? QuarterlyJournal of Economics1996; 111(2): 353-390.

11. Studdert DM, Mello MM, Sage WM, et al. Defensive medicine among high-risk specialist physicians in a volale malpracce environment.JAMA2005 Jun1;293(21):2609-17.

12. U.S Congress, Congressional Budget Oce, The Economics of U.S. TortLiability: A Primer. Washington, DC: US Government Prinng Oce Oct 2003.

13. U.S Congress, Congressional Budget Oce, Medical Malpracce Tort Limits andHealth Care Spending. Washington, DC: US Government Prinng Oce, April 2006.

14. The Factors Fueling Rising Healthcare Costs. Prepared for Americas Health

Insurance Plans, Price Waterhouse Cooper. Americas Health Insurance Plans, 2006.n

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Milestones

Dr. Lavor reresDear friends and colleagues,

Dr. Michael Lavorwrote in

July, it is with mixed

emoons that I write to tell

you of my future plans.

Aer more than 23 years as a

surgeon, I will be rering from

acve surgical pracce. I will,

however, be connuing as

Saguaro Surgicals medical

director. In addion, I will be

connuing as medical director

at The Wound Center where,

through state-of-the-art

treatments, we remain available to provide specialized therapy

for chronic or non-healing wounds.

First and foremost, I want to assure you that each member of

the Saguaro Surgical medical team remains strong, commied

to excellence, and able to oer your paents the full range of

general and vascular surgical services youve come to expect.

In a few weeks Saguaro

Surgical welcomes the newest

general surgeon to our team,

Dawn Ellio, M.D., a nave of

Arizona who received her M.D.

at The University of Arizona.

Dr. Ellio, along with Saguaro

Surgicals four other surgeons,will connue to meet all the

surgical needs of your paents.

Our sta remains commied to

assisng your oce and making

certain you receive detailed

updates on each paent you trust to our care. As medical director I

will focus not only on assuring our high medical standards are

maintained, but also that all of the latest technologies and services

are available here for you and your paents.

I have valued our relaonship as medical colleagues and feel

both fortunate and grateful to have had the opportunity tomeet your paents surgical needs over the years. I sincerely

hope you will develop new and strong relaonships with my

colleagues at Saguaro Surgical, allowing us to connue to

provide general and vascular surgical care for your paents

even aer I step back from my role as a surgeon.

Although I will, obviously, remain acve in our community, my

rerement from acve pracce as a surgeon is something to be

noted and for my wife, Irene, and mesomething to celebrate.

Sincerely,

Michael Lavor, M.D., Saguaro Surgical

Dr. Lavor is an Ohioan born in 1949. He earned his M.D. in 1985

at University of New Mexico Medical School. He interned at

University of Chicagos Michael Reese Hospital, and did his

residency and chief year at University of Illinois Metropolitan

Group Hospitals, Chicago. He was a U.S. Navy Corpsman with

the Marines 1967-69. He is American Board of Surgery

cered.

Dr. Ellio earned her bachelors degree in microbiology at NAU,

and then her M.D. at The University of Arizona College of

Medicine, with a post-sophomore Fellowship in pathology. She

did her GS residency and internship with Grand Rapids (Mich.)

Medical Educaon Partners at Spectrum Health and Mercy

Health hospitals.

She has a special interest in complex hernia repair and advanced

laparoscopy including inguinal and ventral hernia repair, an-

refulx procedures, hiatal and paraesophageal hernis repair,

splenectomy, adrenalectomy, and colectomy.

Physiatry Associates

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

pracce is pleased to have

added Nancy Lipson, M.D.

She joins Charles Blake, M.D.,

John Larson, M.D., and

Michael Goodman, D.O. at the

pracce at 2102 N. Country

Club Rd. Building B.

Dr. Lipson graduated from

Wayne State University School

of Medicine in Detroit, andcompleted her PM&R residency

at The Ohio State University. She pracced for 25 years in

Indianapolis, Ind. before moving to Tucson in June 2014.

Dr. Lipson has experse in all areas of general rehabilitaon, and

is subspecialty board-cered in Spinal Cord Injury Medicine. She

is currently accepng new paents.

Chicanos Por La Causa honorsDr. Lpez

Ana Maria Lpez, M.D., M.P.H.,F.A.C.P., medical director of the

Arizona Telemedicine Program,

professor of medicine and

pathology at The University of

Arizona College of Medicine

Tucson, and member of

University of Arizona Cancer

Center, was one of three

women recently honored for

being a cornerstone of our

community by Chicanos Por La

Causa (CPLC) at its 34th Annual



Southern Arizona Dinner celebraon, The Art of Being a

Woman.

An internaonally recognized oncologist, Dr. Lpezs work focuses

on paent-centered care of women with cancer that includes the

family and community, and on enhancing equity and access to

healthcare through innovave technology. She also is a leader in

addressing disparies and diversity in the health professions. She is

a principal invesgator for several breast and ovarian cancer clinical

trials focused on quality-of-life care and innovave treatments.

A nave of La Paz, Bolivia, she holds a bachelors degree in

philosophy from Bryn Mawr (Pa.) College; a medical degree from

Jeerson Medical College, Philadelphia; and a masters in public

health with a concentraon in health administraon and policy

from the UA Mel and Enid Zuckerman College of Public Health.

Dr. Doraiswamy joins UACollege of Medicine

Dr. Vijay A. Doraiswamy, a

resident member of PCMS, is

one of the UofA Cardiology

Fellows preparing for the next

phase of their careers, the

university reports.

In June UofA Sarver Heart

Center celebrated graduaon

of ve Fellows from the

Cardiovascular Medicine

Fellowship

Program,

and two

from the

Intervenonal Cardiology Fellowship

Program. Dr. Doraiswamy is joining the UA

College of Medicine, Division of Cardiology

as an assistant professor, primarily praccing

at UA Medical CenterSouth Campus.

Dr. Fodeman 2014Claremont LincolnFellowThe Claremont Instute, a center for polical

philosophy and statesmanship dedicated to

recovering the American idea, reported inJune that it had named Dr. Jason Fodeman

as a 2014 Lincoln Fellow.

An occasionalSombrerocolumnist, Dr.

Fodeman is a board-cered IM physician

and currently an Assistant Professor of

Medicine at The University of Arizona, and

medical director of the University of Arizona

Medical Center Home Health.

He previously studied as an adjunct scholar

at the James Madison Instute. During his

residency at Cedars Sinai

Medical Center, he was a

Senior Fellow in Health Care

Studies at Pacic Research

Instute, and president of the

Docs4PaentCare California

Chapter. He has completed a

Graduate Health Policy

Fellowship at the Heritage

Foundaon.In addion to these pages his

work has appeared in

the Washington

Examiner,Arizona

Republic, Naonal Review Online, and The Washington Times. He

is studying for an M.B.A. at the UofA. He holds an M.D. from

Albert Einstein College of Medicine at Yeshiva University, and a

B.A. in economics from The Johns Hopkins University.

Carondelet St. Marys,

St. Josephs awardedfor stroke careBeing honored for providing excellent care is the best

recognion a hospital can get, Carondelet Health Network says,

and Carondelets Tucson hospitals connue to receive valuable

recognion each year from the American Heart Associaon/

American Stroke Associaon.

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The Get With The Guidelines Stroke Gold Plus Quality

Achievement Award was recently bestowed on St. Marys

Hospital for the third consecuve year, and St. Josephs Hospital,

home of Carondelet Neurological Instute, for the fourth

consecuve year.

The two hospitals, both Joint Commission-cered Primary Stroke

Centers, also earned the Target: Stroke Honor Roll Award for the

third consecuve year. Both awards are historically given to the

highest performing Stroke Centers in the country. These awards

recognize Carondelet hospitals commitment to exceponal carefor their stroke paents by the adherence to the latest evidence-

based guidelines based on the latest scienc research.

Guidelines were established by AHA/ASA in 2003 and were

designed to improve stroke care by promong consistent

adherence to the latest scienc treatment guidelines,

according to AHA/ASA. Parcipang hospitals enroll in the

program and submit data through a Web-based Paent

Management Tool provided by AHA/ASA, which is then

evaluated to determine both the hospitals baseline and

improvements. Hospitals receive these quality awards based on

adherence to the quality metrics for a designated me.

Carondelet Tucson hospitals have received the Gold Plus andTarget Stroke Honor Roll recognion for their ongoing focus on

quality stroke care.

College of Medicinewelcomes 2018 classThe University of Arizona College of MedicineTucson welcomed

its newest class of medical students with free iPads and three-

days of community-building acvies beginning July 30, the

university reported. One hundred een students began three

days of orientaon on their four-year, hands-on training

commitment to learn leading-edge paent care under the

mentorship of disnguished clinician-educators at the University

of Arizona College of MedicineTucson.

Students were welcomed by campus leaders including Joe G.N.

Skip Garcia, M.D., UA senior vice president for health sciences

and interim dean of the UA College of MedicineTucson;

Francisco Moreno, M.D.,deputy dean for diversity and inclusionand professor of psychiatry; and Kevin Moynahan, M.D., deputy

dean for educaon, director of the UA College of Medicine

Tucson Sociees Program and associate professor of medicine.

Included was a community service-learning day, during which

the medical students will volunteer with local community

organizaons to build a sense of community and to gain an

understanding of some of the social issues the Tucson

community faces.

The goal of orientaon the university says, is to develop a

sense of professional identy, community and collegiality among

a diverse group of future physicians. The College of Medicine

Tucson Class of 2018 includes 33 students who graduated from

the UA, 40 percent of the students are Arizona residents, 25 hold

graduate or professional degrees, a lile more than half are

female and two are student-veterans. n



Society welcomes students, interns at Mix

Mix At Six

By Dennis Carey

P

CMS had its latest a Mix At Six social July 25 at La Paloma

Country Clubs 19 thHole, with former PCMS and ArMA

President Thomas, Rothe, M.D., serving as host.

Society members welcomed several medical students and interns

to the local medical community, providing an opportunity for

them to meet praccing physicians and other students in an

informal seng.

Students and interns have been very enthusiasc about the Mix

Dr. Basil Skeif and his wife,Allison, and Dr. Ken Sandock enjoyrefreshments and conversation inMix At Sixs relaxed atmosphere.

Former PCMS presidents MichaelHamant, M.D. and Timothy Fagan,M.D. sample the guacamole andappetizers while relaxing at LaPaloma Country Clubs 19th Hole.

New PCMS student members SeanBehan, Edwin Telemei and Jack Rusingenjoy their frst Mix At Six social.

New PCMS student members Pooja Rajguru, CarolynSleeth, Jared Brock and Joelle Wang were amongMix At Sixs early arrivals.

Dr. Steve Cohen and med student JeffBrown fll out nametags at the mix.

At Six events, PCMS Execuve Director Bill Fearneyhough said.

Its a great opportunity for them to network with colleagues and

introduce themselves to praccing physicians. We look forward to

their parcipaon in the Society, and in the medical community.

More Mix At Sixes will be given throughout the year. Watch for

noces of coming events here in Sombrero, on the Society

website pimamedicalsociety.org, and in e-mail. As the clich

goes, be there or be square! n



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Arizona: Grape Canyon StateBy Hal Tretbar, M.D.

Behind the Lens

A

rizona is beginning to be

recognized for the newines coming from our

wineries. It all started in the

Sonoita-Elgin area when UofA

professor Gordon Du

recognized that soil and

weather condions were similar to noted French Burgundy

vineyards. More recently excellent vineyards have become

established in Santa Cruz, Cochise, and Graham counes.

Where there are vineyards there are wineries. In the Elgin regiontwo of the oldmers, Dus Sonoita Vineyards (1983) and

Callaghan Vineyards (1990), have had their best served in the

White House on numerous presidenal occasions.

Then it was determined that the Verde Valley along lower OakCreek south of Sedona near Cornville has the climate and soil

similar to the Rhone region of Southern France. Mediterranean

and Spanish varietals such as Mourverde, Roussanne, Grenache,

Syrah, Viognier, and Connoise now ourish there.

Recently Dorothy and I drove the Verde Valley Wine Trail. If youstart from Sedona, go south 12 miles on 89A and turn le of Page

Springs Road. If you are coming o of Interstate 17, turn west at

exit 293. Go 9 miles to Cornville to reach Page Springs Road, and

3.5 miles in either direcon brings you to three of the vewineries in the Verde Valley. Oak Creek, Javelina Leap, and Page

Springs Cellars are just down the road from each other. Echo

Canyon is near Sedona, while Alcantara is closer to Camp Verde.I certainly am not a wine connoisseur; maybe a someme

acionado. We watched a family friend give up his hobby storebusiness in Tucson to become a vintner. Robert Bob Webb was

a pioneer in Cochise County when he planted 20 acres of

Cabernet Sauvignon, Merlot, and Riesling, at Kansas Selement

in1983. This was at the at thesame me Gordon Du

started in Santa Cruz County.

Bob built the nice

Mediterranean- style

R.W.Webb Winery on I-10

just east of Tucson. In spite

of quality wines, the wineryfailed because of manage-

ment problems, poor locaon,and lack of ambience.

I was in a limited partnership

for Terra Rosa Vineyards,

located a few miles west of

Elgin. We planted 20 acres of

Merlot and other popular

varietals. Aer four years ofincreasing producon and

some excellent vintages, we

were wiped out by Pierce disease, transmied by the glassy-

winged leaopper. As oen happens with limited partnerships,

there was insucient funding to replant.

In spite of aging tastebuds and possibly early anosmia (loss of smel

ability), I sll enjoy stopping at tasng rooms to chat with the localsand sip what they are passionate about. I tend to go with the

whites because my cardiologist said red wine might aggravate an

arrhythmia. I can tell you what appeals to my taste, but I cantdepict it as a Chenin Blanc has been described at Javelina Leap.There are honeysuckle aromas followed by layers of apple, honeymango, and pineapple with hints of buerscotch and lemon curd.

There was acvity in the yard next to the Javelina Leap Vineyard

entrance when we stopped by in mid-August.

A forkli was moving large

empty plasc containers and

the driver said, We are aboutready to harvest, and the crush

should be good this year.

Annie Jones was behind the

bar in the tasng room and

gave us the vineyard historyas we tasted several

varietals. Rod, a chef, and

Cynthia Snapp started from

the ground up nine years ago

and have been open for eight

years. They have developed

a number of outstanding

varietals including a pinkPinot Grigio, Chenin Blanc,

and a Tempranillo. Most of

the grapes are from 20 acres

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

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



in the Verde and Skull valleys.

Javelina Leap has become well known for its

Zinfandels. Their 2012 AZ Zinfandel comes

from their Dragoon Vineyard. The 2012 Estate

Legacy Zinfandel is from the 4.5 acres ofseven-year-old vines outside the front door.

They oer only one blend, made with Arizona

Zinfandel, Merlot, and Pete Sirah.

The Page Springs Cellars tasng room wasbusy with a hum of relaxed conversaon.

Beyond the sunlit room with its tradional

bar and wine bole racks was an inving

alcove. Subdued lighng and so musictempts one to sink into a so leather sofa and

linger over a glass of wine.

We chose to have a Flight that combined both

reds and whites. A Flight gives you a chance totry four or ve of the winerys favorites, usually

all red, white, or specialty. A splash of each can

be snied and rolled on the tongue for about $8

to $10. Tim Godin was our very knowledgeable

Tasng Room associate. Some that we chose tosample were the Rhone style 2011 La Serrana

($26), the 2012 Arizona Chardonnay ($24) and a

red 2012 El Serrano ($32).

The Serrana is a pleasant blend of 75 percent

Viognier and 25 percent Roussanne from theStronghold vineyard at Kansas Selement.

The Chardonnay was fresh and spirited. It is 100 percent varietal,

combining Chardonnay grapes from both Bonita Springs and

Arizona Stronghold. Dorothy enjoyed the Serrano, the agship

blend from Page Springs Cellars. This is their 10thyear of blending42 percent Mourvedre, 41 percent Syrah and 17 percent PeteSirah, all from Arizona.

The owner, inspiraon, driving force, and vintner for the cellars is

Eric Glomski, who comes from a California winemaking

background. He briey worked at Echo Canyon Winery before aprime property became available on Oak Creek near Cornville.

The rst vines were planted in 2004, and Eric planned to have a

small bouque aair.

In 2007 he partnered with Maynard James Keenan, a well-known

rock singer who came from an Italian winemaking family.

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

a fair price all across the country. They bought the 80-acre Dos

Cabezas vineyard at Kansas Selement from Don Buel. Don had

expanded the original 20 acres planted by Bob Webb. Theyrenamed it Arizona Stronghold. Later they added the Bonita

Springs Vineyard 20 miles north of Wilcox. The Stronghold winery

is in Camp Verde and the tasng room is in Coonwood.

Aer an intense cross-country tour and adversing campaign,

they were ready to sell in 38 states as well as in Canada, Australia,and New Zealand. In 2012 Arizona Stronghold produced 12,000

cases of wine.

Soon there was a clash of personalies and in the spring of this

year the divorce happened. TheArizona Republicreported onMay 12, 2014 that Keenan would take possession of theStronghold vineyard in Kansas Selement and change the name

Danielle and Barry of Gilbert enjoy the cool Page SpringsCellars Vineyard.


16/28



PCMS News

Sellout Summer?Buyout Binge?Within a month of each other, two large local healthcare

organizaons, that reportedly lost more than $30 million each

last year, made agreements to be fully or partly bought.In June, University of Arizona Health Network and Banner Health

entered what they called a long-term agreement.

In July, Ascension (formerly Ascension Health) and Carondelet

Health Network signed a leer of intent to form a partnership

with Tenet Healthcare and Dignity Health, exploring a joint

venture that would aquire Carondelet.

UAHN, Banner

In announcing the move, UAHN and Phoenix-based Banner

Health called it an historic eort to create a statewide

organizaon to transform and advance healthcare in Arizona.

The university press release called plans a comprehensive new

model for academic medicine. This ground-breaking agreement

will formalize discussions and is intended to lead to nal

denive agreements someme in Fall.

The proposed transacon is ancipated to generate

approximately $1 billion in new capital, academic investments,

and other consideraon and value benecial to UA and the

community, the university reported. The ancipated transion

of 6,300 employees working at UAHNs two hospitals, the health

plan, and the medical group into Banner will create Arizonas

largest private employer with more than 37,000 employees.

The acon followed votes from the UAHN and Banner boards ofdirectors in support of proceeding with negoaons, as well as a

vote by the Arizona Board of Regents (ABOR) to authorize the

UofA to also move forward with UAHN and Banner. The pares

will now work together towards nal denive agreements,

ancipated to be completed and signed in September. The

denive agreements must also be approved by ABOR and the

boards of directors of UAHN and Banner. The proposed

transacon is expected to close a few months following the

signing of the denive agreements.

They stated these proposed key transion elements:

To create an Arizona-based, statewide health system that

improves care for all the states cizens by reliably and

compassionately delivering superior care to all who turn to this

system;

To create a naonally leading health system that provides

beer care and improved paent and member experiences at

lower costs through valued-based or accountable care

organizaons that ulize populaon health management models

that emphasize wellness;

To expand University of Arizona Medical Center capabilies

for complex academic/clinical programs such as transplantaons,

neurosciences, genomics-driven precision health, geriatrics, and

pediatrics while providing for investment opportunies in other

areas;

To bolster scal sustainability, eliminang persistent shorall

and low operang margins currently experienced by UAHN.

In addion to solving the immediate nancial needs, they said,

the proposed agreement will:

Eliminate the debt burdening UAHN (currently projected to

be $146 million);

Provide resources for improved hospital infrastructure,

including the $21 million purchase of land currently leased to

UAMC and $500 million within ve years to expand and renovate

the medical center, and build new facilies as appropriate, suchas a major, mul-specialty outpaent center to be constructed in

Tucson;

Create a $300 million endowment which will provide a

$20-million-per-year revenue stream to advance the UAs clinical

and translaonal research mission;

Preserve historic funding levels between the clinical and

academic partners in addion to a $20 million per year

enhancement;

Allow addional funding support based on growth in

revenues generated by the clinical and academic partnership;

Improve operaonal eciencies;

Secure and sustain a lasng relaonship with, and

commitment to, the University of Arizona, anchored by an

Academic Division within Banner. The Academic Medical Centers:

The University of Arizona Medical CenterUniversity and South

Campuses and Banner Good Samaritan Medical Center and the

faculty pracce plan, will support the growing needs of the

Colleges of Medicine in Phoenix and Tucson and create a value-

based delivery system;

The Phoenix and Tucson academic medical centers will be

infused with operaonal strength through the proposed

transion and rapidly evolve into major economic drivers that wil

aract highly skilled, trained and paid professionals, elevang

Arizona as a bioscience desnaon;

Train more physician specialists and allied healthprofessionals, including pharmacists and advanced pracce

nurses for Arizona;

Provide a comprehensive plaorm for the development of

physician-sciensts who will drive discovery across basic science

studies, paent-oriented clinical research, health services

research, and populaon health;

Enhance and elevate academic medical excellence across

Arizona to naonal leadership levels; and

Secure and sustain an operaonal foundaon for the College

of Medicine in Tucson and Phoenix that will maximize the value

of the ongoing state funding received annually through legislave

appropriaons.

When these respected organizaons unite, the potenal for

delivering top-er academic medicine throughout the state,

recognized naonally, becomes a reality, UAHN Board Chairman

Steve Lynn said.

Added UAHN President and CEO Michael Waldrum, M.D., Im

especially pleased that this proposed transion will infuse

stability and energy into our organizaon. This will benet our

paents, faculty, sta and students as we pursue excellence.

Ulmately, were moving from a situaon in which we can only

maintain status quo, to a situaon in which we can create a

premier Academic Medical Center.



With healthcare here in Arizona and across the naon facing

new challenges and opportunies every day, this agreement will

allow the Arizona Health Sciences Center and the enre UA to

advance our mission to provide educaon, conduct research and

enhance paent care that will transform healthcare at the state

and naonal level, said UofA President Ann Weaver Hart.

Combining the world-class care at UAHN and Banner will beer

meet the needs of paents in Arizona and throughout the region,

while also providing tremendous learning experiences for

students at the University of Arizona. By forming thiscollaboraon we will accomplish more for Arizonas residents and

for the advancement of medical knowledge and pracce than we

could do in isolaon.

Added Banner Presidient and CEO Peter S. Fine, Were honored

that the UAHN Board of Directors strategically sought Banner to

create Arizonas rst statewide health system to help strengthen

medical educaon. Banners vision is to sustain a posion of

naonal leadership. This opportunity to join with a premier

academic organizaon signicantly advances Banner towards this

vision. In addion, were especially mindful of UAHNs legacy of

excellence in Tucson and throughout the state, which must be

maintained, nourished and strengthened.

The press release said that The University of Arizona Colleges ofMedicine and Banner Health have a long history of successful

aliaon through the Graduate Medical Educaon program at

Banner Good Samaritan Medical Center in Phoenix. Each year,

Banner and the UA Colleges of Medicine

collaborate in the training of nearly 260

physicians in ve residency programs and

in numerous fellowships.

Ascension & CHN, Tenet & Dignity

In a July 22 press release datelined St.

Louis, Mo. and Tucson, involved pares

announced that Ascension and CarondeletHealth Network had signed a leer of

intent to form a partnership with Tenet

Healthcare and Dignity Health, and that

they will ex-plore a joint venture that

would acquire Carondelet. Ascension is

the parent of CHN. They called the leer

with a Tenet subsidiary exclusive and

non-binding.

Upon closing, they said, it is ancipated

that Ascension would retain a minority

interest in such a joint venture. The pares

have launched a period of due diligencewhich they expect will result in a denive

agreement.

Under the proposed agreement, Tenet

would be the majority partner in the joint

venture with management responsibility

for all operaons of Carondelets assets,

including St. Josephs and St. Marys

Hospitals in Tucson Holy Cross Hospital

in Nogales Carondelet Medical Group,

Carondelet Specialist Group, and

Carondelets ancillary businesses. Once

the acquision is complete, the joint

venture would maintain Carondelets

heritage and identy, connuing

Carondelets Catholic sponsorship.

Tenet and Dignity Health both own and

operate hospitals in the Phoenix area.

Their parcipaon in a Tucsonbased joint

venture will connect Carondelet to a

regional healthcare system, including

Tenets and Dignity Healths growing

accountable care organizaon, Arizona

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Care Network; strengthen and grow Carondelets relaonships

with physicians; and fund strategic growth iniaves in Southern

Arizona.

We are excited to pursue this relaonship with Tenet and Dignity

Health, Carondelet President and CEO James K. Beckmann said.

Like Carondelet, Tenet and Dignity Health are commied to

providing high quality, low cost, person-centered care. This

relaonship is an opportunity to strengthen those eorts,

enhance healthcare across Arizona, and connue Catholic

sponsorship of Carondelet. The people of Tucson and SouthernArizona will connue to benet from the tremendous dedicaon

and talent of Carondelets associates and physician partners.

The pares said they do not plan to provide any further detail

unl such point as a denive agreement is reached.

Tenet Healthcare Corp. described itself as a leading healthcare

services company, through its subsidiaries operates 79 hospitals,

193 outpaent centers, including six hospitals and four

outpaent centers in Arizona, and Conifer Health Soluons, a

leader in business process soluons for healthcare providers

serving more than 700 hospital and other clients naonwide.

[www.tenethealth.org]

Dignity Health in Arizona said it includes four outstanding

hospitals: Chandler Regional Medical Center, Mercy Gilbert

Medical Center, St. Josephs Hospital and Medical Center, which

includes Barrow Neurological Instute and St. Josephs Westgate

Hospital. From this foundaon, Dignity Health in Arizona has

expanded into a comprehensive health care system, which

includes imaging centers, clinics, specialty hospitals, urgent cares,

an insurance provider, an accountable care organizaon and

other clinical partnerships. The Dignity Health Medical Group

employs more than 250 physicians, who cover a wide range of

speciales. Dignity Health, Arizona Service Area, is part of Dignity

Health, one of the naons ve largest health care systems.

Ascension reported that last year it provided $1.5 billion in care of

persons living in poverty and in community benet programs, and

that it employs more than 155,000 associates serving in more

than 1,900 sites in 23 states and the District of Columbia.

Ascensions direct subsidiaries provide services that include

healthcare delivery, medical equipment management, treasurymanagement, resource and supply management, venture capital

invesng, physician pracce management, and risk management.

CMS: Open PaymentsSunshine program meansmore transparencyBy Betsy Thompson, M.D., DrPH, Region 9 CMO

As part of the Open Payments program, the Centers for Medicare

& Medicaid Services will soon make data about the nancial

relaonships between the health care industry and physicians

(e.g. including medical doctors, doctors of osteopathy, densts,

chiropractors, and others) and teaching hospitals available to the

public. Oering this data will create more transparency and allow

those interested to use, analyze and monitor it.

Open Payments, previously known as the Sunshine Act, is a

federal transparency program enacted by Congress in 2010. Under

this program, CMS collects and publicly reports data about



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payments (transfers of value), ownership,

or investment interests between drug and

device manufacturers and physicians and

teaching hospitals. Beginning with the last

ve months of 2013, CMS will collect this data

annually from industry and make it publicly

available, downloadable, and searchable.

Every year CMS will connue to release this

nancial informaon as it becomes available

about the prior year (e.g. by June 30, 2015 for2014 data).

These nancial interacons can happen for

many reasons: research, conference travel

and lodging, gis, and consulng. They can

foster collaboraon among physicians,

teaching hospitals, and industry

manufacturers that may contribute to the

design and delivery of life-saving drugs and

devices. However, they also can potenally

lead to conicts of interest in how health

care providers prescribe medicaons or give

medical care.

While CMS doesnt make assumpons or

draw conclusions about the reported

informaon, the Agency will take steps to

ensure that only accurate informaon is

made public. For example, as part of this

inial data collecon process, CMS has

The Faces of Casa are the

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engaged stakeholders as pilot users to ensure that reporng

systems are user-friendly and performing properly.

In addion, CMS will give physicians and teaching hospitals an

opportunity to be sure that informaon reported about them is

accurate. In order to review the data and make correcons if

necessary, physicians and teaching hospitals must rst register in

CMS Enterprise Portal starng on June 1, 2014. Then, starng in

July, they must register in the Open Payments system (via CMS

Enterprise Portal). This voluntary review and dispute period is

open for 45 days.

CMS strongly encourages physicians and teaching hospitals to

register in our Enterprise Portal and Open Payments systems so

they can review their specic data. Any data that physicians or

teaching hospital dispute, but is not corrected by industry within

the dispute resoluon period, will be included when the data is

made public and marked as disputed.

It is important that physicians or teaching hospitals know about

this program, how and what nancial relaonships are reported,

and how to answer quesons from paents. Visit go.cms.gov/

openpayments to get more informaon about Open Payments

(the Sunshine Act) and the resources available to understand the

program. Health care providers and others with quesons and

concerns can be e-mailed to [email protected].

This informaon was provided by the United States Department

of Health and Human Services.

Hyperbaric ambulance:fast HBOT treatmentsaves brainsBy Carol L Henricks, M.D.

A hyperbaric oxygen therapy (HBOT) equipped ambulance is beingdeveloped in North Carolina through a collaborave eort of the

FDA, Wake Forest University Hospital system, and the UHMS.

The hyperbaric ambulance will prolong the therapeuc window

to allow TPA therapy (ssue plasminogen acvator or clot

buster) to be given to paents who have suered an acute

stroke and have a long travel me to a hospital.[1] TPA improves

stroke outcome=less disability.

HBOT intervenon, preferably within three hours of rescue, also

improves the outcome in acute anoxic brain injury caused by

near-drowning and cardiopulmonary arrest. Hyperbaric

ambulances and/or acute HBOT treatment would change the

associated disability of these injuries forever! The research of

French physician Dr. Mathieu suggests a mechanism by which you

interrupt the cascade of intracellular injury caused by acute

anoxia under hyperbaric condions at 2.0 ata 100% medical

oxygen.[2]

In the worldwide literature we know that Japan has been using

hyperbaric ambulances since the 1970s. In Japan, if you call 911

and may have a heart or brain related emergency, EMS will arrive

in a hyperbaric ambulance to minimize the loss of heart and brain

ssue.[3]

Oxygen under pressure provides physiological benets that are

not present when a paent is breathing oxygen under

atmospheric pressure condions. HBOT creates oxygen radicals in

a hyperoxic environment and triggers healing mechanisms

including acute arrest of the cascade of intracellular injury,

release of stem cells, induced healing, bacteriostac eects, and

modicaon of gene expression.

All physicians should get to know the benets of hyperbaric

oxygen therapy.[4]

REFERENCES

1. Membership Newsleer of the Undersea & Hyperbaric Medical Society

(UHMS ). Stroke Ambulance in Development. Pressure: 23. Nov/Dec 2013.

2. Mathieu D et al. Hyperbaric oxygenaon in acute ischemic encephalopathy

(near-hanging). Eur J Neurol 7(Suppl3);151.

3. Discussed at the Third Internaonal Symposium for Hyperbaric Oxygen

Therapy in 2003, Fort Lauderdale, Fla.

4. Henricks C. HBOT acvates healing mechanisms. Sombrero Feb 2014.

AMA: Prevent diabetesbefore it startsGiven that 86 million Americans have pre-diabetes, you likely

have paents with this common but treatable condion.

To help these paents and improve outcomes for your pracce,

you can refer people who have prediabetes to an evidence-based

diabetes prevenon program at the YMCA of Southern Arizona.

This program can have a posive impact on paents, providers,

and communies such as ours seeking to reduce the incidence of

type 2 diabetes.

In the Tucson area, a grant covers the cost for people over age 65

with pre-diabetes to aend the YMCAs Diabetes Prevenon

Program. Adults under 65 who have pre-diabetes can sll

parcipate by paying out-of-pocket or by having a health plan

that covers parcipaon.

The YMCAs Diabetes Prevenon Program is based on the Centers

for Disease Control and Prevenons Naonal Diabetes

Prevenon Program. AMA and the YMCA of the USA are

collaborang to increase the number of Medicare parcipants in

the YMCAs Diabetes Prevenon Program. Addionally, YMCA of

the USA is parcipang in a Center for Medicare & Medicaid

Innovaon grant that pays for at-risk people older than 65 to

aend its diabetes prevenon program in 17 communies across

the country, including Tucson and Phoenix.

Physician referral tools

While physician pracces can already refer paents with pre-

diabetes to the YMCAs Diabetes Prevenon Program, AMA isseeking to enhance a referral process that works well across

dierent types of pracces. It has created tools to:

Increase educaon and awareness of pre-diabetes by

promong physician screening of those at risk.

Increase physician referrals of people with prediabetes to the

diabetes prevenon program oered by the YMCA.

Create a feedback loop linking the paents progress in the

program to the physicians pracce so that informaon can be

integrated into the paents care plan.

These easy-to-use tools, created as part of a pilot project with

physician pracces in Delaware, Indianapolis and Minneapolis/St.



Paul, are available to physician pracces at no cost and can be

adapted to meet a pracces specic needs. Check out and

download the tools at ama-assn.org/go/prediabetes, and/or contact

Janet Williams at [email protected] to receive them.

AMA is also engaging insurers to collaborate on strategies for

expanded coverage of evidence-based services shown to prevent

type 2 diabetes, including services delivered through YMCA.

YMCAs Diabetes Prevenon Program

This program is a one-year, community-based program led by atrained lifestyle coach. Parcipants and the coach gather in a

relaxed classroom seng, at a local YMCA or elsewhere in the

community, and work together in small groups for 16 weekly

sessions, then eight monthly sessions to incorporate healthier

eang and moderate physical acvity into their daily lives.

The program is based on research funded by the Naonal

Instutes of Health and published in the New England Journal of

Medicinein 2002. The research showed that among people with

pre-diabetes who enrolled in a diabetes prevenon program,

there was a 58 percent reducon in the total number of new

diabetes cases, and a 71 percent reducon in new cases among

those 60 or older.

Reserve Corps works oncivilian casualty caretraining, moreMedical Reserve Corps of Southern Arizona reports that it has

undertaken threesignicant projects this summer:

The MRCSA Nurses Task Force, together with Tucson Electric

Power, will host a high-level Emergency Power Outage Roundtable

on Friday Sept. 19, bringing together key stakeholders to discuss

the funconal and access needs of community members who arehomebound or have condions requiring durable medical

equipment during an extended power outage.

Parcipang organizaons will be asked to summarizetheir

current emergency plans that address needs of the target

populaon during a power outage of more than three days.

Similaries and gaps will be idened and next steps will be

proposed. Those interested in aending the roundtable should

contact MRC for more informaon or to join up: 520.445.7035;

e-mail [email protected].

Emergency Civilian Casualty Care (E3C) training, established in

February of this year, has provided life-saving instrucon to more

than 300 medical professionals, business leaders, security

personnel and students.

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

training, E3C is based on the militarys Taccal Combat Casualty

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

saving trauma care including the proper use of tourniquets,

traumac and life-threatening wound treatment, triage, violent

encounters, situaonal awareness and community resilience.

Goals are to train 1,500 people within the rst year, develop a

train-the-trainer program, and enlist a cadre of individuals who

will provide E3C training throughout Southern Arizona.

Individuals interested in becoming a trainer are encouraged to

contact the MRCSA oce at 520.445.7035.

MRCSA is also working to beer address the needs of the

Southern Arizonacommunity through Community Needs

Assessment surveys. Focus is on jointly establishing priories and

planning eorts with Tucson metro hospitals, community clinics

and emergency response agencies.

Surveys are designed to provide a current snapshot of communit

preparedness and awareness of available resources foremergency and disaster response and recovery. MRCSA will use

the informaon it gets to create a volunteer corps of physicians,

nurses, pharmacists, mental health professionals and others

that most eecvely addresses the needs of the community.

Our objecve is to be stronger and beer prepared in the event

of any emergency situaon through an investment in long-term

community resiliency, MRCSA said in a release. Project partners

include University of Arizona Medical Center, Northwest Medical

Center, Tucson Medical Center, Carondelet Medical Group,

Kindred Hospital, Tucson Fire Department, the University of

Arizona College of Nursing, Arizona HOSAFuture Health

Professionals, and Pima County Public Health Nurses.

PCOA: Reach nutrionout to eldersBy Debra Adams

Access to an adequate amount of nutrious food is important for

everyone, but can be even more crical as you age. Good

nutrion plays a crical role in prevenng and managing chronic

condions, maintaining energy levels, aiding in recovery and

promong overall health.

Many physiological and socio-economic factors aect the

nutrional status of our communies elders, leading to foodinsecurity. For some, limitaons on physical mobility interfere with

the independent performance of daily living acvies including

shopping for and preparing healthy, well-balanced meals.

For others, depression and social isolaon lead to inadequate

consumpon of enough calories because many seniors do not eat

regularly when having to dine alone. Sll others cannot aord to

buy nutrious food because they live on very limited xed

incomes. If not addressed, these factors can lead to poor health

and eventual loss of independence.

Every three years Pima Council On Aging conducts a Community

Needs Assessment to idenfy the needs and concerns of Pima

Countys older adults. Preparing nutrious meals moved into the

top eight serious problems for the rst me in the 2012

Community Survey. In prior years this problem has been noted as

a serious concern for survey respondents 85+ years of age, but

has now been idened as a serious problem for all 60+ age

groups combined.

PCOAs Nutrion Program for the Elderly, and its component

services of Congregate Meals and Home-Delivered Meals, has for

the last 34 years been a reliable source for nutrious, prepared

meals for many of Pima Countys older adults. These programs



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decrease social isolaon and assist many frail older adults in

remaining safely and comfortably in their own homes.

Ten Congregate Meal Centers in Tucson have been strategically

placed to be accessible to older individuals across the community,

while also targeng the most vulnerablethose in greatest

economic need, minority elders, and individuals with limited

means for transportaon. The City of Tucson Parks & Recreaon

Dept. administers programs at Armory Park, Archer, Donna Liggins,

William Clements, Freedom and El Rio centers. The Tucson Urban

League operates at the Quincie Douglas Neighborhood Center.Catholic Social Services administers sites at El Pueblo

Neighborhood Center, Flowing Wells/Ellie Towne Neighborhood

Center and the Eastside/El Dorado Center. Three addional sites

are available in Robles Ranch, Ajo, and Green Valley.

For those who are unable to aend a Congregate Meal site, PCOA

contracts with two agencies to deliver nutrious, prepared

home-delivered meals throughout the metropolitan Tucson area

and select areas of Pima County.

Both the Congregate and Home-Delivered Meals meet one third

of the Daily Reference Intake. Meals are provided on a donaon

basis with individuals contribung what they can aord toward

the cost of the meal.

Of the 1,237 nutrion program parcipants who completed the

program evaluaon survey in FY 13-14, 90 percent stated that the

meals helped them maintain their health; 88 percent stated that

the meals provided a larger variety of fruits, vegetables and

meats than they would be able to prepare for themselves; and 84

percent stated that meals increased their daily intake of food.

Please help PCOA in reaching out to those older individuals who

nd themselves unable to prepare or access the foods necessary

to maintain good health. Assistance is available. Encourage your

paents to call the PCOA Help Line at (520) 790.7262 or visit

www.pcoa.org.Debra Adams is PCOA chief operang ocer.

PCOA, Carondelet partner

in post-hospital paentsupportCarondelet Health Network reported Aug. 13 that with the goal

of of improving paent care quality and safety, and reducing

hospital readmissions, they are collaborang with Pima Council

On Aging.

The Centers for Medicaid and Medicare Services (CMS)

recognized the Tucson program as a Best Pracce and says this

community-based Care Transions Program is a valuable model

for other communies to consider, CHN reported.

The program focuses on Medicare paents with mulple

chronic illnesses who have been discharged recently from the

hospital. Carondelet nurses and PCOA care coordinators partner

on making regular visits to the homes of these paents, providing

much-needed medical follow-up care and a variety of other kinds

of social support to help the paent manage their recuperaon

and maintain their health aer they leave the hospital.

Weve seen some real success with this program, said CHN CMO

Donald Denmark, M.D. Paents are improving their health

and their well-being simply by receiving the support necessary to

remain healthy and stay out of the hospital.

The program is an outgrowth of the Aordable Care Act, CHN

said. The federal government reached out to healthcare

providers in 2011, challenging them to design programs thatprovide high quality care and cut costs to the overall healthcare

system. Carondelet took up the charge, and in doing so,

recognized that medical care is only part of what paents need

aer they leave the hospital. Carondelet partnered with Pima

Council on Aging, a well-respected organizaon providing

important in-home and community-based services and social

support to older adults and family caregivers.

CHN quoted PCOA President and CEO W. Mark Clark: The Care

Transions Program works because of the unique partnership of

Carondelet nurses and PCOA coaches and navigators. Each of us

brings our medical and social service skills to the focused care of

these paents in their homes, providing medical follow-up and

specic social supports that can improve the health outcome for

the paent. n



Arizona Medical Associaon News

A year at ArMAs megaphoneBy Dr. Thomas C. Rothe

In May I nished my one-year term as Arizona Medical

Associaon president. Fortunately, it was an easy year for

healthcare in Arizona, as Gov. Jan Brewer got the Medicaid

expansion passed in early 2013.

Legislators were so burned out by the prolonged ght over this

issue that they had lile energy le for anything related to

healthcare. As such, I was able to escape frequent trips to

Phoenix since the skirmishes were few!

ArMA has a threefold mission: paent advocacy, physician

advocacy, and scope of pracce oversight. This year ArMA has

stepped up to protect paents from non-physicians purporng to

deliver healthcare services (non-nurse mid-wives wanng to do

VBACs at home, psychologists requesng prescribing privileges,

chiropractors asking to deliver hormone therapy, etc.) I would not

call this turf protecon as some do.

ArMA follows more than 175 bills each year introduced into the

Arizona Legislature, and prides itself, and is widely respected for,

making sure we separate fact from opinion: legislators know if we

give them a fact, even if they do not agree with our opinion, the

fact has been veed and is reliable. Our credibility is surpassed by

no one at the Capitol, and our support is considered essenal

when it comes to healthcare and physician services. The governor

and sta are in close

communicaon

with ArMA as the

voice of physicians.

They know

polically we candrive an issue, and

we speak with

credibility and

honesty.

In addion, your

state medical society

has worked closely

with the Mutual

Insurance Company

of Arizona (MICA)

to cut down on

frivolous lawsuits.This has resulted

in stabilizaon,

and rebates in

malpracce

insurancepremiums.

Likewise, ArMA

works to protect

these reforms and

diligently watches

for legal-system end-

runs around them.

The biggest frustraon of my ArMA tenure was going to

Washington, D.C. to ght for the permanent repeal of the SGR, onlyto have it postponed once again. In both the House and Senate,

Republicans and Democrats overwhelmingly agreed that this

problem should be xed. Docs from all backgrounds and the AMA

vigorously fought for this, but legislators said they could not comeup with a way to pay for it. The take-home message is crystal clear:

naonal policians do not care about physician interests because of

fragmentaon and dierences within the physician community.

They know that, sense that, docs will eventually go along with

whatever legislaon is passed, and frankly would just as soon see

docs ght it out themselves. Their only interest is to maintain

power and give lip-service to everything else.

Statewide is another maer. Like medical care, all polics is local

and the representaves seem to be more interested in physician

opinions, perhaps because it relates specically to their

constuents more directly. Passage of the Medicaid expansion by

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

This was good for both the cizens of Arizona as well as the

physicians. Regardless of your polical feelings on this maer,

having money to pay for medical care for those who need it most

is paramount to a healthy and more producve Arizona.

Dr. Rothe, a PCMS past-president and member since 1982,

pracces with La Cholla Family Pracce.

Annual ArMA meeng reportBy Bill Fearneyhough

PCMS Execuve Director

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

conversaons as delegates from across the state gathered in

Phoenix May 30 and June 1 for the Arizona Medical Associaons

annual meeng.

Along with elecon of new ocers and general business,

delegates had a full agenda of resoluons to discuss, including

two divisive proposals for establishment of a single-payer

healthcare insurance system, and a moratorium on the

medicalizaon of capital punishment.

As in the past PCMS was well represented. Aending were PCMS

President Timothy Marshall, M.D., and PCMS Board members

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



doctors Timothy Fagan, Screven Farmer, Gary Figge, Michael

Hamant, William Mangold, and Thomas Rothe. Doctors Richard

Dale and Thomas Hicks also aended. Doctors Farmer, Figge, and

Hicks served on the Reports and Resoluons Commiees.

Presidents Address

Fridays aernoon session saw Immediate Past-President Thomas

Rothe, M.D. introduce Dr. Je Mueller as the 123rdArMA

President. Dr. Mueller is Associate Dean of Hospital Pracce for

Mayo Clinics 23 hospitals, and medical director and a sta

anesthesiologist at Mayo Clinic Hospital, Phoenix.

Dr. Mueller spoke on the numerous challenges facing physicians,

including increased hospital, clinic and physician group

consolidaons; increasing pracce administrave costs; new

payment models; the polically-driven substuon of non-

physicians for physicians; and the ever-increasing reducons in

reimbursement as demand for healthcare services escalate.

To answer these challenges and more eecvely use ArMA

resources, Dr. Mueller said the associaon should focus more on

state-based advocacy, called for physicians to acvely seek and

assume formal leadership posions within hospitals and health

systems, and recommended that the state organizaon more

closely coordinate its advocacy acvies with county and statespecialty sociees. Currently ArMA leadership meets with these

sociees once a year, but Dr. Mueller suggested meengs be held

at least twice a year to discuss how all could work together more

eciently and eecvely on behalf of Arizona physicians.

Elecons

Tucson family praconer Timothy Fagan, M.D. was voted AMA

Alternate Delegate and connues to serve as a PCMS Director;

Michael Hamant, M.D. was elected ArMA Secretary; Screven

Farmer, M.D. will serve as At-Large Director and Thomas Hicks,

M.D. as a delegate to AMA. Dr. Timothy Marshall was elected

PCMS Director, replacing Dr. Charles Katzenberg who resigned the

post earlier in the year. All join fellow ArMA Board membersdoctors Gary Figge, William Mangold, and Thomas Rothe.

Resoluons

The House of Delegates debated a multude of signicant

resoluons. Uncharacteriscally, PCMS sponsored a single

resoluon, dealing with GME funding.

Resoluons receiving delegate support:

Transferral of authority to establish membership dues from

the ArMA House to the ArMA Board of Directors.

Join with the University of Arizonas Valley Fever Center for

Excellence, public health departments, and other organizaons

to promote coccidioidomycosis awareness and/or acvely seek

funding resources for cocci awareness and educaon. Support increased GME funding in Arizona and oppose

funding cuts. The PCMS Board-approved resoluon was adopted

from a posion paper submied by PCMS Board student

members Jamie Fleming and Jerey Brown.

Propose that AMA peon the U.S. government and the

Naonal Instute of Health (NIH) requiring publicaon of all NIH-

Naonal Center for Complementary and Alternave Medicine-

funded studies without regard to results. ArMA would also

propose to AMA and the Associaon of American Medical

Colleges that medical student educaon be limited to sciencally

sound medical pracce that adheres to evidence-based physics,

chemistry, pharmacology, and biology. It also ca

Documents

Aug-Sept 2014 Sombrero