Featured Columnist

James C Cotter, MD

Napa County Health Rankings 2015

Have you wondered how the health status of Napa County ranks compared to other California’s other 57 counties? Napa ranked 13/58 on the most recent survey in 2015.  Health Outcomes are based on many factors including heath behaviors, clinical care, social and economic factors and physical environment.  Here are some of those factors:

 Napa           California 
 Health Behavior                         
 Adult Smoking 9% 13%
 Adult Obesity  24% 23%
 Excessive Drinking 24% 17%
Teen Births  25% 34%
High school graduation  88% 83%
College degree   31.3% 30.7%
Unemployment   6.3% 8.9%
Per Capita income (2013)      $34,795   $29,527
Median household income (2013)  $70,443    $61,094 
Children in poverty 14% 24%
Physical Environment     
Air Pollution - particulates  7.6 9.3
Severe housing problems 25% 29%
Persons 65 years and older 16.8% 12.9%
Clinical Care     
Uninsured population  18%  20%
MediCal population  19% 29%
Cancer rate: breast   125.4 122.4
Cancer rate: prostate  173.8 136.4
Cancer rate: colon   45.4 41.5
Cancer rate: lung   62.0 49.5
All cancer mortality  167.8 157.1
Age adjusted cancer rate (2014) 488.9 424.9

Before the Affordable Care Act (ACA), California had the largest number of uninsured of any state in the country.  Since the ACA, California expanded MediCal to cover all nonelderly adults with incomes below 138% of the federal poverty level ($16,242 for an individual or $27,724 for a family of 3).  Enrollment in MediCal grew by 37% between October 2013 and May 2015.  Since the ACA, the uninsured rate for the nonelderly in California dropped from 19.1% to 13.4%.

It is not clear why the Napa County’s cancer rates are so high.  The numbers are age adjusted and not dependent on our higher percentage of people over 65.  The overall cancer incidence in Napa County is second highest for California counties.  Air quality (pesticides), alcohol consumption and obesity rates have been considered as factors.  

James Cotter, MD MPH

Napa Managing Pain Safely Coalition

James C. Cotter, MD

Napa County formed a Managing Pain Safely Coalition in 2014.  We have representatives from physician groups, pharmacists, from intervention and treatment programs and from law enforcement and public safety.  It is a broad coalition with members of NCMS, Kaiser Permanente, Ole Health, Queen of the Valley Medical Center, the Veterans Home, emergency department physicians, the County of Napa and Partnership Health Plan.

The committee was formed in response to some alarming statistics about opioid use in this country.  There has been a significant increase in opioid deaths in the US with over 6500 deaths in 2010, more than three times higher than deaths due to benzodiazepines, antidepressants and four times higher than cocaine and heroin deaths combined.  Almost all prescription drugs involved in overdoses originate from prescriptions we write.  About 80% of all opioid prescriptions come from 20% of opioid prescribers.
Our vision statement: The community of Napa manages pain through improving the quality of life and functionality for individuals with pain, and the consistent, safe and transparent use of medications.

The primary aim of this group is to have all Napa prescribers order opioids for the appropriate indications, at safe doses and in conjunction with other treatment modalities.  
What can you do?
Use caution when starting use of opioids.
Understand that patients who start and remain on opioids for 90 days may be on them for life.
Always use CURES before starting opioids and on some regular basis for chronic opioid patients.
Have a signed drug contract that outlines patient responsibilities and consequences.
Regularly use urine drug screens for patients on chronic opioids (at least once a year).
See your chronic opioid patients at least twice a year.
Avoid escalation of total opioid dose beyond 120 mg equivalents of morphine (MED) per day.
Avoid further escalation for patients already on 120 MED or more.
Consider multi-disciplinary programs for patients with chronic pain.

Our coalition is in the process of developing opioid treatment guidelines for all Napa county prescribers.  We will share these with all Napa County physicians.  We welcome your participation in this process.

James Cotter, MD
Regional Medical Director
Partnership HealthPlan of California


The 2015 AMA Annual Meeting 

Peter N Bretan, MD, FACS, AMA Alternate Delegate Report

See full coverage of the meeting at AMA Wire®. From MOC to vaccines: Top 10 stories from AMA Annual Meeting



Highlights include:

1. More transparent, physician-friendly MOC focus of new policy

Physicians took on the maintenance of certification (MOC) process at the 2015 AMA Annual Meeting Monday, calling for more transparency and education surrounding the process.


2. “Innovation ecosystem” shaping medicine’s future

 The AMA is improving the health of the nation by crafting an “innovation ecosystem,” AMA Executive Vice President and CEO James L. Madara, MD, said in his address. This includes the launch of the AMA’s STEPS Forward website, which offers a free series of physician-developed, proven solutions to make physician practices thrive.


3. Doctors call for two-year grace period for ICD-10 implementation

 With less than four months to go before the deadline for implementing the ICD-10 code set, physicians agreed to seek a two-year grace period to avoid financial disruptions, during which CMS would refrain from withholding payments because of coding mistakes. This would facilitate a smoother transition that would allow physicians to continue providing quality care to their patients.


4. From Rx monitoring to treatment: Solutions for overdose epidemic

 As the nation continues to grapple with its epidemic of opioid misuse, overdose and death, physicians supported additional steps to address this pressing public health issue.


5. Facing challenges strengthens physician-patient bond: AMA president

 In his final address as AMA president, Robert M. Wah, MD, congratulated physicians on undertaking numerous challenges this year, including accelerating change in medical education and improving health outcomes for patients with prediabetes and high blood pressure. He also called for true “meaningful use” by interoperability of EMR to harness technology to improve care, instead of it harnessing us.


6. New public health policies patients need to know—and why

Many of today’s precautions for public health and safety had their start with physicians at the AMA. Public health issues that doctors want to tackle next range from barring people younger than 21 from purchasing e-cigarettes to protecting youths with concussions.


7. GME funding, doc shortage tackled in new policy

 Physicians passed policy to address insufficient funding for graduate medical education (GME) ahead of a predicted shortage of 46,000-90,000 physicians over the next decade.


8. A story of hope: New AMA president points to power of physicians

For each story of frustration in the medical profession, “there is a story of vision, perseverance and success,” AMA President Steven J. Stack, MD, said in his inaugural address. “When it comes to something as important as shaping a better, healthier future, it will take every single one of us.” Dr Stack is an ER physician who practices in Lexington, Ky. He was sworn in as the 170th president of the AMA and is the youngest president in the past 160 years.


9. Medical reasons should be the only exemptions from vaccinations

As the debate around vaccinations continues to rage in the public, outbreaks of dangerous preventable diseases have continued to increase. For public health experts, the question has become, “Should individuals be given exemptions from required immunizations for non-medical reasons?” Physicians provided some answers with policy passed on Monday of the HOD.

 10. New AMA policy calls for research on violence against physicians

 Policy adopted Tuesday supports a new study on methods that will prevent violence against health care professionals while in the workplace. Attacks at hospital and social service settings account for almost 70 percent of nonfatal workplace assaults.


Regarding the California Resolutions:

The following were placed on the Reaffirmation Calendar:

Res 109 Medicare Coverage of Physician Administration of Medications Procured by Patients

Res 205 Doctor hospital Ownership

Res 410 mental Health Crisis Interventions

Res 411 Homeless Veterans

Res 509 Long Acting Reversible Contraception and Teen Pregnancy

The following were adopted by the HOD:

Res 009 Parent to Parent Ed on Child Vaccination

Res 107 Reimbursement for End-of-Life Counseling

Res 116 Study the Impact of the ACA Medicaid Expansion

Res 412 Electronic Cigarettes.


Respectfully submitted.

Peter N Bretan, MD, FACS.

James C Cotter, MD

The Importance of Vaccinating Your Children

By James C. Cotter, MD

The recent outbreak of measles has stimulated quite a lot of discussion about immunizations in our country. There is no debate, however, about the value and safety of childhood immunization. These vaccines save thousands of lives every year. Vaccination against preventable diseases has been one of the finest achievements in health care over the last 50 years. I could talk about the value of more than 15 different vaccines if you give me the chance, but I will focus on just two right now: measles and pertussis.

Measles is very easy to catch if you are not immunized. The virus can remain suspended in the air for several hours – you just have to walk by someone with active measles to catch it. Prior to measles vaccine in 1963, there were 3-4 million cases of measles every year in the US with 500 deaths and 4,000 cases of encephalitis with 1,000 children getting permanent brain damage from the encephalitis. Can you imagine having your child’s brain stop developing at age 2 due to measles encephalitis? In my medical practice, I cared for a middle age man with the brain of a 2 year old caused by measles encephalitis – it is incredibly sad. Measles vaccine is very safe and very effective with 97-99% protection against measles after 2 shots.

There were 10,000 cases of pertussis (whooping cough) in the US last year. Pertussis is very dangerous for children under 12 months. Two thirds of children get apnea (stop breathing) and one fourth of children who have pertussis require hospital admission for pneumonia. Adults and adolescents have less serious complications, but a significant number of adults break their ribs from the severe coughing caused by Pertussis. Pertussis vaccine loses its effectiveness over time and requires boosters, even for adults.

So why aren’t all children immunized?

There are several reasons why children may fall behind on their immunizations: the child may be uninsured; the child may have skipped a well child visit and missed a scheduled shot; parents may request an alternate schedule of immunizations to lessen the shot burden at any one visit; or parents may object to immunizations for personal or religious reasons.

If you or your child does not have health insurance or lacks a medical home, in Napa, please call the Napa Children’s Health Initiative (707-227-0830); in Solano County, call one of the many community health centers. They can get your child insured and connected to a medical home.

Some children just miss shots. They miss a well-child visit or have a mild illness and skip a shot (immunizations are actually OK even with most mild illnesses). It is really important to get that first measles shot by age 12 months and to have the whole primary series of immunizations complete by 18 months. Our school system requires the full childhood schedule to be done by entry into kindergarten.

I can understand the thoughts behind spreading out vaccination over a longer period of time, but it is not really a good idea. The youngest children are at the highest risk for complications and death from these illnesses. Many studies have been done to prove that multiple shots work just as well when they are combined as if they were done individually. Many immunizations have been combined into one injection to make it easier for children. The currently recommended schedule is the result of lots of research to get children the best protection they can have as soon and as safely as possible.

People who object to immunizing their children are not stupid. In fact, many are well educated, but they are misinformed. Many people still consider the risk of autism as their reason not to vaccinate. Andrew Wakefield started that lie and he was banned from medicine for life and his study in Lancet was retracted because he made money for himself by linking MMR to autism. People should not base their medical decisions on Mr. Wakefield’s lies. Studies involving 34 million children have shown that there is no connection between MMR and autism.

There is a school in Beverly Hills with a 75% vaccine refusal rate. I would not want to live in that neighborhood. Luckily, less than 5% of parents refuse vaccines for their children in Napa; in Solano County, immunization rate is 95% completion at kindergarten entry. Nonetheless, refusing these life-saving vaccines is a serious and potentially dangerous decision. Refusing vaccines puts your children at risk, but also puts any infants near your children or any children with compromised immune systems at risk of dying from a preventable disease. Please talk to your doctor about this. If you want straight information about vaccine safety, please go to CDC.GOV/vaccines

Please vaccinate your children. It is an act of love for them and everyone around you.