APRIL 2009 


Joseph  R.  Kuntze, M.D., CUA President

It seems that, like it or not, change is in the air. The new administration has articulated an intention to 'reform' the health care system. As we all know, change can be good or detrimental. READ MORE

CUA 2008 Accomplishments

By Jeffrey E. Kaufman, M.D., F.A.C.S., Chair, Health Policy Committee, WSAUA

The old Chinese curse "may you live in interesting times" certainly applies to today's health care delivery system and attempts to improve it. READ MORE

William Bonney, M.D.

On March 25th the California Medical Association convened its Council on Legislation, to finalize CMA's position on current issues in the California legislature . READ MORE


AB 646 (Swanson) and AB 648 (Chesbro), two bills which would erode the patient protections of the bar on the corporate practice of medicine in California, took an ominous step towards passage today when they passed the Assembly Business and Professions Committee. READ MORE

Western Section AUA Annual Meeting
Oct. 25-29, 2009, J.W. Marriott
Las Vegas, Nevada

Health Policy Forum
October 25, 2009, J.W. Marriott
Las Vegas, Nevada

CUA Annual Meeting,
October 27, 2009, J.W. Marriott
Las Vegas, Nevada

California Urological Association
1950 Old Tustin Ave.
Santa Ana, CA 92705
TEL: 714-550-9155
FAX: 714-550-9234
WEB: www.cuanet.org

By: Gregg Marshall, CPMR, CSP

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Joseph  R.  Kuntze, M.D., CUA President

It seems that, like it or not, change is in the air. The new administration has articulated an intention to 'reform' the health care system. As we all know, change can be good or detrimental. It is important for all of us to be involved in the system. The emerging consensus is increased funding for primary care (sound familiar?). As providers of primary care services to men we need to access our congressional leaders and make them aware of the value we bring to the system. Whether this is in the form of psa screening, stone prevention, treatment of erectile dysfunction or incontinence, referreral for colonoscopy or noting that high blood pressure; we are the defacto primary providers for many of our patients. When the buck stops, let's be sure some of them stop with us! 

On another note, it seems like the insurance plans continue to throw up road blocks to the delivery of efficient, cost effective care. In the coming months I will ask our staff to contact the major insurers in California and try to get the AUA best practice policies authorization free for the areas in which they have been developed. Hopefully this will decrease the hassle factor and allow us once again to focus on patient care.

CUA 2008 Accomplishments


Jeffrey Kaufman, MD, FACS, Chair, Health Policy Committee - WSAUA

The old Chinese curse "may you live in interesting times" certainly applies to today's health care delivery system and attempts to improve it.  All of you are aware by now of President Obama's plans for health care reform.  But you may not appreciate how significant the proposed changes will be to your day to day practice of urology. 

In order to achieve the goals Congress and the administration have set, we are likely to see a move away from traditional fee-for-service emphasizing instead pay-for-performance unlike anything previously experienced. The new buzzword is Value Based Purchasing, paying for quality of care, not quantity of care. For many, this will present a new paradigm, focusing on wellness and prevention rather than treating disease.  Irrespective of how this is implemented, the one thing we can count on is that change is coming.

Even though the president has listed 8 principles he would like to see incorporated into any new plan, at the time of writing this report legislation has not yet been presented and the final details are still being decided.  Therefore, what follows is a broad outline of where we are today and what we are likely to see introduced into Congress in the next couple of months.  Bear in mind that the timeline will be short in order to have passage this year and there are strong political reasons why it must be done before 2010 if it is to be done at all.  In order to have a bill passed before the August break, legislation must be ready to be marked up by June.  That means that staff is putting pen to paper ironing out the details of their new plan as we speak.  In response, the Western Section representatives, the AUA and the AACU must be ready to respond as soon as those details are known in order to protect our practices and our patients.  Certainly every other stake holder is actively involved and advocating for their own narrow special interests-often at cross purposes to ours.

For the past several years, our efforts inWashington D.C. have focused on trying to convince lawmakers how badly the system is flawed.  In that respect, there is no disagreement today that health care delivery in America is in crisis.  In 2007, total health care expenditures constituted 16% of the entire Gross Domestic Product.  That figure increases by 2025 to 25%, an unsustainable amount that crowds out spending on other vital services.  The debate more recently has focused on how to fix the system and how to pay for that reform.  From March 14-17, 2009, the AACU and AUA worked together to sponsor urology's fourth annual Joint Advocacy Conference in Washington, D.C.  As usual, this year, with a record turnout of more than 135 urologists from all over the country, the Western Section was heavily represented.  As part of the meeting, we spent time visiting with the Congress, Senate and their staffers (the ones who actually do the work and write the bills) in a very successful attempt to have them understand our concerns.  Coming as it did just as the decisions are being made on how to best craft legislation, our efforts were particularly focused this year.  Of course, what final appearance reform will take depends on how it is funded and what political horse trades are necessary to secure passage.  What we can count is that the bill will have something for every stakeholder to hate.  No one will love every part of the new system, but that is the compromise necessary to move this plan forward. 

Although many different proposals are currently being discussed, they all have in common 3 basic goals: improving access to care, improving the quality of care delivered and controlling costsOur concern as urologists is that we are included in the decision making of how quality is defined and measured, that the quality measures do not become new unfunded mandates, that oversight and regulation do not become so burdensome that practices are strangled, that we continue to control those elements of urologic practice necessary to insure proper outcomes (especially with respect to participating in various ancillary services that improve patient care such as imaging, ASCs and radiation therapy) and that we are fairly compensated for our efforts. 

Although we have been reasonably successful so far at controlling the processes that define quality care, major challenges remain:  barriers are being raised to participation in ancillary services, the carrot and stick approach to encouraging performance promises to emphasize the stick more than the carrot and the ongoing principle of "budget neutrality" poses a major threat as Congress adjusts fee schedules to value primary care services at the expense of all other care, shifting major funding away from specialists toward various forms of bundled payments that favor family doctors and some internists.

Although some feel that reform may not succeed unless sufficient funding is secured, Obama's current budget proposal and recent legislation have already begun the process.  In addition to requesting $634 billion as part of his new budget to be set aside as a down payment on reform, other funds have already been approved.  Twenty billion dollars have already been committed to develop health information technology that will become uniform, interoperable and universal across all elements of health care.  It is now taken as an article of faith in Washington that electronic health records are necessary for the salvation of the system.  The experts are convinced that using proper software will cut costs, avoid duplicative efforts and testing, and improve quality.  Obviously, there are many challenges to this dream that remain unsolved but those writing reform legislation have no doubt they will be overcome.

As part of that effort, the carrot and stick model promises bonuses that diminish over time to physicians who participate in electronic records beginning in 2011 totaling $44,000 before transitioning to increasing penalties up to 3% of total Medicare allowable charges or more for failing to use HIT starting 2015.  Already, bonuses of 2% of Medicare allowable charges are available beginning this year for the use of electronic prescribing.  By 2012, failure to use approved ERx will result in penalties up to 2%.  At the same time, the PQRI pay for performance process remains funded for at least another year providing an opportunity for additional 2% of Medicare allowable charges as bonus although it is unknown whether this too might develop into a penalty for failure to participate in the future.  In a similar fashion, we can count on future bonuses and penalties to encourage cooperation in other efforts to improve quality and cut costs.

At the same time, $1.1 billion has already been funded for Comparative Effectiveness Research.  While some would term this "rationing", the intent is to critically analyze data in order to determine what treatments provide the best outcomes at the best price.  The addition of the cost component to outcome measures raises concerns among many groups that the new system will not be able to provide everything to everyone, when they want it, all the time.  If cost is the product of price times quantity (C=PxQ) and cutting fees is a crude undesirable tool, then the variable that remains to manipulate has to be quantity.  Indeed, those with the political courage to speak out acknowledge that in order to control the burgeoning costs of healthcare, some limits will be necessary.  Panels have already been established to oversee this research and funding for grants is already available.  Unfortunately, because of economic pressures, this research is likely contribute to more aggressive turf battles as one specialty or area of focus tries to dominate treatment of a particular condition.  Therefore, it is important that urology retains the lead in this research, developing appropriate evidence based guidelines and standards so that we-and no one else-retain control of our areas of expertise.

Up until this year, one of our biggest demands of Congress was that the failed Sustained Growth Rate formula used to update Medicare fees be revised.  Since most private payers in one way or another base reimbursement on this figure, all payments are ultimately controlled by a system that is based on incorrect data, includes costs for part B drugs that are out of our control and artificially limits volume by relating health care expenditures to the Gross Domestic Product.  Updates from this calculation have been negative for many years but Congress, to avert steep cuts, has repeatedly and temporarily suspended each cut back in favor of small increases that still have not kept up with inflation (never mind accounting for substantial increases in overhead).  Because those updates were simply loans-never a gift--which the SGR formula demanded be repaid, each delayed cut caused the final adjustment to be steeper and steeper creating a debt Congress was unable to resolve.

Fortunately for us, since the current economic crisis has bloomed and figures are now thrown around Washington in the trillions of dollars without embarrassment, the amount of money necessary to "re-base" the SGR seems small in comparison.  Indeed, in Obama's budget, he has called for $330 billion to resolve the previous deficit and at the least, avoid an impending 40% cut in Medicare fees over the next couple of years.  Even if little else is done to correct the SGR formula, this forgiveness of past loans will completely alter the trajectory of future updates.  Coupled with the recommendation that part B drugs be removed from the formula (an adjustment worth $170 billion), we now project a modest increase over time.  However, no one is satisfied that the SGR as it's currently structured is accomplishing what it was intended for-to control volume and costs in the system overall.  The logical response for any given physician faced with diminishing fees is to increase his own volume of work.  This is exactly the opposite of what was intended and as a consequence, the SGR will never succeed.  

Revised plans are targeting what are perceived as the biggest growth areas in medical care: office based testing, minor procedures and high end imaging.  Reform will involve cutting and redistributing fees, re-aligning priorities, removing incentives, bundling fees, withholding payment for bad outcomes and rewarding value.  Current proposals to replace the SGR include substituting 6 different targets for the current monolithic structure (separate limits for primary care E&M, all other E&M, major surgeries, minor procedures, imaging and labs, anesthesia,etc). 

Although this new plan might bode well for some urology practices depending on the nature of any given individual office, the revised formula involves transferring funds to reward and support primary care which is   viewed as a specialty threatened with extinction by an array of economic forces.  As such, there is wide spread sympathy in Washington that differentially greater reimbursement must be given which, because of budget neutrality restrictions, will come at the expense of specialists.  Although we have argued that robbing surgeon Peter to pay family doctor Paul will have unintended negative consequences, Congress is set to implement this transfer in one way or another.

This asymmetric shift in funding may be done in various ways: bundled payments may be given to a hospital-based groups surrounding a major event such as cancer or open heart surgery (Events of Care), to an outpatient group responsible for managing chronic medical disease such as diabetes or CHF (Accountable Care Organizations) or physicians may be allowed to participate in savings derived from efficient cost effective treatments without violating kick back laws (gain sharing).  Each of these proposals to bundle payments threatens specialists since it gives over authority on how to divide up payments to someone with an inherent conflict of interest (do you really want your local hospital deciding your fee schedule?).  However, the most politically popular concept at present is for the Medical Home.

Viewed as a team focusing on integrated health care services emphasizing preventative care and chronic disease management, all of which is necessary to control costs, the Medical Home looks like a hybrid of the classic family medicine practice crossed with the gate keeper, capitated managed care model.  While few could argue that better coordination of care will improve quality and cut costs, shifting funds from specialty care to this structure will be detrimental to urology practices and recalls memories of what impact using gate keepers had on efficient specialty referral. 

Despite arguing that many urologists already serve as the "principle" (if not "primary") health care provider for many of their patients, proposed models for the Medical Home will not allow urology participation.  While we acknowledge the value of primary care and even support the concept of a Medical Home, we have argued that any increase in financial support should not invoke budget neutral offsets to other health care providers.  Congress intends to pay more to family physicians for services beyond the classic face to face episode, such as time spent on the phone coordinating care for their patients.  Who do they think is on the other end of that phone call spending equal time integrating treatment?  We are and we deserve equal consideration.

In another effort to realign priorities and remove incentives for what is perceived as over-utilization, Congress seems predisposed to closing out all participation in ancillary services.  As you know by now, an accommodation has been reached to allow most lithotripsy partnerships to continue, even using "per click" reimbursement.  Restructuring ESWL treatments to provide a "service" instead of renting equipment avoids Stark prohibitions.  Unfortunately, because of language in the law, this understanding does not extend to other partnerships such as laser, microwave, and cryotherapy units although a lawsuit has recently been filed in this regard. 

Similarly, rules prohibiting pathology and imaging partnerships have been modified to allow some participation as long as the arrangement meets legal criteria.  Unfortunately, urologists' continued use of in office imaging equipment continues to come under attack from organized radiology.  It is imperative that we remain alert to proposed legislation nationally and locally and make our case to legislators that since no one knows our patients better, we should retain control of any testing necessary for diagnosis and treatment.  This threat is especially important with respect to urology involvement with radiation treatment partnerships.  Radiation oncologists have repeatedly attempted to nullify Stark safe harbors by changing the definition of "ancillary services" (a legal term of art) in the AMA House of Delegates as well as in the halls of Congress.  We are hoping to open dialogue with them to show that their efforts will have negative results for their own members but much work remains in this respect. 

Space prohibits discussing many more challenges in detail.  However, it is important for the Section to note the amount of resources and energy now devoted by the AUA to health policy.  In addition to a much larger division with much more staff support and a robust committee structure involving many urologists from around the country, the AUA board of directors has made a clear and emphatic statement that they will continue to fund and emphasize these efforts. 

Out of the 2009 AUA budget of $39 million, although health policy related revenues only comprise $1.26 million, the health policy budget totals $5.935 million.  Funding lobbyists, supporting multiple committee activities, opening a new Washington D.C. office and expanding individual urologists' involvement, we are well positioned to address whatever new changes health care reform creates.


William Bonney, M.D.

On March 25th the California Medical Association convened its Council on Legislation, to finalize CMA's position on current issues in the California legislature.

Listed below are selected legislative issues of possible interest to our CUA members.  If theses or other issues concern you, please use this website to identify your California Senate and Assembly members.  Call or send e-mail to the appropriate Legislative Assistant in each office.

Official California Legislative Information
-- Home Page
-- Updates on specific Assembly or Senate bills
-- To contact legislative members from your own district


(This was a major issue discussed at the Council on Legislation)

A. The Process:

Mandated by JCAOH (Joint Commission for Accreditation of Hospitals and Clinics), hospitals must retrieve patient records a) by random sample, also b) for all cases with major complications. 

These are reviewed by hospital staff colleagues in each specialty, with the process and conclusions reviewed by a locally appointed Hearing Officer.  The physician under review can negotiate for further review by an outside, independent review body.  For physicians with repeated adverse outcomes, remedial professional education is required, or hospital privileges may be suspended.

The Peer Review Process is systematic and fair in most hospitals, but there are flaws in many situations.  In 2007 CMA created a committee to review this process.  

The CMA committee's recommendations included:
a. A clear policy which condemns 'sham peer review' for professional competitive reasons or administrative preferences.  Peer review is only to ensure patient safety and quality of care. 
b. Hospital contracts may not exclude the Peer Review and Report process.  Medical staff must oversee Quality of Care.
c. Hearing Officer must be an attorney, able to streamline the Review/Hearing process.
d. Hearing Officer is mutually selected by all parties in the review process.
e. External Peer Review (by outside body) must be provided if requested.
f. The judicial review committee must include one physician with the same licensure and another of the same specialty as the physician under review.

(In addition, any electronic medical records under review must remain secure.)

B.   '805' Reports:

California law, Sections 805 and 805.1 of the Business and Professions Code, specify certain peer review outcomes which require the hospital to submit an '805 report' to the Medical Board of California. About 150 of these '805 reports' are submitted each year, but many others are never sent forward--often because the physician under review voluntary withdrew from hospital privileges early in the review process.  (Therefore, these records are not representative outcomes data for assessment of the Peer Review process.)

C. The Lumetra Report:

 Lumetra is the western region's Medicare Quality Improvement Organization that won a bid from the Medical Board of California in 2007 to perform a comprehensive study of California's peer review system (to determine if functions well).  This study was mandated by the Legislature, and the final report was released in July 2008.  It's conclusions are critical of the Peer Review process.

The CMA has analyzed this report and questions its validity. The number of '805 reports' submitted each year is not a quality marker of Peer Review. The 805 generally follows comprehensive review of a physician after multiple complications.  On the other hand, most Peer Review is conducted early (to prevent complications) and therefore does not generate an 805.  Of the 366 hospitals under review, Lumetra visited only 6.  In Lumetra's direct physician survey, most respondents declined to submit the documents needed to evaluate the peer review process in each case.  

D.  Peer Review Legislative Action:

1.  Co-sponsored by CMA:

AB 120 (Hayashi) PEER REVIEW

Nearly all peer review done in California is done efficiently, timely, and in a manner that protects patients from quality of care deficiencies.  However, the current peer review system can be strengthened.  For example, improper or biased review can be utilized to remove physicians for non-quality of care concerns.  In rare circumstances peer review can be delayed to the point that patients are placed in danger by the inability to promptly remove a physician that is providing substandard care.  AB 120 improves an already robust system to make it even more effective in ensuring high quality care in CA hospitals.

TITLE  :  An act to amend Sections 809, 809.2, and 809.3 of, and to add Sections 809.04, 809.07, and 809.08 to, the Business and Professions Code, relating to healing arts.

TOPIC:  Healing arts: peer review.

CURRENT BILL STATUS:  Committee on  Business & Professions

2.   "Bills of Interest" to CMA:

834 (Solorio) PEER REVIEW

This is a spot bill introduced at the request of the California Hospital Association.  It is currently in "spot form" stating only legislative intent to reform the peer review process

SB 58 (Aanestad) PEER REVIEW

This bill has been amended to revise the peer review system in California.  It mirrors some of the provisions included in AB 120 but adds provisions not supported by the CMA.  It would demand external review for certain medical outcomes and errors that are adequately addressed in properly functioning peer review bodies.  This bill is involved in ongoing negotiations regarding the peer review reforms
Referred to Senate Judiciary Committee and Senate Business & Professions Committee; 4/20/09

SB 700 (Negrete McLeod) PEER REVIEW

This bill revises the definition of peer review by stating the goal of peer review is to determine qualifications for the practice of medicine.  It would also require peer review to be done in all medical settings including private practice offices with one physician.  CMA comment:  Peer review is better done at facilities where the majority of physicians have credentials.  This bill is also the subject of ongoing negotiations.
Referred to Senate Business & Professions Committee; 4/20/09.


Health Care Reform--CMA Perspectives:

1. Tax credits and direct subsidies to low-income families
    . . then impose individual mandates to obtain insurance
2.  Outreach--enrollment of families already eligible for Medicaid and SCHIP
3.  Improve access: 
    Medi-Cal physician reimbursement --> wider physician participation
4.  Improve cost-efficiency (Health Care plans devote 85% of revenue)

Please see Attachment to this message: 
CMA Perspectives on Health Reform

Take-home Message--Health Care Reform:
We as physicians must join this collaborative effort, take the lead, and protect a) the doctor-patient relationship and b) a healthcare system which allows independent, high quality practice with adequate reimbursement.   Problem:  we have not figured out how to organize ourselves and get this done.


May 19th Special Election in California:
Health and Human Services budget

Vote 'Yes' on Proposition 1d:   To move $268 million from Tobacco Tax funds (1998 Prop 10) and place that money into HHS (Calif Health & Human Services) for children's health care (CHIP, Medicaid) and other services.

Physician reimbursement is a key outcome.


Other Calif Legislature bills of interest
(including those sponsored or opposed by CMA)

 Please see Attachment to this message:  
CMA Hot list.doc



CMA Organized Medical Staff Section Representatives:

AB 646 (Swanson) and AB 648 (Chesbro), two bills which would erode the patient protections of the bar on the corporate practice of medicine in California, took an ominous step towards passage today when they passed the Assembly Business and Professions Committee.  AB 646 is sponsored by AFSCME, a labor union interested in unionizing doctors; AB 648 is sponsored by the California Hospital Association, whose members want to hire and control doctors.   

One other bill eroding the corporate bar has also been introduced in the Legislature this year: SB 726 (Ashburn).

We need your help to defeat these bills!

AB 646 and AB 648 will both be heard in Assembly Health Committee next Tuesday, April 28.  For all doctors who have a member of the Assembly Health Committee in your county, we ask that you and your colleagues CALL, EMAIL, or FAX those legislators and urge them to Vote No on AB 646 and AB 648.    Counties with legislators on the Committee include:  Sacramento, San Diego, San Bernardino, San Francisco, Tulare, Los Angeles, ACCMA, Santa Barbara, and Ventura County. 

Phone calls are most effective, but emails and faxes are important too.  A complete list of legislators on the committee can be found at: http://www.assembly.ca.gov/acs/newcomframeset.asp?committee=10.  A sample letter and talking points are below. 

SB 726 will be heard in Senate Business and Professions Committee on Monday, April 27.  For all doctors who have a member of the Senate Business and Professions Committee in your county, we ask that you and your colleagues CALL, EMAIL, or FAX those members and urge them to Vote No on SB 726.  Counties with Senators on the Committee include: Santa Barbara, San Diego, Butte-Glenn, Yuba-Sutter-Colusa, ACCMA, Orange, Fresno, Los Angeles, San Francisco, and San Mateo. 

Again, phone calls are most effective, but emails and faxes are important too.  A complete list of legislators on the committee can be found at: http://www.senate.ca.gov/ftp/sen/committee/STANDING/BUSINESS/_home1/PROFILE.HTM.  The same sample letter and talking points apply. 

To the extent possible, please let us know what calls, emails, and faxes you are able to generate.  This is critical information for our lobbyists when they speak to legislators.  If you or your colleagues choose to submit an email or fax to your legislator(s), we strongly encourage that you personalize the letter, which will greatly increase its impact. 

Your involvement is critical to ensure that legislators understand the impact these bills will have on the quality of care their constituents receive in California hospitals.  We need to let these legislators hear from as many doctors as possible that these bills are bad for patients (their constituents). 

More information on these bills can be found on the CMA website at: http://www.cmanet.org/news/hotlist.aspIf you have additional questions, please contact Ned Wigglesworth, Vice President – Communications, California Medical Association, at 916.551.2873 or at nwigglesworth@cmanet.org.


1) The ban on corporations practicing medicine is an important protection for patients in California hospitals.  This protection ensures that those who make decisions that affect the provision of medical services (1) understand the quality of care implications of that medical service; (2) have a professional ethical obligation to place the patient's interest first; (3) are subject to the Medical Board of California.

2) AB 646, AB 648, and SB 726 will erode the quality of care in California hospitals.  AB 646, AB 648, and SB 726 will grant control over treatment decisions to hospital CEOs and administrative staff who have different motivations and mandates than physicians.  This will create conflicted loyalties in an institution that must remain true to the patient's interests, and will erode the quality of care patients receive in California hospitals.  

3) Placing doctors under the oversight of hospital administrators and CEOs who are under enormous pressures to cut costs or increase revenue will threaten the independent medical judgment necessary to ensure patients are protected. 

4) Hospitals are already interfering with medical staffs' ability to ensure quality care through independent self-governance.  For example, some hospitals have adopted medical management protocols which have resulted in inappropriate hospital tests, procedures, and stays, jeopardizing patients and increasing costs.

5) Allowing a hospital to directly employ a physician will NOT increase access to physician services.  The hospital will push patients to their preferred provider thereby controlling the competitive market.  Other non-employed physicians will not be able to compete and likely be forced out of town resulting in no increased access.

6) CMA supports policies that will truly increase access to care, without compromising the quality of care.   The CMA supported bills last year that will provide over $2 million dollars in medical school loan repayment for physicians who agree to practice in these areas.  Since loan repayment obligations is one of the primary reasons physicians will not go to underserved areas, this will attract physicians to these areas without compromising the quality of care patients receive.




Dear (Legislator),

I am writing to request that you oppose [AB 646 and AB 648, or SB 726], a [bill(s)] that would eliminate important legal protections for patients by allowing hospitals to directly employ physicians. 

It is critical for the integrity of patient care in California hospitals that physicians remain independent from the corporate influence of hospital administrators and CEOs, who must answer to priorities other than patient care.  By eliminating this protection for patients, [AB 646 and AB 648 or SB 726] will erode the quality of care those patients receive in California hospitals.

The ban against the corporate practice of medicine provides a fundamental protection for patients by ensuring their physicians' sole interest is what is best for the patient.  When hospitals are allowed to directly employ and charge for physician services, quality of care suffers due to the fact that hospitals derive income from patient beds being filled.

I recognize there is a shortage of physicians in some areas.  However, there are ways to address that shortage without allowing hospitals to control physician employment.  Increasing slots for medical training in California by developing the medical school at UC Merced and expanding access to California's loan repayment program will truly ensure physicians go to and stay in rural and underserved areas.

Simply allowing hospitals to employ physicians may actually result in reduced access and increased costs.  Hospital employment of physicians eliminates competition for outpatient services and instead forces all care to be delivered through the hospital.  As hospitals gain market share in small communities, physicians not employed will likely be forced out of business and surgery centers outside the hospital will likely be forced to close.  This results fewer options for patients and increased costs as the hospital is able to charge higher rates with the elimination of competition.

For these reasons I request that you vote against bills that would allow hospital to directly employ and charge for physician services.  Thank you for your consideration.




Free Conference Call Options

Need to set up a conference call and can't even figure out how to add a third person to a call, much less have 10 people on the same call?

Don't want to pay monthly fees and/or 10+ cents a minute for conference calls?

There are free alternatives.  One I've been using for several years is

You go to their web site and register for a free account.  They send you an email with a call-in telephone number and a conference call code. 

You email those to the group you want to talk to with the date and time.  Everyone dials the telephone number and at the prompt enters the conference call code.  Voila, everyone is on a conference call.

And you can even record the call (for free).

Where's the catch?  The telephone number everyone calls is a toll number (e.g. a long distance call).  I've only had one person notice/care.  Most people have unlimited long distance or pay less than 3 cents a minute, so it really isn't that much a cost.

You can't beat the price, or the ease of use.

Gregg Marshall, CPMR, CSP, is a speaker, author and consultant. He can be reached by e-mail at gmarshall@repconnection.com, or visit his website at


Do Away With Voice Mail

I hate voice mail.

You have to call in to retrieve it, if it's for your cell phone getting your voicemail is burning minutes.

A lot of the messages aren't worth returning, and some people leave their whole life history in each voice mail.

I don't do voice mail any more.

I switched over to PhoneTag (http://www.phonetag.com), until just recently called Simulscribe).

They sent me a magic "code" to key into my cell phone, which set it to call forward calls when I don't answer to a special telephone number they assigned me when I signed up.

So if you call me and I don't answer you hear the same message I would have used for my cell phone.  You leave your message.  PhoneTag transcribes it.  I get the message via text message and email (the email includes an MP3 recording of the message).

Because the text message arrives silently, I can see your message while in a meeting...  Or while overseas.

Feel free to use my referral code to sign up


I even promise to return your call.

Gregg Marshall, CPMR, CSP, is a speaker, author and consultant. He can be reached by e-mail at gmarshall@repconnection.com, or visit his website at http://www.repconnection.com.


Carry Your Apps With You

Everyone has a flash drive, right?

Beyond carrying important documents, like a scan of your passport, you can carry a complete office set up that will run on any Windows computer you can find, such as a spare at a client or the hotel's business center.

Rather than worry if they have the right applications, carry them with you on your flash drive.

The first implementation of this was U3, a proprietary system for running applications off flash drives, created by Kingston Memory.  It's problem was, being proprietary, not many applications bothered with modifying their programs to work with U3.

Now there's an open source (aka free like Linux) option called Portable Apps (http://portableapps.com/).  It provides a similar environment as U3, but has better support, especially by open source applications.

So along with Portable Apps, you can have Open Office (very compatible with Microsoft Office and free), Firefox (quickly becoming my favorite web browser) with its bookmarks, Thunderbird (a good Outlook alternative), GIMP (a Photoshop alternative), Audacity (audio editing software)-in other words, everything you need to work.  And all free.

Even my tricked out collection of almost everything barely takes half of a 1 gigabyte flash drive.

Programs and data stay on the flash drive.  You plug it in, do your work, and when you are done, remove it.  All trace of your visit goes with you.

Are you sure you need to lug that notebook on every trip?  Even a 2 pound Mac Air is heavy compared to a 1 ounce flash drive.

Gregg Marshall, CPMR, CSP, is a speaker, author and consultant. He can be reached by e-mail at gmarshall@repconnection.com, or visit his website at http://www.repconnection.com.


Clean Up Your Hard Drive for More Speed

Is your computer getting slower?  I've often thought that Microsoft and Intel have conspired to slow computers down over time so you'll buy a new one every year.

Actually as you use your computer, install new programs and get updates, your computer develops what I call plaque, just like your teeth.

So it's time to "brush" your computer.

Start by getting rid of all the "bloatware" that came with your computer.  The easiest solution to that is PC Decrapifier (yes that's its name, it's at http://www.pcdecrapifier.com/). 

Then uninstall all those neat programs you might have decided to try and never use.  Go to your control panel and choose Add/Remove Programs (XP) or Programs And Features (Vista). 

If you don't know what's on your PC, try WinAudit (http://www.pxserver.com/winaudit.htm), a great utility for generating a comprehensive report of everything about your computer.

After cleaning off all the extraneous programs, do a disk defragmentation.  You can use Windows defragmenter by going to Start then My Computer and right clicking on the C drive.  From the context menu that pops up, select properties, then tools.  Do a disk clean up first, then do a defragment.  Another option is to use Diskkeeper (http://www.diskeeper.com/defrag.asp) that automatically defragments your disk in the background.  My favorite is Disktrix' Ultimate Defrag (http://www.disktrix.com), which not only defragments your hard drive, it moves frequently used files to the same area to keep the seek time to a minimum. 

That will clean up your hard drive, next time we clean the Windows.

Gregg Marshall, CPMR, CSP, is a speaker, author and consultant. He can be reached by e-mail at gmarshall@repconnection.com, or visit his website at http://www.repconnection.com.


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