November 2009

November 2009

official publication of the san diego county medical society

You’re Either at the

table

or on the

Menu SDCMS and CMA Advocating for YOU

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1

technologym atters

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Volume 96, Number 11

features

16

Hasta La”Vista, B aby

6 Legislative Advocacy Who Cares? What Difference Does It Make?

Why Bother?

22 What the H*ll Happened?

Healthcare Reform 2009 28 Healthcare Reform 2009 An Early Look Back, From the Liberal Perspective 32 CMA’s 2009 Legislative wrap-up 36 Politics and Advocacy 10 Pretty Good Rules 40 Three Keys to Successful

Legislative Advocacy vious version s of Window s must ha

How NOT to Be a Successful code names of ve haand A d Windows 6, W indows 5, etc While that is .

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at least someone who had other hand was ine. a Democratic real world of medic en months ago, some sense of the ce of inaugurated ss to a cynical audien president was being In fact, his addre at an AMA legrating in excess cians physi 500 with an approval more than on the other March drew a and, early t, in percen rence 70 of islative confe st to ress ia Avenue, a Cong — in marked contra standing ovation end of Pennsylvan in den officials by senior Clinto majorities not seen similar addresses with Democratic with all go to work. And, g some 16 years ago. in a similar settin cades was ready to from of the ents failure uncem the d from nd the early prono the lessons learne how ed what seemed Plan” in 1993–94, the president reflect “Clinton Health not ry input. Four health system reform to be sound adviso could significant ss: 1) proce the well for in particular boded be a fait accompli? was that written, it appears health system reform But as this is being that the goal of ng of but to repair it; perhaps even nothi to replace the system not not too much and year. would in this will come to pass ng the uninsured coveri that 2) real significance if cost mistakes nt payment, even happen? What fact require upfro How could this that and in the future; 3) on the policy side savings might accrue were made, both la worthh rate (SGR) formu growt And can anything side? nable l sustai tactica the the ces be Medicare ts and our practi cian payment in governing physi while for our patien billion should be $228 that flawed was so salvaged? ed President Obama to block the plann y one: diatel square at imme Let’s start allocated physispent -the-board cuts to expert. In fact, he 40 percent, across is not a healthcare beJanuary ry season last year to take effect by cians scheduled the Democratic prima take the issue by no would the ress on Cong led 2013; and 4) that ing publicly schoo a select Hillary bill, as opposed to t Secretary of State lead in writing a less than curren ing interacWhite House releas point where their secret group in the Clinton — to the n TV satire ct, à la the Bill Clinto rly lampooned on their finished produ tions were regula ed Includ Live. ay Night approach. shows such as Saturd rt presithe suppo was of all was that ent’s positions Perhaps the best among the presid test where litmus passing our key “guaranteed issue,” dent seemed to be for the idea of us insurance officials. Those of apply for health for politicians/elected one can wait to has of San m — a policy that ent the physicians who proudly repres until one has a proble ums have learned ed healthcare premi ty and of California Coun Diego more than doubl tried officials: types of elected the states that have that there are two for individuals in avare part of ” to decrease the e that physicians those who believ it. He also “guaranteed um healthhealthcare premi problems facing the solution to the erage annual family e that physicians sing taxes on 98 believ increa who ut those witho care, and by $2,500 since ding to (a promise long problem. By respon are actually the percent of Americans sing” of the tort reform, of “re-ba a area with the in AMA the urging of abandoned). And in a the trial reaching out to AMA stock position of SGR, and by then he articulated the overt — ums have and premi subtle actice both myriad of ways — bar that high malpr d to rather the White House seeme jury awards, but the signal from the little to do with in done rs, even be to d insure al neede med-m be that health reform excess profits of harder, al insurers are physi make it easier, not ways that would though many med-m good was rofit.

This physician. most are nonp to be a practicing cian-owned and govyear this usual the start in contrast to the o it was clear from news, and stood g underpositions comin of overpromise, that the policy ernment approach deothers House would be the physicians and from the White fund, and then let to adthe president chose pieces. the up pick pendent on who get he How did things care and what advice So what happened? vise him on health ic the president’s rhetor them. so far off track? First, would take from were d back early indications care issue has shifte That said, the about the health ry role went to the year, such that adviso ghout major throu A and forth promising. uel, MD who, on oots supporters have Eman grassr l his of Ezekie even many oncologist had presiSecond, Congress the brother of the been left confused. the one hand, was on the chief of staff, but dent’s hard-nosed

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ou missed th e party — act ually, several thousan use Windows d parties.

7 during its be all things Microsoft, there ta testing, reis an explanatio lease candidate On October n.

22, 2009, Mi (RC) stage an Windows 6 wa crod now in ful soft released W Release to Ma s in fac l t Windows Vi indows 7 to mu nufacturing (RT and Window sta, ch s 5 was Wind M). As Comsomehow ma puter Weekly ma ows XP, but pri naging to co gazine attests, to that the log or nvince housands of pe “W ic bre ind is ak Mi ow s down. There crosoft’s most s7 ople around th fac sig wa t Windows 1.0 nificant opera s in e globe heir own “laun tem since Wind ting sysback in Nove ch” parties. Af mb ow W er s 95.” indows 2.0, W 1985, ter all, word-of-mouth indows 3.0, an In our testing, and subsequen d in April 1992 the very Microsoft Wind t ree the most fla popular Wind ows 7 has proven to be ttering of all ow mu s 3.1 ch more stable Windows 95 , then compli, Windows 98 Microsoft despe , faster — on same hardware , Windows 98 rately needed — and more Second Editio good intuitive than n, Windows ause we all kn its predecesso ow that the wo ME r, , Windows Windows Vista NT, Window rd-ofs 2000 — we . As a matter r Microsoft Vis of fact, this pa ll, you get th ta was definite st summer mo picture. Let’s e ly not st of our projust say there nd rather unfla duction deskt we ttering. re too many op machines versions and in our office we not enough wh he “buzz” aro wi pe d re an d ole number asreinstalled wi und the launc signments, an th Windows 7. h pard they did no signed to get It is therefore t get it “right” people to enter until Window important th the at s XP nd host them yo ma . u te acc yo liurself to Wind in order to rec ows 7 and lev eive y of Window your knowled erage 9 s 7 Ultimate ge when makin Wha and a g IT decisions 2 t0Yo0u Need To winning a PC in th e coming mont . I, personally r mabout Windows Know hs . , did o f but maybe yo 7 Architecture u did or some r e As little as po e TabWhy Is You’re Either on ssible if you can r e at the a It le Ca help it. Withlle c d ou W t getting into co indows 7? or on the Menu t H what IT profes Le mplexities of sionals and sh software development an e taus lgo back in time, shall we? Co ops H tio d su btl do over the pa nvennal wisdom su eties of hardw st 12 months ggests that be forms, all you are platis cause the curneed to know rent version is Californiahasperhap are the terms code-named W 32-bit and 64 sreplacedWimpyas indows 7, pre -bi t.

These terms themost 23 ous example of refer to thfam PHYSI CIAN. OrG O PH YS ICI AN way a compute ert E. Hertzka, MD 2009 SAN DIEGO Rob ber row bor e Novem .Or G By the opinions of SDCMS ing aga reflects article r’s No ve mb er inst the future processor hand currently an leaders. Neither to add financing reform 200 9 of SDCMS’ physici are res two healthc from s s of tod opinion les inforay’s appetite. This g views on the issue contain solicited ration of opposin begins on page 28, conside and .org. which ion SDCMS article, year to Editor@ Dr. Priver’s thoughtful discuss

? d e n e p p 22 a h ”

“I’ll Gladly Pay yo u

tuesday for a hamburG This and to the editor ed here to provoke by sending your letters They are publish join the discussion or CMA as a whole.

Please feel free to nation’s capitol. underway in our ber 2009 CIAN. OrG Novem SAN DIEGO PHYSI

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departments 4 Contributors This Issue’s Contributing Writers 6 From Your Executive Director

S

8 SDCMS Seminars/webinars/Events 10 Community Healthcare Calendar 12 Briefly Noted Ask Your Office Manager Advocate and More … marked ano 16the rTechnology Matters significant erosion of California’s financial situation, forcing the gov7: ern or

Windows Hasta La Baby and Leg islaturVista, grapple with a multib e to illion-dollar budget deficit.

20 Risk Management Hospitalists: New Specialty and New Risks 35 SDCMS Endorsed partner benefits Potential Value: $10,000-$17,000 42 Physician Marketplace Classifieds 44 SDCMS Member benefits Concierge Care (Free With Membership) for You and Your Office Manager

Political observers surely felt that Sacramento had fallen Finally, on July into a time warp 28, 2009, Gove as parrnor tisan bickering Schwarzenegger overshadowed signed a new “bala problem nced solving, leaving budget” that prima Californians to endu rily relied on massi re another historically ve cuts and billions late budget. Other in borrowing to pressfill the ing matters, includ defici t.

But even ing prison reform that budget is , water now $4 shortages, and Califo billion in the red rnia’s ever-increa as California’s econo sing my number of unins conti nues to struggle, and ured, took a back next year’s budseat to the budget defici get deficit may t. exceed $10 billio n based n 2008 the gover on current estim ates. It is very likely nor signed two sepathat rate budget accor the Legislature will ds that were suppo once again have to take sed to solve California’s midyear action to address the defici budget woes. Those t now deals proved to be and in the future . badly out of balan ce To make matte rs worse, the gover almost immedinor continued his well-w orn pattern of veiled ately after they threats toward legisla tors for their failur were signed. e to act on issues such as the budge Facing a $40 t, water, and prisons. The governor used a billion budget variety of methods to try to force legisla deficit, legislators to act. At one point the governor sent Senat tors were forced e President Pro Tem Darrell Steinberg to reconvene in (D-Sacramento) a bronz ed sculpture of bull early 2009 and testipass a new budge cles, insinuating t that would suppo that the legislature sedly needed keep California solven a pair. Not surprisingl t through 2010. y, Steinberg and That other budget contained legislators were not $15 billion in cuts, amused. $12.5 billion in new taxes, y the end of the $7.8 billion in federa legislative sesl stimulus money, sion, the governor and $5.4 billion threatened to in borrowing. That budge veto all legislation t also fell short, causin sent to him g the state to face until lawmakers a $21 billion defici sent him a wat by July 2009. ter deal he found acceptable. That threat caused considerab he continual focus le consternation on the budget among Republicans and and the ongoing Democrats alike. need to make Ultimately, the gover massive cuts or nor backed off find new revenues from his paralyzed lawm threat and acted akers for months. on the bills before him.

Democrats refused to The continuing consider any addit strain between the ional Legislacuts and Repub ture and the gover licans were equal nor does not bode well ly adamant that they as major problems would not suppo facing the state rt any continue new taxes. The to loom. Is it any partisan stalemate wonder that the forced Field Poll California to start recently found that the new fiscal year both the governor on and July 1, 2009, witho Legislature suffer ut a balanced budge from historically low apt in place. Many thous proval ratings of 27 percent and 13 ands of state worke percent rs and businesses that respectively? The contract with the only governor with state lower went unpaid, hospi approval ratings tals were left witho than Schwarzen egger ut was reimbursements, Gray Davis, the man and some patien whom Schwarzen ts lost their state-provided egger replaced throu health insurance gh a recall electi while on the governor and in 2003. legislators continued to feud over a soluti For CMA it was on. another busy year.

State budget cuts

t o d a y ” 32 er

— J. Wellington W or the Great State impy of California CMA’s 2009 L e g i s L At i v e

stiD nICo 2BySdu A N E Grco O ran P HY S I CI A N .org 32

SAN DIEGO PHYS ICIAN .OrG

Novem ber 2009

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N ov emb e r 2009

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contributors Dustin Corcoran Mr. Corcoran is senior vice president of the California Medical Association (CMA), a nonprofit organization dedicated to protecting public health and promoting the science and art of medicine. Mr. Corcoran leads a group of six lobbyists in representing CMA’s interests and issues before the California State Legislature. Mr. Corcoran also speaks frequently to organizations about effective lobbying, the political process, and healthcare issues in California. In 2005, Mr. Corcoran was named “Most Effective Lobbyist Under 40” by AroundtheCapitol.com.

TO M G E H RIN G Mr. Gehring is executive director and CEO of the San Diego County Medical Society.

RO B E RT E . H E RT Z K A , M D Dr. Hertzka, SDCMS and CMA member since 1988, is past president of both the San Diego County Medical Society and the California Medical Association, and a current member of the American Medical Association Council on Medical Service. In addition to being an influential force in both health policy and politics at the county, state, and national levels, Dr. Hertzka also teaches two courses on health policy and politics at the UCSD School of Medicine, and serves locally as the chair of San Diegans for Health Care Coverage, an entity created by the County Board of Supervisors to address the issue of the uninsured in San Diego County.

Managing Editor Kyle Lewis Editorial Board Van Cheng, MD, Adam Dorin, MD,

Ted Mazer, MD, Robert Peters, MD, PhD, David Priver, MD, Roderick Rapier, MD Marketing & Production Manager Jennifer Rohr Sales Director Dari Pebdani Project Designer Lisa Williams Copy Editor Adam Elder

SDCMS Board of Directors Officers 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

geographic directors East County William T. Tseng, MD,

Heywood “Woody” Zeidman, MD

D A V I D P RI V E R , M D

Hillcrest Roneet Lev, MD, Thomas V. McAfee, MD

Dr. Priver, SDCMS and CMA member since 1980, is semi-retired from the practice of obstetrics and gynecology. He has been active in SDCMS leadership since 1989 when he began serving on the SDCMS council. He has held a variety of positions, including chairing several committees, president in 1996, and chair of the San Diego CMA delegation from 2001 to 2007. He continues to serve on SDCMS’ board of directors.

Kearny Mesa Adam F. Dorin, MD, John G. Lane, MD

S u s a n Shep a r d Ms. Shepard is director of patient safety education for The Doctors Company, SDCMS’ endorsed partner for professional liability insurance.

O F E R S H I M RAT Mr. Shimrat is founder and CEO of Soundoff Computing Corporation, SDCMS’ endorsed partner specializing in IT products and services.

K at h l ee n S t i l lw e l l Ms. Stillwell is patient safety/risk management account executive for The Doctors Company, SDCMS’ endorsed partner for professional liability insurance.

La Jolla J. Steven Poceta, MD, Wayne Sun, MD North County Arthur “Tony” Blain, MD, Douglas

Fenton, MD, James H. Schultz, MD South Bay Vimal I. Nanavati, MD,

Anna Sanchez Seydel, MD At-large Directors 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,

L a u r e n We n d l e r Ms. Wendler is your SDCMS office manager advocate. She can be reached at (858) 300-2782 or at LWendler@SDCMS.org with any questions your office manager may have.

Send your letters to the editor to Editor@SDCMS.org 4

S A N D I E G O P HY S I CI A N .org N ov emb e r 2009

James T. Hay, MD AMA Alternate Delegates Albert Ray, MD,

Lisa S. Miller, MD

Opinions expressed by authors are their own and not necessarily those of San Diego Physician or SDCMS. San Diego Physician reserves the right to edit all contributions for clarity and length as well as to reject any material submitted. Not responsible for unsolicited manuscripts. Advertising rates and information sent upon request. Acceptance of advertising in San Diego Physician in no way constitutes approval or endorsement by SDCMS of products or services advertised. San Diego Physician and SDCMS reserve the right to reject any advertising. Address all editorial communications to Editor@SDCMS.org. All advertising inquiries can be sent to DPebdani@SDCMS.org. San Diego Physician is published monthly on the first of the month. Subscription rates are $35.00 per year. For subscriptions, email Editor@SDCMS.org. [San Diego County Medical Society (SDCMS) Printed in the U.S.A.]

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fromyourexecutivedirector

By Tom Gehring

Legislative Advocacy Who Cares? What Difference Does It Make? Why Bother?

A

s physicians struggle with the day-to-day challenges of healing patients and running a business, it’s tough to remember that advocacy really matters. After all, advocacy is something someone else does, and physicians almost never see the results today.

In this, our annual advocacy issue, we want to remind you that advocacy matters to every physician — and it matters a lot!

First, the results are often hidden. In his short story “Silver Blaze,” Sherlock Holmes speaks of the guard dog that didn’t bark as the clue to solving a murder. Often, the “dog that didn’t bark” is the bad legislation that wasn’t enacted, the poor decision that was stopped, and the awful ruling that was never made. We all see the affirmative successes, but we seldom see the averted disasters.

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S A N D I E G O P HY S I CI A N .org N ov emb e r 2009

Second, advocacy results often take years to show themselves. Consider that every candidate for state and national office from San Diego County is interviewed, educated, and contacted in a way that, as candidates, they understand physician issues, and, as office holders, they are frequently reminded.

They may not always agree with every position we have, but they sure as heck understand the issues and their impacts.

Third, advocacy is not an arena where everything goes your way. So, while a particular issue may not go exactly the way one would like, sometimes organized medicine has to compromise. Remember: It’s not the operating room where the doctor has the final say!

Fourth, when you speak, the politicians listen. When you are quiet, the voices of

our opponents win. So when we ask you to call your congressional representative or U.S. senators, to fax your California assemblyperson or senator, or to contribute to a campaign, your participation matters, and your failure to participate is noticed.

Lastly, we need you — all of you! Advocacy is the voice of one or two, but with a chorus behind them. That chorus is physician membership. It is the power of one to speak for many. Absent the many, we who do this all the time are just empty voices. We need your membership, we need your contributions to CALPAC, and we need you to get involved when we ask you to. Contact me anytime on my cell at (619) 206-8282 or email me at Gehring@SDCMS.org to discuss how you can get involved!

(About the Author} Mr. Gehring is CEO and executive director of the San Diego County Medical Society.

Solarizing Your Practice

Letter to the

Editor “Primary care physicians should be warned that their responsibilities to their patient do not end upon referral!”

By the very nature of your practice, you are forming long-term bonds with the community. The patients you are seeing today will be the parents and grandparents of patients you will see in the future. Are you taking the same long-term strategic approach to managing your electricity costs?

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In your October issue [“Clinical Trials: Improving Patient Care and Our Ability to Provide It”], there are interesting and related articles concerning healthcare and practices in our area.

Though initially seeming not directly related, the article on “Personalized Medicine” and the one dealing with “Who’s in Charge?” speak to what I perceive as growing problems as we rush to government health control.

Too many private practitioners, particularly in family practice and internal medicine, are becoming triage specialists. They see their panel of patients, and, if care beyond prescriptions is needed, refer the “consumer” to another office or to a (so-called) “hospitalist.”

If that physician shares his cover with other doctors, then the chain of patient custody stretches far too thin and, so often, breaks.

The “Lesson From Litigation” taught in that article should not have been a CPC on epidural abscesses but on maintaining close doctorpatient contact, even if the patient’s primary care has been taken over by another doctor.

Primary care physicians should be warned that their responsibilities to their patients do not end upon referral!

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San Diego SDCMS welcomes comments from our physician Physician readers who are not SDCMS-CMA members [email Response: Editor@SDCMS.org]. Moreover, we would welcome

and encourage nonmember physicians to become part of the solution by becoming SDCMS-CMA members, i.e., by using their beliefs and talents to effect change rather than simply comment on it.

Novemb er 2009 SAN DIEGO P HY SIC I A N. org

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For further information, visit SDCMS.org or contact Lauren Wendler, your SDCMS office manager advocate, at (858) 300-2782 or at LWendler@SDCMS.org.

*

8

November

“Preparing to Practice: What You Need to Know BEFORE You Begin Your Practice” Resident and New Physician Workshop 14 (Sat.) 8:30am–3:30pm “Electronic Health Records: Are You Ready?”

Risk Management Webinar 18 (Wed.) 6:30pm–7:30pm or 19 (Thu.) 11:30am–12:30pm

SDCMS is currently scheduling its 2010 seminars, webinars, and events. Please let us know which topic or topics you’d like us to cover by sending us an email at Editor@SDCMS.org.

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

6th Annual “Top Doctors” Gala

Nov. 7 • The New Children’s Museum • (858) 565-8888, JOhmstede@SDCMS.org

Fresh Start’s Surgery Weekend

Nov. 7–8 • Center for Surgery of Encinitas • freshstart.org

New Developments and Best Practices in Colorectal Cancer Screening

7th Annual Natural Supplements: An Evidence-based Update

Melanoma 2010: 20th Annual Cutaneous Malignancy Update

Scripps Cancer Center’s 30th Annual Conference: Clinical Hematology and Oncology

Nov. 14 • Admiral Baker Clubhouse (Presidio Room) • (858) 458-9439, sbazzo@sandiegoafp.org

Jan. 16–17 • Hilton San Diego Resort and Spa • scripps.org/conferenceservices

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S AN D I E G O P HY S I CI A N . org N ov e mb e r 2009

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brieflynoted

Your Office Manager Advocate Has the Answers!

By Lauren Wendler

Q

We have received a request from an attorney’s office to release a patient’s medical records free of charge because there is a pending Social Security disability claim.

It also states that if the appeal is successful, the provider may bill the patient for the records at up to $0.25 per page, plus reasonable clerical costs. How would we know if the appeal was successful and when to bill

the patient?

Since all of these records are public, you can track when an appeal is successful online if you know in what court the case is being heard (e.g., 1st District Court of Appeal) and the case number or parties in the case. With this information, you can check the online docket system (www. courtinfo.ca.gov/courts/courtsofappeal) and

A

›› Billing Patients for Medical Records ›› Renewing Your DEA License ›› And a Follow-up Question From the August Issue 12

S AN D I E G O P HY S I CI A N . org N ov e mb e r 2009

retrieve the status of the case. For further information, consult CMA’s ON-CALL document #1150, “Patient Access to Medical Records” — available free to SDCMS-CMA members at CMANet.org.

Q A

I do not know if my DEA license has expired. How often do I need to renew my license, and how long does it take?

Your DEA license must be renewed every three years. Renewal applications are mailed out 45 days prior to the expiration date to the last address listed with the DEA; however, the United States Postal Service will not forward applications to a new address. Contact the San Diego DEA field office at (858) 616-4100 if you need to change your address. Renewal applications are processed within approximately four weeks.

Q

In the August issue of San Diego Physician, the article “Medical Records: Frequently Asked Questions” included the question: “Can I thin and purge medical records prior to storage?” The answer was yes,

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Did you know that SDCMS member physicians and their office managers have access to hundreds of practice management questions and answers at SDCMS’ website? Go to www.SDCMS.org/faq to search from among hundreds of economic, legal, employment, licensure, and other questions critical to successfully managing your practice. To access the answers to the questions located in our online FAQ database, you will need to log in. Member physicians should contact Kyle Lewis for assistance in logging in at (858) 300-2784 or at KLewis@SDCMS.org, and member office managers should contact Lauren Wendler at (858) 300-2782 or at LWendler@SDCMS.org. And if you don’t see the question or answer you’re looking for, go ahead and submit your question online as well at the bottom of the www.

SDCMS.org/faq page!

they may be purged because the originals are maintained by the hospital. As a follow-up to this question, one of our SDCMS member office managers asked if hospice records and their progress notes under the category of hospital records can also be purged from records in storage.

The hospice organization should have its own medical records and, as such, the progress notes are maintained in the hospice record. If copies that are sent from the hospice organization to the physician are included in the office practice medical record, then yes, the notes can be thinned and purged. If the hospice organization does not have its own records, the physician should keep the copies of the progress notes in the office practice medical record. The “Medical Records” article from the August issue, along with all San Diego Physician magazine articles, are posted at SDCMS.org.

A

{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.

{

risk tip

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Did You Know?

A Well-planned Patient Selection Process Is a Valuable Tool

By The Doctors Company

M

any medical malpractice claims occur with patients who request elective procedures and are then dissatisfied with the outcome. A well-planned patient selection process can not only be a valuable tool for loss control, but it can also help identify patients who are good surgical candidates. During the initial visit, asking the following questions may help avoid the stress and disruption of a lawsuit or an adverse outcome: • Is this a repeat surgery or repair of another physician’s work?

• Does the patient’s spouse or significant other know about the procedure?

• If yes, does he or she agree with the decision for surgery? If not, why?

• Is the patient financially able to handle the costs associated with the procedure and any additional procedures?

• Is there a history of compliance with pre- and post-op instructions?

• Is the patient a smoker? If so, can he or she desist from smoking for the period of time necessary for maximum healing?

• During the past two weeks (or in the two weeks prior to surgery), has or will the patient experience periods of extended sedentary situations (e.g., long flights, bed rest, extended car rides, etc.)?

It is always beneficial to assess the patient’s body language behavior. Red flags that may warrant additional assessment include, but are not limited to, the following: • Patient appears angry and hostile, and exhibits negative facial expressions.

• Patient is resentful of questions and makes defensive, short, or one-word responses.

• Patient has unrealistic expectations.

• Patient blames another physician for previous treatment.

• Patient appears to be engaged in “doctor shopping.”

Better integration of the patient’s voice in the selection process, as well as increased personal attention to each patient, may help minimize the potential risks of the surgical outcome.

Physicians Get Noticed …

November 7 Assemblywoman Lori Saldaña California State Assembly P.O. Box 942849 Sacramento, CA 94249-0076 T: (916) 319-2076 F: (916) 319-2176 E: assemblymember.saldana@assembly.ca.gov

November 24 Assemblyman Kevin Jeffries California State Assembly P.O. Box 942849 Sacramento, CA 94249-0066 T: (916) 319-2066 F: (916) 319-2166 E: assemblymember.jeffries@assembly.ca.gov

November 11 Senator Barbara Boxer United States Congress 112 Hart Senate Office Building Washington, DC 20510 T: (202) 224-3553 F: (202) 228-2382 E: www.boxer.senate.gov

december 7 Congressman Duncan D. Hunter United States Congress 1429 Longworth House Office Building Washington, DC 20515 T: (202) 225-5672 F: (202) 225-0235 E: www.hunter.house.gov

Wish Your Legislators a Happy Birthday!

Novemb er 2009 SAN DIEGO P HY SICIA N. org

13

brieflynoted

AfterShingles.com w eb s i t e

s n a p s h o t

A

pproximately 1 million Americans will develop herpes zoster, more commonly known as shingles, each year, and everyone who has had chickenpox is at risk.

Twenty percent of shingles sufferers go on to develop post-herpetic neuralgia (PHN) The Patchwork of Hope Network, an educational campaign led by the National Council on Aging and the National Pain Foundation, is designed to raise awareness of shingles and PHN. Featuring several live events throughout the year and in cities across the United States, the campaign combines online educational resources with expert opinion from physicians to help patients understand that they do not have to suffer alone. Event attendees learn about PHN signs

and symptoms and treatment options from local physicians, hear patient testimonials, and meet others affected by the condition.

There is no cure for PHN, but both oral and topical medications are available to help treat the often-debilitating pain associated with the condition. If you have patients or know someone suffering from shingles or PHN, please direct them to AfterShingles.com, an online educational resource about shingles and PHN, its impact on people’s lives, and steps to take to help manage this condition.

SDCMS Foundation Scholarship Winner Embodies Spirit of Service Ruben Carmona, first-year medical student at UC San Diego, believes “whatever you can do to help people, you should do it.” And despite a heavy class schedule, he walks this talk. Whether volunteering across the Mexico border with medical teams, caring for his disabled brother, transporting patients, or offering a shoulder of support to terminal cancer patients, Carmona gives his all. Promoting education among minorities and motivating youths in his community are also very important to Carmona.

His actions, combined with a deep belief in volunteer medical service, are what recently earned him the 2009 SDCMS Foundation Medical Student Scholarship of $1,000 per year for up to four years. The medical student scholarship has been helping future physicians since 2007.

After he graduates from the UCSD School of Medicine in 2013, Carmona plans to give back throughout his medical career be-

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cause, as he states, “I am deeply committed to giving back in a way that honors all who have helped me find my way.” He cited “hope and comfort” as two primary things he will offer his future patients, as he has witnessed the positive difference they make.

Ellen Beck, MD, chair of the Student Scholarship Committee, says, “The selection committee was very impressed with the quality and depth of the applicants. Several finalists, including Ruben, have overcome obstacles, served the community with depth and commitment, and have dreams of service to the underserved.”

Carmona is an inspiration and a great role model for local youth interested in medicine. He is proof that with love in your heart, a desire to succeed, and a solid education, you can realize your dream of being a doctor.

Grateful for the scholarship assistance, Carmona says, “I’ll be an advocate [of the Foundation] for the rest of my career.”

You can read Ruben Carmona’s full essay on the SDCMS Foundation website at SDCMSF.org.

Get in

Touch

Your SDCMS and SDCMSF Support Teams Are Here to Help!

SDCMS Contact Information

Address 5575 Ruffin Road, Suite 250, San Diego, CA 92123 Telephone (858) 565-8888 Fax (858) 569-1334 Email SDCMS@SDCMS.org Website SDCMS.org • SanDiegoPhysician.org CEO/Executive Director Tom Gehring at (858) 565-8597 or at Gehring@SDCMS.org COO/CFO James Beaubeaux at (858) 300-2788 or at Beaubeaux@SDCMS.org Director of Membership DevelopmenT Janet Lockett at (858) 300-2778 or at JLockett@SDCMS.org Director of Membership Operations and Physician Advocate Marisol Gonzalez at (858) 300-2783 or at MGonzalez@SDCMS.org Office Manager Advocate Lauren Wendler at (858) 300-2782 or at LWendler@SDCMS.org Director of Engagement Jennipher Ohmstede at (858) 300-2781 or at JOhmstede@SDCMS.org Director of Communications and Marketing Kyle Lewis at (858) 300-2784 or at KLewis@SDCMS.org Specialty Society Advocate Karen Dotson at (858) 300-2787 or at KDotson@SDCMS.org administrative assistant Betty Matthews at (858) 565-8888 or at BMatthews@SDCMS.org Letters to the Editor Editor@SDCMS.org General Suggestions SuggestionBox@SDCMS.org

SDCMSF Contact Information Address 5575 Ruffin Rd., Ste. 250, San Diego, CA 92123 Fax (858) 560-0179 Executive Director Kitty Bailey at (858) 300-2780 or KBailey@SDCMS.org Associate Executive Director Tana Lorah at (858) 300-2779 or at TLorah@SDCMS.org Patient Care Manager Barbara Rodriguez at (858) 300-2785 or at BRodriguez@SDCMS.org Patient Care Manager Brenda Salcedo at (858) 565-8161 or at BSalcedo@SDCMS.org Program Manager, Surgery Days Alisha Mann at (858) 565-8156 or at AMann@SDCMS.org Healthcare Access Manager Lauren Radano at (858) 565-7930 or at LRadano@SDCMS.org

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

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

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

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

CPA’s and Consultants

SDCMS Tweets!

Follow SDCMS on Twitter.com to keep abreast of H1N1 updates, the latest healthcare reform developments, disaster alerts, and more!

Novemb er 2009 SAN DIEGO P HY SICIA N. org

15

technologymatters

By Ofer Shimrat

Windows 7 Hasta La Vista, Baby

Y

ou missed the party — actually, several thousand parties.

On October 22, 2009, Microsoft released Windows 7 to much fanfare, somehow managing to convince tens of thousands of people around the globe to host their own “launch” parties. After all, positive word-of-mouth and subsequent referrals are the most flattering of all compliments. Microsoft desperately needed good vibes because we all know that the word-ofmouth for Microsoft Vista was definitely not positive and rather unflattering.

In fact the “buzz” around the launch parties was designed to get people to enter the contests and host them in order to receive a free copy of Windows 7 Ultimate and a chance at winning a PC. I, personally, did not attend, but maybe you did or someone you know.

Instead, what IT professionals and shops like ours did do over the past 12 months is

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use Windows 7 during its beta testing, release candidate (RC) stage and now in full Release to Manufacturing (RTM). As Computer Weekly magazine attests, “Windows 7 is Microsoft’s most significant operating system since Windows 95.”

In our testing, Microsoft Windows 7 has proven to be much more stable, faster — on same hardware — and more intuitive than its predecessor, Windows Vista. As a matter of fact, this past summer most of our production desktop machines in our office were wiped and reinstalled with Windows 7.

It is therefore important that you acclimate yourself to Windows 7 and leverage your knowledge when making IT decisions in the coming months.

Why Is It Called Windows 7?

Let us go back in time, shall we? Conventional wisdom suggests that because the current version is code-named Windows 7, pre-

vious versions of Windows must have had code names of Windows 6, Windows 5, etc.

While that is partially true, like all things Microsoft, there is an explanation.

Windows 6 was in fact Windows Vista, and Windows 5 was Windows XP, but prior to that the logic breaks down. There was in fact Windows 1.0 back in November 1985, Windows 2.0, Windows 3.0, and in April 1992 the very popular Windows 3.1, then Windows 95, Windows 98, Windows 98 Second Edition, Windows ME, Windows NT, Windows 2000 — well, you get the picture. Let’s just say there were too many versions and not enough whole number assignments, and they did not get it “right” until Windows XP.

What You Need To Know about Windows 7 Architecture

As little as possible if you can help it. Without getting into complexities of software development and subtleties of hardware platforms, all you need to know are the terms 32-bit and 64-bit. These terms refer to the way a computer’s processor handles infor-

If your patients and clients have difficulty…

• Seeing • Hearing • Speaking • Moving • Remembering The California Telephone Access Program (CTAP) has specialized phones available at NO COST to them!

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For You!

Patients!

Now your patients and clients can stay connected with family, friends, and you!

Ask your patients and clients to contact the California Telephone Access Program today!

Visit: www.ddtp.org Call: 1-800-806-1191 TTY: 1-800-806-4474

To become part of CTAP’s Medical Professionals Referral Network; to order equipment applications; or to schedule an Outreach Presentation about the California Telephone Access Program for your office...

ALL available in multiple languages and AT NO COST TO YOU! Please call

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SDPHYS300

There is no cost, obligation, age, or income requirement for this State mandated program.

technologymatters

XP mode within Windows 7 is a virtual machine that runs a full copy of Windows XP Service Pack 3 — for free. mation and can fully leverage the amount of random access memory (RAM) installed in the system.

The 32-bit version of Windows 7 handles up to a maximum of 4 GB of RAM, while the 64-bit version of Windows 7 can theoretically handle 16 EB — if you must ask, that’s exabytes.

Keep in mind that not all computer hardware is 64-bit capable, and, more importantly, your line-of-business (LOB) application or EMR suite at your office may not be 64-bit compatible.

So moving forward for the next six to 12 months, the safest hardware/software combination for your practice is 64-bit capable hardware and 32-bit version of Windows 7.

Windows 7 Versions

While many editions of Windows 7 were released worldwide, only five versions are for sale in the United States. These five main versions are available through retail or through a Microsoft licensing agreement with your IT vendor or reseller: • Windows 7 Starter: Only available in 32bit and cannot join a business network, this version is pre-installed on small form factor computers (i.e., Netbooks) and for educational purposes. Do not consider this version for your practice.

• Windows 7 Home Premium: This version is available for both 32-bit and 64-bit machines and is primarily designed for the home market segment. It includes numerous multimedia features but cannot join a business network. As in the case of Windows 7 Starter versions, do not consider this version for your practice.

• Windows 7 Professional: This edition includes all of the features of Windows 7 Home Premium but does include the ability to join a business network, server, or domain. It adds additional businesscentric functions like remote access,

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location-aware printing, encrypted file system, and XP mode (see below). This version should be considered for the small- to medium-size practice.

• Windows 7 Ultimate: This version includes all features of Windows 7 Professional and adds additional business functionality designed for larger businesses such as drive encryption, managed application access, UNIX application support, etc. This version should be considered for medium- to large-size practices and can be purchased via retail or via Microsoft licensing from your IT vendor or reseller.

• Windows 7 Enterprise: All the features of Windows 7 Ultimate but not available through retail or system builder channels (i.e., HP, Dell). This edition is only distributed through Microsoft licensing and does include additional enterprise-level features, including a license allowing the running of multiple, virtual machines, multi-lingual user interfaces, etc. This edition targets the large to very large practice or hospital.

So take note: While there may be five versions of Windows 7 offered in the United States, only three are right for your practice. All three of them have a feature called XP mode.

XP Mode

There are many new features introduced in Windows 7, and while many of them improve on usability, stability, screen ergonomics, and performance, there are also numerous advances made to the operating system that offer compelling business advantages. Among them is a new feature that is called XP mode. This feature only comes with the aforementioned Windows 7 version recommendations of Professional, Ultimate, or Enterprise.

Without delving too deeply into the technical aspects, you need to know that XP mode within Windows 7 is a virtual ma-

chine that runs a full copy of Windows XP Service Pack 3 — in other words, Windows 7 runs a virtualized copy of Windows XP within itself — for free.

This is huge.

It effectively future-proofs your new hardware/software investment by allowing you to run new applications under Windows 7 in the foreground and legacy (i.e., EMR, financial, medical) applications under a virtual Windows XP session in the background.

Of course, you will have to check with your software vendor to ensure that XP mode is supported, but the possibilities are endless.

The Bottom Line

The decision on how and when to move to Windows 7 may be easier than you think.

Three scenarios: • I f your practice is still using computers running Windows XP — released exactly eight years ago in 2001 — you will want to seriously consider new hardware and Windows 7 installed.

• If your computer is newer and already running Windows Vista, then the hardware specs are good enough for Windows 7 to run as well or better.

• I f you are planning to purchase a new computer, laptop, or tablet, make sure it comes with Windows 7 installed. Do not settle for Windows Vista.

In all cases with Windows 7 make sure the versions are business-friendly — Professional, Ultimate, or Enterprise — and that your specific line-of-business application (LOB) or EMR supports Windows 7 or XP mode. At this time we are recommending Windows 7 Professional or Windows 7 Ultimate.

Moving forward with proper planning, the selection of the right version and architecture of Windows 7 should allow you to bid “Hasta la Vista, baby.”

{About the Author}

Mr. Shimrat is founder and CEO of Soundoff Computing Corporation, a consultancy specializing in IT products, hardware/software, and managed services. Originally an applications developer, he brings database methodology approaches to network implementations. He combines practical experience as a thrice business owner with best practices in providing organizations with needs analysis, business logistics, IT infrastructure, and proactive maintenance. Visit SoundoffComputing. com or reach him at (858) 569-0300.

POLITICAL REALITY:

You’re Either at the Table or You’re on the Menu We’re at the Table, Every Day …

By choosing to join the San Diego County Medical Society (SDCMS), over 3,000 practicing physicians, residents, and medical students in San Diego County have given voice to our patients and to our communities in the health care reform discussions and in every single health care issue being debated today locally, in Sacramento, and in Washington, DC.

The next time you see your doctor, 1be sure to ask: 11“Are You a Member of SDCMS?”

San Diego County Medical Society (SDCMS) 5575 Ruffin Road, Suite 250 San Diego 858.565.8888 SDCMS.org

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Tired of paying inflated legal bills? With a physician-attorney on your side, you won’t. Our system uses NO BILLABLE HOURS, saving you about half the normal fee.

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riskmanagement

By Susan Shepard and Kathleen Stillwell

Hospitalists New Specialty and New Risks I neffective handoffs can lead to inappropriate treatment, delays in diagnosis, and potentially life-threatening adverse events. In the October 2009 article, “Who’s in Charge? Lessons From Litigation” by David B. Troxel, MD, medical director of The Doctors Company, each of the hospitalists in the case study missed opportunities to diagnose the patient’s condition due to communication gaps and inattention to documentation among the members of the healthcare team: • Hospitalist B did not review the medical record and did not communicate to hospitalist A that the patient fell.

• Neither hospitalist A nor B examined the patient following the fall, and the fall was

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not communicated to hospitalist C. • Hospitalist C did not communicate with either A or B about the patient’s inability to stand.

• Hospitalist D failed to communicate the urgency of the MRI to the on-call neurologist.

In “Who’s in Charge?” there are many examples of communication and handoff breakdowns that led to the patient injury.

Because the hospitalists involved in the case study didn’t use a standard set of critical elements to be communicated with each handoff or interaction, there were delays in diagnostic testing and treatment and failures in recognizing the patient’s neurological deficits, which resulted in the unfortunate

outcome.

By understanding the problems that can occur during handoffs and planning effective communications, the hospitalists in this case could have minimized risk and enhanced patient safety.

The Shift Toward Hospitalists

Over the past decade there has been a dramatic shift away from primary care-directed hospital care toward a model in which hospital-based physicians — hospitalists — provide care to inpatients.

In fact, the hospitalist field has now become the fastest-growing specialty in the history of American medicine, skyrocketing from 1,000 physicians nationally in the mid-1990s to more than 28,000 today.

Researchers at the University of Texas Medical Branch (UTMB) at Galveston have produced the first quantitative analysis of the increase in the number of hospitalists.

In a paper appearing in the March 12, 2009, issue of the New England Journal of Medicine, UTMB Associate Professor Yong-Fang Kuo

used Medicare data to calculate that the percentage of internal medicine physicians practicing as hospitalists jumped from 5.9 percent in 1995 to 19 percent in 2006. (1)

Hospitalists and Effective Communication

The goal of the hospitalist medicine model is to provide a coordinated approach to the care of inpatients. This requires the hospitalist to be skilled in effective communication between physicians and the rest of the hospital clinical team involved in the care of the patient. The processes and systems within the hospital environment create potential barriers to effective communication, in areas including: • key information unknown or not passed along; • poorly defined roles of hospitalist, admitting physician, and specialist(s); • high volume of information arising from a multitude of sources; • and lack of standardization of processes within the facility.

In fact, studies have indicated that lack of communication is the single most common root cause that can lead to liability claims.

However, all of the above concerns can be minimized with effective communication techniques and processes.

Handoffs

The primary objective of a handoff is to provide accurate information about a patient’s care, treatment, current condition, and any recent or anticipated changes. Handoffs are interactive communications allowing the opportunity for questioning between the provider and the recipient of patient information. For hospitals, the handoffs that occur during the time when a patient is moved to another unit, sent for a diagnostic test, or transferred to a new physician can create continuity of care issues. Hospitalists can use the following tips to improve effective communication during handoffs: • Use standardized communication tools such as the mnemonic “HANDOFFS” (2).

• Allow interactive communication for questions/discussion and require repeatback of the exchanged information.

• At a minimum, include the following during handoffs: diagnoses, current condition, recent changes in condition or treatment, anticipated changes, and warning signs of changes in the patient’s condition.

• Limit interruptions during handoffs.

• Use the following questions for guidance in organizing communication during the handoff: • What is important to communicate?

• Who needs to know what information?

• When should communication occur?

• How should the information be transmitted?

• How can I validate the communication was successful?

Conclusion

The hospitalist is responsible for the comanagement of patients involving a wide range of physicians and other clinicians. It is critical for the hospitalist to communicate effectively with the healthcare team, the patient, and the patient’s family to limit risks and enhance patient safety.

“Privileged to Provide Care and Clinical Research Since 1975”

To better serve you and your patients … The San Diego Arthritis Medical Clinic announces

new exTenDeD hOurS Of InfuSIOn ServICeS— Mission valley 7:00AM until 6:00pM Monday thru friday

(About the Authors}

Ms. Shepard is director of patient safety education and Ms. Stillwell is patient safety/risk management account executive, both for The Doctors Company, SDCMS’ endorsed partner for professional liability insurance. Most SDCMS members are eligible for a 5 percent discount on insurance premiums and a 7.5 percent dividend credit. To learn more, contact Janet Lockett at SDCMS at (858) 300-2778 or at JLockett@SDCMS.org. Visit TDC online at TheDoctors.com.

References 1. Kuo Y, Sharm G, Freeman J, Goodwin J. Growth in the care of older patients by hospitalists in the United States. N Engl J Med. 2009;360(11):1102-1112.

2. Brownstein A, Schleyer A. The art of HANDOFFS: a mnemonic for teaching the safe transfer of critical patient information. Resident and Staff Physician [serial online]. 2007;53(6).

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

providing excellence in the administration of remicade, Orencia, rituxan, reclast, Aredia, Boniva Iv and other leading medications for the treatment of rheumatologic, dermatologic and gastroenterologic disorders San Diego Arthritis Medical Clinic 3633 Camino del rio South, #300 (intersection of I-8 and I-15)

San Diego, CA 92108-4014

Michael I. Keller, M.D., Director Puja Chitkara, M.D. Ara H. Dikranian, M.D. Oleg Gavrilyuk, M.D. G. Paul Ignat, M.D. Smitha Chiniga Reddy, M.D. Timothy F. Lazarek, F.N.P. Jennifer Marconato, R.N. For more information, please contact Vicki, Infusion Coordinator

619.287.9730 x 590 www.SanDiegoArthritis.com Offices: Mission Valley, Poway, Chula Vista, El Centro, & Yuma, AZ

Novemb er 2009 SAN DIEGO P HY SICIA N. org

21

You’re Either at the Table

or on the Menu

”

h t T A H W

e n e pp a h H e althcar

e

R e form

By Robert E. Hertzka, MD This and Dr. Priver’s article, which begins on page 28, contain solicited opinions from two of SDCMS’ physician leaders. Neither article reflects the opinions of SDCMS or CMA as a whole. They are published here to provoke thoughtful discussion and consideration of opposing views on the issue of healthcare financing reform currently underway in our nation’s capitol. Please feel free to join the discussion by sending your letters to the editor to Editor@SDCMS.org.

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2

e h

? d e 0 0 9

T

en months ago, a Democratic president was being inaugurated with an approval rating in excess of 70 percent, and, on the other end of Pennsylvania Avenue, a Congress with Democratic majorities not seen in decades was ready to go to work. And, with all the lessons learned from the failure of the “Clinton Health Plan” in 1993–94, how could significant health system reform not be a fait accompli?

But as this is being written, it appears that not too much and perhaps even nothing of real significance will come to pass this year.

How could this happen? What mistakes were made, both on the policy side and the tactical side? And can anything worthwhile for our patients and our practices be salvaged?

Let’s start at square one: President Obama is not a healthcare expert. In fact, he spent the Democratic primary season last year being publicly schooled on the issue by no less than current Secretary of State Hillary Clinton — to the point where their interactions were regularly lampooned on TV satire shows such as Saturday Night Live. Included among the president’s positions was support for the idea of “guaranteed issue,” where one can wait to apply for health insurance until one has a problem — a policy that has more than doubled healthcare premiums for individuals in the states that have tried it. He also “guaranteed” to decrease the average annual family healthcare premium by $2,500 without increasing taxes on 98 percent of Americans (a promise long since abandoned). And in the area of tort reform, he articulated the stock position of the trial bar that high malpractice premiums have little to do with jury awards, but rather the excess profits of med-mal insurers, even though many med-mal insurers are physician-owned and most are nonprofit. o it was clear from the start this year that the policy positions coming from the White House would be dependent on who the president chose to advise him on healthcare and what advice he would take from them.

That said, the early indications were promising. A major advisory role went to oncologist Ezekiel Emanuel, MD, who, on the one hand, was the brother of the president’s hard-nosed chief of staff, but on the

S

other hand was someone who had at least some sense of the real world of medicine.

In fact, his address to a cynical audience of more than 500 physicians at an AMA legislative conference in early March drew a standing ovation — in marked contrast to similar addresses by senior Clinton officials in a similar setting some 16 years ago. nd the early pronouncements from the president reflected what seemed to be sound advisory input. Four in particular boded well for the process: 1) that the goal of health system reform was not to replace the system but to repair it; 2) that covering the uninsured would in fact require upfront payment, even if cost savings might accrue in the future; 3) that the sustainable growth rate (SGR) formula governing physician payment in Medicare was so flawed that $228 billion should be allocated immediately to block the planned 40 percent, across-the-board cuts to physicians scheduled to take effect by January 2013; and 4) that Congress would take the lead in writing a bill, as opposed to a select secret group in the White House releasing their finished product, à la the Bill Clinton approach.

Perhaps the best of all was that the president seemed to be passing our key litmus test for politicians/elected officials. Those of us who proudly represent the physicians of San Diego County and of California have learned that there are two types of elected officials: those who believe that physicians are part of the solution to the problems facing healthcare, and those who believe that physicians are actually the problem. By responding to the urging of AMA with a “re-basing” of the SGR, and by then reaching out to AMA in a myriad of ways — both subtle and overt — the signal from the White House seemed to be that health reform needed to be done in ways that would make it easier, not harder, to be a practicing physician. This was good news, and stood in contrast to the usual government approach of overpromise, underfund, and then let the physicians and others pick up the pieces.

So what happened? How did things get so far off track? First, the president’s rhetoric about the healthcare issue has shifted back and forth throughout the year, such that even many of his grassroots supporters have been left confused. Second, Congress had

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much more ambitious goals than anything the president campaigned on, and much more ambitious than what the American people, as it turns out, seem willing to pay for. But most importantly, the president and his White House team of political advisers (who supplanted the influence of the healthcare advisers over time) have underestimated the complexity of the issue of the uninsured.

To the latter, I have used the term “Guantanamo-ization of healthcare” to predict and now describe the challenges that the president and Congress have been facing this year in health system reform. Recall that the president precipitously announced his decision to close the infamous Guantanamo prison this past January without a clear plan. At that time most observers real-

college expenses, who happens to have just lost their job, or who works for some kind of unenlightened employer who does not provide health insurance. Most believe that the low-income worker at minimum wage has access to Medicaid or some other safety net program — perhaps even the president thought this. owever, the hard truth is anything but that. According to the most recent (October 2009) Kaiser Family Foundation survey, in California and 30 other states, childless adults are ineligible for Medicaid coverage, leaving them with only county indigent programs as an option.

And parents do little better: Thirty-three states consider them “fat cats,” ineligible for Medicaid if their income is at or above the federal poverty level (FPL), even though the

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dent, thinks they are. We are all disgusted by the multimillion dollar salaries of the top management of the big insurers, but if you actually look up the compensation numbers and realize that the large private-sector health insurers cover more than 100 million Americans, the “rebate” if all the top managers of all the big for-profit health insurers worked for free would come out to no more than $1 per covered life.

And those much-disdained administrative costs that are there for the taking in a reformed healthcare system? Well, according to the Democratically controlled CBO, the Democratically controlled White House Office of Management and Budget, and the much-respected Kaiser Family Foundation, the amount of the healthcare dollar that goes to private-sector administration is

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t appears that not too much and perhaps even nothing of real significance will come to pass this year. How could this happen? What mistakes were made, both on the policy side and the tactical side? And can anything worthwhile for our patients and our practices be salvaged? ized that the issue of relocating hundreds of committed terrorists was far more complex than the president realized, and that in one form or another, the president would end up with a difficult implementation, and perhaps even backtracking on that decision, as he is presently doing. imilarly with health reform, it was not going to take long for the realities and the complexities of health system reform to overwhelm the politics. And while one could write an entire article on any one of these, here are just two of many examples of where the ambitions of this year’s health system reform efforts have met with reality: ONE: The uninsured are not nearly as affluent as most observers think. Most Americans who voted for the president and who want to see the uninsured get covered imagine that the uninsured are “just like you and me.” That is to say, a person with a home and at least one car, saving for their child’s

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FPL is only $10,830 for a single person and $14,570 for a couple.

Who then makes up the bulk of the uninsured? Well, according to the latest figures from the Congressional Budget Office (CBO), some 29 million (65 percent) of the nation’s 47 million uninsured are adults who live above their state’s Medicaid eligibility level but below 150 percent of FPL, meaning that they are a single person with an income below $16,245 per year or a couple with income below $21,855 per year.

These folks are poor, if not flat-out destitute, and cannot become insured with the assistance of a small government subsidy; they need the taxpayers to pay the entire bill. Oh, and by the way, at least 15 percent of those 29 million, and probably more, are undocumented.

TWO: The private-sector health insurers despised by all are not the big pot of money that everyone, including the presi-

7 percent. And for those salivating to grab even that 7 percent of the healthcare dollar, it gets worse. It turns out that most of that 7 percent goes to: a) eliminating the kind of fraud that is rampant in publically administered programs (10–15 percent in Medicare, up to 20 percent in Medicaid); and to b) forming provider networks. That is why, despite the ongoing political rhetoric about setting up a nonprofit, governmentrun health insurance plan — or “public option” — to “compete” with private insurers, the CBO has scored zero savings from such a plan, unless such a government option “hijacks” existing Medicare providers at existing and underpaying Medicare rates. ut while these and other challenges may have been underestimated as the health system reform debate took shape this year, there were those who felt certain that the president’s calm demeanor and unquestion-

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able intelligence would carry him through.

And he certainly had a great message: Forty-seven million uninsured Americans is a national embarrassment, so a proposal that reduces that number would be a good thing.

Even most Republicans agreed with that. hy then did the president immediately start to use discredited statistics and hyperbole to sell the idea of health system reform? In his first address to the nation about reform back in February, one of the first things he said was that healthcare costs cause a bankruptcy every 30 seconds (more than 1 million people per year). How does that work? Does taking Lipitor make you miss your mortgage payment? It turns out that the president was advised to rely on discredited studies from single-payer advocates that included as victims of “medical bankruptcy” people whose bankruptcy filing showed that they had had $1,000 in medical bills over the prior year, even if their bankruptcy involved $500,000 or more in other debts. Folks who felt deProject4:Layout 1 9/22/08 pressed prior to their bankruptcy filing 11:22 and

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people who were filing bankruptcy solely from gambling debts were also included as “medically bankrupt,” even if they had no medical bills. The true “medical bankruptcy” rate? At most 5 percent of all bankruptcies.

It just seemed odd. If you have a 70 percent approval rating and health reform is a good idea, why scare people? Why say that 14,000 people a day are losing health insurance when every day 11,000 people are signing up? What is the big rush? Why try to scare the American people, unless you suspect that you are about to try to sell them something that they may not want?

And as the year has proceeded, the president has never stopped trying to scare people and never really left “campaign mode” — yet has dramatically changed his message from month to month. In February, the message was that health system reform was the key to an economic recovery, even though our economic problems related more to a housing bubble than a healthcare crisis. By April, the new message was that health sysAM Page 1was going to help with our longtem reform

term budget deficit, even though it was clear that more than $1 trillion would be spent over the next 10 years without any consensus on where that kind of revenue would be found. Remember, passing Medicare in 1965 was controversial, but the message was clear: Millions of retired seniors without access to job-based health insurance needed a program. Clear; simple. ut despite a need for such clarity, the message from the White House kept changing, alternating between a moral imperative to “do the right thing” and an economic imperative to save money. In May it was “bend the cost curve,” highlighted by a series of orchestrated press events where physicians, hospitals, pharma, and others pledged savings — but had no real plans. And in June it was time to show some love to AMA with a nationally televised address skillfully written to draw a nonstop series of standing ovations.

Meanwhile, Congress had no time for speeches and little concern for arguments.

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The congressional leadership saw a oncein-a-lifetime chance to get all Americans covered and, as such, developed some very extensive legislation. Their bills all mandated that everyone would have to get health insurance (which is, in fact, a necessary step to get the “young invincibles” into the insurance pool and lower costs for everyone else), but the benefit packages mandated by all of the bills were extensive and expensive: comprehensive, all-inclusive insurance with limited co-pays for all, subsidized 100 percent by the taxpayers for at least 65 percent of the currently uninsured. nd most disappointing was that the mechanism for insuring many of the currently uninsured under these congressional proposals would be an expansion of the current Medicaid program, with enhanced funding for primary-care services only. Given that Medicaid has been largely abandoned by specialty physicians and is a major cost drain to most hospitals, calling this an expansion of access to care is at best wishful thinking and at worst a cruel joke.

The entire debate until mid-June was about how extensive the expansion of coverage in health system reform should be.

That changed, however, that June day the president addressed AMA. But not because of the speech — it was because one hour after the speech, the CBO began to release a series of analyses detailing just how expensive these plans would be.

Overnight, the debate began to turn on not what was in these $1-trillion proposals, but rather how to make them “budgetneutral,” i.e., pay for them. And the reality is that there are not enough rich people to tax to pay for health insurance coverage for 47 million people, nor are there enough vices (cigarettes, liquor, high-fructose soda) to tax.

And the president’s own idea — decreasing the value of home mortgage and charitable deductions by 30 percent for those families making over $250,000 — was dead on arrival in Congress. ut there remained one revenue source that the CBO estimated could provide more than $400 billion over 10 years, which was to tax those individuals with more luxurious healthcare coverage on the “high end” of their benefits.

If there ever was a tax that could make sense, this is it. Recall that the largest tax

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break — by far — in our entire tax code is that employees are not taxed on the value of the health insurance that is provided to them by their employers — no matter how generous. So the status quo is that tens of millions of Americans have health insurance that may give them any and all brandname pharmaceuticals with no co-pay, and any and all scans with no co-pay — in fact little to no co-pay on any service. So while most of our patients in San Diego County have to pay extra for brand-name drugs and the like, these fortunate folks, numbering in the tens of millions (mostly in the unionized Midwest and Northeast), are positioned to receive most any healthcare service they wish — at little or no cost to them. Good for them, except that we taxpayers subsidize them to the tune of tens of billions of dollars per year. A better way would be that everyone could continue to receive health insurance that covers a standard set of services tax-free, but that those who receive so-called “Cadillac plans” costing up to $40,000 per family per year would pay income tax on the difference between a standard benefit package and their “Cadillac” level. t looked promising. The critically important Senate Finance Committee appeared close to what would have been a bipartisan health reform bill funded half or more by this revenue. But this is where the president made what may end up being viewed as a big mistake by rejecting outright this funding option. Apparently, the labor unions that have negotiated these kinds of benefits were opposed to seeing them subject to taxation, and the president’s political advisers reminded him that he had promised not to increase taxes on anyone making less than $250,000. [NOTE: The idea of taxing “Cadillac benefits” has since been resurrected, but now as a tax on the insurance companies themselves. This is not nearly as good an idea, as the insurance companies will just pass on the costs of those new taxes to the price of their premiums.]

However, despite removing the most promising funding source by far from consideration, the president insisted that legislation be fast-tracked to pass both houses by the end of July using other funding sources.

That frenzied July effort failed in both the House and the Senate but made the public more uneasy about the whole process.

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Heading into the August recess, the president pivoted again, this time to say that passing health system reform legislation was the only way to get insurance reform.

The new message was that no one was safe from their private insurer, that any day your policy could be retroactively cancelled, or the life-saving treatment recommended by your physician could be denied. That message certainly had some truth, and certainly polled well, but the American people could not help but ask why eliminating preexisting-condition clauses and the like from their health insurance policies would cost the country $1 trillion. ext came the town halls, which seemed like democracy reborn to one side of the partisan divide and domestic terrorism to the other. But for all the noise and fury, and putting aside all the death panel rhetoric, extensive polling by entities such as The New York Times and summarized just weeks ago by esteemed pollster Robert Blendon in The New England Journal of Medicine showed just how deep a hole the president and the Democrats in Congress have dug for themselves.

No less than 65 percent of Americans now believe that if health system reform passes, their own healthcare costs, if anything, will go higher. An identical 65 percent believe that the quality of their healthcare, if anything, will get worse. And 91 percent believe that if health system reform passes this year, their own taxes will go up in order to help pay for it. (As a side note, 90 percent of Americans believe that they are already paying as much federal tax as they can handle, leaving 1 percent who are OK with having their taxes raised for health system reform.) he response of health system reform proponents to the town halls was not helpful. Calling people un-American or pawns of insurance companies or spreaders of lies does not help the cause. Neither does a national call to send “fishy emails” to the White House — can one imagine the horror if President Bush had made a similar request?

And then, when the tone of the debate needed to get less rather than more contentious, the president made what in my mind was his biggest mistake of the year, which was to repetitively attack the rank-and-file physician. First came his statement that

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tonsillectomies are done to pad physician income. This was followed by a statement that implied that rather than counseling a diabetic, we physicians cannot resist the time efficiency and apparent “$30,000, $40,000, or $50,000” fee associated with a foot amputation (actual reimbursements range from $400 to $700 depending on the surgery). Who was won over by those statements and others remains a mystery, but there is no doubt that the president has lost considerable standing among physicians as a result of these statements — and for no apparent reason. o where do we stand today as a nation? In Washington, DC, the president continues to speak out about health system reform, and has now added the “fiscal responsibility” message that he will sign no bill that adds to the deficit in the first 10 years. Fair enough, but since all the 10-year bills in Congress raise taxes for all 10 years but defer providing any coverage of the uninsured until at least year five, they are all in deficit by year 10 and will all then have a significant negative impact on the deficit in the second 10 years.

All this is hardly reassuring to those who assign a high priority to our nation’s long-term fiscal stability. And it is terrifying to physicians looking at a 21 percent Medicare fee cut on January 1, 2010, with another 20 percent to follow by 2013. It is impossible to fix the flawed sustained growth rate (SGR) formula without adding to the deficit. [LATE NOTE: An attempt to pass a $228 billion SGR fix as a separate piece of legislation has failed.]

To the general public, peripatetic efforts notwithstanding, the president finds himself facing a situation where the solid support level for the current health system reform efforts stands at his Democratic base level of 30 percent, with a comparable number in vehement opposition. The remaining 40 percent tell pollsters that they are deeply confused, and this after the most public exposure ever on a single issue by one of history’s most inspirational communicators. n an individual level, seniors are worried about how they will be affected by hundreds of billions in Medicare “savings.” And if there really are hundreds of billions to be saved within Medicare, should not those savings be applied to the looming

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multi-trillion dollar Medicare deficit?

And young people wonder about being mandated to buy comprehensive insurance when a catastrophic plan is all that most might really need. Can the president persuade more than half of those currently undecided that what he has been talking about 24/7 for months is actually good for them after all?

In Congress, the House of Representatives has 257 Democrats (218 constituting a majority), but 72 of those representatives are in districts that voted Republican for either Congress or president within the past four years, including 50 districts that voted for John McCain in 2008. Passage of comprehensive legislation is still possible, but far from certain. he Senate has 60 Democrats (including two Independents that usually vote with the Democrats) but has nowhere near 60 votes for the kind of major health reform bill that may come out of the House. More specifically, there are not 60 votes in favor of any significant funding mechanism. The one exception might be the flawed “Cadillac tax” proposal, but 173 House Democrats (and every House Republican) are already on record as opposed to that. With that option gone, where does the Senate go? There are not 60 votes to tax rich people, or tax medical devices, or even to dramatically squeeze the so-called Medicare Advantage plans. inally, where do we stand as physicians? After what started out as a promising process that seemed to involve physicians as part of the solution to America’s healthcare problems, we find ourselves in the uncomfortable — and incorrect — position of being identified as a big part of the problem. We are also looking at the potential of one more overpromised, underfunded government program that will make it impossible for many thousands of our colleagues to even stay in practice.

One more thing: As physicians, one has to wonder why, in a situation where everyone in healthcare will end up making economic sacrifices, the one group who will apparently walk away unscathed will be the lawyers.

What would have saved this whole process would have been to start over, to learn from this year’s mistakes, and to put together policies that could easily garner support of more than 50 percent of the people. One

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of these would be an individual mandate geared toward catastrophic and preventative care, which would both prevent those medical bankruptcies that do occur, as well as allow for the kind of insurance reforms that Americans want. That is because once everyone has to obtain a minimum level of insurance, it is then feasible to reform the insurance market such that we could have “guaranteed issue” and a reasonable level of community rating. nother good policy would be to establish insurance exchanges such as have been up and running in Massachusetts. Such exchanges have been very successful and save small businesses the hassle and expense of using brokers to shop for their health insurance (brokers often take 10 percent or more of premium in commission). Subsidies to participate in such an exchange could easily be made available for many millions of the uninsured, funded easily by the aforementioned tax on high-end healthcare benefits.

And still another good policy would be to nationalize the kind of student loan repayment program for primary care physicians that we have in California, where for all of $3.5 million per year, we have 100 full-time, board-eligible physicians working in underserved areas.

But this is not the time to suggest good policies in Washington, DC. Rather, it is the time when urgency, anger, bluster, and panic all come together in a frenzied attempt to “pass a bill.” Then the politicians all go home and we physicians hope that they have not actually made things worse.

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{About the Author} Dr. Hertzka, SDCMS and CMA member since 1988, is past president of both the San Diego County Medical Society and the California Medical Association, and a current member of the American Medical Association Council on Medical Service. In addition to being an influential force in both health policy and politics at the county, state, and national levels, Dr. Hertzka also teaches two courses on health policy and politics at the UCSD School of Medicine, and serves locally as the chair of San Diegans for Health Care Coverage, an entity created by the San Diego County Board of Supervisors to address the issue of the uninsured in San Diego County.

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Healthcare

Reform

2009 An Early Look Back, From the Liberal Perspective

By David Priver, MD

NOTE: This and Dr. Hertzka’s article, which begins on page 23, contain solicited opinions from two of SDCMS’ physician leaders. Neither article reflects the opinions of SDCMS or CMA as a whole. They are published here to provoke thoughtful discussion and consideration of opposing views on the issue of healthcare financing reform currently underway in our nation’s capitol. Please feel free to join the discussion by sending your letters to the editor to Editor@SDCMS.org.

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09

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You’re Either at the Table

or on the Menu

In the months and years to come, there will certainly be no shortage of retrospective analyses of the events that currently comprise the efforts to reform what is, by all reasonable viewpoints, a most dysfunctional system of financing the healthcare provided to America’s citizens.

That there is a need for such reform is universally agreed upon, with the glaring exception of the one industry that continues to thrive with the status quo: private companies that sell health insurance policies.

For the health insurance industry, it would be hard to imagine a more profitable system. For everyone else, it’s hard to contemplate a less beneficial one. The United States pays far more than any other country for healthcare but ranks nowhere near the top in the quality of its citizens’ health. This has been the case for at least the past 60 years.

No wonder, then, that repeated efforts have been made to find a way to make the care we receive become worth what we pay for it. Despite these massive costs, there remain fully 47 million Americans who are uninsured. he year 2009 will be looked back upon much like so many of these previous efforts. At this exact moment in time, it is anyone’s guess as to what, if any, legislation will finally emerge from our Congress. There is, however, something unique about the present situation. Never before has there been such intense acrimony and hostility accompanying the debate.

One can argue over why this is so. It’s hard to imagine that either side looks upon what has transpired so far as an optimal and gratifying exercise in policymaking. The depth of feeling that has been created over this issue certainly has the potential to make future bipartisan and cooperative efforts on other issues just that much harder to secure.

For these reasons, then, it is, I believe, not unreasonable to look back over the past several months and consider whether it had to be this way. What strategies might have been

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employed by the “liberal” side that would have rendered the matter what it should have been: a reasoned, informed, and courteous negotiation with the goal of producing not only improved quality of healthcare but a sense of cooperative accomplishment with a focus on common ground instead of differences? In the following paragraphs, I will present some thoughts on how the liberal community, of which I proudly consider myself a member, could have and should have stepped forward to promote the wellbeing of its citizens by reforming the system by which healthcare is financed. I do so not out of any sense of impending failure or capitulation to those who are in opposition. I believe (and by the time you read this, I may be proven wrong) that there is still an opportunity for success. As Winston Churchill once said, “Americans always manage to do the right thing, but not until they’ve tried everything else first.” he most easily identified failing on the part of reform proponents was the violation of Santayana’s timeless warning that those who do not study history are doomed to repeat it. Over and over again our presidents, dating all the way back to Harry Truman, have found their efforts to bring healthcare access to all citizens met by powerful resistance by those whose vested interests lay in avoiding any changes. As recently as 1965, the efforts of President Lyndon Johnson to pass Medicare were characterized as a Communist plot designed to take away freedom. None less than future president Ronald Reagan appeared in a propaganda film that warned of the dangers of this program. He said that if Medicare comes to pass, “We will spend our

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sunset years telling our grandchildren what America was like when men were free.” One of the saddest features of this fear-mongering campaign was that the major promoter of it was none other than our own American Medical Association (AMA). In the more recent iterations of reform, such as that proposed by President Clinton in 1993, the role of chief naysayer had been passed to its present occupier, the health insurance industry.

To its great credit, AMA this time around has displayed the wisdom and presence of mind to make efforts to work with the administration in a cooperative fashion so as to remain at the table and seek the changes it requires in a harmonious fashion. t would have been ever so much more effective to have headed off the most frequently voiced argument against the offering of a “public option,” i.e., that it will put the private carriers out of business. This could have been easily accomplished by citing the history of another form of insurance, that of workers’ compensation. In the early 20th century, a number of states proposed the creation of state funds overseen and operated by governments to offer an alternative to businesses that were required to purchase this insurance so as to protect injured workers. Such funds were vehemently opposed by private insurers who complained that they would not be able to compete against the government (sound familiar?). When

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The Obama administration, in an effort to avoid the Clinton mistakes, has failed to spell out its objectives, preferring to let Congress create the legislative package. This brings to mind the oft-quoted line that there are two things that are just too unpleasant to watch being created: sausage and legislation. As a result, Congress has created numerous proposals, with major differences among them.

Even the term “universal coverage” suffers from vagueness. Does it mean that all people are provided with free healthcare with no personal expenses? Or does it mean that everyone is legally required to purchase a policy no matter what the cost? And what kind of policy is meant by that term? Is it to be comprehensive or catastrophic? What do we even mean by “insurance”? In its most traditional definition, insurance means the bringing together of large numbers of risksharers for the purpose of avoiding individual financial catastrophe. Somehow, that definition no longer seems to be in play as policies have become so comprehensive that often quite minor expenses are covered, such as doctors’ office visits. Clearly, that is not insurance as it used to be known. If the individual mandate is to come to fruition, it must be made clear whether required policies are to be comprehensive or catastrophic.

The latter should not engender major costs, but should largely eliminate medical bankruptcies. This distinction should have been made clear at the outset of the reform effort.

It would have been immensely helpful had it been appreciated that many perceive government involvement in healthcare in terms only of the single-payer systems of England and Canada, as they are so frequently cited as examples of how regulated care doesn’t work. Little or no attention has been paid to the numerous universal coverage systems in place in Europe that work extremely well. France is recognized to have a system that employs private health insurance that is highly regulated and that provides highquality care at reasonable costs. So too with Spain, Germany, and Switzerland, but no effort was made by the proponents of reform to educate both the public and Congress as to the wisdom of emulating these systems.

he most easily identified failing on the part of reform proponents was the violation of Santayana’s timeless warning that those who do not study history are doomed to repeat it.

the funds were created, the private carriers reduced their premiums by an average of 30 percent and have continued to compete effectively to this day. This is quite likely what would happen if a public option for health insurance came into being at this time. To have put forward this historical event at the outset would have deprived the opponents of today’s efforts of their favorite misrepresentation. lack of clear and precise language as to what the goals of reform are has created a good portion of the fear and anger that have been so prominent.

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Finally, it has been discouraging to hear the term “public option” promoted and reviled in the absence of any clear definition as to what it means. One might well assume that it means a change in the Medicare system so as to open it up to anyone who wishes to buy into it, no matter what their age or disability status. Such a proposal is not only clear and easy to understand, but does not require the creation of new bureaucracies. This level of clarity has not been forthcoming. his linguistic imprecision ties directly to the issue of failure to be clear about the monetary costs of reform.

As stated above, costs are massively variable depending on the nature of the reform being sought. If Medicare membership were to be offered to all citizens, there would need to be a massive rededication to eliminating the so-called “big three”: fraud, waste, and futility. Estimates range to 30 percent as the amount of money expended on these three features of care. Currently, Medicare pays very little attention to fraud, which is a major cost factor. Arguably the biggest cause of wasteful spending is defensive medicine, which nearly all of us feel compelled to resort to in an effort to protect ourselves against lawsuits. We patiently await proposals to include reasonable tort reform so as to dramatically reduce wasteful medical costs.

Among the most sensitive reform issues is the problem of futility. It has been estimated that up to 50 percent of the money spent on an individual’s lifetime of healthcare is expended in the final 30 days of life. It’s hard to imagine that we can’t do better than that.

This, however, is a very sensitive issue, suggesting that we must bring an end to costly and hopeless medical endeavors. Is there, for example, any reasonable justification to fund treatments with the colon cancer drug Erbitux at a cost of $10,000 per month when it has been shown that it extends survival for an average of only 45 days? Try, however, getting Medicare to refuse to cover this treatment, futile though it may be, and the Sarah Palins of the world will rant about “death panels.” nother avoidable failure was the absence of any effort to enforce party discipline among congressional Democrats. In 1965, Lyndon Johnson took an extremely hard line in personally approaching and persuading any party member who may have been wavering. This resulted in the sort of unity that allowed Medicare to pass. It is difficult to understand how conservative Democratic

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he industrialized world is watching, perhaps with bemused detachment, to see if the United States can at long last join with the majority of countries that long ago settled upon the realization that universal access to quality and affordable healthcare is in everyone’s best interests.

congressional representatives, known as “Blue Dogs,” mostly from under-populated states, can have been permitted to oppose their own president on his most difficult initiative. The law should have been laid down well in advance and in no uncertain terms.

In Lyndon Johnson’s terms, a “trip to the woodshed” would have been in order.

Finally, the Obama administration was remiss in not powerfully emphasizing the win-win nature of the proposed reforms. It has been a sad spectacle to witness lowermiddle-class Americans fighting against a

program that is so obviously in their best interests to support, especially those who have been rendered so hysterical and ill-informed as to shout about “keeping the government away from my Medicare!” It would have been remarkably easy to inform the citizenry about how the only losers in the reform package will be the insurance companies, the very same people who refuse to cover you if you’ve ever had any sort of illness in the past and who so often stand in the way of care recommended by your doctor.

Although I happen to believe that mean-

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• mAY 2009

Update on the Future of Healthcare

New Asso s: No More Doubciate le Dipping P.16 Removing Shac kles, Moving Boun Mental Heal daries: May is th Month P.18 Science of Addi ction: A Brain Disea se

Contact Dari Pebdani at 858-231-1231 or dpebdani@sdcms.org

{About the Author}

Dr. Priver is semi-retired from the practice of obstetrics and gynecology. He has been active in SDCMS leadership since 1989 when he began serving on the SDCMS council. He has held a variety of positions, including chairing several committees, president in 1996, and chair of the San Diego CMA delegation from 2001 to 2007. He continues to serve on SDCMS’ board of directors.

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ingful healthcare reform is an idea whose time has come, the process of generating public and Congressional support for it has been much harder than it needed to be. We’ve reviewed a few of the ways in which some of the difficulties could have been avoided. There are probably going to be more shortcomings before the matter is settled. The industrialized world is watching, perhaps with bemused detachment, to see if the United States can at long last join with the majority of countries that long ago settled upon the realization that universal access to quality and affordable healthcare is in everyone’s best interests.

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You’re Either at the Table

or on the Menu

”

“I’ll Gladly Pay You

Tuesday for a hamburger

toda — J. Wellington Wimpy or the Great State of California C M A ’ s 2 0 0 9 L e g i s l a t i v e Wr a p - u p

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CaliforniahasperhapsreplacedWimpyasthemost famous example of borrowing against the future to address today’s appetite. This year marked another significant erosion of California’s financial situation, forcing the governor and Legislature to grapple with a multibillion-dollar budget deficit.

Political observers surely felt that Sacramento had fallen into a time warp as partisan bickering overshadowed problem solving, leaving Californians to endure another historically late budget. Other pressing matters, including prison reform, water shortages, and California’s ever-increasing number of uninsured, took a back seat to the budget deficit. n 2008 the governor signed two separate budget accords that were supposed to solve California’s budget woes. Those deals proved to be badly out of balance almost immediately after they were signed.

Facing a $40 billion budget deficit, legislators were forced to reconvene in early 2009 and pass a new budget that would supposedly keep California solvent through 2010. That budget contained $15 billion in cuts, $12.5 billion in new taxes, $7.8 billion in federal stimulus money, and $5.4 billion in borrowing. That budget also fell short, causing the state to face a $21 billion deficit by July 2009. he continual focus on the budget and the ongoing need to make massive cuts or find new revenues paralyzed lawmakers for months. Democrats refused to consider any additional cuts and Republicans were equally adamant that they would not support any new taxes. The partisan stalemate forced California to start the new fiscal year on July 1, 2009, without a balanced budget in place. Many thousands of state workers and businesses that contract with the state went unpaid, hospitals were left without reimbursements, and some patients lost their state-provided health insurance while the governor and legislators continued to feud over a solution.

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Finally, on July 28, 2009, Governor Schwarzenegger signed a new “balanced budget” that primarily relied on massive cuts and billions in borrowing to fill the deficit. But even that budget is now $4 billion in the red as California’s economy continues to struggle, and next year’s budget deficit may exceed $10 billion based on current estimates. It is very likely that the Legislature will once again have to take midyear action to address the deficit now and in the future.

To make matters worse, the governor continued his well-worn pattern of veiled threats toward legislators for their failure to act on issues such as the budget, water, and prisons. The governor used a variety of methods to try to force legislators to act. At one point the governor sent Senate President Pro Tem Darrell Steinberg (D-Sacramento) a bronzed sculpture of bull testicles, insinuating that the legislature needed a pair. Not surprisingly, Steinberg and other legislators were not amused. y the end of the legislative session, the governor threatened to veto all legislation sent to him until lawmakers sent him a water deal he found acceptable. That threat caused considerable consternation among Republicans and Democrats alike. Ultimately, the governor backed off from his threat and acted on the bills before him.

The continuing strain between the Legislature and the governor does not bode well as major problems facing the state continue to loom. Is it any wonder that the Field Poll recently found that both the governor and Legislature suffer from historically low approval ratings of 27 percent and 13 percent respectively? The only governor with lower approval ratings than Schwarzenegger was Gray Davis, the man whom Schwarzenegger replaced through a recall election in 2003.

For CMA it was another busy year. State budget cuts consumed many hours of hard

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CMA-sponsored/ supported Legislation and CMA-opposed Legislation For a detailed description of these bills, visit SDCMS.org/publications.

CMA-sponsored and Supported Legislation ■ UNLAWFUL RECISSION: INDEPENDENT REVIEW (AB 2 • De La Torre) Passed by Legislature, Vetoed by Governor on October 11, 2009 ■ PEER REVIEW (AB 120 • Hayashi) Passed by Legislature, Vetoed by Governor on October 11, 2009 ■ STEVEN M. THOMPSON LOAN REPAYMENT PROGRAM: OSTEOPATHIC PHYSICIANS (SB 606 • Ducheny) Signed by Governor, Effective January, 1, 2010 ■ HEALTH CARE PROGRAMS: CALIFORNIA CHILDREN AND FAMILIES ACT OF 1998 (AB 1422 • Bass) Signed by Governor, Took Effect on September 22, 2009

CMA-opposed Legislation ■ HOSPITALS: EMPLOYMENT OF PHYSICIANS AND SURGEONS (SB 726 • Ashburn) Killed by CMA! ■ PHYSICIANS AND SURGEONS: EMPLOYMENT (AB 646 • Swanson) Killed by CMA! ■ RURAL HOSPITALS: PHYSICIAN SERVICES (AB 648 • Chesbro) Killed for 2009 by CMA ■ PHYSICAL THERAPY DIRECT ACCESS (AB 721 • Nava) Killed for 2009 by CMA ■ THE PUBLIC EMPLOYEES’ HEALTH CARE ACT: BILLING DISPUTES (AB 1126 • Hernandez) Killed for 2009 by CMA ■ HEALTH INSURANCE RATE REGULATION (AB 1218 • Jones) Killed for 2009 by CMA ■ DRUGS: ADVERSE EFFECTS REPORTING (AB 1458 • Davis) Killed for 2009 by CMA ■ WRITTEN ACKNOWLEDGEMENT: MEDICAL NUTRITION THERAPY (AB 1478 • Ammiano) Killed for 2009 by CMA ■ PEER REVIEW (SB 700 • Negrete McLeod) Killed by CMA! ■ SINGLE PAYER HEALTH CARE (SB 810 • Leno) Killed for 2009 by CMA

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MA was able to defeat every bill that we opposed. Not a single bill we opposed made it to the governor, and every bill was defeated in their first committee.

work as we defended the already abysmally low Medi-Cal reimbursement rates. Ultimately, CMA’s Center for Legal Affairs was forced to sue the state to block the governor’s attempts to reduce rates by 10 percent. Fortunately, the court found in favor of physicians and ordered an injunction against the state, prohibiting implementation of the cuts. n the Legislature we faced fights difficult and sometimes ugly — fights over scope of practice, peer review, the bar on the corporate practice of medicine, and rescission of insurance policies. Fortunately, CMA was able to defeat every bill that we opposed. Not a single bill we opposed made it to the governor, and every scope bill was defeated in their first committee.

The pharmacists, nurse practitioners, and physical therapists all pursued scope of practice expansions this year. Pharmacists attempted to get legislative approval to administer vaccines directly to patients without a physician protocol; that bill was overwhelmingly defeated. The nurse practitioners finally abandoned their efforts to establish independent practice and worked proactively with CMA to provide greater clarity to their practice protocols. The physical therapist legislation proved to be the most contentious scope bill of the year with their legislative staff asserting that physical therapists were more qualified to diagnose patients than physicians. Needless to say, that argument did not carry the day and the bill was soundly rejected. his year the fight to preserve the prohibition on the corporate practice of medicine was difficult, to say the least. Three bills were introduced to destroy or undermine the corporate bar and allow for the direct employment of physicians by hospitals. Both the California Hospital Association and the American Federation of State, County, and Municipal Employees union sponsored measures to take direct control of physicians through employment. The bills were passed out of

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the Assembly but were defeated in the Senate. Both organizations have made it clear that they intend to pursue their efforts next year, so the fight will continue.

CMA sponsored several bills, and ultimately three made it through the legislative process and to the governor. The first bill, AB 2, would have prohibited insurance companies from rescinding a patient’s insurance policy without proving that the patient intentionally misled the company when they sought coverage. Unfortunately, this bill was vetoed by the governor. Our second sponsored bill, which would have made needed changes to the peer review system, was also vetoed. The governor did sign our third sponsored bill, SB 606, to expand the Steven M. Thompson medical school loan repayment program to provide additional funding to physicians willing to practice in underserved areas. verall, it was another year that was lost to the budget morass that the state continues to find itself in. It is likely that the final year of Governor Schwarzenegger’s term will again be dominated by budget deficits. The projected $10 billion shortfall will be extremely difficult to address since the state is out of easy or politically acceptable means of bridging the gap.

Perhaps Wimpy will take Minerva’s place on the Seal of the Great State of California.

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{About the Author}

Mr. Corcoran is senior vice president of the California Medical Association (CMA), a nonprofit organization dedicated to protecting public health and promoting the science and art of medicine. Mr. Corcoran leads a group of six lobbyists in representing CMA’s interests and issues before the California State Legislature.

Mr. Corcoran also speaks frequently to organizations about effective lobbying, the political process, and healthcare issues in California. In 2005, Mr. Corcoran was named “Most Effective Lobbyist Under 40” by AroundtheCapitol.com.

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You’re Either at the Table

or on the Menu

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Politics&

Advoc

10 Pretty Good Rules

By Tom Gehring 36

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& ocacy Note: This article was originally published in the September 2008 issue of San Diego Physician.

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

1

Look at politicians as either those who view physicians as part of the solution or those who view physicians as part of the problem.

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

2

Respect the truth ... always.

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

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

3

The most powerful spokesman for your cause is someone who has no direct stake in the outcome.

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

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If SDCMS and CMA are not building those relationships, making the case for physicians, walking the halls of power, then a nonphysician will tell you how to practice medicine and reach into your pockets — and directly affect your ability to provide patient care.

4

Count your votes before the vote.

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

5

Focus on the persuadables.

While actual percentages may vary, on any given issue, about 30 percent will be in full-throated support, and roughly 30 percent are stridently opposed. Focus 90 percent of your energy on the 40 percent who are convincible.

6

No one bats 1.000 in advocacy.

If you expect to win every issue, you’ve chosen the wrong avocation.

It’s a game of percentages. Work for the long haul, and be patient.

7

It’s about the relationship, not about the issue.

• Variation 1: When it’s a core issue, then it is about the issue.

• Corollary 2: Choose your core issues very, very carefully.

There are a million issues. Choose the ones you’re willing “to die for” very carefully. So treasure the relationship. Those you lobby may not agree with you (see rule #8 below), but the value of the relationship is that you get a fair and fast hearing. Being able to pick up the cell phone (and having the cell phone number) and calling a state legislature is incredibly useful.

8

Today’s opponent is tomorrow’s ally, and vice versa.

Note, I did not say enemy ... I said opponent (see rule #9 below). Alliances come and go; accept that the greater good sometimes makes for strange bedfellows.

Therefore, never, ever personalize a disagreement because you may be looking for a partner someday soon!

9

Respect the elected officials, their staffs, and your adversaries.

You haven’t run for office. You haven’t had to fly to Sacramento or Washington, DC, every week. You haven’t spent interminable hours in meetings listening to ... well, let’s just say that our legislators work incredibly hard, and every move they make is scrutinized, criticized, and secondguessed. Respect them for what they do and who they are.

The staff are just as, and sometimes more, important as the elected official. Never, ever, ever treat the staff with anything but respect. They may be young, they may be underpaid, they may work under very challenging conditions, but they have the ear of the decision maker. Make them your allies, even your advocates!

Badmouthing your opponents (or worse, not respecting the truth) will invariably cause you to be ineffective. And the word gets around. Quickly!

10

It’s 90 percent on the politics, only 10 percent on the merits.

• Corollary 1: You don’t get to the merits until AFTER you deal with the politics.

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Deal with (and understand) the politics before you speak to the merits. Those of us educated in deterministic, objective, and data-driven disciplines (engineering in my case, medicine in my spouse’s) are resolutely convinced that the merits of any argument will always prevail. Sadly, in the world of politics and advocacy, that is rarely the case. In fact, many decisions are made in the absence of, or even contravention of, the facts. Decision makers have to do things, e.g., their party leadership may demand a vote, maybe they need to vote against something we like that is passing easily but they have a constituency to appease, the list goes on. Get over it! That’s the world we live in.

So who cares about advocacy and politics anyway? You do. If SDCMS and CMA are not building those relationships, making the case for physicians, walking the halls of power, then a nonphysician will tell you how to practice medicine and reach into your pockets — and directly affect your ability to provide patient care. Which brings me to the last, and most important rule (with apologies to the famous line from the 1992 presidential campaign): It’s the patient care, stupid. Everything we do as advocates for physicians has to focus on the ultimate goal of healing the sick. Honestly framed as a patient care issue, it’s hard to lose an argument!

{About the Author} Mr. Gehring is executive director and CEO of the San Diego County Medical Society.

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You’re Either at the Table

or on the Menu

”

Three

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hysicians are in many ways poorly suited to be legislative advocates.

We function in a world that acknowledges our extensive training and experience and is respectful of scientific analysis. And, despite all the difficulties of practicing in the 21st century, we still get what we want in most situations. When we make a diagnosis and propose a treatment plan, our patients usually go along with it.

And when we want things to go a particular way in our clinical settings, be it the office or the operating room, they usually do.

However, in the world of legislative advocacy, we are back to square one. Important decisions are not necessarily made by the best trained or the most experienced, statistics and other data are manipulated if not ignored, and the influence we are used to exerting in our clinical settings seems not to exist.

In the legislative arena, it is not uncommon for a group of us to meet with a legislator who has had less than a third of our formal education. In such a meeting, we as a group will typically, and with great patience, explain our sage analysis and thoughtful recommendation regarding a piece of legislation. But, not uncommonly, we find out later that the legislator ended up voting “the other way.”

While in the vast majority of cases it turns out that the legislator’s pre-existing beliefs would have in fact predicted their “vote,” we physicians do not deal well with the frustration of having our advice going unheeded.

In fact, we find it so frustrating that, over the years, I have seen it drive dozens of would-be physician advocates to just walk away from the process. And even worse, I have seen this frustration result in behavior that was counterproductive and even detrimental to what we were trying to accomplish.

For those of you who are interested in advocacy and willing to learn, there are three bottom-line points from the experience of those who advocate for you that will serve you well.

Success is never guaranteed, but if you follow these three points, be assured that you will never really “fail.” And to illustrate what can go wrong, I will relate three scenarios — all of which actually took place in the setting of a group of physicians meeting with a state legislator in their office in Sacramento or with a member of Congress in their office in Washington, DC. Each of these scenarios illustrates some of the behavior that simply must be avoided if one is to be a successful advocate.

s y e K l u f s s e c c y c u a S c o o t v d A e v i t a l s i Leg

And How NOT to Be a Successful Legislative Advocate

By Robert E. Hertzka, MD 40

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Respect Elected Officials and Their Staff Nothing you or I will ever do as a physician will put us in the position of constantly living in the crucible of public opinion as much as an elected official. Only an elected official knows what it is like to have their every action scrutinized by not just the public but the media, both of whom often lack all the facts but still have the constitutional freedom to publicly criticize at will. And at election time, every elected official knows that their every opinion and vote stands to

I

educate legislative staff on an issue is usually well worth our time.

How Not to Be a Successful Legislative Advocate, Example 2: After a legislator stated to a group of physicians that he had decided to vote for a CMA-opposed bill, one physician proceeded to pepper the legislator with a series of escalating questions designed to change his mind, the last of which was, “Do you want people to die?”

The reality in this case is that it is quite rare for a legislator to actually volunteer to a visiting group that they are voting in opposition to one of their top positions. When that happens, it means that the legislator has already given the issue significant thought and is highly unlikely to change his or her mind. A barrage of interrogative questions in that situation is basically saying that we believe that the legislator is being stupid — not a good idea (even if true).

n the end, all that we really have as advocates for the profession is our credibility.

be distorted by their opposition into something evil, which is then stuffed into every local, high-propensity voter’s mailbox and/ or displayed on television.

Whether you agree or disagree with an elected official about a given issue, or even about their entire political philosophy, you must give these folks their due. They have taken on something that the vast majority of us could never even attempt to do in a credible fashion.

I cannot emphasize this enough. If you are not capable of being respectful to a broad philosophical range of elected officials, stop reading now and instead seek out other physicians to be involved in legislative advocacy.

Finally, staff members are also worthy of our respect. The staff of elected officials are usually underpaid, under appreciated, and over blamed. And, in many cases, and particularly in Washington, DC, they are at times flat out overworked.

How Not to Be a Successful Legislative Advocate, Example 1: After being told that a legislator was unavailable to meet with us and that we would have to meet with a staff member instead, one of the physicians in the group openly protested, along the lines of, “Doesn’t he know that the doctors are here?” Well, as it turns out, a legislator’s first priority when in Sacramento or in DC is to attend their committee meetings, which often end up being in conflict with the times when groups wish to meet with them. In addition, an opportunity to

Respect Your Adversaries In the vast majority of cases, those who oppose us on issues actually believe what they are saying. They may be lacking in the appropriate background or experience, such as nonphysicians seeking a scope-of-practice expansion, or just have an entirely different view of the world, such as attorneys who believe that med-mal lawsuits act to improve medical quality (bizarre but true). It is important that we never allow our disagreements with our adversaries to in any way diminish our fundamental respect for the fact that they, like us, are willing to stand up for what they believe.

To use the same example, I for one sincerely believe that the trial lawyers who want to weaken or repeal MICRA are wrong, wrong, wrong on that issue, but I also believe that most do in fact believe that MICRA infringes on the rights of those few truly harmed by medical malpractice. I have also fought for years with various “business lobbies” over their lockstep devotion to the agenda of health plans, but I have never doubted that most of their advocates truly believe that CMA’s legislative successes against health plans have made health insurance less affordable.

To ascribe evil motives to one’s opponents in the legislative arena is a losing strategy.

Many of our opponents do it to us, and, in fact, it almost always ends up being to their detriment. The legislators know that those who are in their office disparaging others are only a tough vote or two away from disparaging them.

Respect the Truth This should be an easy one. In the end, all that we really have as advocates for the profession is our credibility. As hard as it is, in a profession where we are always supposed to have all of the answers, many of us need to learn to say, “I don’t know, but I can find out,” when responding to the questions of an elected official or their staff member.

How Not to Be a Successful Legislative Advocate, Example 3: Some years back, in a burst of enthusiasm when discussing a CMA proposal to increase Medi-Cal fees, a physician in Sacramento for the first time volunteered that, in the past, CMA had never objected to Medi-Cal fee cuts when the state budget was in a bad situation, so that it was only fair that we should receive an increase when the state budget was doing better. While enthusiastic and well intentioned, that statement was patently untrue (and that particular veteran legislator knew it) — CMA has always strongly opposed any cuts to the profoundly underfunded Medi-Cal program. But once you make an untrue statement, even with the best of intentions, your credibility with that legislator for anything else you might say drops to zero.

{About the Author} Dr. Hertzka, SDCMS and CMA member since 1988, is past president of both the San Diego County Medical Society and the California Medical Association, and a current member of the American Medical Association Council on Medical Service. In addition to being an influential force in both health policy and politics at the county, state, and national levels, Dr. Hertzka also teaches two courses on health policy and politics at the UCSD School of Medicine, and serves locally as the chair of San Diegans for Health Care Coverage, an entity created by the County Board of Supervisors to address the issue of the uninsured in San Diego County.

Novemb er 2009 SAN DIEGO P HY SICIA N. org

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CARMEL VALLEY OFFICE SPACE TO SHARE: Sublease and share extra space in 4,600-sf cosmetic surgeons’ office. Surgery center and X-ray on site.

Beautiful space in very attractive, welllocated building on El Camino Real in the heart of Carmel Valley. Ideal for a surgeon, satellite office, or solo physician not needing space full time. Potential for sharing staff / overhead.

Contact Chris Ross at 858.677.5329 email chris.ross@colliers.com UTC / LA JOLLA MEDICAL SPACE AVAILABLE: Medical suites available at UTC La Jolla. For available suites, floor plans, and leasing information, contact Kelly Tang at (858) 622-1240. [761] LOOKING TO RENT OFFICE SPACE IN GREATER SAN DIEGO AREA: I am a physician specializing in pain medicine. I am currently looking to rent office space from a family/general medicine doctor in the greater San Diego area, approximately once a week. I am pretty flexible in setting up the arrangement. Please contact me at guptaa3@hotmail.com or call me at (760) 285-8866. [762]

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] DOWNTOWN OFFICE SPACE AVAILABLE: Family practice physician in downtown San Diego has office space available. If interested, please call (858) 270-7633. [735]

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 BEAUTIFULLY APPOINTED MEDICAL OFFICE space to sub-lease and share with established plastic surgeon near Alvarado Hospital campus.

Spectacularly upgraded and furnished, slate floors, custom ceiling, lighting, marble accents, and wall painting. 1,200 usable square feet that includes three exam rooms and office/consultation room.

Separate reception and front desk space, rest room, and patient entrance. Option to share our staff. Contact office manager at (619) 286-6446 or email aips@sbcglobal.net. [756] SCRIPPS ENCINITAS CONSULTATION ROOM/ EXAM ROOMS: Available consultation room with two examination rooms on the campus of Scripps Encinitas. Will be available a total of eight half days per week. Receptionist help provided if needed.

Contact Stephanie at (760) 753-8413. [703] NORTH COUNTY INLAND OFFICE SPACE TO SHARE: We have a busy, long-established family practice that is centrally located near I-15 and Poway Road in the North County Inland area of San Diego in the attractive Sabre Springs neighborhood, and we have office space and exam rooms available. Traditional medical practice preferred, please no esthetics, etc. Contact Dr. Wickes at awickes@ sbcglobal.net. [751] 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. [745] PHYSICIANS WANTED TO SHARE OFFICE IN CLINIC, YUMA, AZ: Directly across from new Yuma Regional Medical Center. Prime location.

Several office spaces available. Your private office would be in a fully operational clinic. Shared services include reception/billing, X-ray, exam rooms, and more. Ample onsite parking, public transportation nearby. Located at 2475 S. Avenue A. For tour and questions, direct inquiries to (858) 349-2007 or dottie.surdi@svn.com. [741] MEDICAL OR PROFESSIONAL OFFICE SUITES FOR LEASE, EL CENTRO, CA: In historic downtown area, near County offices, courthouse, and El Centro Regional Medical Center. Prime location; build to suit, and competitive rates with tenant incentives. 6,000ft2 can be divided; with private entrances. Near I-8 and public transportation with ample parking. Located at 441 W. State St., El Centro, CA. Direct inquiries to (858) 349-2007 or dottie.surdi@svn.com. [686]

NEW MEDICAL OFFICE BUILDING: Now leasing! Gateway Chula Vista is a new 230,000 SF SMART complex with COX Fiber broadband equipped. Conveniently located near I-5 & I-805 Freeways in Downtown Chula Vista, across and adjacent to Scripps Mercy Hospital & Sharp Rees-Stealy Urgent Care. Suites available from 950 – 20,000 SF and include generous Tenant Improvement Allowances provided. Free onsite & ample parking (Over 4 per 1000 SF).

For additional information please contact James Pieri, Jr., (619) 422.8400, jamesd@mountainwest.com www.mountainwest.com MEDICAL OR PROFESSIONAL OFFICE SUITES FOR LEASE, YUMA AZ: Directly across from new Yuma Regional Medical Center. Prime location; build to suit, and competitive rates with tenant incentives. Ideal for sole practitioners. 1,000ft2 suite with private entrance or 150ft2 to 4,000ft2 within the clinic. Ample onsite parking, public transportation nearby. Located at 2475 S. Avenue, Yuma AZ. Direct inquiries to (858) 349-2007 or dottie.surdi@ svn.com. [685] SUITES FOR LEASE, MISSION VALLEY PROFESSIONAL MEDICAL/OFFICE BUILDING: Prime location, build to suit, and competitive rates with tenant incentives make this a fabulous value.

Suites approximately 1,000ft2. At RT 15 and RT 8, just minutes from six major hospitals. Ample parking. Easy freeway access and public transportation nearby. Visit website for Riverview Center, 3633 Camino del Rio South at http://lease.svn. com/3633Camino. Contact (858) 349-2007 or dottie.surdi@svn.com. [684]

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 $150 (100-word limit) per ad per month of insertion.

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LA MESA OFFICE SPACE TO SHARE: Over 6,000ft2 OB/GYN office of three doctors, with space available immediately. 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] REAL ESTATE INCREDIBLE OCEAN, MOUNTAIN, AND PASTURE VIEWS make this one of the most unique and tranquil parcels in all of San Diego County, with several magnificent building sites on the property to choose from. A tapestry of La Jolla and San Diego County lights can be seen from the distant southwest on most nights to highlight the end of the day in the quaint hillside of Julian. Contact (561) 716-7577 or dave.a.sanderson@gmail.com. http://visitorscreening.net/jim/julian.html [754] PHYSICIAN POSITIONS AVAILABLE PHYSICIANS NEEDED: Full-time, part-time, and per-diem opportunities available for family medicine, pediatric, and OB/GYN physicians. Vista Community Clinic is a private, nonprofit outpatient clinic serving the communities of North San Diego County. Must have current CA and DEA licenses.

Malpractice coverage provided. Bilingual: English/ Spanish preferred. Forward resume to hr@vistacommunityclinic.org or fax to (760) 414-3702. Visit our website at http://www.vistacommunityclinic. org. EOE/M/F/D/V [760] FAMILY MEDICINE / HIV PHYSICIAN: Sharp Rees-Stealy Medical Group, a 400+ physician multispecialty group in San Diego, is seeking a half-time job share BC/BE family medicine physician with HIV management experience to join our staff. We offer a first-year competitive compensation guarantee and an excellent benefits package. Please send CV to SRSMG, Physician Services, 2001 Fourth Avenue, San Diego, CA 92101. Fax: (619) 233-4730. Email: Lori.Miller@sharp.com. [752] FAMILY PRACTICE DOCTORS NEEDED: Full time and part time. Days, nights, weekends available. Fax CV to La Costa Urgent Care at (760) 6037719. [750] PHYSICIAN EMPLOYMENT OPPORTUNITIES: Part-time and full-time openings for primary care physicians. Board-certified family practice or internal medicine physicians wanted to join our successful, prominent East County private medical group.

Located on the Grossmont Hospital campus, our primary care group practices full spectrum family medicine, including hospital care. Sharp Community Medical Group providers. Ownership opportunities available. Interested applicants please send CV to eva.leonard@gfmg.net. For further information, visit us at www.gfmg.net. [747] OB/GYN PHYSICIAN SITE DIRECTOR: Founded in 1972 and located in North San Diego County. We provide the highest quality services in five different locations throughout Vista and Oceanside. Vista Community Clinic is a private, non-profit medical, dental, and social services center, including advocacy and education programs. We serve people who experience social, culture, or economic barriers to healthcare in a comprehensive, high-quality setting.

We are currently looking for a director of our OB/

GYN department. This individual will be responsible for oversight of all obstetrics and gynecological services by directing and providing care for clinic and hospital patients. Providing clinical and administrative leadership for OB/GYN multi-provider clinic and multi-physician hospital group. Cover a minimum of one 24-hour per week panel shift and two clinic shifts per week. Oversee panel scheduling.

Participate in clinical alliances. Must hold current CA license, DEA license, CPR certification, and be board certified in obstetrics and gynecology. Five years post-graduate clinic experience. A minimum of four years administrative experience. Bilingual English/Spanish is helpful. Malpractice coverage is provided by the clinic. May apply for state/federal loan repayment programs. Forward resume to hr@ vistacommunityclinic.org or fax to (760) 414-3702.

Visit our website at www.vistacommunityclinic.org.

EOE/M/F/D/V [748] CHIEF MEDICAL OFFICER TO SERVE FIVE FEDERALLY QUALIFIED HEALTH CENTERS: MHCS is a mission-driven organization that serves both rural and urban residents of San Diego County. We have been in business for 35 years and offer a competitive salary, medical benefits, vacation, paid holidays, sick time, CME reimbursement, and license reimbursement. Board certified, family practice, and bilingual English/Spanish preferred.

This position will require 60 percent clinical and 40 percent administrative. Send CV to tfindahl@ mtnhealth.org or (619) 478-9164. You may contact HR directly at (619) 478-5254, ext 30. Visit www. mtnhealth.org. [738] FAMILY PRACTICE PHYSICIAN FOR A BUSY FEDERALLY QUALIFIED HEALTH CENTER: MHCS is a mission-driven organization that serves both rural and urban residents of San Diego County.

We have been in business for 35 years and offer a competitive salary, medical benefits, vacation, paid holidays, sick time, CME reimbursement, and license reimbursement. Board certified and bilingual English/Spanish preferred. Send CV to tfindahl@ mtnhealth.org or (619) 478-9164. You may contact HR directly at (619) 478-5254, ext 30. Visit www. mtnhealth.org. [737] SOUTHERN INDIAN HEALTH COUNCIL INC. IN ALPINE IS SEEKING A BOARD-CERTIFIED MEDICAL DIRECTOR/PHYSICIAN: Great benefits and competitive wages! Please call (619) 445-1188, ext. 291, for details or visit our website at http://www.sihc.org — look under “Employment” and then “Medical.” [736] 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 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]

MD Seeks PT/FT Position Skilled physician with extensive experience including: Radiology, Primary Care, research and teaching. Board certified in addiction medicine. Available immediately. Very flexible with terms and location.

Please contact 412-606-1681

PULMONARY/CRITICAL CARE/SLEEP MEDICINE PHYSICIAN: Would like to join similar group or solo physician. Highly experienced in critical care (fellowship at Cook County Hospital in Chicago).

Also certified in GI. Fax: (619) 934-4566. [743] NONPHYSICIAN POSITIONS AVAILABLE NURSE PRACTITIONERS NEEDED: Part-time and per-diem opportunities available for family medicine, pediatric, and OB/GYN nurse practitioners. Vista Community Clinic is a private, nonprofit outpatient clinic serving the communities of North San Diego County. Must have current CA license.

Malpractice coverage provided. Bilingual: English/ Spanish preferred. Forward resume to hr@vistacommunityclinic.org or fax to (760) 414-3702. Visit our website at http://www.vistacommunityclinic. org. EOE/M/F/D/V [759] BILLER WANTED: Looking for biller with ambulatory billing experience. If interested, call Mira at (619) 464-9876 or email your resume to mirap@ pacbell.net. [749] EXPERIENCED MEDICAL BILLER NEEDED: Experienced medical biller needed immediately. Four to five years experience required. Full-time position, M–F. Benefits include health insurance and pension.

Must be organized, reliable, detail oriented, and work independently. Please call (858) 292-7527 or email resume to sdddc5@yahoo.com. [744] MEDICAL EQUIPMENT/OFFICE FURNITURE MEDICAL EQUIPMENT: Bone densitometer, hologic, full-size hip and spine, slightly used, $19,000.

Call (760) 703-0691. [755] OFFICE FURNITURE FOR SALE: Chairs $10.00 each, desk $50.00, exam stools $10.00, and two exam tables. Call (619) 585-0476. [746] THREE FULL-SERVICE EXAMINATION TABLES: Excellent condition. $1,000 each. Call (619) 585-0476 and ask for Cindy. [739]

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

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sdcmsmemberbenefits

Delivering Concierge Care to Our Members and Their Staff!

Your Physician Advocate and Your Office Manager Advocate Get Issues Resolved!

At right are some of the comments received by Marisol Gonzalez and Lauren Wendler — your full-time SDCMS physician advocate and office manager advocate respectively — from member physicians and their staff.

If you have an issue you need help with, please feel free to contact Marisol and Lauren first. Marisol can be reached at (858) 300-2783 or at MGonzalez@SDCMS.org, and Lauren can be reached at (858) 300-2782 or at LWendler@SDCMS.org.

Marisol

“Wow. Amazing customer service. I’m so impressed. Thank you for the information. Have a wonderful evening.”

— SDCMS Member Since 2006

“Thanks for your help.

You are great. I will call Tom personally to thank him. These are reasons for us to become members of the Society. Thanks for all the good work.”

— SDCMS Member Since 2009 “Marisol, You are the greatest! Please forward my email to Tom so that he knows what a great help you are to us!

Thanks so much.”

— SDCMS Member Since 1990 “Thank you so much for all your help.”

— SDCMS Member Since 2007 “Thank you so much. I really appreciate how quickly you respond and get things done!!”

— SDCMS Member Since 2009

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Lauren

“Marisol, Thank you so much for your wonderful and prompt help with getting me started […]. Thank you again.”

— SDCMS Member Since 2009 “You are totally awesome! Thanks so much for your help with this!”

— SDCMS Member Since 2007 “Marisol, We got two old checks today re-mailed to us to the correct address and one check addressed to the correct address. I would like to thank you, your staff, and CMA for intervening swiftly and getting the results for us.”

— Office Manager of SDCMS Member Since 1990 “Thanks for all your help. It’s greatly appreciated.”

— Office Manager of SDCMS Member Since 2006 “Lauren, Just wanted to say thank you for all of your help over the last few years. Words cannot fully express my sincerest gratitude!”

— Office Manager of SDCMS Member Since 2002

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