Aug-Sept 2014 Sombrero

Sombrero
Pima County Medical Society

Home Medical Society of the 17th United States Surgeon-General
AUGUST/SEPTEMBER 2014
The war on doctors

Banner to acquire UAHN
Tenet to acquire Ascension/CHN
Arizona: Grape
Canyon State
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SOMBRERO August/September 2014
Sombrero
Pima County Medical
Society Officers
Official Publication of the Pima County Medical Society
Michael Connolly, DO
Michael Dean, MD
Howard Eisenberg, MD
Afshin Emami, MD
Randall Fehr, MD
Alton Hallum, MD
Evan Kligman, MD
Kevin Moynahan, MD
Soheila Nouri, MD
Wayne Peate, MD
Scott Weiss, MD
Leslie Willingham, MD
Gustavo Ortega, MD (Resident)
Snehal Patel, DO (Resident)
Joanna Holstein, DO (Resident)
Jeffrey Brown (Student)
Jamie Fleming (Student)
President
Timothy Marshall, MD
President-Elect
Melissa Levine, MD
Vice President
Steve Cohen, MD
Secretary-Treasurer
Guruprasad Raju, MD
Past-President
Charles Katzenberg, MD
PCMS Board of Directors

Eric Barrett, MD
Diana Benenati, MD
Neil Clements, MD
Executive Director
Bill Fearneyhough
Phone: 795-7985
Fax: 323-9559
E-mail: billf 5199@gmail.com
Editor
Stuart Faxon
Phone: 883-0408
E-mail: tjjackal@comcast.net
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Members at Large
Vol. 47 No. 7
At Large ArMA Board
R. Screven Farmer, MD
Donald Green, MD
Veronica Pimienta, MD
Pima Directors to ArMA

Timothy C. Fagan, MD
Timothy Marshall, MD
Board of Mediation
Timothy Fagan, MD
Thomas Griffin, MD
George Makol, MD
Mark Mecikalski, MD
Edward Schwager, MD
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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
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Inside
5 Letters: Drug war is really pain patient war.
6 Dr. Timothy Marshall: Our president knows
when enough enforcement becomes too
much.
8 Milestones: Recognitions and achievements

of our members.
Sombrero
Home Medical Society of the 17th United States Surgeon-General
AUGUST/SEPTEMBER 2014
The war on doctors

Banner to acquire UAHN
Tenet to acquire Ascension/CHN
Arizona: Grape
Canyon State
12 Mix At Six: Members and student members

meet informally.
14 Behind the Lens: Dr. Hal Tretbar and
Dorothy tour and sample Arizona wineries

and wines.
17 PCMS News: If rising healthcare costs never

hit a ceiling, will big local healthcare
organization buyouts change anything?
24 Arizona Medical Association News: Dr. Tom
Rothes year as ArMA president, plus annual

meeting report.
26 CME: Pima County Medical Foundation has

your most-local credits.
On the Cover
Sonoita Vineyards and Winery south of Elgin, founded by Gordon
Dutt in 1983, began statewide development of Arizona as a
locale for quality wineries and product. Gordon is still active in
management. For your virtual tour of the Grape Canyon State,
see this issues Behind the Lens (Dr. Hal Tretbar photo).
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4
Leers
Pain patients casualties

of War on Drugs
To the Editor:
The actions of the Drug Enforcement Administration to eliminate
diversion of Oxycodone is working to decrease its legitimate
manufacture and availability in pharmacies. It has become difficult
for patients to fill their prescriptions for appropriate use as well as
for the one to two percent who dont use them appropriately.
Patients have been forced to go to multiple pharmacies because
of the limited supply. They are often turned away by pharmacists
who are fearful to dispense, having been intimidated by the DEA.
Often their poorly substantiated rationale is the patient does not
fit their good faith dispensing profile.
The paradox is that Oxycodone is affordable (covered by AHCCCS),
an effective pain reliever with few side effects,* but at the same
time the easily crushable favorite of abusers. Besides, not being
able to obtain a medication which may have worked well for
them to increase their function in the past, patients face
prejudice from poorly informed friends, families, and health
professionals. All this adds to the chronic pain and disability
which brought them to seek treatment in the first place.
There is also the irony that government actions have doubled
the street price of Oxycodone. Overdoses seen in our ERs are
now more frequently from black tar heroin. The profit for the
black market has also been aided by the threats and actions that
have frightened off medically licensed competitors who might
consider prescribing.
interest, in a community watch to identify those who are

misusing these medications, so that they may either be treated
for their problems or eliminated from their unintended
consequence of their actions that upend prescribers practices.
Developing better approaches to these issues of prescription and
non-prescription medication and drug abuse, decreasing the
need for and expense of more prisons for patients and nonpatients (and for more Suburbans for those who fight the war),
depends on evolution of public understanding and our law. The
issues for education include:
That these medications provide legitimate pain relief to many
who have a legal right to access to them via the Americans
With Disabilities Act;
that misuse becomes less socially acceptable and tolerated by
a society that is willing to recognize regulated access to
medication and treatment;
and that physicians are in the best position and have a
responsibility to lead this process.
*Oxycontin is costly and its new non-crushable formulation is
difficult for many to digest. Continent or Morphine ER causes
intolerable side effects for many. The Fentanyl Patch causes
irritation for many and is costly as is the long-acting Hydrocodone.
Affordable Methadone has the potential for arrythmias as well as
other undesirable features especially when used in combination
with other opiates.
Sincerely,
David A. Ruben, M.D., M.B.A.
Dr. Ruben is a diplomate in adult and child psychiatry, addiction,
and pain medicine. He writes and speaks on issues of medical
practice and consults with lawyers and doctors on regulatory
interactions. He can be reached at meds2016@aol.com
n
These actions have been effective strategies to create negative

publicity and misinformation for not only the medical professions,
but for politicians and the public. The often-quoted statistic, that
anyone who dies and has an opiate in their blood is counted as a
opiate death no matter what other disease they may have or
medications they may take, fuels the fire with scientific
misinformation.
The visibility and sometimes budgets of state medical boards, the
Justice Department, local police, the militarized border patrol,
the prison industry, and the courts have increased. This is a
reflection of political and public sentiment that patients on drugs
must be abusers and physicians who prescribe them drug
pushers. Both are seen as making a profit and being a threat to
taxpayers who feel, I dont need those drugs, why do they?
Maricopa County Sheriff Joe Arpaio, on the other hand, has been
reported to sayand which was reported to be echoed by Pima
County Attorney Barbara LaWallthat we need prescribed
medication for pain patients or theyll become their clients.
We advise our patients to act to protect their legitimate access to
the appropriate use of prescribed controlled medications. They
are the real victims of these confused policies. We suggest first,
that they call on their federal representatives to re-examine DEAs
marching orders and state licensing boards. Second, that they
explain that they are not diverters or addicts, but rather that
controlled medication allows them to better function. Third, that
they record their experiences at pharmacies and with physicians
and complain when they are treated with prejudice and
disrespect. Fourth, that they participate, in their own selfSOMBRERO August/September 2014
Suttons Law and the war against doctors

By Timothy Marshall, M.D.
PCMS President
hy is it that every time I

order home oxygen for a
patient I need to sign a form
that threatens me with criminal
liability? Can I actually go to jail
for prescribing someone oxygen?
It seems the answer is yes.
When asked why he robbed
banks, bank robber Willie Sutton replied, Because thats where
the money is. Federal attorneys are aggressively prosecuting
physicians for the same reason. They think thats where the
money is. My argument is that only part of the solution to the
high cost of healthcare lies with preventing fraud. The fact that
this administration does nothing to allow tort reform, has
reduced the burden of proof necessary to convict physicians for
fraud, while piling on regulations, the burden of EHR, ICD 10,
PQRI, it all amounts to a war against physicians.
According to the FBI, Rooting out healthcare fraud is central to
the well-being of both our citizens and the overall economy.
Healthcare fraud costs the country an estimated $80 billion a
year. And its a rising threat, with national healthcare spending
topping $2.7 trillion and expenses continuing to outpace
inflation. Recent cases also show that medical professionals are
more willing to risk patient harm in their schemes. [FBI.gov] The
governments healthcare fraud prevention and enforcement
efforts recovered a record $4.2 billion in taxpayer dollars in Fiscal
Year 2012. This is a result of President Obama making the
elimination of fraud, waste, and abuse, particularly in healthcare,
a top priority for the administration.1
Im sure all physicians would agree with prosecuting cases of
actual premeditated fraud, such as performing bypass graft
surgery in the absence of coronary disease, or providing home
healthcare for patients who dont exist, is very reasonable and
necessary. We do not, however, want to be persecuted, or
prosecuted, for practicing medicine to the best of our ability in
good faith.
After researching this article I have discovered that any of us
could be jailed for a coding error! Congress has created new
crimes specifically addressing healthcare fraud. Under this
statute, any healthcare provider who presents a false or fictitious
claim or demand to the government, seeking reimbursement for
medical goods or services, can be liable. The long-standing
requirement of proof of criminal intent in connection with the
federal prosecution of physicians has been eliminated. The False
Claims Act may be applied to physicians providing services that
were not provided, or were not medically necessary. The
punishment for a criminal conviction under the act is up to five
years imprisonment and a fine of $250,000.00 for each
infraction. Civil penalties can be up to $11,000 per incident, plus
three times the amount claimed.
A continuing example is the case of Dr. John Natale, a cardiovascular
surgeon who spent 10 months in a federal prison even though
the jury found him not guilty on all fraud charges. But he was
6
convicted on two counts of making false statements in his

operative reports. The term false statement suggests a
deliberate lie, but it could be a simple mistake. The prosecutor
does not need to prove that a doctor knowingly and willfully
lied in order to pad his fee, but only to show that an incorrect
AMA code or incorrect description to an incorrect AMA code was
used and that the doctor intended to get paid for his work. The
implications of the case are profound, the judge noted: Any error
in any medical record related to a health program could be a
federal crime. And just when you think coding errors are getting a
little out of hand, the government imposes ICD 10.
Are there other ways to save money in healthcare? Lets look at
malpractice reform and defensive medicine. Defensive medicine
refers to the practice of recommending a diagnostic test or
treatment that mainly serves to protect the physician against the
patient as potential plaintiff. Defensive medicine is said to be a
reaction to the rising costs of malpractice insurance premiums. I
dont practice defensive medicine because my insurance
premiums rise. I practice defensive medicine because one lawsuit
could erase 30 years of hard work, take away all my assets, my
home, and my future.
As youd expect, the medical literature and the trial lawyers have
a very different take on the extent of defensive medicine. Clearly
accurate measurement of defensive medicine is extremely
difficult. A survey of 300 physicians found that more than 76
percent of the physicians responded that malpractice litigation
had hurt their ability to provide quality care to patients. Because
of their fear of the excesses of the litigation system:
79 percent said they had ordered more tests than they would
have based only on professional judgment.
74 percent had referred patients to specialists more often
than they believed was medically necessary.
51 percent had recommended invasive procedures such as
biopsies to confirm diagnoses more often than they believed
were medically necessary.
41 percent said they had prescribed more medications, such
as antibiotics, than they would have based only on their
professional judgment, and 73 percent had noticed other
doctors prescribing medications similarly.
The American Association for Justice (Formerly Association of
Trial Lawyers of America) not surprisingly has a different opinion:
To the extent that defensive medicine does exist, research has
found that the motivation behind it is not liability but rather a
desire to simply help a patient or, in some cases, boost physician
income. One government agency found that doctors chose not to
order any tests or diagnostic procedures 95 percent of the time.
Doctors who ordered tests almost always did so because of
medical indications, and only one half of one percent of all cases
involved doctors who ordered tests due solely to medical
negligence concerns. Of all the diagnostic tests I order here in
Tucson that I would not have done in Canada, I can tell you its far
greater than half of one percent! In my opinion the lawyers
assertion is ludicrous.
How much does defensive medicine cost? Not surprisingly, the

true cost of defensive medicine is hard to discern. Kessler and
McClellan noted that limits on noneconomic damage awards,
such as those California has had in effect for 25 years, can reduce
healthcare costs by between 5 percent and 9 percent without
substantial effects on mortality or medical complications.
Applying non-economic damage limits to the country as a whole,
with its national healthcare expenditure of $1.4 trillion, would
reduce healthcare costs by as much as $126 billion, and reduce
the federal governments share of such costs by as much as $50
billion, according to McClellans 2003 estimate. Imagine what we
could save based upon more recent healthcare expense
estimates. These cost savings would be dwarfed by what we could
actually achieve by removing defensive medicine altogether.
So it would stand to reason that if you want to reduce healthcare
cost, all aspects would be implemented, not just those that
protect your election donors. The criminalization of medicine has
to be stopped. The governments burden of proof requirement of
criminal intent must be reinstituted. Criminalizing speech,
without requiring proof of intent to defraud, creates a new risk of
imprisonment for anyone who is less than perfect in what he or
she documents or codes.
Some of these financial numbers and references may be old, but
are useful for illustration. The more I researched for this article, the
more I felt as Hamlet, besieged by the slings and arrows of our
outrageous government, justice system, and malpractice attorneys.
The war on physicians is fully underway on many levels. Watch
your coding!
REFERENCES
1.U.S. Department of Justice. Departments of Justice and Health and Human
Services Announce Record-Breaking Recoveries Resulting from Joint Efforts to
Combat Health Care Fraud, Department of Justice. Office of Public Affairs, Feb 11,
2013.
2.Hellinger FJ, Encinosa WE. The Impact of State Laws Limiting Malpractice
Damage Awards on Health Care Expenditures. Am J Public Health 2006
Aug;96(8):1375-81.
3.Kessler D, McClellan M. Do Doctors Practice Defensive Medicine? Quarterly
Journal of Economics 1996; 111(2): 353-390.
4.Studdert DM, Mello MM, Sage WM, et al. Defensive medicine among highrisk specialist physicians in a volatile malpractice environment. JAMA 2005 Jun
1;293(21):2609-17.
5.U.S Congress, Congressional Budget Office, The Economics of U.S. Tort
Liability: A Primer. Washington, DC: US Government Printing Office Oct 2003.
6.U.S Congress, Congressional Budget Office, Medical Malpractice Tort Limits
and Health Care Spending. Washington, DC: US Government Printing Office, April
2006.
7.The Factors Fueling Rising Healthcare Costs. Prepared for Americas Health
Insurance Plans. Price Waterhouse Cooper, Americas Health Insurance Plans, 2006.
8.U.S. Department of Justice. Departments of Justice and Health and Human
Services Announce Record-Breaking Recoveries Resulting from Joint Efforts to
Combat Health Care Fraud. Office of Public Affairs, Feb 11, 2013.
9.Hellinger FJ, Encinosa, WE. The Impact of State Laws Limiting Malpractice
Damage Awards on Health Care Expenditures. Am J Public Health 2006
Aug;96(8):1375-81.
10.Kessler D. McClellan M. Do Doctors Practice Defensive Medicine? Quarterly
Journal of Economics 1996; 111(2): 353-390.
11.Studdert DM, Mello MM, Sage WM, et al. Defensive medicine among highrisk specialist physicians in a volatile malpractice environment. JAMA 2005 Jun
1;293(21):2609-17.
12.U.S Congress, Congressional Budget Office, The Economics of U.S. Tort
Liability: A Primer. Washington, DC: US Government Printing Office Oct 2003.
13.U.S Congress, Congressional Budget Office, Medical Malpractice Tort Limits and
Health Care Spending. Washington, DC: US Government Printing Office, April 2006.
14.The Factors Fueling Rising Healthcare Costs. Prepared for Americas Health
Insurance Plans, Price Waterhouse Cooper. Americas Health Insurance Plans, 2006. n
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7
Milestones
Dr. Lavor retires

Dear friends and colleagues,
Dr. Michael Lavor wrote in
July, it is with mixed
emotions that I write to tell
you of my future plans.
After more than 23 years as a
surgeon, I will be retiring from
active surgical practice. I will,
however, be continuing as
Saguaro Surgicals medical
director. In addition, I will be
continuing as medical director
at The Wound Center where,
through state-ofthe-art
treatments, we remain available to provide specialized therapy
for chronic or non-healing wounds.
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
certified.
Dr. Elliott 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 Education Partners at Spectrum Health and Mercy
Health hospitals.
She has a special interest in complex hernia repair and advanced
laparoscopy including inguinal and ventral hernia repair, antirefulx procedures, hiatal and paraesophageal hernis repair,
splenectomy, adrenalectomy, and colectomy.
Physiatry Associates
adds Dr. Lipson
First and foremost, I want to assure you that each member of

the Saguaro Surgical medical team remains strong, committed
to excellence, and able to offer your patients the full range of
general and vascular surgical services youve come to expect.
Physiatry Associates, Ltd.

Recently announced that the
practice is pleased to have
added Nancy Lipson, M.D.
In a few weeks Saguaro

Surgical welcomes the newest
general surgeon to our team,
Dawn Elliott, M.D., a native of
Arizona who received her M.D.
at The University of Arizona.
Dr. Elliott, along with Saguaro
Surgicals four other surgeons,
will continue to meet all the
surgical needs of your patients.
She joins Charles Blake, M.D.,

John Larson, M.D., and
Michael Goodman, D.O. at the
practice at 2102 N. Country
Club Rd. Building B.
Our staff remains committed to

assisting your office and making
certain you receive detailed
updates on each patient you trust to our care. As medical director I
will focus not only on assuring our high medical standards are
maintained, but also that all of the latest technologies and services
are available here for you and your patients.
I have valued our relationship as medical colleagues and feel
both fortunate and grateful to have had the opportunity to
meet your patients surgical needs over the years. I sincerely
hope you will develop new and strong relationships with my
colleagues at Saguaro Surgical, allowing us to continue to
provide general and vascular surgical care for your patients
even after I step back from my role as a surgeon.
Although I will, obviously, remain active in our community, my
retirement from active practice as a surgeon is something to be
noted and for my wife, Irene, and mesomething to celebrate.
Sincerely,
Michael Lavor, M.D., Saguaro Surgical
8
Dr. Lipson graduated from

Wayne State University School
of Medicine in Detroit, and
completed her PM&R residency
at The Ohio State University. She practiced for 25 years in
Indianapolis, Ind. before moving to Tucson in June 2014.
Dr. Lipson has expertise in all areas of general rehabilitation, and
is subspecialty board-certified in Spinal Cord Injury Medicine. She
is currently accepting new patients.
Chicanos Por La Causa honors

Dr. 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
residency at Cedars Sinai

Medical Center, he was a
Senior Fellow in Health Care
Studies at Pacific Research
Institute, and president of the
Docs4PatientCare California
Chapter. He has completed a
Graduate Health Policy
Fellowship at the Heritage
Foundation.
Southern Arizona Dinner celebration, The Art of Being a

Woman.
An internationally recognized oncologist, Dr. Lpezs work focuses
on patient-centered care of women with cancer that includes the
family and community, and on enhancing equity and access to
healthcare through innovative technology. She also is a leader in
addressing disparities and diversity in the health professions. She is
a principal investigator for several breast and ovarian cancer clinical
trials focused on quality-of-life care and innovative treatments.
A native of La Paz, Bolivia, she holds a bachelors degree in
philosophy from Bryn Mawr (Pa.) College; a medical degree from
Jefferson Medical College, Philadelphia; and a masters in public
health with a concentration in health administration and policy
from the UA Mel and Enid Zuckerman College of Public Health.
In addition to these pages his

work has appeared in
theWashington
Examiner,Arizona
Republic,National Review Online, andThe 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.
Dr. Doraiswamy joins UA

College of Medicine
Carondelet St. Marys,

St. Josephs awarded
for stroke care
Dr. Vijay A. Doraiswamy, a

resident member of PCMS, is
one of the UofA Cardiology
Fellows preparing for the next
phase of their careers, the
university reports.
In June UofA Sarver Heart
Center celebrated graduation
of five Fellows from the
Cardiovascular Medicine
Fellowship
TINNITU
S
Program,
and two
from the
Interventional Cardiology Fellowship
TINNITUS
Program. Dr. Doraiswamy is joining the UA
BUZZING
College of Medicine, Division of Cardiology
as an assistant professor, primarily practicing
HUMM
at UA Medical CenterSouth Campus.
Being honored for providing excellent care is the best

recognition a hospital can get, Carondelet Health Network says,
and Carondelets Tucson hospitals continue to receive valuable
recognition each year from the American Heart Association/
American Stroke Association.
BUZZING
RING
BUZZ
RING
Dr. Fodeman 2014

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

Fodeman is a board-certified IM physician
and currently an Assistant Professor of
Medicine at The University of Arizona, and
medical director of the University of Arizona
Medical Center Home Health.
We are preferred providers

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He previously studied as an adjunct scholar

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6969 E Sunrise Dr, Ste 203 Tucson
520.648.3277
512 E Whitehouse Canyon Rd, Ste 196

Green Valley
Janis Gasch, Au.D.
Doctor of Audiology, Founding Director
9
The Get With The Guidelines Stroke Gold Plus Quality

Achievement Award was recently bestowed on St. Marys
Hospital for the third consecutive year, and St. Josephs Hospital,
home of Carondelet Neurological Institute, for the fourth
consecutive year.
The two hospitals, both Joint Commission-certified Primary Stroke
Centers, also earned the Target: Stroke Honor Roll Award for the
third consecutive year. Both awards are historically given to the
highest performing Stroke Centers in the country. These awards
recognize Carondelet hospitals commitment to exceptional care
for their stroke patients by the adherence to the latest evidencebased guidelines based on the latest scientific research.
Guidelines were established by AHA/ASA in 2003 and were
designed to improve stroke care by promoting consistent
adherence to the latest scientific treatment guidelines,
according to AHA/ASA. Participating hospitals enroll in the
program and submit data through a Web-based Patient
Management Tool provided by AHA/ASA, which is then
evaluated to determine both the hospitals baseline and
improvements. Hospitals receive these quality awards based on
adherence to the quality metrics for a designated time.
Carondelet Tucson hospitals have received the Gold Plus and
Target Stroke Honor Roll recognition for their ongoing focus on
quality stroke care.
College of Medicine
welcomes 2018 class
days of community-building activities beginning July 30, the

university reported. One hundred fifteen students began three
days of orientation on their four-year, hands-on training
commitment to learn leading-edge patient care under the
mentorship of distinguished clinician-educators at the University
of Arizona College of 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 inclusion
and professor of psychiatry; and Kevin Moynahan, M.D., deputy
dean for education, director of the UA College of Medicine
Tucson Societies Program and associate professor of medicine.
Included was a community service-learning day, during which
the medical students will volunteer with local community
organizations to build a sense of community and to gain an
understanding of some of the social issues the Tucson
community faces.
The goal of orientation the university says, is to develop a
sense of professional identity, community and collegiality among
a diverse group of future physicians. The College of Medicine
Tucson Class of 2018 includes 33 students who graduated from
the UA, 40 percent of the students are Arizona residents, 25 hold
graduate or professional degrees, a little more than half are
female and two are student-veterans.
n
The University of Arizona College of MedicineTucson welcomed

its newest class of medical students with free iPads and three-
10
11
Mix At Six
By Dennis Carey
Society welcomes students, interns at Mix

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

Country Clubs 19 th Hole, with former PCMS and ArMA
President Thomas, Rothe, M.D., serving as host.
Society members welcomed several medical students and interns

to the local medical community, providing an opportunity for
them to meet practicing physicians and other students in an
informal setting.
Students and interns have been very enthusiastic about the Mix
At Six events, PCMS Executive Director Bill Fearneyhough said.

Its a great opportunity for them to network with colleagues and
introduce themselves to practicing physicians. We look forward to
their participation in the Society, and in the medical community.
More Mix At Sixes will be given throughout the year. Watch for
notifices of coming events here in Sombrero, on the Society
website pimamedicalsociety.org, and in e-mail. As the clich
goes, be there or be square!
n
New PCMS student members Sean

Behan, Edwin Telemei and Jack Rusing
enjoy their first Mix At Six social.
Dr. Basil Skeif and his wife,

Allison, and Dr. Ken Sandock enjoy
refreshments and conversation in
Mix At Sixs relaxed atmosphere.
Dr. Steve Cohen and med student Jeff
Brown fill out nametags at the mix.
Former PCMS presidents Michael

Hamant, M.D. and Timothy Fagan,
M.D. sample the guacamole and
appetizers while relaxing at La
Paloma Country Clubs 19th Hole.
12
New PCMS student members Pooja Rajguru, Carolyn

Sleeth, Jared Brock and Joelle Wang were among
Mix At Sixs early arrivals.
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13
Behind the Lens
Arizona: Grape Canyon State

By Hal Tretbar, M.D.
rizona is beginning to be
recognized for the fine
wines coming from our
wineries. It all started in the
Sonoita-Elgin area when UofA
professor Gordon Dutt
recognized that soil and
weather conditions were similar to noted French Burgundy
vineyards. More recently excellent vineyards have become
established in Santa Cruz, Cochise, and Graham counties.
Where there are vineyards there are wineries. In the Elgin region
two of the oldtimers, Dutts Sonoita Vineyards (1983) and
Callaghan Vineyards (1990), have had their best served in the
White House on numerous presidential occasions.
Then it was determined that the Verde Valley along lower Oak
Creek south of Sedona near Cornville has the climate and soil
similar to the Rhone region of Southern France. Mediterranean
and Spanish varietals such as Mourverde, Roussanne, Grenache,
Syrah, Viognier, and Connoise now flourish there.
Recently Dorothy and I drove the Verde Valley Wine Trail. If you
start from Sedona, go south 12 miles on 89A and turn left of Page
Springs Road. If you are coming off of Interstate 17, turn west at
exit 293. Go 9 miles to Cornville to reach Page Springs Road, and
3.5 miles in either direction brings you to three of the five
wineries in the Verde Valley. Oak Creek, Javelina Leap, and Page
Springs Cellars are just down the road from each other. Echo
Canyon is near Sedona, while Alcantara is closer to Camp Verde.
I certainly am not a wine connoisseur; maybe a sometime
aficionado. We watched a family friend give up his hobby store
business in Tucson to become a vintner. Robert Bob Webb was
a pioneer in Cochise County when he planted 20 acres of
Cabernet Sauvignon, Merlot, and Riesling, at Kansas Settlement
in1983. This was at the at the
same time Gordon Dutt
started in Santa Cruz County.
Bob built the nice
Mediterranean- style
R.W.Webb Winery on I-10
just east of Tucson. In spite
of quality wines, the winery
failed because of management problems, poor location,
and lack of ambience.
I was in a limited partnership
for Terra Rosa Vineyards,
located a few miles west of
Elgin. We planted 20 acres of
Merlot and other popular
varietals. After four years of
increasing production and
some excellent vintages, we
14
Tasting Room Associate Tim Godin at Page Springs Cellars is

ready to pour a splash of a Rhone Valley-type blend.
were wiped out by Pierce disease, transmitted by the glassywinged leafhopper. As often happens with limited partnerships,
there was insufficient funding to replant.
In spite of aging tastebuds and possibly early anosmia (loss of smell
ability), I still enjoy stopping at tasting rooms to chat with the locals
and sip what they are passionate about. I tend to go with the
whites because my cardiologist said red wine might aggravate an
arrhythmia. I can tell you what appeals to my taste, but I cant
depict it as a Chenin Blanc has been described at Javelina Leap.
There are honeysuckle aromas followed by layers of apple, honey,
mango, and pineapple with hints of butterscotch and lemon curd.
There was activity in the yard next to the Javelina Leap Vineyard
entrance when we stopped by in mid-August.
A forklift was moving large
empty plastic containers and
the driver said, We are about
ready to harvest, and the crush
should be good this year.
At the Javelina Leap tasting room, Annie Jones says that a Zinfandel
would go well with the pizza snack.
Annie Jones was behind the

bar in the tasting room and
gave us the vineyard history
as we tasted several
varietals. Rod, a chef, and
Cynthia Snapp started from
the ground up nine years ago
and have been open for eight
years. They have developed
a number of outstanding
varietals including a pink
Pinot Grigio, Chenin Blanc,
and a Tempranillo. Most of
the grapes are from 20 acres
The Chardonnay was fresh and spirited. It is 100 percent varietal,

combining Chardonnay grapes from both Bonita Springs and
Arizona Stronghold. Dorothy enjoyed the Serrano, the flagship
blend from Page Springs Cellars. This is their 10th year of blending
42 percent Mourvedre, 41 percent Syrah and 17 percent Petite
Sirah, all from Arizona.
The owner, inspiration, driving force, and vintner for the cellars is
Eric Glomski, who comes from a California winemaking
background. He briefly worked at Echo Canyon Winery before a
prime property became available on Oak Creek near Cornville.
The first vines were planted in 2004, and Eric planned to have a
small boutique affair.
In 2007 he partnered with Maynard James Keenan, a well-known
rock singer who came from an Italian winemaking family.
Together that had big plans. They wanted to put the best wines at
a fair price all across the country. They bought the 80-acre Dos
Cabezas vineyard at Kansas Settlement from Don Buel. Don had
expanded the original 20 acres planted by Bob Webb. They
renamed it Arizona Stronghold. Later they added the Bonita
Springs Vineyard 20 miles north of Wilcox. The Stronghold winery
is in Camp Verde and the tasting room is in Cottonwood.
After an intense cross-country tour and advertising campaign,
they were ready to sell in 38 states as well as in Canada, Australia,
and New Zealand. In 2012 Arizona Stronghold produced 12,000
cases of wine.
Danielle and Barry of Gilbert enjoy the cool Page Springs

Cellars Vineyard.
Soon there was a clash of personalities and in the spring of this

year the divorce happened. The Arizona Republic reported on
May 12, 2014 that Keenan would take possession of the
Stronghold vineyard in Kansas Settlement and change the name
in the Verde and Skull valleys.

Javelina Leap has become well known for its
Zinfandels. Their 2012 AZ Zinfandel comes
from their Dragoon Vineyard. The 2012 Estate
Legacy Zinfandel is from the 4.5 acres of
seven-year-old vines outside the front door.
They offer only one blend, made with Arizona
Zinfandel, Merlot, and Petite Sirah.
The Page Springs Cellars tasting room was
busy with a hum of relaxed conversation.
Beyond the sunlit room with its traditional
bar and wine bottle racks was an inviting
alcove. Subdued lighting and soft music
tempts one to sink into a soft leather sofa and
linger over a glass of wine.
We chose to have a Flight that combined both
reds and whites. A Flight gives you a chance to
try four or five of the winerys favorites, usually
all red, white, or specialty. A splash of each can
be sniffed and rolled on the tongue for about $8
to $10. Tim Godin was our very knowledgeable
Tasting Room associate. Some that we chose to
sample were the Rhone style 2011 La Serrana
($26), the 2012 Arizona Chardonnay ($24) and a
red 2012 El Serrano ($32).
The Serrana is a pleasant blend of 75 percent
Viognier and 25 percent Roussanne from the
Stronghold vineyard at Kansas Settlement.
15
The cozy, inviting alcove off the main Page Springs Cellars
tasting room.
Doug and Heidi Ruff of Jacksonville, Fla. took a wine tour

from Sedona. They are beside shady Oak Creek at
Page Springs Cellars.
to the Al Buhl Memorial Vineyard. Glomski would keep the

Arizona Stronghold name and retain the winery.
guy known as Apple Bob Mertis. We are so impressed with it that

we are selling a 2013 Mertis as a desert wine. It is 80 percent apple
and 20 percent pear juice. I sniffed and tasted it not knowing what
to expect. I found it to be attractive, palatable, and not too sweet.
A press release from Arizona Stronghold on May 24, 2014 stated

that Eric Glomski had now gained full control of all Stronghold
activities. He will retain the name, winery, current inventory, and
the Bonita Springs property. He has a five-year contract on key
blocks of Keenans Al Buhl Memorial Vineyard.
As Dorothy and I tasted our Flight at Page Springs Cellars, I asked
Tim Godin what was new. He said they had just released a vintage
that was something different for them. A year ago we agreed to
ferment a few hundred gallons of an apple-pear juice blend for a
Lynn Polonski, M.D.
4021 E. Sunrise Dr.

Ste. 121
Phone: (520) 576-5110
Fax: (520) 529-7165
Before we left Page Springs Cellars we ambled down under a

vine-covered trellis through the vineyards to a lovely picnic deck
beside gently flowing Oak Creek. I chatted with a couple having
lunch. Doug and Heidi Ruff were from Jacksonville, Fla. and were
on a wine tour out of Sedona. Doug said, I like trying new wines.
Im not really into red wines. I really like this white that we bought
here. It is smooth, mellow, and very slightly sweet. It is this one
called Mertis.
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To bolster fiscal sustainability, eliminating persistent shortfalls

and low operating margins currently experienced by UAHN.
PCMS News
Sellout Summer?
Buyout Binge?
Within a month of each other, two large local healthcare
organizations, that reportedly lost more than $30 million each
last year, made agreements to be fully or partly bought.
In June, University of Arizona Health Network and Banner Health
entered what they called a long-term agreement.
In July, Ascension (formerly Ascension Health) and Carondelet
Health Network signed a letter of intent to form a partnership
with Tenet Healthcare and Dignity Health, exploring a joint
venture that would aquire Carondelet.
UAHN, Banner
In announcing the move, UAHN and Phoenix-based Banner
Health called it an historic effort to create a statewide
organization to transform and advance healthcare in Arizona.
The university press release called plans a comprehensive new
model for academic medicine. This ground-breaking agreement
will formalize discussions and is intended to lead to final
definitive agreements sometime in Fall.
The proposed transaction is anticipated to generate
approximately $1 billion in new capital, academic investments,
and other consideration and value beneficial to UA and the
community, the university reported. The anticipated transition
of 6,300 employees working at 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 action followed votes from the UAHN and Banner boards of
directors in support of proceeding with negotiations, as well as a
vote by the Arizona Board of Regents (ABOR) to authorize the
UofA to also move forward with UAHN and Banner. The parties
will now work together towards final definitive agreements,
anticipated to be completed and signed in September. The
definitive agreements must also be approved by ABOR and the
boards of directors of UAHN and Banner. The proposed
transaction is expected to close a few months following the
signing of the definitive agreements.
They stated these proposed key transition elements:
To create an Arizona-based, statewide health system that
improves care for all the states citizens by reliably and
compassionately delivering superior care to all who turn to this
system;
To create a nationally leading health system that provides
better care and improved patient and member experiences at
lower costs through valued-based or accountable care
organizations that utilize population health management models
that emphasize wellness;
To expand University of Arizona Medical Center capabilities
for complex academic/clinical programs such as transplantations,
neurosciences, genomics-driven precision health, geriatrics, and
pediatrics while providing for investment opportunities in other
areas;
In addition to solving the immediate financial needs, they said,

the proposed agreement will:
Eliminate the debt burdening UAHN (currently projected to
be $146 million);
Provide resources for improved hospital infrastructure,
including the $21 million purchase of land currently leased to
UAMC and $500 million within five years to expand and renovate
the medical center, and build new facilities as appropriate, such
as a major, multi-specialty outpatient center to be constructed in
Tucson;
Create a $300 million endowment which will provide a
$20-million-per-year revenue stream to advance the UAs clinical
and translational research mission;
Preserve historic funding levels between the clinical and
academic partners in addition to a $20 million per year
enhancement;
Allow additional funding support based on growth in
revenues generated by the clinical and academic partnership;
Improve operational efficiencies;
Secure and sustain a lasting relationship with, and
commitment to, the University of Arizona, anchored by an
Academic Division within Banner. The Academic Medical Centers:
The University of Arizona Medical CenterUniversity and South
Campuses and Banner Good Samaritan Medical Center and the
faculty practice plan, will support the growing needs of the
Colleges of Medicine in Phoenix and Tucson and create a valuebased delivery system;
The Phoenix and Tucson academic medical centers will be
infused with operational strength through the proposed
transition and rapidly evolve into major economic drivers that will
attract highly skilled, trained and paid professionals, elevating
Arizona as a bioscience destination;
Train more physician specialists and allied health
professionals, including pharmacists and advanced practice
nurses for Arizona;
Provide a comprehensive platform for the development of
physician-scientists who will drive discovery across basic science
studies, patient-oriented clinical research, health services
research, and population health;
Enhance and elevate academic medical excellence across
Arizona to national leadership levels; and
Secure and sustain an operational foundation for the Colleges
of Medicine in Tucson and Phoenix that will maximize the value
of the ongoing state funding received annually through legislative
appropriations.
When these respected organizations unite, the potential for
delivering top-tier academic medicine throughout the state,
recognized nationally, becomes a reality, UAHN Board Chairman
Steve Lynn said.
Added UAHN President and CEO Michael Waldrum, M.D., Im
especially pleased that this proposed transition will infuse
stability and energy into our organization. This will benefit our
patients, faculty, staff and students as we pursue excellence.
Ultimately, were moving from a situation in which we can only
maintain status quo, to a situation in which we can create a
premier Academic Medical Center.
17
With healthcare here in Arizona and across the nation facing

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

that the UAHN Board of Directors strategically sought Banner to
create Arizonas first statewide health system to help strengthen
medical education. Banners vision is to sustain a position of
national leadership. This opportunity to join with a premier
academic organization significantly advances Banner towards this
vision. In addition, 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 of
Medicine and Banner Health have a long history of successful
affiliation through the Graduate Medical Education program at
Banner Good Samaritan Medical Center in Phoenix. Each year,
Banner and the UA Colleges of Medicine
collaborate in the training of nearly 260
physicians in five residency programs and
in numerous fellowships.
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18
Ascension & CHN, Tenet & Dignity

In a July 22 press release datelined St.
Louis, Mo. and Tucson, involved parties
announced that Ascension and Carondelet
Health Network had signed a letter of
intent to form a partnership with Tenet
Healthcare and Dignity Health, and that
they will ex-plore a joint venture that
would acquire Carondelet. Ascension is
the parent of CHN. They called the letter
with a Tenet subsidiary exclusive and
non-binding.
Upon closing, they said, it is anticipated
that Ascension would retain a minority
interest in such a joint venture. The parties
have launched a period of due diligence
which they expect will result in a definitive
agreement.
Under the proposed agreement, Tenet
would be the majority partner in the joint
venture with management responsibility
for all operations of 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 acquisition is complete, the joint
venture would maintain Carondelets
heritage and identity, continuing
Carondelets Catholic sponsorship.
Tenet and Dignity Health both own and
operate hospitals in the Phoenix area.
Their participation in a Tucsonbased joint
venture will connect Carondelet to a
regional healthcare system, including
Tenets and Dignity Healths growing
accountable care organization, Arizona
Care Network; strengthen and grow Carondelets relationships

with physicians; and fund strategic growth initiatives in Southern
Arizona.
We are excited to pursue this relationship with Tenet and Dignity
Health, Carondelet President and CEO James K. Beckmann said.
Like Carondelet, Tenet and Dignity Health are committed to
providing high quality, low cost, person-centered care. This
relationship is an opportunity to strengthen those efforts,
enhance healthcare across Arizona, and continue Catholic
sponsorship of Carondelet. The people of Tucson and Southern
Arizona will continue to benefit from the tremendous dedication
and talent of Carondelets associates and physician partners.
The parties said they do not plan to provide any further detail
until such point as a definitive agreement is reached.
Tenet Healthcare Corp. described itself as a leading healthcare
services company, through its subsidiaries operates 79 hospitals,
193 outpatient centers, including six hospitals and four
outpatient centers in Arizona, and Conifer Health Solutions, a
leader in business process solutions for healthcare providers
serving more than 700 hospital and other clients nationwide.
[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 Institute and St. Josephs Westgate
Hospital.From this foundation, Dignity Health in Arizona has
expanded into a comprehensive health care system, which
includes imaging centers, clinics, specialty hospitals, urgent cares,
an insurance provider, an accountable care organization and
other clinical partnerships. The Dignity Health Medical Group

employs more than 250 physicians, who cover a wide range of
specialties. Dignity Health, Arizona Service Area, is part of Dignity
Health, one of the nations five largest health care systems.
Ascension reported that last year it provided $1.5 billion in care of
persons living in poverty and in community benefit programs, and
that it employs more than 155,000 associates serving in more
than 1,900 sites in 23 states and the District of Columbia.
Ascensions direct subsidiaries provide services that include
healthcare delivery, medical equipment management, treasury
management, resource and supply management, venture capital
investing, physician practice management, and risk management.
CMS: Open Payments

Sunshine program means
more transparency
By Betsy Thompson, M.D., DrPH, Region 9 CMO
As part of the Open Payments program, the Centers for Medicare
& Medicaid Services will soon make data about the financial
relationships between the health care industry and physicians
(e.g. including medical doctors, doctors of osteopathy, dentists,
chiropractors, and others) and teaching hospitals available to the
public. Offering this data will create more transparency and allow
those interested to use, analyze and monitor it.
Open Payments, previously known as the Sunshine Act, is a
federal transparency program enacted by Congress in 2010. Under
this program, CMS collects and publicly reports data about
19
payments (transfers of value), ownership,

or investment interests between drug and
device manufacturers and physicians and
teaching hospitals. Beginning with the last
five months of 2013, CMS will collect this data
annually from industry and make it publicly
available, downloadable, and searchable.
Every year CMS will continue to release this
financial information as it becomes available
about the prior year (e.g. by June 30, 2015 for
2014 data).
The Faces of Casa are the
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Working in hospice allows me to

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wonderful holistic patient care focused
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These financial interactions can happen for

many reasons: research, conference travel
and lodging, gifts, and consulting. They can
foster collaboration among physicians,
teaching hospitals, and industry
manufacturers that may contribute to the
design and delivery of life-saving drugs and
devices. However, they also can potentially
lead to conflicts of interest in how health
care providers prescribe medications or give
medical care.
520.544.9890 | www.casahospice.com
Hospice services are paid for by Medicare
While CMS doesnt make assumptions or

draw conclusions about the reported
information, the Agency will take steps to
ensure that only accurate information is
made public. For example, as part of this
initial data collection process, CMS has
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engaged stakeholders as pilot users to ensure that reporting

systems are user-friendly and performing properly.
In addition, CMS will give physicians and teaching hospitals an
opportunity to be sure that information reported about them is
accurate. In order to review the data and make corrections if
necessary, physicians and teaching hospitals must first register in
CMS Enterprise Portal starting on June 1, 2014. Then, starting in
July, they must register in the Open Payments system (via CMS
Enterprise Portal). This voluntary review and dispute period is
open for 45 days.
CMS strongly encourages physicians and teaching hospitals to
register in our Enterprise Portal and Open Payments systems so
they can review their specific data. Any data that physicians or
teaching hospital dispute, but is not corrected by industry within
the dispute resolution period, will be included when the data is
made public and marked as disputed.
It is important that physicians or teaching hospitals know about
this program, how and what financial relationships are reported,
and how to answer questions from patients. Visit go.cms.gov/
openpayments to get more information about Open Payments
(the Sunshine Act) and the resources available to understand the
program. Health care providers and others with questions and
concerns can be e-mailed to openpayments@cms.hhs.gov.
This information was provided by the United States Department
of Health and Human Services.
Hyperbaric ambulance:
fast HBOT treatment
saves brains
By Carol L Henricks, M.D.
A hyperbaric oxygen therapy (HBOT) equipped ambulance is being
developed in North Carolina through a collaborative effort of the
FDA, Wake Forest University Hospital system, and the UHMS.
The hyperbaric ambulance will prolong the therapeutic window
to allow TPA therapy (tissue plasminogen activator or clot
buster) to be given to patients who have suffered an acute
stroke and have a long travel time to a hospital.[1] TPA improves
stroke outcome=less disability.
HBOT intervention, preferably within three hours of rescue, also
improves the outcome in acute anoxic brain injury caused by
near-drowning and cardiopulmonary arrest. Hyperbaric
ambulances and/or acute HBOT treatment would change the
associated disability of these injuries forever! The research of
French physician Dr. Mathieu suggests a mechanism by which you
interrupt the cascade of intracellular injury caused by acute
anoxia under hyperbaric conditions at 2.0 ata 100% medical
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
tissue.[3]
Oxygen under pressure provides physiological benefits that are
not present when a patient is breathing oxygen under

atmospheric pressure conditions. HBOT creates oxygen radicals in
a hyperoxic environment and triggers healing mechanisms
including acute arrest of the cascade of intracellular injury,
release of stem cells, induced healing, bacteriostatic effects, and
modification of gene expression.
All physicians should get to know the benefits of hyperbaric
oxygen therapy.[4]
REFERENCES
1.Membership Newsletter of the Undersea & Hyperbaric Medical Society
(UHMS ). Stroke Ambulance in Development. Pressure: 23. Nov/Dec 2013.
2.Mathieu D et al. Hyperbaric oxygenation in acute ischemic encephalopathy
(near-hanging). Eur J Neurol 7(Suppl3);151.
3.Discussed at the Third International Symposium for Hyperbaric Oxygen
Therapy in 2003, Fort Lauderdale, Fla.
4.Henricks C. HBOT activates healing mechanisms. Sombrero Feb 2014.
AMA: Prevent diabetes

before it starts
Given that 86 million Americans have pre-diabetes, you likely
have patients with this common but treatable condition.
To help these patients and improve outcomes for your practice,
you can refer people who have prediabetes to an evidence-based
diabetes prevention program at the YMCA of Southern Arizona.
This program can have a positive impact on patients, providers,
and communities such as ours seeking to reduce the incidence of
type 2 diabetes.
In the Tucson area, a grant covers the cost for people over age 65
with pre-diabetes to attend the YMCAs Diabetes Prevention
Program. Adults under 65 who have pre-diabetes can still
participate by paying out-of-pocket or by having a health plan
that covers participation.
The YMCAs Diabetes Prevention Program is based on the Centers
for Disease Control and Preventions National Diabetes
Prevention Program. AMA and the YMCA of the USA are
collaborating to increase the number of Medicare participants in
the YMCAs Diabetes Prevention Program. Additionally, YMCA of
the USA is participating in a Center for Medicare & Medicaid
Innovation grant that pays for at-risk people older than 65 to
attend its diabetes prevention program in 17 communities across
the country, including Tucson and Phoenix.
Physician referral tools

While physician practices can already refer patients with prediabetes to the YMCAs Diabetes Prevention Program, AMA is
seeking to enhance a referral process that works well across
different types of practices. It has created tools to:
Increase education and awareness of pre-diabetes by
promoting physician screening of those at risk.
Increase physician referrals of people with prediabetes to the
diabetes prevention program offered by the YMCA.
Create a feedback loop linking the patients progress in the
program to the physicians practice so that information can be
integrated into the patients care plan.
These easy-to-use tools, created as part of a pilot project with
physician practices in Delaware, Indianapolis and Minneapolis/St.
21
Paul, are available to physician practices at no cost and can be

adapted to meet a practices specific needs. Check out and
download the tools at ama-assn.org/go/prediabetes, and/or contact
Janet Williams at janet.williams@ama-assn.org 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 Prevention Program

This program is a one-year, community-based program led by a
trained lifestyle coach. Participants and the coach gather in a
relaxed classroom setting, at a local YMCA or elsewhere in the
community, and work together in small groups for 16 weekly
sessions, then eight monthly sessions to incorporate healthier
eating and moderate physical activity into their daily lives.
The program is based on research funded by the National
Institutes of Health and published in the New England Journal of
Medicine in 2002. The research showed that among people with
pre-diabetes who enrolled in a diabetes prevention program,
there was a 58 percent reduction in the total number of new
diabetes cases, and a 71 percent reduction in new cases among
those 60 or older.
Reserve Corps works on

civilian casualty care
training, more
Medical Reserve Corps of Southern Arizona reports that it has
undertaken three significant projects this summer:
The MRCSA Nurses Task Force, together with Tucson Electric
Power, will host a high-level Emergency Power Outage Roundtable
on Friday Sept. 19, bringing together key stakeholders to discuss
the functional and access needs of community members who are
homebound or have conditions requiring durable medical
equipment during an extended power outage.
Participating organizations will be asked to summarize their
current emergency plans that address needs of the target
population during a power outage of more than three days.
Similarities and gaps will be identified and next steps will be
proposed. Those interested in attending the roundtable should
contact MRC for more information or to join up: 520.445.7035;
e-mail mrcsa@outlook.com.
Emergency Civilian Casualty Care (E3C) training, established in
February of this year, has provided life-saving instruction to more
than 300 medical professionals, business leaders, security
personnel and students.
Created by Dr. Sheldon Marks and Capt. Kris Blume for civilian
training, E3C is based on the militarys Tactical Combat Casualty
Care (TCCC). The program teaches the newest advances in lifesaving trauma care including the proper use of tourniquets,
traumatic and life-threatening wound treatment, triage, violent
encounters, situational awareness and community resilience.
Goals are to train 1,500 people within the first year, develop a
train-the-trainer program, and enlist a cadre of individuals who
will provide E3C training throughout Southern Arizona.
22
Individuals interested in becoming a trainer are encouraged to

contact the MRCSA office at 520.445.7035.
MRCSA is also working to better address the needs of the
Southern Arizona community through Community Needs
Assessment surveys. Focus is on jointly establishing priorities and
planning efforts with Tucson metro hospitals, community clinics
and emergency response agencies.
Surveys are designed to provide a current snapshot of community
preparedness and awareness of available resources for
emergency and disaster response and recovery. MRCSA will use
the information it gets to create a volunteer corps of physicians,
nurses, pharmacists, mental health professionals and others
that most effectively addresses the needs of the community.
Our objective is to be stronger and better prepared in the event
of any emergency situation through an investment in long-term
community resiliency, MRCSA said in a release. Project partners
include University of Arizona Medical Center, Northwest Medical
Center, Tucson Medical Center, Carondelet Medical Group,
Kindred Hospital, Tucson Fire Department, the University of
Arizona College of Nursing, Arizona HOSAFuture Health
Professionals, and Pima County Public Health Nurses.
PCOA: Reach nutrition

out to elders
By Debra Adams
Access to an adequate amount of nutritious food is important for
everyone, but can be even more critical as you age. Good
nutrition plays a critical role in preventing and managing chronic
conditions, maintaining energy levels, aiding in recovery and
promoting overall health.
Many physiological and socio-economic factors affect the
nutritional status of our communities elders, leading to food
insecurity. For some, limitations on physical mobility interfere with
the independent performance of daily living activities including
shopping for and preparing healthy, well-balanced meals.
For others, depression and social isolation lead to inadequate
consumption of enough calories because many seniors do not eat
regularly when having to dine alone. Still others cannot afford to
buy nutritious food because they live on very limited fixed
incomes. If not addressed, these factors can lead to poor health
and eventual loss of independence.
Every three years Pima Council On Aging conducts a Community
Needs Assessment to identify the needs and concerns of Pima
Countys older adults. Preparing nutritious meals moved into the
top eight serious problems for the first time in the 2012
Community Survey. In prior years this problem has been noted as
a serious concern for survey respondents 85+ years of age, but
has now been identified as a serious problem for all 60+ age
groups combined.
PCOAs Nutrition Program for the Elderly, and its component
services of Congregate Meals and Home-Delivered Meals, has for
the last 34 years been a reliable source for nutritious, prepared
meals for many of Pima Countys older adults. These programs
decrease social isolation and assist many frail older adults in

remaining safely and comfortably in their own homes.
of social support to help the patient manage their recuperation

and maintain their health after they leave the hospital.
Ten Congregate Meal Centers in Tucson have been strategically

placed to be accessible to older individuals across the community,
while also targeting the most vulnerablethose in greatest
economic need, minority elders, and individuals with limited
means for transportation. The City of Tucson Parks & Recreation
Dept. administers programs at Armory Park, Archer, Donna Liggins,
William Clements, Freedom and El Rio centers. The Tucson Urban
League operates at the Quincie Douglas Neighborhood Center.
Catholic Social Services administers sites at El Pueblo
Neighborhood Center, Flowing Wells/Ellie Towne Neighborhood
Center and the Eastside/El Dorado Center. Three additional sites
are available in Robles Ranch, Ajo, and Green Valley.
Weve seen some real success with this program, said CHN CMO
Donald Denmark, M.D. Patients are improving their health
and their well-being simply by receiving the support necessary to
remain healthy and stay out of the hospital.
For those who are unable to attend a Congregate Meal site, PCOA
contracts with two agencies to deliver nutritious, prepared
home-delivered meals throughout the metropolitan Tucson area
and select areas of Pima County.
Both the Congregate and Home-Delivered Meals meet one third
of the Daily Reference Intake. Meals are provided on a donation
basis with individuals contributing what they can afford toward
the cost of the meal.
Of the 1,237 nutrition program participants who completed the
program evaluation survey in FY 13-14, 90 percent stated that the
meals helped them maintain their health; 88 percent stated that
the meals provided a larger variety of fruits, vegetables and
meats than they would be able to prepare for themselves; and 84
percent stated that meals increased their daily intake of food.
Please help PCOA in reaching out to those older individuals who
find themselves unable to prepare or access the foods necessary
to maintain good health. Assistance is available. Encourage your
patients to call the PCOA Help Line at (520) 790.7262 or visit
www.pcoa.org.
Debra Adams is PCOA chief operating officer.
PCOA, Carondelet partner

in post-hospital patient
support
The program is an outgrowth of the Affordable Care Act, CHN

said. The federal government reached out to healthcare
providers in 2011, challenging them to design programs that
provide high quality care and cut costs to the overall healthcare
system. Carondelet took up the charge, and in doing so,
recognized that medical care is only part of what patients need
after they leave the hospital. Carondelet partnered with Pima
Council on Aging, a well-respected organization providing
importantin-home and community-based services and social
support to older adults and family caregivers.
CHN quoted PCOA President and CEO W. Mark Clark: The Care
Transitions Program works becauseof the unique partnership of
Carondelet nurses and PCOA coaches and navigators. Each of us
brings our medical and social service skills to the focused care of
these patients intheir homes, providing medical follow-up and
specific social supports that canimprove the health outcome for
the patient.
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Carondelet Health Network reported Aug. 13 that with the goal

of of improving patient care quality and safety, and reducing
hospital readmissions, they are collaborating with Pima Council
On Aging.
The Centers for Medicaid and Medicare Services (CMS)
recognized the Tucson program as a Best Practice and says this
community-based Care Transitions Program is a valuable model
for other communities to consider, CHN reported.
The program focuses on Medicare patients with multiple
chronic illnesses who have been discharged recently from the
hospital. Carondelet nurses and PCOA care coordinators partner
on making regular visits to the homes of these patients, providing
much-needed medical follow-up care and a variety of other kinds
ROC #278632
23
Arizona Medical Associaon News
A year at ArMAs megaphone

By Dr. Thomas C. Rothe
In May I finished my one-year term as Arizona Medical

Association president. Fortunately, it was an easy year for
healthcare in Arizona, as Gov. Jan Brewer got the Medicaid
expansion passed in early 2013.
Legislators were so burned out by the prolonged fight over this
issue that they had little energy left for anything related to
healthcare. As such, I was able to escape frequent trips to
Phoenix since the skirmishes were few!
ArMA has a threefold mission: patient advocacy, physician
advocacy, and scope of practice oversight. This year ArMA has
stepped up to protect patients from non-physicians purporting to
deliver healthcare services (non-nurse mid-wives wanting to do
VBACs at home, psychologists requesting prescribing privileges,
chiropractors asking to deliver hormone therapy, etc.) I would not
call this turf protection as some do.
ArMA follows more than 175 bills each year introduced into the
Arizona Legislature, and prides itself, and is widely respected for,
making sure we separate fact from opinion: legislators know if we
give them a fact, even if they do not agree with our opinion, the
fact has been vetted and is reliable. Our credibility is surpassed by
no one at the Capitol, and our support is considered essential
when it comes to healthcare and physician services. The governor
and staff are in close
communication
withArMA as the
voice of physicians.
They know
politically we can
drive an issue, and
we speak with
credibility and
honesty.
In addition, your
state medical society
has worked closely
with the Mutual
Insurance Company
of Arizona (MICA)
to cut down on
frivolous lawsuits.
This has resulted
in stabilization,
and rebates in
malpractice
insurance premiums.
Likewise, ArMA
works to protect
these reforms and
diligently watches
for legal-system endruns around them.
24
New ArMA President Jeffrey Mueller, M.D., left, accepts the

gavel from outgoing President Thomas C. Rothe, M.D. May 31
at the ArMA Annual Meeting.
The biggest frustration of my ArMA tenure was going to

Washington, D.C. to fight for the permanent repeal of the SGR, only
to have it postponed once again. In both the House and Senate,
Republicans and Democrats overwhelmingly agreed that this
problem should be fixed. Docs from all backgrounds and the AMA
vigorously fought for this, but legislators said they could not come
up with a way to pay for it. The take-home message is crystal clear:
national politicians do not care about physician interests because of
fragmentation and differences within the physician community.
They know that, sense that, docs will eventually go along with
whatever legislation is passed, and frankly would just as soon see
docs fight it out themselves. Their only interest is to maintain
power and give lip-service to everything else.
Statewide is another matter. Like medical care, all politics is local
and the representatives seem to be more interested in physician
opinions, perhaps because it relates specifically to their
constituents more directly. Passage of the Medicaid expansion by
a Republican governor in a right-wing-crazy state like Arizona was
a major accomplishment!
This was good for both the citizens of Arizona as well as the
physicians. Regardless of your political feelings on this matter,
having money to pay for medical care for those who need it most
is paramount to a healthy and more productive Arizona.
Dr. Rothe, a PCMS past-president and member since 1982,
practices with La Cholla Family Practice.
Annual ArMA meeting report

By Bill Fearneyhough
PCMS Executive Director
It was early morning coffee, rolls, fresh fruit, and cloistered

conversations as delegates from across the state gathered in
Phoenix May 30 and June 1 for the Arizona Medical Associations
annual meeting.
Along with election of new officers and general business,
delegates had a full agenda of resolutions to discuss, including
two divisive proposals for establishment of a single-payer
healthcare insurance system, and a moratorium on the
medicalization of capital punishment.
As in the past PCMS was well represented. Attending were PCMS
President Timothy Marshall, M.D., and PCMS Board members
doctors Timothy Fagan, Screven Farmer, Gary Figge, Michael

Hamant, William Mangold, and Thomas Rothe. Doctors Richard
Dale and Thomas Hicks also attended. Doctors Farmer, Figge, and
Hicks served on the Reports and Resolutions Committees.
Presidents Address
Fridays afternoon session saw Immediate Past-President Thomas
Rothe, M.D. introduce Dr. Jeff Mueller as the 123rd ArMA
President. Dr. Mueller is Associate Dean of Hospital Practice for
Mayo Clinics 23 hospitals, and medical director and a staff
anesthesiologist at Mayo Clinic Hospital, Phoenix.
Dr. Mueller spoke on the numerous challenges facing physicians,
including increased hospital, clinic and physician group
consolidations; increasing practice administrative costs; new
payment models; the politically-driven substitution of nonphysicians for physicians; and the ever-increasing reductions in
reimbursement as demand for healthcare services escalate.
To answer these challenges and more effectively use ArMA
resources, Dr. Mueller said the association should focus more on
state-based advocacy, called for physicians to actively seek and
assume formal leadership positions within hospitals and health
systems, and recommended that the state organization more
closely coordinate its advocacy activities with county and state
specialty societies. Currently ArMA leadership meets with these
societies once a year, but Dr. Mueller suggested meetings be held
at least twice a year to discuss how all could work together more
efficiently and effectively on behalf of Arizona physicians.
Elections
Tucson family practitioner Timothy Fagan, M.D. was voted AMA
Alternate Delegate and continues to serve as a PCMS Director;
Michael Hamant, M.D. was elected ArMA Secretary; Screven
Farmer, M.D. will serve as At-Large Director and Thomas Hicks,
M.D. as a delegate to AMA. Dr. Timothy Marshall was elected
PCMS Director, replacing Dr. Charles Katzenberg who resigned the
post earlier in the year. All join fellow ArMA Board members
doctors Gary Figge, William Mangold, and Thomas Rothe.
Resolutions
The House of Delegates debated a multitude of significant
resolutions. Uncharacteristically, PCMS sponsored a single
resolution, dealing with GME funding.
Resolutions receiving delegate support:
Transferral of authority to establish membership dues from
the ArMA House to the ArMA Board of Directors.
Join with the University of Arizonas Valley Fever Center for
Excellence, public health departments, and other organizations
to promote coccidioidomycosis awareness and/or actively seek
funding resources for cocci awareness and education.
Support increased GME funding in Arizona and oppose
funding cuts. The PCMS Board-approved resolution was adopted
from a position paper submitted by PCMS Board student
members Jamie Fleming and Jeffrey Brown.
Propose that AMA petition the U.S. government and the
National Institute of Health (NIH) requiring publication of all NIHNational Center for Complementary and Alternative Medicinefunded studies without regard to results. ArMA would also
propose to AMA and the Association of American Medical
Colleges that medical student education be limited to scientifically
sound medical practice that adheres to evidence-based physics,
chemistry, pharmacology, and biology. It also calls for teaching of

Complementary and Alternative Medicine to follow the same
rigorous requirements of research and published studies showing
efficacy before being included in medical school curricula.
Encourage appropriate healthcare providers to review the
American Endocrine Society guidelines for testosterone
replacement therapy in adult men with Androgen Deficiency
Syndrome, and urge a thorough discussion of the risk vs. benefit
of the therapy be discussed between the provider and patient.
Educate ArMA members, as prescribed by the Agency for
Healthcare Research and Quality guidelines, that allergen
immunotherapy be administered in a setting allowing prompt
recognition and management of adverse reactions unless withholding
such therapy would seriously jeopardize a patients health.
Have ArMA participate in the Arizona Prescription Drug
Misuse and Abuse Initiative and urge state legislators to
adequately fund efforts to adequately fund initiative efforts;
encourage voluntary CME regarding use and management of
controlled substances; encourage licensed prescribers to enroll
and use, where appropriate, the Arizona Controlled Substances
Monitoring Program; endorse ongoing efforts by the Arizona
Department of Health to develop Opioid Prescribing Guidelines.
Resolutions referred back to ArMA committees for further study:
Calls to renew federal CDC funding for gun violence research,
and support legislation directing the Arizona Department of
Public Safety to notify the National Instant Criminal Background
Check System when an individual has been adjudicated for courtordered psychiatric treatment. Delegates voted to send the
resolution back to the Public Health Committee for further study
and recommendations.
Calls for ArMA to propose to the Association of American
Medical Colleges and the American Medical College Application
Service that they adopt a similar matching service for residencies
as provided by the National Residency Matching Program. The
resolution would streamline the application process, saving
medical school applicants time and expenses associated with
applying to a multitude of medicals schools. It also offers rejected
applicants time to make alternate plans for a coming academic
year. Delegates voted to send the resolution to ArMAs Executive
Committee with the recommendation that the committee seek
input from medical schools.
Direct the state association to seek legislation that would lift
the cap on the number of patients physicians may treat for opioid
dependence and eliminate the lengthy certification process for
physicians using buprenorphine to treat such patients. Delegates
voted to send the resolution to the Executive Committee for
further action and study. It was noted that past efforts to change
Drug Addiction Treatment Act language have failed to get action
from the state legislature.
Failed Resolutions:
Directed ArMA to support the adoption of a single-payer
financing mechanism for health insurance.
Ask the state medical association to urge AMA request all
states with active capital punishment statutes enforce a
moratorium on all future executions until resolution of the
problems associated with medicalization of the death penalty.
Highlighting Friday evenings Presidents Awards Banquet was
Gov. Jan Brewers keynote address.
n
25
CME
Local CME from Pima County

Medical Foundation
PCMF has scheduled these CME events for its Tuesday Evening Speaker
series. Dinner is served at 6:30 p.m. presentation follows at 7.
Sept. 9: New Medical and Surgical Treatments for Prostate
Cancer presented by UA medical oncologist Frederick Ahmann,
M.D., and UA radiation oncologist Shona Dougherty, M.D.
Oct. 14: Dermal Fillers and Fat Stem Cells in Plastic Surgery
presented by plastic surgeon John Pierce, M.D.
Nov. 11: Newer Anticoagulants and their Role in A-Fib, DVT, and
Pulmonary Embolism presented by Timothy Fagan, M.D.
September
Sept. 4-6: The Association of American Physicians and Surgeons

71st Annual Meeting: Rescuing Patient Care from Failed Policy
and Flawed Science is at the DoubleTree by Hilton in the Historic
District of Charleston at 181 Church St., Charleston, S.C. 29401.
Up to 16 AMA PRA Category 1 CME credits are available in
accordance with accreditation requirements of the New Mexico
Medical Society through joint providership of Rehoboth McKinley
Christian Health Care Services and AAPS.
Doctors must lead the charge tostop the subjugation of patient
care to the interests of the government, third parties, and so-called
guidelines, AAPS says. This meeting will arm you with the tools
youll need to help in this fight. Learn how you can make a
difference, including steps you can take now to free your practice
and your patients from ObamaCare while others wait around for
politicians to fix American medicine, and much more.
Speakers include AAPS President Tom Kendall, M.D.; Kris Held, M.D.
of www.Rebel.md; Avik Roy of Forbes.com; Citizens Council for
Health Freedom founder Twila Brase, R.N.; Physicians Declaration
of Independence author and AAPS President-Elect Richard
Amerling, M.D.; Paul Kempen, M.D., Ph.D. of ChangeBoard Recert.
com; Parvez Dara, M.D. of Jedis Medicine; AAPS Executive Director
Jane Orient, M.D.; and Charles Sauer of The Market Institute.
Learn more and register online at AAPSonline.org/2014am. You
may register for full meeting or individual sessions. For hotel
reservations call 877.408.8733 and mention AAPS to receive
group rate of $149 per night. Cost as of Aug. 4 is $475 AAPS
members, $625 non-members, $625 new members including first
years dues, and $250 spouse/guest registration. Partial
registration options available.
Sept. 6: The Future of Heart and Vascular Care: An Update for
the Practitioner is a Carondelet Heart & Vascular Institute
syposium at Loews Ventana Canyon Resort, 7000 N. Resort Drive,
Tucson, 85750. Register at www.carondelet.org/chviconference.
CME: Up to 7.5 AMA PRA Cateogory 1 credits.
Event targets primary care physicians, cardiologists,
cardiothoracic surgeons, vascular surgeons, PAs, NPs, RNs and
radiologic technologists. Symposium highlights recent advances
and best practices in heart and vascular medicine, and new
treatments to improve patient outcomes for those with heart
failure, valve disease, or A-fib. Presentations emphasize emerging
and changing concepts that influence guidelines for cholesterol
and diseases affecting the hearts valves.
CHVI is a new 92,000-square-foot facility based at Carondelet St.
Marys Hospital. It includes a dedicated Cardiovascular ICU, allprivate bed Progressive Care Unit, three cardiac cath labs,
electrophysiology suite, three dedicated Ors, and a unique hybrid
operating suite.
CHN is a ministry of Ascension Health, the nations largest
Catholic, not-for-profit healthcare system. In Fiscal Year 2013,
Carondelet reported nearly $69 million in Community Benefit to
improve community health and access to healthcare.
Sept. 13: Acute and Chronic Leukemias 2014: A Case-Based
Discussion is at Mayo Clinic Education Center, 5665 E. Mayo Blvd.,
Phoenix 85054. Accreditation is to be determined.
Activity is designed to provide up-to-date information on
practical, current and evolving therapies using real-case-based
scenarios. Attendees will be able to discuss practical cases with
faculty knowledgeable in specific specialties. Course has breakout
sessions for one-on-one interaction between faculty and learners.
One-day comprehensive symposium targets hematologist and
oncologist physicians, NPs, RNs, PAs and pharmacists. Full
program details, including schedule, faculty, accommodations,
and registration will be available prior to event.
Website: http://www.mayo.edu/cme/hematology-and-oncology2014s435
Contact: Lilia Murray, Mayo School of Continuous Professional
Development, 13400 E. Shea Blvd., Scottsdale 85259; phone
480.301.4580; fax 480.301.8323.
mca.cme@mayo.edu http://www.mayo.edu/cme
26
27
MICA_Sombrero08'14ad_MICA_Sombrero05'04ad 6/30/14 9:14 AM Page 1
Did you know?

MICA members are eligible
for retirement tail when they retire
completely from the practice
of medicine at age 55 or older,
with one year of MICA coverage
immediately preceding retirement.
Medical Professional
Liability Insurance
(602) 956-5276
(800) 352-0402
www.mica-insurance.com
The policyholder benefits presented here are illustrative and are not intended to create or alter any insurance coverage. They
should not be relied on and may differ from actual MICA policy language. Coverage provided by MICA is always subject to the terms
and conditions of your policy, and MICA strongly encourages you to read your policy in its entirety.
28

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Pima County Medical Society

The war on doctors

You may reach all locations at

Cameron Javid MD,

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

SOMBRERO August/September 2014

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The war on doctors

12 Mix At Six: Members and student members

14 Behind the Lens: Dr. Hal Tretbar and

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17 PCMS News: If rising healthcare costs never

24 Arizona Medical Association News: Dr. Tom

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26 CME: Pima County Medical Foundation has

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Physiatry Associates, Ltd.

In a few weeks Saguaro

She joins Charles Blake, M.D.,

Our staff remains committed to

Dr. Lipson graduated from

Chicanos Por La Causa honors

residency at Cedars Sinai

Southern Arizona Dinner celebration, The Art of Being a

In addition to these pages his

Dr. Doraiswamy joins UA

Carondelet St. Marys,

Dr. Vijay A. Doraiswamy, a

Being honored for providing excellent care is the best

Dr. Fodeman 2014

An occasional Sombrero columnist, Dr.