November 2008 by San Diego Physician

2008 MAGGIE AWARD WINNER

OFFICIAL PUBLICATION OF THE SAN DIEGO COUNTY MEDICAL SOCIETY NOVEMBER 2008

for

Pay performance How do you measure Quality?

interview witH stuart a. CoHen, md, mPH, sdCms President P.18 PHysiCian emPloyment emerging miCrobial Quality and agreements strongly resistanCe in san Cross-Cultural reCommended .26 HealtHCare pP.22 diego County p.34 “ 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 ”

Richard E. Anderson, MD, FACP Chairman and CEO, The Doctors Company

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We proudly announce SCPIE and The Doctors Company have united. Together, we set a higher standard. We aggressively defend your name. We protect good medicine. We reward doctors for their loyalty. We ensure members benefit from our combined strength. We are not just any insurer. We are now the largest insurer of physician and surgeon medical liability nationwide. On June 30, 2008, The Doctors Company and SCPIE officially joined forces. With the addition of SCPIE, we have grown in numbers, talent, and perspective—strengthening our ability to relentlessly defend, protect, and reward our 43,000 members nationwide. Endorsed by the San Diego County Medical Society since 2005, The Doctors Company remains committed to protecting your livelihood and reputation. To learn more about our professional liability program for SDCMS members, call (858) 452-2986, or visit us at www.thedoctors.com.

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contents VOL. 95 | NO. 11

for

Pay performance

[ F e a t u r e s ]

Pay-FOr-PerFOrmaNce

The experience of Sharp reeS-STealy Medical Group

4 6 8 10 12 18 20 2

MeMo To phySicianS froM aMa on pQri

QualiTy MeaSureS for 2008 pQri

california phySician perforMance iniTiaTive (cppi)

[ D e P a r t m e N t s ] conTriBuTorS: This Issue’s Contributing Writers

ediTor’S coluMn: Quality Reporting: It’s Here to Stay

SdcMS SeMinarS and evenTS: 2008–2009

coMMuniTy healThcare calendar Briefly noTed: Ask Your Physician

Advocate, Risk Management Tip, and More ...

SdcMS leaderShip SpoTliGhT: Stuart A. Cohen, MD, MPH, SDCMS President

22 24 28 39 41 44

ucSd School of Medicine: Class of 2012 White Coat Ceremony

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riSk ManaGeMenT: Physician Employment Agreements

puBlic healTh: Improving Oral Health

riSk ManaGeMenT: Treating Patients in a Difficult Economy

in MeMoriaM: Mike Bajo, MD

phySician MarkeTplace: Classifieds

hiSTory of Medicine: The Caduceus

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Contributors Arthur Blain, MD, MBA Dr. Blain, who sits on the SDCMS board of directors, is a faculty physician at the Camp Pendleton Family Practice Residency, expert medical reviewer for the Medical Board of California, and voluntary faculty at the UCSD School of Medicine and Uniformed University of Health Sciences. Stuart A. Cohen, MD, MPH Dr. Cohen, a pediatrician with Children’s Primary Care Medical Group, is the current president of the San Diego County Medical Society (SDCMS). Bill Fleming

Mr. Fleming, a registered professional liability underwriter, is assistant vice president of underwriting for The Doctors

Company.

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. Steven Green, MD

Dr. Green has practiced with Sharp Rees-Stealy Medical Group (SRSMG) since finishing his residency in 1988, and currently chairs the department of family medicine and the Council of Department Chairs. He also serves as secretary and treasurer of the California Academy of Family Physicians.

Michael D. Maves, MD, MBA

Dr. Maves is executive vice president and CEO of AMA.

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.

Susan Shepard

Ms. Shepard is the director of patient safety education for The Doctors Company.

Peggy B. Yamagata

Ms. Yamagata, a registered dental hygienist, is the program manager for San Diego County’s Dental Health Ini-

tiative/Share the Care.

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

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, PhD, 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 DIRector, BUSINESS DEVELOPment & MARKETING MARKETING & PRODUCTION manager

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 Arthur Blain, MD Vimal Nanavati, MD Anna Seydel, MD Jeffrey Leach, MD Robert Peters, PhD, 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, PhD, 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 Lisa Williams 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.]

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Editor’s Column

By Joseph E. Scherger, MD, MPH

Quality reporting it’s here to stay

ome might think pay-for-performance (P4P) is just a passing fancy of the healthcare-financing melodrama. I don’t think so. I believe that P4P is just the beginning of a sea change in medicine where healthcare is paid for based on results. In the past, healthcare has been payment for doing. The more you do, the more you get paid. All cognitive services and procedures are coded by complexity of the service and paid for by doing them. Results have been assumed. No more. One would need to be asleep not to have noticed that quality reporting has permeated healthcare for years now, and both the purchasers and recipients of healthcare want to know what they are getting for their money. Payment just for doing will become a memory of a simpler time in medicine. 6

Now that we have better information systems, and the cost of healthcare has become a lightening rod for personal or social spending, results matter more than ever. George Halvorson, the CEO of Kaiser, has a new book, Health Care Reform Now! in which he describes how purchasers of healthcare will increasingly pay attention to results. He writes, “When we have reached the point where the cost of healthcare at GM exceeds the cost of steel in a car and the cost of healthcare coverage at Starbucks exceeds the actual cost of coffee, then it’s time for the major buyers to stop thinking of healthcare

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as a cost-plus, un-engineered, externally shaped, seller-defined, completely unmanaged purchasing expense.” Purchasers of care want to know just what results they are buying, much the same as when they buy anything else today, such as the quality of the steel and coffee. Quality reporting is the only way to accomplish this. Is quality reporting fair? Not always. Every physician knows that quality reporting only captures a slice of the care that is delivered in the physician-patient relationship. The slice that is measured often feels out of context of the total care being delivered. Worse yet, physicians see themselves penalized by patients who are not compliant with their care and do not take responsibility for getting good results. Quality reporting feels like a game that physicians must play, and when that happens, gaming the system becomes a reactionary behavior. A recent editorial in JAMA highlights the potential dark side of quality reporting, with physicians engineering only mild diabetes into their practice and then easily getting them into control and looking great, while others can take care of the more difficult patients (1). Despite all that, accountability in medical practice will no longer be assumed but measured. Increasingly sophisticated information systems allow for an analysis of care across a population of patients in every medical practice. When populations of diabetic and hypertensive patients are well controlled, healthcare costs go down. Payers want that, and medical practices will be rewarded for doing that. The processes of care will shift from the traditional “make an appointment, come and get it” reactive style of care to more proactive models in which patients with chronic illnesses will be contacted by the practice to receive care. Such proactive care has been shown to achieve dramatically better results. Einstein said, “Not everything that can

Both the purchasers and recipients of healthcare want to know what they are getting for their money.

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be counted counts and not everything that counts can be counted.â&#x20AC;? Quality reporting in medical practice will always be a partial and imperfect look at the care being delivered. Like always, physicians will need to derive their own satisfaction from a job well done with challenging patients. But all physicians that are paid by third-party payers will need to accept the challenges of achieving best practice management in medical practice and report their results. Physicians with extensive practice experience will need to be in control of these payment-for-quality reporting systems to be sure that they recognize the complexities and vagaries of caring for any mixed population of patients. Getting a diabetic patient who is extremely out of control to fair control is just as valuable as getting one in fair control into excellent control. The challenge of the former is usually greater. Quality reporting systems should not be fixed on ideal numbers but should reward clinical improvement at all levels. I believe that the transition to payment for results will be messy but overall worthwhile. Medical practice will improve, and our patients will be healthier. Populationfocused proactive care will be better than traditional, individually delivered, reactive care, where the overall results in a community were unknown. Hopefully, the medical profession will meet the challenge of improved care and not spend time trying to game the reporting systems. Ultimately, new models of accountability will catch up with us all.

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References: â&#x20AC;˘ Halvorson G. Health Care Reform Now! San Francisco: Jossey-Bass, 2007 pp. 173â&#x20AC;&#x201C;174. â&#x20AC;˘ Hayward RA, Kent DM. 6 EZ Steps to Improving Your Performance: (or How to Make P4P Pay 4U!) JAMA, July 16, 2008; 300: 255â&#x20AC;&#x201C;256.

About the Author:

10/15/08

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Contributors sDcms seminars and events

2008–2009

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.

2009

reSidenT and new phySician SeMinar “preparinG To pracTice: whaT you need To JOSEPH E. SCHERGER, MD, MPH riSk Dr. Scherger is clinical professor of family medicine at UCSD. He is also medical director of AmeriChoice, which adminisManaGeMenT weBinarS collecTionS SeMinar know Before you BeGin your ters San Diego County Medical Services. Dr. Scherger, along with editing San Diego Physician is chair of the SDCMS Communications Committee. (office, ManaGerS foruM) Nov. 12, 11:30 a.m. – 12:30 p.m. pracTice” Jan. 15, 11:30 a.m. –1:00 p.m. Apr. 18, 8:30 a.m. – 3:30 p.m. GAYLE WHITE, MPH, RN Ms. Whiteand 6:30 p.m. – 7:30 p.m. is the maternal and child health coordinator in Maternal, Child, and Family Health Services. She has held this position for

TOM GEHRING

NOVemBer

J a N u a ry

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

the past six years and oversees the Perinatal Care Network, Comprehensive PerinatalriSk Services program, Fetal and Infant Mortality Review program, and the Black ManaGeMenT weBinarS eMr SeMinar riSk ManaGeMenT SeMinarS Infant Health program. Jan. 21, 6:30 p.m. –7:30 p.m.;

Nov. 20, 6:00 p.m. – 8:00 p.m.

Apr. 22, 6:30 p.m. – 8:00 p.m.; Apr. 23, 11:30 a.m. – 1:00 p.m.

Jan. 22, 11:30 a.m. –12:30 p.m.

reSidenT and new phySician SeMinar “preparinG To EAST COUNTY DIRECTOR pracTice: whaT you need HILLCREST DIRECTOR To know Before you BeGin your pracTice” KEARNY MESA DIRECTOR Nov. 22, 8:30 a.m. – 3:30 p.m.

Along with its many social events held LA JOLLA DIRECTOR throughout the year, the EDITOR Joseph Scherger, MD, MPH Kyle Lewis sanMANAGING diegoEDITOR County NORTH COUNTY DIRECTOR ASSISTANT EDITOR Ketty La Cruz DecemBer mediCal soCiety BOARD Adam Dorin, MD SOUTH BAY DIRECTOR (sdCms)EDITORIAL strives to build a younG phySicianS Social Robert Peters, MD robust schedule of AT-LARGE DIRECTOR David Priver, PhD,Dec. 5, 6:00 p.m. – 9:00 p.m. MD Roderick Rapier, MD free seminars for our Joseph Scherger, MD, MPH physician members and Newest Member their staffs.

Benefit: SDCMS YOUNG PHYSICIAN DIRECTOR Offers Webinars! RESIDENT PHYSICIAN DIRECTOR

MarkeTinG The phySician William Tseng, MD pracTice SeMinar Woody Zeidman, MD Jan. 28, 6:30 p.m. – 8:30 p.m.; Roneet Lev, MD Thomas McAfee, MD Jan. 29, 11:30 a.m. – 1:00 p.m. Adam Dorin, MD Sherry Franklin, MD (Office managers Forum)

m ay

SDCMS EXECUTIVE COMMITTEE

PRESIDENT Stuart Cohen, MD, MPH PRESIDENT-ELECT Lisa Miller, MD eMr road Show Albert Ray, MD PAST PRESIDENT Robert Wailes, MD SECRETARY may 6, 4:00 p.m. – 8:00 p.m.; TREASURER Susan Kaweski, MD may 7, 9:00 a.m. – 12:30 p.m. COMM. CHAIR Joseph Scherger, MD, MPH (Office managers Forum) Jeffrey Leach, MD DELEGATION CHAIR BOARD REP. Sherry Franklin, MD Peters, MD BOARD REP. BillinGRobert SeMinar LEGISLATIVE CHAIR Robert Hertzka, MD (officeTom ManaGerS Gehring foruM) EXECUTIVE DIRECTOR

Steven Poceta, MD Wayne Sun, MD James Schultz, MD Douglas Fenton, MD Tony Blain, MD Vimal Nanavati, MD Anna Seydel, MD conTracT Jeffrey Leach, MD, may 20, 11:30 a.m. – 1:00 p.m. Theodore Mazer, MD SDCMS CMA TRUSTEES neGoTiaTionS SeMinar Robert Peters, PhD, MD Albert Ray, MD David Priver, MD Feb. 11, 6:30 p.m. – 8:30 p.m.; Robert Wailes, MD Wayne Iverson, MD Feb. 12, 11:30 a.m. –1:00 p.m. OTHER CMA TRUSTEES Catherine Moore, MD Paul Kater, MD Diana Shiba, MD John Allen, MD (Office managers Forum) Kevin Malone, MD AMA DELEGATES James Hay, MD leGal SeMinar Mihir Parikh, MD Robert Hertzka, MD Kimberly Lovett, MD Jun. 17, 6:30 p.m. – 8:30 p.m.; Albert Ray, MD ALTERNATE DELEGATE Glenn Kellogg, MD Jun. 18, 11:30 a.m. – 1:00 p.m. Lisa Miller, MD Geraldine Kang

F e B r u a ry

JuNe

For further information RETIRED PHYSICIAN DIRECTOR marcH MEDICAL STUDENT DIRECTOR about any of these For those who can’t get (Office managers Forum) away from the office to seminars or events, watch inSurance ServiceS SeMinar attend our seminars in mar. 18, 6:30 p.m. – 8:30 p.m.; your emails and faxes, cMa SeMinar “TakinG charGe: PRESIDENT Jim Fitzpatrick Published by ACCOUNT EXECUTIVE Dari Pebdani person, SDCmS has begun mar. 19, 11:30 a.m. – 1:00 p.m. STepSHedberg To evaluaTinG relaSullivan PUBLISHER Maureen PROJECT DESIGNER Jessica visit www.SDCmS.org, to offer to our members (Officers managers Forum) Back DIR., BUSINESS DEVELOP. & MARKETING Heather ADVERTISING ART DIRECTOR Geneen Montgomery TionShipS and preparinG for or email us at and their staff the ability to MARKETING & PRODUCTION MNGR. Jennifer Rohr COPY EDITOR Adam Elder neGoTiaTionS — a focuS on SDCmS@SDCmS.org. “attend” from wherever you payor conTracTinG” 1450 Front Street • San Diego, CA 92101 • 619-230-9292 • Fax: 619-230-0493 • 800-600-CITY (2489) • www.sandiegomagazine.com are — all you need is access Details may change as aPriL Jun. 24, 4:30 p.m. – 8:30 p.m. OPINIONS expressed by authors are their own andto the Internet! For further not necessarily those of San Diego Physician or SDCMS. San Diego Physician reserves the right to edit all contributions for clarity and seminars approach – 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 details, contact cMa SeMinar “Back To BaSicS: pracTice ManaGeMenT 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 contact SDCmS to confirm. 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. lauren Wendler at SeMinar Apr. 15, 5:00 p.m. – 9:00 p.m.; Apr. 16, 9:00 a.m. – 1:00 p.m. (Office managers Forum)

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.]

thank you for your membership!

(858) 300-2782 or at lWendler@SDCmS.org.

a STep-By-STep Guide To MaxiMizinG your caSh flow” (office ManaGerS foruM) Jun. 25, 9:00 a.m. – 2:00 p.m.

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 DEVELOPMENT: Janet Lockett at (858) 300-2778 or at JLockett@SDCMS.org DIRECTOR OF MEMBERSHIP OPERATIONS AND 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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S E P T E M B E R

DIRECTOR OF ENGAGEMENT: 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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community Healthcare calendar

freSh STarT’S 2008 SurGery weekendS More than 100 volunteers 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 nonmedical volunteers are needed to make children’s transformations possible. Nov. 1–2 at the Center for Surgery of Encinitas. Call (760) 448-2021 or visit www.freshstart.org.

3rd annual hearT failure and arrhyThMiaS: froM prevenTion To cure This program will update 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. Contact (858) 652-5486 or med.edu@ scrippshealth.org.

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, USD. $225. CME: 8. Contact (858) 652-5482 or med.edu@scrippshealth.org.

The Science and clinical applicaTion of inTeGraTive holiSTic Medicine

MelanoMa 2009: 19Th annual cuTaneouS MaliGnancy updaTe

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

This course is designed for healthcare professionals with an interest in, and basic understanding of, skin cancer. Jan. 24 at the Omni San Diego. CME: 10. Contact (858) 652-5486 or med.edu@scrippshealth.org.

The fuTure of GenoMic Medicine ii diaGnoSiS and TreaTMenT of viTaMin d deficiency SeMinar This course is designed for all healthcare personnel to address the vitamin D deficiency with appropriate diagnosis and treatment. Dec. 2 at the Liebow Auditorium, UCSD. $45. Visit http:// grassrootshealth.org/events/seminars.php.

2008 updaTe in rheuMaToloGy Physicians specializing in rheumatology are invited to attend this event. Dec. 6 at the Rebecca and John Moores UCSD Cancer Center, Goldberg Auditorium. Visit http://cme.ucsd.edu/rheumatology/index.html.

aneSTheSia updaTe 2009 The program contains state-of-the-art elements in all the anesthesia subspecialties and discusses important new problems and their solutions. Jan. 14–17 at the Kona Kai Resort, San Diego. Call (619) 543-5560 or visit http://anessom.ucsd.edu/update1.htm.

13Th annual fall wound conference This educational presentation has been developed to provide healthcare professionals with comprehensive clinical information for improving their clinical practice in skin and wound care with emphasis on pressure ulcers and present on admission (POA) regulations. Nov. 20 at the Marriott San Diego in Mission Valley. $160. Call (800) 827-4277.

naTural SuppleMenTS: an evidence-BaSed updaTe This course provides practical information for healthcare professionals who make nutritional recommendations or manage dietary supplement use. Jan. 22–25 at the Paradise Point Resort and Spa, San Diego. CME available. Contact (858) 652-5486 or med.edu@scrippshealth.org.

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The goal of this seminar is to examine the salient progress and challenges in the field of genomics. Feb. 27–28 at the Neurosciences Institute Auditorium on the Scripps Research Institute campus in La Jolla. Contact (858) 6525486 or med.edu@scrippshealth.org.

aMerican occupaTional healTh conference (aohc) 2009 Topics to be discussed include occupational medicine/research, infectious disease, toxicology, workers’ compensation, ergonomics, and environmental pollution. Apr. 26–29 at the Manchester Hyatt Hotel, San Diego. CME: 24. Call (847) 818-1800, ext. 374, or visit www. acoem.org.

To submit a community healthcare event, email Editor@SDCmS.org. All events should be physician-focused and take place in San Diego County. Events also available online at www.SDCmS.org.

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y l f e i r B

Noted

tracted with Medi-Cal, you can bill your usual and customary rate. Keep in mind that if you are currently contracted with Medi-Cal, and you decide that you no longer want to be contracted with them, you need to take the appropriate steps to cancel your contract. You cannot begin to bill your usual and customary rate until Medi-Cal has communicated to you that you are no longer a contracted provider. This may take up to six months, and you may need to make some phone calls to follow up with them.

You cannot begin to bill your usual and customary rate until Medi-Cal has communicated to you that you are no longer a contracted provider.

Ask Your

PhysiCiAn AdvoCAte

By Marisol Gonzalez

Medical Assistants • Medi-Cal Contracts • e-Prescribing

ueSTion: if a receptionist is trained by the physician they work for to perform the duties of a medical assistant, is there anything wrong with this from a professional liability standpoint? anSwer: As long as the physician has documented the required hours of training as defined by the Medical Board of California and has this employee covered in their professional liability coverage policy, there is nothing wrong with

having your receptionist perform the duties of a medical assistant. For further information on medical assistants, see “Risk Management Tip” on page 14.

ueSTion: if i were to drop my Medi-cal contract but still see Medi-cal patients in the emergency room, can i bill my usual and customary rate or will i still be limited to Medi-cal rates? anSwer: If you are no longer con-

ueSTion: if we decide to purchase an e-prescribing module, will we really be paid 2 percent more on all Medicare claims through our local intermediary in 2009? anSwer: CMS has yet to develop specific guidelines for the e-prescribing incentive. We at SDCMS will be working closely with Palmetto (local intermediary) to monitor CMS’ progress. As soon as these guidelines are made available, we will promulgate them to our member physicians.

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.

aBOut tHe autHOr:

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.

S A N D I E G O P H Y S I C I A N . o r g | N O v E m B E R 2 0 0 8

Which insurance carrier has distributed dividends* 15 of the last 18 years?

MIEC reduced its already low rates in the last 15 of 18 years (1991-2008) with dividend

credits on premiums for $1M/3M limits - averaging a 24.4% savings a year to its policyholders. Has your professional liability carrier done that for you? If not, it may be time to ask why not! Other benefits include: Q Q

We have a ZERO profit motive MIEC is 100% owned and governed by its policyholders We have provided California policyholders continuous service for over 30 years We have resolved over 24,000 malpractice claims and lawsuits reported by our policyholders. Nearly 90% were closed without payment. We are rated A- {excellent} by AM Best’s

Cumulative California Dividends 110,000,000

88,000,000

66,000,000

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2 0 0 8

For more information or to apply: Go to www.miec.com or call 1-800-227-4527, and a helpful receptionist (not an automated phone tree) will connect you to one of our knowledgeable underwriting staff. * Future dividends cannot be guaranteed.

Medical Insurance Exchange of California

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MIEC S A N D I E GOwned O P by H Y I C I A N . o we r g protect. 13 theS policyholders

y l f e i r B

Noted

risk MAnAgeMent tiP: Medical Assistants

By the Doctors company

octors, beware! Are you putting your medical practice at risk by using a medical assistant (MA) improperly? The ability of MAs to perform certain tasks is of great benefit to physicians and licensed midlevel healthcare practitioners in providing effective and efficient patient care. However, no matter how competent an MA may be, he or she is an unlicensed professional and therefore should not be assigned the roles of licensed healthcare professionals.

No matter how competent an MA may be, he or she is an unlicensed professional and therefore should not be assigned the roles of licensed healthcare professionals. The functions that MAs may perform have been defined by California’s Business and Professions Code and by the California Code of Regulations. The Medical Board of California (MBC) and the California Medical Association (CMA) provide additional guidelines based on the governing laws. These laws provide a category of specifically delineated tasks called “technical supportive services,” which include the following: • Administer medication by methods other than injection. • Apply and remove bandages and dressings; remove (not apply) casts, splints, and other external devices. • Remove sutures or staples from superficial incisions or lacerations.

• Provide patient information and instructions as authorized by the physician. Medical assistants must carry out all job duties under the supervision of the physician who maintains responsibility for the patient’s treatment and care. The supervising physician must always be physically present in the facility when

S A N D I E G O P H Y S I C I A N . o r g | N O v E m B E R 2 0 0 8

an MA is performing patient care. Violating any of the relevant codes — either deliberately or due to misunderstanding of the codes — puts you and your medical assistant at risk for serious sanctions by the Medical Board of California. It also makes your medical practice more vulnerable to medical malpractice lawsuits.

Welcome our new and Rejoining sdCMs Members new members takeo Kasumi, md • Anesthesiology • Encinitas, (760) 753-1104 John Charles lowry, do • Psychiatry • Child and Adolescent Psychiatry • Campo, (619) 445-6200 thomas Joseph maino, md • Family medicine • Sports medicine • San Diego, (858) 793-2727

saVe tHe Date the UCsd school of Medicine Celebrates its 40th anniversary

geoffrey Peter radoff, md • Family medicine • San Diego, (323) 333-0788 dimitri atanasov sherev, md • Internal medicine • Cardiovascular Disease • Interventional Cardiology • la mesa, (619) 668-7475 reJoining member amir alexander Pirouzian, md • Ophthalmology • San Diego, (619) 543-9287

Join with colleagues and community members to celebrate the UCSD School of Medicine’s 40th anniversary on Friday, November 14, 2008, at the Hyatt Regency La Jolla at Aventine. The evening will include dinner, dancing to the band NRG, and comments by Brian Druker, MD, SOM ’81, one of the developers of Gleevec. For more information, visit www.somanniversary.ucsd.edu or call (858) 822-3455.

Poem From 1918 Bulletin (former name of san Diego Physician) O Soul Sublime, Brother Physician of mine! “Twas not yours to only creep, content, With feet on the earth and duty in the skies; Nor deterred you, the dangers to him that flies. You, no earth-bond could hold, None other commanded; your only desire, To be nearest where duty lies And tend the hurt of your fold. O Soul Sublime! may I, like him, learn to fly And if need be, die, to be near my goal.

“Privileged to Provide Care and Clinical Research Since 1975”

The San Diego Arthritis Medical Clinic is a leading investigational site for the study of:

Rheumatoid Arthritis Osteoarthritis Osteoporosis Fibromyalgia Gout Lupus

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. Timothy F. Lazarek, F.N.P. Michael Meng, D.C.

619.287.9730 www.SanDiegoArthritis.com

By H.F. Andrews, MD

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

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S A N D I E G O P H Y S I C I A N . o r g

y l f e i r B

Noted Congratulations to

randal vecchione, md 2008 Health Care Champion!

he second annual Health Care Champion Award was presented to Randal J. Vecchione, MD, by the San Diego Business Journal on August 21, 2008. Dr. Vecchione was nominated for the award because of his public service and consistent emergency room response for the past

“

25 years, which has earned him the respect of many ER physicians and medical providers throughout San Diego County. Dr. Vecchione is a true asset to the medical profession as well as the community. He has been a member of SDCMS since 1983. Congratulations, Dr. Vecchione!

Quotation Quality in a proDuct or service FoR novemBer is not what the supplier puts in. CHMB_SDP_08:Layout 1 9/11/08 11:15 AM Page 1

”

It is what the custoMer gets out and is wIllInG to pay for.

— PETER DRUCKER (1909 –2005), “THE OF MODERN MANAGEMENT” Project4:Layout 1 FATHER 9/22/08 11:22 AM Page 1

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S A N D I E G O P H Y S I C I A N . o r g | N O v E m B E R 2 0 0 8

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Stat for November

entury

Seventy-seven percent of registered California voters oppose funding 21_SDP_08:Layout 10/24/08 2:10 PM Page 1 cuts1 to healthcare programs for lowincome Californians and the disabled. Source: The Field Poll, Release #2275, June 10, 2008.

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S A N D I E G O P H Y S I C I A N . o r g

SDCMS Leadership Spotlight

Stuart A. Cohen, MD, MPH

SDCMS President, 2008–2009 San Diego Physician: Why did you choose

to become a doctor? Dr. Cohen: I was attracted to the profession since I was a young child because it seemed like a very honorable vocation. As I got older and narrowed down my career choices, I decided that I wanted to do something that would be mentally challenging, would allow me to actively engage with people, and would be different all the time. I think I ended up going into the right profession for the right reasons. SDP: You graduated from

medical school in Canada. What brought you to the United States?

Dr. Cohen: During my residency, I was able to travel numerous times to outposts in very small communities in the Arctic Circle and near Hudson Bay where I helped to run medical clinics for native Indians and Eskimos. Through that experience I became interested in public health and decided to augment my pediatric training with a master’s degree in that field. Being from Winnipeg, where there are only two seasons (hockey season and summer), I decided to come to sunny San Diego to earn my master’s degree in public health. After a brief return to Canada to fulfill a university teaching commitment, I returned to San Diego in late 1987.

SDP: Did you practice medi-

cine in Canada? If so, what would you say are the differences between the Canadian and U.S. healthcare systems?

Dr. Cohen: Yes, I did. There are numerous

differences between the two systems. In Canada, all medical training is publicly funded and supported, so if you don’t pass your residency training, you just keep going until you can make the grades or accomplish what you need to do to finish your exams and become board certified. This is not the case in the United States where medical training is more of a mix between public and private funding. The training in the United States, while exemplary, is more work-oriented. Also, the training in Canada, as in the rest of the Commonwealth, is more patientoriented, where here it’s more focused on appropriate diagnostic testing. A second issue is obviously access to care. The Canadian system is a more egalitarian system; medical care is rationed, and everybody gets treated the same. Access to care in the United States, on the other hand, is mostly based on the patient’s ability to pay. Of course, there are tradeoffs. For example, Canadians have longer waiting lists for surgeries and other procedures, and newer technologies are not as readily available or widely adopted as they are in the United States. Regionalization of services and diagnostic equipment is standard, and there are very limited options there for privately offered services.

SDP: Discuss your present group, Children’s Primary Care Medical Group. Dr. Cohen: I joined Children’s Primary Care Medical Group in 1996 and have been on the board since that time. With over 80 pediatricians, it is the largest group of its kind in the United States. It is a physician-hospital organization, affiliated with Rady Children’s Hospital, and we are integrated into our own IPA, Children’s Physicians Medical Group (CPMG), which includes the majority of non-CPCMG pediatricians in private practice in the county, as well as the Rady Children’s Specialists of San Diego Medical Group (CSSD). We also have our own MSO (medical services organization)

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that does the contracting for our group, CPMS, Children’s Physicians Medical Services. But what I am most proud of is our group’s mission to serve all comers. We serve patients that have private insurance, a very large percentage of the Medicaid (or Medi-Cal in California) population in our community, and about 70–75 percent of all the foster kids in the San Diego County system. It’s been a very positive experience watching the group grow and develop into a major entity in our community. SDP: How is the underfunding of Medi-

care and Medicaid affecting you and your group? Dr. Cohen: There are many issues to discuss with Medicare and Medicaid; both programs are flawed and have a lot of difficulties inherent in each of them. Historically, there has been poor oversight from Congress and the Centers for Medicare and Medicaid Services over how the funds for these programs are spent. People assume that we, as pediatricians, don’t have to worry about Medicare. But since most of our private insurance payments are based on Medicare RBRVS with a conversion factor that’s proprietary, a decrease in Medicare means a decrease in our commercial health insurance payments. So it’s vitally important to preserve appropriate reimbursement from Medicare so that our commercial population can reimburse us in appropriate terms. Medicaid is a federal-state entitlement program that, unlike Medicare, has not had cost-of-living adjustments over many years. Although equal-access provisions in federal law mandate that physician payment should be sufficient to ensure access to care as is found in the commercial population beneficiaries, this has never been enforced, and states are free to set their own rates, pretty much without regard to outside factors. The average Medicaid rates overall are only 60 percent of Medicare. Because reimbursement rates haven’t kept up with the increasing cost of healthcare, the sustainability and viability of primary care practices that look after the Medicaid population are in jeopardy. Access to specialty care, primarily for adults but in

some cases for children, is also in peril. SDP: Why did you join SDCMS? Dr. Cohen: I’ve always been involved with

organized medicine. In fact, I held prominent positions as a resident and fellow at my institution in Canada. Being involved helped me realize that I did have a say in how things were run and could make significant changes to the problems that I noticed. One of the first things I did when I came to San Diego, aside form getting my medical license and board certifications in order, was to join SDCMS.

“

I want to look incrementally at what we can do, and use SDCMS resources to make more physicians aware of and involved in the different opportunities to help locally and countywide with providing medical services to needy uninsured and underinsured patients.

”

SDP: Why do you think doctors should

become involved with organized medicine? Dr. Cohen: It’s very important to be involved for a multiplicity of reasons. We physicians need to take a stake in our own profession and guide its destiny. If we don’t set and take charge of our own standards, if we don’t take charge of how we are treated by third parties, then other institutions will do that for us. We also need to look after the means of sustainability of our practices. There are a lot of scope-of-practice issues, thirdparty payors who are monopolizing the insurance industry and trying to increase profits by undervaluing and underpaying for physicians services, issues with access to care in our country for people that are uninsured or underinsured, and increasing governmental and quasi-governmental regulatory issues. If we don’t have a say on how these things are developed and regulated, we will not be able to maintain the viable and sustainable profession as

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we know it today. So we need to be involved, we need to have our voices heard, we need to be part of a fair and active process that includes the public (our patients), the government (as our regulators and overseers), and ourselves working together to make sure we serve the public in the noble way in which we first entered into our profession. SDP: What do you want to accomplish as president of SDCMS? Dr. Cohen: Well, first and foremost, I want to maintain the momentum that started in the last few years with the leadership of Drs. Hertzka, Hay, Young, Mazer, and Ray, who have really established us as the strongest county medical society in all of California. I feel a strong sense of obligation to carry on in their tradition in keeping our medical society active and viable. We have a very strong mission and a number of local projects, and I want to make sure the leadership on the bench coming forward is in tune with what we’re doing with regard to access to care. I would also like to partner with the SDCMS Foundation, County Medical Services (CMS), and the Hospital Association of San Diego and Imperial Counties (HASDIC) to discuss and implement projects that will aid in access to care in our county. I want to look incrementally at what we can do, and use SDCMS resources to make more physicians aware of and involved in the different opportunities to help locally and countywide with providing medical services to needy uninsured and underinsured patients. Second, I would like to use San Diego Physician magazine, and other SDCMS communication vehicles, to highlight ongoing volunteerism that many of our members engage in within the local, regional, national, and international communities. SDP: What thoughts would you like to leave us with? Dr. Cohen: It’s been an honor to be chosen and approved by my peers to have the bully pulpit as SDCMS president for 2008–09. I’m going to do the best I can to honor the position and my peers, and I look forward to a challenging year.

S A N D I E G O P H Y S I C I A N . o r g

Medical Students

UCSD School of Medicine

Class

2012

White Coat Ceremony By Stuart A. Cohen, MD, MPH

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[Note: The following speech was delivered by Dr. Cohen to the UCSD School of Medicine Class of 2012 on August 29, 2008.]

Colleagues, Friends, Medical Students, and Invited Guests:

am honored, as current president of the San Diego Medical Society, representing all of San Diego County’s physicians from all specialties and from every conceivable practice modality, to welcome you, the UCSD Department of Medicine’s Class of 2012, into the medical profession. The white coat ceremony is a rite of passage, welcoming you into the medical community, laying the groundwork for your teachers who will be inculcating you, over the next four years, with the idealism and altruism of being a medical doctor. With that privilege comes, of course, the rights and responsibilities of exemplifying the highest standards of medical care and compassion for patients, all the while attaining supreme clinical skills and competencies, a commitment to lifelong learning and continuous quality improvement while striving to always adapt to one’s own community of patients and their changing needs, and finally a dedication to professionalism, always putting the patient’s needs first. This is my 20th year in private pediatric practice. I have reflected about what message to give you today, so I have condensed my pearls of wisdom to 10 wise rules. May you inscribe them into your cerebral cortex. 1) Remember always the joy of being a medical doctor. As you go forward into practice and life, you will have many obligations thrust your way: medical, personal, family, financial, edu-

cational, community, etc. You will have days where you doubt the ability of modern medicine to heal and improve lives. You will have days when you question yourselves and your competencies. You will have times when you question your choice of careers. Always go back to the joys of the unique patient-physician relationship, the trust patients and their families have in you. This joy will carry you through the tough times.

school, faith-based institutions, political or community advocacy, healthcare for the uninsured, etc. Opportunities are there; seek them out and they will enrich your lives multi-fold. 6) Keep focused. Develop a personal mission statement with life goals and objectives, and update it from time to time. This will help you strive for excellence and reach personal goals while staying in touch with your own ideals.

Life is the journey, not the destination. 2) Be a better listener. The patient interview is still the most important aspect of being a good doctor, better than all the black-box gimmicks modern medicine can provide. A healthy dose of listening and empathy are necessary, indeed critical, to help diagnose and heal your patients. This skill may even improve your marriage and/or significant relationships. 3) Have a positive attitude. Make a conscious effort to surround yourself with positive friends, colleagues, and ancillary professionals as part of your inner-sanctum. You will have a much healthier outlook on life and a more positive effect on others, especially your patients. 4) Be humble. Remember your roots. As you become successful and more accomplished and honored in your profession, stay humble. Only with humility can we keep our goals in life in proper focus, and pass the baton of our profession on successfully to the next generation. 5) Remember the altruism and idealism with which you enter the profession today. Seek out volunteer community activities that suit you:

Learn that differences of opinion with your colleagues, be they scientific, political, religious, or ideological, are not personal affronts, but opportunities to learn and grow personally. no v e m ber

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7) Accept/embrace diversity. Learn that differences of opinion with your colleagues, be they scientific, political, religious, or ideological, are not personal affronts, but opportunities to learn and grow personally. You can always embrace the person, even if you don’t embrace his or her opinions. Science is often advanced on the basis of these disagreements. 8) Remember your family and friends. When you are done with your career, you will be more remembered for your involvement and influence on your family and friends. 9) Medicine is lifelong learning pursuit — we never stop. 10) Have a good sense of humor at all times. Take your job seriously but not yourself. Along with a positive attitude, a good sense of humor is always appreciated by all around you. Your days will run much easier and be more enjoyable. Life is the journey, not the destination. The physicians of San Diego County welcome you and look forward to working with you, the class of 2012.

Abo u t t h e A u t ho r : Dr. Cohen, a pediatrician with Children’s Primary Care Medical Group, is the current president of the San Diego County Medical Society (SDCMS).

S A N D I E G O P H Y S I C I A N . o r g

risk management tain applicable tail or prior acts (“nose”) coverage. A healthcare business attorney is your best source for ensuring that your employment agreements have all of the necessary elements. When creating a contract with your attorney, you should consider the following questions: • Who is responsible for purchasing coverage (not only active insurance but also prior acts and tail coverage)? • Who selects the program features (policy limits, deductibles — including who pays the deductible)? • Who can change the policy, including the right to cancel coverage for the physician? • Will the group allow the policy to provide coverage for prior acts unrelated to the group (including those in another state)? • Will the policy cover the physician for moonlighting? • Who has the right to request tail coverage from the insurer? • Does the physician pay in the event of resignation or termination with cause? • Does the group pay a portion of the premium based on years of service? By Bill Fleming • Is payment required when tail is selected, or is it deducted from the physician’s income? • Can the doctor obtain prior acts coverMost professional liability policies age from his or her next insurer, and are written on a claims-made or claimsdoes he or she have to provide proof of reported basis. When a physician is covit to the group? ered on a group’s claims-made policy, it Numerous courts have weighed in means that the policy applies to claims on issues related to professional liabilthat a) arise out of the physician’s actions ity requirements in employment conon behalf of the group, and b) are made tracts. Both physicians and administrawithin the policy tors should note period. When a that many of these When a contract does physician leaves the suits include alleganot specify rights and group, he or she is responsibilities regarding tions of breach of not covered under contract, specific professional liability the group’s policy insurance coverage, the performance, and unless an extended group and the physician declaratory relief. reporting period (or might find themselves in a Generally, these “tail”) endorsement types of allegations wasteful legal battle over is added to the polare not covered by insurance issues. icy. For most insurany type of insurers, including The Doctors Company, ance, which means that the parties rean entity is covered for its vicarious litain and pay their own attorneys, and ability for a physician who leaves the they personally pay any judgment that policy unless that physician fails to obmay result.

PhysiCiAn eMPloyMent AgReeMents

strongly recommended

ringing a new physician into a growing practice can be exciting for both the group and the new hire. But even the best professional relationships can come to an end, and clarity at the beginning will serve all parties well, particularly if a departure is accompanied by hard feelings. For that reason, we strongly recommend that all groups make use of written agreements, whether the physician is an employee or an independent contractor. When a contract does not specify rights and responsibilities regarding professional liability insurance coverage, the group and the physician might find themselves in a wasteful legal battle over insurance issues. Even small groups, which are often the least able to absorb the cost of unexpected litigation, can benefit from using employment agreements.

S A N D I E G O P H Y S I C I A N . o r g | N O v E m B E R 2 0 0 8

B of

In Byrne v. Joliet Medical Group, Ltd., tion of the contract or, alternatively, that Dr. Byrne was required by his employhe never agreed to pay for tail coverage ment contract to purchase his own proin any circumstance. fessional liability insurance. When he The employment agreement adleft Joliet Medical Group, he obtained dressed tail coverage only by stating that prior acts coverage from his subsequent Dr. Barton would be responsible for tail insurer. The court held that the contract coverage if her employment terminated required Dr. Byrne to specifically purprior to the end of the term. By failing chase tail coverage from Joliet’s insurer. to state who would be responsible for the In Barton v. King, the cost of tail coverage in all court found in favor of Silence is not golden situations, Dr. King was when it comes to forced to pay for the tail Dr. Barton, an employed professional liability coverage. physician who sued her terms in employment physician-employer, Dr. In Frederick v. Clark, agreements. King, for the cost of tail Drs. Frederick and Clark coverage. The employment agreement made an oral agreement, followed by a provided that Dr. King would pay proconfirming letter that stated “insurance A_SDP_08:Layout 10/9/08premiums 2:38 PM Page 1 provided for you” without furfessional liability 1insurance will be if Dr. Barton honored the employment ther specifics. Dr. Frederick was subseagreement. quently terminated by Dr. Clark, who At the end of the two-year agreement, advised Dr. Frederick that he would not Dr. Barton notified Dr. King that she did pay for her tail coverage. A breach-ofnot plan to continue working for family contract lawsuit followed, and Dr. Fredreasons. Dr. King refused to pay for tail erick ultimately prevailed, despite Dr. coverage, claiming that Dr. Barton’s failClark’s arguments that 1) the letter was ure to become board certified prior to not an employment contract, and 2) he the end of the contract term was a violanever intended to agree to pay for tail

coverage. In Meyer v. Superior Clinic, the court reached a different result based on the clinic’s bylaws, which provided professional liability insurance for “employees.” Since the bylaws do not mention “ex-employees,” the provision did not apply to tail coverage. The court also looked to the clinic’s pattern of having provided tail coverage for only one of the 19 doctors who had left the clinic. Silence is not golden when it comes to professional liability terms in employment agreements. Medical groups and member physicians must invest in clear and specific contract terms regarding the purchase, maintenance, and termination of insurance coverage. Those that do can look forward to more amicable partings, with more time spent practicing medicine and less time in court. Mr. Fleming, a registered professional liability underwriter, is assistant vice president of underwriting for The Doctors Company.

Abo u t t h e A u t ho r :

Achieve your practice goals with Bank of America. At Bank of America, we earn our reputation by focusing on practices like yours. Whether you need to accelerate revenue, improve collections, or reduce your exposure to check fraud, we offer solutions designed to address your current and future challenges. Managing cash flow is an essential part of any healthcare practice. Let us address your financial needs so you can attend to those who matter most to your practice. Your patients. To learn more, contact your healthcare specialist/client manager: Katrin Engel San Diego 888.852.5000 ext. 8260 katrin.engel@bankofamerica.com Karen Turner North County 888.852.5000 ext. 8277 karen.turner@bankofamerica.com bankofamerica.com/healthcare12 ©2008 Bank of America Corporation.

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S A N D I E G O P H Y S I C I A N . o r g

County Public Health Officer’s Update

Improving Oral Health Coming Together to Make a Difference By Peggy B. Yamagata, RDH, MEd.

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alifornia is still struggling to address the dental needs of its residents. In 2003, a California report stated that 4 percent of the children in classrooms are unable to concentrate because they are actually in pain or suffering from a dental abscess. The report went on to call dental disease a hidden epidemic of California’s school children. The surgeon general’s report in 2000 stated that dental caries is the single most common chronic disease of children — five times more common than asthma and seven times more common than hay fever. Following up on the report in 2003, the surgeon general’s office issued a “National Call to Action to Promote Oral Health.” This public-private partnership was a wake-up call against the silent epidemic of oral disease. The five strategies outlined called for a change in perception about oral disease, removal of barriers, building of a diverse and flexible work force, building a science base, and increases in collaboration. While this destructive infectious epidemic has received attention, the battle is far from being won.

utensils. In addition, studies show that The oral health of California children is during the early stages of decalcification, substantially worse than other states. Of the decay can be reversed by use of fluo25 states recently surveyed by the National ride products and other identified mechaOral Health Surveillance System, only nisms. However, restoring decayed teeth Arkansas ranked below California in kids’ does not stop the disease from re-occurdental health. In 2004–05, a survey of ring. Up until recently, dental health pro200 randomly selected California schools fessionals have faced this dilemma alone, showed that 70 percent of the kindergarten but recent science shows that dental health and third-grade students had experienced may impact more than just the oral cavity, dental decay; at any given moment, more and now other health professionals must than a quarter had untreated tooth decay; get involved. and, finally, poor children and children of Untreated color are much decay is promore likely Up until recently, dental health gressive, cuto have tooth professionals have faced this m u l a t i v e, decay and sufdilemma alone, but recent science and becomes fer the conseshows that dental health may more complex quences. impact more than just the oral over time. As As the scicavity, and now other health disease ence base adprofessionals must get involved. the spreads, the dressing oral decayed teeth disease has serve as a reservoir of pathogens that cirexpanded, it has shown that tooth decay culate throughout the body, leaving the is infectious and is often passed to babies individual prone to other potential health from their caregiver through saliva transcomplications related fer occurring in various ways, including Bressi_SDP_1008:Layout 1 9/23/08 4:00 PM Page 1 to heart disease, diabetes, pre-term, low-birth-weight babies, cleaning pacifiers and sharing of food and

pneumonia, sinus infections, and medical complications. Media has told the story more then once that these dental related complex outcomes can ultimately lead to death. In response to the dental epidemic, in 2007, the California Legislature passed AB1433, which requires an oral health evaluation by a dental professional for children entering public school for the first time. This legislation is designed to identify children who need further examination and dental treatment and to help them establish a dental home. Results of the first year of implementation show that in San Diego, 40 percent of kindergarteners completed the oral health assessment with nearly 10 percent having visible caries or fillings. Despite the visibility of the caries, 22.5 percent were left untreated. Worrisome is that 60 percent of the parents opted out of this evaluation for their child, often reporting a lack of resources or inability to find a dental professional, but more often they saw no need for the evaluation. As a medical professional you can help

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improve the oral health of San Diego residents. Medical and dental professionals working together can reduce and help to eradicate the dental disease epidemic. The following lists provides “10 Actions to Eradicate Dental Disease” that you can take to help address this issue: 1) Refer children by age one for their first dental exam as recommended by both the

Health Stats • In San Diego County, 78 percent of children ages 2–17 have dental insurance, according to the California Health Interview Survey 2005 (1). • There were 3,500 dental-related emergency department discharges — a rate of 114 per 100,000 population — in San Diego County for fiscal year 2005–06 (2).

American Academy of Pediatrics and the American Academy of Pediatric Dentistry. 2) Look at the teeth and refer all children to a dental home during all periodic medical exams. 3) Check the teeth when a parent complains about a child crying or not eating. 4) Explain to parents the outcome of ignored dental disease — “They’re just baby teeth … why bother?” — can lead to hospitalization and death. 5) Apply fluoride varnish at the medical office to reduce dental decay. 6) Get to know dentists in your area, and establish a referral list to assist patients in finding a dental home. Call the San Diego County Dental Society at (619) 275-0244 for a list of dentists in your area. 7) Remind parents that children entering kindergarten need an oral evaluation. 8) Suggest a mouth guard during a sports physical. 9) Refer families to San Diego Kids Health Assurance Network for assistance

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, visit www.sdhealthstatistics.com.

References: 1) 2005 California Health Interview Survey, ask CHIS accessed 7-7-08 www.chis.ucla.edu/main/ default.asp. 2) HASDIC, CHIP, County of San Diego, Health and Human Services Agency, Emergency Medical Services, Emergency Department Database; SANDAG, Current Population Estimates, 9/27/2006.

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with dental insurance at (800) 692-8428. 10) Remember a healthy mouth is part of a healthy body, and be sure you and your staff have good oral health. Committing to just one of these actions will help improve the health of today’s children. San Diego’s goal is that 100 percent of the children entering school have a dental home and have an opportunity to learn pain free. For more information on oral health, contact “Share the Care” at (619) 692-8858 or visit www.sharethecaredental.org. [Note: For a list of references for this article, email Editor@SDCMS.org.]

the A u t ho r : Ms. Yamagata, a registered dental hygienist, is the program manager for San Diego County’s Dental Health Initiative/Share the Care.

Abo u t

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AMERICAN SECURITY RX

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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.

PRACTICE PERFORMANCE GROUP (PPG)

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.

COASTAL HEALTHCARE CONSULTING GROUP, INC.

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.

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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.

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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.

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.

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risk management

treating Patients in a Difficult economy

FReqUently Asked qUestions By susan shepard, msN, ma, rN, cPHrm

his article answers questions that our regional patient safety/ risk managers address about the serious problems that are occurring when patients become unable or don’t pay their co-pays or when they refuse to pay their physician charges. Q: when a patient is dissatisfied with care, can he or she dispute the charge with the credit card

company? a: A credit card customer can always request that a charge be questioned. Normally, when this occurs, the credit card issuer will open an investigation into the disputed charge. In the meantime, the card issuer may also withhold paying the credit charge amount to the physician. Q: what is the appropriate response when an established pa-

tient comes in but is unable to pay? a: Talk to the patient first. Investigate why the patient isn’t paying the bill, e.g., is he or she unhappy with the care? After that, you can consider alternative financing options, including bill collection. It is helpful to have a written policy summarizing the practice’s policy on financial matters that you give to each patient at the initial visit. A physician has the right to expect payment for services rendered. The practice should have a policy and apply it consistently in a nondiscriminatory fashion. When you can, “remind” a patient that he or she received a copy of your policy at the time of the first visit. It makes handling this type of difficult situation easier. If you decide to terminate the patient relationship for nonpayment, you must follow a formal process that includes giving the patient proper notice and treating emergencies in the interim. For more information, read our article “Terminating Patient Relationships” under Practice Guidelines at www.thedoctors. com/patientsafety. Q: Can the physician refuse to establish a patient-physician relationship based on the patient’s inability to pay? a: Yes, as long as the patient is not seeing you based on a referral from an emergency department where you were on call when the patient was seen. If that is the case, determine the requirements of the particular hospital as established in the hospital’s medical staff bylaws and rules and regulations. You must follow those requirements. At a minimum, you will likely be required to see the patient at least one time to determine the patient’s status and whether he or she has an emergency medical condition under EMTALA. If the patient is in need of emergent treatment, you will likely be required to provide the care regardless of his or her ability to pay, although you can ask for

The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. They attempt to define principles of practice for providing appropriate care. The principles are not inclusive of all proper methods of care nor exclusive of other methods reasonably directed at obtaining the same results. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider in light of all circumstances prevailing in the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

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payment or payment arrangements. If the patient did not come to you as a result of an ED call and you have an established policy of not accepting patients who cannot pay, you can refuse to establish the relationship. Potential patients should be given some indication of your practice’s financial requirements when they make an initial appointment for treatment. If the potential patient is not aware of your financial requirements, he or she

It is helpful to have a written policy summarizing the practice’s policy on financial matters that you give to each patient at the initial visit. may delay making other arrangements for care while waiting for an appointment with you. If the patient then arrives for an appointment and you decide not to accept him or her for financial reasons, your decision can appear questionable in retrospect if the patient is injured by the subsequent delay in receiving medical care. A process in which the biller checks the status of coverage before the patient comes in can expedite your decision on whether to accept him or her as your patient. Q: when a patient is dissatisfied with the result of an elective procedure and demands a concession (a free revision, a refund, a discount, or refuses to pay credit card charges), what recourse does the physician have? a: Selecting the correct patient, providing very thorough informed consent, and keeping the lines of communication open are your best defenses against patient dissatisfaction. However, once a patient who is dissatisfied asks for compensation, contact your patient safety/ risk manager, who will help you evaluate the situation from professional liability and compliance standpoints. In some situations, making a concession may be viewed as a “courtesy” gesture and may

be a positive factor in the defense of a claim. Other situations may warrant the use of a release of claims form. Q: what factors should i consider in choosing a commercial credit company to provide a line of credit to my patients? where can i find a reputable company? a: Some commercial credit companies hold the physician responsible if the patient defaults on a payment. Before using a commercial credit company, read the contract carefully to make sure you won’t be liable for a patient’s outstanding balance. You should also be aware of your state’s consumer protection laws regarding lending and disclosure and make sure that your patients understand the terms and conditions of the financing. Your bank, SDCMS, or other professional societies can help you locate a commercial credit company. Patient saFety tiPs:

• A credit card company will notify the physician in writing about an inquiry into a charge that is being challenged. It is very important that you respond to the letter. If you don’t clarify the dispute, the charge will be disallowed. Educate your office staff so that they recognize these letters and bring them to your attention. Be sure to respond to any letter related to charges that are in question • If you accept a credit card for pay-

ment, you may want to consider a limit on allowable credit card charges. The limit can be a percentage of the total treatment charge or a dollar limit, e.g., $3,500, $5,000, or not more than 50 percent of the procedure cost. • Payment plans should be in writing and signed by the patient. • Be sure to obtain a reference for credit applications. This will ultimately assist you in locating the patient if the account needs to be sent to a collection agency. • Put a time limit on any adjustments or revisions to the original procedure (such as 60 or 90 days from the procedure date). Otherwise, a patient could come in years later and request a revision that was discussed when the procedure was first done. • Identify poor payers early on and deal with the problem. Do not wait until the situation reaches a crisis point and puts your doctor-patient relationship at risk. • Make sure you select a reputable collection agency. There are very specific state laws dealing with fair debt collection. A physician who selects an agency that violates state laws could face liability for negligent selection.

a B O u t t H e a u t H O r : Ms. Shepard is director of patient safety education for The Doctors Company.

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S A N D I E G O P H Y S I C I A N . o r g

Pay-for-Per

by steven gReen, Md

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PAyforPeRFoRMAnCe

erformance the experience of sharp rees-stealy Medical group

At Sharp Rees-Stealy Medical Group (SRSMG), we have participated in the pay-for-performance (P4P) program for several years now, recently being recognized by Blue Cross and Aetna as the number one medical group in California in these quality measures.

4P is an attempt to measure and reward quality. It’s not perfect. There are always questions about how each quality parameter is chosen, measured, and rewarded. A more basic question is whether quality should be measured, and, if so, whether it should be specifically rewarded. I’ve heard physicians outside our group say that better quality is something that physicians should inherently be providing, and the idea that it should be rewarded somehow takes away our professionalism. At SRSMG, we’ve decided that while it is an assumption all physicians strive to provide better quality, some physicians seem to get better out-

comes than others, and we can all learn from those doing better. It is not enough for a physician to suggest a woman should have a mammogram. If the patient leaves not appreciating the importance of getting it, or if the system to follow through with the mammogram leads to the test not happening, then the woman is at risk for later diagnosis of cancer. Likewise, suggesting a woman should have a pap smear is not enough. If we can explain the purpose and motivate the patient to get the test, as well as make it convenient, then she will have a lower risk of cervical cancer. I suspect most physicians would say

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they agree that having their patients undergo recommended screening tests is a good thing, and they do their best to ensure patients get such tests. Who wouldn’t agree it’s bad for diabetics to have poor glycemic control resulting in glycohemoglobin levels over 9 percent, and diabetics should have their LDL measured and well controlled? The reality is, even though we all mean well and want our patients to get these things done, sometimes it just doesn’t happen. The more traditional way physicians have delivered this type of care was to wait for patients to schedule a physical or a specific visit to care for their diabetes or

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other chronic problem. If a patient didn’t schedule a physical, prevention didn’t get done. Even if patients were in the office for an acute or chronic problem, if it wasn’t a physical, then we didn’t think of prevention. Many physicians are now going to a more comprehensive style where every visit is viewed as an opportunity to deliver acute, chronic, and preventive care. This is much more challenging than a unidimensional visit that focuses on only one problem. Disease management involves taking care of patients even when they have not scheduled an appointment. For example, we use our databases to generate lists of patients who appear to be in need of having a pap smear or mammogram. The support staff reviews the records to verify the patient fits the demographic criteria for the test and indeed appears to have not had it done recently. They double check with the physician to confirm the recommendation for the patient to have the test. If approved, the nurse or staff person contacts the patient and advises the patient of the recommendation and helps schedule an appointment. A key point is the staff does the work of generating the lists of patients needing the test and checks the records, and all the physician needs to do is double check that the test is really warranted. The staff handles setting up the appointment. Physicians don’t have much extra time in their days, so it’s important to have the as-

Anything we can do from a system perspective will help us to do better for our patients.

who can never manage to do labs prior to their appointments or remember to bring in their blood glucose logs. We call these people in advance of the visit and remind them. In addition, for diabetics with LDLs above goal, a sheet is clipped to the progress note, essentially reminding the doctor to

address the LDL at the visit. When I first saw this, I have to admit I thought it wasn’t necessary, as I “always” addressed the LDL. Many times the sheet is unnecessary, but there have been times when looking at it reminded me that I needed to address the LDL, and I’m not sure I’d have caught it otherwise. The idea is that physicians are busy and take care of many things at each visit. Anything we can do from a system perspective will help us to do better for our patients. In summary, I think we’ve learned that, while not perfect, quality measures like the ones measured with P4P are things that, when done well, are good for patients. Physicians will do better if they are prompted

A more basic question is whether quality should be measured, and, if so, whether it should be specifically rewarded. sistance of nonphysician staff. Another example of how we’ve learned to better manage diabetic patients is by identifying poorly controlled patients and contacting them to come in for labs and appointments. We’ve all seen diabetics

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that patients are due for specific tests or interventions. Adequate staff support is essential to achieve the goals. Any time the patient comes in can be a chance to ad-

dress acute, chronic, and preventive care. A disease or health management approach where patients needing various interventions are identified even when they are not in the office can help improve our success at enhancing the health of patients.

a B O u t t H e a u t H O r : Dr. Green has practiced with Sharp Rees-Stealy Medical Group (SRSMG) since finishing his residency in 1988, and currently chairs the department of family medicine and the Council of Department Chairs. He also serves as secretary and treasurer of the California Academy of Family Physicians.

PAyforPeRFoRMAnCe memO tO: Physicians FrOm: Michael D. Maves, MD, MBA, Executive Vice President, CEO, AMA Date: October 22, 2008 suBJect: Physician Quality Reporting Initiative (PQRI) According to the Centers for Medicare and Medicaid Services (CMS) data, approximately 16 percent of physicians and eligible professionals participated in the 2007 program, but nearly 50 percent of participants did not receive any bonus payment. AMA conducted a survey in September to assess experience with the 2007 PQRI. Four hundred and eight surveys (408) were completed. Summary of 2007 PORI Survey Results • Sixty-one percent of total respondents rate the program moderately, considerably, or extremely difficult to participate in. • Regarding whether a practice earned a bonus payment for its participation, 40 percent said yes, 29 percent said no, and 31 percent did not know. • 34 percent received $10,000 or more; 26 percent received $2,501–$10,000; 16 percent received $1,001–$2,500; 13 percent received $600–$1,000; and 11 percent received less than $600. • According to CMS, the average bonus payment amount for individual participants is over $600, and over $4,700 for physician group practices. • Only 22 percent of respondents successfully downloaded the PQRI Feedback Report for their practice, and less than half found it instructive. • Fifty-seven percent of respondents found accessing the 2007 PQRI Feedback Report from the CMS website to be moderately, considerably, or extremely difficult. • Fifty-nine percent of those who asked for assistance in PQRI reporting rated their satisfaction with CMS responsiveness as “no satisfaction” or “low satisfaction.” • Survey respondents are “discouraged” by their participation in the PQRI program, and “furious” by the inability to find out why they were found by CMS to have not successfully participated in the program. The survey did not identify why 50 percent of the 2007 PQRI participants did not receive a bonus payment. However, we be-

lieve it is due to several factors: • NPI Attribution: The 2007 PQRI launched during the transition to NPI. If a physician did not have an NPI on the form, or CMS had not completed the internal processing to confirm that an NPI matched up with a particular physician, the reporting of the quality data codes did not count. • Measure Validation: If a physician was found by the Measure Applicability Validation Process (MAV) to have been eligible to report on three or more measures but only reported on one or two, the physician did not qualify for an incentive payment. • Complexity of Measures and Coding Errors: Physicians were confused by measure specifications and were not able to understand how their CPT codes needed to match up with the denominator of the measure they were reporting. • Medicare Carrier Errors: Medicare carrier clearinghouses inadvertently cut off the bottom of some CMS 1500 claim forms, resulting in some quality data codes not being counted. In addition, carriers frequently could not answer physicians’ questions regarding PQRI. • 2007 PQRI Cap: The incentive payments were subject to a cap, which reduced the 1.5 percent bonus payment if physicians reported only relatively few measures or failed to report on at least three applicable measures 80 percent of the time during the reporting period. This cap has been eliminated going forward.

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Key lessons learned From ama survey Early Education and Outreach: AMA is urging CMS to develop an effective educational and outreach program for physicians and to train contractors about PQRI. Interim Feedback Reports: Confidential interim and final feedback and compliance reports must clearly inform physicians of any reporting errors and how to correct these errors. Congress and CMS must seek input from physicians and other eligible professionals on what content and format would be most instructive. These reports must also be issued on a timely basis. Access to Feedback Report, Problems With IACS: To access feedback reports, individuals and organizations must register in the Individuals Authorized Access to CMS Computer Services (IACS) system. This system is also tied to Medicare enrollment, and if a physician’s contact information has changed, it may impact a physician’s ability to access their feedback report. CMS must alleviate the undue burden associated with registering for and accessing an IACS account. Appeals Process: Physicians who report PQRI measures but who are not deemed by CMS to have successfully reported and therefore do not receive their incentive payments should have the ability to appeal. next steps AMA will be working with Congress and the Administration to secure changes to the PQRI such as the establishment of interim feedback reports and an appeals process. We are also pressuring CMS to rectify the various administrative issues that contributed to the challenges of the program.

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Quality measures

2008 PqRi

2008 P H ys i C i a n Q ua l i t y

r e P o rt i n g i n i t i at i v e ( P Q r i ) by tHe ameriCan mediCal assoCiation (ama)

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PAyforPeRFoRMAnCe the 119 quality measures included in the 2008 PQri program are listed below. the measures are sorted alphabetically by disease/condition. for each measure that a physician feels might be applicable to his or her practice, there are three PDf documents (“Measure Description,” “Data collection sheet,” and “coding specifications”) available at www.ama-assn.org/ama/pub/ category/print/17493.html. aCute bronCHitis

#116. Inappropriate antibiotic treatment for adults with acute bronchitis. aCute myoCardial inFarCtion

#28. Aspirin at arrival for acute myocardial infarction (AMI). aCute otitis eXterna (aoe)

#91. Topical therapy. #92. Pain assessment. #93. Systemic antimicrobial therapy — avoidance of inappropriate use.

Prostate Cancer #101. Appropriate initial evaluation of patients with prostate cancer. #102. Inappropriate use of bone scan for staging low-risk prostate cancer patients. #103. Review of treatment options in patients with clinically localized prostate cancer. #104. Adjuvant hormonal therapy for high-risk prostate cancer patients. #105. Three-dimensional radiotherapy for patients with prostate cancer. CHest Pain (non-traumatiC)

astHma

#53. Pharmacologic therapy. #64. Asthma assessment.

#54. Electrocardiogram performed for non-traumatic chest pain.

Non-Specific #73. Plan for chemotherapy documented before chemotherapy administered. Breast Cancer #71. Hormonal therapy for stage IC-III, ER/PR positive breast cancer. #74. Radiation therapy recommended for invasive breast cancer patients who have undergone breast conserving surgery. Chronic Lymphocytic Leukemia #70. Baseline flow cytometry. Colon Cancer #72. Chemotherapy for stage III colon cancer patients. Multiple Myeloma #69. Treatment with bisphosphonates. Myelodysplastic Syndrome (MDS) #68. Documentation of iron stores in patients receiving erythropoietin therapy. Myelodysplastic Syndrome (MDS) & Acute Leukemias #67. Baseline cytogenetic testing performed on bone marrow.

Coronary artery disease

#06. Oral antiplatelet therapy prescribed for patients with coronary artery disease. #07. Beta-blocker therapy for coronary artery disease patients with prior myocardial infarction. #118. Angiotensin converting enzyme inhibitor (ACE) or angiotensin receptor blocker (ARB) therapy for patients with coronary artery disease and diabetes and/ or left ventricular systolic dysfunction (LVSD). CritiCal Care

CHroniC Kidney disease (CKd) CanCer

#59. Empiric antibiotic for community acquired-bacterial pneumonia.

#120. ACE inhibitor or Angiotensin Receptor Blocker (ARB) therapy in patients with CKD. #121. Laboratory testing [calcium, phosphorus, intact parathyroid hormone (iPTH) and lipid profile]. #122. Blood pressure management. #123. Plan of care — elevated hemoglobin for patients receiving erythropoiesis-stimulating agents (ESA). CHroniC obstruCtive Pulmonary disease (CoPd)

#51. Spirometry evaluation. #52. Bronchodilator therapy.

#75. Prevention of ventilator-associated pneumonia — head elevation. #76. Prevention of catheter-related bloodstream infections (CRBSI) — central venous catheter insertion protocol. dePression — maJor dePressive disorder

#09. Antidepressant medication during acute phase for patients with new episode disease of major depression. #106. Patients who have major depression disorder who meet DSM IV criteria. #107. Patients who have major depression disorder who are assessed for suicide risks. diabetes mellitus

Community-aCQuired baCterial Pneumonia

#56. Vital signs for community-acquired bacterial pneumonia. #57. Assessment of oxygen saturation for community-acquired bacterial pneumonia. #58. Assessment of mental status for community-acquired bacterial pneumonia.

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#01. Hemoglobin A1c poor control in Type 1 or 2 diabetes mellitus. #02. Low density lipoprotein control in Type 1 or 2 diabetes mellitus. #03. High blood pressure control in Type 1 or 2 diabetes mellitus. #117. Dilated eye exam in diabetic patient. #119. Urine screening for microalbumin

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or medical attention for nephropathy in diabetic patients. #126. Diabetic foot and ankle care, peripheral neuropathy: neurological evaluation. #127. Diabetic foot and ankle care, ulcer prevention: evaluation of footwear. end stage renal disease (esrd)

#78. Vascular access for patients undergoing hemodialysis. #79. Influenza vaccination in patients with end stage renal disease. #80. Plan of care for ESRD patients with anemia. #81. Plan of care for inadequate hemodialysis in ESRD patients. #82. Plan of care for inadequate peritoneal dialysis. eye Care

Age-Related Macular Degeneration #14. Dilated macular examination. Diabetic Retinopathy #18. Documentation of presence or absence of macular edema and level of severity of retinopathy. #19. Communication with the physician managing ongoing diabetes care. Primary Open Angle Glaucoma #12. Optic nerve evaluation. gastroesoPHageal reFluX disease (gerd)

#77. Assessment of GERD symptoms in patients receiving chronic medication for GERD. geriatriC Care

#04. Screening for future fall risk. #46. Medication reconciliation. #47. Advance care plan. HealtH inFormation teCHnology (Hit)

#124. Adoption/use of health information technology (electronic health records). #125. Adoption/use of e-prescribing. Heart Failure

#05. Angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) therapy for left ventricular

systolic dysfunction (LVSD). #08. Beta-blocker therapy for left ventricular systolic dysfunction. HePatitis C

#83. Testing of patients with chronic hepatitis C (HCV) for hepatitis C viremia. #84. Initial hepatitis C RNA testing. #85. HCV genotype testing prior to therapy. #86. Consideration for antiviral therapy in HCV patients. #87. HCV RNA testing at week 12 of therapy. #88. Hepatitis A and B vaccination in patients with HCV. #89. Counseling patients with HCV regarding use of alcohol. #90. Counseling of patients regarding use of contraception prior to starting antiviral therapy.

for their cancer. PerioPerative Care

#20. Timing of antibiotic prophylaxis — ordering physician. #21. Selection of prophylactic antibiotic — first OR second generation cephalosporin. #22. Discontinuation of prophylactic antibiotics (non-cardiac procedures). #23. Venous thromboembolism (VTE) prophylaxis (When indicated in ALL patients). #30. Timing of prophylactic antibiotics — administering physician. #45. Discontinuation of prophylactic antibiotics (cardiac procedures). Coronary Artery Bypass Graft (CABG) #43. Use of internal mammary artery (IMA) in CABG surgery. #44. Pre-operative beta-blocker in patients with isolated CABG surgery.

osteoartHritis

#109. Patients with osteoarthritis who have an assessment of their pain and function. osteoPorosis

#24. Communication with the physician managing ongoing care post-fracture. #39. Screening or therapy for osteoporosis for women aged 65 years and older. #40. Management following fracture. #41. Pharmacologic therapy. otitis media witH eFFusion (ome)

#94. Diagnostic evaluation — assessment of tympanic membrane mobility. #95. Hearing testing. #96. Antihistamines or decongestants — avoidance of inappropriate use. #97. Systemic antimicrobials — avoidance of inappropriate use. #98. Systemic corticosteroids — avoidance of inappropriate use. PatHology

#99. Breast cancer patients who have a pT and pN category and histologic grade for their cancer. #100. Colorectal cancer patients who have a pT and pN category and histologic grade

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Preventive Care and sCreening

#110. Influenza vaccination for patients ≥ 50 years old. #111. Pneumonia vaccination for patients 65 years and older. #112. Screening mammography. #113. Colorectal cancer screening. #114. Inquiry regarding tobacco use. #115. Advising smokers to quit. PHaryngitis

#66. Appropriate testing for children with pharyngitis. rHeumatoid artHritis

#108. Disease modifying anti-rheumatic drug therapy in rheumatoid arthritis. stroKe and stroKe reHabilitation

#31. Deep vein thrombosis (DVT) prophylaxis for ischemic stroke or intracranial hemorrhage. #32. Discharged on antiplatelet therapy. #33. Anticoagulant therapy prescribed for atrial fibrillation at discharge. #34. Tissue plasminogen activator (t-PA) considered.

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#35. Screening for dysphagia. #36. Consideration of rehabilitation services. Stroke and Stroke Rehabilitation — Radiology #10. Computed tomography (CT) or magnetic resonance imaging (MRI) reports. #11. Carotid imaging reports.

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the Consortium, including additional background information on the quality measures with both the rationale and evidence base for each measure, please visit www.physicianconsortium.org. For additional information on NCQA and NCQA

measures, please visit www.ncqa.org. For additional information on the PQRI program, please visit the CMS website at www.cms.hhs.gov/pqri.

synCoPe

#55. Electrocardiogram performed for syncope. uPPer resPiratory inFeCtion (uri)

#65. Appropriate treatment for children with upper respiratory infection. urinary inContinenCe

#48. Assessment of presence or absence of urinary incontinence in women aged 65 years and older. #49. Characterization of urinary incontinence in women aged 65 years and older. #50. Plan of care for urinary incontinence in women aged 65 years and older. measures aPPliCable to HealtH Care ProFessionals otHer tHan md/do PHysiCians

#128. Universal weight screening and follow-up. #129. Universal influenza vaccine screening and counseling. #130. Universal documentation and verification of current medications in the medical record. #131. Pain assessment prior to initiation of patient treatment. #132. Patient co-development of treatment plan/plan of care. #133. Screening for cognitive impairment. #134. Screening for clinical depression. Many of the measures in the PQRI were developed by the AMA-convened Physician Consortium for Performance Improvement, in collaboration with the National Committee for Quality Assurance (NCQA), and/or a medical specialty society. For additional information on

Personal: • Income Tax Planning • Wealth Management • Financial Planning

Local: • Employee Benefit Plans • Profitability Reviews • Outsourced professional services (CFO, Controller)

Ron Mitchell, CPA Director of Health Services rmitchell@aktcpa.com 760-431-8440

Global: • Organizational Structure • Succession Planning • Internal Control Review and Risk Assessment 5946 Priestly Drive, Ste. 200 Carlsbad, CA 92008

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CPA’s and Consultants

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PAyforPeRFoRMAnCe

california Physician Performance initiative (cPPi) aFFeCted PHysiCians urged to veriFy tHeir data

he California Physician Performance Initiative (CPPI, www.cchri.org/cppi), started in 2006 by the California Cooperative Healthcare Reporting Initiative (CCHRI, www.cchri.org), is developing an approach to measure and report

quality and cost of healthcare provided by physicians. The goal is to improve the delivery of quality care while moderating costs. CPPI received federal funding in 2006 to develop a system to measure and report on the quality of healthcare provided by physicians. Three California commercial health plans cPPi BQi (cMS-funded Better Quality information to improve joined with Medicare to pool care for Medicare Beneficiaries) Measures for cycle 1, 2, 3 their medical claims data to measure quality of care as CyCle 1: CyCle 2: CyCle 3: measure CoMPleted CoMPleted CoMPleted part of a national effort to MARCh 2008 JUly 2008 oCt. 31, 2008 establish physician perforscreening For Cancer mance standards. Breast Cancer Screening 1 2 3 CCHRI began solicitColorectal Cancer Screening 1 2 3 ing feedback from affected Cervical Cancer Screening physicians as part of CPPI diabetes in October when they were LDL Testing 1 2 3 notified via mail. The quality HbA1c Testing 1 2 3 measure scores were based on Diabetes Nephropathy Testing 2 3 claims data from patient care Diabetes Eye Exam Screening provided in 2007. Physicians Heart disease were provided with a percenCardiovascular — LDL Testing 1 2 3 tile rank compared to their CAD Patients Receiving Lipid-lowering Therapy 2 3 physician peers, performance Post MI Post Discharge Beta-blocking Therapy 2 3 scores by measure, and perPersistence of Beta Blocker Therapy — Post MI 2 3 Annual Monitoring for Patients on Persistent Medications: formance scores by patient 2 3 Ace Inhibitors, Digoxin, Diuretics, Statins group. Percent of Patients After AMI, CABG, or PCI Receiving at Least One LDL-C Screening Physician-specific MediHeart Failure care scores will not at any HF: LVF Testing 2 3 time be released to the pubWarfarin for Patients With CHF and Atrial Fibrillation 2 3 lic by either Medicare or respiratory disease CCHRI. Although CCHRI Pharmacology Management of COPD Patients (PCE) has no plans to publicly Inappropriate Treatment of Adults With Acute Bronchitis release physician-specific Appropriate Medications for Asthma Patients quality scores related to the Spirometry Testing for COPD Patients to Confirm Diagnosis treatment of private PPO paCare for older adults tients, it is possible that the Percent of Patients 65 or Older That Had Glaucoma Eye Exam private health plans could Women With Osteoporosis Age 67 and Older Who Have Had a Fracture Bone Density/Medication use this information in the rheumatology/orthopedics future. However, the private Rheumatoid Arthritis Patients Prescribed a DMARD Drug health plans would only be Low Back Pain Patients Who Receive an Imaging Study provided the scores of their

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network physicians. The California Medical Association (CMA) continues to work closely with CCHRI to vigilantly protect the use of physician information. CMA and SDCMS urge physicians to verify the accuracy of the data used to calculate their scores; physicians can request their private PPO patient lists at the CCHRI website (www.cchri.org/ cppi) where they can download and complete the “Request for Patient List and Appropriate Data Use” form. The completed forms will be sent to Thomson Reuters (the vendor contracted to collect, standardize, and score the data in strict compliance with HIPAA regulations). Requests must be submitted no later than December 5, 2008, and will be processed within five business days of receipt. Additional information about

Requests must be submitted no later than December 5, 2008. CPPI, including the scoring methodology, can be found at www.cchri.org/cppi. Physicians who review their patient lists and believe their scores to be in error can submit correction requests (with supporting data) within 30 days. Thomson Reuters will log the physician’s request and tabulate the frequency and nature of corrections. A letter acknowledging receipt of the correction request will be mailed to each physician. At the end of the comment period, CCHRI will review the nature of corrections with its Physician Advisory Group and Steering Committee to determine appropriate use of the physician scores.

in memoriam

mike Bajo, md September 8, 1919 – September 26, 2008 SDcMS Member: 1948–1998 By Ben Hourani, mD, mBa

was raised in San Ysidro during the 62 years of marriage. late ’40s and ’50s. It was a small He and his wife came to San Ysidro town of little means then and and opened a much-needed mediknown only as the “gateway to Mexico” cal practice in a poor and underserved and the “busiest border crossing” bearea. I remember my mother and father tween the United States and our neightalked about this wonderful doctor who bor to the south. Those of us who grew would often treat the poor for nothing up there knew of a little-known treasure or take chickens or produce in trade that was a family doctor whom all of for his work. He made house calls and us admired and respected. His name would even go out late at night and take was Michael Bajo, and, remarkably, he one or two of his children with him and practiced in our tiny town, which was a talk to them about how wonderful it was godsend to us all. to be able to help people, and regaled Michael Bajo arrived in our town in them with the beauty and privilege of a most unpredictable fashion. Raised in medicine. Indeed, he was my only docChicago by immitor as a child, and I grant Slovak parents think that subI remember my mother really with limited educaconsciously he had and father talked about a great influence on tion, he was blessed this wonderful doctor with both remarkable who would often treat the me in deciding to athletic ability and a poor for nothing or take become a physician. love of medicine. At Dr. Bajo was a suchickens or produce in what is now Beneperb clinician, but, trade for his work. dictine University he most importantly, excelled in baseball and basketball. The he loved to make people well. On a former was his true love, and he still personal note, I’ll never forget the time holds some of the records at that school. that my wife was in labor at a South Bay As a left-handed pitcher, he was signed hospital. She was having a rough time by the Chicago White Sox and pitched with our first child, and I left her side in their minor league system, facing to get some fresh air. When I returned legendary batters such as Jimmie Foxx she was calm and seemingly in much less and pitching against talent like Warren discomfort. I asked the nurse what pain Spahn. medicine or tranquilizer he had gotHis love of medicine called him to ten and the answer was none. My wife Loyola Medical School in Chicago, then told me that a wonderful doctor where he graduated in 1944 in the midst had come in for a “social” call. He recof WWII. He served as a medical officer ognized her last name and had come in on the USS Dobbins, caring for woundjust to see how she was doing and held ed soldiers, where he excelled with his her hand. She related that his countesurgical abilities. Later he was stationed nance, demeanor, and kindness calmed in San Diego and continued training at her immensely. That was Mike Bajo, and Mercy Hospital, where he met a nurse that is the part of medicine that cannot named Sarah who captured his heart be taught. Tragically, this human side of and continued to do so for a remarkable medical practice seems to have disap-

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peared in today’s healthcare. Mike delivered more than 11,000 babies during his career and was an equally skillful physician and surgeon. Indeed, I know of several cases in which boarded OB/GYN physicians would ask his advice during complex deliveries. He was a remarkable physician and a pillar of the medical community in the South Bay for years. In 1988 he was appropriately honored by the San Diego County Medical Society as “Physician of the Year.” On a final note, Mike Bajo’s personal life mirrored his superb professional career. He and Sarah were blessed with 11 wonderful children of their own. Of course, that was not enough for this great couple, so they adopted four more children and raised 15 children in all. The Bajos adopted these four children whom he delivered and who were born out-of-wedlock at a time when this was considered a disgrace and often tore families apart. Some people thought he wanted so many kids so he could have family baseball games and be able to field two teams. There may be some truth in that, but I know differently. He loved life and people, and he wanted all to have a reasonable chance at success both spiritually and professionally. Who else do you know that would always end a successful delivery with his personal moniker: “Gracias a Dios”? In my 32 years of practice I’ve admired and respected many peers. Not one of them, including myself, could hold a candle to Mike Bajo. I think he was as proud of me becoming a doc as he was of his own kids. I’ll bet that slider of his breaks beautifully in heaven.

Dr. Hourani, who is board certified in internal medicine and geriatrics, is a founding partner of Chula Vista Internal Medicine and Cardiology Medical Group and is currently a part-time hospitalist and medical director for quality at Sharp Chula Vista Medical Center.

aBOut tHe autHOr:

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Classifieds OFFICE SPACE

AFFORDABLE OVERHEAD FOR YOUR PRACTICE: Large practice looking to share office space or total

EL CENTRO/IMPERIAL MEDICAL OR COMMERCIAL BUILDING FOR LEASE/RENT: New upscale

overhead. Will consider sublease of space or combining total overhead, including supplies and staff, to reduce cost for all. Space is over 4,000ft2 and includes eight exam rooms. Located in metro region. Close to all major freeways and Sharp Memorial Hospital. Room setup/building facilities could benefit any primary care and meet most specialist needs. Call (858) 268-1111, ext. 311, for further information. [632]

11,761ft building located in the northeast quadrant of Highway 86 and Aten Road, with Highway 86 visibility. Three phase power with 800 amps, ideal for medical imaging or businesses requiring additional power. The building is divisible up to five suites, and bathrooms are stubbed in at each location. Please call Patseay at (760) 562-1436 or email patseay@roadrunner.com for further information. [643] 2

MEDICAL OFFICE SPACE: Beautiful turnkey medical office space to share in the village of La Jolla with ocean view. Available three days a week, including secretary on two days. Space is suitable for physician, psychologist, or therapist. All inclusive rent: $2,000 per month. Parking in building. Contact Jane Reldan, MD, at (858) 454-5527. [642]

LA JOLLA: Newly remodeled medical office space for lease in La Jolla. Shared space with orthopaedic surgeons. Preferably part-time needs. Convenient location near the Orthopaedic Surgery Center in La Jolla. Contact Jo Turner for more information at (619) 733-4068 or at jo@lajollaspine.com. [641]

MEDICAL/SURGICAL OFFICE TO SHARE: Available to board-certified or board-eligible plastic surgeon. Space is located in a very desirable building across from Mercy Hospital. Beautiful first floor, interior decorated office. Includes furnished doctor’s office, exam room, fully equipped AAAHC-accredited operation room, front desk area, common waiting area, and staff restroom. Please contact Denise at (619) 299-7467. [639]

MEDICAL OFFICE SPACE AVAILABLE: Office located in downtown San Diego. Two exam rooms and one office. Please call (619) 985-0017. [631]

3998 Vista Way, Ste. 100, in Oceanside: Three

LA MESA: Medical office space available for sublease in conveniently located La Mesa building. Please call Debbie at (619) 668-4700 for more information. [630]

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) 677-5329; e-mail chris.ross@ colliers.com.

NEW MEDICAL BUILDING ALONG I-15: Pinnacle Medical Plaza is a new 80,000 SF building recently completed off Scripps Poway Parkway. The location is perfect for serving patients along the I-15 from Mira Mesa to Rancho Bernardo and reaches west with easy access to Highway 56. Suites are available from 1,000 -11,000 SF and will be improved to meet exact requirements. A generous improvement allowance is provided. For information, contact Ed Muna at 619-702-5655, ed@lankfordsd.com; www.pinnaclemedicalplaza.com SAN DIEGO: A unique physician opportunity with a highly successful and profitable multispecialty office located in beautiful Bankers Hill. Enjoy the freedom of your private practice in our luxurious medical office. Your personal office has incredible views of the harbor. We are a fully equipped and fully staffed, ready to increase your reimbursement from day one. Let us help build or relocate your practice! Open to all specialties. Call Eric Noll at (619) 233-4044. [637]

medical office spaces (approximately 2,000ft2 each) available for lease. Close proximity to Tri-City Hospital with pedestrian walkway connected to parking lot, and groundfloor 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 Available: Office space at the corner of 8th Ave. and Washington St. 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]

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 El 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]

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

SHARE OFFICE SPACE: Busy family practice, Poway Road and I-15 area in Sabre Springs neighborhood, has office and exam rooms available. Standard medical care preferred. Please no esthetic practice, etc. For more information, contact Dr. Wickes at awickes@sbcglobal.net. [638]

Medical Office Space (Scripps Encinitas Campus): 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]

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

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]

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]

Office Space to Share: Modern, spacious medical office. Close proximity to Alvarado and Sharp hospitals. Call (619) 668-0900 for more information. [616]

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]

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) 452-6226. [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]

Office Space to Share (South County): Chula Vista-area family practice office to sublease at 340 4th 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]

Office Space for Lease (Escondido): PreSolana Beach Medical Center: 2,274ft2 for lease; $1.90/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) 4314238. [584]

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 doctors offices, and consultation

mier furnished medical office space for lease in Escondido. Excellent location near Palomar Medical Center. Please call (760) 743-1033. [501]

Space for Lease (Coronado): Brand new building in Coronado. Last space available: 1,105ft2, $2.75+NNN. Call (619) 742-5555 or email cpatricia@glenncookmd.com. [435]

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

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 75 words.

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Classifieds and/or exam rooms and receptionist. Parking spaces available for rent (off street, covered). Call (858) 354-9833 for further information. [346]

options (office, hospital, or nursing homes). Very light calls mainly over the phone. We are very flexible in job details. Please call Suzi King at (619) 426-9731. [613]

PHYSICIAN POSITIONS AVAILABLE

Interventional Cardiologist Opportunity: Income potential well above national average. Im-

SEEKING A BOARD-CERTIFIED, FAMILY PRACTICE MEDICAL DIRECTOR/PHYSICIAN TO JOIN OUR CLINIC: Minimum two years community-based

mediate 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]

Please call (858) 350-8100 or email résumé to admin@ torreyhillsfamilymedicine.com. [577]

Part-time Medical Assistant/Back Office:

medical practice, managing healthcare delivery, and directing clinical systems. MD or DO with California license to practice and board certification in family practice. Strong supervisory, leadership, team building, and computer skills needed. Competitive compensation and benefits package. Email CV to jobs@sihc.org or fax to (619) 445-7976. Visit www.sihc.org for full job description or call Human Resources at (619) 445-1188, ext. 291. [645]

SEEKING BOARD-CERTIFIED/BOARD-ELIGIBLE FAMILY PHYSICAN: To join a patient-centered practice in Chula Vista specializing in primary care and cosmetic medicine. Successful candidate will be enthusiastic, caring, with positive attitude, good work ethic, and able to build practice with exceptional people skills. Bilingual in Spanish preferred. Competitive compensation and benefits package. Flexible schedule, part or full time. Email CV to doctorwp@pacbell.net or fax to (619) 422-1055. Call Ann at (619) 422-1324 for more information. [640]

TEMPORARY EXPERT PROFESSIONAL (TEP) MD (GENERAL PRACTITIONER) — COUNTY OF SAN DIEGO PUBLIC HEALTH: Examine patients and make recommendations for further study, or treat patients with medical illnesses or complications, and consult with providers in the community on related cases. Assignments may be in the HIV/STD/Hepatitis, TB, or well child exam clinics. TEPs may provide clinical supervision of certified nurse practitioner, public health nurses, staff nurse, vocational nurses, and support staff. California medical license desired. Fax CV to (619) 236-1196. [634]

TEMPORARY EXPERT PROFESSIONAL (TEP) MD (INTERNEST) — COUNTY OF SAN DIEGO: Examine patients and make recommendations for further study, or treat patients with medical illnesses or complications, and consult with providers in the community on related cases. When assigned to the San Diego County Psychiatric Hospital (SDCPH), candidate will serve as a medical consultant to psychiatrists, nursing staff, and medical director. California medical license desired. Fax CV to (619) 236-1196. [633]

OB/GYN PHYSICIAN POSITION: Private practice opportunity to join two board-certified OB/GYNs. Outstanding earning potential. Perinatologists and NICU available 24/7. 1:4 on-call. Fax CV to (858) 451-8473. [625]

Cardiologist Needed: Due to a recent accident resulting in disability, North County cardiologist seeks either an invasive or non-invasive 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) 591-0924. 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, 8:00 a.m. to 4:00 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]

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]

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] FAMILY PRACTICE POSITIONS AVAILBLE: Busy family practice in Escondido is seeking one full-time and one part-time, practice share physician. Please send CV to jshaw@pennelm.com or fax to (760) 745-0451. [644]

Physician positions Wanted FP SEEKING EMPLOYMENT: Family physician look-

seeks full-time or part-time physician. Fax CV to (619) 442-2245. [595]

Partnership Opportunity: ENT position avail-

TEMPORARY POSITION WANTED: Board-certified

able immediately in an existing La Jolla practice. Partnership may be quickly achievable. Please call (858) 4581287 for details. [564]

family physician looking for a part-time position from September to December to work in an outpatient setting. I have my own insurance and have experience working with EMRs. Email brentgmd@aol.com. [626]

Urgent Care: Busy practice established in 1982

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 part time). No weekends, no call, transportation and personal assistant provided. Call Chris Hunt, MD, at (858) 279-1212. [458]

FAMILY PRACTICE (CHULA VISTA): Seeking a fam-

Family Practice Doctors Needed: Full time

mary 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]

needed for group orthopedic practice. Great opportunity, benefits. Please fax CV to (619) 229-3933. [565]

ing for temporary employment in the northern San Diego area from October through December and possibly the first part of 2009. Has experience in urgent care as well as a traditional outpatient setting. Open to hospitalist work if available. If you are looking to fill a temporary position with someone who is ambitious, accountable, and has a positive mental attitude, please email inquires to drdorner@yahoo.com. [628]

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 pri-

standing ASC under construction and set to open late 2009. State-of-the-art, multi-specialty facility (wholly owned property and center). Potential surgeon/surgical group investment opportunities. Call (858) 344-0083 or email afdorinmdmba@aol.com to discuss. [606]

Part-time Cardiologist Needed: One to three

practice physician with interest in holistic health for employment with an integrative medical practice located in San Diego’s Bay Park community. Part- to full-time hours, flexible schedule, generous benefits, light call. Please email résumé to mgolden@CHWBonline.com. [617]

Physical Therapist: Part-time or full-time PT

Medical Receptionist/Front Office: We are RiverView MD Surgery Center: New, free-

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

Internal Medicine/Family Practice Position: Seeking board-certified/eligible internist or family

Two years experience required including phlebotomy. Busy specialist office near Alvarado Hospital. Submit résumés via email to dlpotter22@hotmail.com. [576]

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

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]

Cardiologist Seeking Employment: Noninvasive cardiologist 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) 6333044, or email cvshah@aol.com. [558]

PRACTICES FOR SALE NONPHYSICIAN POSITIONS AVAILABLE 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]

Successful Medical Skin Care Clinic for Sale: Small investment for 51 percent ownership. Looking for a new medical director. Call Leonard Schulkind at (619) 807-5485. [539]

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]

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) 4700996. [621]

Physician Needed: Part-time or full-time position

Registered Nurse: Family medicine office in Torrey

for board-certified/eligible physician to help two physicians in Chula Vista. Cheerful work atmosphere, variety of

Hills seeking a full-time, experienced RN. Previous clinical experience required. Salary and benefits are negotiable.

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MEDICAL EQUIPMENT COSMETIC LASER EQUIPMENT FOR SALE: Preowned lasers in great condition for great prices! Lumenis Quantum SR/HR Intense Pulse Light (IPL) system available for $13,000. Treats: photo facials, telangiectasias, vascular & pigmented lesions. Reliant Fraxel SR 1500 Laser (Fraxel II) available for $65,000. Treats: pigmented lesions, facial rhytides, scars, melasma. Includes Zimmer

Classifieds Cryo5 Chiller. Reliant Fraxel SR 750 Laser (Fraxel I) available for $35,000. For more information, contact Dan Rich at (858) 204-9802 or email drich@laserperfectioninc. com. [627]

or permanent relocation. For private showing or more information, call (619) 585-0476 or email takur01@yahoo. com. [618]

nity 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]

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]

SERVICES OFFERED

RMC Vinyl Repair Plus: Medical equipment up-

Mission Hills Office for Sale: Rare opportuRetired Surgical Practice Operating Room/Surgical Equipment: Perfect for plastic surgery/oral surgery. Endoscopy, cameras, loupes, tools. Waiting room furniture inventory list is available upon request. Email kwahl@san.rr.com. [506]

REAL ESTATE MAMMOTH CONDO FOR SALE (REDUCED FOR QUICK SALE): Large, furnished two-bedroom/two-bath, two-story condo. Convenient town location makes shopping, skiing, and exploring a breeze. Short distance from great vacation destinations including Mammoth Mountain, Yosemite, Convict Lake, and more! Property amenities include BBQ, pool, and jacuzzi. Price: 460K. Call (858) 268-1111, ext. 311, for details. [635]

Vacation in Lake Tahoe: New, fully equipped one bedroom/one 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 Lankford_SDP_08:Layout 1 hiking, 10/27/08 1:22 rink-side cabana. Enjoy biking, 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]

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]

PM Practice Page 1 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]

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

Billing, Consulting, Outsourcing: We are committed to maximizing your bottom line! Our billing service uses state-of-the-art technology to ensure charge

holsterer. Expert 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]

MISCELLANEOUS 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 paltry 100 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) 344-0083. [454]

2003 BMW M3 Convertible (red, manual) (Price slashed $4,000 6/17/08): Very good condition, low miles, and new tires: $33,750. (858) 3440083. [453]

Pinnacle Introducing

Medical Plaza

The Building…

• New 80,000-square-foot Class “A” Medical Office Building • First floor is the new home to Sharp-Rees Stealy Medical Group • Second floor available to independent medical practitioners • New suites available from 1,200 to 11,000 square feet • Offices can be built to meet your exact long-term needs

Location, Location, Location

• Located at 10672 Wexford Street, off the I-15 at Scripps Poway Parkway (92131) • Strategic Scripps Ranch/Poway location perfectly situated off the I-15 to serve the North County Communities of Scripps Ranch, Rancho Bernardo, Poway, Mira Mesa and Carmel Valley • Minutes from SR-52 and SR56 for easy access to the coastal communities

For more information, please call Ed Muna at 619-702-5655 or e-mail ed@lankfordsd.com. • www.PinnacleMedicalPlaza.com

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History of medicine to treat it. The caduceus later represented Asklepios, the legendary Greek god of medicine. Asklepios was the son of Apollo and the nymph Coronis. When his mother died, Asklepios was placed under the care of the famous wise centaur and half brother of Zeus, Chiron. Under the tutelage of Chiron, Asklepios became a great physician. With Epiome, he had four children, two of whom, Machaon and Podaleirios, are physicians mentioned in the famous Greek epic, The Iliad. His two daughters were famous in their own right: Hygieia, goddess of health, represented prevention of disease; and Panaceia, goddess of healing, represented treatment of disease. Their names are related to the etymology of the two well-known medical terms hygiene and panacea. Today, remnants of more than 300 temples honoring Asklepios exist throughout Greece and Rome. These healing temples of Asklepios date back to the 6th century B.C.E., where they were erected in various cities of Greece. Each temple consisted of many buildings and areas, a main temple containing a statue of the god By arthur Blain, mD, mBa Asklepios, other areas displaying statThe caduceus has a ues of members of long history, with its family, and an origins dating back more his incubation site, the than four thousand years. abaton, where hen most people think of in 1857. It was then the However, its use as the doctors or the entire medi- adopted by the U.S. universal medical symbol actual cure of the cal profession, they usu- Public Health Service sick took place. is relatively recent. ally think of a symbol consisting of two in 1871, and by the Asklepios died as snakes wrapped around a winged rod: the U.S. Army Medical Corps in 1902. a result of a fall, having been struck by a caduceus. However, the correct symbol is The first association of the caduceus thunderbolt from Zeus, who was angry actually the staff of Asklepios (or Aescula- and medicine was seen on 3rd century and fearful that Asklepios’ skill might pius), which is a staff entwined with only C.E. oculists’ stamps. These pocket-sized make all men immortal. Although Askleone serpent. tablets were actually solid sticks that con- pios was killed by Zeus, his memory and The caduceus has a long history, with tained medicines used to treat eye dis- ideals live in the hearts and actions of its origins dating back more than four eases, which were common in 3rd century modern-day medical practitioners, who thousand years. However, its use as the C.E. Roman civilization. These stamps are often referred to as Aesculapians. universal medical symbol is relatively re- displayed pictures of caducei on their cent. In 1856, the United States Marine top and bottom surfaces. They were also Service needed a symbol for the uni- inscribed with the name of a disease, the a B O u t t H e a u t H O r : Dr. Blain, formed noncombatant medical person- medicine used to treat it, and the name of who sits on the SDCMS board of directors, nel. They mistakenly chose the caduceus the medical practitioner. Pieces of these is a faculty physician at the Camp Pendrather than the surgeon general’s crest of solid sticks were broken and mixed with leton Family Practice Residency, expert 1818, which correctly displayed the staff oil, honey, butter, or egg until a suitable medical reviewer for the Medical Board of Asklepios. Acceptance of the caduceus liquid medicine was formed. In effect, of California, and voluntary faculty at the began with its being chosen as the sym- these oculists’ stamps served as both a UCSD School of Medicine and Uniformed bol of the U.S. Army hospital stewards prescription pad and the medicine used University of Health Sciences.

the

CAdUCeUs Misinformed Medical symbol

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