August 2009 by San Diego Physician

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We fight frivolous claims. We smash shady litigants. We over-prepare, and our lawyers do, too. We defend your good name. We face every claim like it’s the heavyweight championship. We don’t give up. We are not just your insurer. We are your legal defense army. We are The Doctors Company. Robert D. Francis Chief Operating Officer, The Doctors Company

The Doctors Company built its reputation on the aggressive defense of our member physicians’ good names and livelihoods. And we do it well: Over 80 percent of all malpractice cases against our members are won without a settlement or trial, and we win 87 percent of the cases that do go to court. So what do you get for your money? More than a fighting chance, for starters. To learn more about our medical professional liability program for San Diego County Medical Society members, call (858) 452-2986 or visit us at www.thedoctors.com.

Endorsed by

VITAS is about life, some of the most important moments of life.

I’m not a nurse. But my wife’s failing heart and lungs turned me into one. Before we called VITAS, it felt like I was all by myself. I was overwhelmed ... I was a cop for 35 years—I’d never felt so helpless. Then, there was VITAS. The pain medication was delivered. The medical equipment came when they said it would. Never a check to write. Nurses, nurses aides, social workers, chaplains … even their doctor came to the house. When things got tough, VITAS was there around the clock. VITAS calls it Intensive Comfort Care®. I call it a lifesaver, a friend.

Serving the San Diego area since 1995 For information, please call 1.800.93.VITAS www.VITAS.com

Contents VOL. 96 | NO. 8

t Your Office Manager Advocate Has the Answers! t The Art of the Science of Coding t Become a Certified Medical Coder in Five Days! t Backup and Disaster Recovery t Try This Idea: Payroll RVUs t San Diego County Occupational Employment and Wage Data t Medical Record FAQs t “Oustanding Medical Office Manager” Contest

[DEPARTMENTS]

4 6 8 10 12

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This Issue’s Contributing Writers

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?<8CK?:8I< I<=FID Marcus Welby? He’s History

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What to Expect for the 2009–10 Influenza Season

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With SDCMSF’s Project Access San Diego

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“Outstanding Medical Office Manager” Contest

[WEB EXCLUSIVE] “Maintain Your Practice’s Profitability: Five Practice Management Tips” by Rhonda Buckholtz of the American Academy of Professional Coders

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TRUSTED PARTNER OF SDCMS

Alliant, the specialty insurance leader.

And our commitment and drive pushes us to succeed.

hosen by more healthcare providers for our commitment to excellence and breadth of product knowledge, Alliant Healthcare Solutions offers custom-tailored services and products to meet the needs of any practice. Our highly skilled healthcare insurance professionals can deliver: Medical malpractice through our partnership with The Doctors Company ■ Property and casualty ■ Employee benefits ■

For more than eight decades, Alliant Insurance Services has provided innovative and solutions-oriented programs and services for our clients. As the nation’s largest specialty insurance brokerage firm, Alliant Insurance Services has the experience and drive to meet the needs of SDCMS members.

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Marketing & Production Manager Jennifer Rohr Sales Director Dari Pebdani Project Designer Lisa Williams Copy Editor Adam Elder J;:DJ 9F8I; F= ;@I<:KFIJ

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F==@:<IJ President Lisa S. Miller, MD Immediate Past President Stuart A. Cohen, MD, MPH President-elect Susan Kaweski, MD Treasurer Robert E. Wailes, MD Secretary Sherry L. Franklin, MD

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><F>I8G?@: ;@I<:KFIJ East County William T. Tseng, MD, Heywood â&#x20AC;&#x153;Woodyâ&#x20AC;? Zeidman, MD Hillcrest Roneet Lev, MD, Thomas V. McAfee, MD Kearny Mesa Adam F. Dorin, MD, John G. Lane, MD La Jolla J. Steven Poceta, MD, Wayne Sun, MD North County Arthur â&#x20AC;&#x153;Tonyâ&#x20AC;? Blain, MD, Douglas Fenton, MD, James H. Schultz, MD South Bay Vimal I. Nanavati, MD, Anna Sanchez Seydel, MD

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

Managing Editor Kyle Lewis Editorial Board Van Chang, MD, Adam Dorin, MD, Robert Peters, MD, PhD, David Priver, MD, Roderick Rapier, MD

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8K$C8I>< ;@I<:KFIJ John W. Allen, MD, David E.M. Bazzo, MD, V. Paul Kater, MD, Jeffrey O. Leach, MD, Mihir Parikh, MD, Robert E. Peters, MD, PhD, David M. Priver, MD Communications Chair Theodore M. Mazer, MD Young Physician Director Kimberly Lovett, MD Retired Physician Director Glenn Kellogg, MD Medical Student Director Jane Bugea CMA Trustees Theodore M. Mazer, MD, Albert Ray, MD, Robert E. Wailes, MD, Catherine D. Moore, MD, Diana Shiba, MD AMA Delegates Robert E. Hertzka, MD, James T. Hay, MD AMA Alternate Delegates Albert Ray, MD Lisa S. Miller, MD

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We take pride in being the â&#x20AC;&#x2DC;Referredâ&#x20AC;&#x2122; bank of San Diego county physicians. We invite you to find out more why more of your peers are recommending Torrey Pines Bank over other financial institutions. To learn more please call me or visit us online at torreypinesbank.com. Endorsed Partner,

TORREYPINESBANK.COM

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Message From Your Executive Director By Tom Gehring

often wonder who has the harder task: the physicians who see patients or the office managers who make everything work up to, but excluding, seeing the patients. This, our third-annual issue of San Diego Physician, is focused exclusively on physicians’ office managers because we at the San Diego County Medical Society (SDCMS) recognize that absent effective support from office managers and the office staff, physicians cannot do their job of healing patients. When asked what exactly it is we do as a medical society, my answer is, “We do good for those who do good” — we help physicians so that they can help their patients. Likewise, your office staff does good so you can do good, and our mission is to support them in that endeavor. A good office manager can improve your practice’s efficiency and increase its productivity. And that’s where your SDCMS can help.

We at the San Diego County Medical Society (SDCMS) recognize that absent effective support from office managers and the office staff, physicians cannot do their job of healing patients.

SDCMS Is Here for You — AND Your Office Manager! Please pass this issue of San Diego Physician along to your office manager and let him or her know that we’re here to help!

SAN D IEGO P H YSICIAN . o r g

A u g u s t

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Your office manager’s responsibilities run the gamut from administrative duties such as handling the mail, filing, assisting staff, establishing office policies, leading staff meetings, ordering supplies, managing office IT and office equipment, managing contracts, and OSHA training, to accounting duties such as reviewing daily deposits, managing payroll, preparing budgets, running monthly reports, and to human resources duties like hiring, firing, and evaluating staff, managing employee benefits, managing health plan contracts, ensuring regulatory compliance, billing, coding, oh, and finally … ensuring you’re happy. Which is where we come in. Along with assembling a robust portfolio of member physician benefits (see Table 1), we have for the past several years been working toward developing an equally robust set of benefits for your office manager, which begins with Lauren Wendler, your full-time, SDCMS office manager advocate. Lauren is here

specifically to assist your office manager with his or her job. If she doesn’t know the answer, she’ll get it. Along with the assistance of Lauren, we offer our member office managers: • A discounted certified medical coder (CMC) course (see page 26 for more information and to sign up). • A discounted certified medical office manager (CMOM) course (our next CMOM course will be held in the spring of 2010). • Networking with other San Diego County medical office managers at our regular office manager forums and via our SDCMS medical office manager listserv. • Professional development by attending, free of charge, SDCMS’ seminars and webinars, covering topics such as: • HIPAA • OSHA • contract management • contract negotiations • risk management • legal issues • revenue cycle management • legal notices

• Discounts on magazine subscription services. • Free access for both member physicians and their office managers to valuable, members-only content at SDCMS.org. • A discounted, do-it-yourself HIPAA privacy and security compliance toolkit. • Free access to thousands of pages of medical-legal, regulatory, and reimbursement information through CMA’s online library, CMA ON-CALL. • Deep discounts on everyday office supplies from Staples. Please pass this issue of San Diego Physician along to your office manager and let him or her know that we’re here to help! Contact Lauren Wendler at (858) 300-2782 or at LWendler@SDCMS.org with any questions or if you think we should be providing a certain benefit you don’t see listed here. And, as always, thank you for your membership in SDCMS and CMA! ✚

• dealing with problem employees • coding to optimize compliance and reimbursement • marketing the medical practice • Medicare updates • e-prescribing • collections • electronic medical records • sexual harassment • Palmetto GBA transition issues • disciplinary procedures and terminations • billing • Free, annual San Diego County physician mailing lists to market your practice. • Free, annual SDCMS pictorial membership directory to help you make referrals. • A free coding hotline. • A free subscription to San Diego Physician with its great practice management articles and resources. • Free classified advertising in San Diego Physician and on SDCMS.org. • Discounted display advertising in San Diego Physician. • A free subscription to San Diego Magazine for your waiting room.

A b o u t t h e Au t hor: Mr. Geh-

ring is CEO and executive director of the San Diego County Medical Society.

SDCMS member physicians save thousands of dollars in free and discounted products and services from our many endorsed partners. Contact Janet Lockett, your SDCMS director of membership development, at (858) 300-2778 or at JLockett@SDCMS.org for details on our endorsed partner benefits or to suggest an additional benefit: Table 1:

Member Benefit Category

Endorsed Partner

Accounting Services

AKT CPAs and Business Consultants

AKTCPA.com

Banking Products and Services

Torrey Pines Bank

TorreyPinesBank.com

Billing solutions

CHMB Solutions

CHMBSolutions.com

Collections Services

TSC Accounts Receivable Solutions

TSCARSolutions.com

Contract Analysis

Coastal Healthcare Consulting Group, Inc.

HealthcareConsultant.org

Insurance Products and Services

Alliant Insurance Services, Inc.

AlliantInsurance.com

Legal Services

Alexander & Alexander

ProtectingDoctors.com

Merchant Services, i.e., Credit and Debit Card Processing

Chase Paymentech

ChasePaymentech.com

Practice Management Consulting

Practice Performance Group

PPGConsulting.com

Professional Liability Insurance

The Doctors Company

TheDoctors.com

Tamper-resistant Prescription Pads

American Security Rx

AmericanSecurityRx.com

Technology Solutions

Soundoff Computing Corporation

SoundoffComputing.com

A u g u s t

Endorsed Partner Website

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SAN D IEGO P H YSICIAN . o r g

SDCMS Members-only Benefits

2009

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NOVEMBER

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to Member Physicians and Their Office Staff!

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Your Partner in Health J UNE

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SAN D IEGO P H YSICIAN . o r g

Community Healthcare Calendar 26th Annual Primary Care Summer Conference August 7–9 at the Paradise Point Resort, San Diego. Visit www.scripps. org/conferenceservices.

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

New Advances in Inflammatory Bowel Disease September 12 at the Hilton San Diego Resort, San Diego. Visit www.scripps. org/conferenceservices. 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. September 12–13, and November 7–8 at the Center for Surgery of Encinitas. Visit www.freshstart.org. Building Clinical Excellence for Mental Health and Drug and Alcohol Professionals September 16–17 at the Westin Hotel, San Diego. Visit www.mhsinc.org/ events. American Academy of Urgent Care Medicine’s 2009 Urgent Care Medicine Conference September 23–25. Visit www.aaucm.org.

4th Annual Clinical Update on Heart Failures and Arrhythmias: From Prevention to Cure October 17–18 at the Hilton La Jolla Torrey Pines. Visit www.scripps.org/ conferenceservices. 9th Annual Destination Health: Renewing Mind, Body, and Soul October 18–23 at the Marriott Kauai Resort, Kauai, Hawaii. Visit www. scripps.org/conferenceservices. 20th Annual Coronary Interventions October 28–30 at the Hilton La Jolla Torrey Pines. Visit www.scripps.org/ health-education. 2009 San Diego Day of Trauma October 30 at the Joan B. Kroc Institute for Peace and Justice, USD. Visit www.scripps.org/ conferenceservices. XVII World Congress of Psychiatric Genetics Offers a forum for exchange of the latest scientific data and education for the interested clinician. November 4–8 at the Manchester Grand Hyatt, San Diego. Contact (858) 534-3940 or ocme@ucsd.edu. New Developments and Best Practices in Colorectal Cancer Screening November 14 at the Admiral Baker Clubhouse (Presidio Room). Contact (858) 458-9439 or sbazzo@ sandiegoafp.org. Melanoma 2010: 20th Annual Cutaneous Malignancy Update January 16–17, 2010, at the Hilton San Diego Resort, San Diego. Visit www. scripps.org/conferenceservices. 7thAnnual Natural Supplements: An Evidence-based Update January 21–24, 2010, at the Paradise Point Resort, San Diego. Visit www. scripps.org/conferenceservices. Scripps Cancer Center’s 30th Annual Conference: Clinical Hematology and Oncology February 13–16, 2010, at the Omni San Diego Hotel. Visit www.scripps. org/conferenceservices. ✚

SAN D IEGO P H YSICIAN . o r g

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Pinnacle Introducing

NOWING F O FER

FREE

Medical Plaza

RENT ES! TIV INCEN

The Building…

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

Location, Location, Location

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

For more information, please call Ed Muna at 619-702-5655 or i > Êi`J > v À`Ã`°V °ÊUÊÜÜÜ°* >V i i` V> * >â>°V

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AB O U T TH E AUTH O R : Ms. Gonzalez

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By Marisol Gonzalez ()

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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.

Welcome New and Rejoining SDCMS-CMA Members! New Members Sunil Bhoyrul, MD Surgery La Jolla (858) 457-4917 Deidre Alice Buddin, MD Dermatology Oceanside (760) 758-5340 David John Bylund, MD Anatomic and Clinical Pathology & Immunopathology San Diego (619) 297-4900 Pamela Wertz Deak, MD Obstetrics and Gynecology La Jolla (858) 657-8745 Douglas Jules Ellison, MD Anatomic and Clinical Pathology & Hematology San Diego (619) 297-4900 Lawrence David Goldberg, MD Internal Medicine & Noninvasive Cardiology Del Mar Fadi Assad Haddad, MD Internal Medicine & Infectious Disease San Diego (619) 298-1443 Christopher Michael Hunt, MD Internal Medicine San Diego (858) 279-1212 Christopher Joseph Kane, MD Urology & Urological Oncology San Diego (619) 543-2626 Yu-Po Lee, MD Orthopedic Surgery San Diego Jennifer Altamura Namazy, MD Allergy and Immunology San Diego (619) 245-2900

Maryam Tarsa, MD Obstetrics and Gynecology & Maternal and Fetal Medicine San Diego

Nancy Lee Harrison, MD Anatomic Pathology & Clinical Pathology Chula Vista (619) 691-7138

Curt Andrew Vogel, MD Dermatology Oceanside (760) 758-5340

Lynn Lucille Leventis, MD Obstetrics and Gynecology San Diego

rejoining Members

Slawomir Tadeusz Niewiadomski, MD Anatomic and Clinical Pathology & Cytopathology San Diego (619) 260-7032

Stephen Martin Dorros, MD Diagnostic Radiology & Neuroradiology San Diego

Kumara Swamy Prathipati, MD Internal Medicine San Diego (619) 286-3222 ✚

Lisa Lew Gabhart, MD Pediatrics La Mesa

UC San Diego Medical Center’s

“Rural Residency Rotation” Providing a Role Model for Physicians and the Community

Medicine, and residency program director, Scripps Chula Vista Family Medicine Residency Program. “Rural communities tend not to have direct access to good healthcare, and most new residents haven’t had this kind of hands-on training. It is a great example of the service-learning model in action.” Clara Padron-Spence, MD, who grew up in El Centro, returned to UC San Diego from the University of Iowa School of Medicine for her family medicine training from 1995 through 1998. She worked in the South Bay as a teaching faculty member of the Scripps Family Medicine Residency Program for about two years before returning to El Centro. After a few years as an employee at a private practitioner’s office, Dr. Padron-Spence opened her own practice. With the guidance of Drs. McKennett and Ikeda, Dr. Padron-Spence is working with the ECRMC to develop a full UCSD- and Scripps-affiliated Rural Family Medicine Residency Program. “Part of our oath as doctors is to serve those in need ... populations in poverty, the underserved, and the unserved,” explains Dr. Ikeda. “Dr. Padron-Spence is a shining example of what medicine, homegrown leadership, and true caring can accomplish.” For further information, please visit http://familymedresidency.ucsd.edu or email Dr. Ikeda at tikeda@ucsd.edu. ✚

ne hundred seventeen miles east of San Diego sits a rural town home to three highways, two international border crossings, one county seat (Imperial), and a budding rural residency training experience. Family medicine residents from UC San Diego Medical Center spend two weeks of their training in El Centro, a relatively rural rotation. The residents take care of inpatients at El Centro Regional Medical Center (ECRMC) and the CHC Family Health Center (part of ECRMC), see patients in a private-practice office setting, and visit various Children’s Hospital-affiliated pediatric specialty clinics in the area. In addition to credentialing, the ECRMC supports the experience through the provision of housing for the residents during their two-week rotation. “The rural residency program is a great benefit to the community and for our residents,” says Tyson Ikeda, MD, clinical professor and residency program director, UC San Diego School of Medicine, and vice chief, Division of Family Medicine. Dr. Ikeda developed the training experience with Marianne McKennett, MD, clinical professor, UC San Diego Division of Family

By Kimberly Edwards, UCSD Public Information Officer

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SAN D IEGO P H YSICIAN . o r g

Noted

Volunteering

Made Easy!

By y Lauren Radano, SDCMS Foundation Healthcare Access Manager

he San Diego County Medical Society Foundation is working to increase access to healthcare services for uninsured and underinsured, lowincome San Diego County residents. Three programs aid the SDCMS Foundation in making a positive impact on the health status of the medically underserved: Project Access San Diego (PASD); Surgery Days; and a collaborative project known as the Specialty Care Access Initiative (SCAI). Gifa\Zk 8ZZ\jj JXe ;`\^f G8J; PASD is a physician-led partnership of coordinated charity care that links low-income, uninsured San Diego County residents with physician volunteers who have agreed to see one or more patients free of charge. PASD’s network of volunteers (physicians, hospitals, and other healthcare providers) provides a full range of free healthcare services to enrolled patients, including physician appointments, inpatient and outpatient hospital care, laboratory, imaging, medical equipment, and pharmacy benefits. We understand how the stress of running a medical practice in today’s healthcare environment can often overshadow the joy of caring for patients. To ensure your experience volunteering with PASD is optimal, we have established referral guidelines so that you only see those patients who are most in need, so that you decide how many patients you want to see, and so that we take care of all patient enrollment and follow-up paperwork. PASD gives you the opportunity to

volunteer right here in your own community and to make a difference in someone’s life. Jli^\ip ;Xpj Surgery Days is a partnership with outpatient hospital centers to provide same-day, low-risk surgeries for free to safety-net patients. Sixtyfour surgeries and colon cancer screenings have taken place so far in 2009, totaling more than $400,000 in donated healthcare services. Two more Surgery Days are planned in 2009: August 22 and December 5. K_\ Jg\Z`Xckp :Xi\ 8ZZ\jj @e`k`Xk`m\ J:8@ SCAI is a planned approach to accessing specialty care services for the safety-net population. In partnership with health centers, the SDCMS Foundation is implementing strategies to enhance specialty care access and better coordinating referrals to our region’s specialists. Community benefits associated with the SDCMS Foundation’s programs include lowering the use of emergency departments, lowering dependency on government services, fewer bankruptcies, increasing patients’ abilities to support themselves and their families, and improving San Diego County’s economic health by creating a stronger, more stable workforce. For more information on our programs or to sign up as a physician volunteer, please visit www.SDCMSF.org, or contact Lauren Radano at (858) 565-7930 or at LRadano@SDCMS.org. ✚

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Healthcare Reform By Ronald J. Glasser, MD

Marcus Welby? He’s History [Note: Originally published in the Sunday, May 31, 2009, edition of The Washington Post and reprinted here with permission from the author.]

few decades ago, the biggest problem in medicine was diagnosis. Is that a heart attack or heartburn? The beginnings of dementia or a stroke? Is the tumor benign or malignant? Medical technology has changed all that. The biggest problem in medicine today is not determining what’s wrong with you. It’s knowing whom to call at 2 a.m. — other than 911 — when something happens. And the nasty little secret is not that your doctor is no longer available, but that he or she is no longer in charge. Of the 15,000 students who will graduate from medical school this year — and the roughly 8,000 physicians and surgeons who will finish their specialty training — more than 93 percent will become employees of large clinics, managed-care companies, or hospital systems. These physicians, as I have seen in my own practice in Minneapolis, are no longer patient advocates. In many ways, they’ve

abandoned the patient to the work rules of health plans and the professional demands of managed care. The Hippocratic Oath has been discarded, and the Golden Rule has become: He who has the gold sets the rules. What this means is that the care you get — and how long you get it — is only the care your health plan will reimburse your doctor for. You can see your psychiatrist or psychologist for five visits; you can stay in the hospital for 48 hours following a hip replacement, or three days after a radical prostatectomy. Simple mastectomies go home the same day, and gallbladder removals as soon as they wake up from the anesthesia. If the drug prescribed is not on your health plan’s list, then your doctor will have to prescribe an approved alternative that may not be as effective. This kind of care is simply unsustainable. It’s not just the enormous amount of money we already spend on healthcare or the fact that 45 million Americans are uninsured. America is also graying. By 2015 there will be more 80-year-olds than children under 8, and the elderly need more — and more personalized — care. People respond dif-

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ferently to treatment, and it must be tailored to the individual patient. Our current depersonalized, disease-based system is not only dangerous but also dysfunctional. And any dysfunctional system will eventually fail. It happened to the financial system, and it will happen in medicine. From the end of World War II until the mid-1980s, the average medical or surgical group in the United States was made up of three to five physicians. They ran their practice as a privately held company, treating patients, sending out the bills, setting fees, and organizing night-call and weekend coverage while deciding how much charity care they would also provide. The focus was on maintaining good relationships with patients. Doctors cultivated a trusted bedside manner to maintain referrals and their colleagues’ respect. The physicians in a small practice knew one another’s patients. When someone called after hours, the answering physician would be able to respond to any questions and give realistic suggestions. I care for a number of spina bifida patients along with another physician. These children have complex problems that in-

clude a malfunctioning central nervous system, orthopedic problems, difficulty breathing, and recurrent bladder infections. If I didn’t know these patients, all I could do if they called after hours would be to send them to the nearest emergency room, where they would sit for hours while someone else who didn’t know them tried to figure out what was wrong. But personal knowledge and concern have evaporated in the world of employeephysicians, replaced by cookie-cutter, bestpractice guidelines and rules on prescribing drugs, acceptable lengths of hospital stays, and the number of clinic patients a doctor must see per hour. And why not? Everyone in medicine knows that these are no longer the physician’s patients. They belong to the insurance companies, the health plans, the hospitals. With that understanding comes personal indifference and professional exhaustion. Today, it’s the rare physician who gives a patient his or her private office phone number, something that was almost universal when I first went into practice. Nowadays, if you want to talk to your doctor, you go through the office coordinator or the nurse associate. The new tsunami in employed physicians has also led to something quite new in the medical profession: the part-time doctor. According to a recent survey of one of Minneapolis’s largest medical clinics, more than 50 percent of the doctors in the pediatrics and family practice departments and more than 70 percent in the ob-gyn department were working part-time. This is great for the employer, who doesn’t have to provide retirement or healthcare benefits. But as a medical organization, you do best not to mention your part-timers to the patients. When I talk to one of these physicians, I’m reminded of what a professor of mine at Johns Hopkins medical school in the 1960s said when one student complained about having to be on the wards every other night. The professor offered a quote he told us was from the pianist Arthur Rubinstein: “When I don’t practice one day, I can tell the difference. When I don’t practice two days, my wife can tell the difference. When I don’t practice three days, anyone can tell the difference.” Thank goodness for technology, which has saved both patients and medicine. MRIs, CAT scans, ultrasounds, pulmonary function tests, angiography, PSA testing, mammograms, molecular genetics, needle biopsy specimens — all these have reduced

to hearing it. It is a frequent and unembarrassed response, usually accompanied by the stated desire to go into one of the more lucrative procedure- or diagnostic-based areas of medicine: radiology, dermatology, orthopedics, or cardiology. A good income and more desirable lifestyle matter more than the type of patient the doctor might see. Taking care of the needy is no longer on anyone’s radar screen. When the administration of a large Minneapolis medical clinic surveyed its 600 doctors this year about whether they’d be willing to work more hours, most said no. When asked whether they would work more hours for more pay, they still said no. One result of this new attitude is that fellowship slots in the country’s leading geriatric training programs are increasingly going unfilled, and some of these programs are closing. U.S. medical school deans admit that students no longer plan to go into such primary-care specialties as pediatrics or family practice and are not interested in caring for the elderly because the major insurers won’t pay for the personal involvement and time that primary-care specialties demand. Troublingly, medical school professors have helped push the shift to physicians as employees. They’ve dismissed the concept of a small-group practice as unworkable. On the wards and in the clinics, they emphasize the “team player.” Medical schools now have mandatory courses on getting along in large-group practices. Individual or small practices are dismissed as too complicated and too expensive to run. Large-group-, clinic-, or hospital-based employment is presented as the only realistic post-graduate option. Perhaps we can’t go back to the two- or four-physician group practice. But medical school faculties can quit carrying the water for the managed-care companies and the large hospital systems. Our current medical system is out of whack. And those of us who see the edge of the cliff approaching should begin to warn publicly that medicine cannot survive if its real value — its capacity both to comfort and to heal — is replaced only by the superficial value of price. ✚

the chance of error. But they also offer professional cover to physicians who know little about a given patient apart from that person’s array of symptoms. Why have we witnessed a shift from independent medical practitioner to employee? The accepted reason is the steady growth of managed healthcare since the late 1970s. Thousands of small-group practices, faced with one or two dominant health plans in a city or geographic area, have been forced to merge to cut better deals on reimbursements. But the shift also appears to be generational. Consciously or unconsciously, we have raised a generation that views the medical profession in economic terms, as a career rather than as a calling.

The nasty little secret is not that your doctor is no longer available, but that he or she is no longer in charge. Not long ago, a senior member of one of the Twin Cities’ largest gastroenterology groups confided to me that no one in the group over the age of 55 could tolerate being part of the search committee hiring new physicians. “It isn’t like it used to be when you and I were looking to be hired a few decades ago,” he said. “We were dutiful and respectful and excited to even be offered a job. ... Now, it’s, ‘When will I be completely vested in the retirement plan?’ ‘I can’t work a full day on Friday because the kids play football or soccer on Friday night.’ ‘I don’t want to be on call more than twice a month. And if I do work here, I would like a signing bonus to cover the expenses to move here and the time it would take me to get up to speed.’” Similarly, Claus Pierach, a professor of medicine who serves on the admissions committee at the University of Minnesota Medical School, recently told me that the committee had begun to notice something new a few years ago. When asked, “Why do you want to be a doctor?” most applicants still answered as expected, “Because I want to help people.” But every so often, a candidate would reply that the reason was “job security.” At first, the committee bristled at this answer. But now members have grown used

A u g u s t

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A b o u t t h e Au t hor: Dr. Glasser practices nephrology and is writing a book on medicine and the baby-boom generation. He can be reached at ronglasser@ earthlink.net.

SAN D IEGO P H YSICIAN . o r g

County Public Health Officer’s Update By Wilma J. Wooten, MD, MPH, and Karen Waters-Montijo, MPH

Influenza Season

2009–10 What to Expect?

f it seems that the 2008–09 influenza season was unusually long, perhaps it is just that we have had artificially short influenza seasons in past years. This year was marked by a generous supply of influenza vaccine, expanded recommendations from the CDC for who should receive vaccine, and a push to continue providing vaccine after the initial fall period traditionally associated with “flu” season. The year was also remarkable by the detection of a new strain of influenza A virus that poses its own set of questions about future vaccine availability, administration, and acceptance by the public in the fall. Historically, most influenza vaccine is administered during the months of October through December, even though the flu season may not peak until the early spring. Much of the testing for novel H1N1 was conducted in the month of May, during which time it was clear that there was still significant seasonal or non-novel influenza disease in the community. For the 2009–10 season, progress is under way to manufacture the trivalent vaccine for seasonal influenza that will contain A/Brisbane/59/2007 (H1N1)-like, A/ Brisbane/10/2007 (H3N2)-like, and B/ Brisbane/60/2008-like antigens. Compared to the 2008–09 Northern Hemisphere influenza vaccines, only the B strain has changed.

A frequent topic of discussion among immunization specialists is how to increase the number of healthcare personnel (HCP) who receive annual flu vaccine. While information about vaccine development for the novel H1N1 flu is fluid and subject to change, the reference strains have been sent by the CDC to manufacturers who are initiating processes to create master seed strains to prepare for manufacturing pilot lots. One manufacturer has already

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successfully run the first batch of the vaccine. A decision to develop and manufacture a vaccine is independent from the decision to administer a vaccine. The decision to administer will be based on the evolving epidemiology over the summer and fall as data from the Southern Hemisphere are collected to assess the virulence and attack rate of the virus.

lost days of work for parents. A frequent topic of discussion among immunization specialists is how to increase the number of healthcare personnel (HCP) who receive annual flu vaccine. Recent data from the San Diego Immunization Branch random digit dialing (RDD) survey indicate a plateau at a little over 50 percent of HCP who receive annual flu vaccine. While this percentage may be higher than the national

According to the CDC, if sufficient vaccination coverage among children can be achieved, there may be the indirect effect of reducing influenza among persons who have close contact with children, thereby reducing the overall transmission within communities. The vaccine is considered to be safe and effective for children, and may help to reduce school absenteeism, decrease antibiotic use and medical visits, and reduce

Physicians can set the tone in their practices by having themselves vaccinated and making vaccine available to all office and clinical staff members. It is likely that a new vaccine would require two doses. This means that it will be recommended that some people receive three immunizations: one seasonal plus two novel H1N1. Children ages six months to eight years who have not previously received influenza vaccine should receive two doses of vaccine separated by more than four weeks. Nationally, providers will be encouraged to use their local immunization registries to keep track of doses for clients and to manage inventory. In San Diego, the San Diego Regional Immunization Registry is a web-based system that is available to all interested practices and is currently used by approximately 200 medical facilities that administer immunizations, including public health centers, community health centers, and private medical practices. One of the interesting results of the heightened media coverage for novel H1N1 flu was new attention to the fact that more than 36,000 deaths annually in the United States are attributed to seasonal influenza. To try to impact this, the CDC has continued to expand the target populations for whom seasonal influenza vaccine is recommended. Beginning with the 2008â&#x20AC;&#x201C;09 season, all children aged six months to 18 years of age should be vaccinated against influenza annually. Children typically have the highest attack rates during community outbreaks of influenza and serve as a major source of transmission within communities.

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ceive influenza vaccine include: 1. Close Contacts of Immuno-compromised Persons: Close contacts, including HCP, should be vaccinated to reduce the risk of influenza transmission to persons who are at risk for influenza complications but might have insufficient responses to vaccination. 2. Pregnant Women: Pregnant women are at risk for influenza complications. 3. Breastfeeding Mothers: Vaccination is recommended for women who are contacts of infants and children younger than five years of age. Breastfeeding is not a contraindication for vaccination, and women who are breastfeeding can receive either TIV or LAIV unless contraindicated because of other medical conditions. 4. Travelers: Any traveler who wants to reduce the risk of influenza infection should get vaccinated at least two weeks before departure if they did not receive flu vaccine during the regular season if they are going to the tropics, traveling with an organized tourist group, or traveling to the Southern Hemisphere during April through September. Finally, the influenza vaccine is recommended for anyone who wants to reduce the risk of contracting or transmitting influenza. The San Diego Immunization Branch looks forward to working with its community partners to promote influenza vaccine. Additional information about seasonal and novel H1N1 will be shared as it becomes available. For information about using the

average, there is much room for improvement. All HCP, as well as those in training for healthcare professions, should receive annual flu vaccine. Physicians can set the tone in their practices by having themselves vaccinated and making vaccine available to all office and clinical staff members. In addition to HCP, other groups who can transmit influenza to high-risk persons that should be vaccinated include employees of assisted living and other residences for persons in groups at high risk, persons who provide home care to high-risk individuals, and household contacts (including children) of persons at high risk.

Additional information about seasonal and novel H1N1 will be shared as it becomes available. Traditional groups recommended to receive the seasonal influenza vaccine include persons over 50 years of age and persons with chronic medical conditions such as heart disease, diabetes, or lung disease. According to the CDC 2008–09 Influenza Prevention and Control Recommendations (www.cdc.gov/ flu/professionals/acip/specificpopulations. htm), other specific groups who should re-

registry to help manage the upcoming influenza season, or additional information about vaccines across the lifespan, please go to www.sdiz.org. ✚ A b o ut t h e Aut hor: Ms. Waters-Montijo has worked in Public Health Services for the County of San Diego since 2002 and is the chief of the Immunization Branch. Dr. Wooten, SDCMS and CMA member since 2006, is the public health officer for the County of San Diego, Health and Human Services Agency. She is board certified in family medicine and has a master’s degree in public health.

San Diego County Health Statistics • The percentage of healthcare workers in San Diego who receive influenza vaccine is 61. (Source: San Diego County year-round random-digit-dial telephone survey, 2007–08.) • The percentage of high-risk adults ages 18–64 who receive influenza vaccine is 50.8. (Source: San Diego County year-round random-digit-dial telephone survey, 2008–09.) • In San Diego, it is estimated that 76.5 percent of seniors (age 65 and over) received the influenza vaccine during the 2008–09 influenza season. This leaves approximately 83,498 seniors who were not protected against influenza. (Source: San Diego County year-round randomdigit-dial telephone survey, 2008–09.) To request additional health statistics describing health behaviors, diseases, and injuries for specific populations, health trends and comparisons to national targets, please call the County’s Community Health Statistics Unit at (619) 285-6479. To access the latest reports, data, and data links, go to www. sdhealthstatistics.com. ✚

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Office Manager Ad v o c a c y

Your Office Manager Advocate Has the Answers

SDCMS Member Office Managers: Did you know you have someone on staff at SDCMS to turn to with your questions and concerns? Lauren Wendler, your SDCMS office manager advocate, is here to help you find the answers to your questions, whether they be on OSHA, HIPAA, billing, coding, or what have you! And if she doesn’t know the answer when you call, she’ll track it down. Lauren also coordinates SDCMS’ rich schedule of seminars and webinars and is always looking for new topics and ideas.

Cash Payment From Medi-Cal Patients • Refund Request Time Limits • Pamphlet Translation Requirements

By lau re n we n dle r

Contact Lauren at any time if you have any questions or suggestions, and if you’d like to sign up to be included in our new San Diego County Medical Office Manager email listserv, whereby you can communicate instantly your questions and suggestions to all the other office managers on the listserv, let Lauren know at (858) 300-2782 or at LWendler@SDCMS.org. We’re here to help!

QUESTION: We have a Medi-Cal patient who wants to pay cash for the doctor’s services instead of billing Medi-Cal. Is it okay if we form an agreement with the patient? answer: Once a physician knows that a patient is a Medi-Cal patient, the physician cannot allow the patient to pay cash for any services that the physician may provide. Private payment agreements have a significant potential for abuse. Providers must submit a claim for re-

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imbursement according to the rules and regulations of the Medi-Cal program and not attempt to obtain payment from the recipients. For further information, consult CMA’s ON-CALL document #0150, “Side Agreements With Medi-Cal Patients” — available free to SDCMS-CMA members at www.cmanet.org. QUESTION: Medicare is requesting a refund for a payment they made three years ago. What is the time limit that third-party payors and Medicare have to request a refund from payments that we received? answer: Private health plans, Blue Cross, Blue Shield, etc., can only go back 365 days from the date of the last action of the plan. The federal government (Medicare) can go back as far as they want, particularly if they suspect fraud; thus, there is no time limit for Medicare to request a refund. For further information, consult CMA’s ON-CALL document #0135, “Plan Requests for Refunds From Physicians” — available free to SDCMS-CMA members at www.cmanet.org.

Interpreters” — available free to SDCMSCMA members at www.cmanet.org. ✚ About the Author: Ms. Wendler is your SDCMS office manager advocate. She can be reached at (858) 3002782 or at LWendler@SDCMS.org with any questions your office manager may have.

QUESTION: Is there a regulation that requires physician practices to provide all medical forms and pamphlets in Spanish? answer: Physicians need to provide written translations of pamphlets depending on the number of patients with limited English proficiency (LEP) that the physician treats. Federal Department of Health and Human Services’ Policy Guidance on Foreign Language Interpreters provides a “safe harbor” with respect to written translations. The safe harbor applies to protect physicians who provide (1) written translations of “vital documents” with respect to each LEP patient group that comprises 5 percent of the practice or 1,000 patients, whichever is less or, if there are fewer than 50 persons in a large group that reaches the 5 percent trigger, and (2) written notice in the primary language of the group of the right to receive competent oral interpretation of those materials, free of cost. Examples of vital documents include consent and complaint forms, intake forms with the potential for important consequences, etc. For more information, consult CMA’s ON-CALL document #0813, “Language

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Office Manager

Ad v o c a c y

t would be hard to imagine a situation where coding, which has ramifications in reimbursement and compliance, could be “under-explained” without potentially affecting both reimbursement and compliance. For that reason we will limit our content here to a couple of key coding-related items that, in our experience, seem to cause a lot of confusion and questions.

The Art of the Science of Coding

Compliance and Documentation In matters of coding, first and foremost, compliance must be taken into account. Two key phrases among coders are these: “If it wasn’t documented, it didn’t happen,” and “If the documentation isn’t legible, it didn’t happen.” The principles of documentation are applicable to all types of medical and surgical services in all settings. The medical record should be complete and legible. The documentation of each patient encounter should include the following: reason for the encounter and relevant history; physical examination findings and prior diagnostic test results; assessment, clinical impression, or diagnosis; plan for care; and date and legible identity of the observer. Inappropriate Coding of Consultations Instead of New Patient Visits It is important to differentiate between a new patient visit and a consultation.

Mistakes, Misconceptions, and Missed Revenue Opportunities B y

K a r r i e

M ay

When seeing a new patient to determine if it is a consultation or a new patient visit, we need to know the intent of the referring physician; if it is to transfer care, then you would bill for the visit as a new patient visit and not a consultation. If it is an established patient, bill as an established patient. The exception to this is that if a physician is requesting your opinion on something and you are only rendering an opinion for a new condition, you can bill as a consultation. Requirements for Consultations Your dictation should include the fact that the doctor requested you see the patient (i.e., Dr. “X” has requested that I see Patient “Jane Doe” for the following

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reasons). It should have your results or opinion, and it should have a statement that a letter has been sent back to the referring doctor, with a copy of the letter in the chart. A simple way to think of this is the three Rs of consultations: 1. request (by another provider) 2. render (opinion) 3. response (written report) If or when the patient returns to you for care, they are now an established patient and not a follow-up consultation unless a doctor requests your opinion for something else. An outpatient consultation code can be billed for the outpatient hospital or emergency room (you should not bill the ER codes unless you are the ER doctor). If you are called in, you should use consultation codes. Now that you know what a consultation “is” and when to use it, for purposes of differentiation, here are examples of what a consultation “is not”: • a standing order in the medical record for consultations • a consultation done without a specific request • no written report of a consultation sent to the requesting physician • providing care for own patient on an emergency basis Proper Use of Modifiers A modifier is added to a CPT code to show that a service has been modified in its identification or definition. A common use of modifiers is to explain special circumstances or conditions, or to indicate repeat or multiple procedures. It is important to note that not all modifiers can be used with every CPT code. Space and time prohibit reviewing all modifiers, so we would like to focus on a common mistake or misconception many people have in the use of two modifiers: 25 and 57. Per CPT, modifier 25 is a “significant, separately identifiable E&M service by the same physician on the same day of the procedure or other service.” It “indicates the patient’s condition required a significant, separately identifiable E&M service be performed above and beyond the other service provided.” A good standard for determining whether the 25 modifier should be used is this: documented, extra pre-op and/or post-op work beyond what is usually performed with a minor procedure/surgical service. The physi-

cian must determine if the E&M service for which he or she is billing is distinct from the procedure/surgical service. An example of this would be an E&M visit that resulted in a decision to perform a procedure or minor surgery. Per CPT, modifier 57 is “decision for surgery.” “(It is) an E&M service that resulted in the initial decision to perform the surgery. This modifier is used to report an E&M service that resulted in a decision to perform a major surgical procedure on the day of or the day before the surgery.” An E&M service provided the day before or the day of a major surgery that resulted in the initial decision to perform that surgery may be eligible for reimbursement when modifier 57 is appended to the E&M code. A major surgery is defined as having a 90-day global period as assigned by Centers for Medicaid and Medicare Services (CMS). Modifier 57 is not valid for use when the E&M service is associated with a minor surgical procedure (defined as having a zero- or 10-day global period as assigned by CMS). Because the decision to perform a minor procedure is typically done immediately before the service, it is considered a routine preoperative service and therefore not separately reimbursable. Modifier 57 is not valid for use when the E&M service was for the preoperative evaluation. General Modifier Tips • Always have the most recent edition of the CPT book on hand. • Have your billing staff attend coding workshops. • Learn about using modifiers so you can help your billing staff with coding questions. ✚ A bo u t t h e Au t hor: Ms. May is a certified professional coder with CHMB Solutions, SDCMS’ endorsed partner for outsourced medical billing, revenue cycle management services, information technology support, and hardware solutions to physician practices, clinics, and multispecialty organizations. Email your coding questions to Coding@SDCMS.org. For further information, contact Ron Anderson at (760) 520-1340 or at randerson@chmbsolutions.com.

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Office Manager Ad v o c a c y

Become a Certified Medical Coder in Five Days! Limited Spaces Available — Sign Up Now! By L a u r e n W e n d l e r , S D C M S O ffic e m a n a g e r Advoc a t e

ack of adequate training can cost any medical practice dearly in terms of lost revenue due to inaccurate reimbursement. Erroneous claims may even trigger a carrier audit. That is why it makes good business sense to employ certified professionals to handle your reimbursement process. Accredited professionals are more confident in their abilities and able to use that heightened knowledge to train others in the practice. Other benefits include enhanced efficiency and productivity, and a higher level of financial security for the practice. The San Diego County Medical Society (SDCMS) will host the Practice Management Institute (PMI) Certified Medical Coder (CMC) preparatory course at our offices at 5575 Ruffin Road, Suite 250. The class meets on five Fridays beginning on October 23, 2009, and running through November 20, 2009. Registration for this SDCMS-hosted CMC program is limited to 30 participants. SDCMS members and their staff may attend for the discounted rate of $599 each

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(nonmembers pay $999), which includes the certification exam. For more information on this course, contact Lauren Wendler, your SDCMS office manager advocate, at (858) 300-2782 or at LWendler@SDCMS.org. To register today, simply fill in the information requested below and fax this form to SDCMS at (858) 569-1334. Course Curriculum Medical Terminology for Diagnostic and Procedural Coding: • Roots, Prefixes, and Suffixes • Anatomy and Physiology • Body Structure and Body Systems ICD-9-CM Diagnostic Coding: • Coding Conventions • Guidelines From CMS • Primary vs. Secondary Codes • Signs/Symptoms and Ill-defined Conditions • Neoplasms and Adverse Effects • Injuries, Burns, Fractures, and Wounds • Supplementary Classifications • Ob-gyn Codes CPT Procedural Coding: • CPT Categories, Format, and Guidelines • Diagnostic vs. Therapeutic Services

quired materials include CPT, ICD-9CM Volume 1 and 2, HCPCS manual, and a medical dictionary.

• E&M Services for All Categories Plus Modifiers • Surgical Coding Guidelines and Procedures • Modifiers for Surgical Procedures • Coding From Chart Notes and Operative Reports

Presented By: This course is presented by the Practice Management Institute (PMI) and hosted by the San Diego County Medical Society (SDCMS) and the California Medical Association (CMA).

Ancillary Services and Advanced Coding • Maternity and Delivery Services • Radiology • Pathology and Lab Services in the Physician’s Office • Medicine and Intervention • Coding Problem Set Exercises • Medical and Surgical Specialties

Cancellation Policy: A full refund less a $20 processing fee is given if cancellation is received seven-plus days prior to program start date. A 50 percent refund is given if cancellation is received six days to 48 hours prior to start date. No refund is given if cancellation is received less than 48 hours in advance. Upon registration, custom materials are printed, refreshments are ordered, and seating is reserved, and, as a result, PMI strictly adheres to this policy.

Course Details When: October 23, 30, November 6, 13, 20 (five Fridays), from 8 a.m. to 4 p.m. each day (sign in 15 minutes prior to program). Where: At the San Diego County Medical Society meeting room, 5575 Ruffin Road, Suite 250, San Diego, CA 92123.

To Register: Fax this page to SDCMS at (858) 569-1334. Questions? Contact Lauren Wendler, your SDCMS office manager advocate, at (858) 300-2782 or at LWendler@SDCMS.org.

Cost: SDCMS member physicians and their staff pay the discounted rate of $599. Only SDCMS member physicians and their staff may attend. Registration fee includes breaks, lunch, instructional materials, and certification exam. Re-

participant Information

Attendee Name

Member Physician Name

Address city / state / zip

Telephone

Fax

Payment Information

o Visa

o MasterCard

o AmEx

o Check

(Make check payable to “Practice Management Institute” and mail to: SDCMS, Attn., Lauren Wendler, 5575 Ruffin Road, Suite 250, San Diego, CA 92123.)

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FAX COMPLETED FORM TO SDCMS AT (858) 569-1334

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Office Manager Ad v o c a c y

Backup and Disaster Recovery Protecting Your Practice From Becoming a Statistic b y g r e gg b l u n d e l l a n d of e r shim r a t The Scene

onday, 7:03 a.m. You arrive at the practice to find your staff a little more animated than usual. One of the building’s restrooms above has flooded overnight, and water has been cascading down into your server room for the last several hours. Total outage: Your network is down, computers cannot log in, no email, no EMR, no billing. Frantically, you call your IT vendor, who arrives onsite to proclaim that most of the computer equipment in the server room is ruined, including the tape drive that backs up each night and the stack of backup tapes kept alongside it. A bad scene that could be repeated for any and all business-altering situations: fire, burglary, hardware failure, human error. You wonder out loud about your insurance coverage for replacement hardware, about your backups. Who is in charge of the disaster recovery? How many hours or days will your practice be down? What about HIPAA Title 2? Business Continuity Impact Like any business, your practice has financial responsibilities contingent on

by Ellen Beck, MD

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keeping your doors open, patients flowing, and turning a profit. Any adverse impact on the ability to make a profit is noteworthy. A data outage, large or small, can be one of those impactful instances. Consider the yearly gross revenue for your practice and divide that number by 223 days. Let’s assume $1 million gross divided by said amount of working days: about $4,500 of potential gross revenue lost per day during an outage if ALL staff are unable to be productive and are sent home — a disaster to be sure. To get a more refined figure per person/hour, divide the daily gross of $4,500 by your number of staff. Very soon you get to see the true, direct financial impact of an outage. We say “direct” because there are indirect costs, such as the need for additional staff to “catch up” when the system is available again, patient dissatisfaction, and the ripple effect of things missed, appointments dropped, files gone, and schedules delayed. Time to ask questions. Risk Assessment Backup and disaster recovery planning are strategies to mitigate risks. Correctly identifying and assessing those risks and their impact is critical to the survival of your practice, your business. Backup and disaster recovery planning are business issues, not technical issues. The word “backup” means many things to many people. For some it is simply the ability to recover that missing or overwritten Excel spreadsheet you spent weeks developing. To others it is something nebulous that is assumed to be taken care of by their IT provider. Mitigating Risks What format is your mission-critical data in? Paper charts? Scanned documents? Transcription files? Imaging files? Fullblown EMR system? Where is your mission-critical data? Onsite client/server? In the cloud on the Internet? A hybrid of both? What is the hierarchy and communications structure in your practice in the event of an outage or data loss? What policies and procedures exist, and who is to implement them? How long can the

practice survive before the finances are significantly depleted, thereby threatening the very existence of the business? In HIPAA jargon your practice is a “covered entity.” HIPAA Title 2, referred to as “administrative simplification,” includes provisions for “the implementation of controls to protect an individual’s health information.” What about destruction and disposal of damaged hardware that may contain patient information? In a recent study by Pepperdine University, the risks associated with data loss include: • hardware failure (40 percent) • human error (29 percent) • software corruption (13 percent) • theft (9 percent) • computer viruses or malware (6 percent) • hardware destruction (3 percent) According to the U.S. Bureau of Labor, 43 percent of companies that suffer largescale data loss due to disasters never reopen, and 29 percent close within two years. Additionally, 93 percent of all companies that experience “significant data loss” are out of business within five years. Risks will exist regardless. Now the strategy of what risks to mitigate and what recovery procedures to have in place. What to Back Up You cannot electronically back up what you do not have stored electronically. Conversely, you cannot electronically recover lost data that you have not backed up. Carefully consider what to back up. The space taken up by the 200 pictures from last year’s holiday party or an employee’s 4GB iTunes collection all of a sudden pale in comparison to the need for backing up X-ray imaging, scheduling calendars, billing data, payroll data, EMR databases, and email mailboxes. Work with your staff to uncover the most important aspects of your data. Work with your technology vendor to find out what gets stored, where it gets stored, and what you will need recovered in a true disaster situation. Create

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You cannot electronically back up what you do not have stored electronically.

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Office Manager Ad v o c a c y

an archive process for information that has been deemed unneeded for regular or frequent business use. Archiving will effectively and in a controlled manner remove data from the day-to-day storage and render into long-term storage. This will save both time and money when coming up with infrastructure solutions to meet your regular backup needs and your disaster recovery planning. Business Recovery Considerations Planning for disaster recovery depends in what business thresholds you set your practice to sustain. In other words, how many hours or days can your practice afford to be down? In IT circles there are two concepts to consider: recovery time objective (RTO) and recovery point objective (RPO). RTO is how long your practice can go without a specific application, e.g., email or EMR. This is often associated with your maximum tolerable outage. If your RTO is zero (cannot go down), then you may opt to have a completely redundant i n f r a s t r u c tu re with replicated data offsite, online, and onsite. If your RTO is 48 or 72 hours, then perhaps a less expensive, less redundant infrastructure will suffice. The RPO dictates the allowable data loss — how much data can your practice afford to lose? In other words, if your practice performs a nightly backup at 7 p.m., and the system crashes at 4 p.m. the following day, everything that was changed since the last backup is lost. The RPO in this particular context is the previous day’s backup. In larger practices that may perform many transactions per hour, the RPO should be down to the last, latest transaction that came in lest an entire day’s transactions have to be reentered. Determining your tolerable business thresholds will directly affect RTO and RPO levels and associated infrastructure costs. You can safely surmise that lower values for RTO and RPO are directly pro-

A good plan clearly states what needs to be done, who needs to do it, where, and when.

by Ellen Beck, MD

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portional to higher implementation costs, so plan accordingly. How to Back It Up Historically, tape has been the default means of taking a system backup, especially where large amounts of data, possibly housed on a server, were concerned. Although tape arguably still maintains the best cost-per-gigabyte up-front cost, there are inherent risks to tape media handling, such as damage or, even worse, media loss. The latter has been plaguing many companies in the financial sector, giving newer technologies a clear advantage. As a matter of fact, we no longer recommend tape backup in new or updated installations. There are alternative technologies that offer faster backups and more reliable restores. Among them: • Disk or Disk Array: The price of disk drive storage has come way down. Hard drive technology tends to be much faster, more reliable, and less susceptible to environmental effects. Large hard drive storage negates the need to use multiple tape media to store a single backup. • Image-based: This newer backup method is quicker, compresses much better, and, when combined with disk media or online storage, allows for a more flexible backup scheme. • Online Storage: Businesses are embracing the Internet as yet another tool for backup, allowing for a method to automatically push offsite backup images out and store them in geographically disparate places without the need for human interaction and very few dependencies. • Hybrid: A combination of the above three technologies. A backup solution can be designed that is able to take data snapshots at very frequent intervals — 15 minutes — while your practice continues to operate normally. Consult with your technology vendor on what you do (or don’t) have in place now and how you can leverage the above technologies. What About Insurance Insurance considerations are topics onto themselves, but, for purposes of disaster recovery planning, make sure your insur-

ance agent reviews the following coverage types and inclusions: • inventory and catalog all IT components (HIPAA) • copy to insurance agent/head office • inland marine coverage • hardware replacement costs plus reinstallation labor • flood insurance • filed class and non-filed class coverage • business interruption coverage • sprinkler systems and smoke alarms • theft vs. burglary • user alarm codes and monitoring • additional umbrella policies as needed A good insurance policy that includes the above provisions is part and parcel of an effective overall disaster recovery plan. It is essential when bringing the IT infrastructure back to normal as quickly as possible. The Bottom Line Simply stated, statistically, your business will not make it in the event of an outage or significant data loss if you do not have a backup and disaster recovery plan in place. Protect your practice from becoming a statistic by designing and implementing a disaster recovery plan that includes risk identification, comprehensive backup, hierarchical communications, insurance coverage, and overall common sense. Be sure to check with your IT provider regarding safe backups, practice runs, test backups, and restores. Once your plan is complete, then have staff practice it, maintain it, and perfect it. A good plan clearly states what needs to be done, who needs to do it, where, and when. ✚ t h e Au t hors : Mr. Blundell and Mr. Shimrat are business partners of SDCMS-endorsed Soundoff Computing Corporation, a consultancy specializing in IT products and services. They combine years of practical computing experience with best practices when providing organizations with needs analysis, business logistics, IT infrastructure, hardware, software and proactive maintenance. To learn more, visit www.soundoffcomputing.com or call (858) 569-0300.

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SAN D IEGO P H YSICIAN . o r g

Office Manager Ad v o c a c y

Try This Idea Payroll RVUs b y j e ff r ey J . D e n n i n g

aying employees fairly sometimes seems like a no-win proposition. If employees are underpaid, you won’t keep the good ones for long. And if you err on the side of generosity, you waste money. To get the best employees, you have to offer competitive pay, benefits, and working conditions. It’s a good idea to survey your community to be sure you’re offering a reasonable pay package. But if your office is considered a better-thanaverage place to work, you may not need to be the compensation leader. We generally recommend that practices aim to pay in the 75th to 90th percentile for like jobs. That means that 75–90 percent of workers with the same job in your community will be paid less than the ones in your office. Of course, that assumes two important stipulations: that working conditions are no worse than average in your office and that your workers are B+ or better employees. A wage survey of your community will tell you what others are paying for similar job titles. Be sure to compare like jobs, though. RNs in nursing homes earn

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more than RNs in medical practices. And a receptionist in an advertising agency is paid mostly for his or her appearance, not her skills on the phone. Beware using wage survey data that was compiled from employers outside your immediate driving radius, too. Wage rates are very locality sensitive. Wage-relative Values If you have trouble coming up with good survey data, though, you may be able to use a relative-value-scale approach. For years, we’ve compiled salary survey data from several regions around the country and dumped them in our great data processing maw to come up with this schedule of relative values for various job titles (see Table 1). This scale assumes the receptionist’s job is worth 1.00 “compensation units.” In this year’s edition of our study, a physician assistant’s is worth 3.14 units. This just means that the average PA working in medical practices is making just over three times as much as the average receptionist. Notable Changes Since we first started compiling this index in the early 1990s, the relative positions haven’t changed much. We always hope the receptionists will move up the scale from their traditional position near the bottom. It makes no sense to us that these hard workers in mission-critical positions are paid so poorly compared to their business office and clinical suite co-workers. To do a good job at the front desk positions requires intelligence, maturity, and accumulated experience at least equivalent to senior medical assistants. Most interesting to us is the way office manager and administrator pay has changed as a multiple of receptionist pay. These titles have historically run 2.5 to 3 times the receptionist rate. That has dropped to 2.36 for administrators and 1.9 for office managers this year. It would appear there is less elasticity of demand for talented, front-line workers than for management types. That correlates with

our observation that manager pay has been stuck in the high five figures for years. Check Yourself To use this idea in your office, just list your employees, their job titles, and the corresponding relative values from our scale. Then compute your internal relative values by dividing each employee’s hourly rate by your receptionist’s hourly rate. If a full-time employee is paid a salary, convert to the hourly equivalent by dividing the annual salary by 2,080 hours (52 40-hour weeks) and prorate for salaried workers of fewer than 40 hours per week. Where your internally computed relative value is greater than ours for the same job title, there’s a chance that your receptionist is paid too low or the other jobs are paid too high. Not Just Arithmetic Of course, how you pay your workers isn’t a simple matter of applying a formula or a cost-of-living escalator. Wage inflation has been modest in recent years. The general Consumer Price Index (CPI) has gone up less than 3 percent per year since 2004 and was down 0.7 percent for the 12 months ending April 2009. So wage increases this year should mostly reflect increased value to the practice (unless you are making up for past below-average compensation). That implies an organized way of deciding whether performance has improved. Employees who are good workers this year but who aren’t materially more valuable than last year shouldn’t expect more than token increases. And, it may be necessary to freeze some workers who have been raised above the market rate for their jobs.

We generally recommend that practices aim to pay in th the 75 to 90th percentile for like jobs.

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SAN D IEGO P H YSICIAN . o r g

Office Manager Ad v o c a c y

Table 1: Wage-Relative Values

Job Title

2007–09 Average

Physician Assistant

44.48

3.14

Nurse Practitioner

38.94

2.75

Controller

37.50

2.64

Triage Nurse

35.58

2.51

MRI Technician

34.13

2.41

Administrator

33.42

2.36

Registered Nurse

30.77

2.17

Business Office Manager

27.89

1.97

Office Manager

26.92

1.90

Satellite Manager

26.44

1.86

2007–09 RV

X-ray Technician (Regular / Certified)

24.22

1.71

Credit / Collections Supervisor

21.25

1.50

Coder

20.13

1.42

LVN / LPN

19.83

1.40

Medical Transcriber

19.71

1.39

Ophthalmic Technician

19.59

1.38

Insurance Supervisor

18.63

1.31

Accountant

18.27

1.29

X-ray Technician (limited license)

18.05

1.27

Administrative Asst. Executive Secretary

17.97

1.27

Insurance Biller

17.55

1.24

Bookkeeper

17.55

1.24

Surgery Scheduler

16.95

1.20

Credit / Collections Clerk

16.83

1.19

Medical Records Supervisor

16.59

1.17

Laboratory Assistant, Certified

15.63

1.10

Patient Account Representative

15.57

1.10

Insurance Claims Clerk

14.86

1.05

Medical Assistant

14.66

1.03

Receptionist

14.18

1.00

Telephone Operator

13.70

0.97

Cashier

13.59

0.96

Front Desk Eligibility

13.10

0.92

Front Desk Authorizations

12.98

0.92

Front Desk Registration

12.68

0.89

Medical Records Clerk

11.89

0.84

Data Entry Clerk

11.60

0.82

Clerk

9.86

0.70

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Of course, how you pay your workers isn’t a simple matter of applying a formula or a cost-of-living escalator. Conduct Your Own Wage Survey Don’t know where to get reliable wagerate information? We generally recommend you try your San Diego component of the Medical Group Management Association (MGMA). The California MGMA compiles a thorough survey every year, and you should participate. SDCMS can put you in touch with other local sources, and sometimes the medical staff liaison at your hospitals or IPA compiles the data, so ask around. Employment and temporary help agencies are sometimes helpful too. But if you just can’t find good wage and salary information in your community, you may need to take the lead and compile it yourself. It’s a way of doing something useful for the medical community, and it might generate some goodwill with referral sources — and potential new ones. Once you collect the data, distribute it to all who participated in your survey. You might even include practices that didn’t participate in this first round of the project to show them the value of helping you next time. ✚ A b o u t t h e Au t hor: Mr. Den-

ning is a principal management consultant with SDCMS-endorsed Practice Performance Group (PPG), a provider of high-performance medical practice management services for physicians, including consulting, expert witness, workshops, speaking, and a monthly newsletter. Contact Mr. Denning at (858) 459-7878 or at jeff@ppgconsulting.com.

Visit SDCMS.org to read these other helpful practice management articles by Jeff Denning: “Fire Up Your Staff” — Motivating workers to produce lots of high-quality work is the central problem for managers. It’s the subject of endless theorizing by academics and a source of lots of frustration for physicians. But the highest-achieving doctors have the most motivated employees, so it’s worth the effort to look for ways to fan their fires. “Make the First Day Count” — Starting a new job should be a big event, and it is for most people. A lot of managers (and physicians) will have to reach far back into their youths to remember how they felt on the first day on a new job. Treating this event with the dignity it deserves can go a long way to cementing the relationship with a new hire and to begin creating loyalty between employer and employee. “Say You’re Sorry” — “My employees are like children sometimes.” Ever feel that way? If so, there’s probably a logical explanation and an opportunity to improve your practice, too. Try applying some of the basic rules of child rearing from top psychologists to your employees to get better results.

“

When times are good, you should advertise. When times are bad, you MUST advertise.*

”

Advertise in the San Diego County Medical Society 2010 Pictorial Membership Directory

Last chance. Call today!

50 off SDCMS Member Physicians Receive

Advertising rates

Color advertisements and premium positions are limited and available on a first-come, first-served basis. Contact Dari Pebdani today: 858-231-1231 or DPebdani@SDCMS.org

*From an article by American Business Media entitled “Making a Recession Work for You.” A u g u s t

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SAN D IEGO P H YSICIAN . o r g

Office Manager Ad v o c a c y

San Diego County Occupational Employment and Wage Data Released June 2009

ollowing is a sampling of survey data from the 2008 Occupational Employment Statistics (OES) survey. The wages have all been updated to the first quarter of 2009 by applying the U.S. Department of Labor’s Employment Cost Index to the 2008 wages. Occupations are classified using the Standard Occupational Classification (SOC) codes. For details of the methodology, see the overview of the OES survey at www. labormarketinfo.edd.ca.gov. For a more complete list of healthcare practitioners and technical occupations, healthcare support occupations, and office and administrative support occupations, please visit the August 2009 issue of San Diego Physician at SDCMS.org.

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1st QTR. 2009 Mean Hourly Wage

1st QTR. 2009 Mean Annual Wage

Occupational Title

May 2008 Employment Estimates

Bookkeeping, Accounting, and Auditing Clerks

15,850

$18.22

$37,890

Cardiovascular Technologists and Technicians

370

$26.76

$55,677

Dietitians and Nutritionists

580

$26.73

$55,601

Emergency Medical Technicians and Paramedics

1,160

$15.75

$32,751

First-line Supervisors / Office Managers

15,200

$25.55

$53,137

Home Health Aides

4,520

$11.55

$24,012

Licensed Practical and Licensed Vocational Nurses

5,790

$22.01

$45,792

Medical and Clinical Laboratory Technicians

1,580

$21.07

$43,825

Medical and Clinical Laboratory Technologists

710

$32.71

$68,018

Medical Assistants

6,590

$14.66

$30,490

Medical Equipment Preparers

340

$16.48

$34,268

Medical Records and Health Information Technicians

1,490

$16.86

$35,053

Medical Secretaries

8,080

$15.25

$31,713

Medical Transcriptionists

440

$19.60

$40,756

Nursing Aides, Orderlies, and Attendants

8,460

$12.56

$26,114

Office Clerks, General

32,140

$14.09

$29,294

Pharmacists

2,200

$57.91

$120,452

Physical and Occupational Therapists

1,980

$37.93

$77,929

Physician Assistants

930

$40.86

$84,995

Radiologic Technologists and Technicians

1,310

$30.05

$62,499

Receptionists and Information Clerks

8,820

$12.94

$26,914

Registered Nurses

24,380

$38.65

$80,389

Surgical Technologists

800

$23.69

$49,270

Switchboard Operators, Including Answering Service

1,780

$12.72

$26,468

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SANâ&#x20AC;&#x2C6; D IEGOâ&#x20AC;&#x2C6;P H YSICIAN . o r g

Office Manager 8 ; M F : 8 : P

Medical Records &REQUENTLY !SKED 1UESTIONS B Y LAURA A. DIXON, BS, JD, RN, CPHRM, AND SUSAN SHEPARD, MSN, MA, RN, CPHRM HL<JK@FE1 How long should records be kept? 8EJN<I1 Although states may have different guidelines or laws, The Doctors Company recommends the following: t $BMJGPSOJB 0OMZ 3FUBJO UIF SFDPSET JOdefinitely or for at least 25 years after the patientâ&#x20AC;&#x2122;s last visit. t "EVMU 1BUJFOUT 5FO ZFBST GSPN UIF EBUF the patient was last seen. t .JOPS 1BUJFOUT 5XFOUZ FJHIU ZFBST from the patientâ&#x20AC;&#x2122;s birth. t %FDFBTFE 1BUJFOUT 'JWF ZFBST GSPN UIF date of death. HL<JK@FE1 Are videos, X-ray films, EKGs, fetal monitor strips, or photos, etc., part of the medical record? 8EJN<I1 Yes. Any and all data collected at the time of a patient encounter is part of the medical/legal document. HL<JK@FE1 Does the medical record include financial information such as billing and insurance data? 8EJN<I1 In some states, yes. Physicians should review billing documents for any reference to the specific healthcare provided.

J 8 E ; @ < > F G ? P J @ : @ 8 E % f i ^ s 8 L > L J K ) ' ' 0

QUESTION: How long should billing records, telephone calls/messages, and appointment books be kept? answer: The Doctors Company recommends the following: • Billing records in all states should be retained for seven years according to the Internal Revenue Service standards and may be kept in a separate file. • Telephone calls that pertain to medical care should be documented in the medical record and kept according to the above medical record retention guidelines. • Appointment books may be kept for one year.

QUESTION: Can records be transferred to microfilm, microfiche, or disk or stored in a computer? answer: Yes. The factors in the previous question can also guide you on transferring records to microfilm, microfiche, or disk and on storing records in a computer. Computer data should be backed up at regular intervals and stored offsite, as in the previous question.

QUESTION: If a patient brings his or her past medical records to my office, am I required to maintain all of the copies? answer: The physician should review, extract, and photocopy any information that he or she might need from that record and then return the original documents to the patient; otherwise, you must maintain such copies for the same length of time as the medical record.

QUESTION: Is it sufficient to back up a copy of an electronic health record (EHR) onto a disk? answer: Yes. However, you should store a copy of the EHR software along with the data itself to make sure the records can be read in the future. Alternatively, you could save the data in PDF format so it can be read without special software. If you use an application service provider — where your data is stored by the EHR vendor and you access it online — your contract should include terms that ensure your data will be available to you when you’re ready to make arrangements for long-term storage (1).

QUESTION: How should hard copy paper records be destroyed? answer: The only safe methods for destroying paper records are incineration or shredding. A destruction method for electronic medical records has yet to be determined.

QUESTION: Can I thin and purge medical records prior to storage? answer: Yes. Copies of other healthcare providers’ medical records, such as hospital records, can be purged because the originals will be maintained by the hospital.

QUESTION: Where can medical records be stored? answer: Inactive records may be thinned from the active patient cases and stored outside the office suite. Take the following factors into consideration when making arrangements for longterm storage: • Privacy: Protect the records from unauthorized persons. • Safety: Protect the records from fire or flood damage and unauthorized access or theft. • Accessibility: Make sure the records are easy to retrieve and copy.

QUESTION: Can I sell my records when I sell my practice? answer: Yes. We suggest that you include the recommended retention time and access capability as part of your sales agreement. QUESTION: If I move to another state, can I take my records with me? answer: Yes, with the same condition prevailing for retention and accessibility. It might be reasonable to alert your active/current caseload of your move in order to give patients an opportunity to request a copy of their medical records.

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SAN D IEGO P H YSICIAN . o r g

Office Manager Ad v o c a c y

QUESTION: If a patient requests a copy before I move, can I give him or her the original record? answer: No. The original is the property of the physician, who has a duty to maintain the record. QUESTION: Can a physician take medical records home for documentation completion? answer: No. The only time an active, original medical record should be out of an office is when it is required to be present in a court of law. QUESTION: If someone claiming to be a representative of a deceased patient’s estate requests a copy of the chart, what do I need to do? answer: You must verify that the individual is a qualified representative of the decedent’s estate (for example, the executor). The individual should provide a copy of an official document from the state as proof. Reference 1) O’Brien L. Long-term storage of electronic records. Modern Medicine. February 2008. Available at www.modernmedicine.com. Accessed July 31, 2008. ✚ A b o u t t h e Au t hors : Ms. Dixon is director of the Department of Patient Safety, Western Region, for The Doctors Company (TDC), and Ms. Shepard is director of patient safety education for TDC. TDC enjoys a reputation as the industry vanguard for low California rates, aggressive claims defense, expert patient safety programs, superior customer service, and exemplary member benefits. Contact Janet Lockett at (858) 300-2778 or at JLockett@SDCMS.org.

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Project Acccess

San Diego Project Access takes the hassle out of volunteering, with our staff doing the legwork so that you and your staff can focus on patient care.

The heart of the program is to assist patients who cannot afford medical services and who do not have insurance or qualify for public health insurance programs.

Project Access is actively recruiting physicians, hospitals, and ancillary service providers to participate in our program. Together we can ensure that our vulnerable populations have access to needed healthcare services.

• Enrolling Patients Based on Need: We verify financial status so that you can be assured that your volunteer service is reaching those who are most in need. • Making Appropriate Referrals: We use referral guidelines that ensure that when a Project Access patient comes to your office, he or she can take full advantage of the visit. • Providing Enabling Services: We provide services such as transportation and translation so that you don’t have to wonder if a patient is going to miss an appointment or if there will be a language barrier. • Providing Case Management Services: We work with each patient one-on-one to coordinate followthrough on all medical needs. • Providing All Needed Services: Through our partnerships, we ensure that a full scope of services is available to all of our patients, from office visits, hospital services, and even a defined pharmacy benefit.

Your commitment to Project Access is needed for our success! Please visit our website at SDCMSF.org to learn more and to sign up.

We need your volunteer commitment to help even one patient. Our Medical Community Liaison, Rosemarie Marshall Johnson, MD, can answer your questions. Dr. Johnson can be paged at 619.290.5351. You may also contact Lauren Radano, healthcare access manager, at 858.565.7930. A u g u s t

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Classifieds CLINICAL STUDIES Clinical Study: Dr. Timothy Bailey, boardcertified endocrinologist and ACRP-certified physician investigator, invites you to participate in a research study to determine if treating obstructive sleep apnea (OSA) may lead to improvements in diabetes control and other health benefits for people with type 2 diabetes. Tests results obtained from wearing a sleep-screening device in your home overnight may indicate whether or not you have OSA. If positive, you will be scheduled for an overnight visit to a sleep clinic and then assigned to sleep apnea therapy and lifestyle counseling or you will receive lifestyle counseling with sleep apnea therapy occurring upon completion of the study, if you would like treatment. If you are interested in this study or would like more information, please call (877) 567-2627 or email us at info@amcrinstitute.com. [731] USE GENETIC INSIGHT TO HELP TAKE CONTROL OF YOUR HEALTH FUTURE AND HELP FURTHER SCIENCE: Join the Scripps Genomic Health Initiative (SGHI), a first-of-a-kind study that uses the latest advancements in technology and medicine to give you insight into your DNA using a simple saliva sample. Lead by principal investigator and SDCMS member, Eric Topol, MD, this study is designed to find out how personal genetic testing will improve health by motivating people to make positive lifestyle changes. Participation includes a scan of your genome that assesses your genetic risk for over 20 health conditions, which includes several types of cancer, type 2 diabetes, Alzheimer’s, and more. You can sign up or learn more at: www.navigenics. com/partners/sdcms. [714]

weekday afternoons. If interested, please contact our office manager at (858) 458-0940 or fax a letter of interest to (858) 458-3688. [732]

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. FREE RENT INCENTIVES and a generous improvement allowance is provided. For information, contact Ed Muna at 619-702-5655, ed@lankfordsd.com www.pinnaclemedicalplaza.com LA JOLLA OFFICE SPACE FOR LEASE: Newly remodeled medical office space for lease in La Jolla. Shared space with orthopaedic surgeons. Preferably part-time needs. Convenient location near the Orthopaedic Surgery Center in La Jolla. Contact Jo Turner for more information at (619) 733-4068 or email jo@lajollaspine.com. [641] CHULA VISTA OFFICE SPACE TO SHARE: Two OB/GYNs occupy an office space over 5,000ft2. A third physician retired, and that space is available immediately. Located on the Sharp Chula Vista campus, this space is ideal for an OB/GYN medical practice or compatible. Contact Dorina at (619) 427-8892, ext. 113, or Gail at (619) 4278892, ext. 109, or fax letter of interest to (619) 422-7660. [728]

OFFICE SPACE Looking for a New or Second Office Location? Brand New Medical Office for lease in City Heights: High walk-by and drive-by traffic, adjacent to 11-year-old established medical practice, state-of-the-art building, modern design with granite and porcelain tile, 1,100ft2. Goldmine for business, surrounded by 40 schools within five miles and located centrally in the second most significant redevelopment zone in San Diego. Very central location near freeways 8, 805, 15, and 94; 10 minutes from downtown San Diego. Huge supermarket next door. For info, call (858) 504-2020. [734] Professional Office Space to Share or Lease: Up to 1,400ft2 in a medical complex, near Alvarado Hospital, SDSU college area. Ample parking, high visibility street location, ideal for any specialty or allied medical professionals. Call (858) 243-2425 or Jim at (619) 441-1115. [733] MIRA MESA MEDICAL OFFICE SPACE AVAILABLE: Three exam rooms, two staff stations, one office/consult room, space is available three

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

LOOKING TO SUBLEASE SPACE IN ENCINITAS: Allergy-immunology specialists interested in subleasing space in Encinitas area. Ideally desire two days a week, three exam rooms and one consultation room. Contact Trudy at (858) 2921144 or at trudybrass@msn.com. [727]

SCRIPPS/XIMED MEDICAL OFFICE SPACE AVAILABLE: 1–1.5 days per week. Receptionist help available if needed. Includes consultation office, exam room, assistant office, front desk, and shared waiting room. Contact Cindi at (858) 452-6226. [725] MEDICAL OFFICE SPACE AVAILABLE ON SHARP CHULA VISTA MEDICAL CENTER CAMPUS: 752 Medical Center Court, Chula Vista, CA 91911. Available July 5, 2009. Rental sublease office space: two (2) exam rooms, share consultation room, front desk space, turnkey operation, clean and friendly environment. For further information, please contact Connie Espinoza, office manager, at (619) 527-7700, ext. 236, or at conniee4@gmail.com. [723] HILLCREST OFFICE SPACE FOR LEASE: Hillcrest, Mercy Medical Building (4060 Fourth Ave., 6th floor). 1,947 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. [671] LEADED PROCEDURE ROOM IN KEARNY MESA FOR SUBLEASE: Located directly across for Sharp Memorial Hospital in the new, Class A Physician’s Medical Center. Perfect for non-sedated, minor procedures, including spinal injections. The space includes an integrated workstation with phone and Internet access. Common areas include kitchen (break room), private restroom, staff work stations, front desk, and patient lobby. A back way entrance accommodates gurney access. This is a potential alternative to costly surgical centers. Terms negotiable. Contact carla. young@clyoungmdinc.com for more details or fax a letter of interest to (858) 565-4146. [722] ESCONDIDO OFFICE/SURGICAL SUITE TO SHARE: Plastic surgeon has 2,000ft2 office with AAAASF-accredited surgical suite to share two days a week. Five minutes to Palomar Medical Center and I-15, this freestanding, single-level office is wheelchair and stretcher accessible. It contains doctor’s office, four staff work stations, three exam rooms, PACU, kitchen/eating area, and two bathrooms equipped for disabled. OR is fully equipped and supplied, and approved for general anesthesia. Save money over surgicenters. Ample parking. Minimum one day per week. Please call Yale Kadesky, MD, at (760) 741-5466 or email yalekadeskymd@gmail.com. [719] HILLCREST MEDICAL OFFICE ACROSS FROM SCRIPPS MERCY HOSPITAL: Office sublet 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, EHR capable, voicemail, website,

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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Classifieds and more! Call for more information and a tour: (619) 205-1480. [674] 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]

Small group seeks parttime, afternoons, Family Medicine, Internal Medicine or Pediatrics physician: Must be bilingual (Spanish/English or Tagalog/ English); EMR familiar; team oriented; no On-Call, office only. Chula Vista. Opportunity to increase hours, as desired. Medical and dental insurance. Flexible hours. Malpractice paid. Low and middle income patients; established and walk-ins. Send resume to MD, Inc., P.O. Box 533, Chula Vista, CA 91912; Lucy@drpolaksoffice.com; fax: 619.427.6821

BEAUTIFUL, 2,000FT2 MEDICAL SUITE IN PRIME LOCATION AVAILABLE FOR SUBLEASE: Women’s healthcare office located next to Sharp Hospital in Chula Vista is available for sub-lease on Mondays, Wednesdays, and Thursdays beginning June 1. For more information, please contact Jessica at (619) 397-2950, ext. 200. [713] BEAUTIFUL BANKER’S HILL OFFICE SPACE: Available for one or two doctors to share in multi-specialty office. Recently remodeled, ocean views, lab on site, underground parking. Share staff or bring your own. Please call Chris Bobritchi at (619) 233-4044 or email HIVDOCS@ yahoo.com. [712] ENCINITAS OFFICE SPACE SUBLEASE: Beautiful, top-floor office on the Scripps Encinitas Hospital campus has available space to sublet part time or full time. Set up well for any specialty. Available at competitive rates. If interested, please contact us at (760) 753-1104, ext. 1107. [710]

PHYSICIAN POSITIONS AVAILABLE

NONPHYSICIAN POSITIONS AVAILABLE

CALIFORNIA-LICENSED MD FOR CONSULTATIVE WORK: Alternative care/medical marijuana clinic looking for California-licensed MD for consultative work. Part time with excellent compensation. Contact James Gould (760) 7033767. [730] FAMILY PRACTICE PHYSICIAN — ENCINITAS: North County Health Services, a Joint Commission, federally qualified community health center, celebrating 35 years of service, has an opportunity for BC/BE family practice MD for a lead position in our Encinitas health center. Work-life balanced hours, include occasional Saturdays (shared with other clinicians). Attractive compensation, including bonus for call and incentive. Benefit program includes extensive health and welfare benefit choices, retirement plan (403b) with match, generous time off (PTO), holidays, malpractice, and reimbursement for CMEs (expense and time) and licensure. This is an opportunity to make a difference in the lives of patients who are under-insured or do not have insurance coverage, without having overhead expense or management concerns. Spanish language knowledge helpful but not required. Please send CV to C. Bekdache at cynthia.bekdache@nchs-health. org or fax to (760) 736-8740. [717] OB/GYN PHYSICIAN — ENCINITAS: North County Health Services, a Joint Commission, federally qualified community health center, celebrating 35 years of service, has an opportunity for BC/BE OB/GYN. Hours and call shared with other clinicians and NMWs. Attractive compensation, including bonus for call and incentive. Benefit program includes extensive health and welfare benefit choices, retirement plan (403b) with match, generous time off (PTO), holidays, malpractice, and reimbursement for CMEs (expense and time) and licensure. This is an opportunity to make a difference in the lives of patients who are under-insured or do not have insurance coverage, without having overhead expense or management concerns. Spanish language knowledge helpful but not required. Please send CV to C. Bekdache at cynthia.bekdache@nchs-health. org or fax to 760-736-8740. [718] PRIMARY CARE JOB OPPORTUNITY: Home Physicians is a fast growing group of doctors who make house calls. Great pay ($60–$100+/ hour), flexible hours, choose your own days (full or part time). No weekends, no call, transportation and personal assistant provided. Call Chris Hunt, MD, at (858) 279-1212. [711] PHYSICIAN POSITIONS WANTED

LA MESA OFFICE SPACE TO SHARE: Over 6,000ft2 OB/GYN office of four doctors with one leaving, available immediately. 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]

OPHTHALMOLOGIST: Retired, early, given current events. Board certified. Spent entire ophthalmology career in San Diego. Seeks part-time office association. Very flexible. Impeccable local references. Email MJB6520@sbcglobal.net or call cell (858) 382-0552. [715]

A u g u s t

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WOMEN’S HEALTH NURSE PRACTITIONER: Progressive Mission Valley office looking for a part-time/full-time nurse practitioner with strong gynecological experience, including HRT. Fax resume to (619) 220-8567. [726] MEDICAL CODING SUPERVISOR: Experienced, with California coding certificate needed for multi-specialty physician group in Imperial County. Knowledge of all aspects of billing necessary. IT experience a plus. Must have great people and communication skills. Excellent benefits. M–F. Email résumé to framirez@ivfcmg. com. [721] MEDICAL EQUIPMENT 2007 NOVASURE EQUIPMENT IN EXCELLENT CONDITION FOR SALE: The NovaSure System is intended to ablate the endometrial lining of the uterus in premenopausal women with menorrhagia (excessive bleeding) due to benign causes for whom child bearing is complete. The NovaSure procedure takes approximately 90 seconds to perform, has excellent patient outcomes and reimbursement for physicians. The 2008 National Average Medicare Reimbursement Rate is 2,014.80 for in-office procedures. Bought New in 2007 for $25K, lightly used. Price $18K. Please call (760) 473-4002. Please visit www.novasure. com/novasure-procedure. [720] ✚ practice management

PRACTICE MANAGEMENT SERVICES/PRACTICE MANAGER/KEY STAFF JOB SEARCHES: Let the practice professionals find you the right person. Plus, you are not identified. We place the ads, receive the applications, interview the better candidates, do reference checking and bring you the best 2 to 4 candidates for final interviewing. We also do the salary and benefits negotiation with the preferred candidate. We know the medical office and can pinpoint what you need. Reasonable fees. Contact Regina Reading or George Conomikes of Conomikes Associates, Inc.; (858) 720-0379 or email rreading@conomikes.com.

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

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Superior Physicians. Superior Protection.

SAN DIEGO ORANGE LOS ANGELES PALO ALTO

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San diego County Medical Society 5575 RUFFIN ROAD, SUITE 250 SAN DIEGO, CA 92123 [ RETURN SERVICE REQUESTED ]

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