February 2009 by San Diego Physician

official publication of the san diego county medical society • february 2009

Children healthcare coverage for

Alzheimer’s Disease in San Diego P.14 if this had been an emergency P.18

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

Contents VOL. 96 | NO. 2 [ F e a t u r e s ]

Healthcare Coverage for Children

• U niversal Health Insurance Coverage for Children: An Incremental Approach Is Likely • Health Insurance for Children: A Proposal • Prescription for Obesity: A Comprehensive, Countywide Database of Programs and Services • Trends in Children’s Health Coverage • More Than Two Million Children With Insured Parents Are Uninsured • MediKids Health Insurance Act

[ D e p a r t m e n t s ]

4 6 8 10 12 14 2

18 20 38 40 44

Contributors

This Issue’s Contributing Writers

Editor’s Column

Will MIPPA Be Better Than HIPAA?

SDCMS’ 2009 Seminars and Events Community Healthcare Calendar Ask Your Physician Advocate Public Health

Alzheimer’s Disease in San Diego

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Emergency Preparedness If This Had Been an Emergency

Healthcare Reform Five Myths About Our Ailing Healthcare System

The Pulse

Uninsured San Diegans Receive Free Surgeries

Physician Marketplace Classifieds

First-person perspective The International Medical Corps in Iraq

Contributors American Academy of Pediatrics The AAP is an organization of 60,000 primary care pediatricians, pediatric medical subspecialists, and pediatric surgical specialists dedicated to the health, safety, and well-being of infants, children, adolescents, and young adults.

Joel A. Harrison, PhD, MPH Mr. Harrison does consulting in epidemiology and research design. He has worked in the areas of preventive medicine, infectious diseases, medical outcomes research, and evidence-based clinical practice guidelines.

Diane Darby Beach, MPH, EdD Ms. Beach is the community edu-

Leonard Kornreich, MD Dr. Kornreich has practiced pediatrics in

cation manager for the Alzheimer’s Association and an adjunct professor in the gerontology program at SDSU.

James Beaubeaux Mr. Beaubeaux is chief operations office and chief financial officer of the San Diego County Medical Society.

Chula Vista since 1974 and is president emeritus of Children’s Primary Care Medical Group. He is a past president of SDCMS and a former chief of staff at Scripps Chula Vista and Rady Children’s Hospital. He currently serves as co-chair of the Healthy San Diego Professional Advisory Board.

Shannon Brownlee Ms. Brownlee, a visiting scholar at the

Joseph E. Scherger, MD, MPH Dr. Scherger is clinical professor

National Institutes of Health Clinical Center, is the author of Overtreated.

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.

Ezekiel Emanuel Mr. Emanuel, an oncologist and author of Healthcare, Guaranteed, is chairman of the National Institutes of Health Clinical Center’s Department of Bioethics.

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.

George Ulrich, MD Dr. Ulrich graduated from medical school at the University of Colorado. He completed ophthalmology training at the Naval Medical Center in San Diego and fellowship training in glaucoma at Duke University. He has extensive experience teaching ophthalmology and cataract surgery to physicians in training and is in private practice in San Diego. Carol Young, MD Dr. Young is president of the San Diego County Medical Society Foundation.

Send your letters to the editor to Editor@SDCMS.org East County Director Hillcrest Director Kearny Mesa Director EDITOR MANAGING EDITOR

Joseph Scherger, MD, MPH Kyle Lewis

editorial board

Van Cheng, MD 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 and 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

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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Merchant Services: Credit/Debit Card Processing Potential Value: $1,500 for high-dollar, high-volume cost! Chase Paymentech provides member physicians fast, secure, and cheaper credit card payment processing, excellent customer service, and innovative payment options. SDCMS members receive upgraded customer service, free online reporting, and a guaranteed 10–20 percent savings from current costs. Let Chase Paymentech provide you with a competitive quote today by sending three months of merchant statements to Janet Lockett at JLockett@SDCMS.org, by fax to (858) 569-1334, or call her at (858) 300-2778. Technology Solutions Potential Value: $1,000! Soundoff Computing Corporation provides bestof-breed hardware, software, and network technologies for your medical practice, utilizing best practices for all aspects of IT implementations. SDCMS member physicians receive free site inspection and subsequent infrastructure recommendations; free inventory and assessment of network and hardware computing assets; free analysis of Internet/telco/ data activity and subsequent ROI recommendations.To learn more, visit www.soundoffcomputing. com or contact Ofer Shimrat at (858) 569-0300 or at ofer@ soundoffcomputing.com. Banking Products and Services Potential Value: $2,500! Torrey Pines Bank is a “lowmaintenance” bank that meets business owners’ high expectations while requiring of them the absolute minimum of time and effort. 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 per 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 per month, and free courier service or remote deposit service. Contact Benjamin Pimentel at (858) 259-5317 or at bpimentel@ torreypinesbank.com. Insurance Products and Services Potential Value: $1,000–$2,500! Alliant Insurance Services, Inc., is California’s largest premier specialty insurance broker and ranks among the 13 largest in the

nation. SDCMS members receive discounts on a comprehensive portfolio of insurance products and services, including savings of 5–10 percent or more off of the cost of insurance, or cash rebates related to practice size, a savings of 7–12 percent on long-term disability income protection, and no-cost human resources consulting. Contact Mark Allan at (800) 654-4609 or at mallan@ alliantinsurance.com. Visit Alliant Insurance Services online at www. alliantinsurance.com. Tamper-resistant Prescription Pads Potential Value: $300! American Security Rx, which is a California Department of Justice and California Board of Pharmacy approved Security Printer (SP-9), provides tamperresistant California security prescription forms for controlled medications. SDCMS members receive discounts on tamperresistant prescription forms. Contact American Security Rx at (877) 290-4262 or at info@ americansecurityrx.com. Visit American Security Rx online at www.americansecurityrx.com. Billing Solutions Potential Value: $1,000! CHMB Solutions 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 percent discount on startup fees and a $33 per-physician-permonth services credit, 10 percent off of outsourced IT support, 10 percent off of already discounted Dell hardware solutions, and a free coding hotline. Contact Ron Anderson at (760) 520-1340 or at randerson@chmbsolutions.com. Email your coding question(s) to SDCMS at Coding@SDCMS.org. Visit CHMB Solutions online at www.chmbsolutions.com. Contract Analysis Potential Value: 10 percent of Net Revenue! 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 contracting analysis, a discount on hourly rates, and a package price on services for contract negotiations, including health plan contracts! Contact Kim Fenton, president, at (949) 481-9066 or at kimf@healthcareconsultant.

org. Visit Coastal Healthcare Consulting Group online at www. healthcareconsultant.org. For consultation scheduling, contact Marisol Gonzalez, your SDCMS physician advocate, at (858) 300-2783 or at MGonzalez@ SDCMS.org. Practice Management Consulting Potential Value: $1,000–$2,500! Practice Performance Group (PPG) 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

and a 7.5 percent dividend credit. To learn more, contact Janet Lockett at SDCMS at (858) 3002778 or at JLockett@SDCMS. org. Visit TDC online at www. thedoctors.com. Collections Services Potential Value: $350–500! TSC Accounts Receivable Solutions has provided personalized, innovative collection and total accounts management services since 1992. This local, family-owned business’ management team has combined experience of more than 50 years in the healthcare billing and collection field. SDCMS members receive a 10 percent discount on monthly charges. Contact Catherine Sherman at (888) 687-

SDCMS

Endorsed Partner Benefits

Total Potential Value to SDCMS Members:

$10,000–$17,000 management, market strategy and tactics, practice acquisitions, sales and mergers, and a free one-year subscription to their newsletter, UnCommon Sense. PPG also conducts free half-day seminars for SDCMS members and their staffs at SDCMS’ offices. Contact Jeffrey Denning or Judy Bee at (858) 459-7878 or at Jeff@PPGConsulting.com. Visit PPG at www.PPGConsulting.com. Professional Liability Insurance Potential Value: $500–$2,500! The Doctors Company (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. Most SDCMS members are eligible for a 5 percent discount on insurance premiums

4240, ext. 14, or at csherman@ tscarsolutions.com. Visit TSC online at www.tscarsolutions.com. Accounting Services Potential Value: $500–$2,000! AKT CPAs and business consulting LLP has provided audit, tax preparation and planning, accounting assistance, and business consulting to San Diego County clients for more than 50 years. SDCMS members receive a 15 percent discount on standard rates for professional services, with an unconditional satisfaction guarantee: “SDCMS members who are not completely satisfied with the work AKT performs for them pay only what they thought the work was worth.” Contact Ron Mitchell at (760) 268-0212 or at rmitchell@ aktcpa.com. Visit AKT at www. aktcpa.com.

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

will

MIPPA be better than HIPAA? Getting Ready for ePrescribing

cronyms have a long tradition in medicine. Recently, they seem to be getting cleverer and more contrived, especially in naming clinical trials and government programs. MRFIT, COURAGE, ACCORD, and JUPITER are just some of the clinical trial names we hear, and we wonder, what did that one show? HIPAA is a government program we would like to forget. Medical information has always been private and confidential, but HIPAA puts lots of regulations on it that make us worried about being caught in “noncompliance.” You might win a trivia bet by asking someone what the P in HIPAA stands for. Chances are the person will say it stands for privacy. Wrong. HIPAA is the Health Insurance Portability and Accountability Act (1996). It was the celebrated Kennedy-Kassebaum bill that made health insurance portable from one job to another. The privacy policy was an add-on that at the time did not get any attention. The actual legislation called for health plans and providers to develop a privacy policy within five years, and if they did not, the feds would do it. The health plans and providers, not being organized and

The government usually does not make participating in any program easy, and e-prescribing will be no exception. not seeing a problem, did not act, so the feds did, and we got the HIPAA privacy regulations with which HIPAA would be forever associated. MIPPA is the Medicare Improvements for Patients and Providers act of 2008. It retroactively set the physician fee schedule away from the onerous cuts that came from the Sustainable Growth Rate (SGR) formula that dates back to the Balanced Budget Act of 1997. An addon to MIPPA that will ultimately define the legislation, like the privacy policies have ultimately defined HIPAA, is the eprescribing incentive. Yet neither of the Ps in MIPPA stands for prescribing.

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Under MIPPA, physicians who use a qualified e-prescribing (eRx) system for their Medicare patients will be eligible to receive a bonus of 2 percent of their Medicare revenue in 2009 and 2010. The bonus amount will drop to 1 percent of Medicare revenue in 2011 and 2012, and to 0.5 percent in 2013. Beginning in 2014, physicians who are not e-prescribing will have their Medicare payments reduced by as much as 2 percent. The carrot becomes a stick. Medicare believes it will come out ahead in this program by reducing the costs associated with medication errors and through better prescribing practices. Physicians would do better through the increased reimbursement. It is expected that other incentives, such as pay-for-performance programs, will reward physicians for eprescribing and using other health information technology (HIT) applications, such as electronic health records (EHRs) with patient registry functions. To embark on e-prescribing, physicians have a choice to either purchase and implement a standalone e-prescribing system or to get an EHR that has the e-prescribing function. Standalone e-prescribing systems range from $2,500 to $3,000, about the same amount as the average estimated bonus payments for the first year of participation in the program. Fully functional EHRs cost anywhere from $20,000 to $50,000 per physician. The only way to justify the added expense of the EHR is to realize additional income from pay-forperformance programs and other incentives that are likely to come. The government usually does not make participating in any program easy, and eprescribing will be no exception. Qualifying for the bonuses will not be as easy as it sounds. The government will require that the e-prescribing system meet Medicare Part D standards that go into effect in April 2009. As of this writing, the details are still being tweaked but should be available by publication at www.cms.hhs. gov/eprescribing. Next will come the proper reporting of e-prescribing activity. Think of how user friendly the Physician Quality Reporting Initiative (PQRI) is. Under PQRI measure No. 125, “qualified” e-prescribing

systems must be able to generate a medication list, provide information on lowercost alternative medications, transmit prescriptions directly to the pharmacy, generate automated alerts offering information on the drug, potential inappropriate dose or route of administration, drug-

E-prescribing Resources for SDCMS Member Physicians Visit www.SDCMS.org

An add-on to MIPPA that will ultimately define the legislation, like the privacy policies have ultimately defined HIPAA, is the eprescribing incentive. Yet neither of the Ps in MIPPA stands for prescribing. drug interactions, allergy warnings, and provide information on tiered formulary medications. Choose an e-prescribing system wisely! Fortunately, SDCMS and CMA are positioning to help physicians participate with e-prescribing (think another member benefit). Sessions for you and your staff are being planned. CMS has published A Clinician’s Guide to Electronic Prescribing that offers practical information on planning, selecting, and implementing an e-prescribing system — available at www.SDCMS.org. Back in July of 2004, Michael Leavitt, secretary of Health and Human Services, declared the decade of health information technology (HIT) to be here, and the imperative to use it will only grow more in the Obama administration. Change is difficult, even when it is for the better. Stay connected to SDCMS and we will help you navigate the journey into modern electronic systems of practice. About the Author: Dr. Scherger is clinical professor of family medicine at UCSD. He is also medical director of AmeriChoice, which administers San Diego County Medical Services. Dr. Scherger, along with editing San Diego Physician, is chair of the SDCMS Communications Committee.

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E-prescribing allows a prescriber to electronically send a readable prescription directly to a pharmacy from the point of care. E-prescribing strives to reduce the number of medication errors and adverse drug effects, while improving standards in patient safety. It is hard to put a finger on which vendor has the best e-prescribing product for your practice. SDCMS has created a webinar and PowerPoint presentation (“E-prescribing for Dummies”) that details the pros and cons of e-prescribing, that explains how to receive Medicare’s 2 percent e-prescribing incentive, and that gives a vendor-neutral overview of some e-prescribing products. In addition to our e-prescribing presentation, SDCMS members can access AMA’s “Clinicians’ Guide to E-prescribing” and Medicare’s “Guide to E-prescribing” — both in PDF format — on SDCMS’ website. If you have any questions on e-prescribing or need help accessing the above resources, please contact Lauren Wendler, your SDCMS office manager advocate, at (858) 300-2782 or at LWendler@ SDCMS.org. Thank you for your membership in SDCMS and CMA!

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SDCMS Members-only Benefits

2009

Seminars and Events

February 11 Wednesday 6:30PM–8:30PM Contract Negotiations Seminar/Webinar 12 Thursday 11:30AM–1:00PM Contract Negotiations Seminar/ Webinar (Office Managers Forum) 18 Wednesday 6:30PM–8:30PM Coding Seminar/Webinar 19 Thursday 11:30AM–1:00PM Coding Seminar/Webinar (Office Managers Forum)

March 18 Wednesday 6:30PM–8:30PM Insurance Services Seminar/Webinar 19 Thursday 11:30AM–1:00PM Insurance Services Seminar/ Webinar (Office Managers Forum)

April 15 Wednesday 5:00PM–9:00PM Practice Management Seminar/Webinar 16 Thursday 9:00AM–1:00PM Practice Management Seminar/Webinar (Office Managers Forum)

18 Saturday 8:30AM–3:30PM Resident and New Physician Seminar: “Preparing to Practice: What You Need to Know BEFORE You Begin Your Practice” 22 Wednesday 6:30PM–8:00PM Risk Management Seminar/Webinar: “How to Handle Legal Notices (Summons, NOI, Subpoenas)” 23 Thursday 11:30AM–1:00PM Risk Management Seminar/Webinar: “How to Handle Legal Notices (Summons, NOI, Subpoenas)”

May 6 Wednesday 4:00PM-8:00PM EMR Road Show 7 Thursday 9:00AM–12:30PM EMR Road Show (Office Managers Forum) 20 Wednesday 11:30AM–1:00PM Billing Seminar/Webinar (Office Managers Forum)

June 17 Wednesday 6:30PM–8:30PM Legal Seminar/Webinar

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Free to Member Physicians and Their Office Staff! SDCMS strives to build a robust schedule of free seminars and events for our member physicians and their office staff. All SDCMS member physicians and their office staff attend SDCMS seminars free of charge (including Office Managers Forums). Our seminars cover a broad range of practice management topics, including legal issues, HIPAA, riskmanagement issues, contract negotiations, and more. For further information about any of these seminars and events, watch your emails and faxes, visit SDCMS’ website at www.SDCMS.org, or contact Lauren Wendler at (858) 300-2782 or at LWendler@SDCMS.org.

Community Healthcare Calendar

Medical Symposium: Maimonides Society of Adat Yeshurun Charitable event with volunteer faculty. Clinical update plus Jewish medical ethics. 30 hours CME. Feb. 12–15 at the Glatt Kosher Winter Retreat, La Jolla. Contact (858) 535-0037 or maimonides@ adatyeshurun.org, or visit www.adatyeshurun.org/ maimonides.

2 Annual UCSD Urology Postgraduate Course nd

Physicians in the fields of oncology, surgery, and urology encouraged to attend this informational conference. Feb. 20–21 at The Lodge at Torrey Pines, La Jolla. Visit http://cme.ucsd.edu/events. cfm for details.

WEST COAST GERIATRIC PSYCHIATRY CONFERENCE Up-to-date, clinically relevant information to assist psychiatrists, primary care physicians, and other health professionals in delivering quality care for the older person. Feb. 25–28 at the Catamaran Resort Hotel. Visit http://cme.ucsd.edu/ geriatricpsych.

THE FUTURE OF GENOMIC MEDICINE II Examines the salient progress and challenges in the field of genomics. Feb. 27–28 at the Neurosciences Institute Auditorium, Scripps Research Institute, La Jolla. Contact (858) 652-5486 or med.edu@scrippshealth.org.

Fresh Start’s Surgery Weekend A team of dedicated medical volunteers donates their time and expertise to provide disadvantaged children with the highest quality medical services and ongoing care. Feb. 28–Mar. 3, Apr. 18–19, Jun. 13–14, Jul. 25–26, Sep. 12–13, and Nov. 7–8 at the Center for Surgery of Encinitas. Contact (760) 448-2021 or mimi@freshstart.org, or visit www.freshstart.org.

32 Annual San Diego Postgraduate Assembly in Surgery nd

Five-day course presented by the UCSD School of Medicine. The practicing surgeon will be brought up-to-date on the latest developments in general surgery. Mar. 3 at the Westin San Diego at Emerald Plaza. Contact (858) 534-3940 or ocme@ucsd.edu.

TOPICS AND ADVANCES IN INTERNAL MEDICINE Topics include neoplastic diseases, rheumatology, geriatrics, infectious diseases, and hospital medicine, among others. Mar. 5–11 at the Hilton San Diego Resort. Visit http://cme.ucsd.edu/ internalmed/index2.html.

PERCUTANEOUS CATHETER ABLATION OF ATRIAL FIBRILLATION Directed at those interested in incorporating percutaneous catheter ablation into their clinical management of patients with atrial fibrillation. Mar. 7 at the Hilton La Jolla Torrey Pines. Contact (858) 652-5400 or med.edu@scrippshealth.org.

2009 Radiology at Alta and snowbird Covering the applications of imaging techniques in the diagnosis of diseases of the brain, spine, musculoskeletal system, and body. Mar. 8–12 at the Cliff Lodge, Snowbird, Utah. Visit http://cme. ucsd.edu/radiology.

ADVANCES IN THE NEUROPSYCHOLOGICAL ASSESMENT AND TREATMENT OF SCHOOL-AGED CHILDREN WITH COGNITIVE DEFICITS Presentation of the latest findings on the assessment and remediation of cognitive and behavioral impairments in school-aged children. Apr. 2–5 at the Hilton San Diego Resort. Visit http://cme.ucsd.edu/neuro.

14th Annual Primary Care in Paradise Will assess current trends in preventive healthcare with an emphasis on endocrinology, orthopedics, obesity, migraines, COPD, melanoma, and sleep apnea; summarize recent developments and changes in the treatment of disease processes likely to be seen in the primary care office setting; and identify and treat problems commonly encountered in primary care clinical practice. Apr. 6–9 at the Hapuna Beach Prince Hotel, Big Island, Hawaii. Contact (858) 652-5400 or med.edu@ scrippshealth.org.

2ND ANNUAL SUDDEN CARDIAC ARREST Apr. 25–26 at the Hilton San Diego Resort. Visit www.scripps.org/health-education.

AMERICAN OCCUPATIONAL HEALTH CONFERENCE 2009 Topics include occupational medicine/research, infectious disease, toxicology, workers’ compen-

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sation, ergonomics, and environmental pollution. Apr. 26–29 at the Manchester Hyatt Hotel in San Diego. Visit www.acoem.org.

ESSENTIAL TOPICS IN PEDIATRICS 2009 May 14-15 at the Catamaran Resort Hotel. Visit http://cme.ucsd.edu/events.cfm.

2009 American Thoracic Society International Conference Educational program for clinicians and researchers in adult and pediatric pulmonary, critical care, and sleep medicine. Sample a broad spectrum of topics or concentrate on critical care, sleep, allergy/immunology or other specialtyrelated to respiratory medicine. May 15–20. Visit www.thoracic.org.

ALZHEIMER’S DISEASE: UPDATE ON RESEARCH, TREATMENT, AND CARE May 21–22 at the Omni San Diego Hotel. Visit http://cme.ucsd.edu/events.cfm.

Riverside County Medical Association: 5th Annual “Cruisin’ Thru CME” (Eastern Mediterranean) Jul. 6–17. Call (800) 745-7545.

20TH ANNUAL CORONARY INTERVENTIONS Oct. 28–30 at the Hilton La Jolla Torrey Pines. Visit www.scripps.org/health-education.

XVII World Congress of Psychiatric Genetics Offers a forum for exchange of the latest scientific data and education for the interested clinician. Nov. 4 at the Manchester Grand Hyatt. Contact (858) 534-3940 or ocme@ucsd.edu.

To submit a community healthcare event for possible publication, email KLewis@SDCMS.org. All events should be physicianfocused and should take place in San Diego County.

Noted

Ask Your

Physician Advocate By Marisol Gonzalez

Medications Purchased Abroad • Designated Civil Surgeon • Flu Vaccine Billing

Your Physician Advocate Has the Answers!

UESTION: Why can’t I recommend a Canadian pharmacy to patients who can’t afford to purchase their medication here in the United States? ANSWER: According to CMA ON-CALL document #0511, “Drug Prescribing: Drugs From Other Countries,” occasionally, U.S. residents purposely travel to other countries to purchase medications (drugs) for personal use. The U.S. Food and Drug Administration (FDA) is concerned that medications purchased abroad may present risks to the user. Medications approved for sale in the United States undergo rigorous testing and review to verify their identity, potency, purity, and stability, and demonstrate that they are safe and effective

for their intended use. Not all countries have approval procedures and manufacturing controls similar to the United States. Due to potential risks, the FDA would like you to know: It can be dangerous to take some medications without medical supervision. The reason why some medications are limited to prescription use in the United States is that either they are unsafe without medical supervision or medical diagnosis is required to assure that the medication is appropriate for your condition. The FDA cannot assure that products not approved for sale in the United States conform with the manufacturing and quality assurance procedures mandated by U.S. laws and regulations. Some medications may be counterfeit versions of U.S.-approved products. Treatment for an adverse drug reaction can be delayed or hindered without sufficient product information. Possession of certain medications without a prescription from a physician licensed in the United States may violate state and local laws. Also, contrary to representations that

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have been made in some advertisements, the personal importation of medications for personal use is not legal. The United States Federal Food, Drug, and Cosmetic Act (21 U.S.C. §§331(d), and 355(a)), which is administered by the FDA, prohibits the interstate shipment (which includes importation) of unapproved new drugs. Unapproved new drugs are drugs, including foreign-made versions of U.S.-

Contrary to representations that have been made in some advertisements, the personal importation of medications for personal use is not legal. approved drugs, that have not received FDA approval to demonstrate they meet the federal requirements for safety and effectiveness. It is the importer’s obligation to demonstrate to the FDA that any drugs offered form importation have been approved by the FDA.

UESTION: I am interested in becoming registered as a designated civil surgeon. What does this entail and how do I go about becoming one? ANSWER: “Designated civil surgeon” is a physician approved by Immigration Services to perform medical exams for people interested in becoming U.S. citizens. The following items need to be submitted to your local district office: • A letter to the district director requesting consideration. • A copy of a current medical license. • A current resume that shows four years of professional experience, not including a residency program. • Proof of U.S. citizenship or lawful status in the United States. • Two signature cards showing name typed and signature below. This information can then be sent to: U.S. Citizenship & Immigration Services Attention: Civil Surgeon Department 880 Front Street, Suite 4251 San Diego, CA 92101

UESTION: With NHIC, I billed the flu vaccine (90658) with the administrative fee of 90471. Palmetto is now denying this combination. Should I be using a different code with the vaccine? ANSWER: Yes. With Palmetto you are no longer required to use the administrative fee of 90471. On the claim, all you would use is the 90658 with the HCPCS code of G0008. 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. Abo u t t h e A u t ho r :

Stat for February:

National Health Spending in 2007 Slower Drug Spending Contributes to Lowest Rate of Overall Growth Since 1998

n 2007, U.S. healthcare spending growth slowed to its lowest rate since 1998, increasing 6.1 percent to $2.2 trillion, or $7,421 per person. The healthcare portion of gross domestic product reached 16.2 percent, up from 16.0 percent in 2006. Slower growth in 2007 was largely attributed to retail prescription drug spending and government administration. With the exception of prescription drugs, most other healthcare services grew at about the same rate as or faster than in 2006. Spending growth from private sources accelerated in 2007 as public spending slowed; however, public spending growth has continued to outpace private sources since 2002. A u t ho r s : Micah Hartman, Anne Martin, Patricia McDonnell, Aaron Catlin — the National Health Expenditure Accounts Team

[Note: See January 2009 Issue of Health Affairs]

Get in Touch Your SDCMS Support Team Is Here to Help! 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

Director of Engagement: Jennipher Ohmstede at (858) 300-2781 or at JOhmstede@SDCMS.org sdcms foundation executive director: Kitty Bailey at (858) 300-2780 or at KBailey@SDCMS.org sdcms foundation associate 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 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

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 he or she may have. Feel free to contact Lauren at (858) 300-2782 or at LWendler@SDCMS.org for help.

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Public Health By Diane Darby Beach, MPH, EdD

Alzheimer’s Disease in San Diego

The Local Chapter of the Alzheimer’s Association Is Available to Help

n estimated 5.2 million people in the United States have Alzheimer’s disease, a number that is expected to grow to 16 million by the year 2050. Specifically, as the “Baby Boomers” age, the incidence of Alzheimer’s disease will proliferate. Alzheimer’s disease is the most prevalent form of dementia in those 65 years of age and older. In fact, one in 10 people over the age of 65 has Alzheimer’s disease, and nearly 50 percent of those age 85 and older are afflicted. In San Diego and Imperial counties, approximately 50,000 are affected by this disease and other forms of dementia. Between 2008 and 2015, this number will increase by 10 percent. Notably, as the Baby Boomers age, this number will grow by 70 percent between 2015 and 2030. Alzheim-

er’s disease is the fourth-leading cause of death among San Diegans. While making an accurate diagnosis has become increasingly straightforward, helping newly diagnosed individuals and their families immediately after the diagnosis is a challenge. As such, the local chapter of the Alzheimer’s Association is available to help. The association offers the following services:

In San Diego and Imperial counties, approximately 50,000 people have the disease. As the first wave of Baby Boomers turn 65, this number will grow dramatically. Helpline: This program is a special-

ized phone support program offered to diagnosed individuals, care partners, and professionals (24 hours a day, seven days a week). This program is staffed by two

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full-time information and referral coordinators; calls are answered at the office between 8 a.m. and 5 p.m. After hours, calls are sent to the national office. The goal of Helpline is to provide information on chapter and community resources and education on Alzheimer’s disease. Callers may be subsequently referred to the Care Consultation program. The 24-hour Helpline can be reached at (800) 272-3900. Care Consultation: A family con-

sultant meets with the family (in office or at home) to discuss their situation in depth, to work with them to prioritize needs, and to problem-solve. The family consultant also informs the family of other chapter programs and community resources and develops a jointly agreed upon care plan. The care plan is then written up and sent to the family. The family consultant follows up two to three weeks following the initial meeting, maintains phone contact as required, and is available for ongoing support. If more direct assistance is necessary, the consultant will refer to outside care management agencies and/or placement services. To speak

with a care consultant, call the Alzheimer’s Association at (858) 492-4400. Support Groups: The Association offers over 30 groups throughout the county. Groups are tailored for adult children, spouses, men, women, diagnosed individuals, and Spanish-speaking individuals and caregivers. These groups meet on a regular basis to discuss ongoing issues in a confidential and supportive environment. A complete schedule can be found at the Alzheimer’s Association website at www.sanalz.org. Community Education: Ongoing

educational workshops are offered for diagnosed individuals and their caregivers throughout the community. These classes are usually two hours in length. Below are descriptions of these courses, with further information, including dates and times, available at www.sanalz.org: Understanding Alzheimer’s Alzheimer’s disease affects more than 360,000 people in our community, those diagnosed, as well as their family, friends, and caregivers. This informational session explains what we know about the disease, the warning signs and symptoms, and how the Alzheimer’s Association can help with programs and services. Family Orientation “Family Orientation” is designed for care partners and family members who are new to the disease. This interactive orientation provides an overview of memory loss and dementia, as well as an opportunity to meet others and to start getting connected with the Alzheimer’s Association. All attendees will receive a free copy of Coach Broyles Caregiver Playbook.

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iving a Brain-healthy Lifestyle L After attending this informative and engaging workshop, participants will be able to identify specific brain-healthy foods, to understand how physical exercise can improve brain health, to learn mentally challenging activities and how they strengthen brain cells, and to recognize the importance of social activities in stimulating mind and body.

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Alzheimer’s Disease Resources Alzheimer’s Association Website: www.sanalz.org Alzheimer’s Association 24-hour Helpline: 1 (800) 272-3900 Alzheimer’s Association Main Office: (858) 492-4400 Physician Guidelines Website:

http://alz.org/san/in_my_community_professionals.asp ulate questions to ask when searching for a facility, and recognize methods to assist in easing the transition to placement.

Memory Matters Memory is a concern for seniors and people of all ages. Although memory problems and loss of mental acuity can often occur in the aging process, a few lifestyle changes can greatly improve memory function. After attending this workshop, participants will be able to identify types of memory, recognize mental changes common with normal aging, learn several memory exercises, and understand strategies for improving memory.

Every 71 seconds, someone in the United States develops Alzheimer’s disease. Addressing Behavior Through Compassionate Communication Upon completion of this program, attendees will be able to articulate tips to

improve their overall communication skills with memory-impaired individuals. They will also be able to identify communication techniques that can play a key role in coping with specific, challenging behaviors such as wandering, shadowing, and agitation. Early Memory Loss: Tools for Successful Living During this workshop, participants will learn about early memory loss and identify ways to enhance daily living by utilizing community resources, maintaining social and family relationships, identifying stress management exercises, eating healthy, and applying new medical research and treatment trends. Making the Placement Decision After attending this workshop, participants will be able to identify some of the emotional issues involved in placement, distinguish among various options for assistance along a continuum of care, artic-

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Professional Education: The Alzheimer’s Association San Diego/Imperial Chapter has a new program available for direct-care staff that includes up-to-date information to empower them to provide the best care possible for residents in longterm care. The training, titled “Foundations of Dementia Care,” includes recommendations for effective dementia care, which are based on person-centered care (care tailored to the abilities and changing needs of each resident). The Alzheimer’s Association has chosen eight priority care areas where intervention can make a significant difference in an individual’s quality of life. The dementia care recommendations define goals for each care area and present strategies for achieving them. The eight areas include: 1. Understanding Dementia 2. Making Connections 3. Reducing Pain 4. Enhancing Mealtimes 5. Preventing Falls 6. Understanding Wandering 7. Encouraging Restraint-free Care 8. Providing End-of-life Care Each topic includes important practice time to instill strategies for success. Continuing Education Units (CEUs) are available for all certified nursing staff, LVNs, RNs, LCSWs, MFTs, and RCFE administrators. Safe Return/Medic-Alert: When a person with dementia wanders or becomes lost, one call immediately activates

a community support network to help reunite the lost person with his or her caregiver. Both the caregiver and the individual with dementia wear a bracelet or necklace with identifying information inscribed. When a person is found, a citizen or law official calls the toll-free, 24-hour emergency response number on the identification product and the individual’s family or caregivers are contacted. The nearest Alzheimer’s Association office provides support during search and rescue efforts. In addition, should medical attention be required, access to a personal health record is immediately available. New enrollment costs $49.95, and the annual renewal fee is $25. To enroll in the program families, can call: 1 (888) 572-8566. To report an incident, the number to call is: 1 (800) 572-1122.

ers turns 65, this number will grow dramatically. As such, the need for supportive services provided by the Alzheimer’s Association will increase considerably. As physicians, you are in a unique position to refer families to these free program. Abo u t t h e A u t ho r : Ms. Beach is the community education manager

for the Alzheimer’s Association. Having worked for the past 20 years in the areas of health promotion and Alzheimer’s disease, she has presented her work at several different national and international conferences and been published in The Gerontologist, The Hospice Journal, The Journal of Gerontological Nursing, and elsewhere. She is also an adjunct professor in the gerontology program at SDSU.

One in 10 people over the age of 65 has Alzheimer’s disease, and nearly 50 percent of those age 85 and older are afflicted. Half-day Programs: The associa-

tion offers yearly, half-day intensive programs focusing on a specific topic. Prior topics include: coping with early memory loss; communicating with the person with Alzheimer’s disease; and legal and financial planning. The upcoming halfday intensive is titled: “Make Your Voice Heard: Early Stage Town Hall Meeting.” This program is the first ever local, open forum for people with early memory loss, Alzheimer’s disease, and other dementias. The program will be held on February 21, 2009, at the University of San Diego. More information can be obtained by calling the Alzheimer’s Association at (858) 492-4400 or by accessing the association’s website at www.sanalz.org.

Summary: Every 71 seconds, someone

in the United States develops Alzheimer’s disease. In San Diego and Imperial counties, approximately 50,000 people have the disease. As the first wave of Baby Boom-

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Emergency Preparedness By James Beaubeaux

Had this Been an actual

Emergency November 13, 2008 “Golden Guardian”

t 10:00 a.m. on Thursday, November 13, 2008, a simulated earthquake, 7.8 on the Richter scale, centered on the southern portion of the San Andreas Fault, shook Southern California. “Golden Guardian,” a statewide California disaster scenario, tested the response capabilities of state, county, and city governmental agencies as well as healthcare representatives. The San Diego County Medical Operations Center (MOC) is where the entire county’s medical needs are coordinated during a disaster. The seats at the MOC are filled by representatives from: • County of San Diego Emergency Medical Services • Hospital Association of San Diego and Imperial Counties • San Diego County Medical Society • San Diego County Public Information Officers

Triage during the Nov. 13, 2008, “Golden Guardian,” a statewide California disaster scenario

• Others, Including Fire and Police Departments SDCMS’ specific role at the MOC involves collecting physician volunteer information and communicating physician availability to the MOC leadership. SDCMS is in a unique position to assist in deploying physicians during a ma-

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jor catastrophic event. The county must, by law, only deploy physicians who are licensed to practice medicine in the state of California. Physicians who “self-deploy” at a shelter or temporary clinic may be turned away due to the liability they place on themselves and on those running the shelter.

During an actual medical emergency, SDCMS will announce — via email, fax, media, etc. — a call for physician volunteers. When a physician without a San Diego County Medical Reserve Corps (MRC) volunteer history wants to help by responding to a current disaster with

IMPORTANT: To volunteer during an actual disaster, call Tom Gehring, CEO of the San Diego County Medical Society, at (619) 206-8282 (cell phone) or at (858) 5658888 (SDCMS offices). ankford_SDP_08:Layout 1 10/27/08 1:22 PM real medical emergencies, they should contact SDCMS. Under an agreement with the County of San Diego, SDCMS is the source for physician volunteers when the need for doctors is greater than

the number of pre-registered MRC physician volunteers. Physicians vetted by SDCMS are placed into the MOC system and require only a proof of identification when they are deployed to the location where they are needed. While notifying SDCMS about your desire to volunteer during a disaster does not guarantee you will be activated, it is the best way to guarantee that if you are needed, the correct people will know of your availability. IMPORTANT: To volunteer during an actual disaster, call Tom Gehring, CEO of the San Diego County Medical Society, at (619) 206-8282 (cell phone) Page 1 or at (858) 565-8888 (SDCMS offices). Tom will take your name, verify your license, and notify the MOC that you are vetted and willing to volunteer. SDCMS encourages those who would like to volunteer before an actual disaster to take 15–20 minutes today and reg-

ister as a California Medical Volunteer for San Diego County at https://medicalvolunteer.ca.gov (Note: For a speedy registration, have available your licenses and certifications before you begin). Do you want to get more involved? Then join the San Diego County Medical Reserve Corps (MRC) by checking the box for MRC during your registration process. Please visit the MRC website at www.sandiegomrc.org to learn more about taking a more active role in your community as a disaster medical volunteer team member. You may also contact Melissa Dredge, MRC volunteer coordinator, at (619) 641-5015 or by email at mrcvolcoord@sdcounty.ca.gov. Abo u t t h e A u t ho r : Mr. Beaubeaux is chief operations officer and chief financial officer of the San Diego County Medical Society.

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Healthcare Reform By Shannon Brownlee and Ezekiel Emanuel

Myths

About Our Ailing Healthcare System

Editor’s Note: In this time of healthcare reform, San Diego Physician magazine will publish occasional articles that carry a diversity of opinions and proposals, which should not be viewed as representing official SDCMS policy.

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With Congress ready to spend $700 billion to prop up the U.S. economy, enacting healthcare reform may seem about as likely as the Dow hitting 10,000 again before the end of the year. But it may be more doable than you think, provided we dispel a few myths about how healthcare works and how much reform Americans are willing to stomach.

America has the best healthcare in the world

Let’s bury this one once and for all. The United States is number one in only one sense: the amount we shell out for healthcare. We have the most expensive system in the world per capita, but we lag behind many developed countries on virtually every health statistic you can name. Life expectancy at birth? We rank near the bottom of countries in the Organization for Economic Cooperation and Development, just ahead of Cuba and way behind Japan, France, Italy, Sweden, and Canada, countries whose governments (gasp!) pay for the lion’s share of healthcare. Infant mortality in the United States is 6.8 per 1,000 births, more than twice as high as in Japan, Norway, and Sweden and worse than in Poland and Hungary. We’re doing a better job than most on reducing smoking rates, but our obesity epidemic is out of control, our death rate from prostate cancer is only slightly lower than the United Kingdom’s, and in at least one study, American heart attack patients did no better than Swedish patients, even though the Americans got twice as many high-tech treatments. Moreover, the quality of healthcare is different in different parts of the country. The Centers for Medicare and Medicaid Services have issued a list of 26 measures of quality, such as making sure that heart-attack patients being discharged from the hospital get a prescription for a beta blocker or aspirin to help reduce the risk of a second attack. It turns out that quality is all over the map, and it isn’t necessarily better in the places we might

expect, such as academic medical centers. Worse still, according to the Congressional Budget Office (CBO), there appears to be no connection between how much Medicare and other payers spend on patients in different parts of the country and the quality of the care the patients receive. You are no more likely to get that beta blocker or aspirin in Los Angeles than in Portland, even though Medicare spends twice as much per beneficiary in Los Angeles.

Somebody else is paying for your health insurance

Nope. Even when your employer offers coverage, he isn’t reaching into his own pocket to cover you and your fellow employees; he’s reaching into your pocket, paying you lower wages than he would if he didn’t have to pay for your health insurance. Rising healthcare costs are partly to blame for stagnant wages. Over the past five years, health insurance premiums have risen 5.5 times faster on average than inflation, 2.3 times faster than business income, and four times faster than workers’ earnings. Four times. That’s why wages have been nearly flat since the 1980s, even as U.S. productivity has been going up. In effect, about half the money you should be earning for being more productive is being sucked up by ever more expensive healthinsurance premiums. If you pay taxes, you’re also paying for the healthcare provided through state and federal programs such as Medicare, Medicaid, the Veterans Administration, and the military. All told, the average family of four is coughing up $29,000 a year for

healthcare through taxes, lower wages, and out-of-pocket medical expenses.

We would save a lot if we could cut the administrative waste of private insurance

The idea that we could wring billions of dollars in savings this way is seductive, but it wouldn’t really accomplish that much. For one thing, some administrative costs are not only necessary but beneficial. Following heart attack or cancer patients to see which interventions work best is an administrative cost, but it’s also invaluable if you want to improve care. Tracking the rate of heart attacks from drugs such as Avandia is key to ensuring safe pharmaceuticals. Let’s just say that we could wave a magic wand and cut private insurers’ overhead by half, to what the Canadian government spends on administering its healthcare system — 15 percent. How much would we save? Not as much as you may think. Private insurers pay a little more than a third of what we spend on healthcare, which means that we’d cut a little more than 5 percent from our total budget, or about $124 billion. That’s not peanuts, but it’s not even enough to cover everybody who’s currently uninsured. More to the point, we only get to save it once. That’s because administrative waste isn’t what’s driving healthcare costs up faster than inflation. Most of the relentless rise can be attributed to the expansion of hospitals and other healthcare sectors and the rapid adoption of expensive new technologies: new drugs, devices, tests, and procedures. Unfortu-

Note: This article reprinted with permission from the authors. Originally published in The Washington Post, November 23, 2008.

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nately, only a fraction of all that new stuff offers dramatically better outcomes. If we’re worried about costs, we have to ask whether a $55,000 drug that prolongs the lives of lung cancer patients for an average of a few weeks is really worth it. Unless we find a cure for our addiction to the new-but-not-necessarily-improved, our national medical bill will continue to skyrocket, regardless of how efficient insurance companies become.

Healthcare reform is going to cost a bundle

Only if you think that covering the uninsured is our only priority. Yes, making healthcare available to all citizens is the right thing to do. But it isn’t the only thing to do. We also have to fix the spectacularly wasteful and expensive way doctors and hospitals deliver care. Our physicians are working within a truly dysfunctional, often chaotic system that prevents them from caring for us properly. Between 50,000 and 100,000 patients die each year from preventable medical errors. According to the Centers for Disease Control, 1.7 million Americans acquire an infection while in the hospital and nearly 100,000 of them die from it. Laboratory imaging tests are routinely repeated because the originals can’t be found. Patients with such chronic illnesses as heart failure and diabetes land in the hospital because their physicians fail to monitor their condition. When patients have multiple doctors, there’s often nobody keeping track of the different medications, tests, and treatments each one prescribes. Our doctors and hospitals are failing to provide us with care we need while delivering a staggering amount that we don’t need. Current estimates suggest that as much as 20 to 30 percent of what we spend, or about $500 billion, goes toward useless, potentially harmful care. There are two bright spots. One: We can improve the quality of care and cut costs without rationing. There are models out there for how to do it right — the Mayo Clinic, the Geisinger Clinic in Pennsylvania, the Cleveland Clinic, and California’s Kaiser Permanente are just a

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few of the organized group practices that domestic product, healthcare is the bigare doing a better job for less. Their docgest single sector of the economy, and it’s 1 8/22/08 3:52 PMproportion Page 1 tors are better than average AKT_SDP_08:Layout at using the consuming a larger and larger best medical evidence available. They’re every year. According to CBO projections, more likely to be using electronic medihealthcare will account for 25 percent of cal records, which can help keep track GDP by 2025 and 49 percent by 2082. of patients who have multiple physicians That’s simply unsustainable. Any plan that and need complex care. And they’re less reforms healthcare has to do more than likely to provide unnecessary care. simply cover the uninsured. The nation’s health and wealth depend on it.

About the Authors: Ms. Brownlee, a visiting scholar at the National Institutes of Health Clinical Center, is the author of Overtreated. Mr. Emanuel, an oncologist and author of Healthcare, Guaranteed, is chairman of the center’s Department of Bioethics. The views expressed here are the authors’ own.

At 17 percent of gross domestic product, healthcare is the biggest single sector of the economy, and it’s consuming a larger and larger proportion every year. According to CBO projections, healthcare will account for 25 percent of GDP by 2025 and 49 percent by 2082. That’s simply unsustainable.

Two: Even moderate reform of the delivery system would improve care and save money. The Lewin Group’s analysis shows that a bill proposed by Sen. Ron Wyden, an Oregon Democrat, calling for a more comprehensive overhaul of the healthcare system than either McCain’s plan or Obama’s could actually insure everyone and save $1.4 trillion over 10 years. More reform is cheaper.

Americans aren’t ready for a major overhaul of the healthcare system

We may be readier than you think. A recent study published in the New England Journal of Medicine found that only 7 percent of Americans rate our healthcare system excellent. Nearly 40 percent consider it poor. A whopping 70 percent believe it needs major changes, if not a complete overhaul. Now is not the time to think small, to cover a few million Americans, and leave the bigger job of controlling costs and improving quality for another day. We can’t afford not to reform the delivery system as soon as possible. At 17 percent of gross

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Healthcare Coverage

for Children

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Universal H e a lt h I n s u r a n c e C o v e r a g e

n e r d l i h for C

An Incremental Approach Is Most Likely By Leonard Kornreich, MD The implementation of universal health insurance coverage for children is a near certainty within the next five years. This worthy goal is supported by the public, legislators at all levels of government, and the administration. It is a major goal of the California Medical Association (CMA), the American Medical Association (AMA), and the American Association of Pediatrics (AAP). The exact form the coverage takes will depend on affordability and the practical logistics of so massive a program. An incremental approach is most likely. San Diego is uniquely situated for a rapid startup of such an undertaking because of a uniquely unified and comprehensive pediatric healthcare delivery system. Three large medical providers account for more than half of the care provided to the 800,000 0 to 17-yearold children in San Diego County: the community clinics, Children’s Primary Care Medical Group, and the Permanente Medical Group. An additional 25 percent of pediatric care is delivered by several other large groups, including Sharp Rees-Stealy, Scripps-affiliated groups, UCSD pediatric group, the Navy Healthcare, Center for Health Care, El Camino Pediatrics, and others. The remaining pediatric care occurs in many fine, small pediatric and family medicine offices. Additionally, many small groups contract for capitated patients though Children’s Physicians Medical Group.

The community has one central pediatric hospital, Rady Children’s Hospital, which delivers 80 percent of pediatric inpatient care. This cohesive system, which includes many safety net and traditional Medi-Cal providers, should ease implementation of any expanded system. There do exist some major impediments to extending insured care to the uninsured. Of the 800,000 children, 240,000 are enrolled in Medi-Cal or Healthy Families. Approximately 75,000 children are uninsured, and, of those, at least 40,000 are eligible for Medi-Cal or Healthy Families. The remainder are members of uninsured working families and a small number of undocumented children. Although San Diego County has a superb healthcare safety net for children, it is near the breaking point because of severe underfunding at all levels. Imposition of additional underinsured children on financially overburdened providers would be untenable. Several modifications must be made to fix current deficiencies in the system before physicians, clinics, and hospitals could take on additional underfunded patients. Reimbursement for FFS medical patients must be adjusted to a minimum of 100 percent of Medicare rates (instead of currently less than 60 percent). Managed Care Medi-Cal and Healthy Families reimbursement should involve significant reimbursement above Medicare rates since access to comprehensive primary and specialty care is assured in an office setting and case management improves overall health status and decreases excess utilization. Private health insurance must be maintained, and under no circumstances may rates for a new program for

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the currently uninsured impact the right of providers to contract for reasonable fees within the private health insurance sector. There must be a marked increase in other needed children’s services, including mental health, dental health, and ancillary and social services for children. The likely scenario for health insurance for the uninsured will include a significant increase in Healthy Families and Medi-Cal in addition to a modest increase in private insurance. Do we have the physician manpower committed to serving the underinsured? Of the 350 primary care pediatricians practicing in San Diego, only about 60 percent would be considered traditional safety net or traditional providers (greater than 250 underfunded government program primary care patients served). If universal health insurance coverage is to have a realistic chance for success, all physicians should commit to caring for these children provided that reimbursements are markedly improved and needed support services enhanced. Universal health coverage for children is coming, and San Diego could be a national model for efficient, effective, and equitable care for our children, our future. Abo u t t h e A u t ho r : Dr. Kornreich has practiced pediatrics in Chula Vista since 1974 and is president emeritus of Children’s Primary Care Medical Group. He is a past president of SDCMS and a former chief of staff at Scripps Chula Vista and Rady Children’s Hospital. He currently serves as co-chair of the Healthy San Diego Professional Advisory Board.

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Healthcare Coverage

for Children

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Insurance for Children A Proposal By Joel A. Harrison, PhD, MPH CHildren are among the most vulnerable of our citizens. They will supply the work and creativity that will drive this nation into the future. We especially need to be good to them since they will choose our nursing homes. Despite their parents’ strengths or failings, children cannot be blamed nor can responsibility for healthcare fall on their fragile shoulders. So how do we provide them with cost-effective, quality care? The adoption of universal health insurance would obviously ensure that all children would receive the highest quality, cost-effective, and timely healthcare. However, while awaiting the adoption of a truly universal health insurance program, I suggest all children be covered by Medicare until their 19th birthday (this allows those who graduate from high school during their 18th year to have insurance while seeking employment). Those continuing their educations could continue coverage up to an additional four years at a modest cost, perhaps $100–$200 per half year. Current student health policies often pay out less than 40 cents on the dollar (an outrageous loss-ratio) and cap lifetime maximum coverage far below the rare but devastating health conditions that

and individual policies would be less excould befall a college-age student. Those pensive. with permanent disabilities or “uninsurA separate maternal and child diviable” chronic conditions already in the sion of Medicare would be established. suggested child Medicare program would For this division, there would be no decontinue coverage for life. In addition, all ductibles or co-pays in order to ensure all maternity care, prenatal care, and delivery receive the same quality of care and to would be covered by Medicare. avoid adding a cumbersome, costly buMedicaid programs vary from state to reaucracy to deal with those who can’t afstate and, as entitlement programs, are ford them. All federal monies now going often subject to budget cuts and complito states for children and obstetric care cated enrollment requirements. Because will be earmarked for Medicare. Children of low fee schedules, many doctors refuse on Medicaid cost less than one-fifth the care to Medicaid patients, resulting in many women not receiving proper prenatal care or deliveries. If the goal is to ensure By continuing coverage of children the health of the child, this from the Medicare program with begins with prenatal care. serious pre-existing conditions, we Those with insurance would continue coverage for all othincrease their opportunities to er medical problems, except become productive, employed those involving maternity members of our communities. care. Medicare would be reFor others, we ensure a level of care quired by law to establish fee schedules based on those althat maintains the best quality of ready existing, ensuring that life possible for them. all expectant mothers and children would have access to quality care. Parents would choose cost of Medicare recipients. The current Medicare tax of 2.9 percent on wages the child’s physicians and the expectant could be raised to, perhaps, 3.9 percent, mother’s obstetrician. Physicians, espewhich together with federal Medicaid cially pediatricians, family physicians, and obstetricians, would have simplified funds being rolled in should be more billing. With children and maternity than adequate. The monies saved by the care removed, employer-based insurance states’ Medicaid funds for children and

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obstetrics could be used to extend coverage to lower-income adults currently earning above state thresholds. Since, years ago, insurance companies and employers fought against mandating maternity care, they should easily accept this change. Many small companies offering health insurance to their employees can’t afford the rate increases that hiring

Giving every child in America the best of care that we have to offer is the least we can do to give them a fighting chance. someone with a costly disability and/or chronic condition would incur. Of course, those already insured by the private sector and who develop chronic conditions should retain their private coverage! By continuing coverage of children from the

Medicare program with serious preexisting conditions, we increase their opportunities to become productive, employed members of our communities. For others, we ensure a level of care that maintains the best quality of life possible for them. By extending Medicare, we would ensure quality medical care to the most vulnerable in our society, to those whom private insurance companies least desire to cover and whom small employers cannot afford to. The lowered premiums for employerbased care would allow many employers who dropped coverage to once again offer it. For this to work, Congress must redesign the Medicare Drug Benefit Program. The pharmaceutical industry over the past several decades has made average net profits of three times all other Fortune 500 companies. The legislation prohibited Medicare from bargaining for drug prices, something the VA, the military, Medicaid, and all private plans are allowed

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to do. Bargaining for prices comparable to those of others will ensure decent profits for the pharmaceutical companies, get rid of the absurd donut hole, and allow for complete coverage for children, pregnant women, those with disabilities and/ or chronic conditions, and our seniors. In fact, covering this large group will ensure reasonable profits for the drug industry. Children, senior citizens, and the disabled and/or chronically ill are among the most vulnerable in our society. In many cases, private insurance either will not cover them or does so reluctantly. Children are our future, regardless of their parent’s ability to provide insurance; guaranteeing them decent healthcare increases the probability they will become productive members of society. America is considered the land of opportunity. Health problems obviously diminish one’s ability to take advantage of this. Giving every child in America the best of care that we have to offer is the least we can do to give them a fighting chance. Providing coverage for those with disabilities and/or chronic illnesses is one of the hallmarks of a compassionate society and for some will allow them to join the workforce. This program will only continue coverage for those who were disabled/chronically ill as children in the program. Insurance companies are known for cherry-picking, i.e., avoiding those already ill. Employer-based premiums would be reduced so that more employers could offer health insurance. If the goal is the most cost-effective, equitable quality of care for the recipients, this proposal should merit serious consideration. Abo u t t h e A u t ho r : Mr. Harrison, a native San Diegan, does consulting in epidemiology and research design. He has worked in the areas of preventive medicine, infectious diseases, medical outcomes research, and evidence-based clinical practice guidelines. He has lived and studied in both Canada and Sweden.

Prescription for

A Comprehensive, Countywide Database of Programs and Services By 211 San Diego Pediatric healthcare providers in San Diego County have a new tool in their fight against childhood obesity: a comprehensive, countywide database of programs and services that address the various aspects of obesity, including diabetes, nutrition, physical activity, and healthy weight. The database, housed at 211 San Diego, allows free access to information about everything from clinical programs and interventions, diabetes and nutrition education, and neighborhood parks, to recreation programs and services. 211 has become known as San Diego’s primary source for free community and disaster information. It gained visibility in the 2007 firestorms and now plays a much wider role as a community information hub. Accessible either by dialing 2-1-1 or at www.211sandiego.org, the organization provides free, confidential, multilingual, 24-hour access to community, health, and disaster services and resources. “We heard healthcare providers’ frustration with a lack of centralized resources,” said Cheryl Moder, director of the San Diego County Childhood Obesity Initiative. “So one of our major initiatives has been to develop this database and make it userfriendly and available to both professionals and the public.” Addressing the child obesity epidemic in our community requires a comprehensive and collaborative approach with a focus on environmental changes to support healthy lifestyle choices. The initiative joined with the Center for Healthier Communities at

Obesity

Rady Children’s Hospital; San Diego Diabetes Coalition; Champions for Change/ Network for Healthy California; and 211 San Diego to get started. Enhancing the 211 database involved widespread networking to determine who is offering relevant programs; distribution of surveys; data collection and compilation; hiring and training call resource specialists; and actually constructing the website that is dedicated to this project. To access the diabetes and obesity prevention program database via the Internet, go to www.211sandiego.org and click on the green apple icon. It is searchable by ZIP code, program type, language, and area. For example, families can be referred to locate a local swimming pool or recreational park, a diabetes educator or a breastfeeding course, within a few miles from their home. Each program has an “agency overview” page that highlights the location of the program (along with a map link), contact information, services offered, and how to access the services. Although all relevant programs are included, low- and no-cost programs related to the categories of nutrition, physical activity, diabetes education, and healthy weight are highlighted. Targeted populations will include children, people with diabetes, and higher-risk populations and regions of San Diego County. New programs will be added regularly. Prescription pads have been developed to assist healthcare providers in linking the families they serve with the programs they need. “For many patients, something the doctor or nurse gives them in writing, especially on a prescription form, takes on greater importance than something the clinician says,” commented Danette Flores, MPH, project coordinator. “Giving them a writ-

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ten prescription for the type of activity or program they need ensures a higher degree of compliance.” Rx pads were mailed to offices earlier this year, accompanied by an explanatory letter and a complimentary BMI wheel to further physicians’ efforts. If you have questions, need more information or an Rx pad refill, or know of programs that should be added to the database, contact Danette Flores, project coordinator with Rady Children’s Hospital San Diego, at (858) 576-1700, ext. 3783, or at dmflores@rchsd.org. This project was made possible by a grant from the Vitamin Cases Consumer Settlement Fund.

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Healthcare Coverage

for Children

New Report and Other Resources Examine Trends In

Children’s Health Coverage Including Changes in State Eligibility and Enrollment Requirements By The Kaiser Family Foundation With Congress poised to reauthorize the State Children’s Health Insurance Program (SCHIP) with a substantial increase in its federal funding, there are potentially new opportunities for reducing the estimated 9 million uninsured children nationwide. At the same time, the nation’s weak economy and growing unemployment have many

more families and children turning to Medicaid and SCHIP for health coverage. To examine the implications of these developments, the Kaiser Family Foundation’s Commission on Medicaid and the Uninsured (KCMU) on January 23, 2009, held a policy briefing on trends in health coverage for children and parents and implications for the future. As part of the briefing, the Foundation released its eighth annual 50-state survey of eligibility rules, enrollment and renewal procedures, and cost-sharing practices in Medicaid and SCHIP for children and families. The report finds that state efforts to expand cov-

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erage to children slowed in state fiscal year 2008 amid uncertainty around SCHIP’s future funding, as Congress and the Bush Administration failed to agree on reauthorization of the program as states experienced the early stages of budget crunches triggered by the nation’s recession. In addition, the Foundation also released two new issue briefs based on the Kaiser Survey of Children’s Health Coverage, a telephone survey of parents conducted in 2007 to learn more about children’s access to coverage and care and the healthcare cost-related pressures facing their families. The first provides key findings from the survey, includ-

ing that many low- and middle-income working families with an uninsured child do not have access to employersponsored health insurance. The other examines health insurance coverage for low-income citizen children whose parents are not citizens and some of the specific barriers to enrolling these children in Medicaid and SCHIP. In addition to the new reports, the Foundation also has updated several related resources: • an interactive timeline that presents enrollment and major policy developments in children’s health coverage in public programs over the past 40-plus years; • an updated chartbook on health insurance coverage of America’s children, which shows how health coverage varies by income and other key demographic breakdowns; and • a fact sheet on efforts to enroll lowincome children in Medicaid and SCHIP. The January 23, 2009, briefing featured report highlights from authors Julia Paradise and Caryn Marks of Kaiser, and Donna Cohen Ross of the Center on Budget and Policy Priorities; as well as comments from Dr. Jay Berkelhamer, past president of the American Academy of Pediatrics and chair of the Academy’s Access Committee; John G. Folkemer, deputy secretary, Health Care Financing, Maryland Department of Health and Mental Hygiene; and Susan Johnson, director, King County Health Action Plan. A webcast of the briefing, moderated by Diane Rowland, executive vice president of the Kaiser Family Foundation and executive director of the KCMU, is also available. For further information, see below or visit http:// www.kff.org/medicaid/kcmu012309pkg.cfm. Abo u t t h e A u t ho r : The Kaiser Family Foundation is a nonprofit private operating foundation, based in Menlo Park, California, dedicated to producing and communicating the best possible information, research, and analysis on health issues.

New Resources from the Kaiser Family Foundation Challenges of Providing Health Coverage for Children and Parents in a Recession: A 50-state Update on Eligibility Rules, Enrollment and Renewal Procedures, and Cost-Sharing Practices in Medicaid and SCHIP in 2009 Overall, more than one-third of the states (19 states) took steps last year to increase access to health coverage for low-income children, pregnant women, and parents, including 15 states that authorized or implemented coverage expansions. At the same time, 10 states enacted at least one measure to restrict access. The report also examines trends in parental coverage and state outreach efforts, including the use of technology to facilitate enrollment. Visit http://www.kff. org/medicaid/7855.cfm. Next Steps in Covering Uninsured Children: Findings from the Kaiser Survey of Children’s Health Coverage This issue brief provides key findings from the Kaiser Survey of Children’s Health Coverage, including that many low- and middle-income working families with an uninsured child do not have access to employersponsored health insurance. The telephone survey of parents that was conducted in 2007 to learn more about children’s access to coverage and care and the healthcare cost-related pressures facing their families. Visit http://www.kff.org/ uninsured/7844.cfm. Covering Uninsured Children: Reaching and Enrolling Citizen Children With Noncitizen Parents This issue brief examines health

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insurance coverage for lowincome citizen children whose parents are not citizens and some of the specific barriers to enrolling these children in Medicaid and the State Children’s Health Insurance Program. It is based on findings from the Kaiser Survey of Children’s Health Coverage, a telephone survey of parents conducted in 2007 to learn more about children’s access to coverage and care and the healthcare costrelated pressures facing their families. Visit http://www.kff.org/ uninsured/7845.cfm Health Insurance Coverage of America’s Children This chartbook provides fundamental facts about children’s health insurance coverage. Visit http://www.kff. org/uninsured/7609.cfm. Enrolling Uninsured Low-Income Children in Medicaid and SCHIP This fact sheet outlines issues in outreach and enrollment for Medicaid and SCHIP. It provides a profile of eligible but uninsured children, discusses the greatest barriers to enrollment, and offers strategies to improve enrollment. Visit http://www.kff. org/medicaid/2177.cfm. Children’s Health Insurance Timeline This interactive timeline presents enrollment and major policy developments in health insurance coverage for children in public programs during the last 40-plus years. As major developments occur, the timeline will be updated. Visit http://www. kff.org/medicaid/childrenshealth_ timeline.cfm.

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More Than Two Million Children With Insured Parents Are

Uninsured Most Are Low or Middle Income By U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality (AHRQ)

Children from low-income families where at least one parent had health insurance were more than twice as likely to be uninsured at some point during the year as were similar children from high-income families.

Some 2.3 million children a year, mostly from low- to middle-income families, have no healthcare coverage to pay for preventive or other medical needs, even though at least one of their parents is insured, according to a study supported by HHS’ Agency for Healthcare Research and Quality (AHRQ) and the National Center for Research Resources, part of HHS’ National Institutes of Health. The new study, published in the October 22-29, 2008, online issue of JAMA, is one of the first to examine the characteristics of uninsured children under age 19 whose parents were insured all year. These children account for a quarter of the estimated nine million uninsured children in the United States. Researchers studied 2002–05 national data from AHRQ’s Medical Expenditure Panel Survey and found that children from low-income families where at least one parent had health insurance were more than twice as likely to be uninsured at some point during the year as were similar children from high-income families. They were also 73 percent more likely to be uninsured for more than six months. In 2005, a typical, low-income family of four earned between roughly $24,000 and $39,000, whereas the typi-

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cal high-income family of four earned more than $77,000 a year. Children from middle-income families — those earning between $39,000 and $77,000 a year for a typical fourmember family — had a 48 percent greater chance of being uninsured with at least one insured parent at some point during the year compared with highincome children and had a 56 percent higher likelihood of being uninsured for over six months. The researchers also found that: • Children living with an insured single parent had two times the odds of being uninsured at any point during the year as children living with two married people of whom at least one was insured and more than twice the odds of having a coverage gap lasting six months or more.

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17.1

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■ children (ages 0-17)

0 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Percent of population group uninsured Project4:Layout 1

• Children with at least one parent who did not complete high school were 44 percent more likely than children whose parent or parents were high school graduates to be uninsured at any point during the year, and they had 87 percent greater odds of being uninsured for more than six months. • Hispanic children had a 65 percent higher probability than non-Hispanic, white children of being uninsured at some point during the year with an insured parent and an 80 percent greater chance of being uninsured for more than six months. • Children whose parents had Medicaid or other public insurance were 54 percent less likely to be uninsured at any point during the year than children with privately insured parents and 59 percent less likely to be uninsured for more than six months. • Children living in the South and those in the West had 70 percent and 52 percent greater odds, respectively, of being uninsured at some point during a year with a parent covered all year, compared to children living in the Northeast. They also had an 83 percent and 49 percent greater likelihood, respectively, of being uninsured for more than six months.

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✚

MediKids Health Coverage for Every Infant, Child, Adolescent, and Young Adult By The American Academy of Pediatrics

Health Insurance Act The Problem:

Too Many Children Are Uninsured Although Medicaid and the State Children’s Health Insurance Program (SCHIP) have helped reduce the number of uninsured low-income children by one-third over the last decade, there are still too many children in this country who are uninsured. Currently, more than 9 million children and adolescents lack basic healthcare coverage, accounting for nearly one-fifth of the nation’s uninsured population. While approximately 6 million of these children are eligible for Medicaid and SCHIP, there is growing concern that we might never

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achieve healthcare for every child and adolescent in the United States with existing cost containment and healthcare programs. Uninsured children are vulnerable to long-term effects of not receiving preventive health services. Compared to insured children, uninsured children: • are more likely to be hospitalized for conditions that could have been treated by a primary care doctor; • are up to six times more likely to have gone without needed medical, dental, or other healthcare; • are two times more likely to have

gone without a physician visit during the previous year; • are up to four times more likely to have received delayed care because their parents were worried about the cost of treatment; • are up to 10 times less likely to have a regular source of care. Even though children are the least expensive segment of the population to insure, 9 million children continue to go without health insurance. Without preventive care, uninsured children are much more susceptible to communicable and other illnesses and, once sick, are barred from finding insurance to pay for their care. These children often get their care too late and end up being seen in emergency rooms or hospital clinics, thus driving up overall health costs.

Last Major Action: • S 2522 was introduced December 19, 2007. The bill was referred to the Senate Finance Committee. The bill currently has two cosponsors. • HR 2357 was introduced May 17, 2007. The bill was referred to the House Energy and Commerce Subcommittee on Health. The bill currently has 31 cosponsors.

The MediKids Health Insurance Act represents the American Academy of Pediatrics’ gold standard for access to care for all children.

The solution:

The MediKids Health Insurance Act There is no better investment than preventing health problems and promoting healthy development of the nation’s children. Studies have shown that preventive care early in life is imperative to developmental and educational success. The MediKids Health Insurance Act would create a streamlined and comprehensive system that would achieve the American Academy of Pediatrics’ goal of health insurance for all children regardless of family income. With health reform a major concern for many families, the time is right to make the health and well-being of America’s children a national priority.

overview:

The MediKids Health Insurance Act History: Medikids was first introduced in 2000 in the 106th Congress. Senator John D. Rockefeller (D-WV) and Representative Pete Stark (D-CA) have served as the champions of the legislation and have reintroduced the legislation in the Senate and House of Representatives in the past four Congresses. Both the Senate bill (S 2522) and the House companion bill (HR 2357) have been referred to their committees.

The Details — Enrollment: • Automatic enrollment into MediKids at birth for every child born after December 31, 2008. • Five-year enrollment phase-in for all other children through age 22. • Phase-in Schedule Year 1: All children through age 5. Year 2: All children through age 10. Year 3: All children through age 15. Year 4: All children through age 20. Year 5: All children through age 22.

• Once enrolled, children will remain enrolled in the program until they reach the age of 23. Choice of Coverage: • Private commercial insurance will be maintained. Parents can decline MediKids and keep their children in private insurance or government programs such as Medicaid or SCHIP. • During periods of equivalent coverage by other sources, there will be no premium charged for MediKids given the individual demonstrates to the satisfaction of the secretary that the individual has basic health insurance coverage for that month. • During any lapse in other insurance coverage, MediKids will automatically cover child health insurance needs.

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Affordability: • Families with incomes below 150 percent of the federal poverty level (FPL) would not have to pay a premium or out-of-pocket expenses. • Premiums for families with incomes between 150 and 300 percent of the FPL would be based on a sliding scale according to income and capped at 5 percent of income. • Guaranteed refundable tax credit for cost sharing. Benefits: • Based on Medicare and Medicaid Early Periodic Screening, Diagnosis, and Treatment (EPSDT) benefits for children. • EPSDT is the child health component of Medicaid. It’s required in every state and is designed to improve the health of low-income children by financing appropriate and necessary pediatric services. The Deficit Reduction Act (DRA) of 2005 (P.L. 109-171) now provides states with the authority to fundamentally redefine the meaning of Medicaid coverage for beneficiaries, including low-income children covered through EPSDT, thus limiting the scope of EPSDT and consequently the benefits available to children. • Prescription drug benefit. • The secretary of Health and Human Services shall further develop ageappropriate benefits as needed. • The secretary shall include provisions for annual reviews and updates to the benefits, with input from the pediatric community.

Abo u t t h e A u t ho r : The American Academy of Pediatrics is an organization of 60,000 primary care pediatricians, pediatric medical subspecialists, and pediatric surgical specialists dedicated to the health, safety, and well-being of infants, children, adolescents, and young adults.

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

Pulse The

Uninsured San Diegans Receive

Project Access San Diego Teams Up With Kaiser Permanente San Diego to Care for 19 Uninsured Patients

n December 6, 2008, 19 uninsured and underserved patients received life-changing surgical procedures through an innovative partnership between the San Diego County Medical Society Foundation (SDCMSF) and Kaiser Permanente. Many Surgery Day patients had been living with pain and debilitating conditions for years. They would not otherwise have been able to afford the procedures,

Free Surgeries

which will now enable them to return to work and provide for their families. One patient who needed a double hernia surgery, and is the sole provider for his family, was working through the pain and had started going to work at 4:30 a.m. instead of 6 a.m. to have enough time to get his work done through the pain. Another patient who needed cataract surgery is excited to be able to resume volunteering at her church’s administrative office and is now able to take on more responsibilities at work. The surgeries were possible through the generosity of more than 100 medical and nonmedical volunteers who took a Saturday to open up the Kaiser Permanente Otay Mesa Surgery Center and perform these procedures. One surgeon noted that he felt good that this was an opportunity to provide free medical care to people in his own backyard, instead of going overseas.

Project Access San Diego (PASD), a project of SDCMSF, screened patients for eligibility and helped them navigate the system of pre-op procedures, out-

The surgeries were possible through the generosity of more than 100 medical and nonmedical volunteers. patient surgery, and post-op care. For more information about SDCMSF and PASD, please contact Kitty Bailey, SDCMSF executive director, at (858) 3002780 or at KBailey@SDCMS.org. Abo u t t h e A u t ho r : Dr. Young is president of the San Diego County Medical Society Foundation.

By Carol Young, MD

Photos courtesy of Maura Leonard Photography

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5 1 PASD patient Lenora excited coming out of surgery. She knows that she will be able to take on more responsibility at her job and gain more independence. 2 PASD volunteer and Kaiser Permanente urology and gynecology surgeon, Karl Luber, MD, was instrumental in providing surgeries for women with ovarian cysts. He also volunteers at the UCSD Student-Run Free Clinic. 3 PASD patient Miguel Ortiz plans to get back to work as soon as possible. His hernia had severely limited the amount of work he was able to do and greatly impacted his ability to provide for his family.

4 Volunteer Kaiser nursing staff get ready to welcome PASD patients in the post-op room. 5 PASD patient Mario Sandoval feels as if he has “won the lottery.” He has worked for the same company for 18 years and has been unable to afford healthcare to get his painful bilateral hernias repaired. 6 SDCMSF executive director Kitty Bailey and deputy director Tana Lorah. 7 Volunteers get ready for surgery.

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Classifieds OFFICE SPACE Office Space for Lease: Hillcrest, Mercy Medical Building (4060 Fourth Ave., 6th floor). 1947 usable square feet, consisting of four exam rooms, one large OR-style procedure room, two business offices, large waiting area, and small lab area. Beautiful views of San Diego. Copious shelves for medical files. Reception counter. T1 capability, and 220 volt outlet. Please call (858) 361-7300 or the onsite building manager at (619) 293-3081. Available by the end of January 2009. [671]

OFFICE SPACE TO SHARE: Currently occupied by orthopedic surgeon situated in La Mesa. Five minutes away from Alvarado Hospital and 10 minutes from Grossmont Hospital. Looking to share with part-time or full-time physician. Fully furnished, fully equipped, with X-ray equipment and three exam rooms. Please call (619) 668-0900 or email either rcham1000@aol.com or carmen@drcham.com. [666]

Class “A” Medical building for sale or lease: 3-Story, 55,450/SF located at 838 Nordahl Road in San Marcos, CA. Suites from 1,000/ SF. Premier location. Easy freeway access & close proximity to restaurants & Sprinter. Shower & locker facilities. Resort quality restrooms. Tropical landscaping. Koi ponds. Panoramic views. Latest in “green” building design standards with utility cost savings. Scheduled for completion in April 2009. For more information contact Mark Avilla (760) 431-4223 mavilla@breg.com www.nordahlmedicalcentre.com www.brecomercial.com LA JOLLA Office space available at XiMed Medical Building: Brand new, renovated office space available, preferably to a primary care MD to share. This is a rare opportunity to have a presence at the prestigious XiMed Medical Building right next to Scripps Memorial Hospital and to reduce your overhead by sharing space. Currently, the office is being used by a single physician part of the time. Flexible to any arrangement proposed. Call (858) 837-1540 or email melkurtulus@hotmail.com. [664]

NEW DOWNTOWN OFFICE SPACE AVAILABLE: New cozy family medicine office space available to share. Furnished office includes three exam rooms and one bathroom. Office ideal for solo practitioner interested in starting a new practice or in expanding to a new area. Call (619) 200-9664. [658] LOOKING FOR BEAUTIFUL, BRAND-NEW, STATEOF-THE-ART, AFFORDABLE OFFICE SPACE?: For internist, podiatrist, surgeon, pain management, chiropractor, or other healthcare specialist. Brand-new office (River View MD Spa, a Medical-Dental Spa) in new development in Santee. Offering office space, ability to share reception area, and a minimum of one beautiful exam room (sometimes up to two rooms) to see patients. $1,650/month rent plus shared expenses if applicable. Call (619) 456-4555. [655]

MISSION HILLS OFFICE FOR SALE: Why rent when you can own? North Mission Hills physician’s office for sale. Beautifully restored house located in the West Lewis Planned District. Classic hardwood floors, stained glass, craftsmanship woodwork throughout, recessed lighting, complete exam rooms,

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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

ENCINITAS MEDICAL OFFICE SPACE: Spacious, ocean view office to share or sublease with three other physicians. Minutes from the 5 freeway and Scripps Encinitas Hospital. Office includes private bathroom and entrance, common waiting area, wireless Internet, and free parking. LabCorp and MRI center are located in the same building. Contact DeeAnn Wong, MD, at (760) 753-7341, ext. 2#. [650]

LA MESA OFFICE SPACE TO SHARE: Over 6,000ft2 OB/GYN office of four doctors with one leaving, available January 2009. Space is ideal for a medical practice or clinical studies, and is located on Grossmont Hospital campus. Contact La Mesa OB/GYN at (619) 463-7775 or fax letter of interest to (619) 463-4181. [648]

Leasing, Renewals & 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 your area, or for valuable vacancy and absorption information. Use our knowledge and expertise to help you negotiate a new lease, renewal, or purchase to assure you obtain the best possible terms. There is no charge for our consulting services. Contact Chris Ross at 858.677.5329; email chris.ross@colliers.com. MEDICAL OFFICE SPACE FOR LEASE IN ENCINITAS: Available August 2009. Share space with established physician-owner. Office located in new LEED-certified professional office development on Encinitas Blvd., close to 5 freeway, Scripps Hospital, and public transportation. Free parking, private bathroom, front desk area, and additional storage space included. One to two offices 11x14 are available full or part time. Affordable lease rate in desirable area. Contact Wendy Khentigan, MD, at (760) 845-0434 or at wendykmd@aol.com. [646]

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]

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 halfdays per week. Email sbrooksreceptionist@yahoo.com or call (760) 753-8413. [557]

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 SPACE AVAILABLE: In the Mercy Medical Building directly across from Scripps Mercy Hospital. Great space for an adult primary care or a specialist. First floor, excellent staff, T1 line, HER capable, voicemail, website, and more! Call for more information and a tour: (619) 205-1480. [674]

PHYSICIAN POSITIONS AVAILABLE PART-TIME RESEARCH PHYSICIAN: Profil Institute for Clinical Research, an independent carbohydrate metabolism research institute, is seeking a part-time (4pm – 8pm) research physician to supervise clinical studies. Candidate should be trained in internal medicine (fellowship in endocrinology preferred) and have practice experience in diabetes management or a clinical research background in metabolism. Unrestricted medical license required (CA preferred). Email resumes to hrpicr@profil-research.com. Visit www. profil-research.com for further information. [670]

INTERNAL MEDICINE PRIVATE PRACTICE, UNUSUAL FLEXIBILITY, UNIQUE OPPORTUNITY: North San Diego County, part-time position, looking for board-certified internist. If interested, please call (619) 248-2324. [668]

NEUROLOGY POSITION: Position available immediately for board-certified/board-eligible neurologist in Mission Valley. Experience with forensics or workers’ compensation preferred. Physician must go out on medical leave and needs coverage. This is a very busy practice that does include some pain management. Currently we have an MD with musculoskeletal experience (fellowship at UCLA in acupuncture) and foreign graduate MD serving as PA to assist with practice. Position has potential to evolve into permanent position or partnership depending upon compatibility issues. Respond to dovemd@sbcglobal.net for further details. [667] Kaiser Permanente — Cardiology EPS Opportunity: At Kaiser Permanente Southern California, we believe our achievements are best measured by the health and wellness of the community we serve. That’s why we provide a fully integrated system of care guided by values such as integrity, quality, service, and, of course, results. If you would like to work with an organization that gives you the tools, resources, and freedom you need to get the best outcomes possible for your patients, come to Kaiser Permanente. For consideration, please forward your CV to: Bettina.X.Virtusio@kp.org or call Bettina at (800) 541-7946. We are an AAP/EEO employer. http://physiciancareers.kp.org/scal. [665]

PHYSICIANS NEEDED: Full-time, part-time, and perdiem opportunities available for family medicine, pediatric, and OB/GYN physicians. Vista Community Clinic is a private, nonprofit outpatient clinic serving the communities of North San Diego County. Must have current CA and DEA licenses. Malpractice coverage provided. Bilingual English/Spanish preferred. Forward resume to hr@vistacommunityclinic.org or fax to (760) 414-3702. Visit our website at www.vistacommunityclinic.org. EOE/M/F/D/V [659]

ACROSS FROM SHARP CHILDREN’S HOSPITAL:

To submit a classified ad, email Kyle Lewis at KLewis@SDCMS.org. SDCMS members place classified ads free of charge (excepting “Services Offered” ads). Nonmembers pay $250 (100-word limit) per ad per month of insertion.

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Corporate Legal Services Receive a free consultation and discounts on corporate legal services. Call Ladd Young Attorneys at Law at (619) 5646696. San Diego County Physician Mailing Lists Receive one free physician mailing list annually and a discount on all additional mailing lists requested in the same year. Contact SDCMS at (858) 5658888. SDCMS Membership Certificate Receive a free SDCMS membership certificate. Contact SDCMS at (858) 565-8888. Investments Invest with Dunham & Associates and discount your SDCMS dues by $150. Call Jeff Dunham at (619) 308-9700. SDCMS Pictorial Membership Directory Appear in SDCMS’ annual pictorial membership directory. Receive a free directory each year and a 50% discount on additional directories purchased, as well as discounts on directory advertising. Contact SDCMS at (858) 565-8888. Coding Hotline Access a free coding hotline (provided by CHMB Solutions). Email your coding question(s) to SDCMS at Coding@SDCMS.org. San Diego Physician Magazine Receive a free subscription to the voice of San Diego County’s physicians. Place free classified ads and discounted display ads. Contact SDCMS at (858) 5658888. San Diego Magazine Receive a gift subscription (active physician members) or a discounted subscription (resident physician members). To sign up, contact SDCMS at (858) 565-8888. To update your subscription address, contact San Diego Magazine at (888) 3500963 or at sdgm@kable.com. SDCMS Email Newsletter, “News You Can Use” Receive the latest in medical, local, state, and federal news critical to your practice … free to members and free of advertising. Contact SDCMS at (858) 5658888. SDCMS Seminars SDCMS member physicians and their office staff attend free

of charge all SDCMS seminars (including Office Managers Forums), covering legal issues, HIPAA, risk management issues, how to begin your practice, contract negotiations, getting paid, billing, and much more. Contact SDCMS at (858) 5658888.

involved in any of a broad spectrum of engagement opportunities both SDCMS and CMA afford their member physicians, including joining an SDCMS or CMA committee or becoming a physician leader. Contact SDCMS at (858) 5658888.

California Emergency Driving Emblem Receive a free California physician emergency driving emblem and additional emblems discounted at $10. Contact SDCMS at (858) 565-8888.

Hertz Discounts Save up to 15% on daily Hertz car rental rates. Special international discounts are also available. Visit www.Hertz.com or call Hertz at (800) 654-2200. Frequent traveler miles and bonus points may be earned for qualifying rentals. An SDCMS-CMA members-only code is needed to take advantage of this discount — email MGonzalez@SDCMS.org to receive your code.

Local, State, and Federal Physician Advocacy SDCMS and CMA continue to be vigilant in our protection of MICRA, in fighting against non-physician scope of practice expansions, in working closely with our political representatives and other healthcare stakeholders to fix our broken healthcare financing system, and in doing everything we need to do to protect physicians’ interests wherever they are challenged. Contact SDCMS at (858) 5658888. Full-time SDCMS Physician Advocate Have a question? Don’t know where to begin? Contact your fulltime, SDCMS physician advocate, Marisol Gonzalez, free of charge, to get the answers to all your questions, at (858) 300-2783 or at MGonzalez@SDCMS.org. Full-time SDCMS Office Manager Advocate Let your office manager and staff know that they have a full-time office manager advocate on staff at SDCMS ready to help them with any questions they may have, free of charge. Contact Lauren Wendler at (858) 3002782 or at LWendler@SDCMS.org. SDCMS News Alerts Stay informed of the news that affects your bottom line and your patients’ health with faxed and emailed alerts sent by SDCMS to you, free of charge … and free of advertising! Contact SDCMS at (858) 565-8888. SDCMS and CMA Websites Access members-only SDCMS and CMA websites to find valuable resources, such as a list of San Diego County physician NPIs, updated weekly. Contact SDCMS at (858) 565-8888. Engagement in Healthcare Issues Be part of the solution! Become

residents receive a 50% discount. Contact Epocrates at (800) 2302150 or visit www.cmanet.org. CMA ON-CALL Documents You can access, free of charge, thousands of pages of medical-legal, regulatory, and reimbursement information, through CMA’s online library. Contact CMA at (415) 882-5144, at legalinfo@cmanet.org, or visit www.cmanet.org. CMA’s Weekly Newsletter, “Alert” Delivered directly to you, free of charge, via email or fax. Contact Katherine Gallia at CMA at (916) 551-2074 or at kgallia@cmanet. org. Free CMA Reimbursement Hotline (888) 401-5911

SDCMS

Other Member Benefits See Page 5 for a Listing of Our Endorsed Partner Benefits

Auto Insurance Along with your spouse, receive 4.5–14% discounts on all lines of coverage from the Automobile Club of Southern California. Contact SDCMS at (858) 5658888. HIPAA Compliance Receive a discount on a complete, do-it-yourself HIPAA privacy and security compliance toolkit (CD ROM). Call David Ginsberg at PrivaPlan at (877) 218-7707. Epocrates Clinical Reference Guides Receive a 30% discount off of a one-year subscription and a 35% discount off of a two-year subscription to Epocrates’ clinical reference guides. Students and

Free CMA Legal Hotline (415) 882-5144 Free CMA Legislative Hotline (866) 462-2819 Free CMA Physician Confidential Line A 24-hour phone service for physicians, dentists, medical students, residents, and their families and colleagues who may have an alcohol or other chemical dependence or mental/behavioral problem. Completely confidential. Using it will not result in any form of disciplinary action or referral to any disciplinary body. Call (213) 383-2691.

Classifieds OB/GYN PHYSICIAN: Seeking board-certified/board-eligible OB/GYN physician to join our group practice in North San Diego County. Please email CV to madrod1@cox.net. [656] Kaiser Permanente is Hiring Per-Diem and Full-Time Physicians: We have current openings for full-time and per-diem physicians in the East County of San Diego. These positions are available at our La Mesa, Rancho San Diego, and Bostonia medical offices. For more information regarding these opportunities, please contact Kathy Dundovich, area operations administrator at (619) 589-3206 or at kathy.l.dundovich@kp.org. [653]

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

SENIOR PHYSICIAN, HIV/STD/HEPATITIS BRANCH, COUNTY OF SAN DIEGO: Are you looking for a rewarding career that spans individual patient care and county-wide public health program development? As the medical director of the County STD clinic that provides HIV screening, diagnosis and treatment for sexually transmitted diseases, and hepatitis immunization, the Senior Physician manages a team responsible for providing excellence in clinical services. We are looking for a candidate who has strong leadership skills and the ability to work collaboratively with team members. Functional application of data, aptitude with technical writing and the desire to build bridges in the community are also desirable skills. We require a license to practice medicine in the State of California and at least three (3) years of post-internship training. Particularly suitable is a background in Internal Medicine, Family Practice, Ob-Gyn, Urology or Infectious Diseases. Please be aware that availability to work flexible schedules at multiple sites, including some evenings, is expected. If you meet the above, we are interested in YOU! Please visit www.sdcounty.ca.gov/hr to file an application. [675]

The International Medical Corps in Registered Nurse (RN): Family medicine office in Torrey Hills seeking a full-time, experienced RN. Previous clinical experience required. Salary and benefits are negotiable. Please call (858) 350-8100 or email résumé to admin@torreyhillsfamilymedicine.com. [577] Part-time Medical Assistant/Back Office: Two years experience required including phlebotomy. Busy specialist office near Alvarado Hospital. Submit résumés via email to dlpotter22@hotmail.com. [576]

MEDICAL ASSISTANT/BACK OFFICE: Busy OB/GYN practice needs experienced MA to start 08/09. Competitive wage and benefits. Spanish a plus but not required. Fax resume to (619) 298-4250. [673] PHYSICIAN POSITIONS WANTED CARDIOLOGIST AVAILABLE: Non-invasive cardiologist (ex-professor) wants to work in office-based practice. Board eligible. Experienced in echo, stress test, stress echo, nuclear and CT. Willing to work in academic position. Call (760) 633-3044, or (858) 922-8354, or email cvshah@aol.com. [558]

MD SEEKING PART-TIME EMPLOYMENT: Elderly MD in North San Diego with prior legal, weight, etc., experience seeking part-time employment. Call (949) 492-0198. [651]

PRACTICES FOR SALE FAMILY PRACTICE FOR SALE — NORTH COUNTY COASTAL: Solo practice, established 15 years with strong patient base. Beautiful beach community. Excellent lifestyle. No HMO, no ER call. Call (760) 809-2390. Email wlljkd5@ aol.com. [679]

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]

MEDICAL EQUIPMENT

MOONLIGHTING PSYCHIATRIST WANTED: Flexible

MEDICAL EQUIPMENT FOR SALE: Ritter 100 teal exam

1+ weekends/month at Pomerado Inpatient Geropsychiatric Unit. Must be board eligible or board certified. $200+/hr. Contact Jason Keri, MD, at (619) 299-4374. [676]

table, physician stool, plastic-encased pillow, and exam room chair(s). $500.00 each set. Call (858) 485-6644. [678]

REAL ESTATE PT/FT PSYCHIATRIST WANTED: To join respected multi-specialty group serving nursing homes. Office and hospital optional. Partnership and growth opportunities. Highly flexible schedule. $180k+. Contact Jason Keri, MD, at (619) 299-4374. [677]

NONPHYSICIAN POSITIONS AVAILABLE PART-TIME PA OR NP: Small family practice in Chula Vista, two blocks north of Scripps Chula Vista Hospital, is seeking a bilingual PA or NP for part-time employment. Please call Drs. Jenkin or Tetteh if interested at (619) 804-7252. [669] NURSE PRACTITIONER/PHYSICIAN ASSISTANT: Flexible, part-time schedule. Patient-centered practice specializing in primary care, neurology, cardiology. Successful candidate will be caring, enthusiastic, and with positive attitude and work ethic. Bilingual in Spanish preferred but not a condition. We’ll provide necessary training, so newly graduates are welcome to apply. Good fringe benefits. Email CV to harmonymedicalgroup@yahoo.com or fax: (619) 393-0830. [661]

NURSE PRACTITIONERS NEEDED: Part-time and perdiem opportunities available for family medicine, pediatric, and OB/GYN nurse practitioners. Vista Community Clinic is a private, nonprofit outpatient clinic serving the communities of North San Diego County. Must have current CA license. Malpractice coverage provided. Bilingual English/Spanish preferred. Forward resume to hr@vistacommunityclinic.org or fax to (760) 414-3702. Visit our website at www.vistacommunityclinic.org. EOE/M/F/D/V [660]

MEXICO VILLA: Sell or rent. Fifty-year trust. Ocean front. Twenty-five miles to border. Two bedrooms. Two baths. Two alcoves. Sleeps eight. Security. Pool. Spa. Furnished. Rent $1,500/month. Sell $595,000. (619) 659-9555. [657] Mission Hills Office for Sale: Why rent when you can own? North Mission Hills physician’s office for sale. 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; 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]

Place your advertisement here Contact Dari Pebdani at 858-231-1231 or DPebdani@sdcms.org

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Iraq

continued from page 44

site involved traversing numerous checkpoints and submitting to scrutiny of our credentials. We hit the ground running and began our weeklong symposium the day after arriving. I had been briefed to expect the Iraqi ophthalmologists to be at a basic level of knowledge and expertise. This was far from the case. These were well-trained and highly experienced ophthalmologists with a very current fund of knowledge. While few have ever received visas to travel abroad, they have made tremendous and successful efforts to be current in ophthalmic knowledge. They accomplished this by having access to the Internet and the professional resources available online. They have utilized the American Academy of Ophthalmology basic and clinical sciences materials, also electronically accessible. They have electronic access to our peerreviewed journals. Their surgical skills are sound. While they have extensive surgical experience, they have been hampered by lack of access to the equipment currently in common use for intraocular surgery. For example, their standard practice in cataract surgery is similar to the extracapsular large incision technique most ophthalmologists in the United States performed in 1990. Accordingly, I adjusted my presentation to address their desire to transition to small incision surgery by phacoemulsification. In glaucoma, as in other diseases, the limited number of ophthalmologists and standing clinics has left the population of 28 million Iraqis underserved. This makes it very difficult to effectively treat recognized cases. It also causes people to present in late stages of the disease when nothing can be done to restore sight that has been lost and little can be done to preserve what is left. This is most unfortunate, considering that glaucoma, when recognized in the early stages, can usually be arrested or slowed down. Again, I adjusted my presentation to coordinate

TOP: Iraq Ophthalmology Congress. This is the group of Iraqi ophthalmologists who attended the conference. We are seated center front row. Not that it matters, but I am just to the right of center. LEFT: Ophthalmology group. I am center with a group of Iraqi ophthalmologists who participated in the conference.

a discussion with them on how this significant but not inevitable public health problem could be addressed. Over several days a plan evolved for them to obtain a number diode lasers to be used to lower eye pressure by trabeculoplasty or by transscleral cyclophotocoagulation, without so much need for medication and for close supervision. Once this equipment is obtained and distributed to existing clinics, it is expected to have a significant impact on preventing vision

loss from glaucoma. They will also need to implement a concerted effort at informing individuals to present for evaluation at the early stages of vision loss. The doctors I interacted with were highly professional, collegial, and courteous. They were most appreciative of our being there to conduct this seminar series. They invited us to tour the large eye hospital in Baghdad. I became acquainted with their style of practice and with the equipment they have. They

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function exceptionally well with what is available to them. Stability in Iraq is dependent on functioning institutions and infrastructure. I believe that our visit made a contribution toward enhancing their eye care institution and their healthcare system in general. It helped reestablish collegial contacts and interaction and it promoted an exchange of ideas. To this end I hope my team was able to make some small, positive difference in this troubled part of the world. Abo u t t h e Au t ho r : Dr. Ulrich graduated from medical school at the University of Colorado. He completed ophthalmology training at the Naval Medical Center in San Diego and fellowship training in glaucoma at Duke University. He has extensive experience teaching ophthalmology and cataract surgery to physicians in training and is in private practice in San Diego.

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First-Person Perpective By George Ulrich, MD

The International Medical Corps in

Iraq

Invigorating Iraq’s Healthcare System

raq has been involved in a long stretch of conflicts beginning with the Iran-Iraq war from 1980 to 1988. This was followed in 1990 by the invasion of Kuwait and an aftermath of 13 years of embargo. Then there was the invasion by coalition forces in 2003 and its aftermath. Iraq is in a state of reorganization. Accordingly, physicians in Iraq have had limited general access to the world medical community. They have also been occupied with practicing medicine in a prolonged state of armed conflict and embargo. The International Medical Corps (IMC) is one of several organizations involved in invigorating Iraq’s own healthcare system. A current project involves providing continuing medical education to physicians in various specialties. The intent is to help Iraqi physicians stay current in the rapidly evolving field of medicine, to establish rapport, and to allow for

the exchange and development of new ideas that can be implemented in Iraq as public health and policy measures. This CME is coordinated between the IMC and Iraq’s Ministry of Health. The IMC project has involved assembling and deploying teams of physicians with ex-

These were well-trained and highly experienced ophthalmologists with a very current fund of knowledge. While few have ever received visas to travel abroad, they have made tremendous and successful efforts to be current in ophthalmic knowledge. pertise in their respective specialties. They travel to Iraq to meet with their counterpart Iraqi physicians and to conduct continuing medical education seminars. Be-

cause of my experience teaching cataract surgery and glaucoma at the Naval Medical Center in San Diego, and because of my experience with medical organization, I was invited to participate as a member of the ophthalmology team. Besides myself, my team of ophthalmologists included Robert Butner, MD, a retinal specialist from the University of Texas who had ophthalmology experience in the Bosnia conflict, James Stadler, MD, an ophthalmologist from Minnesota with extensive teaching experience around the world, and Baxter McClendon, MD, a South Carolina ophthalmologist who has years of practice experience in Tanzania. We corresponded over several months and developed a curriculum for our visit. We also went through the arduous process of obtaining the credentials and clearance to be in the country. This included training and orientation on the state of affairs in Iraq as well training in personal security measures. We arrived in Baghdad at night. Security was a major issue. We had escort and liaison with IMC throughout our visit. Travel from the airport to our meeting continued on page 42

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