September 2008 by San Diego Physician

2008 MAGGIE AWARD WINNER

OFFICIAL PUBLICATION OF THE SAN DIEGO COUNTY MEDICAL SOCIETY SEPTEMBER 2008

“Physician, INFORMTHYSELF” SDCMS BRINGS YOU A PRIMER ON THE ISSUES.

“ P H Y S I C I A N S U N I T E D F O R A H E A LT H Y S A N D I E G O ”

Contents

VOL. 95 | NO. 9

“Physician, INFORMTHYSELF” SDCMS BRINGS YOU A PRIMER ON THE ISSUES.

[ F E A T U R E S ] “PHYSICIAN, INFORM THYSELF” — THE LEGISLATIVE ADVOCACY ISSUE

History of CMS Programs • SGR • GPCI • Bar to the Corporate Practice of Medicine • Pay for Performance • Medi-Cal • MICRA • RICO Lawsuit: Policing the Health Plans • Scope of Practice

[ D E P A R T M E N T S ]

4 6 8 10 12 16 2

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CONTRIBUTORS: This Issue’s Contributing Writers

EDITOR’S COLUMN: Fixing Medicare Reimbursement

SEMINARS: SDCMS’ 2008 Seminars and Events

COMMUNITY HEALTHCARE CALENDAR BRIEFLY NOTED: Ask Your Physician Advocate, New and Rejoining Members, and More

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MARK YOUR CALENDARS: SDCMS’ 2009 Seminars and Events

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INFANT MORTALITY: Still a Need for Action

POLITICS AND ADVOCACY 10 Pretty Good Rules

SDCMS FOUNDATION: “The Pulse”

PHYSICIAN MARKETPLACE: Classifieds

ONCE IS ENOUGH: The Long and Fascinating History of Vaccination

Contributors MARISOL GONZALEZ

Ms. Gonzalez is your SDCMS physician advocate. She can be reached at (858) 300-2783 or at MGonzalez@SDCMS.org with any questions you may have about your practice or your membership.

TOM GEHRING

Mr. Gehring is the CEO/executive director of SDCMS.

JOSEPH E. SCHERGER, MD, MPH

Dr. Scherger is clinical professor of family medicine at UCSD. He is also medical director of AmeriChoice, which administers San Diego County Medical Services. Dr. Scherger, along with editing San Diego Physician, is chair of the SDCMS Communications Committee.

GAYLE WHITE, MPH, RN

Ms. White is the maternal and child health coordinator in Maternal, Child, and Family Health Services. She has held this position for the past six years and oversees the Perinatal Care Network, Comprehensive Perinatal Services program, Fetal and Infant Mortality Review program, and the Black Infant Health program.

EAST COUNTY DIRECTOR HILLCREST DIRECTOR KEARNY MESA DIRECTOR EDITOR MANAGING EDITOR ASSISTANT EDITOR

Joseph Scherger, MD, MPH Kyle Lewis Ketty La Cruz

EDITORIAL BOARD

Adam Dorin, MD Robert Peters, MD David Priver, MD Roderick Rapier, MD Joseph Scherger, MD, MPH

LA JOLLA DIRECTOR NORTH COUNTY DIRECTOR

SOUTH BAY DIRECTOR AT-LARGE DIRECTOR

YOUNG PHYSICIAN DIRECTOR RESIDENT PHYSICIAN DIRECTOR RETIRED PHYSICIAN DIRECTOR MEDICAL STUDENT DIRECTOR

Published by

PRESIDENT PUBLISHER DIR., BUSINESS DEVELOP. & MARKETING MARKETING & PRODUCTION MNGR.

William Tseng, MD Woody Zeidman, MD Roneet Lev, MD Thomas McAfee, MD Adam Dorin, MD Sherry Franklin, MD Steven Poceta, MD Wayne Sun, MD James Schultz, MD Douglas Fenton, MD Tony Blain, MD Vimal Nanavati, MD Anna Seydel, MD Jeffrey Leach, MD, Robert Peters, MD David Priver, MD Wayne Iverson, MD Paul Kater, MD John Allen, MD Kevin Malone, MD Mihir Parikh, MD Kimberly Lovett, MD Glenn Kellogg, MD Geraldine Kang

Jim Fitzpatrick Maureen Sullivan Heather Back Jennifer Rohr

SDCMS EXECUTIVE COMMITTEE PRESIDENT PRESIDENT-ELECT PAST PRESIDENT SECRETARY TREASURER COMM. CHAIR DELEGATION CHAIR BOARD REP. BOARD REP. LEGISLATIVE CHAIR EXECUTIVE DIRECTOR

Stuart Cohen, MD, MPH Lisa Miller, MD Albert Ray, MD Robert Wailes, MD Susan Kaweski, MD Joseph Scherger, MD, MPH Jeffrey Leach, MD Sherry Franklin, MD Robert Peters, MD Robert Hertzka, MD Tom Gehring

SDCMS CMA TRUSTEES

Theodore Mazer, MD Albert Ray, MD Robert Wailes, MD

OTHER CMA TRUSTEES

Catherine Moore, MD Diana Shiba, MD

AMA DELEGATES ALTERNATE DELEGATE

ACCOUNT EXECUTIVE PROJECT DESIGNER ADVERTISING ART DIRECTOR COPY EDITOR

James Hay, MD Robert Hertzka, MD Albert Ray, MD Lisa Miller, MD

Dari Pebdani Jessica Hedberg Geneen Montgomery Adam Elder

1450 Front Street • San Diego, CA 92101 • 619-230-9292 • Fax: 619-230-0493 • 800-600-CITY (2489) • www.sandiegomagazine.com OPINIONS expressed by authors are their own and not necessarily those of San Diego Physician or SDCMS. San Diego Physician reserves the right to edit all contributions for clarity and length as well as to reject any material submitted. Not responsible for unsolicited manuscripts. Advertising rates and information sent upon request. Acceptance of advertising in San Diego Physician in no way constitutes approval or endorsement by SDCMS of products or services advertised. San Diego Physician and SDCMS reserve the right to reject any advertising. Address all editorial communications to Editor@SDCMS.org. All advertising inquiries can be sent to cpinfo@sandiegomag.com . San Diego Physician is published monthly on the first of the month. Subscription rates are $35.00 per year. For subscriptions, email Editor@SDCMS.org. [SAN DIEGO COUNTY MEDICAL SOCIETY (SDCMS) PRINTED IN THE U.S.A.]

Send your letters to the editor to Editor@SDCMS.org SDCMS

Get In Touch ADDRESS: 5575 Ruffin Rd., Ste. 250, San Diego, CA 92123 TELEPHONE: Dareen Nasser, office manager, at (858) 565-8888 or at DNasser@SDCMS.org FAX: (858) 569-1334 CEO/EXECUTIVE DIRECTOR: Tom Gehring at (858) 565-8597 or at Gehring@SDCMS.org COO/CFO: James Beaubeaux at (858) 300-2788 or at Beaubeaux@SDCMS.org DIRECTOR OF MEMBERSHIP AND MEMBER SERVICES: Janet Lockett at (858) 300-2778 or at JLockett@SDCMS.org PHYSICIAN ADVOCATE: Marisol Gonzalez at (858) 300-2783 or at MGonzalez@SDCMS.org OFFICE MANAGER ADVOCATE: Lauren Wendler at (858) 300-2782 or at LWendler@SDCMS.org

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DIRECTOR OF EVENTS AND LEADERSHIP SUPPORT: Jennipher Ohmstede at (858) 300-2781 or at JOhmstede@SDCMS.org SDCMS FOUNDATION INTERIM EXECUTIVE DIRECTOR: Tana Lorah at (858) 300-2779 or at TLorah@SDCMS.org DIRECTOR OF COMMUNICATIONS AND MARKETING: Kyle Lewis at (858) 300-2784 or at KLewis@SDCMS.org ASSISTANT EDITOR AND WEBMISTRESS: Ketty La Cruz at (858) 565-7930 or at KLaCruz@SDCMS.org SPECIALTY SOCIETY ADVOCATE: Karen Dotson at (858) 300-2787 or at KDotson@SDCMS.org LETTERS TO THE EDITOR: Editor@SDCMS.org GENERAL SUGGESTIONS: SuggestionBox@SDCMS.org

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Editor’s Column By Joseph E. Scherger, MD, MPH

Fixing Medicare Reimbursement

new administration in Washington that Geographic Practice Cost Index (GPCI) places the care of people over the profits of portion of the Medicare RBRVS payment corporations. Whether Democrat or Resystem. After 20 years of practice, I find it publican, the members intolerable that we have faced of the San Diego cuts year after year under an Organized medicine stands ready acknowledged broken calcuCounty Medical Society unite for the welfare to work with a new administra- lation system, only to be told of patients and the that we are ‘saved’ each year tion to carve out an improved when rates are held flat. physicians who care for them. On the eve of In the meantime, Medicare Medicare program that is truly sending the Medicare Advantage PFFS programs are sustainable year after year. legislation to the presibeing paid 112-119 percent dent, the following letmore per patient than is allotter was sent electronically to the White ted in the standard Medicare program. Yet House by past SDCMS president and the White House feels that the taxpayer CMA trustee Ted Mazer: should continue to overpay these programs for their ‘add-on’ services, while private physicians lose the viability of their practices DEAR MR. PRESIDENT, in the ever-shrinking payment by Medicare The time is late for suggesting that some and these same private MA programs. Yes, other means for avoiding the draconian cuts the private payers profit at the expense of the to Medicare physician reimbursement taxpayer, but those monies are not passed on should not come from overpaid private into the providers of actual care, and, simultasurers, as the entire Medicare access system neously, Medicare pays the providers less and is ready to implode. I am a Republican less in real dollars every year. If the private physician (although these days I find it hard sector insurers can offer Medicare beneficito defend the Republican positions on aries the same, better, or more services AT healthcare financing) practicing in San Diego, California, an area that CMS and THE SAME COST AS THE REGULAR PROGRAM TO THE TAXPAYER, then Congress still consider to be rural under the

hysicians dodged another bullet this year as Congress overrode the president’s veto of legislation to block the scheduled 10.6 percent cut in physician reimbursement in the Medicare program. With the Sustainable Growth Rate (SGR) formula as law, similar cuts have been scheduled every year for several years, and each time a frenzy of activity from organized medicine has been able to prevent the cuts from being enacted. How long will we go on like this before meaningful reform in Medicare reimbursement takes place? We Americans spend about twice as much for healthcare as other similar countries, yet physicians in private practice are paid at rates that are not sustainable to a medical practice. This paradox has many causes, including excessive money spent for administration, profit-taking by health plans, and many imbalances in the reimbursement schedules to favor gadgets over real care. As I watch the Scooter Store commercials, or the ones for pulmonary and diabetic supplies, I wonder how much profit is built into these companies that have a direct line into Medicare funds — certainly enough to pay for prime time national television marketing! I am a registered Democrat hungry for a

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by all means I support such an approach to privatization of Medicare. But such is not the case in the current MA PFFS programs! In San Diego County it is even worse with Medicare underpaying the doctors for fee-for-service (FFS) Medicare more than $30 million a year, despite recognizing the unfairness of the GPCI calculations. As a loyal Republican, and as a practicing physician, I implore you to get past the politics and the showdown mentality, and address the pending collapse of access to care in the Medicare program, by signing the current legislation and moving for future corrections to the entire flawed payment system as soon as possible. I have already closed my practice to new California Medicaid (Medi-Cal) patients as of the first of July due to 10 percent cuts in that already underfunded program. Having served Medi-Cal patients for 20 years, I cannot afford to take any more cuts and pay out of pocket to take care of patients. The same will be true in the Medicare program should the 10.6 percent cuts be allowed to go through. I, and many of my colleagues, will be left with little choice but to cut the number of new Medicare patients we will see, simply in order to maintain the viability of our practices. That serves no one at all! Ted Mazer, MD Otolaryngology, Private Practice Past President, San Diego County Medical Society Trustee, California Medical Association Hopefully, this will be the last year that we have to scramble just to keep our heads above water. Medicare does not lack funds, yet it is time that they use them wisely and recognize the physicians that care so well for seniors. With the Baby Boomers entering the Medicare program over the next 20 years, waste and inefficiency can no longer be tolerated. Organized medicine stands ready to work with a new administration to carve out an improved Medicare program that is truly sustainable year after year.

Rosenberg, Shpall & Associates, APLC If your medical license or privileges are on the line…

A P R O F E S S I O N A L L A W C O R P O R AT I O N

Members Of The Firm: David Rosenberg, J.D. Tomas A. Shpall, J.D. Annette Farnaes, J.D. Steven H. Zeigen, J.D. Corey Marco, M.D, J.D. Jason L. Nienberg, J.D. Amy C. Lea, J.D. Wells Fargo Bank Plaza 401 “B” Street, Suite 2209 San Diego, California 92101 Telephone: (619) 232-1826 Facsimile: (619) 232- 1859 Email: RSALAW@yahoo.com

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DEADLINE TO ADVERTISE: SEPTEMBER 10 To run display advertising in San Diego County Medical Society Membership Directory, please contact Dari Pebdani for information and rates. 619-744-0528 or darip@sandiegomag.com

ABOUT THE AUTHOR: Dr. Scherger is clinical professor of family medicine at UCSD. He is also medical director of AmeriChoice, which administers San Diego County Medical Services. Dr. Scherger, along with editing San Diego Physician, is chair of the SDCMS Communications Committee.

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Seminars 2008 San Diego County Medical Society Seminars and Events Along with its many social events held throughout the year, the SAN DIEGO COUNTY MEDICAL SOCIETY (SDCMS) strives to build a robust schedule of free seminars for our physician members and their staffs (attendance rates for nonmember physicians and their staffs vary by seminar). For further information about any of these seminars or events, watch your emails and faxes, visit SDCMS’ website at www.SDCMS.org, call SDCMS at (858) 565-8888, or email us at SDCMS@SDCMS.org. Details may change as seminars approach – contact SDCMS to confirm. Thank you for your membership!

SEPTEMBER

NOVEMBER

YOUNG PHYSICIANS SOCIAL

RISK MANAGEMENT WEBINARS

YOUNG PHYSICIANS SOCIAL

Sep. 13, 3 p.m. – 8 p.m.

Nov. 12, 11:30 a.m. – 12:30 p.m., and 6:30 p.m. – 7:30 p.m.

Dec. 5, 6 p.m. – 9 p.m.

OCTOBER CERTIFIED MEDICAL OFFICE MAN-

Oct. 10, 17, 24, 31, 9 a.m. – 4 p.m.

AGER COURSE

RESIDENT AND NEW PHYSICIAN SEMINAR “PREPARING TO PRACTICE: WHAT YOU NEED TO KNOW BEFORE YOU BEGIN YOUR PRACTICE,” Nov.

22, 8:30 a.m. – 3:30 p.m. SEXUAL HARASSMENT TRAINING —

Oct. 15, 6:30 p.m. – 8:30 p.m.

FOR PHYSICIANS

SEXUAL HARASSMENT TRAINING — OFFICE MANAGERS FORUM

Oct. 16, 11:30 a.m. – 1:30 p.m.

Elizabeth Hos.

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Community Healthcare Calendar

NEW ADVANCES IN INFLAMMATORY BOWEL DISEASE This conference is intended for physicians, nurses, social workers, and others involved in the care of patients with Crohn’s disease or ulcerative colitis. Sept. 13 at the Sheraton La Jolla Hotel. $125. Call (858) 652-5486 or email med.edu@scrippshealth.org.

FRESH START’S 2008 SURGERY WEEKENDS — Come join together to provide free reconstructive surgery and related medical services to disadvantaged children with physical deformities caused by birth defects, accidents, abuse, or disease. Both medical and non-medical volunteers are needed to make children’s transformations possible. Sept. 13–14, Nov. 1– 2 at the Center for Surgery of Encinitas. Call (760) 448-2021 or visit www.freshstart.org.

19TH ANNUAL CORONARY INTERVENTIONS — This conference features live case demonstrations, lectures, and panel discussions that will focus on the state-of-the-art concepts and techniques of interventional cardiology. Sept. 17–19 at the Hilton La Jolla Torrey Pines. Call (858) 652-5486 or email med.edu@scrippshealth.org.

2008 HEALTH AND WELLNESS FORUM: DEVELOPMENTAL DISABILITIES — Conference will include five

3RD ANNUAL HEART FAILURE AND ARRHYTHMIAS: FROM PREVENTION TO CURE — This program will up-

sets of workshops focusing on autism, genetics, early intervention, risk management, and special populations, as well as keynote presentations and a poster session/reception. Sept. 24–26 at the Catamaran Resort Hotel, San Diego. Call (858) 534-3940 or email ocme@ucsd.edu.

date the primary care provider and practicing cardiologist on the latest treatments for heart failure and atrial arrhythmias, as well as new therapies being developed. Nov. 1 at the Paradise Point Resort and Spa, San Diego. Call (858) 652-5486 or email med.edu@scrippshealth.org.

THE CALIFORNIA HEART RHYTHM SYMPOSIUM — This conference will highlight what is known about basic arrhythmia mechanisms, how our clinical therapeutic strategies are driven by science, and how observations from clinical therapeutics have created new avenues for research. Oct. 2 at the Manchester Grand Hyatt, San Diego. $300. CME: 15.5. Call (858) 534-3940 or email at ocme@ucsd.edu.

2008 SAN DIEGO DAY OF TRAUMA — An outstanding faculty of leading civilian and military trauma surgeons will review the most important lessons from the war and develop practice recommendations for the care of the injured at our civilian trauma centers in the United States. Nov. 7 at the Joan B. Kroc Institute for Peace and Justice, University of San Diego. $225. CME: 8. Call (858) 652-5482 or email at med.edu@ scrippshealth.org.

TEENS WITH MENTAL HEALTH DISORDERS — Youth THE SCIENCE AND CLINICAL APPLICATION OF INTEGRATIVE HOLISTIC MEDICINE — Lectures followed by Q&A

workers need to understand and recognize youth with mental health disorders and differentiate those at risk from those dealing with normal developmental issues. Oct. 23 at the San Diego County Office of Education. $30. CME: 3.5. Call (858) 652-5482 or email med.edu@scrippshealth.org.

sessions, experiential morning programs, and evening study groups. Nov. 17–21 at the Paradise Point Resort and Spa, San Diego. Reduced rates for attendees. Call (858) 652-5486 or email med.edu@scrippshealth.org.

THE LEUKEMIA AND LYMPHOMA SOCIETY’S LIGHT THE NIGHT WALK — This is a nationwide, annual

NATURAL SUPPLEMENTS: AN EVIDENCE-BASED UPDATE — This course provides practical information

fundraising walk to celebrate and commemorate people whose lives have been touched by cancer. Oct. 24 at Qualcomm Stadium. Call (858) 427-6651 or email danielle.litke@lls.org.

for healthcare professionals who make nutritional recommendations or manage dietary supplement use. Jan. 22–25, 2009, at the Paradise Point Resort and Spa, San Diego. CME available. Call (858) 6525486 or email med.edu@scrippshealth.org.

2008 UPDATE ON PARKINSON’S DISEASE — This educational event will highlight all the changes in Parkinson’s disease management and treatment. Sept. 20 at the Hilton La Jolla Torrey Pines. Free. CME available. Call (858) 273-6763 or visit www.pd asd.org.

To submit a community healthcare event for possible publication, visit www.SDCMS.org, click on “Calendar,” then “Community Events,” then “Submit a Community Event.” All events should be physician-focused and take place in San Diego County.

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fly Noted e i r B Ask Your Physician Advocate! By Marisol Gonzalez

Copays, PTANs, and Patient Information Given By Family Members to Physicians

UESTION: We have a patient who is asking for a copy of her medical records. With these medical records she also wants phone messages and emails that were given to me in confidence by her family. Should I release these as well? ANSWER: According to CMA ON-CALL document #1110, “Confidentiality of Sensitive Medical Information,” a physician sometimes receives information given to them in confidence by members of a patient’s family or others. There are special protections under California law for this information. For example, if a patient is requesting information about their own medical care (including medical records, which must be disclosed to the patient), California law exempts “information given in confidence to a healthcare provider by a person other than another healthcare provider or the patient.” There are similar exceptions in the Lanterman-Petris-Short (LPS) Act protecting the confidentiality of such information. For example, the LPS Act

UESTION: I had a patient come in who didn’t have any money for the copay. They have lab results to pick up, and I want to hold onto the results until they pay what is owed. Can I do this? ANSWER: No. You cannot refuse a patient’s request for medical records because of an unpaid bill for health services. Many practice consultants advise that you try and collect copayments while the patient is still in the office. It is far easier to collect at the time of service than through a statement later mailed to the patient. Unless you have signed any contracts prohibiting you from doing so (including Medicare and Medi-Cal contracts), you can charge your patients interest on copayment amounts that are overdue.

UESTION: I am trying to opt my physician out of Medicare, and the form is asking for a PTAN number. What is this? ANSWER: PTAN is the acronym for “Provider Transaction Access Number.” This number can also be referred to as the “legacy number” or the “Medicare PIN Number.”

permits disclosure of information concerning a minor, ward, or conservatee upon the written authorization by his or her parent, guardian ad litem, or conservator, “except that nothing in the article shall be construed to compel a physician, psychologist, social worker, nurse attorney, or other professional person to reveal information that has been given to him or her in confidence by members of a patient’s family.” Another section of the LPS Act exempts confidential information given to the healthcare provider by family members from disclosure to a patient’s attorney. (Welfare & Institutions Code §5328.)

ABOUT THE AUTHOR: Ms. Gonzalez is your SDCMS physician advocate. She can be reached at (858) 3002783 or at MGonzalez@SDCMS.org with any questions you may have about your practice or your MARI SO L G O NZALE Z membership.

DOES YOUR OFFICE MANAGER HAVE A QUESTION TOO? Lauren Wendler, your SDCMS office manager advocate, is on staff and ready to help your office manager with any questions they may have. Feel free to contact Lauren at (858) 300-2782 or at LWendler@SDCMS.org for help. And don’t forget to sign up to receive SDCMS’ new office manager e-newsletter.

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The Institute for Medical Quality IMPROVING THE QUALITY OF CARE PROVIDED TO PATIENTS

terested in any of the following programs or in becoming a surveyor, please call (415) 882-5151, email dly@imq.org, or visit www.imq.org. CME ACCREDITATION PROGRAM: Accredits providers within the state of California to offer AMA PRA Category 1 Credit(s)â&#x201E;˘ for continuing medical education activities.

he Institute for Medical Quality (IMQ), a subsidiary of the California Medical Association (CMA), is a 501(c)(3) non-profit organization dedicated to improving the quality of care provided to patients across the continuum of healthcare. IMQ offers a wide range of educational, accreditation, consultation, and certification programs. IMQ is different from other healthcare quality organizations in that it makes providing quality care easier and eliminates, rather than creates, barriers to doing so. What makes IMQ special is its emphasis on education, counseling, and direct involvement of practicing physicians. Some, but not all, IMQ programs involve surveys of facilities and medical practices. Each program is carefully developed and continuously updated by physicians whose practices are similar to those they are currently evaluating or advising. Physician surveyors make every effort to keep materials relevant, current, and meaningful, and discard components that may be outdated or unnecessarily burdensome. If you are in14

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CME CULTURAL AND LINGUISTIC COMPETENCY PROGRAM: Provides resources and contacts for

cultural and linguistic competency and assists California CME providers in complying with Assembly Bill 1195. CME CERTIFICATION PROGRAM: Assists physicians in providing documentation of AMA PRA Category 1 Credit(s)â&#x201E;˘ and awards a four-year CMA certification in continuing medical education. AMBULATORY CARE REVIEW PROGRAM: Accredits a wide range of healthcare organizations, including ambulatory surgery centers, occupational health centers, medical offices/medical groups, and other outpatient settings administering anesthesia. Recognized by MBC and insurance carriers. |

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CONSOLIDATED ACCREDITATION LICENSURE SURVEY PROGRAM: The Joint Commission,

the Department of Public Health (DPH), and the Institute for Medical Quality (IMQ) jointly survey acute-care hospitals for accreditation and licensure. CORRECTIONS & DETENTIONS SURVEY PROGRAM:

Offers onsite reviews of medical programs in juvenile halls and jails for consultation and accreditation. PEER REVIEW & MEDICAL STAFF CONSULTATIONS: Provides onsite, objective peer review

of physician clinical practice with a focus on education, consultation, and quality improvement. Consultations individually designed for medical staffs. EDUCATIONAL PROGRAMS: IMQ offers a series of educational seminars and webinars that help physicians and healthcare organizations meet regulatory and accreditation standards and provide better care. Topics include a series of ethics programs, medical staff education, disruptive physician, performance improvement, peer review, CME, regulatory requirements, standards, legal issues, etc.

National Depression Screening Day

NEW MEMBERS MARC AARON DAVIS, MD Emergency Medicine San Diego, (619) 686-3800 SHANG I. BRIAN JIANG, MD Dermatology La Jolla, (858) 657-8322 MATTHEW R. KIRK, MD Ophthalmology La Jolla, (858) 457-3050 MEL M. KURTULUS, MD Obstetrics and Gynecology La Jolla, (858) 699-3578 EDITH RACHEL LEDERMAN, MD Internal Medicine & Infectious Disease San Diego, (619) 532-7475

NARESH CHAMKUR RAO, DO Family Medicine San Diego, (619) 398-2960

ROBERT MICHAEL BITER, MD Obstetrics and Gynecology Encinitas, (760) 642-0800

RALPH ERIK RYNNING, MD Orthopedic Surgery San Diego, (619) 286-9480

REJOINING MEMBERS

MICHAEL SHIM, MD Internal Medicine Oceanside, (760) 724-8782 HEATHER SUZANNE VOLPP, MD Internal Medicine San Diego, (858) 458-0940 CLAYTON BOYD WHITING, MD Emergency Medicine San Diego, (619) 686-3800 LAURA ANN WILLIAMS, MD Family Medicine Alpine, (619) 445-0204

JESS MANDEL, MD Internal Medicine, Pulmonary Disease & Critical Care Medicine La Jolla, (858) 534-1378 UJWALA DESHMANE RAJGOPAL, MD Surgery Encinitas, (760) 753-5667

KENTARO EMIL YAMADA, MD Ophthalmology San Diego, (619) 299-1100 TINA ZIAINIA, MD Obstetrics and Gynecology San Diego, (858) 621-4036

ROBERT ALAN FRIEDMAN, MD Psychiatry & Child and Adolescent Psychiatry San Diego, (858) 279-1223 JACK JOSEPH KLEID, MD Internal Medicine & Cardiovascular Disease San Diego, (858) 274-2560 PHILLIP MARK MILGRAM, MD Obstetrics and Gynecology San Diego, (858) 455-6100 HOSSEIN M. SADEGHI, MD Internal Medicine, Cardiovascular Disease & Interventional Cardiology Chula Vista, (619) 216-3113 VISHAL VERMA, MD Diagnostic Radiology San Diego, (858) 752-9735

TESTIMONIAL

“

One of the best investments I’ve made has been becoming a member of the San Diego County Medical Society.

“

riday, Oct. 10, 2009, is the 18th Annual National Depression Screening Day. As part of this public education campaign, individuals can fill out a simple questionnaire to see if their stress, sadness, or anxiety could be the result of depression or a related disorder. Thousands of organizations nationwide will host events [visit www.MentalHealthScreening.org to locate a site near you] where members of the public can assess their risk for depression, learn what to do about it, and talk to a mental health professional about their personal situations. The program is free and anonymous.

WELCOME NEW AND REJOINING SDCMS-CMA MEMBERS!

— Dr. Chrystal E. de Freitas

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SDCMS Mark Your Calendars to Attend SDCMS’ 2009 Seminars and Events

BOTH MEMBER PHYSICIANS AND THEIR OFFICE STAFF INVITED TO ATTEND Insurance Services Seminar (Office Managers Forum) Thursday, March 19, 11:30 a.m. – 1 p.m.

JANUARY 2009 Collections Seminar (Office Managers Forum) Thursday, Jan. 15, 11:30 a.m. – 1 p.m. Risk Management Webinar Wednesday, Jan. 21, 6:30 p.m. – 7:30 p.m. Risk Management Webinar Thursday, Jan. 22, 11:30 a.m. – 12:30 p.m. Marketing the Physician Practice Seminar Wednesday, Jan. 28, 6:30 p.m. – 8:30 p.m. Marketing the Physician Practice Seminar (Office Managers Forum) Thursday, Jan. 29, 11:30 a.m. – 1 p.m.

APRIL 2009 Practice Management Seminar Wednesday, April 15, 5 p.m. – 9 p.m. Practice Management Seminar (Office Managers Forum) Thursday, April 16, 9 a.m. – 1 p.m. “Preparing to Practice: What You Need to Know BEFORE You Begin Your Practice” (Resident and New Physician Seminar) Saturday, April 18, 8:30 a.m. – 3:30 p.m. Risk Management Seminar Wednesday, April 22, 6:30 p.m. – 8 p.m. Risk Management Seminar Thursday, April 23, 11:30 a.m. – 1 p.m.

FEBRUARY 2009 Contract Negotiations Seminar Wednesday, Feb. 11, 6:30 p.m. – 8:30 p.m. Contract Negotiations Seminar (Office Managers Forum) Thursday, Feb. 12, 11:30 a.m. – 1 p.m.

MAY 2009 EMR Road Show Wednesday, May 6, 4 p.m. – 8 p.m. EMR Road Show (Office Managers Forum) Thursday, May 7, 9 a.m. – 12:30 p.m.

MARCH 2009 Insurance Services Seminar Wednesday, March 18, 6:30 p.m. – 8:30 p.m.

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Billing Seminar (Office Managers Forum) Wednesday, May 20, 11:30 a.m. – 1 p.m.

JUNE 2009 Legal Seminar Wednesday, June 17, 6:30 p.m. – 8:30 p.m. Legal Seminar (Office Managers Forum) Thursday,June18,11:30a.m.–1p.m. “Taking Charge: Steps to Evaluating Relationships and Preparing for Negotiations — A Focus on Payor Contracting” (CMA Seminar) Wednesday, June 24, 4:30 p.m. – 8:30 p.m. “Back to Basics: A Step-by-Step Guide to Maximizing Your Cash Flow” (CMA Seminar — Office Managers Forum) Thursday, June 25, 9 a.m. – 2 p.m.

JULY 2009 Risk Management Webinar Wednesday, July 22, 6:30 p.m. – 7:30 p.m. Risk Management Webinar Thursday, July 23, 11:30 a.m. – 12:30 p.m.

“Privileged to Provide Care and Clinical Research Since 1975”

GENERAL INFORMATION COVERING MOST SDCMS SEMINARS AND EVENTS

The San Diego Arthritis Medical Clinic

WHEN: During lunchtime or dinnertime, with lunch and dinner provided free of charge. WHERE: San Diego County Medical Society offices at 5575 Ruffin Road, Suite 250, San Diego 92123.

is a leading investigational site for the study of:

ATTENDANCE: Only SDCMS member physicians and their office staff are allowed to attend. Attendees are asked to pre-register.

Rheumatoid Arthritis Osteoarthritis Osteoporosis Fibromyalgia Gout Lupus

COST: Open to SDCMS member physicians and their staff free of charge. QUESTIONS: For further information, watch your emails and faxes, visit www.SDCMS.org, call (858) 565-8888, or email SDCMS@SDCMS.org. Details may change as seminars and events approach — please contact SDCMS to confirm.

Certified Medical Coder (CMC) Course Five Fridays, Oct. 23, 30 and Nov. 6, 13, 20, 8 a.m. – 4 p.m.

AUGUST 2009 HIPAA Update (Office Managers Forum) Wednesday, Aug. 12, 11:30 a.m. – 1 p.m.

NOVEMBER 2009 Risk Management Webinar Wednesday, Nov. 18, 6:30 p.m. – 7:30 p.m. Risk Management Webinar Thursday, Nov. 19, 11:30 a.m. – 12:30 p.m. “Preparing to Practice: What You Need to Know BEFORE You Begin Your Practice” (Resident and New Physician Seminar) Saturday, Nov. 21, 8:30 a.m. – 3:30 p.m.

OCTOBER 2009 Financial Issues Seminar (Including Estate Planning) Wednesday, Oct. 14, 6:30 p.m. – 8:30 p.m. Financial Issues Seminar (Office Managers Forum) Thursday, Oct. 15, 11:30 a.m. – 1 p.m.

If your patient's musculoskeletal or rheumatologic condition is not well-controlled, please contact us about our research at:

619.287.1966

San Diego Arthritis Medical Clinic 3633 Camino del Rio South, 3rd Floor (1.7 miles east of Texas Street) San Diego, CA 92108

Michael I. Keller, M.D., Director Puja Chitkara, M.D. Ara H. Dikranian, M.D. Oleg Gavrilyuk, M.D. G. Paul Ignat, M.D. Roger Kornu, M.D. Timothy F. Lazarek, F.N.P. Michael Meng, D.C.

Announcing Allscripts as a Preferred Vendor of the San Diego County Medical Society Allscripts is pleased to announce that it will offer preferred pricing to SDCMS members on the award winning HealthMatics® Office Practice Management and Electronic Health Records solution. This integrated PM and EHR solution offers state of the art technology that includes: • • • •

Complete work flow management P4P, clinical and financial reporting Advanced Scheduling Comprehensive Claims management

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E-prescribing with formularies Electronic orders and results Automated Health Maintenance Online Patient Portal

www.SanDiegoArthritis.com

For more information please contact Jamie Smolin at 619.955.6929 or at jamie.smolin@allscripts.com. Visit us online at www.allscripts.com/healthmatics.

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Offices: Mission Valley, Poway, Chula Vista, El Centro, & Yuma, AZ

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County Public Health Officerâ&#x20AC;&#x2122;s Update

Infant Mortality Still a Need for Action By GAYLE WHITE, MPH, RN

Note: For a copy of this article with references, email Editor@SDCMS.org. percent, occur in the first week of life, and Diego County? The leading causes of infant about two-thirds in the first 28 days. While deaths in San Diego are congenital anominjury prevention and good medical care alies (birth defects), prematurity and low during the first year of life are important birth weight, perinatal complications, and considerations, focusing on these measures Sudden Infant Death Syndrome (SIDS), a alone will not signifipattern comparable to cantly impact the inthat seen nationwide. In 2005, 230 infants One promising, yet challenging, focus fant mortality rate. A major concern in under age one died in San Diego County, an that may help unravel the mysteries the United Sates is that Americans infant mortality rate of the inequality in infant mortality is African carry an unequal share of five deaths per looking at the motherâ&#x20AC;&#x2122;s health and ex- of the infant mortality 1,000 live births. By comparison, that same periences over the course of her life burden. In San Diego County in 2005, the year there were 119 before and during the pregnancy. African-American indeaths among chilfant mortality rate was dren between the ages 13.2, more than two of 1 and 17 in San and a half times as high as the overall rate. Diego County, a death rate of 16.5 per A similar gap between African Americans 100,000. The fact that the two rates are calculated using a different denominator tends and all other groups has persisted over time. to mask the fact that a child is 30 times One factor contributing to this inequality more likely to die during the first year of life is a higher rate of premature births among than at any time during the next 17 years. African Americans, 16.3 percent in San The majority of infant deaths, about 50â&#x20AC;&#x201C;55 Diego County in 2005 compared to 11.1

n the United States, we do not often hear a lot about infant deaths except for the periodic news reports of the unfavorable ranking of our infant mortality rate compared to other countries. The latest estimates place the United States between 30th and 40th from the top. Infant mortality, the death of a live-born infant before one year of age, is a concern on several different levels. Clearly, for the individual family, almost no event is more tragic than the death of a baby. For the community, the death of an infant means the loss of many years of potential contributions to society. From a public health perspective, the infant mortality rate has long been considered one of the best barometers to measure the health and wellbeing of populations. Improving overall health and reducing the number of infant deaths are intertwined. The good news is that the infant mortality rate has been decreasing steadily for several decades. The national rate was 26 per 1,000 live births in 1960 and had fallen to 6.5 in 2005. So what about infant mortality in San

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The Maternal, Child, and Family Health percent for all other groups. Despite signifServices branch (MCFHS) of Public Health icant advances in neonatal care, very low Services works with community partners to birth weight infants (under 1,500 grams) reduce infant mortality and the inequality have a mortality rate of 251/1,000 births. of African-American infant deaths. The Nationally, research into the factors conBlack Infant Health program provides an tributing to African-American infant morarray of services to protality has found that mote health and social while the rates for all racial and ethnic Nationally, research into the factors support during pregand the baby’s groups have been dropcontributing to African-American infant nancy first year of life for ping, the difference between black infants and mortality has found that while the rates more than 500 clients year. The Fetal other groups has befor all racial and ethnic groups have each and Infant Mortality come even larger in the last 10 years. Studies been dropping, the difference between Review (FIMR) proidentifies gaps in controlling for many black infants and other groups has be- gram the community system risk factors, including multiple births, premacome even larger in the last 10 years. of care through indepth review of infant turity, genetics, materand fetal death cases nal education, and leading to recommendations to improve socioeconomic status, indicate that these faccare. Focusing on African-American deaths tors do not fully explain the disparity for since 2005, FIMR-initiated projects have African Americans. included an innovative educational tool to One promising, yet challenging, focus inform African-American women of the imthat may help unravel the mysteries of the portance of good health before and between inequality in infant mortality is looking at pregnancies. The tool is currently being disthe mother’s health and experiences over seminated through community organizathe course of her life before and during the tions. MCFHS received a grant from the pregnancy. Part of the risk for AfricanMarch of Dimes to adapt the tool for SpanAmerican women may come from higher ish-speaking and multicultural audiences rates of certain chronic or infectious condiduring 2008. Other FIMR recommendations. Women who come into a pregnancy tions have led to projects raising awareness with health problems, particularly if they of the signs of premature labor and prohave not had access to high quality healthmoting a woman-carried portable prenatal care to help address and control the condirecord so that health information will be tions before the pregnancy, run a higher risk available in case of emergency. of an adverse birth outcome or infant For information about MCFHS prodeath. In addition, some researchers point grams working to reduce infant mortality to stress on African-American women due in San Diego County, please call Gayle to the undercurrent of racism that has afWhite, maternal and child health coordifected their life course since childhood. The nator, at (619) 692-8667. physiological pathway in response to stress can restrict blood flow to the uterus as well as contribute to inflammation, which can trigger premature birth. Racism as a ABOUT THE AUTHOR: Ms. White is the chronic, long-term stressor is believed to maternal and child health coordinator in have the potential to contribute to such reMaternal, Child, and Family Health Servsponses. One recent study showed that ices. She has held this position for the past women who believed that they had been six years and oversees the Perinatal Care treated unfairly on the basis of their race, Network, Comprehensive Perinatal Servfor example, in employment, work, and ices program, Fetal and Infant Mortality other settings, had twice the risk of deliverReview program, and the Black Infant ing a preterm infant than women who did Health program. not have the same perceptions.

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SAN DIEGO COUNTY HEALTHCARE STATS September is National Infant Mortality Awareness Month. For more information, please visit www.healthy startassoc.org. • In 2005, 11.3 percent of babies born in Sand Diego County were at increased risk of death due to premature birth (before 37 completed weeks of gestation). Mothers under 19 and 35 and older had the highest rates of premature births, 12.5 percent and 13.5 percent respectively (1). • More than one-half (55 percent) of all infant deaths in the United States in 2004 occurred to the 22 percent of infants born at fewer than 32 weeks of gestation. Infant mortality rates for late preterm (34– 36 weeks of gestation) infants were three times those for term (37–41 week) infants (2). To request additional health statistics describing health behaviors, diseases, and injuries for specific populations, health trends and comparisons to national targets, please call the County’s Community Health Statistics Unit at (619) 285-6479. To access the latest data and data links, including the Regional Community Profiles document, go to www.sd healthstatistics.com. REFERENCES: 1. State of California, Department of

Health Services, Center for Health Statistics, Birth Statistical Master Files. Prepared by County of San Diego, Health and Human Services Agency, Maternal, Child, and Family Health Services (MCFHS). 2. Mathews TJ, MacDorman MF. Infant mortality statistics from the 2004 period linked birth/infant death data set. National vital statistics reports; vol 55 no 14. Hyattsville, MD: National Center for Health Statistics. 2007.

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Politics and Advocacy

10 Pretty Good Rules By TOM GEHRING

being (even inadvertently) untruthful. And remember, few are more respected than those who say, “I don’t know, but I will find out,” and then actually find out and inform the legislator.

ver the past seven years as your executive director, I’ve had the pleasure of meeting and learning from many exceptional physicians and physician leaders. I want to share some of these pretty good rules about politics and advocacy, and start by thanking Dr. Bob Hertzka (past CMA president), Dr. Jim Hay (future CMA president), and Joe Dunn (CMA CEO).

3) THE MOST POWERFUL SPOKESMAN FOR YOUR CAUSE IS SOMEONE WHO HAS NO DIRECT STAKE IN THE OUTCOME.

When you speak to a decision maker, and you have a clear interest in the outcome, you will be politely listened to, but your words will be assessed in the context of a special interest. When those same thoughts come from someone without a (perceived) conflict, those words become (magically) much more compelling. So, for example, when a family physician speaks to the lunacy of letting optometrists operate on the eye, that’s a powerful statement — much more so than if the ophthalmologist, who may in fact be making a much more fact-based argument, did the same (see rule #10).

1) LOOK AT POLITICIANS AS EITHER THOSE WHO VIEW PHYSICIANS AS PART OF THE SOLUTION OR THOSE WHO VIEW PHYSICIANS AS PART OF THE PROBLEM.

In the world of political parties, we are seduced into thinking that the party affiliation drives “goodness” or “badness.” Not so. We in the leadership team use a very simple litmus test: Does the decision maker trust physicians or not? If they do, it matters not whether they are a Republican or a Democrat. 2) RESPECT THE TRUTH … ALWAYS.

This rule can’t get any easier — and more difficult to adhere to in the heat of the moment. Never, ever BS. Never, ever fudge. Your reputation, and that of your organization, can be destroyed in 30 seconds by

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4) COUNT YOUR VOTES BEFORE THE VOTE.

Don’t find out you’re close (or behind) during the vote. Do everything in your power to find out who is with you and who isn’t, then lobby the heck out of the issue.

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5) FOCUS ON THE PERSUADABLES.

While actual percentages may vary, on any given issue, about 30 percent will be in fullthroated support, and roughly 30 percent are stridently opposed. Focus 90 percent of your energy on the 40 percent who are convincible. 6) NO ONE BATS 1.000 IN ADVOCACY.

If you expect to win every issue, you’ve chosen the wrong avocation. It’s a game of percentages. Work for the long haul, and be patient. 7) IT’S ABOUT THE RELATIONSHIP, NOT ABOUT THE ISSUE.

• Variation 1: When it’s a core issue, then it is about the issue. • Corollary 1: Choose your core issues very, very carefully. There are a million issues ... choose the ones you’re willing “to die for” very carefully, but always remember to treasure the relationship! Those you lobby may not agree with you (see rule #8 below), but the value of the relationship is that you get a fair and fast hearing. Being able to pick up the cell phone (and having the cell phone number) and calling a state legislator is incredibly useful.

Everything we do as advocates for physicians has to focus on the ultimate goal of healing the sick. 8) TODAY’S OPPONENT IS TOMORROW’S ALLY, AND VICE VERSA.

Note, I did not say enemy... I said opponent (see rule #9 below). Alliances come and go; accept that the greater good sometimes makes for strange bedfellows. Therefore, never, ever personalize a disagreement because you may be looking for a partner someday soon!

party leadership may demand a vote, maybe they need to vote against something we like that is passing easily but they have a constituency to appease, the list goes on. Get over it! That’s the world we live in. So who cares about advocacy and politics anyway? You do. If SDCMS and CMA are not building those relationships, making the case for physicians, walking the halls of power, then a nonphysician will tell you how to practice medicine and reach into your pockets — and directly affect your ability to provide patient care. Which

brings me to the last, and most important rule (with apologies to the famous line from the 1992 presidential campaign): It’s about the patient care, stupid. Everything we do as advocates for physicians has to focus on the ultimate goal of healing the sick. Honestly framed as a patient care issue, it’s hard to lose an argument!

Mr. Gehring is executive director and CEO of the San Diego County Medical Society. ABOUT THE AUTHOR:

9) RESPECT THE ELECTED OFFICIALS, THEIR STAFFS, AND YOUR ADVERSARIES.

You haven’t run for office. You haven’t had to fly to Sacramento or Washington, DC, every week. You haven’t spent interminable hours in meetings listening to ... well, let’s just say that our legislators work incredibly hard, and every move they make is scrutinized, criticized, and second-guessed. Respect them for what they do and who they are. The staff are just as, and sometimes more, important as the elected official. Never, ever, ever treat the staff with anything but respect. They may be young, they may be underpaid, they may work under very challenging conditions, but they have the ear of the decision maker. Make them your allies, even your advocates! Bad-mouthing your opponents (or worse, not respecting the truth) will invariably cause you to be ineffective. And the word gets around. Quickly!

AKT

10) IT’S 90 PERCENT ON THE POLITICS, ONLY 10 PERCENT ON THE MERITS.

• Corollary 1: You don’t get to the merits until AFTER you deal with the politics. Deal with (and understand) the politics before you speak to the merits. Those of us educated in deterministic, objective, and data-driven disciplines (engineering in my case, medicine in my spouse’s) are resolutely convinced that the merits of any argument will always prevail. Sadly, in the world of politics and advocacy, that is rarely the case. In fact, many decisions are made in the absence of, or even contravention of, the facts. Decision makers have to do things, e.g., their

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“Physician, INFORMTHYSELF” We are 2,500 physicians in San Diego County who have chosen, by becoming SDCMS members, NOT to stand idly by... To paraphrase Thomas Jefferson, “An enlightened physician community is indispensable to the proper functioning of a healthcare system.” With that in mind, we would like to begin educating San Diego County’s physician community by informing you of the issues that directly affect your patients and your practices, as well as our overall healthcare system ... and by describing how the San Diego County Medical Society (SDCMS) and the California Medical Association (CMA) affect these same issues as they get played out by politicians, lawyers, corporations, and others throughout the year, and — more often than not — year after year. Although students finish medical school having studied a myriad of subjects in preparation for becoming a physician — organ physiology, human anatomy, histology, cell biology, biochemistry, basic neurology, etc. — they are more and more beginning their medical practices wholly unprepared for the realities of a healthcare system on the brink of collapse due to ongoing Medicare cuts, underfunded government programs, scope of practice threats to patient safety, Byzantine health plan contracts, HIPAA requirements, increasing professional liability insurance premiums, mandatory CME, government agency overregulation, and much, much more. This is where the San Diego County Medical Society (SDCMS) and the California Medical Association (CMA) step in. We are approximately 2,500 physicians in San Diego County and 25,000 physicians across California who have chosen, by becoming members, NOT to stand idly by while our colleagues, our patients, our communities, and our very own practices suffer under the weight of a system in such need of repair. Thank you to those physicians who have stepped forward to take back control of their practices and the care of their patients by becoming SDCMS and CMA members ... and by becoming informed, and educated! NOTE: Look to future issues of San Diego Physician for detailed descriptions of other issues important to physicians, beginning in October with a look at what the Department of Managed Health Care calls “balance billing,” but what we prefer to call “billing for services rendered.” 22

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TABLE OF CONTENTS CMS Programs ..............................24 SGR ..................................................26 GPCI..................................................28 Corporate Practice Bar................30 Pay for Performance....................31 Medi-Cal ..........................................32 MICRA ..............................................34 RICO Lawsuit..................................36 Scope of Practice ..........................37

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CMS PROGRAMS

Key Milestones MEDICARE, MEDICAID, HIPAA, SCHIP … B

elow are some of the key legislative milestones that have shaped Medicare, Medicaid (California’s MediCal program), the Clinical Laboratory Improvement Amendments (CLIA), the Health Insurance Portability and Accountability Act (HIPAA), and the State Children’s Health Insurance Program (SCHIP): 1965: Medicare and Medicaid were enacted as Title XVIII and Title XIX of the Social Security Act, extending health coverage to almost all Americans aged 65 or older and providing healthcare services to low-income children deprived of parental support, their caretaker relatives, the elderly, the blind, and individuals with disabilities. Seniors were the population group most likely to be living in poverty, with about half having insurance coverage. 1966: Medicare was implemented and more than 19 million individuals enrolled on July 1. 1967: An Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) comprehensive health services benefit for all Medicaid children under age 21 was established. 1972: Medicare eligibility was extended to individuals under age 65 with long-term disabilities and to individuals with end-stage renal disease (ESRD). Medicare was given the authority to conduct demonstration programs. Medicaid eligibility for elderly, blind, and disabled residents of a state could be linked to eligibility for the newly enacted Federal Supplemental Security Income program (SSI). 1973: The HMO Act provided for start-up grants and loans for the development of health maintenance organizations (HMOs); HMOs meeting federal standards relating to comprehensive benefits and quality were given preferential treatment in the marketplace. 1977: The Health Care Financing Administration (HCFA) was established to administer the Medicare and Medicaid programs. 1980: Coverage of Medicare home health services was broadened. Medicare supplemental insurance — also called “Medigap” — was brought under federal oversight. 1981: Freedom of choice waivers (1915b) and home and community-based care waivers (1915c) were established in Medicaid; states were required to provide additional payments to hospitals treating a disproportionate share of low-income patients (i.e., DSH hospitals). 1982: The Tax Equity and Fiscal Responsibility Act made it eas24

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ier and more attractive for health maintenance organizations to contract with the Medicare program. In addition, the act expanded the agency’s quality oversight efforts through Peer Review Organizations (PROs). 1983: An inpatient acute hospital prospective payment system for the Medicare program, based on patients’ diagnoses, was adopted to replace cost-based payments. 1985: The Emergency Medical Treatment and Labor Act (EMTALA) required hospitals participating in Medicare that operated active emergency rooms to provide appropriate medical screenings and stabilizing treatments. 1986: Medicaid coverage for pregnant women and infants (up to one year of age) to 100 percent of the federal poverty level (FPL) was established as a state option. 1987: The Omnibus Budget Reconciliation Act of 1987 (OBRA87) strengthened the protections for residents of nursing homes. 1988: The Medicare Catastrophic Coverage Act, which included the most significant changes since enactment of the Medicare program, improved hospital and skilled nursing facility benefits, covered mammography, and included an outpatient prescription drug benefit and a cap on patient liability. Medicaid coverage for pregnant women and infants to 100 percent of FPL was mandated; special eligibility rules were established for institutionalized persons whose spouses remained in the community to prevent “spousal impoverishment”; Qualified Medicare Beneficiary (QMBs) program was established to pay Medicare premiums and cost-sharing charges for beneficiaries with incomes and resources below established thresholds. The Clinical Laboratory Improvement Amendments (CLIA) strengthened quality performance requirements for clinical laboratories in order to assure accurate and reliable laboratory tests and procedures. 1989: The Medicare Catastrophic Coverage Act of 1988 was repealed after higher-income elderly protested new premiums. A new Medicare fee schedule for physician and

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other professional services, a resource-based relative value scale, replaced charge-based payments. Limits were placed on physician balance billing above the new fee schedule.

Physicians were prohibited from referring Medicare patients to clinical laboratories in which their physicians, or physicians’ family members, have a financial interest. Medicaid coverage of pregnant women and children

“PHYSICIAN,

INFORM THYSELF” under age 6 to 133 percent of FPL was mandated; expanded EPSDT requirements were established. 1990: Phased in Medicaid coverage of children ages 6 through 18 under 100 percent of FPL was established; Medicaid prescription drug rebate program was established; Specified Low-Income Medicare beneficiary eligibility group was established (SLMBs) for Medicaid programs to pay Medicare premiums for beneficiaries with incomes at least 100 percent but not more than 120 percent of FPL and limited financial resources. Additional federal standards for Medicare supplemental insurance were enacted. 1991: Medicaid Disproportionate Share Hospital (DSH) spending controls were established, and provider-specific taxes and donations to states were capped. 1996: Welfare Reform: The Aid to Families with Dependent Children (AFDC) entitlement program was replaced by the Temporary Assistance for Needy Families (TANF) block grant; the welfare link to Medicaid was severed; a new mandatory low-income group not linked to welfare was added; and enrollment/termination of Medicaid was no longer automatic with receipt/loss of welfare cash assistance. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) had several provisions. First, it amended the Public Health Service Act, the Employee Retirement Income Security Act of 1974 (ERISA), and the Internal Revenue Code of 1986 to provide for new federal rules improving continuity or “portability” of coverage in the large group, small group, and individual health insurance markets. CMS implements HIPAA provisions affecting the small group and individual markets. Second, it created the Medicare Integrity Program, which dedicated funding to program integrity activities and allowed CMS to competitively contract for program integrity work. Third, it created national administrative simplification standards for electronic healthcare transactions. Fourth, it required HHS to issue privacy regulations if Congress failed to enact substantive privacy legislation. 1997: Balanced Budget Act of 1997 (BBA): the State Children’s Health Insurance Program (SCHIP) was created; limits on

Medicaid payments to disproportionate share hospitals were revised; new Medicaid managed care options and requirements for states were established. Medicare changes include: • Establishing an array of new Medicare managed care and other private health plan choices for beneficiaries, offered through a coordinated open enrollment process; • Expanding education and information to help beneficiaries make informed choices about their healthcare; • Requiring CMS to develop and implement five new prospective payment systems for Medicare services (for inpatient rehabilitation hospital or unit services, skilled nursing facility services, home health services,

hospital outpatient department services, and outpatient rehabilitation services); • Slowing the rate of growth in Medicare spending and extending the life of the trust fund for 10 years; • Providing a broad range of beneficiary protections; • Expanding preventive benefits; • Testing other innovative approaches to payment and service delivery through research and demonstrations. 1998: The Internet site www.medicare.gov was launched to provide updated information about Medicare. 1999: The toll-free number, 1-800-MEDICARE (1-800-6334227), was available nationwide. The first annual Medicare and You handbook was mailed to all Medicare beneficiary households. 1999: The Ticket to Work and Work Incentives Improvements Act of 1999 (TWWIIA) expanded the availability of Medicare and Medicaid for certain disabled beneficiaries who return to work. Established optional Medicaid eligibility groups and allowed states to offer a buy-in to Medicaid for working-age individuals with disabilities. The Balanced Budget Refinement Act of 1999 (BBRA) increased payments for some Medicare providers and increased the amount of Medicaid DSH funds available to hospitals in certain states and the District of Columbia. Other related legislation improved Medicaid coverage of certain women’s health services. 2000: The Benefits Improvement and Protection Act (BIPA) further increased Medicare payments to providers and managed healthcare organizations, reduced certain Medicare beneficiary co-payments, and improved Medicare’s coverage of preventive services. BIPA created a new Medicaid prospective payment system for Federally Qualified Health Centers and Rural Health Clinics, and it modified the amount of Medicaid DSH funds available to hospitals, while it provided a one-year extension on the sunset of transitional medical assistance provided to families eligible for welfare. 2003: The Medicare Prescription Drug, Improvement, and Modernization Act (MMA) made the most significant changes to Medicare since the program began. MMA creates a prescription drug discount card until 2006, allows for competition among health plans to foster innovation and flexibility in coverage, covers new preventive benefits, and makes numerous other changes. In 2006, the new voluntary Part D outpatient prescription drug benefit is available to beneficiaries from private drug plans as well as Medicare Advantage plans. Employers who provide retiree drug coverage comparable to Medicare’s will be eligible for a federal subsidy. Medicare will consider beneficiary income for the first time; beneficiaries with incomes less than 150 percent of the federal poverty limit will be eligible for subsidies for the new Part D prescription drug program; beneficiaries with higher incomes will pay a greater share of the Part B premium starting in 2007.

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MEDICARE’S

Sustainable Growth Rate Formula Unsustainable at Any Measure

ection 1848(f ) of the Act, as amended by section 4503 of the Balanced Budget Act of 1997 (BBA) (Pub. L. 105-33), enacted on Aug. 5, 1997, replaced the Medicare Volume Performance Standard (MVPS) with a Sustainable Growth Rate (SGR) provision. Section 1848(f)(2) of the Act specifies the formula for establishing yearly SGR targets for physicians’ services under Medicare. The use of SGR targets is intended to control the growth in aggregate Medicare expenditures for physicians’ services. The SGR targets are not direct limits on expenditures. Payments for services are not withheld if the SGR SDCMS-CMA — THE FIGHT TO FIX THE target is exceeded by actual expendi(UN)SUSTAINABLE GROWTH RATE FORUMALA tures. Rather, the fee schedule update, This past July’s Medicare victory in Congress speaks for itself to the power as specified in section 1848(d)(4) of and value of organized medicine, but this win was not magic, not a miracle, the Act, is adjusted to reflect the comnot even amazing. It was, simply put, the product of incredible work by CMA parison of actual expenditures to tarstaff in Washington, DC, by AMA, by county medical societies, and by the hunget expenditures. If expenditures dreds of physicians who got involved in California and the thousands who exceed the target, the update is redid so across the nation. The power of physicians to make and shape policy duced. If expenditures are less than has lain mostly dormant for years. As CMA works to become a more aggresthe target, the update is increased. sive advocate for physicians, it will be able to better direct and unleash this Under the statute, the update for a power. Instead of constantly fighting to maintain the status quo, we physiyear is determined by comparing cucians will be positioned to advance our cause and our agenda. In the years mulative actual expenditures to cuto come, we will need every physician’s voice as we work to find a permamulative target expenditures (referred nent fix to this grossly flawed Medicare SGR formula. to as “allowed expenditures” in the statute) from April 1, 1996 through the end of the year preceding the year at issue. For instance, the 2009 update will reflect a comparison of cumulative actual to cumulative target expenditures from April 1, 1996 through Dec. 31, 2008. Target expenditures for each year are equal to target expenditures from the previous year increased by the SGR (which is a percentage figure computed by combining four factors specified below). The statute specifies a formula to calculate the SGR based

[NOTE: FROM THE CENTERS FOR MEDICARE AND MEDICAID SERVICES]

HOW SDCMS HELPS YOU

Future bleak for seniors, baby boomers. Medicare to cut payments as boomers enter the program Sources: Physician cost data is from the MEI, a conservative index of practice cost growth maintained by the Centers for Medicare & Medicaid Services. Medicare physician payment updates are from the 2006 Medicare Trustees report, with adjustments for 2008 to reflect the Congressional Budget Office analysis of the “Tax Relief and Health Care Act of 2006.” Any change in pay that may result from use of the $1.35 billion “physician assistance and quality initiative fund” for 2008 is not included.

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“PHYSICIAN,

INFORM determine the SGR. However, section 1848(f)(2)(c) of the Act, as amended by section 601(b) of the MMA, requires the Secretary to calculate the SGR using the 10-year annual average growth in real gross domestic product per capita.

THYSELF”

Section 1848(d)(1)(E) of the Act requires publication in the Federal Register no later than Nov. 1 of each year (beginning with 2000) of the actual conversion factor, update and allowed expenditures that will apply to physicians’ services for the succeeding year. Another section of the law (section 1848(f)(1)) requires that we publish in the Federal Register no later than Nov. 1 of each year, using the best available data as of Sept. 1, the SGR for the following year, the contemporaneous year, and the preceding year. By Nov. 1, 2008, we are required to publish, based on the best data available to us as of Sept. 1, 2008, the SGRs for CY 2007, CY 2008, and CY 2009. We plan to implement these provisions as part of the physician fee schedule final rule for 2009.

on our estimate of the change in each of four factors. The four factors for calculating the SGR are as follows: 1. The estimated percentage change in fees for physicians’ services. 2. The estimated percentage change in the average number of Medicare fee-for-service beneficiaries. 3. The estimated 10-year average annual percentage change in real gross domestic product (GDP) per capita. 4. The estimated percentage change in expenditures due to changes in law or regulations. Prior to enactment of the Medicare Prescription Drug Improvement and Modernization Act (also known as the Medicare Modernization Act, or MMA), the statute required the SGR to be calculated using estimated projected growth in real GDP per capita. That is, the Secretary was required to use an estimate of a single year’s real GDP per capita to determine the SGR. However, section 1848(f )(2)(c) of the Act, as amended by section 601(b) of the MMA, requires the Secretary to calculate the SGR using the 10-year annual average growth in real gross domestic product per capita. Section 1848(d)(1)(E) of the Act requires publication in the Federal Register no later than Nov. 1 of each year (beginning with 2000) of the actual conversion factor, update and allowed expenditures that will apply to physicians’ services for the succeeding year. Another section of the law (section 1848(f)(1)) requires that we publish in the Federal Register no later than Nov. 1 of each year, using the best available data as of Sept. 1, the SGR for the following year, the contemporaneous year, and the preceding year. By Nov. 1, 2008, we are required to publish, based on the best data available to us as of Sept. 1, 2008, the SGRs for CY 2007, CY 2008, and CY 2009. We plan to implement these provisions as part of the physician fee schedule final rule for 2009. Thus, in this document, we are providing (i) our current estimates (as of March 1, 2008) of the SGRs for CY 2007, CY 2008, and CY 2009, (ii) our current estimate of allowed expenditures under the SGR system through the end of 2009, and (iii)

Thus, in this document, we are providing (i) our current estimates (as of March 1, 2008) our theandphysician schedule update and of thecurrent SGRs for estimate CY 2007, CYof 2008, CY 2009, (ii)fee our current estimate of allowed expenditures under the SGR system through the endbe of 2009, and (iii) our current of all conversion factor for 2009. We will providing updates estimate of the physician fee schedule update and conversion factor for 2009. We will be this information moreusing recent datadata in inthe physician providing updates of all using this information more recent the physician fee fee schedule final rule for 2009. The updated values scheduled to be published in the final schedule final rule for 2009. The updated values scheduled rule by Nov. 1, 2008 will be used to determine the actual update for physician paymentsto 2009. bein CY published in the final rule by Nov. 1, 2008 will be used to Table 1 showsthe our actual current estimates the aforementioned SGRs. determine updateof for physician payments in CY 2009. T a b l e 1 . C u r r e n t E s t i m a t e s o f S G R s f o r C Y 20 0 7 , C Y 20 0 8 , a n d C Y 20 0 9 CY 2007 Factor 1: Increase in Fees

CY 2008

CY 2009

1.9%

2.1%

–2.5%

–2.1%

–0.2%

Factor 3: Increase in 10-year moving average Real Per Capita GDP

1.9%

1.7%

1.8%

Factor 4: Increase due to changes in Law or Regulations

1.9%

0.4%

–2.9%

Total Sustainable Growth Rate

3.2%

1.9%

0.7%

Factor 2: Increase in Enrollment

Table shows our current ofitsthe aforementioned Table 2 1 shows the historical values of theestimates SGR as well as predecessor, the Medicare Volume Performance Standard (MVPS). The MVPS applied for FY 1990 through FY SGRs. 1997. Figures reflect a weighted average MVPS for FY 1991 through FY 1993 when there were two different MVPSs (one for surgical services, and one for all other services) and FYP1994 FY when T a bfor le 2 h y s i cthrough ian MV P S1997 / SG R there were three different MVPSs (for surgical services, primary care services, and all other services). Year

Physician MVPS / SGR

Year

Physician MVPS / SGR

FY 1990

9.1%

FY 1999

4.2%

FY 1991

7.3%

FY 2000

6.9%

FY 1992

10.0%

CY 2000

7.3%

FY 1993

10.0%

CY 2001

4.5%

FY 1994

9.4%

CY 2002

8.3%

FY 1995

7.5%

CY 2003

7.3%

FY 1996

1.8%

CY 2004

6.6%

FY 1997

-0.3%

CY 2005

4.2%

FY 1998

3.2%

CY 2006

1.5%

Table 2 shows the historical values of the SGR as well as its <sidebar> predecessor, the Medicare Volume Performance Standard SDCMS-CMA — The Fight toapplied Fix the (Un)Sustainable Growth Rate Forumala (MVPS). The MVPS for FY 1990 through FY 1997. Figures reflect a weighted average MVPS for FY 1991 Word word word word word word word word word word. Word word word word word word word word word word. Word word word word word word word word word word. through FY 1993 when there were two different MVPSs Word word word word word word word word word word. Word word word word word word word word word. Word word word wordfor wordall word word word word word. (one for word surgical services, and one other services) and Word word word word word word word word word word. Word word word word word for FY 1994 through FY 1997 when there were three differword word word word word. Word word word word word word word word word word. Word word word word word word word word word word. <end> ent MVPSs (for surgical services, primary care services, and all other services).

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T H E G EO G R A P H I C P R AC T I C E meant that physician fees varied greatly. Eventually, insurers behe woeful state of physicame reluctant to pay at different cian reimbursement derates. A cry of injustice was heard serves careful study. Just throughout the land. The media how did we get here and warned that doctors were operathow can we fix it? It all started with ing outside the law and demanded the development of the relative that the RVS be eliminated. value scale (RVS). At the time in In 1979, the Federal Trade the mid-1950s, it seemed logical Commission charged that the and efficient to apportion a docRVS system placed private-practor’s daily tasks by difficulty and time consumption so that he could tice physicians in violation of federal provisions against price fixing. more reasonably and correctly bill for his work. In addition, a perPayers were exempt from the ruling. Why were payers allowed to act sonalized multiplication factor added to the RVS could reflect overlike businesses when solo and small-group physicians were not? head costs and that factor could change as overhead costs changed. The result was that physicians secretly hid their RVS books deep Further, others could use the RVS and modify their work product in office file drawers and developed individual billing schedules that with their own personal multiplication factor. The final result would looked remarkably like the RVS. Young physicians just starting their be a universal formula — a usual, customary and reasonable rate to medical practices bought gray market RVS books and kept them charge — and all would be happy. under lock and key. With this incentive, the California However, when it came time for the govMedical Association (CMA) went to ernment to pay for Medicare and Medicaid, work. In 1956, CMA launched a project standardized billing was suddenly recognized More and more physicians titled “California Relative Value Studies.” as an essential component. The shoe was on are considering their alternaFirst, every possible procedure and diagthe other foot. The government established nosis was listed as a code number — the national standard rates and fees based on a tives: opting out of Medicare, Current Procedural Terminology, or CPT defined and limited total pool of money, opening concierge practices, code, as it was later named by the Ameriwhich they defined as a “resource.” In 1989, can Medical Association. Then a relative the Health Care Financing Administration limiting their practices, or revalue unit (RVU) reflected the physician’s developed a Resource-based Relative Value fusing to contract. time, resources, and work intensity necesScale (RBRVS) to redistribute a fixed budget sary to accomplish each CPT code. Next, of Medicare funds to physicians. Healthcare an individual physician assigned a “conrationing, disguised as cost containment, rapversion” factor to the formula based on inidly won legislative approval. dividual office overhead expenses and local area of practice. When In 1970, projected Medicare spending for 1990 was $16.3 bila physician multiplied the conversion factor by the RVU, the “unilion. In 1990, the actual cost of Medicare was $109 billion. A few form” fee was revealed. extra billion here and there, and pretty soon the healthcare delivery At the time, just about every physician’s office had an RVU rate system added up to major government debt. The RBRVS did not do schedule. The booklet was an essential first purchase for any doctor what the RBRVS was supposed to do. starting a medical practice. In 1969, CMA published its “California Then, because no good deed goes unpunished, the government Relative Value Studies.” It was revised and published again in 1974. came up with an even more confusing dynamic for payment. From CMA finally published the “California Standard Nomenclature” in the 1991 proposed rule in the Federal Register: 1979. The final CMA publication is still referred to as the “RVS book.” Payment = [{RVUws x GPCIwa} + {RVUpes x GPCIpea} + The recommended use of conversion factors to reflect differences {RVUms x GPCIma}] x CF WHERE DID THE GEOGRAPHIC PRACTICE COST INDEX COME FROM?

Cost Index Inequity TIME TO FIX IT

[Note: This article by Ralph Di Libero, MD, then-President of LACMA, was originally published in 2006 in Southern California Physician magazine.]

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“PHYSICIAN,

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• RVUws = Physician work relative value units for the service. • GPCIwa = Geographic practice cost index value reflecting one fourth of the geographic variation in physician work applicable in the fee schedule area. • RVUpes = Practice expense relative value units for the service. • GPCIpea = Geographic practice cost index value for the practice expense applicable in the fee schedule area. • RVUms = Malpractice relative value units for the service. • GPCIma = Geographic practice cost index value for malpractice expense applicable in the fee schedule area. • CF = Uniform national conversion factor. All of the above only served as more subterfuge. The resource for Medicare funding was based on Americans having an average life expectancy of 65 years in 1964. By 2000, that life expectancy was 78 years and today it is 80 years. The fastest growing segment of our society is older people. The resource is grossly inadequate. In an era of expanding technologies, the amount of funding available for physician fees from a fixed-dollar resource mathematically decreased. The logical next step was to increase the resource base, but neither side of the political aisle appears to be interested in confronting this painfully obvious solution. So now, more and more physicians are considering their alternatives: opting out of Medicare, opening concierge practices, limiting their practices, or refusing to contract. All of these actions are becoming more SDCMS-CMA — THE FIGHT TO FIX THE GPCI INEQUITY common, but they do not solve the probUntil the system is made equitable, SDCMS and CMA will fight for fair lem of patient access to physicians in medMedicare reimbursements that underpay San Diego County’s physiical emergencies. cians approximately 7 percent per annum ($24 million). In June 2007, There is a great void in our American after more than four years of sustained advocacy, the County of San healthcare delivery system. Many emerDiego joined six other counties in suing the federal government for gency rooms are closing their doors because retroactive and prospective Geographic Practice Cost Index (GPCI) rephysician specialists naturally avoid the siglief to bring Medicare geographic payment equity to San Diego County nificant financial risk in the offering of physicians and other impacted counties and states across the counemergency care. Perhaps part of the hometry — approximately $160 million for San Diego County’s physicians land defense budget should be diverted to alone, and more than $2.4 billion nationally for physicians in the 174 healthcare for emergency services. Perhaps underpaid counties. our government officials should get their act together and properly fund programs so that those who actually deliver healthcare are adequately reimbursed.

HOW SDCMS HELPS YOU

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The

CORPORATE Practice of Medicine

B A R R E D !

he Medical Practice Act, Business and Professions Code section 2052, provides that “any person who practices or attempts to practice, or who holds himself or herself out as practicing … [medicine] without having at the time of so doing a valid, unrevoked, or unsuspended certificate … is guilty of a public offense.” Business and Professions Code section 2400, within the Medical Practice Act, provides in pertinent part that “corporations and other artificial entities shall have no professional rights, privileges, or powers.” The policy expressed in Business and Professions Code section 2400 against the corporate practice of medicine is intended to prevent unlicensed persons from interfering with or influencing the physician’s professional judgment. [Note: The involvement of corporations in medical practice gained attention in the early part of the 20th century when mining companies needed to hire physicians to provide care for employees in remote areas. Problems arose when physicians’ loyalties to their employers conflicted with patients’ medical needs.] The decisions described below are examples of some of the types of behaviors and subtle controls that the corporate practice doctrine is intended to prevent. From the Medical Board’s perspective, the following healthcare decisions should be made by a physician licensed in the State of California and would constitute the unlicensed practice of medicine if performed by an unlicensed person: • Determining what diagnostic tests are appropriate for a particular condition.

HOW SDCMS HELPS YOU SDCMS-CMA — PROTECTING THE BAR TO THE CORPORATE PRACTICE OF MEDICINE CMA considers the corporate practice of medicine doctrine “a fundamental protection against the potential that the provision of medical care and treatment will be subject to commercial exploitation.” CMA’s legal counsel defines the corporate practice of medicine bar broadly as a prohibition on lay entities hiring or employing physicians or other healthcare practitioners, or interfering with physicians or other healthcare practitioners’ practice of medicine. Lay entities are also prohibited from contracting with healthcare professionals to render services. CMA further notes that the corporate practice of medicine bar “… is designed to protect the public from possible abuses stemming from the commercial exploitation of the practice of medicine,” and that California’s courts and legislature have upheld the corporate practice of medicine bar to protect physicians from the “pressures of the commercial marketplace.”

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• Determining the need for referrals to, or consultation with, another physician/specialist. • Responsibility for the ultimate overall care of the patient, including treatment options available to the patient. • Determining how many patients a physician must see in a given period of time or how many hours a physician must work. In addition, the following “business” or “management” decisions and activities, resulting in control over the physician’s practice of medicine, should be made by a licensed California physician and not by an unlicensed person or entity: • Ownership is an indicator of control of a patient’s medical records, including determining the contents thereof, and should be retained by a California-licensed physician. • Selection, hiring/firing (as it relates to clinical competency or proficiency) of physicians, allied health staff, and medical assistants. • Setting the parameters under which the physician will enter into contractual relationships with third-party payers. • Decisions regarding coding and billing procedures for patient care services. • Approving of the selection of medical equipment and medical supplies for the medical practice. The types of decisions and activities described above cannot be delegated to an unlicensed person, including, for example, management service organizations. While a physician may consult with unlicensed persons in making the “business” or “management” decisions described above, the physician must retain the ultimate responsibility for, or approval of, those decisions. The following types of medical practice ownership and operating structures also are prohibited: • Non-physicians operating in a business for which physician ownership and operation are required: any business advertising, offering, and/or providing patient evaluation, diagnosis, care, and/or treatment. These are services that can only be offered or provided by physicians. • Physician(s) operating a medical practice as a limited liability company, a limited liability partnership, or a general corporation. • Management Service Organizations arranging for, advertising, or providing medical services rather than only providing administrative staff and services for a physician’s medical practice (non-physician exercising controls over a physician’s medical practice, even where physicians own and operate the business). • A physician acting as “medical director” when the physician does not own the practice. For example, a business offering spa treatments that include medical procedures such as Botox injections, laser hair removal, and medical microdermabrasion, that contracts with or hires a physician as its “medical director.” In the examples above, non-physicians would be involved in the unlicensed practice of medicine, and the physician may be aiding and abetting the unlicensed practice of medicine. [Note: From the Medical Board of California —www.medbd.ca.gov.] 2 0 0 8

“PHYSICIAN,

INFORM THYSELF”

Payfor

PERFORMANCE QUALITY BY WHOSE MEASURE?

uality-based purchasing, also known as payproaching a comprehensive program. The Centers for for-performance, is the use of payment Medicare and Medicaid Services (CMS) will provide methods and other incentives to encourage technical assistance to those states that voluntarily elect to quality improvement and patient-focused, high-value implement pay-for-performance programs. CMS also care. There are many models for financial and nonplans to work with states to encourage that evolving payfinancial incentives used in pay-for-performance for-performance programs include an evaluation comprograms and strategies. It is important to remember that ponent to provide evidence of the effectiveness of this pay-for-performance programs should be viewed as only methodology. one component of a broader strategy of promoting healthcare quality. At least 12 states throughout the country have implemented a wide range of pay-for-performance initiatives under Medicaid. The strategies may also be of interest to SCHIP. States use both payment differenIt is critically important that physicians be involved in the design of paytials and non-financial incentives, for-performance programs, which are intended to improve the effectivesuch as auto-enrollment and public ness and safety of patient care. Collecting and reporting data must be reporting, to reward performance. reliable and easy for physicians and should not create financial or other Pay-for-performance is in its early burdens on physicians or their practices, and program incentives should stages of development, and a great include reimbursement for any added administrative costs, including softdeal of work still must be done to ware purchases, installation, and training. CMA has advocated from the determine the best method of ap-

HOW SDCMS HELPS YOU

[From the Centers for Medicare and Medicaid Services]

beginning — and will continue to advocate — that CMS and others work with physicians when formulating guidelines for shaping pay-forperformance programs.

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Medi-Cal WHAT IS MEDI-CAL?

edi-Cal, California‘s Medicaid program, is the main source of healthcare insurance for 6.6 million people, or one in six Californians. It draws more than $20 billion in federal funds into the state‘s healthcare system and accounted for 17 percent of General Fund spending in fiscal year 2006– 07. Medi-Cal is a complex program that pays providers for essential primary, acute, and long-term care services delivered to a wide range of beneficiaries, including children, their parents, seniors, and non-elderly adults with disabilities. Because it is the single largest source of health insurance coverage in California and a major source of funding for safety-net providers, a thorough grasp of Medi-Cal is essential to understanding how healthcare is financed and delivered in California. For all its success, Medi-Cal faces numerous challenges, including enrollment barriers, poor access to specialty care, and rising healthcare costs.

ABOUT MEDICAID

• Is a program created by Title XIX of the Social Security Act that provides coverage for acute and long-term care services to 52 million Americans, including low-income children, parents, seniors, and people with disabilities. • Is state-administered, governed by federal and state rules, and jointly funded with federal and state dollars. • Is an entitlement program that requires federal and state governments to spend the funds necessary to operate mandatory program components. • Is the nation’s largest purchaser of healthcare services,

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CALIFORNIA’S MEDICAID PROGRAM collectively spending more than $317 billion in fiscal year 2005 in federal and state dollars. • Is a 40-year-old program that is continually evolving in terms of the populations it covers, the services for which it pays, and the manner in which care is delivered and financed. ABOUT MEDI-CAL

• Is the nation’s largest Medicaid program in terms of the number of people it serves (6.6 million), and is the second largest in terms of dollars spent ($40 billion). • Is the source of health coverage for: • Almost one in five of Californians under age 65; • One in three of the state’s children; • And the majority of people living with AIDS. • Pays for: • Forty-six percent of all births in the state; • Two-thirds of all nursing home residents; • And almost two-thirds of all net patient revenue in California’s public hospitals. • Brings in more than $20 billion in federal funds to California’s healthcare providers. LOOKING AHEAD

In addition to addressing enrollment barriers, poor access to specialty care, and rising costs, Medi-Cal faces other important and difficult challenges: • Implementing policy changes at the federal level, such as the new documentation requirements. • Making better use of technology to improve quality of care and administrative efficiency. • Continuing to expand community-based alternatives to facility-based long term care. • Monitoring impact of changes in hospital financing on safety-net providers. • Measuring and monitoring the effectiveness of the feefor-service system. • Planning for healthcare reform.

“PHYSICIAN,

INFORM THYSELF”

HOW SDCMS HELPS YOU SDCMS-CMA — CAN MEDI-CAL BE FIXED?

Spending per Beneficiary

Medicaid State Spending Average per Beneficiary (2007)

10 Most Populous States and U.S. Average

With the California Department of Health Care Services scheduled to cut Medi-Cal reimbursement rates to physicians by 10 percent on July 1, 2008, CMA turned to the courts in May and filed a lawsuit against the Department of Health Care Services to enjoin the cut. Unfortunately, the state court justice ruled unfavorably in CMA’s lawsuit, denying CMA’s motion for preliminary injunction. CMA, as of press time, has been coordinating with plaintiffs in other lawsuits that are seeking to stop the Medi-Cal cuts. CMA and SDCMS continue to fight assiduously on behalf of physicians and their patients to make sure physicians are reimbursed fairly for the services they provide to those Californians covered by Medi-Cal.

Spending per Resident

Medicaid State Spending per Resident

10 Most Populous States and U.S. Average

Medicaid Physician Payment Rates as Percentage of Medicare

10 Most Populous States and U.S. Average

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CALIFORNIA’S

Medical Injury Compensation INCREASING PATIENT ACCESS TO CARE THE CRISIS

In the early 1970s, a medical malpractice insurance crisis gripped California. Liability premiums soared more than 300 percent because of more frequent and severe liability claims and larger malpractice jury awards. Many physicians — particularly in high-risk specialties such as obstetrics and neurosurgery — were forced to close their doors, either unable to get insurance or unable to afford inflated rates. Denied access to affordable care, California’s patients suffered. In 1975, then-Governor Jerry Brown called a special session of the California Legislature to solve the “malpractice crisis.”

HOW SDCMS HELPS YOU SDCMS-CMA — PROTECTING MICRA Many organizations, spearheaded by the trial lawyers, want to weaken, if not overturn, MICRA. CMA legal advocacy has prevailed in the past in defending MICRA (e.g., Palmer vs. Sharp Rees-Stealy Medical Group when there was an attempt to define medical groups as not qualifying as “healthcare providers” under the law and as such as not being protected by MICRA) and will prevail in the future with the help of those physicians who’ve decided to defend their practices and their patients by joining SDCMS-CMA.

CALIFORNIA’S RESPONSE

MICRA’S IMPACT:

During that special session, on a bi-partisan vote, legislators took action to fix the broken system by enacting the Medical Injury Compensation Reform Act, or MICRA. Specifically, MICRA: • LIMITS ATTORNEY CONTINGENCY FEES. In an action against a healthcare provider for professional negligence, an attorney’s contingency fee is limited to 40 percent of the first $50,000 recovered; 33 percent and 1/3 of the next $50,000; 25 percent of the next $500,000, and 15 percent of any amount exceeding $600,000. • LIMITS ON NON-ECONOMIC DAMAGES. Non-economic damages in a claim against a healthcare provider for medical negligence are limited to $250,000. Economic damages, such as lost earnings, medical care, and rehabilitation costs, are not limited by statute. California Civil Code Section 3333.2. • ALLOWS EVIDENCE OF COLLATERAL SOURCE PAYMENTS. A defendant in a medical liability action may introduce evidence of collateral source payments (such as from personal health insurance) as

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they relate to damages sought by the claimant. If a defendant introduces such evidence, the claimant may also introduce evidence of the cost of the premiums for such personal insurance. California Civil Code Section 3333.1.Ensures compensation for economic damages such as present and future medical costs, lost wages, future earnings, custodial care and rehabilitation. • PROVIDES A STATUTE OF LIMITATIONS ON CLAIMS. In California, a claim for alleged medical negligence must be brought within one year from the discovery of an injury and its negligent cause, or within three years from injury. California Code of Civil Procedure Section 340.5. • REQUIRES ADVANCE NOTICE OF A CLAIM. To further the public policy of resolving meritorious claims outside of the court system, MICRA requires a claimant to give a 90-day notice of an intention to bring a suit for alleged professional negligence. If the notice is given within 90 days of the expiration of the statute of limitations, the statute is extended 90 days from the date of the notice. California Code of Civil Procedure Sections 364 and 365. • ALLOWS FOR BINDING ARBITRATION OF DISPUTES. Patients and their healthcare providers may agree that any future dispute may be resolved through binding arbitration. California statute requires specific language for such contracts and also provides that all such contracts be revocable within 30 days. California Code of Civil Procedure Section 1295. • PROVIDES FOR PERIODIC PAYMENTS OF FUTURE DAMAGES. A healthcare professional may elect to pay a claimant’s future economic damages, if more than $50,000, in periodic amounts. This avoids a claimant’s wasting of an award prior to actual need. California Code of Civil Procedure Section 667.7.

S E P T E M B E R

• MICRA has increased patients’ access to healthcare by keeping doctors, nurses, and other healthcare providers in practice and hospitals and clinics open. • California now has some of the lowest malpractice premiums in the United States and the American Medical Association (AMA) and the American Hospital Association (AHA) hail MICRA as a “model.” • Without MICRA, the decline in the number of obstetric providers in the state will only get worse, further threatening women’s access to comprehensive, quality reproductive healthcare. • MICRA saves California’s healthcare system billions of dollars each year. • Injured patients receive their awards 26 percent sooner than patients in states without MICRA reforms. • Patients receive the lion’s share of settlements and awards — not attorneys.

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SDCMS Members

BE SURE TO TAKE ADVANTAGE OF THE FOLLOWING MEMBERSONLY BENEFITS FROM SDCMS’ ENDORSED PARTNERS!

AKT, LLP

AKT has provided audit, tax preparation and planning, accounting assistance, and business consulting to San Diego County clients for more than 50 years. AKT understands physician practices, and their personal, local, and global services can help you achieve success. SDCMS members receive a 15% discount on standard rates for professional services, with an unconditional satisfaction guarantee: Disappointed clients pay only what they thought the work was worth. Call Ron Mitchell (760) 268-0212 or email him at rmitchell@aktcpa.com.

ALLIANT INSURANCE SERVICES

As California’s largest premier specialty insurance broker, and ranking among the 13th largest in the nation, Alliant Insurance delivers a comprehensive portfolio of insurance products and services. SDCMS members receive a savings of 5–10% or more off of the cost of insurance, or cash rebates related to practice size, a savings of 7–12% on long-term disability income protection, and no-cost human resources consulting. Contact Mark Allan at (800) 654-4609 or at mallan@alliantinsurance.com, call Alliant Insurance Services at (888) 849-1337, or visit www.alliantinsurance.com.

ALLSCRIPTS

Allscripts offers substantial discounts to SDCMS members on its award-winning practice management and electronic health records. Allscripts’ solutions provide improved patient care, complete workflow management, P4P and P4Q clinical and financial reporting, e-prescribing with builtin formularies, built-in claims scrubbing, and complete revenue cycle management for your practice. SDCMS members receive special preferred early-adopter pricing and discounts on HealthMatics EHR and practice management solutions. For more information, call Jamie Smolin at (619) 665-6139, call Allscripts at (888) 672-3282, or visit www.allscripts.com/ healthmatics.

AMERICAN SECURITY RX

American Security Rx (ASRX) is a California Department of Justice and California Board of Pharmacy approved security printer (SP-9) to provide tamper-resistant California security prescription forms for controlled medications. SDCMS members receive discounts on tamper-resistant prescription forms. Call American Security Rx at (877) 290-4262, email them at info@americansecurityrx.com, or visit ww.americansecurityrx.com.

CHMB SOLUTIONS

CHMB provides outsourced medical billing, revenue cycle management services, information technology support, and hardware solutions to physician practices, clinics, and multi-specialty organizations. SDCMS members receive a 50% discount on startup fees, a $33 per physician per month services credit, and a free coding hotline. Contact Ron Anderson (CHMB Solutions) at (760) 520-1340 or at randerson@chmbsolutions.com. Email your coding question(s) to SDCMS at Coding@SDCMS.org.

COASTAL HEALTHCARE CONSULTING GROUP, INC.

Coastal Healthcare Consulting Group, Inc., is a specialty consulting firm that assists clients with managed care contracting, contract negotiations, credentialing, revenue enhancement and strategic planning.

SDCMS members receive a free consultation, a discount on hourly rates, and a package price on services for contract negotiations. Contact Kim Fenton at (949) 481-9066, at kimf@healthcareconsultant.org, or visit www.healthcareconsultant.org for more information. For consultation scheduling, contact Marisol Gonzalez, your physician advocate, at (858) 300-2782 or at MGonzalez@SDCMS.org.

PRACTICE PERFORMANCE GROUP (PPG)

Practice Performance Group provides high performance medical practice management services for physicians, including consulting, expert witness, workshops, speaking, and a monthly newsletter. SDCMS members receive discounted management consulting on productivity and patient flow, personnel, governance and management, market strategy and tactics and practice acquisitions, sales and mergers, and a free one-year subscription to their newsletter, UnCommon Sense ®. PPG also conducts free half-day seminars for members and their employees at SDCMS (watch your faxes and emails). Contact Jeffrey Denning or Judy Bee at (858) 459-7878 or at Jeff@PPGConsulting.com, or visit www.PPGConsulting.com.

THE DOCTORS COMPANY (TDC)

TDC enjoys a reputation as the industry vanguard for low California rates, aggressive claims defense, expert patient safety programs, superior customer service, and exemplary member benefits. Everyday, The Doctors Company relentlessly strives to reduce unreasonable legal liability, improve the environment in which all healthcare professionals practice, lead legislative and judicial reform, and enhance patient safety for the benefit of its members. Most SDCMS members are eligible for a 5% discount on insurance premiums, and a 7.5% dividend credit. To learn more, contact Janet Lockett at (858) 300-2778 or at JLockett@SDCMS.org.

TORREY PINES BANK

Torrey Pines Bank is familiar with the business challenges facing medical professionals. Their goal is to be a “low maintenance” bank, meeting business owners’ high expectations, with the absolute minimum time and effort required of them. They offer a full array of banking services. Approved SDCMS members receive no-fee lines of credit, $1,000 fee discounts on commercial real estate loans, waived monthly maintenance fees on personal accounts for practice partners and employees up to $10/month, free first order of standard checks for personal accounts, increased deposit interest rates, waived monthly maintenance fee for business online banking and bill pay services, ATM fees waived up to $15/month, and free courier service or remote deposit service. Contact Benjamin Pimentel at (858) 259-5317 or at bpimentel@torreypinesbank.com.

TSC ACCOUNTS RECEIVABLE SOLUTIONS

TSC Accounts Receivable Solutions has provided personalized, innovative collection and total accounts management services since 1992. This local San Diego family-owned business management team has a combined experience of more than fifty years in the healthcare billing and collection field. SDCMS members receive a 10% discount on monthly charges. Contact Catherine Sherman at (888) 687-4240, ext. 14, at csherman@tscarsolutions.com, or visit www.tscarsolutions.com.

CMA’s RICO Lawsuit STOPPING THE HEALTH PLANS’ FRAUDULENT AND UNFAIR BUSINESS PRACTICES

n May 25, 2000, CMA filed a class-action lawsuit against California’s three largest for-profit HMOs — Blue Cross/WellPoint, Foundation/Health Net, and PacifiCare — seeking to stop their allegedly fraudulent and unfair business practices that improperly interfered with and controlled the physician-patient relationship. This lawsuit was originally filed in federal court in California, but was transferred to U.S. District Court in Miami and consolidated with numerous other lawsuits filed by physicians and other medical associations against a number of health plans, in front of Judge Federico Moreno. The lawsuit is based primarily on allegations that 10 for-profit health plans — Humana, Aetna, Prudential (prior to its acquisition by Aetna), CIGNA, Coventry, Health Net, PacifiCare, United, WellPoint, and Anthem — violated the Racketeer Influenced and Corrupt Organizations Act (RICO) by engaging in fraud and extortion in a common scheme to wrongfully deny payment to physicians. CMA’s primary focus in pursuing this litigation was to obtain prospective relief — a court order prohibiting the plans from continuing these fraudulent and extortionate practices.

HOW SDCMS HELPS YOU SDCMS-CMA — POLICING THE HEALTH PLANS, BRINGING MILLIONS BACK TO PHYSICIANS CMA’s RICO class-action lawsuit challenging the rapacious tactics of the forprofit managed care industry saw a further settlement in 2007, directing millions more dollars to San Diego County’s physicians. Of even greater significance than the $40 million Humana settlement (roughly $1.3 million of which came to San Diego County physicians) is the settlement’s prospective relief, which is valued at more than $80 million. The following award amounts were received in 2007 by San Diego County physician groups, with a total approaching $800,000: • Scripps Medical Group: $188,541 • Sharp Rees-Stealy Medical Group: $144,297 • UCSD Medical Group: $106,577 • Anesthesia Service Medical Group: $103,196 • Emergency and Acute Care Medical Corporation: $97,265 • Children’s Specialists of San Diego: $45,193 • Sharp Mission Park Medical Group: $35,347 • Children’s Primary Care Medical Group, Inc.: $24,494 • Park Terrace Medical Association: $21,944 • Mercy Physicians Medical Group: $14,056 In addition, CMA continued to monitor the health plans in 2007 to ensure they abided by the terms of their RICO settlements. CMA filed disputes after discovering Health Net, CIGNA, and Blue Cross had each violated the terms of their respective RICO settlements in 2007.

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“PHYSICIAN,

INFORM

FOR IMMEDIATE RELEASE: MAY 25, 2000

THYSELF” CMA FILES SUIT FOR INJUNCTIVE RELIEF AGAINST MAJOR HEALTH PLANS UNDER FEDERAL RICO LAWS

LOS ANGELES — The California Medical Association (CMA) today filed a federal lawsuit against the three largest for-profit national health plans in California for imposing unfair contract terms, unnecessarily denying and delaying payments for procedures patients need, and reimbursing physicians at rates that are insufficient to cover costs. The suit against Wellpoint/Blue Cross of California, HealthNet and Pacificare was filed in U.S. District Court in San Francisco under the civil RICO (Racketeer Influenced and Corruption Act) laws. The suit, California Medical Association v. Blue Cross of California et. al., claims that racketeering activity by those three plans has damaged the businesses of and victimized the patients of California physicians. Click here for Questions and Answers Concerning CMA’s Participation in the Suit. CMA alleges that the health plans used coercive, unfair and fraudulent means to dominate and control physician-patient relationships for their own financial gain to the detriment of both patients and physicians, the suit further states. CMA is seeking injunctive relief. CMA President Marie Kuffner, MD, said she hopes the lawsuit will be the last step in what has been an excruciating and lengthy effort to get the health plans to give physicians the means to care for their patients. “It is with sadness that we are forced to this last resort,” said Dr. Kuffner, a UCLA professor of anesthesiology. “We as physicians have tried to work with the for-profit HMOs in the marketplace and have attempted to curb the abuses through the legislative process, all to no avail. We cannot continue to allow our patients’ health to be jeopardized by corporate greed.” Dr. Kuffner stated, “For years these profit-driven companies denied needed services, interfered with medical decisions and valued dollars more than lives. We are here today to say, ‘No more in the State of California.’” More than nine million Californians, or about two-thirds of those covered by for-profit plans in the state, are insured by the defendant plans. The plans had no intention of keeping their promise to provide access to quality care at a reasonable cost, CMA’s suit charges. Instead, these companies have conspired to generate profits for themselves while delaying payments to doctors, denying necessary and timely care to patients, and refusing to provide the data necessary for physicians to treat their patients – hence committing fraud on both physicians and patients. “CMA’s role as plaintiff shows how crucial the health care problem is in the nation, particularly in California, where 21 million people belong to a managed care health plan of some kind,” said Archie Lamb, a Birmingham, Ala. attorney who filed the suit on CMA’s behalf. Lamb already has filed a lawsuit against Aetna, Cigna, Humana and Prudential on behalf of physicians seeking national class certification. “It is ironic that here in the state where the HMO concept was born, the abuses of managed care are most egregious,” Lamb said. “We are here today to demand that the HMO industry return to the principle on which managed care was founded. The CMA, on behalf of its membership, physicians all over America, and all their patients

Scope of Practice ENSURING PATIENT CARE IS NOT JEOPARDIZED

“

cope of practice” is used by licensing boards for various professions that define the procedures, actions, and processes that are permitted for the licensed individual. The scope of practice is limited to that which the individual has received education and experience, and in which he/she has demonstrated competency. Each state has specific regulations based on entry education and additional training and practice.

HOW SDCMS HELPS YOU SDCMS-CMA — ENSURING PATIENT SAFETY While SDCMS-CMA does not oppose all expansions of scope of practice, we believe that patients are put at risk when non-physician practitioners provide care for which they are inadequately trained. SDCMS-CMA believes that any such proposal must be carefully studied to ensure that patient care is not jeopardized. In 2007, for example, CMA defeated all non-physician scope of practice expansion attempts (i.e., by acupuncturists physical therapists, nurse practitioners, psychologists, and audiologists).

say, ‘Enough is enough.’ “The for-profit HMOs have engaged in a scheme that included lying to employers about the benefits for employees, lying to physicians about commitment to payment for quality health care and fraudulently promising patients that they would be there in the time of greatest need. And so, we start here today in California and will take this fight all the way to the East Coast, until patients can once again trust that their doctor can provide them with the care they need, free of interference by companies driven only by greed,” Lamb said.

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building a healthier San Diego by addressing unmet healthcare needs for all patients and physicians through education, innovation and service

The

Pulse

No 42

MESSAGE FROM THE PRESIDENT “WHEN YOU CAN DO THE COMMON THINGS OF LIFE IN AN UNCOMMON WAY, YOU WILL COMMAND THE ATTENTION OF THE WORLD.”

— George Washington Carver Dear Friends: Volunteering is a way of life for many in our healthcare community, and volunteering to do something you already do in an uncommon way will bring to life our core mission at the Foundation: to address unmet San Diego healthcare needs for all patients and physicians through innovation, education and service. Volunteerism is high on the Foundation’s list this month as we continue to recruit physicians and supportive ancillary services to serve safety net patients in the Foundation’s flagship program: Project Access San Diego (PASD). This important access-to-care initiative de-

pends on our region’s physicians and health providers who volunteer their time to see one or two patients per year on a pro-bono basis or at discounted rates. More than ever, patients are in need with Medi-Cal and Medicare cutbacks affecting the availability of services they can receive. Every year we see need in our community — on the news, in the newspaper, and in our offices. Every year, more and more San Diegans fall through the cracks in the healthcare system, be it a lack of insurance, a lack of specialty care, or even a lack of transportation to receive care for a chronic illness. The need for help is ongoing, and many San Diego physicians step up to the plate, not just with the Foundation, but in other communitybased organizations as well. I commend each and every volunteer! I urge you to seek opportunities to vol-

unteer in the community. There are numerous ways to volunteer using your skills and expertise through the San Diego County Medical Society Foundation. Please contact Tana Lorah, interim executive director, at (858) 300-2780 to learn how you can be a Foundation volunteer. Eleanor Roosevelt is famous for her quote, “Tomorrow starts today.” Tomorrow’s patients and physicians will benefit from the work we are doing today, and that is a powerful motivator for our Foundation. With your support, we are confident that we can make a difference! Thank you for all that you do for the patients in San Diego. Sincerely,

Carol L. Young, MD, President of the Board

BOARD OF DIRECTORS Carol Young, MD, President, Rheumatology, Escondido Ralph Ocampo, MD, Secretary/Treasurer, General Surgery, Retired James Hay, MD, Immediate Past President, Family Medicine, Encinitas Ellen Beck, MD, Family Medicine, San Diego John Berger, MD, Family Medicine, San Diego Edgar D. Canada, MD, Anesthesiology, San Diego Judy Forrester, Consultant, Forrester Enterprises Tom Gehring, CEO, San Diego County Medical Society

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Theodore M. Mazer, MD, Otolaryngology and Head and Neck Surgery, San Diego Albert Ray, MD, Family Medicine, San Diego

Richard S. Ledford, President, Ledford Enterprises Michael I. Neil, BGN, USMC Retired, President, Neil, Dymott, Perkins, Brown and Frank

ADVISORY COUNCIL

STAFF

James Lewis Bowers, PhD, Consultant for Philanthropy Steven A. Escoboza, President/CEO, Hospital Association of San Diego and Imperial Counties Ronne Froman, RADM, USN Retired, Chief Operating Officer, City of San Diego

Tana Lorah, Interim Executive Director Stephen H. Carson, MD, Chief Medical Officer Pediatrics, San Diego Claudia Gastelum, PASD Care Coordinator

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Showcasing a Foundation Inititative

In the Spotlight: Meet a Physician Volunteer

Legislative and Policy Training One of the core initiatives at the SDCMS Foundation is to assist medical students with their education through scholarship awards, loans, and legislative and policy training. Legislative and policy training for medical students is one of the ways we support students as they complete their training to become physicians. With the continuing barrage of legislative challenges for practicing physicians, it is more important than ever to give medical students the tools they will need to thrive in the world of medicine. With the help of deeply committed member physicians, the San Diego County Medical Society continually advocates for physicians by helping to defend, support, and promote the practice of medicine both regionally and statewide. The Foundation encourages medical students to reach out and learn the legislative process so they will have the background to champion their own practices and support the practice of medicine at large. Medical students join our CEO, Tom Gehring, and San Diego County Medical Society Foundation leaders on trips to Sacramento on a regular basis. Medical students walk the halls of the State Capitol, participate in meetings with elected officials, and learn the art of advocacy. To find out more about supporting medical students or Project Access San Diego (PASD), contact Tana Lorah at (858) 300-2780 or TLorah@SDCMS.org.

Save RETIRED PHYSICIANS SOCIETY EVENTS Thursday, October 3, 2008, Sharp Chula Vista Thursday, January 22, 2009, San Diego Zoo Hospital

MEET DR. ROBERT HERTZKA Anesthesiologist Former President of SDCMS and CMA WHEN DID YOU BEGIN PRACTICING MEDICINE? I earned my medical degree from UCSD and completed my residency and fellowship in anesthesiology at the University of California, San Francisco (UCSF). Following two years on the faculty at UCSF, I have been in private practice with Anesthesia Service Medical Group (ASMG) since 1987. WHAT IS YOUR BACKGROUND OF INVOLVEMENT IN THE COMMUNITY? I have long been active in policy development and advocacy for a wide variety of issues, including access to healthcare and improved patient safety. In 1999, I was the president of SDCMS, and, in 2004, I served as the president of the 35,000-member California Medical Association (CMA). I have been a member of the CMA board of trustees, chair of the California Medical Political Action Committee, and chaired several policy committees at CMA. On the national level, I have served a term as the chair of the American Medical Associationâ&#x20AC;&#x2122;s political action committee (AMPAC), the nationâ&#x20AC;&#x2122;s largest such entity representing physicians. Advocacy on behalf of medical students and young physicians remains a mainstay in my political activities in the community. In partnership with the SDCMS Foundation, I sponsor medical students on legislative visits to Sacramento to give them a real-world vision of how our government works and how medicine plays a role in the process. WHY DO YOU THINK SAN DIEGO COUNTY PHYSICIANS SHOULD GET INVOLVED WITH THE SDCMS FOUNDATION? Physicians in San Diego County play an important role in the landscape of San Diego County politics and culture. With the proximity of the medical school at UCSD, we have an opportunity to cultivate future physicians who plan to start their practices in San Diego County. The Foundation supports students who are preparing to become doctors by offering medical student scholarship awards and loans. The essential political advocacy and legislative policy training will not only benefit the prospective physician, but serve the entire profession by mentoring our future colleagues. I encourage San Diego County physicians to join the Foundation and learn how to support the many initiatives that elevate practicing and prospective physicians, and positively affect the patients we serve in our region. Robert Hertzka, MD S E P T E M B E R

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Honoree

Michael I. Keller, M.D.

Co-Chairs

San Diego Arthritis Medical Clinic June Barrymore-Ash & Sandy Redman

Saturday, October 4, 2008 HYATT REGENCY LA JOLLA

AVENTINE

Celebrate the Freedom to Move

San Diego Area Chapter Tel: 858-492-1090 www.arthritis-sandiego.org/gala

Classifieds DONATED ITEMS FREE CPAP MACHINE: This is an opportunity to obtain a used CPAP machine in excellent condition for a deserving patient or institution. Call Irv Sherman at (858) 487-6370. [548]

"DEAR EDITOR: I wanted to formally thank you for helping me find

OFFICE SPACE

employment through your magazine, San Diego Physician. I will be joinEL CENTRO OFFICE SPACE: 1,500ft2 medical office space available two blocks from ECRMC for sublease on Mondays, Wednesdays, and Fridays. Call (619) 644-0488 for details. [620]

SHARED MEDICAL OFFICE SPACE (POWAY): Brand new, built-out space in high-end medical office building. 3,000ft2, fully furnished, located close to Pomerado Hospital. Exam rooms, consultation rooms, procedure room with fluoroscopy unit, spacious waiting room, private provider area, and free parking. For more information, call (858) 668-6502 or email hsears@sdcpms.com. [617]

LEASING, RENEWALS AND SALES: Call the Healthcare Real Estate Specialists at Colliers International for a complete inventory of all available medical office space for lease or for sale in San Diego County. Use our knowledge and expertise to help you negotiate a new lease, renewal, or purchase agreement to assure you obtain the best possible terms. There is no charge for our consulting services. Contact Chris Ross at (858) 6775329; e-mail chris.ross@colliers.com. OFFICE SPACE TO SHARE: Modern, spacious medical office. Close proximity to Alvarado and Sharp Hospitals. Call (619) 6680900 for more information. [616]

ing a family medicine practice, and found the ad in the classifieds. I really appreciate the services SDCMS provides, and I plan to be an even more active member in the organization as I begin my practice. Thanks!" - SDCMS Member Physician

tenant. Space located in Mission Valley with easy access to I-8 and I-15. Call (619) 398-1862 or (619) 723-0074. [599]

YUMA: Medical space from 1,000ft2 to 2,200ft2 available. Existing medical professional tenants, mixed. Will do tenant improvement to suit. Space located across from hospital. Call (619) 398-1862 or (619) 723-0074. [598]

SOLANA BEACH MEDICAL CENTER: 2,274ft2 for lease; EL CENTRO: Medical office space up to 5,000ft2 available. Will provide tenant improvement to suit. Existing medical tenant in building. Call (619) 398-1862 or (619) 723-0074. [597]

CARMEL VALLEY OFFICE SPACE: Office space to share or sublease in busy, solo OB/GYN office. Ideal for OB/GYN, internal medicine, osteopath, dermatology, or other sub-specialty. Excellent referral potential. Scripps medical office building. Call Liz at (858) 259-9900. [593]

PREMIUM MEDICAL SPACE AVAILABLE: Approximately 2,600ft2 of medical space for sublease in prominent Del Mar Heights building, fronting El Camino Real. Building is shared with fertility practice, surgery center, and plastic surgeon. If interested, call Russ Sande at (858) 794-5500 [612]

OFFICE SPACE FOR RENT: Convenient location, free parking, in Clairemont (Balboa/Genesee). 1,350ft2, three exam rooms, two bathrooms, lab, share with one other doctor. Office located next to lab/draw station, Internet access ready. Reasonable rent. Call (858) 277-9669 or email ykidsd@aol.com. [588]

MISSION HILLS OFFICE FOR SALE: Rare opportunity to own prestigious North Mission Hills physician’s office. Beautifully restored house located in the West Lewis Planned District. Classic hardwood floors, stained glass, craftsmanship woodwork throughout, recessed lighting, complete exam rooms, two patient waiting areas, and four offices. Neighborhood atmosphere for patient care. Perfect for primary or specialty practice. Ample street parking. Mills Act designation with significant tax savings. Call Annamarie Clark at (619) 962-2095 for photos and appointment. [610]

CLAIREMONT MESA BLVD.: Nicely decorated, 3,000ft2 medical office with adjoining treatment rooms, X-ray, and private offices. Ideal for a medical professional looking for ancillary site for physical or occupational therapy or need for an open area. Space has a separate entry, lobby, bathrooms, and small offices great for reception and billing. Ample free parking. Easy access to all freeways. Please call Joan McComb at (619) 291-8930 for more information. [605]

CARMEL VALLEY: Beautiful medical office space available to rent in a Class A+ building, centrally located in an affluent area off the I-5 and Highway 56 junction. Renter to share suite with board-certified plastic surgeon. The building also houses a fully accredited surgical center and spa facility. Address: 11515 El Camino Real, Ste. 150, San Diego, 92130. If interested, please call Melanie at (858) 720-1440. [602]

MEDICAL OFFICES FOR SALE FROM 1,500 SF: OWN FOR LESS THAN LEASING! 10—building medical campus. Suites from 1,500 -6,300 sq. ft. Strategically located between TriCity Medical Center & Scripps Encinitas. Purchase your office. Prices starting about $650,000. Outstanding signage available on Melrose Dr. and Sycamore Ave. For information call: Jon Walters, Colliers International at (760) 438-8950; John Hoffmann, Cushman Wakefield at (760) 929-2000. www.premiercrossing.com CLAIREMONT MESA: Small, two-office space for rent in newly constructed medical office. Not a shared space! Approximately 400ft2, built to maximize space, light and airy. Great for therapist, research, small specialty practice, etc. Building is recently renovated, common-area bathrooms, break rooms, elevator, TI available, and free parking. Centrally located between highways 52, 805, 163, and 15 for easy hospital and facility access. Call (858) 268-1111, ext. 311, for more details. [587] OFFICE SPACE FOR RENT IN ENCINITAS (92024): Convenient lo-

SAN DIEGO: Space available from approximately 800ft2 to 1,200ft2. Professional, mixed-use building with medical as major

consultation/doctor’s office, lunchroom, private bathroom, and a spacious waiting room shared with one other doctor. Share lab, ultrasound, and bone density equipment. Very affordable rent. Office located at the corner of Encinitas Boulevard and Manchester Avenue. Call (858) 756-3021 or email ktagdiri@gmail.com for more information. [586]

cation five minutes from Scripps Encinitas Hospital. Close to 5 freeway. Features include two spacious exam rooms, private

$2.25/ft2 plus utilities and janitorial services. Ready to move in but tenant improvement allowable. Easy access to I-5. Serving Del Mar through Encinitas. Call (760) 431-4238. [584]

OCEANSIDE OFFICE: Office with ocean view available in 1,000ft2 suite. Prefer full time, but part time is available. Share suite with psychologist. Includes furnished waiting room, lots of storage, locking file cabinets, and receptionist area. Currently furnished, but unfurnished is an option. Available immediately. Contact Michael Samko, PhD, at (760) 721-1111 or at michael@michaelsamko.com. [580]

PRIME OFFICE SPACE TO SHARE: Office currently occupied by orthopedic surgeon situated in highly desirable location in a beautiful new building at 7910 Frost St. The new hospital under construction for Sharp Memorial Hospital is directly across the street. Digital X-ray, MRI, fluoro, CT Scan, pharmacy, PT, and other in the building. Wired for and using EMR. Please call (858) 220-0700 or email dglosrsc@mac.com. [579]

ACROSS FROM SHARP AND CHILDREN’S HOSPITAL: Beautifully furnished 2,000ft2 office, fully equipped, five exam rooms. Share with part-time physician. Please call (619) 823-8111 or (858) 279-8111. [385]

SUBLEASE NEW MEDICAL OFFICE IN SAN MARCOS: Premium, class-A medical office space in San Diego County’s fastest growing city! All or part of an approximately 1,950ft2 newly constructed suite in San Marcos’ city hall building. Spacious reception area, large procedure room with hardwood floors, four exam rooms, two restrooms, doctor’s office with large window, and reserved parking. Easy access to I-78. Ample patient parking. Contact Kristina at (760) 942-9028 or at kristina@sdsleepclinic.com for more information. [520] SUBLEASE OPPORTUNITY IN HIGH-END MEDICAL SPA IN CARMEL VALLEY: A portion of an upscale, 4,000ft2 medical spa available for sublease. Ideal for an ophthalmologist, plastic surgeon, ENT, and cosmetic dentist. Sublease includes a spacious reception and waiting area, six exam/procedure rooms, surgery suite, two dental chairs, three doctor offices, and consultation room. Easy access to I-5, 805, 56, and I-15. Located inside a medical and dental office building within a retail center. Contact Janice at (858) 481-7701 or at janice@laser-clinique.com for more information. [561]

TO SUBMIT A CLASSIFIED AD, email Ketty La Cruz at KLaCruz@SDCMS.org. SDCMS members place classified ads free of charge (excepting “Services Offered” ads). Nonmembers pay $250 for a maximum total of 100 words.

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Classifieds MEDICAL OFFICE SPACE (SCRIPPS ENCINITAS CAMPUS):

MEDICAL OFFICE SPACE AVAILABLE: Medical office space located

RIVERVIEW MD SURGERY CENTER: New freestanding ASC under

OB/GYN-type consultation room and one to two exam rooms with staff, receptionist, etc. Equipment is available at extra cost. Surgical center next door. Free parking. Perfect for low-volume hospital campus consultations one to five half-days per week. Email sbrooksreceptionist@yahoo.com or call (760) 753-8413. [557]

in Hillcrest available. The space is approximately 4,500ft2 with several advantages for a group of one to four surgical specialists. There is ample parking, a full outpatient surgical center on first floor of the building, and a therapy area on the second floor. Ample medical records storage space and phone and computer wiring already installed. For more information, please call (619) 299-0007. [462]

construction and set to open late 2009. State-of-the-art, multispecialty facility (wholly owned property and center). Potential surgeon/surgical group investment opportunities. Call (858) 3440083 or email afdorinmdmba@aol.com to discuss. [606]

3998 VISTA WAY, STE. 100 IN OCEANSIDE: Three medical office spaces (approximately 2,000ft2 each) available for lease. Close proximity to Tri-City Hospital with pedestrian walkway connected to parking lot, and ground floor access. Lease price: $2.40/ft2+NNN. Tenant improvement allowance. For further information, please contact Lucia Shamshoian at (760) 931-1134 or at shamshoian@coveycommercial.com. [556]

OFFICE SPACE TO SUBLET: Internal medicine practice in Escondido has office space available for one part-time physician/healthcare professional. Excellent location near Palomar Medical Center. Please contact office manager at (760) 4326644 or at EIM2006@sbcglobal.net. [459]

OFFICE SPACE AVAILABLE: Office space at the corner of Eighth

SPACE FOR LEASE (CORONADO): Brand new building in Coronado.

Avenue and Washington Street in Hillcrest. Surgical center in building. Ample parking and simple freeway access. Close proximity to Scripps Mercy Hospital. Call (619) 297-6100 or email rbraun@handsrus.com. [555]

Last space available: 1,105ft2, $2.75+NNN. Call (619) 742-5555 or email cpatricia@glenncookmd.com. [435]

OFFICE TO SHARE: Office available in desirable building on Scripps Encinitas lot. Share elegant office that has just undergone complete interior design renovation. Includes doctor’s desk, your own exam room, front desk, common waiting area, staff bathroom (including shower), and kitchen. Call us at the San Diego Vein Institute at (760) 944-9263. [546]

COSMETIC OFFICE AVAILABLE TO SHARE: East County location with accredited operating room. Ideal for facial or general plastic surgeon to use as satellite office. Central location with ample parking. For more information, please call (619) 701-4786. [542]

OFFICE SPACE FOR SUBLEASE: Office available part time for Scripps doctor in desirable Scripps/Ximed building in La Jolla. Share elegant office. Available full day Mondays and Friday afternoons. Includes consultation office, two exam rooms, front desk, common waiting area, staff bathroom, and kitchen. Use of operating suite or use on other days negotiable. Call Cindi at (858) 4526226. [535]

SHARE MEDICAL OFFICE SPACE IN POINT LOMA AREA (OFF MIDWAY): Share fully furnished, six-exam-room/two-office suite with internist. Ample free parking, great location. Contact Elaine Watkins at (858) 945-3813 or at ejwatkins@gmail.com. [527]

NORTH COUNTY OFFICE SPACE TO SHARE (POWAY): In-house, accredited surgery office available. 3,000ft2 includes exam room, dexa scanner, and physical therapy. Ideal for a pain management or newly starting orthopedic physician. Call John at (619) 5498870 for more details. [398] LARGE SUITE (CHULA VISTA): Beautiful suite, 4,550ft2, adjacent to Scripps Hospital, includes large reception and front office, audiology lab, private office space as well as three large area rooms, many built-in storage cabinets, and staff lounge. Previous tenant was Children’s Hospital. Contact Sammye at (619) 342-7207, ext. 8, or at baymedical@smiser.net. [389]

OFFICE SPACE TO SHARE (SOUTH COUNTY): Chula Vista-area family practice office to sublease at 340 Fourth Ave., Ste. 10, just north of Scripps Mercy Chula Vista Hospital. Office includes three exam rooms and one treatment room, and is 1,700ft2. Support staff available. Call Dr. Jenkin or Dr. Tetteh at (619) 804-7252. [521]

MEDICAL SPA AVAILABLE TO SHARE: Brand new, upscale medical spa in Eastlake available to sublet a portion of the facility to a specialist. Ideal for plastic surgeon or aesthetic physician performing minimally invasive procedures. Also open to acupuncturist or wellness/anti-aging physician, which complements the spa and noninvasive aesthetic services currently being offered. Call (619) 228-4483 for more information. [519] MEDICAL OFFICE AVAILABLE TO SHARE: Primary care office available to share. Storefront building with great visibility and recently updated interior. Current physician has been in practice for 10 years and wants to cut down on hours. Lots of opportunities for a starting physician or specialist. Office staff available to share if needed. Call (619) 575-4442 or fax letter of interest to (619) 575-1297. [518]

OFFICE SPACE FOR LEASE (ESCONDIDO): Premier furnished medical office space for lease in Escondido. Excellent location near Palomar Medical Center. Please call (760) 743-1033. [501] MEDICAL OFFICE SPACE: Approximately 1,289ft2; conveniently located about one mile east of Tri-City Hospital in a four-unit building. Three exam rooms (one leaded) and two baths. Nice layout and ample parking. Office is ideal for a solo practitioner. For further details, call Wendy Shumate, MD, at (760) 630-4715 or Aruna Garg, MD, at (760) 724-8562. [478]

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ability, North County cardiologist seeks either an invasive or noninvasive cardiologist to work part-time in an outpatient setting. No night call. No pager. Hours, days, and number of hours per week negotiable. Can start immediately. Fax CV to (760) 5910924. Call (619) 806-1229 or email achavira@roadrunner.com for more information. [604]

PER DIEM OPENING: BC/BE family practice physician, part time, as needed. Office practice only. Variable days (Monday through Friday, 8 a.m. to 4 p.m.), half- and full-day shifts depending on need. California license and unrestricted DEA license required. Please fax CV to (619) 445-0988, attn: Teresa Mogielnicki, MD, or email to teresam@sycuanmed.org. [601] MD OR DO WANTED: San Diego occupational/urgent care clinic has opening for a MD or DO to work part- or full-time. Previous experience in occupational, emergency, internal medicine, or general practice preferred. Current unrestricted license to practice medicine in California and DEA license required. Board certified or qualified preferred. Fax CV to (858) 565-6932 or email to sheri.alley@ushworks.com. [600]

URGENT CARE: Busy practice established in 1982 seeks full-time or part-time physician. Fax CV to (619) 442-2245. [595]

CHULA VISTA: Several suites available now at Bay Medical Plaza.

INTERNAL MEDICINE (SAN MARCOS): North County Health Serv-

We are conveniently located near Scripps Hospital, major freeways, and many restaurants and retailers. There’s an onsite pharmacy, a good parking ratio, and building is secure. This is a great opportunity to expand or relocate your medical practice in Chula Vista. For more information, contact Sammye at (619) 342-7207, ext. 8, or at baymedical@smiser.net. [387]

ices, a Joint Commission, federally qualified community health center, has opportunity for full-time BC/BE internal medicine physician to work Monday through Friday and one Saturday per month. Attractive compensation package includes bonus for call and incentive. Benefits package includes PTO, holidays, malpractice, and reimbursement for CMEs (expense and time) and licensure. Spanish language knowledge helpful. Please send CV to C. Bekdache at cynthia.bekdache@nchs-health.org or fax to (760) 736-8740. [590]

BEAUTIFUL, NEWLY RENOVATED OFFICE SPACE TO SHARE: Located in Hillcrest/Uptown San Diego. Physician with large suite seeking physician/healthcare professional or other business professional to share offices and/or exam rooms and receptionist. Parking spaces available for rent (off street, covered). Call (858) 354-9833 for further information. [346]

MEDICAL SPACE FOR LEASE: 2,350–11,761ft2 completed shell building on Highway 86 in Imperial County for $2.05ft2/month. Please contact Dr. Maghsoudy at (760) 730-3536 or at afsaneh_maghsoudy@hotmail.com. [525]

CARDIOLOGIST NEEDED: Due to a recent accident resulting in dis-

PHYSICIAN POSITIONS AVAILABLE PART-TIME CARDIOLOGIST NEEDED: One to three days a week. No hospital call. Please send CV to zuniweave@aol.com or call (619) 843-9028. [623]

KAISER PERMANENTE IS HIRING FULL-TIME AND PER-DIEM PHYSICIANS: We have daytime primary care staffing needs at all of our North County medical offices, which include Carlsbad, Escondido, Rancho Bernardo, San Marcos, and our newest facilities in Oceanside. We also have morning, afternoon, and evening perdiem shifts available. For more information on these opportunities, please contact Dave Horton, area operations administrator, at (760) 510-5745 or at david.h.horton@kp.org. [614]

PHYSICIAN NEEDED: Part-time or full-time position for board-certified/eligible physician to help two physicians in Chula Vista. Cheerful work atmosphere, variety of options (office, hospital, or nursing homes). Very light calls. We are very flexible in job details. Please call Suzi King at (619) 426-9731. [613] FAMILY MEDICINE PHYSICIAN: Sharp Rees-Stealy Medical Group, a 350+ physician multi-specialty group in San Diego, is seeking full-time or half-time job share BC/BE family medicine physicians to join our staff. We offer a first-year competitive compensation guarantee, excellent benefits package, and shareholder opportunity after two years. Please send CV to SRSMG, Physician Services, 2001 Fourth Ave., San Diego, CA 92101; fax to (619) 233-4730; or email lori.miller@sharp.com. [611]

INTERVENTIONAL CARDIOLOGIST OPPORTUNITY: Income potential well above national average. Immediate opening to take over 20-year private practice in North County. Excellent referral basis, limited HMO care, new cath lab opening in July. One-in-three interventional call, mature hospitalist program for other call. Office diagnostic services include: nuclear, holtor, accredited ECHO lab. Fax CV to office manager at (760) 940-8153. [607]

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FAMILY PRACTICE (OCEANSIDE): North County Health Services, a Joint Commission, federally qualified community health center, has opportunity for BC/BE family practice physician to work Monday through Friday and occasional Saturdays (shared with other clinicians). Attractive compensation package includes bonus for call and incentive. Benefits package include PTO, holidays, malpractice, and reimbursement for CMEs (expense and time) and licensure. Spanish language knowledge helpful. Please send CV to C. Bekdache at cynthia.bekdache@nchs-health.org or fax to (760) 736-8740. [591]

OB/GYN PHYSICIAN (ENCINITAS): North County Health Services, a Joint Commission, federally qualified community health center, has an opportunity for BC/BE OB/GYN. Hours and call shared with other clinicians and NMWs. Attractive compensation includes call and incentive pay. Benefit program includes PTO, holidays, malpractice, and reimbursement for CMEs (expense and time) and licensure. Spanish language knowledge helpful. Please send CV to C. Bekdache at cynthia.bekdache@nchs-health.org or fax to (760) 736-8740. [592]

EXCELLENT OPPORTUNITY FOR OB/GYN: Full service OB/GYN position available in North County. Willing to consider part- and fulltime positions. Advanced 3D/4D ultrasound, in-office procedures (Essure, endometrial ablations), minimally invasive gynecology, urogynecology with urodynamics, infertility, and obstetrics. Amazing future. Combine the best of technology with compassionate care. Email CV to robertbiter@gmail.com or fax to (760) 642-0802. [589]

UROLOGIST NEEDED: We have an immediate opening for a parttime or per-diem urologist to join our multi-specialty medical office located in La Mesa. We are a busy office with exceptional staff, and we need an exceptional individual to join our team. We offer flexibility, independence, and a great office environment. Please contact Sedrak at (310) 717-9121 or email your résumé to harmonymedicalgroup@yahoo.com. [585]

SPORTS MEDICINE/FAMILY PRACTICE POSITION: Seeking boardeligible/certified family practice physician with an interest in mus-

Classifieds culoskeletal and sports medicine for a busy multidisciplinary pain management practice located in Kearny Mesa across from Sharp Memorial Hospital. The office is state-of-the-art, complete with procedure room. Part-time or full-time opportunities are available. No after-hours calls. Fax CV to Hjordis Williams, office manager, at (858) 565-4146, email to hjordis.williams2@sharp.com, or call (858) 565-4117. [578]

WOMEN’S HEALTH NURSE PRACTITIONER: Progressive Mission

MISSION HILLS OFFICE FOR SALE: Rare opportunity to own pres-

Valley office looking for a part-time nurse practitioner with strong GYN experience including HRT. Fax résumé to (619) 2208567. [573]

tigious North Mission Hills physician’s office. Beautifully restored house located in the West Lewis Planned District. Classic hardwood floors, stained glass, craftsmanship woodwork throughout, recessed lighting, complete exam rooms, two patient waiting areas, and four offices. Neighborhood atmosphere for patient care. Perfect for primary or specialty practice. Ample street parking. Mills Act designation with significant tax savings. Call Annamarie Clark at (619) 962-2095 for photos and appointment. [610]

PHYSICAL THERAPIST: Part-time or full-time PT needed for group orthopedic practice. Great opportunity, benefits. Please fax CV to (619) 229-3933. [565]

PER DIEM/WEEKEND PHYSICIAN INDEPENDENT CONTRACTOR: Temecula independent diagnostic testing facility seeks physician to monitor patient examinations requiring contrast. Position requires availability of at least two Saturdays a month, typically scheduled for nine-hour shifts. Candidates must have California license. Please call Lynn at (619) 819-6577 for more information, or fax your CV to (619) 241-7790 for immediate consideration. [572]

PARTNERSHIP OPPORTUNITY: ENT position available immediately in an existing La Jolla practice. Partnership may be quickly achievable. Please call (858) 458-1287 for details. [564]

MEDICAL RECEPTIONIST/FRONT OFFICE: We are looking for a front office receptionist for a busy OB/GYN practice. Bilingual in Spanish and OB/GYN experience is a must. Résumés can be faxed to (858) 565-0033. [563]

SERVICES OFFERED

NURSE PRACTITIONER: Four-physician internal medicine practice in Chula Vista seeks part-time/full-time nurse practitioner. Work with a quality group; reasonable hours. Previous experience is preferable; salary negotiable depending on experience. Call (619) 421-4470 or (619) 421-4000. [488]

MEDICAL BILLING CONNECTION (MBC): After your patients’ care, the most important aspect of your business is your billing. MBC provides full-practice management to ensure your billing and collections are optimal. With MBC, expect great services and great results! The difference is our service. Let MBC make the difference for you. Call (800) 980-4808, ext. 102. [575]

PHYSICIAN POSITIONS WANTED VOLUNTEER FP/IM PHYSICIANS NEEDED: Camp Pendleton family practice residency is looking for a few enthusiastic volunteer family practice or internal medicine physicians interested in teaching to help preceptor residents and medical students in our outpatient family practice clinic. Please call CAPT John Holman at (760) 725-1398. [511]

MEDICAL OPHTHALMOLOGIST (PER DIEM): Board-certified medical ophthalmologist available two days per week for per-diem or locums work in the San Diego or nearby areas. Highest ethical standards. Experienced and skilled in therapeutic and cosmetic Botox and dermal fillers. Also experienced in clinical trials. Email bshaw1@san.rr.com. [569]

PRACTICE FINANCING FOR PHYSICIANS: Up to 100 percent financing available for physicians! Includes purchase of a practice, equipment, partner buyout, working capital, and real estate. Contact Monica Coburn at CBN Financial at (702) 310-7111 or at mcoburn@communitybanknv.com. [522]

PRIMARY CARE JOB OPPORTUNITY: Home Physicians is a fast growing group of doctors who make house calls. Great pay ($60– $100+/hour), flexible hours, choose your own days (full- or parttime). No weekends, no call, transportation and personal assistant provided. Call Chris Hunt, MD, at (858) 279-1212. [458]

CARDIOLOGIST SEEKING EMPLOYMENT: Noninvasive cardiologist

FAMILY PRACTICE (CHULA VISTA): Seeking a family practice

PRACTICES FOR SALE

physician to cover solo physician practice one week every two months. Contact Ann at (619) 422-1324 or at doctorwp@pacbell.net. [451]

UROLOGY PRACTICE FOR SALE (SAN DIEGO): Practice opportu-

FAMILY PRACTICE DOCTORS NEEDED: Full time and part time; days, nights, and weekends available. Fax CV to La Costa Urgent Care at (760) 603-7719. [449]

wants to join IM or cardiology practice (office based). Board eligible. Experienced in echo, stress test, nuclear, and CT. Call (858) 922-8354 (cell), (760) 633-3044, or email cvshah@aol.com. [558]

nity in San Diego. Busy solo practitioner to retire in October 2008. Thriving practice; multiple contracts; turnkey operation with Spanish language and laparoscopy skills. Can’t miss. Interested applicants email rvsmith13@san.rr.com. [571]

SUCCESSFUL MEDICAL SKIN CARE CLINIC FOR SALE: Small in-

NONPHYSICIAN POSITIONS AVAILABLE

vestment for 51 percent ownership. Looking for a new medical director. Call Leonard Schulkind at (619) 807-5485. [539]

FULL-TIME MEDICAL ASSISTANT WANTED: Busy cardiology office in National City needs an MA to work in the front office. Must be very organized, responsible, detail oriented, and have a good attitude. Experience preferred, but not necessary. Tagalog/Spanish speaker a plus. Please call Polina at (619) 470-7700 or fax résumé to (619) 470-0996. [622]

FLASH ELECTRONIC MEDICAL BILLING: Outsource your billing with FLASH for faster claims turnaround and reimbursements. Call us for all your billing needs. Our medical billers never underestimate the value. “We simply do it better.” Call (760) 231-1116. [624]

DEL MAR-AREA GENERAL PRACTICE: Prime location, huge potential for practice expansion in fast growing Carmel Valley community. Established in 1990; terms available. Inquiries call (858) 755-0510. [185]

BILLING, CONSULTING, OUTSOURCING: We are committed to maximizing your bottom line! Our billing service uses state-ofthe-art technology to ensure charge capture, code validation, electronic submission and remittance, payment postings, patient statements, structured follow-up and appeals, electronic document storage and meaningful reporting. Supplemental services include online appointment scheduling, automated call reminders, scan systems, and other technological advances. Consulting services include accounts payable, auditing, business development, electronic medical record selection and implementation, credentialing, contracting (payor, physician, and staff), executive assistant, financial management, information systems, operational management, practice assessment, practice management, relocation management, and other technological advances. Contact us today for your free consult. Contact Kena Galvan at (619) 326-0700 or at kena.galvan@abs-sol.com. [452]

RMC VINYL REPAIR PLUS: Medical equipment upholsterer. Expert

MEDICAL EQUIPMENT

in repair and replacement of medical fixture upholstery, including exam room equipment and waiting room furniture. Free estimates and mobile service. Call (619) 443-4060. [400]

ULTRASOUND, STRESS, ECG: HP 2000 ultrasound — cardiac, vas-

MISCELLANEOUS

PA OR NP FOR CARDIOLOGY OFFICE: Very busy cardiologist needs second PA or NP to help with starting IVs, taking history of patients for nuclear stress tests, and seeing patients in office setting. Spanish speaker a plus. Call Iona at (858) 337-4931 or fax résumé to (619) 470-0996. [621]

WOMEN’S HEALTH NURSE PRACTITIONER OR PHYSICIAN ASSISTANT: Chula Vista office looking for a part-time NP or PA with

cular, abdominal, small parts, five transducers: $6,000. Quinton 4000 monitor with Q55 treadmill, recording paper, electrodes, crash cart, defibrillator: $2,500. HP ECG Pagewriter XLE, lots of recording paper and electrodes: $700. Call (619) 460-0083 or (619) 518-9542. [513]

strong OB/GYN experience. Flexible schedule, EMR, Spanish speaker a plus. Fax résumé to (619) 482-8072. [603]

RETIRED SURGICAL PRACTICE OPERATING ROOM/SURGICAL EQUIPMENT: Perfect for plastic surgery/oral surgery. Endoscopy,

MEDICAL BILLER: Experienced in imaging preferred. Hours are

cameras, loupes, tools. Waiting room furniture inventory list is available upon request. Email kwahl@san.rr.com. [506]

Monday through Friday, 7 a.m. to 3:30 p.m. Friendly staff, good working conditions. Call (760) 730-3536 or email info@carlsbadimaging.com for salary range and more information. [596]

2005 SEA RAY SUNDANCER 30-FOOT LOADED POWERBOAT (PRICE SLASHED $5,000 6/17/08): Excellent condition; 2K in recent/routine maintenance, new front eisenglass, 3.5 years remaining on full warranty ($6,000 value), only a paltry100 hours for two pristine 220-hp engines, GPS, generator, TV/DVD/stereo/air/heat and much more. Exact boat with less features costs $150K; $98,000 (firm) to first buyer. (858) 3440083. [454]

2003 BMW M3 CONVERTIBLE (RED, MANUAL) (PRICE SLASHED $4,000 6/17/08): Very good condition, low miles, and new tires:

REAL ESTATE

$33,750. (858) 344-0083. [453]

VACATION IN LAKE TAHOE: New, fully equipped one bedroom/one RN, NP, OR PA: Registered nurse, nurse practitioner, or physician assistant needed for Encinitas ENT, facial plastic surgery practice. Dermatology, laser, and filler experience preferred. Call Carol at (760) 944-4211. [594] REGISTERED NURSE: Family medicine office in Torrey Hills seeking a full-time, experienced RN. Previous clinical experience required. Salary and benefits are negotiable. Please call (858) 350-8100 or email résumé to admin@torreyhillsfamilymedicine.com. [577] PART-TIME MEDICAL ASSISTANT/BACK OFFICE: Two years experience required including phlebotomy. Busy specialist office near Alvarado Hospital. Submit résumés via email to dlpotter22@hotmail.com. [576]

bath condominium (sleeps four) in the brand new Village at Northstar. The Village offers dining, shopping, roller/ice rink with open-air bar/eateries and rink-side cabana. Enjoy biking, hiking, golfing, onsite gym, hot tubs, and ‘saline’ pool. Enjoy the beach, water sports, a scenic drive, or raft the Truckee River. Fall: $175.00/night; three-night minimum. Also available in the winter. Call (858) 412-5239 or email lhikel@san.rr.com. [619]

HOME FOR SALE: Located in an exclusive area of Chicago. Northern suburb, five-bedroom ranch on one acre of landscaped property. Approximately 5,000ft2 living space with more room to add. Ideal for vacation property or permanent relocation. For private showing or more information, call (619) 585-0476 or email takur01@yahoo.com. [618]

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History of Medicine

Once Is Enough THE LONG AND FASCINATING HISTORY OF VACCINATION By WILLIAM P. HANEY, MD

group of senior citizens was recently debating the pros and cons of vaccination. Reports had indicated that traces of harmful elements, chemicals, or compounds could be found in vaccines. Autism, retardation, and other long-term complications of unknown etiology were suspected as resulting from these vaccines. The “hot” question was, “Should children, or adults for that matter, be subjected to such hazards, and do they have the right to refuse and thereby protect themselves and their loved ones against such complications?” The arguments drifted back and forth. It is very difficult, I thought, to convince people of the dangers of diseases that most of them have never seen and about which they know very little. Consider Sir William Osler’s “most terrifying disease to behold” — smallpox. It has been wiped right off the face of the planet by vaccination. Running a close second in fear and horror is a disease that lurks today in every small animal population of the world. The mention of rabies or hydrophobia chills every doctor’s bone marrow as it has for several thousand years. While a second-year medical student, I saw a short, silent, black and white film clip of a case of rabies. A crib held a small child. The top of the crib was covered by a net. The highly agitated infant was shaking the crib side bars. A small glass of water was held out

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and the doomed child went berserk, clawing tions, and the stricken child survived. Jacob at the mattress, banging his head, and scream- Meister became the gatekeeper of the Pasing silently. It was an unforgettable experience. teur Institute where he served for many Working with dogs and rabbits, the years. Ironically, he committed suicide in French chemist, Louis Pasteur, found that he 1940, when the invading Nazis demanded could create immunity to rabies by injecting that he open Pasteur’s crypt, a desecration small amounts of air-dried spinal cords of he refused to permit. Jacob’s statue guards rabid animals into normal animals. And the the entrance of the institute to this day. real stroke of genius Vaccination has a — truly a serendipilong and fascinating The “hot” question was, “Should history. The terrifying tous event of the first magnitude — was his children, or adults for that matdiseases that have discovery that he been removed from ter, be subjected to such haz- our could treat the norexperience need mal animal after it ards, and do they have the right to be occasionally rehad been bitten but before meanto refuse and thereby protect visited prior to actual signs ingful decisions about of disease. Most peothemselves and their loved ones its value can be made. ple don’t realize what The senior citizen against such complications?” a miracle that was. debate continued. His message was, Faith healing, holistic “Bring me the victim within the first few therapy, the power of prayer, God’s will, days after the mad dog, bat, wolf, or raccoon homeopathic medicine, and trace elements has bitten, and I can almost guarantee a 100 were discussed. And I thought to myself, percent cure rate.” Miraculous! maybe these people needed to see a case of Pasteur’s first case in 1885 was nine-year- rabies. But for myself, no thanks, once is old Jacob Meister. The little French lad had enough. I never was to see another! been bitten by a mad wolf 15 times. Pasteur hesitated. His work had been with dogs and rabbits. A human child was altogether an- ABOUT THE AUTHOR: Dr. Haney, a reother matter for a scientist who had no tired ophthalmologist, has held a long-time medical training whatsoever. The parents in- interest in the history of medicine, often sisted. Pasteur went ahead with the injec- contributing articles to San Diego Physician.

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