June-July 2016 Sombrero

Sombrero
Pima County Medical Society

Home Medical Society of the 17th United States Surgeon-General
J U N E / J U LY 2 0 1 6
SOMBRERO June/July 2016
Sombrero
Pima County Medical
Society Officers
Official Publication of the Pima County Medical Society
Jerry Hutchinson, DO
Roy Loewenstein, MD
Kevin Moynahan, MD
Snehal Patel, DO
Wayne Peate, MD
Kenneth Sandock, MD
Sarah Sullivan, DO
Salvatore Tirrito, MD
Debra Townsend, MD
Fred Van Hook, MD
Scott Weiss, MD
Leslie Willingham, MD
Jaren Trost, MD (Resident)
Aditya Paliwal, MD (alt. resident)
Jared Brock (student)
President
Timothy C. Fagan, MD
President-Elect
Michael A. Dean, MD
Vice-President
Susan J. Kalota, MD
Secretary-Treasurer
Unfilled / Appointment
Past-President
Melissa D. Levine, MD
PCMS Board of Directors

David Burgess, MD
Howard Eisenberg, MD
Kelly Ann Favre, MD
Members at Large
At Large ArMA Board
Charles Krone, MD
Clifford Martin, MD
Robert M. Aaronson, MD
R. Screven Farmer, MD
Board of Mediation
Pima Directors to ArMA

Timothy C. Fagan, MD
Thomas Griffin, MD
Evan Kligman, MD
George Makol, MD
Sheldon Marks, MD
Mark Mecikalski, MD
Delegates to AMA
Timothy C. Fagan, MD (alternate)
Gary R. Figge, MD
Michael F. Hamant, MD (alternate)
Thomas H. Hicks, MD
Arizona Medical
Association Officers
Michael F. Hamant, MD
Vice President
Thomas C. Rothe, MD
Outgoing Past President
Executive Director
Bill Fearneyhough
Phone: (520) 795-7985
Fax:
(520) 323-9559
E-mail: billf 5199@gmail.com
Editor
Bill Fearneyhough
I welcome your feedback and story ideas.
E-mail: billf 5199@gmail.com
Printing
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Advertising
Dennis Carey
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Publisher
Pima County Medical Society
5199 E. Farness Dr., Suite 151
Tucson, AZ 85712
Phone: (520) 795-7985
Fax: (520) 323-9559
Website: pimamedicalsociety.org
CENTRAL
Charming 1952 Sam Hughes Bungalow.

Brand new roof. 1,616 sq. ft.,
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solid oak floors, 1 car garage.
$325,000
Vol. 49 No. 6
SOMBRERO (ISSN 0279-909X) is published monthly

except bimonthly June/July and August/September by the
Pima County Medical Society, 5199 E. Farness, Tucson,
Ariz. 85712. Annual subscription price is $30. Periodicals
paid at Tucson, AZ. POSTMASTER: Send address changes
to Pima County Medical Society, 5199 E. Farness Drive,
Ste. 151, Tucson, Arizona 85712-2134. Opinions expressed
are those of the individuals and do not necessarily represent
the opinions or policies of the publisher or the PCMS Board
of Directors, Executive Officers or the members at large,
nor does any product or service advertised carry the
endorsement of the society unless expressly stated. Paid
advertisements are accepted subject to the approval of the
Board of Directors, which retains the right to reject any
advertising submitted. Copyright 2016, Pima County
Medical Society. All rights reserved. Reproduction in whole
or in part without permission is prohibited.
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3
Inside
5 Dr. Timothy C. Fagan: More thoughts on the Arizona
Legislature Regarding Medical Issues.
6
UA College of Medicine: Dr. Charles B. Cairns discusses

the future of academic medicine in Tucson.
In Memoriam: Remembering Dr. Michelle McDonald.
10 Makols Call: Not all physicians profit from our

increasing obesity.
12 ArMA News: Delegates discuss UA-Phoenix
resignations and submit resolutions on future state
legislation.
18 Opinion: Healthcare lawyers Robert Milligan and
Steven Lawrence want physicians to break their
silence in order to fix or bury the Stark Law.
21 Southwestern Conference on Medicine: TOMF
Primary Care CME Event sets new attendance record.
Chair Dr. Jerry Hutchinson oversees growth of
conference from local gathering to national player.
23 BUMC News: Banner University Medical Center
breaks ground on new tower at health center.
On the Cover
24 Behind the Lens: Legend of local crested saguaro

cactus grows.
26 Public Health: UA researcher helps map Zika danger
areas.
This crested saguaro in the Tucson foothills draws lots of

attention from people passing by. The stem and three of the four
arms are becoming crested. (Dr. Hal Tretbar photo).
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So how did things turn out in the

Arizona Legislature?
By Dr. Timothy C. Fagan
PCMS President
he Arizona Legislature
adjourned on May 7th.
Overall, things turned out
better than I expected.
S1473, the Advanced Practice
Registered Nurse scope of
practice bill died, due to unified
opposition by organized
medicine regarding safety issues.
An agreement was reached on
H2236, changing the language
regarding collaboration of NPs
and CNMs with physicians.
However, the nurses did not
pursue this. It is widely expected that the Arizona Nurses
Association will seek similar legislation next year. On the same
topic, on May 25th, the Department of Veterans Affairs released a
proposed rule for all Advanced Practice Registered Nurses to
practice independently within the VA system. There are 30 days for
comment, before a final rule is published.
The obvious flaw in this law is that there is no requirement to check

the database for other medications with high abuse potential,
other than opioids and benzodiazepines, in Schedules II, III and IV.
S1112, increasing Pharmacist scope of practice to include
additional immunizations, was passed and signed. This bill
requires the Pharmacist to make a good faith effort to notify the
patients physician, and specifies ways that this may be done.
S1363 requires equal payment for health care services provided
by telemedicine as for the same services provided in person. This
bill was sponsored by Senator Gail Griffin and will become
effective on July 1, 2017.
H2310 was passed and signed, allowing pharmacist substitution
of biosimilar products.
S1324 required a physician, prescribing mifepristone for medical
abortion, to provide outdated and scientifically unsound
information to the patient, and to prescribe three times the
effective dose, with associated increased risk of adverse events.
The bill was passed and signed. Meanwhile, the FDA released
updated and scientifically sound prescribing information. S1324
was subsequently repealed as an amendment to another bill.
KidsCare reinstatement, introduced as H2309, died in the Senate

when Andy Biggs refused to assign it to a Committee. There was
hope that it could be revived as part of the budget process, but
this did not happen. However, with the united efforts of
organized medicine, it was reintroduced as an amendment to
Senator Bradleys S1457 for empowerment scholarships for
persons with disabilities. This was passed and signed by the
Governor. There is a possibility of an opposing lawsuit, since the
amendment is not on the same topic as the original bill.
Applications for children for KidsCare begin on July 26, with
coverage beginning September 1, 2016.
A balanced Arizona State Budget was passed and signed. It

includes no payment
cuts to AHCCCS
providers and
provides restoration
of Podiatry services in
AHCCCS. The Budget
also restored some
funding for K-12 and
State University
education.
H2502, the Interstate Medical Licensure Compact was passed and

signed by Governor Ducey. This will streamline the process for
obtaining a Medical License in another Compact State for
physicians already licensed in one of the Compact States.
This was a
controversial,
strongly contested
year in the Arizona
Legislature.
Important health
related legislation
was passed. Several
bills with significant
adverse
consequences for
patients were
defeated or repealed.
All in all, it could have
been much worse;
without the united
efforts of organized
medicine, it would
n
have been.
S1283, the Controlled Substances Prescription Monitoring

Program (CSPMP) was passed and signed. This law requires a
medical practitioner, before prescribing an opioid analgesic or
benzodiazepine listed in Schedules II, III or IV, to obtain a patient
utilization report from the CSPMP for the previous 12 months at
the start of each new course of treatment and at least quarterly
while that medication remains a part of treatment. This
requirement will begin on October 1, 2017 or 60 days after the
Arizona Health Exchange has integrated the program data into the
Exchange. There are eight exceptions to this mandate, including a
patient on hospice or receiving palliative care, a patient with
cancer or on dialysis, and inpatient treatment of a patient.
There is no liability or potential disciplinary action, for a goodfaith act or failure to act on the information in the CSPMP report.
UA College of Medicine
Shaping the Future of Academic Medicine in

Tucson and Across Arizona
By Charles B. Cairns, MD, Dean, College of Medicine Tucson University of Arizona
he stage was set for a new

paradigm in academic
medicine last February when
Banner Health bought
University of Arizona Health
Network (UAHN) and became
the exclusive clinical partner
for the University of Arizona
(UA) Colleges of Medicine in
Tucson and Phoenix.
Charles B. Cairns, MD
Its no secret that academic

medical centers have been on
shaky financial ground across
the U.S., and UAHN was no
exception. While UAHN had
been modestly successful with
a vibrant academic portfolio
and relatively stable finances for many years, the combination of

reduced state funding, reduced care contract reimbursements
and increasing cost for information systems and technologies
began to take their toll. By 2013 UAHN was consistently seeing
annual deficits.
Around that same time Phoenix-based Banner Health was
interested in forming an academic partnership to enhance
innovation and recruit high-quality providers. Banner Health is
comprised of 29 hospitals located across seven states and has a
reputation as a leader in healthcare delivery innovation, including
being identified as the leader in cost savings while maintaining
quality and performance in the CMS Pioneer Accountable Care
program of the Centers for Medicated and Medicare. The UA
recognized the organizations successes and strengths and
realized that partnering with Banner Health cuts our risk and
allows us to focus on our mission of education, research and
patient care.
With many months of work happening
behind the scenes, the UA and Banner
Health signed a 30-year Academic Affiliation
Agreement on February 28, 2015. The
intended outcome of this commitment is the
creation of a state-wide system that reliably
and compassionately provides high quality
health care throughout all Banner Health
providers and facilities and supports the
state of Arizonas position as a first-tier
research and training destination with
world-class physicians. Additionally, Banner
University Medicine will become a nationally
leading organization that transforms health
care by delivering better care, enhanced
service and lower costs through new,
wellness-focused approaches; eventually the
educational, research and care innovations
developed through Banner University will be
implemented into the entire Banner Health
System.
A Common Core
Its our shared values on substantive issues
in academic medicine that has allowed this
partnership to move forward. For example,
we value the need for:
rapid evolution in health care delivery and what that means

for education, training and research.
fiscal responsibility.
evolution of medical training for the future health care
workforce.
The UA College of Medicine benefits from:

increased visibility and brand enhancement.

new and unique competencies in patient care.
new health systems competencies.
new health care systems strategies.
new education and training paradigms.
new physician compensation and faculty development
programs.
new competencies and resources in population health.
catalyst for business acquisitions and mergers.
A Commitment to Success
Within the first year of this partnership, the Academic
Management Council which serves as the governing body of
the Banner University Medicine physician faculty practice plan
approved more than 200 additional faculty positions for the
Colleges in Tucson and Phoenix and five new residency and
fellowship programs.
Banner Health has invested in director positions for Clinical Trials
and Phase I studies and a new Clinic Research Nurse program for
acute and critical care. It is providing critical capital and resources
to improve facilities in Tucson and Phoenix, including a
$500-million investment in a new hospital and clinic in Tucson.
And the Academic Enhancement Fund supports the development
of University of Arizona Health Sciences centers, the UA
Comprehensive Cancer Center and recruitment and retention at
the Colleges of Medicine.
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Looking ahead
As we move forward, we will address how to provide
comprehensive clinical strategy and incorporation of narrow
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innovations into the Colleges of Medicine, Banner University
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The UA-Banner partnership addresses the need for a rapid
evolution in health care delivery with far-reaching implications
for education, training and research. We are creating a new,
fiscally responsible, innovative paradigm in academic medicine
here in Tucson, and medical schools across the country are
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Leer to Editor
The nuclear weapons threat to humanity

continues unchecked
R
ecently an Israeli defense official was asked whether he

was worried about a nuclear attack by Iran. Paraphrased, he
replied, No! Why would they want to cause self-destruction by
nuclear exchange?
weapons and contemplating an attack self-destruction is a

guarantee! So why, when nuclear weapons are not usable under
any circumstances, are 10 nations still possessing them, and
others lusting after them?
This sums up the situation of any two nations possessing nuclear
Albert Einstein answered it many years ago: The splitting of the

atom has changed everything but mans way of thinking, and thus
we drift toward unparalleled disaster.
We have come close several times. On one occasion a U.S.
weather rocket launched from Norway was misinterpreted as an
attack. Someone at the end of the Soviet chain of command
advised then-President Yeltsin that it seemed very unlikely that
it was nuclear, and a retaliatory strike was averted by mere
minutes.
There are two fundamental factors controlling these weapons:
computers and humans. It is plainly evident that both are
vulnerable to malfunction. The incident noted above occurred
because a single individual did not pass on the required
notification about the weather rocket test.
There is no logical reason why human beings, using the most
basic thought processes, cannot conclude that these weapons
need to be totally eliminated. This is the conclusion that 127
nations have come to. ICAN (International Campaign to Abolish
Nuclear Weapons) is a recently formed organization dedicated to
eliminating the legal obstacles to complete and total nuclear
disarmament. Unfortunately, the U.S. and Russia, possessing
90% of these weapons, have not signed on.
Many major health organizations support this international
effort; the American Medical Association released a resolution to
this effect last year.
Instead, an all-out effort to develop new and increasingly
complex weapons is underway. The U.S. currently spends TWO
MILLION DOLLARS PER HOUR on existing nuclear weapons! It
would not take very many days at this level of spending to fund
any number of civilian projects, take education for instance. The
only beneficiary of this is the military-industrial complex of which
President Eisenhower warned us. Congress has the power to
stop this process, if the American citizens demand it. They
should.
Another President, Jimmy Carter, said years ago, The risk of a
nuclear conflagration has not lessened. It has not happened yet,
but that can give us little comfort, for it only has to happen once.
Raymond F. Graap, M.D.
Schuyler Hilts, M.D.,Cmdr.(Ret.) USNR
Both are members of Physicians
for Social Responsibility
n
8
In Memoriam
Dr. Michelle McDonald 1954-2016

By Dennis Carey
ichelle Mickey
McDonald, MD,
former Chief Medical
Officer of the Pima County
Health Department,
passed away May 11 after
a prolonged illness due
to carcinoid tumors.
She was 61.
McDonald was born in

Warren, Ohio on July 21,
1954. She received her
undergraduate degree in
philosophy from Stanford
University in 1976 before
attending the University of
California-Berkley for premedical school courses. She graduated from Albert Einstein
College of Medicine in Bronx, NY in 1983 and completed her
family practice residency at the University of Massachusetts in

Worcester in 1986.
After serving as a staff physician for the Kayenta, Arizona Indian
Health Services Clinic, McDonald moved to Tucson in 1989. She
was in family practice at Thomas Davis Medical Center, St.
Elizabeth of Hungary and El Pueblo clinics until joining the Pima
County Health Department in 2001.
McDonald was a member of the Pima County Medical Society
and was a frequent contributor of Sombrero magazine public
health articles.
She is survived by her husband, Bob Johnson; children Helen
Cordier (Kye), Erik McDonald Johnson, Amelia McDonald
Johnson; grandchild Brynn Rose Cordier and sister
Megan McDonald. A celebration of her life was
held at Tohono Chul Park on May 20.
n
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Makols Call
Fat people = fat physician wallets

By Dr. George J. Makol
have chosen to transition to

this months subject by
looking back briefly to my last
column which focused on a
subject dear to my heart - food.
I received a number of
comments regarding my take
on the four major food groups.
It is apparent that many of you
when bachelors or
bachelorettes partook of takeaway, drive through, dine-in
and delivery as I did.
This leads us to consider an acute American problem, obesity,
and its direct relationship to this months subject - the just
released Medscape 2016 Physician Compensation Report.
Guess who the highest earning MDs are? You may have guessed
correctly with the hints Ive provided. The top earners among
physicians are orthopedic surgeons. This is not because more
persons than ever are having skiing accidents or getting tennis
elbow, but because Americans are fatter than ever. Joints that
were meant to hold 154.324 pounds (the famous 70 kilogram
man that we all studied) are often wearing out by the time these
folks are 60 years old. We now have the 70 kilogram kid, and a
mom that may carry almost double that weight.
The last time I took my youngest daughter to Disneyland, my
favorite ride in the entire park, Its A Small World was closed for
remodeling. I first took this ride as a kid in 1956, not long after
the park opened. It seems that the average American has gained
25 pounds since the ride was built in 1955, causing the boats to
scrape the bottom of the artificial river. The standard seat width
designed for four persons in the 1950s now held just three. They
had to make the water deeper and the boats more buoyant
because of the additional load! We are lucky that they did not
change the theme song to Its a Chubby World after all.
So todays orthopedists are pulling down a six-figure salary with
no 1s, 2s or 3s in that number; they were smart enough to see
the future I guess.
I will not even have you guess the bottom earners, because you
already know that pediatricians always bring up the rear of these
surveys. They do not have any lucrative procedures, and I guess
insurers must figure that if you get paid a certain fee to take care
of a six-foot man, you should make half of that taking care of a
three-foot child. That makes as much sense as the rest of the
reimbursement schemes.
10
Allergist/Immunologists used to be in the middle, but in this

survey we are fourth from the bottom. In fact, if you look at the
procedure oriented MDs, they dominate the top half of the
survey. Those that do not scope, cath or cut make generally less
than two-thirds of those doctors that do. Now, before everyone
writes in nasty letters, I do not think that the surgical/procedure
oriented doctors make too much, I think the pediatricians, family
doctors and internists make too little.
Laymen reading this might say that doctors make a lot of money,
but lets compare what we earn to what health insurers pay their
own employees. Inova is a relatively small, non-profit health care
system in Virginia, controlling about five hospitals. Their 2013
financial report to the IRS showed that two dozen Inova
executives were making more than $500,000 per year. Not one
specialty in the Medscape 2016 Physicians Compensation report
makes that average income!
The average HMO CEO salary for 2014 according to Fierce
HealthPayer was between 10 and 15 million dollars, or more than
30 times their highest paid physician provider. Think of where
the insurance companys earnings would be without the doctor
and the patient, yet the patient is hit with never ending higher
premiums and deductibles (thank you President Obama for
promising each family would save $2500 a year on health
insurance with the Affordable Care Act while they actually pay
about $2,500 more now for lousy coverage). At the same time
doctors are being squeezed at the other end with lower and
lower reimbursements.
Enough with the complaining! Let us look at how they did this
survey. They queried about 20,000 physicians in 26 different
specialties. When I first read the numbers, considering what
doctors earn in Tucson, I figured that all 20,000 doctors practiced
in Beverly Hills. However, they did differentiate by geographic
locations, and doctors in the Southwest region were the second
lowest paid of all the sectors.
Even more disturbing is the companion Medscape report,
Physicians Debt and Net Worth Report 2016. Considering
that orthopedists are earning well into six figures, only about
12% have a net worth exceeding five million dollars. Less than
40% have a net worth of between two and five million dollars.
The rest of us are not doing much better as only 12% of female
doctors and 20% of male doctors make the two million net
worth category. How can this be happening? I have three words
for you, BMW.
On an even more ridiculous note, physicians were asked if they
ever made an investment mistake, and incredibly the majority
said NO. The only way this is possible is if they never made an
investment. This is quite possible, when you consider that less
than 20% of a group earning low six figures on average saves two
million dollars in a lifetime.
Sixty-nine percent of pediatricians claimed they never made an
investment mistake; maybe they should have invested in
becoming orthopedists!
However, due to new medical breakthroughs, it is possible that
this joint replacement bonanza may not go on forever. I myself
have started on one of the new drugs for weight loss that
reportedly works as serotonin agonists, or at least thats what
medical researchers conjecture is their mode of action. I, while
being a patient on one of these drugs, have discovered exactly
how these drugs work. It is not so much their effect on serotonin
receptors in the brain, but their effect on dead president
receptors found in your wallet. Once you start paying for one of
these drugs, you actually do not have enough money left to buy
food, hence you lose weight. It actually may be more cost
effective to move to France where a ham sandwich costs $50 and
you have to walk everywhere. You hence will lose weight while
shelling out about the same amount as you would for this
medication! As a bonus in socialistic France you may retire at 50
and live off the government, Voil`a Bernie.
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Contact Dr. George Makol at Alvernon Allergy, phone
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Hysteroscopy Equipment:
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Sony Color Video Printer UP-21MD
USED MEDICAL EQUIPMENT FOR SALE:
Magnavox 15 Color Monitor
One NovaSure Endometrial Ablation RF Controller

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11
ArMA News
ArMA House of Delegates approves

NO CONFIDENCE vote for
UA Medical school officials
By Bill fearneyhough
ne could only describe the June 4 Arizona Medical Association

annual meeting agenda as perfunctory, but at the eleventh
hour the meeting took a seriously dramatic turn when the House
of Delegates was asked to approve an end-of-session-crafted
resolution calling on the Arizona Medical Association (ArMA) to
release a public statement of No Confidence in the University of
Arizona executive and Health Sciences oversight leadership of the
College of Medicine - Phoenix.
The adopted resolution was in response to a series of serious

concerns raised by the resignation of six senior-level Deans in
Phoenix, including concerns over accreditation and the Deans
authority. Those who have resigned include Phoenix Medical
School Dean Dr. Stuart Flynn who has subsequently accepted a
like position in Texas.
UA Phoenix recently received a mid-tier accreditation from the
independent Liaison Committee on Medical Education (LCME),
The Faces of Casa are the

James Nicolai, M.D.
Associate Medical Director
even though LCME warned college officials last year to make fixes
to maintain and advance its accreditation.
The resolution also called on the Arizona Board of Regents to
immediately conduct an independent investigation into the
departure of the senior leadership and take corrective action.
ArMA released their public statement on June 7th.
Elections
Michael F. Hamant, MD was elected President-Elect and will serve
on ArMAs Executive Committee. Hamant is a private-practice,
board-certified family and sports medicine physician. More
recently he served as the state associations vice president and
alternate AMA delegate. He has been a member of the Pima
County Medical Society since 1989 and is a past president.
Several other Society members won election to key positions.
Thomas Hicks, MD was elected Delegate to
the AMA while PCMS President Dr. Timothy
C. Fagan will serve as the AMA Alternate
Delegate. Dr. Robert Aaronson was elected
At-Large Director. Drs. Fagan and PCMS
President-Elect Michael Dean will serve as
Pima Directors. All will serve on ArMAs
Board of Directors.
As a hospice physician, it is
incredibly satisfying to work with
a team of individuals totally
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patients and their loved ones.
This is why I became a doctor in
the first place.
Gretchen Alexander, MD becomes ArMAs

new President. She replaces outgoing
President Dr. Nathan Laufer. Alexander is a
graduate of the University of Pennsylvania
School of Medicine. Alexander practices with
the District Medical Group at Maricopa
Medical Center, where she is an attending on
the Inpatient Psychiatry Service and
Associate Program Director for the MIHS
Psychiatry Residency Training Program. She is
an Associate Clinical Professor of Psychiatry
at the University of Arizona College of
Medicine-Phoenix.
Resolutions
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Hospice services are paid for by Medicare
12
PCMS brought three Board-approved

resolutions to the table while Dr. Jane Orient,
a Society past president and current Public
Health Committee Chair, went solo on
another.
1.MIANTENANCE OF CERTIFICATION
(MOC): The resolution calls on ArMA to
investigate legislation, like that proposed in
other states, to prohibit hospitals from denying admitting

privileges solely on the basis of failure to participate in MOC or to
prohibit insurers from refusing to pay for services rendered by a
physician who has not maintained certification. Passed.
2.PRESCRIPTION DENIALS AND PRIOR AUTHORIZATIONS: This
resolution called on ArMA to craft legislation and or rule changes
at the Department of Insurance and or Board of Pharmacy that
would require all prescription denials or requests for prior
authorization to contain information regarding substitute
medications which are on formulary or do not require prior
authorization. Passed.
3.IMPROVING PATIENT ACCESS TO PHYSICIANS AND MEDICAL
FACILITIES: Calls for the state association to work with the
Arizona Insurance Commission to actively
pursue legislation to ensure network
adequacy of all state health insurance plans
and requires insurance products to maintain
transparency and accuracy of their provider
networks. Passed.
4.INTERSTATE MEDICAL LICENSURE
COMPACT (IMLC): During this years session
of the state legislature, the IMLC became law.
This resolution, authored by Dr. Jane Orient,
calls on ArMA to investigate and inform
Arizona physicians of potential adverse
consequences of Compact licensure,
especially pertaining to loss of due process
rights and additional defense costs should a
licensure Board complaint arise in a Compact
state. Failed.
Other resolutions included:
1.DEPARTMENT OF INSURANCE
LEGISLATION: In this resolution, outgoing
ArMA President Nathan Laufer called on the
creation of a division within the Arizona
Department of Insurance (DOI) whose
responsibility it would be to accept and
resolve problems identified and presented by
providers and patients regarding insurance
company practices that negatively impact
providing medical services by physicians and
other health care providers. It would also:
d. Requires DOI to review and take correct action where

necessary for retrospective denials of payment for
procedures already authorized and performed.
e. Requires DOI to assess the impact on quality of patient care
by unjustified delays in service authorizations and take
corrective action to address the problem.
The resolution received overwhelming support and passed.
2.SALARY CAPS FOR HEALTH CARE LEADERS: In November, the
health care arm of the Service Employees International Union
wants to ask Arizona voters to cap salaries for health care
executives. This resolution directed the state medical association
to oppose such efforts. Passed.
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a. Seeks to create within DOI a system

whereby providers can be assured that
authorization for services also serves as
verification of the financial
responsibility of the third party payer
or managed care company to pay for
the authorized treatment or diagnostic
procedures.
b. Establishes requirements for insurance
companies to expedite the
credentialing and activation process for
physicians and residents in a timely
manner.
c. Requires the DOI to evaluate the
timeliness of payments and take
corrective action to assure they are in
compliance with state statute.
13
3.END OF LIFE TASK FORCE: Asks that ArMA, along with other
appropriate medical organizations, form a task force to examine
medical and end of life decisions, and assist physicians to
effectively engage patients and families regarding decisions,
options and care for these patients. Passed.
4.CONTROLLING THE SPREAD OF ZIKA AND MOSQUITO-BORNE
ILLNESSES: Calls on ArMA to support State and Federal efforts to
control the spread of Zika and other Mosquito-borne illnesses in
Arizona and provide the necessary funds to support their efforts.
Passed.
5.APPROPRIATE USE OF ANTIMICROBIAL MEDICATIONS: Asks
ArMA to urge the states public health agency, hospitals and other
health care organizations to develop physician and other health
care provider education and training programs about the
Your partner
appropriate prescription and use of antibiotics in order to

minimize the emergence of resistant strains. Passed.
6.PUBLIC HEALTH FUNDING IN ARIZONA: Calls on the
association to support increased, strategic and transparent
funding for state and county public health. Passed.
7.POSITION ON LEGALIZING RECREATIONAL MARIJUANA: On
November 8, Arizonans may have the opportunity to approve an
initiative permitting the recreational use of Marijuana. In this
resolution, ArMAs Committee on Public Health calls on the state
association to not take a position on recreational use. Failed.
8.TRANSFER JURISDICTION OVER REQUIRED CLINICAL SKILLS
EXAMINATIONS TO U.S. MEDICAL SCHOOLS: Asks ArMA
delegates to AMA to work through the AMA and the Federation
of State Medical Boards and state medical
licensing boards to advocate for the
elimination of the exam as a requirement for
Liaison Committee on Medical Education
accredited graduates who have passed a
school-administered clinical skills
examination. 2) Update AMAs directive on
clinical skills assessment by determining and
disseminating to medical schools a
description of what constitutes appropriate
compliance with the accreditation standard
that schools should develop a system of
assessment to assure students have
acquired and can demonstrate core clinical
skills and require that medical students
attending LCME-accredited institutions pass a
school-administered clinical skills
examination to graduate from medical
school. Passed.
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Note: AMA passed this resolution at their

annual meeting on June 15th.
9.MEDICAL SCHOOL AUTONOMY: Directs
ArMA to work to ensure that the Liaison
Committee on Medical Education accredited
medical schools have independent
governance under the direction of the Dean,
who has both responsibility and authority to
direct the medical school. Passed.
Resolution 1-16 which would allow ArMAs
Board to make changes to its Articles and
bylaws failed while resolution 2-16 expanding
the use of electronic communication for
association business was approved.
Society members attending the meeting
were PCMS President Timothy Fagan MD,
Gary Figge MD, Michael Hamant MD, Tom
Hicks MD, Jane Orient MD, Dick Dale MD
and medical students Jared Brock and
Danny Hintze.
If you are interested in being a Society Board
member, ArMA annual meeting delegate or
would like to submit a resolution for
consideration, please contact me at
billf5199@gmail.com.
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Q&A
Transplant Program Alive and Well

By Bill Fearneyhough
recently sat with PCMS

member Scott Lick MD,
Professor of Surgery at the
University of Arizona, to
discuss the Universitys storied
heart and lung transplant
programs. Many in the
medical community have been
wondering if the programs are
still active after Jack Copelands
departure about five years
ago. Scott returned to Tucson
in 2014 as Director of the
Universitys Heart and Lung
transplant programs, and was
glad to set the record straight:
Scott D. Lick, MD
Q: Is U of Arizona still
transplanting hearts and
lungs?
A: Yes, the heart and lung transplant programs are alive and
well at U of Arizona!
Q: Why havent we heard more about them?
A: The lung program was pretty much shut down for three
years, as there was a long period without any lung transplant
surgeon. We re-started it March 2015 and are keeping a low
publicity profile until we get Medicare re-approval which we
applied for earlier this year, immediately after we completed
our 10th lung transplant. Next comes their site visit to certify
us. Most insurers follow Medicares suit. So once we regain
Medicares blessing, well play the trumpets!
The heart program was closed for a shorter time, for the same
reason; it re-opened in mid-2014 and continues to be a
Medicare-approved program.
Q: Why did the programs temporarily close?
A: Frankly, the place went through a post-Copeland purge: the
previous Chairman of Surgery made life uncomfortable for
anyone tied to Jack, and they left. And they were the heart and
lung transplant surgeons. It went through some dark times.
Light started re-emerging shortly before Leigh Neumayer, MD,
became Chair of Surgery in 2014. She understands that
thoracic transplant is a core identity of the Department of
Surgery. She is one of our biggest champions.
Q: Is U of A still implanting ventricular assist devices and
artificial hearts?
A: Definitely. We still have the whole Artificial Heart
Department intact, including Rich Smith, MSEE, who has been
running that show for some three decades. We implant all the
currently approved long-term devices: Heartware, Heartmate,
and the SynCardia total artificial heart (TAH). Were involved in
TAH trials, and implant devices as both bridges-to-transplant,
16
and as end-destination therapy. We have clinical engineers on

call 24/7, along with clinical VAD coordinators. Zain Khalpey
MD, PhD, is the surgeon in charge of the devices, and he loves
device patients.
Q: How does the acquisition by Banner Health play into this?
A: First, the Banner purchase stabilized our hospital, which had
been losing money hand over fist. Our fiscal goal this year is to
break even, and well be close to that. We needed to pull out of
that financial dive to be around for the future and do what we
do well.
Second, in Banners chain of 20-some hospitals, we are the only
hospital that does thoracic organ transplants. So were a
natural complement to their system.
Third, Banner is building us a new hospital. Were long overdue
for one.
Q: How did you end up here?
A: I trained here 87 to 94, in General Surgery and then in CT
Surgery, under Jack Copeland, and then went off to run the
heart and lung transplant programs at the University of Texas
Medical Branch (UTMB), which is on Galveston Island, Texas.
UTMB is the oldest medical school west of the Mississippi, with
a long teaching history. There I learned a different school of
cardiac surgery from the division chief, Vince Conti MD -basically, the University of Alabama at Birmingham technique.
So I consider myself double-trained. Long story short, after two
decades at UTMB, the U of Arizona needed someone who does
exactly what I do: teach a cardiac surgery resident to operate,
and run the heart and lung transplant programs. So I came back
in 2014. And its good to be back!
Q: How does U of A Cardiothoracic Surgery fit into the Tucson
medical picture?
A: Like a lot of academic CT Surgery programs around the
country, we take on project patients other surgeons and
hospitals wont or cant. Such patients often need the blood
banking, critical care and anesthesiology support a trauma and
academic center provides. And these cases are great for
teaching, particularly residents, which is our core mission.
Examples would be ECMO, endocarditis needing a homograft,
aortic dissections, post-infarct ventricular septal ruptures, VADs
and transplants.
We are under no delusion that bread-and-butter cases will be
sent to us in large numbers from outside hospitals (although we
always welcome the business!). But we do fill a complementary
role for them.
Q: What makes a good transplant candidate?
A: The overlying theme is single-organ disease that is
progressive despite all other therapies. By single-organ, I mean
their other organs have to be working reasonably well. We do
make the occasional exception, such as a young patient in need
Q: What else is going on in CT Surgery at U of A?

A: Mary Jane Barth, MD, a senior congenital heart surgeon in
Oklahoma, is coming to re-start our congenital heart surgery
program this year. All residency programs throughout the
hospital radiology, pulmonary, pediatrics, etc - gain from having
congenital heart surgery in house, so thats an important boost.
of a combined heart/kidney transplant. But single-organ

disease is a good general rule.
Q: Why should community physicians send thoracic organ
failure patients to U of A? Wont they just disappear into a
black box?
A: First, a lot of cardiologists dont really want to take care of
heart failure patients. Readmission is always looming over
them, with bad reimbursement implications for the hospital.
And, it is a labor-intensive patient group. So
we have built, under Nancy Sweitzer MD, PhD,
a full-time cardiology heart failure service. They like taking care
of these patients. And they will work with the referring doc so
that its not a black box.
Sam Kim, MD, has developed a nice trachea resection practice.

At five-10 resections/year, he does more each year than many
thoracic surgeons do in a career. So he is a local treasure, and a
good resource.
We put into place some standardized improvements to the
adult heart surgery practice after 2014 (mainly, intra-op heart
preservation, cardiac exposure, and timing of operation). As a
result, mortality plummeted. Were now getting better-thanexpected risk-adjusted mortality for both cardiac and thoracic
surgery. The University Health Consortium recently came out
risk-adjusted mortality rankings for 2015: We ranked 17th of 117
academic cardiac surgery programs, and 3rd of 105 academic
thoracic surgery programs. In investment parlance, were
beating the Street. So you can rest assured your patients will
get a good operation at U of A.
Second, it is far better to refer patients earlier than later. Its

not so much a referral for transplant as a referral for possible
transplant. We see a lot of people who are too early for
transplant, and thats fine. They benefit from a second set of
eyes, and we identify in advance if there are other issues to
address before considering a transplant.
The tragedy is when one is referred too late: non-ambulatory,
kidneys failing, cachectic. We often cant help them, as theyre
too far gone to survive any operation lung transplant, heart
transplant, or VAD.
These same reforms directly led to better teaching of residents,

because when heart preservation is predictably good and
exposure is good, you can teach. So the CT Surgery residents
are being taught how to do predictably safe surgery.
Third, there is a life-long relationship of necessity between a

transplant recipient and hospital. We werent made to have
someone elses organs, and so follow-up is forever. If a patient is
from Tucson, it certainly is easier for her to have her posttransplant follow-up in Tucson! Think local, and stay local.
Q: How experienced are the U of Arizonas
current transplant teams?
A: In a word: very.
On the lung side, Steve Knoper, our primary
transplant pulmonologist, has been taking
care of lung recipients since we were
residents together in the early 1990s. Our
other transplant pulmonologists include
Josh Malo, Jim Kneppler, Janet Campion
and Afshin Sam -- and two mid-levels,
Christopher Prescott and Hossai Shah.
Importantly, we have very experienced
transplant pulmonologist allies in Phoenix
(Banner Good Samaritan) who carry dual
appointments with us Rajeev Saggar and
Tony Hodges. We do a lot of
teleconferences with them, and they are
part of our program.
On the heart side, the transplant/heart
failure cardiologists are Nancy Sweitzer,
Mark Friedman, Prakash Suranarayana,
Elizabeth Juneman, and Jennifer Cook.
Along with them, we have 2 midlevels, Pam
Pomeroy and Sharon Gregoir.
As for surgeons, Sam Kim and I do the lung
transplants, and Zain Khalpey and I do the
heart transplants. Ive done well over 100
lung and 200 heart transplants over the last
20-plus years.
So we have seasoned teams and deep benches.
These are good days for U of A CT Surgery.

We really look forward to building the transplant and VAD
programs, and working with the community.
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17
Opinion
Fix or Bury the Stark Law

By Robert J. Milligan and Steven T. Lawrence
hen are we going to fix or bury the so-called Stark Law?

The law, which started as an attempt to establish bright
line rules governing physician referrals for certain designated
health services has deteriorated into a regulatory morass that is
so complex, counter-intuitive and dysfunctional that even the
architect of the law, former United States Representative H.
Fortney Stark has called for its repeal.
While Representative Stark feels strongly enough about the
problems with his namesake law to express his opinion publicly,
national physician and hospital associations have been curiously
silent on the subject. This silence has continued through years in
which enforcement agencies and private plaintiffs (and their
attorneys) have used the Stark law to extract hundreds of millions
of dollars from physicians and other providers, often based on
conduct that most people would characterize as honest mistakes.
Perhaps these organizations fear that if they speak up for changes
to or elimination of the law, they will be cast as proponents of
fraud and abuse, the tactically brilliant name that proponents
of Stark and other laws have created to encompass conduct
ranging from intentional crimes to honest and understandable
mistakes regarding compliance with the horribly complex rules
governing whether, how and when providers can bill for
medically necessary services. In any event, it is time for
physicians to stop being silent.
This article provides a brief history of the law, from its reasonably
well-intentioned origins through years of regulatory tinkering, to
its current form. It also summarizes the basic features and flaws of
the law, and the penalties associated with violations (including
innocent violations of the law). Following a brief discussion of the
enforcement environment, we offer a few suggestions for change,
and a request for physicians to take the lead in pushing for change.
A Brief History
Frustrated with the need to prove intent to establish a violation
of the federal Anti-Kickback Act, one of Representative Starks
staffers proposed the idea of a statute that would establish a
18
bright line test for regulating financial incentives relating to

physician referrals. The staffer was an attorney and physician (a
bit of irony) whom Stark later characterized as the worst kind of
staffer. That suggestion led in 1989 to the passage of Stark I,
which regulated physician referrals to laboratories owned by the
physicians. Physician ownership of labs was targeted initially
because of evidence that physicians who owned labs ordered 45%
more lab services than physicians who did not have ownership.
In the years following the adoption of Stark I, multiple studies
demonstrated an association between ownership and increased
utilization for a variety of other types of ancillary services.
Concerns prompted by those studies led to the passage in 1993
of Stark II, which expanded the application of the law to ten
designated health services (DHS), including imaging, therapy,
outpatient drugs, hospital services and other services.
In addition to these statutory changes, regulations adopted
under the law were proposed, modified, implemented, modified
again, and clarified on what seemed like an annual basis since
the 1990s.1 These efforts, which consumed more than 850 pages
of federal publications (by way of comparison, Anna Karenina
weighs in at 864 pages), reflected the challenge of reconciling a
bright line test with the complex and continuously changing
reality of health care. In some cases, these changes worked what
can only be characterized as an injustice. For example, one group
of physicians paid a six figure penalty because of an arrangement
that was perfectly legal when it was structured, but became
perfectly illegal as a result of a change in the law. The bright line
has become an impenetrable maze.
The Current State of Affairs
As currently embodied, the law prohibits a physician; from
making a referral; of a Medicare or Medicaid patient; to an
entity; with which the physician; or an immediate family
member; has a financial relationship; if the referral involves
designated health services; unless an exception applies. Each of
the underlined terms is defined, clarified or otherwise
expounded upon in the federal publications referenced above.
For example, there currently are thirty five exceptions to this

bright line rule, and the definitions and commentary on many of
these exceptions occupy many pages of text in documents issued
over the years. Few of the exceptions are simple and
straightforward; some are impenetrable and counter-intuitive.
The byzantine complexity of the law was one of the reasons
reported for Representative Starks criticism of his namesake in
2007. According to an article on the Forbes blog that year, (Stark
Regrets: I shouldnt Have Written That Law):
While the laws intent was good, the law banning these
businesses might have done more harm than good,[Stark] says
now: It gave every shyster and promoter a loophole. A whole
industry of Stark-compliant businesses was born--not unlike the
sector devoted to tax avoidance. Stark had to rewrite and clarify
the laws in 1995, and theres still debate about it.... We now
have to keep rewriting the laws like the tax code,Stark says.
Stark says that today hed go back and strip [out] the original fuzzy
language so the law simply forbids kickbacks. I think we would have
stopped more of the shenanigans that way, he says. He concedes
that he created a whole cottage industry of entrepreneurs and Stark
law firms that create and sign off on convoluted legal arrangements
between doctors and their vendors.
Representative Stark called for a repeal of the law, as it currently
exists, in a 2013 article in Modern Healthcare.com. Neither his
former legislative colleagues nor health care associations have
expressed much interest in making an effort to pursue that
suggestion.
To compound problems that arise because of the complexity of
the law, the penalties are downright confiscatory. For starters,
the entity to which a prohibited referral is made (e.g., a physician
practice that provides DHS and does not fit within the applicable
exception) is prohibited from submitting a claim for the service,
regardless of whether the service is medically necessary and
otherwise appropriate. For the referring physicians, sanctions
include civil monetary penalties of up to $15,000 per prohibited
referral and possible exclusion from Medicare and Medicaid.
Thats just for starters. Government agencies and private qui tam
relators routinely and successfully take the position that by
submitting a claim arising out of an arrangement that violates the
Stark law, the entity also has violated False Claims Act. A violation
of the False Claims Act in turn carries potential penalties of
between $5,500 and $11,000 per claim. To provide a sense of how
quickly those penalties can add up to real money, consider United
States v Krizek. In that case, a psychiatrist who was charged with
FCA violations (not involving Stark) relating to claims totaling
$245,392 faced a possible damage award of $80,750,000.]
We are not done yet. If a physician practice learns that claims
submitted and paid previously were not billable because of the
Stark law, and fails to promptly report and repay those claims, the
practice can be exposed to additional False Claims Act liability
and criminal prosecution.
The Enforcement Environment
Enforcement activities relating to the full spectrum of health care
laws have been an extremely lucrative business. For example,
the March, 2015 joint DOJ/OIG press release reported that
enforcement activities generated $3.3 billion dollars in

recoveries. This amounted to a return on investment of nearly
$8:$1, and the ROI has at approximately that level for several
years. The fiscal year 2012 report by the DHHS Health Care Fraud
and Abuse Program stated that enforcement activities had
generated $23 billion in recoveries since 1997.
Given that return, it is not surprising that the federal budget has
included hefty investments in enforcement activities. For
example, the Affordable Care Act included $10 million in
additional funding for the Health Care Fraud and Abuse Control
Account, $250 million per year in additional funding for the
Medicare Integrity Program and $75 million per year in additional
funding for the Medicaid Integrity Program.
In addition to federal initiatives, private parties and their
attorneys are very active pursuing False Claims Act whistleblower cases, alleging that arrangements that violated the Stark
law give rise to False Claims Act violations. These private whistleblowers, known as qui tam relators, bring suit on behalf of the
government, and they are entitled to between fifteen and thirty
percent of any recovery. A January 8, 2016 Google search for
health care whistleblower attorneys yielded 870,000 hits. It
seems very unlikely that the public or private appetite for these
cases will diminish any time soon.
The low point, to date, in Stark-related enforcement activities is
almost certainly US ex rel Kunz v Halifax. In that case, a hospital
employed medical several medical oncologists, and it established
a compensation system that included bonuses from a profit pool
that averaged approximately $250,000 per year. This pool
yielded average bonus compensation of about $40,000 per
physician per year.
The lawsuit filed by the qui tam relator took the position that the
mechanism for funding the pool violated the Stark law. Many
health care attorneys disagree with this position. Unfortunately,
the trial judge agreed with the relator and entered an order
setting the hospital on course for a trial in which the hospital
faced a $1 billion damage award if it lost the case. Ultimately, the
hospital settled the case for $85,000,000, plus an additional
$10,000,000 for the relators attorneys fees, on top of
$23,400,000 in legal fees spent to defend itself. That is a lot of
money that will not be available for patient care.
Possible Solutions
The most appealing solution would be to abolish the law, and to rely
on the Anti-Kickback Act to regulate financial incentives relating to
referrals. Admittedly, that seems unlikely. A combination of other
less dramatic goals might effect a significant improvement over the
status quo, however. For example, the potential sanctions for Stark
violations might be lessened dramatically, so that the sanctions are
at least somewhat proportionate to the seriousness of the
transgression. Also, the law might be changed to require a showing
that the referring physician knowingly (or recklessly, etc.) made a
prohibited referral.
Taking a slightly different tack, the law could be amended to
provide an exception to the Stark prohibition for providers who
disclose the existence of an otherwise prohibited financial
relationship to the patient and the payor; that type of free
market approach would allow patients and payors to scrutinize
19
carefully any referral decisions that might be influenced by

financial considerations. Alternatively, an exception might be
created for situations in which whatever compensation the
physician received as a result of a financial relationship with an
entity is fair market value for the services the physician provided
to, or the investment the physician made in, the entity.
Conclusion
It will not be an easy task to persuade Congress to change a
fundamental part of a regulatory scheme that raises billions of
dollars a year. The fact that it will not be easy does not mean it
cannot be done, or that the effort should not be made. No one
else is going to make the effort. If physicians and their national
associations fail to take action, things will continue to get worse,
and they may never get better.
About the Authors:
Robert J. Milligan is a
shareholder in the Phoenix,
Arizona law firm of Milligan
Lawless, P.C. He focuses his
practice on the representation
of physicians, physician
organizations and other health
care and life sciences clients,
providing advice on a wide
variety of matters including
business transactions,
regulatory compliance,
licensing, medical research,
professional liability and risk
management.
Mr. Milligan is a director of the Arizona Association of Health Care
Lawyers. He is a frequent speaker, panelist and author on health
care issues and life sciences issues, and is often quoted in local
and national media on those issues.
In addition to his law degree from De Paul University, Mr. Milligan

has a Masters of Law (LL.M.) degree in Biotechnology and
Genomics from the Sandra Day OConnor College of Law at
Arizona State University. He is listed in The Best Lawyers in
America, and in Chambers USA, for health care law.
Steven T. Lawrence is a
shareholder in Milligan
Lawless, and focuses his
practice on healthcare
transactions, including practice
acquisitions, employment
arrangements and hospitalphysician transactions. Steve is
listed in Best Lawyers in
America for Corporate Law and
Chambers USA for
Corporate/M&A Law.
Steve holds a J.D. With
Distinction from the University
of the Pacific McGeorge School of Law, a M.B.A. from the W.P.
Carey School of Business at Arizona State University and a B.S. in
Business Administration from California State University,
Sacramento. Steve holds a Master of Laws (LL.M.) in Health Law
from Loyola University Chicago. He also holds a Master of Laws
(LL.M.) in Health Law from Loyola University Chicago. In
obtaining his LL.M. degree he prepared and defended a thesis
entitled The Stark Law: Revisions are Mandated To Grow the
American Healthcare System, which argues for substantial
changes in the Stark Law.
1
There have been a total of 32 proposed and final changes, clarifications, etc.
since 1992, including nine in the last ten years, as follows: 1992 (proposed rule),
1995 (final rule), 1998 (proposed rule), 2001 (phase 1 final rule), 2004 (phase II
final rule), 2005 (proposed and final rules), 2006 (proposed and final rules), 2007
(proposed and final rules, phase III final rule), 2008 (proposed and final rules),
2009 (proposed and final rules), 2010 (proposed and final rules), 2011 (proposed
and final rules), 2013 (final rule), 2014 (final rule), 2015 (final rule).
20
Southwestern Conference on Medicine
TOMF Conference celebrates 25 years with

record number of attendees
By Tyler Smith, TOMF Program Associate
record 424 physicians,

physician assistants and
nurse prac- .tioners from 28
states gathered at The Westin
La Paloma April 28-May 1 for
30 hours of CME during the
silver anniversary of the
Southwestern Conference on
Medicine, presented by the
Tucson Osteopathic Medical
Foundation (TOMF) in joint
providership with Cleveland
Clinic. The conference,
founded in 1991, has become
known for its first-rate primary
care continuing medical
education and use of local
physician speakers.
Our boost in attendance,
especially among MDs and out
of state osteopathic physicians,
can be attributed to seeking
American Academy of Family
Physicians prescribed credits
for the first time, said Nicole
Struck, TOMF program and
meetings manager.
Without the year-long, behind the scenes efforts of staff the Southwestern Conference on Medicine
would just be another CME event: L-R: Susan Henderson, TOMF director of operations; Nicole
Struck program & meetings manager; Tyler Smith, program associate; Csilla Myers manager of
global CME at the Center for International Medical Education at Cleveland Clinic and Daniella
Elliott, TOMF administrative assistant.
That, and the fact weve done this for 25 years, said Steve Nash,
TOMF executive director. You learn some things over a quarter
of a century.
TOMFs joint provider relationship with Cleveland Clinic means
AMA PRA Category 1 Credits and AOA Category 1A Credits can be
offered at the same time.
The Southwestern Conference on Medicine was first held in 1991
at what is now the Omni Resort. It moved to Westward Look,
which built a conference room to accommodate the annual event,
and remained there until it outgrew that space. It has been held at
JW Marriott Starr Pass and The Westin La Paloma since.
I recall attending the first or second Conference out at Tucson
National, Nash said, It was a little like being back in high school
with 20 or 30 of us sitting at desks and taking notes; seeing a filled
ballroom today with more than 400 is something I never
dreamed of 25 years ago.
William C. Ludt DO, the first osteopathic physician to serve on the

PCMS Board of Directors and recent retiree from Carondelet
Medical Group, attended the first conference and served on the
first iteration of the Conference Planning Committee. There was
a physician from Phoenix who was kind enough to come down for
our first program, Ludt recalls. And at the end he thanked me
and said, This is a very good program, but it really isnt going to
go anywhere.
Today the programs that were in Phoenix in 1991 arent there
anymore, Ludt says, The facility that they took place in does
exist anymore and, frankly, we have become the regional site for
southwest physicians in terms of education in primary care.
Sadly, one of TOMFs founding Board members, Harmon L. Myers
DO, died just before the Conference began. Myers, who joined
and worked with the PCMS History Committee in the early 2000s,
died April 4. He had a 41-year medical career in Tucson. The
Conference program was dedicated to him.
21
Dr. Hutchinson oversees

dramatic growth of conference
Jerry Hutchinson, DO did
not start the Southwestern
Conference on Medicine
but, as chair or co-chair
of the event since 1995,
he has been a primary
reason it has grown from
a one-day meeting with
30 DOs to a weekend
event with more than
400 primary care
providers.
A packed conference room gives credence to the tremendous
growth the Southwestern Conference on Medicine has
experienced during these past 25 years.
Conference topics were aimed directly at primary care, with take

home points ranging from the role of diet, exercise and stress in
maintaining a healthy immune system to how to care for
pediatric cancer survivors in adulthood. Workshops included
survival medical Spanish and patient motivation to change
behavior.
Roughly half the Conference speakers are local. The rest of the
faculty flies into Tucson for the Conference.
Local speakers in 2016 included: Robert Aaronson MD, Eric
Bergstrom PharmD, Thomas Coury DO, Archita Desai MD, Sean
Elliott MD, Hemanth Gavini MD, Robert Kahler MD, Lisa Kopp DO,
Victoria Maizes
MD, John Manfredonia DO, Michael Maricic MD, Sang O DO,
Kenneth Snow DO, Sasha Taleban MD, F.P. Wedel DO and
Tirdad Zangeneh DO.
Planning a conference of this magnitude is a year-round affair.
Chairing the Planning Committee is PCMS Board member Jerry H.
Hutchinson, Jr. DO. PCMS President Tim Fagan MD also serves on
the Planning Committee. The Committee meets monthly, and is
already gathering topics and possible speakers for 2017. The
Conference next year will be held at La Paloma, April 27-30.
Others serving on the Planning Committee are Deborah Jane
Power DO, Peter Catalano DO, Issa Y. Hallaq DO, William Inboden
DO, John Manfredonia DO, Bridget Walsh DO and Howard Zveitel
DO. Also serving: Nicole Ciffone FNP-C, Daniel Walton DO from
Phoenix and Leonard Calabrese DO from the Cleveland Clinic,
who serves as the programs Co-Activity Director.
If you have questions about the 2017 Conference, contact Nicole
Struck at TOMF, 299-4545, nicole@tomf.org.
n
There was an obvious

need for primary care
continued education in
the area, said
Hutchinson, a member of the PCMS Board of Directors. It
was not easy to get primary care CME outside the major
metropolitan areas. It started as a way for Tucson physicians
to get primary care CME without having to put in extra
travel time and expenses. Most of the people who attend
are from the southwest, but we are getting more and more
attendees from around the country.
Hutchinson said the growth of the conference, which has
been sponsored every year since 1991 by the Tucson
Osteopathic Medical Foundation, is the quality of the
training. TOMF has partnered with Cleveland Clinic to
bring in AMA accredited programs for MDs helping to
boost attendance.
We have been fortunate to have quality speakers and
the providers who come to our conference are getting
something valuable to take back with them to their
practice, Hutchinson said. Quality primary care CME
has not been as easy to find as compared to some of the
specialties. There were times we veered from primary
care, but I think we are back on track. We want to keep
primary care as the focus of the conference
All money generated from the conference registration fees
goes back into the event. It is not a fund-raiser for TOMF
or any other organization other than costs associated with
the conference. Its not all business. We want those who
attend to enjoy themselves. There arent as many social
outlets as there used to be for physicians to meet, so I
think some like that aspect of the conference.
The impact of training technology has not escaped
Hutchinsons attention. He expects the conference to
evolve as the methods of delivering CME training change.
I hope we can keep the conference on the leading edge
of primary care CME training. Hutchinson said. My
generation is old school and is used to a class-room-style
setting with lectures and slide presentations. As
technologies change and advance, CME training is going
to change with them. I think there will always be a need
for the conference, but to be a leader we are going to
have to adjust as changes come along. Involving the next
generation of physicians is important in keeping the
conference as a leading CME event.
Plans are already under way for next years conference
so they dont plan to be left behind anytime soon.
22
BUMC News
Banner breaks ground on new tower

B
anner University Medical

Center held a
groundbreaking ceremony
May 26, for a $400 million,
nine-story tower schedule to
open in Tucson in early 2019.
It is the centerpiece of a $1
billion construction project
by Banner Health in support
of the UA Colleges of
Medicine and academic
medical centers in Tucson
and Phoenix.
The 670,000-square-foot
facility will feature:
A new main entry, cafeteria

and support departments
on the first floor.
New diagnostic imaging,
diagnostic cardiology,
cardiac cath labs and
interventional radiology
on the second floor.
L-R: Charles Cairns MD, dean, UA College of Medicine Tucson; Ann Weaver Hart, UA president;
Akinlolu Ojo MD, associate vice president for Clinical Research and Health Initiatives, UA Health
Sciences; Kathy Bollinger, executive vice president, Banner University Medicine; Tom Dickson, chief
executive officer, Banner University Medical Center Tucson; Jonathan Rothschild, mayor of Tucson.
New operating rooms and patient prep/recovery space on the

third floor.
204 new patient rooms on floors five through nine.
Woman and Infant Services on the fifth floor.
Medical/surgical and ICU beds on floor six through eight.
Pima County
Medical Foundation
Speakers Series
Sept 13:

Balloon Dilation of the Sinuses,

The Only Constant in Life is Change
Dr. Steven Blatchford.
Medical/surgical beds on the ninth floor.

Shelled space on the ninth floor for 24 future patient rooms.
More than $50 million in new patient care equipment and
computers for state-of-the-art care.
Construction is also under way for the new outpatient Banner
Health Center adjacent to University of Arizona Cancer Center at
Campbell Avenue and Allen Road. At a budget of $100 million,
the three-story center will be 207,000 square feet with 33,000
square feet set aside for future expansion.
October 11:

Treatment of Thrombophlebitis

and other Vascular Problems
Dr. Christopher Compton.
Services will include outpatient, radiation oncology, medical

imaging and adult multi-specialty clinics with more than 100
exam room. Major site improvements are a three-story parking
garage, repaving of Allen Road, increase storm water detention,
modification of the Healing Garden and $20 million in new
patient care equipment and computers.
November 16:

Radiology Ltd. to provide the topic

and speakers.
It is scheduled to open in late 2017 or early 2018.
All programs begin at 7 p.m. at the Tucson

Osteopathic Medical Foundation, 3182 N.
Swan Road.
23
Behind the Lens
Rare Crested Saguaro Attracts City-Wide Visitors

Story and photos by Dr. Hal Tretbar
What happens when you have
a carnegia gigantea forma
cristata growing in your front
yard? You become well- versed
with information about a
crested or cristate saguaro
cactus. Thats because
neighbors and strangers stop
and want to talk about the
bizarre shapes of the normally
straight arms on your saguaro.
Delann and Cliff DeBenedetti
MD have lived on a winding
lane in the Tucson foothills for
decades. Many of their neighbors have large magnificent
saguaros but none have one with the interesting tips suggestive
of broccoli. Over the years they have watched several of the arms
slowly become crested.
The web site for Saguaro National Park states, Crested saguaros
form when cells in the growing stem begin to divide outward,
rather than in the circular pattern of a normal cactus. This is an
unusual mutation which results in the growth of a large fanshaped crest at the growing tip of saguaros main stem or arms.
The crests generally measure between three and five feet.
According to Wikipedia this phenomenon is called fasciation. This
abnormal growth pattern has been found in over 100 plant
species. Crested desert plants include agave, hedgehog, cholla,
and prickly pear. It is not clear what causes these deformities but
may be genetic, hormonal, bacterial, and environmental
exposures.
Delann and Cliff DeBenedetti with a portrait of their front yard

attraction.
Although cristate saguaros are fairly rare, about one in 200,000

normal cacti, there are at least 27 documented on the East side of
Saguaro National Park and 30 of the West side. Other places
around Tucson where crested saguaros are reported to be easily
seen are Colossal Cave Park, Tohono Chul Park, and the ArizonaSonora Desert Museum.
Often a back lighted image is more interesting. The petals and

the bees seem to be spotlighted.
24
The crested saguaro growing in the DeBenedettis front yard has

other peculiarities. It blooms earlier than most saguaros. It starts
in March and April and then again has blossoms in October and
November. This carnegia gigantea has caught the attention of our
local PBS station, Channel 6. They have filmed the cactus and
interviewed Delann and Cliff for an upcoming episode on Arizona
Illustrated.
The bizarre formations are said to resemble broccoli but the

bees dont care if they do.
For some reason the Gila woodpeckers seem to prefer the crests
rather than the stems.
Four of the five tips are crested. This cactus is more unusual
because it blooms twice a year.
A lady from Spokane, Washington photographs the crested

saguaro at the entrance to the Arizona-Sonora Desert Museum.
Delann said, Our cactus is becoming so well known that a lady

who lives on the east side of Tucson brought two of her friends
from Michigan to see the crests and learn about our unusual
saguaro.
. I photographed this cristated saguaro north of Sasabe.
Check out the website: crestedsaguarosociety.org for more

information. Look at the photo gallery to see the multiple
bizarre shapes that develop on the crested arms.
25
Public Health
UA Researcher Helps Map and Advises

Congress on Potential Danger Areas for Zika
W
ith concern growing over a

potential Zika virus epidemic,
a team of scientists with
collaborators from the University of
Arizona has defined higher risk areas
in the United States. The team was
led by National Center for
Atmospheric Research scientist,
Andrew Monaghan, PhD.
Researcher Kacey Ernst, PhD,
MPH,associate professor and
infectious disease epidemiologist at
the UA Mel and Enid Zuckerman
College of Public Health, said the
factors included in the assessment of
the 50 jurisdictions were:
1) The relative modeled abundance
ofAedes aegypt mosquito;
2) Travel from areas where Zika is
currently transmitted; and
3) Poverty as an indicator of vectorhuman contact.
TheAedes aegyptimosquito, which
is spreading the Zika virus in Latin
America and the Caribbean, is
expected to increase across much of
the southern and eastern United
States as the weather warms, according to a recent study led by
mosquito and disease experts at the National Center for
Atmospheric Research (NCAR) and the UA.
See the accompanying map for the best estimate of potential
range of mosquitoes that could transmit the Zika virus, according
to the study. This does not mean that all areas will be affected,
nor does it mean all other areas are guaranteed safe. Mosquito
monitoring and surveillance in the U.S. is not consistent across
jurisdictions, said Dr. Ernst.
The study results are a step toward providing information to the
broader scientific and public health communities on the highest
risk areas for Zika emergence in the U.S., she said, but more
research is needed to determine the role ofAedes albopictus,
which is also capable of transmitting Zika virus and has a broader
geographic range, but does not feed on humans as much
asAedes aegypti. Other gaps include the extrinsic incubation
period of Zika virus and whether there is vertical transmission
from infectedAedes aAegyptifemales to their offspring, which
might mean the virus could survive in eggs that would hatch the
following year.
26
Dr. Ernst spoke before the U.S. House of Representatives

Committee on Science, Space, and Technology, Subcommittee on
Research and Technology, in Washington, D.C., on May 25.
Video and transcript of her testimony can be viewed at: https://
science.house.gov/legislation/hearings/full-committee-hearingscience-zika-dna-epidemic
Mosquito experts recommend removing standing water to help
eliminate breeding grounds. The Centers for Disease Control and
Prevention guidelines are at: http://www.cdc.gov/zika/
prevention/.
A transcript of Dr. Ernsts testimony before the U.S. House of
Representatives Committee on Science, Space, and Technology is
available athttps://science.house.gov/sites/republicans.science.
house.gov/files/documents/HHRG-114-SY-WStateKErnst-20160525.pdf
All committee advisories and news releases are available
athttps://science.house.gov/news

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Pima County Medical Society

SOMBRERO June/July 2016

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24 Behind the Lens: Legend of local crested saguaro

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