November 2010 by San Diego Physician

✖ SDCMS Celebrates Its 140th Anniversary in 2010 ✖ Reaching 8,500 Physicians Every Month

november 2010

official publication of the san diego county medical society

Disast er Preparedness Patterns of Disease After Natural Disasters page 20

Apocalypse! Crisis! Disaster! Pestilence! page 24

A 7.2 Hits on Sunday, April 4, 2010 page 28

The ARC Is Seeking Local Medical Professionals page 30

“ P h y s i c i a n s U n i t e d F o r A H e a l t h y S a n D i e g o ”

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The Doctors Company built its reputation on the aggressive defense of our member physicians’ good names and livelihoods. And we do it well: Over 82 percent of all malpractice cases against our members are won without a settlement or trial, and we win 87 percent of the cases that do go to court. So what do you get for your money? More than a fighting chance, for starters. The San Diego County Medical Society has exclusively endorsed our medical professional liability program since 2005. To learn more about our benefits for SDCMS members, call (800) 328-8831, extension 4390, or visit us at www.thedoctors.com/sdcms.

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S A N D I E G O P HY S I CI A N .or g N o v e m b e r 2010

November 2010 SAN DIEGO P HY SIC I A N. o rg

thismonth Volume 97, Number 11

features Disaster Preparedness

20 Patterns of Disease After Natural Disasters: Time to Broaden Our Focus by Robert E. Peters, PhD, MD

SDCMS Board of Directors Officers President Susan Kaweski, MD Past President (AMA Alternate Delegate) Lisa S. Miller, MD President-elect (CMA District 1 Trustee) Robert E. Wailes, MD

24 Apocalypse! Crisis! Disaster! Pestilence! Physicians Need to Know What to Do As Individuals and How to Work Within Their Healthcare System by Susan Shepard

Treasurer Sherry L. Franklin, MD Secretary (SDCMS At-large Director) Robert E. Peters, PhD, MD

geographic and geographic alternate Directors East County William T. Tseng, MD, Heywood “Woody” Zeidman,

28 A 7.2 Hits on Sunday, April 4, 2010:

Managing Editor Kyle Lewis Editorial Board Van L. Cheng, MD, Adam F. Dorin, MD, Kimberly M. Lovett, MD, Theodore M. Mazer, MD, Robert E. Peters, MD, PhD, David M. Priver, MD, Roderick C. Rapier, MD Marketing & Production Manager Jennifer Rohr Sales Director Dari Pebdani Project Designer Lisa Williams Copy Editor Adam Elder

Observations From Imperial County by Thomas W. Henderson

30 The American Red Cross: Seeking Local Medical Professionals by Joe W. Craver

MD (A: Venu Prabaker, MD) Hillcrest Niren Angle, MD, Steven A. Ornish, MD Kearny Mesa John G. Lane, MD (A: Jason P. Lujan, MD) La Jolla J. Steven Poceta, MD, Wynnshang “Wayne” Sun, MD (A: Matt H. Hom, MD) North County James H. Schultz, MD, Doug Fenton, MD (A: Steven A. Green, MD) South Bay Vimal I. Nanavati, MD, Mike H. Verdolin, MD (A: Andres Smith, MD) At-large and At-large alternate Directors Jeffrey O. Leach, MD, Bing S. Pao, MD, Kosala Samarasinghe, MD, David E.J. Bazzo, MD, Mark W. Sornson, MD, Mihir Y. Parikh, MD (A: Carol L. Young, MD (sdcms foundation president), Thomas V. McAfee, MD, Ben Medina, MD, James E. Bush, MD, Alan A. Schoengold, MD)

departments 4 SDCMS Seminars, Webinars, and Events

other board members

4 Community Healthcare Calendar

Communications Chair Theodore M. Mazer, MD Young Physician Director Van L. Cheng, MD

6 Briefly Noted SDCMS Medical Office Manager Bulletin Board, and More …

Alternate Young Physician Director Kimberly M. Lovett, MD Resident Physician Director Katherine M. Whipple, MD Alternate Resident Physician Director Steve H. Koh, MD Retired Physician Director Rosemarie M. Johnson, MD

10 SDCMS Foundation and Net Chemistry Introduce eConsults to San Diego

Alternate Retired Physician Director Mitsuo Tomita, MD Medical Student Director Adi J. Price

by Lauren Radano

CMA Speaker of the House James T. Hay, MD

12 Don’t Take It Out on Them: Make Sure You Are Billing for Accurate Amounts!

ex-officio, nonvoting board members

by Melissa Brown

14 CMA Practice Resources: October/November 2010

CMA Past Presidents Robert E. Hertzka, MD, Ralph R. Ocampo, MD CMA district I Trustees Sherry L. Franklin, MD, Albert Ray, MD,

Robert E. Wailes, MD CMA Trustee (other) Catherine D. Moore, MD, CMA Solo and Small-group Practice Forum Delegates

Michael T. Couris, MD, James W. Ochi, MD

18 Sharp Rees-Stealy Medical Group: Delivering 21st-century Ideal Healthcare

Alternate CMA Solo and Small-group Practice Forum Delegate Dan I. Giurgiu, MD AMA Delegates James T. Hay, MD, Robert E. Hertzka, MD

by Donald C. Balfour III, MD

Alternate AMA Delegates Lisa S. Miller, MD, Albert Ray, MD

34 Physician Marketplace Classifieds

36 A Summer at the Capitol: An Insider’s View Into the Daily Activities of Running Our Country by Rachel Hogen, MS-II

sdcms.org exclusive • Haiti Impressions

January 23–26 and Jan. 28–Feb. 3, 2010 by A. Brent Eastman, MD, Scripps Health

S A N D I E G O P HY S I CI A N .or g N o v em b e r 2010

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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November 2010 SAN DIEGO P HY SIC I A N. o rg

CHMB DELIVERS THE HIGHEST LEVEL OF SERVICE AND EXPERTISE TO ENSURE A SWIFT, SMOOTH AND SUCCESSFUL EHR COMPLETION.

calendar

sdcms Seminars / Webinars / Events Free to member physicians and their staff. For further information, contact Sonia Gonzales at (858) 300-2782 or at SGonzales@SDCMS.org, or visit SDCMS.org. “Physician Leader’s Toolbox” (seminar) Fri.–Sat., Nov. 12–13, 8:00am–4:00pm “Emerging Patient Safety Issues Impacting Office Practices” (risk management webinar) Wed., Nov. 17, 6:30pm–7:30pm

community Healthcare Calendar

“Emerging Patient Safety Issues Impacting Office Practices” (risk management webinar) Thurs., Nov. 18, 11:30am–12:30pm

4th Annual UCSD Hands-on NOTES and Single Site Surgery Symposium Nov. 11–13 • Omni San Diego Hotel • cme. ucsd.edu/notes

West Coast Geriatric Psychiatry Conference Feb. 16–19, 2011 • Catamaran Resort Hotel, San Diego • cme.ucsd.edu

“Preparing to Practice” Workshop (seminar) Sat., Nov. 20, 8:00am–4:00pm

“Parkinson’s Disease Update for a New Decade” Nov. 13 • Hilton La Jolla Torrey Pines • Free • 4 CMEs • pdasd.org or (858) 273-6763

Topics and Advances in Internal Medicine Mar. 7–13, 2011 • San Diego Marriott, La Jolla • cme.ucsd.edu

SDCMS Membership Social Sun., Jan. 30, 5:00pm–8:00pm

“Brain Tumors: First Annual Collaborative Care Conferences” Jan. 15 • 7:30am • $25–$65 • UC San Diego Moores Cancer Center Goldberg Auditorium • cme.ucsd.edu/braintumors/ index2.html

Topics and Advances in Pulmonary and Critical Care Medicine Mar. 13–14, 2011 • San Diego Marriott, La Jolla • cme.ucsd.edu Annual San Diego Science Festival Mar. 19–26 • Petco Park • sdsciencefestival.com/host-an-event. html

To submit a physician-focused, San Diego County healthcare event for possible publication, email KLewis@SDCMS.org.

S A N D I E G O P HY S I CI A N .or g N o v em b e r 2010

November 2010 SAN DIEGO P HY SIC I A N. o rg

brieflynoted

SDCMS Medical Office Manager By Sonia Gonzales, Your Office Manager Advocate

ATE

VOC D A N IA C SI Y H P R U O Y K AS o we suspect may If we have a patient wh dications from me ion ipt scr be getting controlled pre acies. Is going to different pharm different physicians, or rt this epo o/r int k loo can that we there a centralized way possibility?

Question:

abase known as the Yes. The state has a dat lualization Review and Eva Controlled Substance Uti n 100 tha re mo s tain con ich tion System (CURES), wh t are lled substance drugs tha million entries of contro scripPre ess acc me l-ti rea is . Th dispensed in California allows Program (PDMP) system tion Drug Monitoring e precar lth hea d nse lice luding pre-registered users, inc tory ula reg enforcement, and scribers, pharmacists, law ce stan sub lled tro con t me patien boards, to access real-ti ts that rus ent MP PD of role e history information. Th and will rs and pharmacists can well-informed prescribe ir patients’ the te lua eva to ise ert use their professional exp g conients who may be abusin care and assist those pat trolled substances. rs PDMP system, prescribe To obtain access to the by S RE CU h wit r iste first reg and pharmacists must at pmp. tion form electronically submitting an applica n must atio istr reg r you addition, doj.ca.gov/pmpreg. In lication app r you of y cop ned sig be followed up with a entayour validating docum and notarized copies of ministraAd ent cem for En g tion, which include: Dru and a state medical license, tion (DEA) registration, il your ma can You n. tio ntifica government-issued ide ized documents to: application and notar orcement (BNE) Enf tic rco Na of Bureau ation istr Attention: PDMP Reg 447 160 P.O. Box Sacramento, CA 95816 presbe to forgo the notary and Another option would sonnel per rn swo ere wh , son per ent your documents in entat your supporting docum will validate and collec office ent em orc Enf tic rco of Na tion. San Diego’s Bureau is located at:

Answer:

9425 Chesapeake Drive 2 San Diego, CA 92123-130 00 Telephone: (858) 268-53 Fax: (858) 268-5353 ort nual Patient Activity Rep You can also fill out a ma report is Th . ine onl r h to registe (PAR) should you not wis 6.pdf. 117 NE fs/B /pd bne ov/ can be obtained at ag.ca.g viality and disclosure pro HIPAA and all confidenti tained con n atio orm inf the cover sions of California law AA rs must comply with HIP in this database. All use iption scr Pre the ng usi en s wh Privacy Rule requirement m System. Drug Monitoring Progra d multiple physiI’m assuming that if I fin patients, narcotics on one of my cians who have written h me wit m ble pro ity” tial den there will not be a “confi t’s conien pat the tors without notifying these other doc that? do to me for n tio iga obl sent. Is there actually an

Question:

-CALL document According to CMA ON ized,” “Generally, hor aut Un g: ibin #0515, “Drug Prescr n is protected by atio al inform unless a patient’s medic ing drug and ern gov s law y the federal confidentialit by state laws or n informatio alcohol abuse treatment te drug treatsta a to ent tin per governing information armacist an ful for a physici or ph ment program, it is law ential pot t’s ien pat a ing regard to convey information care lth hea r stances to anothe abuse of prescriptive sub has also ent um doc is acist.” Th professional or pharm ich al Duty to Report,” in wh a section titled, “No Leg ory tut sta no is re although the it is stated, “Moreover, lthcare hea er oth h wit n atio duty to share such inform by law, acists, unless prohibited practitioners or pharm ating tre er oth h wit red sha be such information should by ed uir req is munication providers where such com . In lth hea t’s ien pat the t protec the standard of care to the ut abo t ien uld warn the pat addition, physicians sho can ers mb me MA SDCMS-C hazards of drug abuse.” ting LL document by contac obtain this CMA ON-CA 88. SDCMS at (858) 565-88

Answer:

E)R RN IN, CPGC, CHCMBO COD (CAHealth.com elle Pena Mich

ce visits when billing for I prevent denials for offi Question: How can 96372)? rapeutic injections (CPT the administration of the iative (CCI), new patient to the Correct Coding Init answer: According sidered compooutpatient visits are con ce/ offi nt tie pa ed lish and estab to support a “signifithere is documentation If e. cod min ad the of nents nagement service by fiable evaluation and ma nti ide y tel er ara sep , tly can er service,” a -25 modifi the same day of the oth on n cia c ysi cifi ph e spe sam iew the ortant to rev office visit CPT. It is imp acts edi may be appended to the ling their bund as not all payers apply payer payment policies cording to the CCI. of a lesion (CPT dicare denying the biopsy Question: Why is Me 000)? The documen17 T inic keratoses (CP act of n ctio tru des h wit 11100) we append -59 modifier arate lesions, therefore sep rt po sup es do ion tat to the destruction. ded to the CPT with the the -59 modifier is appen answer: Commonly, ent of the modifier per is not the correct placem lower RVU or fee. This umn II or compould be placed on the col sho er difi mo e Th ts. coding edi ding Initiative (CCI) reviewing the Correct Co en wh e, cas s thi In T. nent CP 100 due to its being uld be placed on the 11 sho er difi mo -59 the edits, code in the CCI pair. considered the second References: 71.pdf ei/reports/oei-03-02-007 • OIG: http://oig.hhs.gov/o ndler.do ciHa ro/c /ep .com ww.encoderpro • EncoderPro: http://w

[SAVE THE DATES!] ✓ November 20: “Preparing to Practice” Workshop

✓ January 13: “Collection Procedures”

Seminar/Webinar ✓ January 20: “Palmetto GBA/Medicare Provider Enrollment” Seminar/Webinar ✓ January 26–27: “Simple Approaches to Informed Consent and Informed Refusal” Seminar/Webinar ✓ February 3: “Treating Patients Right” Seminar/Webinar

st Office Manager “To Do” Li website at SDCMS.org. • Check out version 3 of our ed features. It has some new and improv . e checklist? Go to SDCMS • Need an OSHA new hir ll scro n the ebinars, and org, click on Publications/W Course” (recorded August down to “OSHA Refresher 18, 2010). er Bulletin Board questions • Email your Office Manag . to SGonzales@SDCMS.org

Ask Your Office Manager Advocate!

Question:

Our physician has been having diffi culty getting reimbursed from a certain health plan . I think they are having financial difficulties because they are giving me the runaround when I call to follo w up. What can I do at this point?

Answer:

You have a few options. First, con tinue to follow up with the health plan and track the com munication and progress on a spre adsheet. For IPA solvency issues, sub mit the claims for payment to the underlying health plans and noti fy them that the claims remain unpaid by the IPA. Request that they pay the claims and deduct the capitati on from the IPA. Your other option is to have you r physician request a meet-andconfer with the medical director of the IPA. Send the request by certified mail with return receipt and ask that the meet-and-confer be sche duled within two weeks. Let the IPA kno w you want to continue to provide quality care to their enrollees but are concerned they are not paying you within the timeframe specified by California law. Another option is to file a formal complaint with the Department of Managed Health Care (DMHC). You can do this via webportal at dmh c. ca.gov — click on “File a Provider Complaint.” CMA has developed a payor solvency checklist to assist you in navigating through these issues — search “payor solvency checklis t” at SDCMS.org. For further info rmation regarding payor solvency, con sult CMA ON-CALL document #10 51, “Physician Complaints About Man aged Care,” and #0131, “Insolve ncy of Health Plan, IPA, or Other Ent ities That Contract With Health Plans (Pre-bankruptcy or Closure).”

November 2010 SAN DIEGO P HY SIC I A N. o rg

brieflynoted OUR 2010 MESSAGE FROM O F T HE YEAR

OFFIC E MANAGER

will reap rewards. ees’ “real lives and needs” the 2009 as sen cho be to or mission to problemIt has been a great hon 4. Employees need per CMS. It SD by er” nag Ma bit of direction, but in ce “Outstanding Offi solve. They may need a to t sen n tio ina er of nom uire management was a joy to read the lett most cases it does not req ine dic Me al ern Int ty un m persists, ask them SDCMS by the North Co involvement. If a proble ate tun for ly tain cer s wa in writing along with (NCIM) physicians. I to identify the problem their office as d cte sele utions. be sol to ted ago some 17+ years a list of their sugges to work with this re asu we all get bored ple nt a n poi e bee som has It manager. 5. Cross-train. At nt elle exc y onl not are o wh ies. Whenever posgroup of professionals, with our day-to-day dut areas of all in st ere int ive act choose the desired poclinicians, but take an sible, let the employee you will find n, noo at ay Frid to expand their skills. ry m Eve their business. sition and allow the y ekl we our in ticipating er become “friends” us, agendas in hand, par 6. Managers should nev up, gro r, hou s thi g rin Du erative that you remain management meeting. with the staff. It is imp blems pro ent em nag ma and a whole and not to an individual physician, objective and neutral as ed. ress add or concerns are individual. practice administranal quirks. If we are As all office managers and Work through generatio 7. vmo y bus too es mon goal, we will tors know, we are sometim all working toward a com se tho all ge led now re than one right ack mo ing about our days to find that there is always lace. This rkp wo l sfu ces suc a m. to ble who contribute way to solve a pro by SDCMS, belongs to surrounded by emhonor, awarded to me am very fortunate to be I and er ual ivid ind ir the for to offer me assistance. Aft all employees of NCIM ployees who never fail zation. ani ce org offi tch the -no at d top a ive to arr n, I group contributions a recent week’s vacatio an . Dene, and team effort creates k was neat and organized des my Their support, energy, d fin to our for y , onl not t, m e suppor er, and gift fro heaven environment of positiv my partner, dragon slay ent em ere nag Th ma os. and cha of ans sici d order out patients but for the phy had, once again, create : “Before you get coffee,” ers fold ked pac ee of NCIM. thr were to build a how on as ide my t,” and the third folder of firs Here are a few “When you finish the wer quickly opened my dra successful team: labeled “Whenever.” I and t set tha l d skil ere the cov et dis me note and 1. Hire employees who to write her a thank-you had a Lis e n. abl itio end pos dep l, the efu personality for my supportive, resourc s. wer. Who of trust with employee organized my “junk” dra and 2. Create a relationship d ane cle and r? hs ngt stre tin ir t pens in that y drawe Take the time to learn the knew that I had 50 Pilo orpoinc ay le, aw sib e pos hom ver le ene fortab weaknesses, and, wh I like this place. It’s a com their job duties. er let Bil ne An – rate their strengths into e. hom from ity. We all have 3. Administrative flexibil . p.m 5 r afte s” live families, as well as “real d to begin at 3 p.m. Some days real lives nee ommodating employAcknowledging and acc

iration to sp n i an ch su g n i be r fo e, nn A u, yo nk ha “T ounty! all the of fice managers in San Diego C

te! MS Office Manager Advoca — Sonia Gonzales, Your SDC

S A N D I E G O P HY S I CI A N .or g N october o v em b e r 2010 2010

you take care of the san diego communit y ’s health. we take care of san diego’s

healthcare communit y.

Get in

touch

3 Income Tax Planning 3 Wealth Management

Your SDCMS and SDCMSF Support Teams Are Here to Help!

3 Employee Benefit Plans 3 Profitability Reviews

SDCMS Contact Information 5575 Ruffin Road, Suite 250 San Diego, CA 92123 T (858) 565-8888 F (858) 569-1334 E SDCMS@SDCMS.org W SDCMS.org • SanDiegoPhysician.org CEO/Executive Director Tom Gehring at (858) 565-8597 or Gehring@SDCMS.org COO/CFO James Beaubeaux at (858) 300-2788 or 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 MGonzalez@SDCMS.org director of medical office manager support and Office Manager Advocate Sonia Gonzales at (858) 300-2782 or SGonzales@ 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 BUSINESS MANAGER Nathalia Aryani at (858) 300-2789 or NAryani@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

3 Outsourced Professional Services (CFO, Controller) 3 Organizational and Compensation Structure 3 Succession Planning 3 Practice Valuations 3 Internal Control Review and Risk Assessment

akt A KT LLP, CPAs and BUSINESS CONSU LTANTS CARL SBAD

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760-431-8440

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SDCMSF Contact Information 5575 Ruffin Road, Suite 250 San Diego, CA 92123 T (858) 565-8888 F (858) 560-0179 W SDCMSF.org Executive Director Kitty Bailey at (858) 300-2780 or KBailey@SDCMS.org project access PROGRAM DIRECTOR Brenda Salcedo at (858) 565-8161 or at BSalcedo@SDCMS.org Healthcare Access Manager Lauren Radano at (858) 565-7930 or at LRadano@SDCMS.org Patient Care Manager Rebecca Valenzuela at (858) 300-2785 or at Rebecca.Valenzuela@SDCMS.org

S ITS 140 CELEBRATE � SDCMS

0� ARY IN 201 ANNIVERS Reaching 8,500

ATION OFFICIAL PUBLIC OCTOBE

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DIEGO” LTHY SAN FOR A HEA NS UNITED “PHYSICIA

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

November 2010 SAN DIEGO P HY SIC I A N. o rg

brieflynoted SDCMS Foundation and Net Chemistry Introduce eConsults to San Diego

Physicians Get Noticed!

Increasing Access for the Uninsured By Lauren Radano

The SDCMS Foundation is pleased to announce a partnership with software development company Net Chemistry1 to bring an e-consult system to San Diego. eConsults will revolutionize the way physicians communicate about patient care and ultimately reduce the need for specialty visits for underserved populations. Through the e-consult system, primary care physicians (PCPs) at community clinics will be able to electronically connect with specialists for “curbside consultations.” With more than 90 sites throughout the county, community clinics provide primary care for the vast majority of safety-net patients in San Diego. These clinic

PCPs are frequently forced to make specialty referrals for issues that they could likely manage at the clinic if they had the input of a specialist. Fortunately, eConsults will allow clinic PCPs to engage in an electronic curbside consultation with a variety of appropriate specialists who are seeking an easier way to provide care for the safety net. PCPs will be able to log onto a user-friendly, HIPAA-compliant, web-based e-consult system that allows them to share patient information and receive a timely response through secure messaging from a specialist. eConsults is an innovative, simple way to reduce healthcare costs while providing critically needed care for the most vulnerable residents of San Diego. Are you a specialist interested in using eConsults? If so, please contact Lauren Radano, healthcare access manager, at (858) 565-7930 or Lauren. Radano@SDCMS.org.

{About the Author} Ms. Radano is your SDCMS Foundation healthcare access manager.

1. Net Chemistry is an Internet solutions provider to the health and financial services industries whose systems have handled billions of dollars in transactions. Net Chemistry specializes in web-based information enrollment, distribution, and tracking systems comprised of secure, scalable software modules that can be rapidly customized to fit each client’s unique business parameters.

Wish Your Legislators a Happy Birthday! Physicians: Let your legislators know that you’re paying attention and that you vote by wishing them a happy birthday! NOTE: Due to mail handling procedures for government office buildings, postal mail to Washington, DC, offices may be delayed by several weeks or even months. Please fax or email if possible.

Birthday: November 1 U.S. Representative Darrell Issa

E: (via website) house.gov/issa Capitol Office: T: (202) 225-3906 F: (202) 225-3303 District Office: 1800 Thibodo Rd., Ste. #310, Vista, CA 92081 T: (760) 599-5000 F: (760) 599-1178

Birthday: November 7 State Assemblymember Lori Saldana

E: assemblymember.saldana@assembly.ca.gov Capitol Office: California State Assembly P.O. Box 942849, Sacramento, CA 94249-0076 T: (916) 319-2076 F: (916) 319-2176 San Diego Office: 1557 Columbia St., San Diego, CA 92101 T: (619) 645-3090 F: (619) 645-3094

Birthday: November 11

U.S. Senator Barbara Boxer E: (via website) boxer.senate.gov Capitol Office: T: (202) 224-3553 F: (202) 228-2382 San Diego Office: 600 B St., Ste. 2240, San Diego, CA 92101 T: (619) 239-3884 F: (202) 228-3863

Membership Directory Errata Please make the following corrections to your copy of SDCMS’ 2010–11 Pictorial Membership Directory. Thank you. 10

Dennis F. Coughlin, MD Additional Address: 7920 Frost St., Ste. 304, San Diego, CA 92123 Zahra Ghorishi, MD Telephone: (858) 939-4198

S AN D I E G O P HY S I CI A N . or g N o v e m b e r 2010

Allan H. Rabin, MD Board-certified Specialties: Child and Adolescent Psychiatry, and Addiction Psychiatry

Smitha Chiniga Reddy, MD No additional addresses. Fane L. Robinson, MD Primary Address: 7695 Cardinal Ct., Ste. 100, San Diego, CA 92123 Website: sdretina.com

Mark D. Smith, MD Primary Address: 7695 Cardinal Ct., Ste. 100, San Diego, CA 92123 Website: sdretina.com

November 2010 SAN DIEGO P HY SICIA N. o rg

practicemanagement By Melissa Brown, RHIA, CPC, CPC-I, CFPC

Don’t take it out on them Make Sure You Are Billing for Accurate Amounts!

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With code changes for a new year once again on our radar, make sure you look for “quantity” changes. HCPCS Level II drug codes particularly are ripe for error if you aren’t checking carefully.

Check Your Math To assign the HCPCS Level II codes correctly, billing staff must calculate the units billed from how the drug is supplied and the amount given to the patient. Recognize that the dosage unit administered and/or listed on the package does not always match the billing unit. Failure to convert the billing units properly could cost you money. The simplest calculations can be seen in this example. A total of 500 mg of Tetracycline (J0120 Injection, Tetracycline, up to 250 mg) is administered to a patient. To capture full payment, bill two units of J0120 (500/250 = 2). The conversions are not always straightforward. For instance, two 2 mL syringes, each containing 1,200,000 units of Bicillin C-R (J0559 Injection, penicillin G benzathine and penicillin G procaine, 2,500 units), are administered. When converting this information, you must make two calculations: 1. for the two vials, and 2. to convert the vials to units. The amount injected is 2,400,000 units (1,200,000 x 2). The units administered then must be converted to billing units. The billing unit in this example is 2,500; therefore, the bill should reflect J0559 with 960 units (2,400,000/2,500 = 960).

Check the Changes Although it’s too soon to tell what the changes for 2011 are, we can look at some examples from the 2010 changes that make the point very clear. The 2,400,000 units of Bicillin C-R above was coded as J0550 Injection, penicillin G benzathine and penicillin G procaine, up to 2,400,000 units in 2009. Notice the importance of accounting for the unit change (2,400,000 in 2009 to 2,500 in 2010). If you fail to adjust the billing units accordingly on your claims (960 billing units in 2010 vs. 1 billing unit in 2009), you could be losing payment for 959 billing units of the drug! For Medicare patients, that could be a difference of getting paid $0.08 vs. $77.68.

Know What and Where You Are Reporting If making calculations for billing units was not challenging enough, the required reporting of the NDC number and units on the claim cannot be left out of the equation. As previously mentioned, the unit number associated with package (thus the NDC) does not always match the billing unit. In our Bicillin C-R example, the billing unit was 960. The medication is supplied in 2 ML syringes, so the line with the NDC units would be reported as ML4 because each syringe used contained 2 ML (2 x 2 = 4).

Don’t Eat the Waste One final calculation that needs to be accounted for is the amount of drug left over after the patient has received the appropriate amount prescribed (assuming single-use vials or packages are used). These leftover units are often referred to as waste. Rather than eating the cost of the waste units, these units should be reported on a separate line item with modifier JW Drug or biological amount discarded/not administered to any patient. By reporting the waste, you may be able to recoup the cost of the drug that cannot be used on other patients. Make sure the medical documentation includes the details related to the amount given and reason for the waste amount.

Why the Math Matters From the examples discussed above, you can see why it’s important to capture every opportunity to recoup the cost of the drugs and biologicals. It’s equally important to check the changes to make sure you aren’t inadvertently overbilling for your drugs. Mistakes that over-report the units will raise red flags and put the practice at risk for charges of fraud. Taking the time to understand how to account for and report the billing units and NDC units properly is critical in making sure you get every penny due to you. So is making sure you know how the code changes will affect your calculations. Happy counting!

Taking the time to understand how to account for and report the billing units and NDC units properly is critical in making sure you get every penny due to you.

{A bou t the Au thor} Ms. Brown is manager of education and reimbursement at the University of Florida Jacksonville Physicians, Inc.

November 2010 SAN DIEGO P HY SICIA N. o rg

practicemanagement By the California Medical Association

CMA Practice

Resources October / November 2010

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Unfair Payment Practice: Timely Filing Denials

Health plans usually impose claim-filing deadlines, which require physicians to submit a claim within a certain time period after the date of service. If the physician fails to meet the deadline, the health plan will not pay for the service provided. California law prohibits health plans and insurers from imposing claim-filing deadlines that are less than 90 days for contracted physicians or 180 days for noncontracted physicians after the date of service. If the payer is not the primary payer under coordination of benefits (COB), the payer cannot impose a deadline for submitting a COB claim that is less than 90 days from the date of payment or date of denial from the primary payer. Moreover, even if the physician fails to submit the claim on time, California law provides a “good cause” exception that requires payers to accept and adjudicate a claim if the physician demonstrates, upon appeal, “good cause” for the delay. Below are steps you can take to prevent timely filing denials: 1. Submit claims as quickly as possible after services are rendered. 2. Where possible, file claims electronically. 3. Retain payer acknowledgement of receipt of claim. As discussed in the August 2010 issue of CPR, California law requires health plans to acknowledge receipt of an electronic claim within two days and a paper claim within 15 days of receipt. 4. Appeal all claims that have been incorrectly denied for timely filing in writing. Include a copy of the payer’s acknowledgment of receipt of the claim with your appeal. 5. Review health plan contracts to ensure that deadlines for filing claims are no less than 90 days. 6. Report health plan violations of the timely filing laws to the appropriate regulator and to the California Medical Association. For a summary of California’s unfair payment practices, see “Know Your Rights: Identify and Report Unfair Payment Practices,” available at SDCMS.org. TIP: As previously reported in the August 2010 issue of CPR, an acknowledgement of receipt of a claim from a clearinghouse is not an acknowledgement that the claim has been transmitted to and received by the payer. Check with your clearinghouse to determine its process for tracking health plan receipt of claims. CMA RESOURCES: CMA ON-CALL document #0146, “Payment Denials by Managed Care Plans and IPAs,” document #1070, “Managed Care Contractual Protections,” and document #1051, “Physician Complaints About Managed Care Plans,” “Know Your Rights: Quick Guide for Appeals,” and “Know Your Rights: Identify and Report Unfair Payment Practices.”

Aetna Notifies Physicians of New Consult Code Reimbursement Policy

Aetna recently notified 12,750 contracting physicians that the insurer will no longer recognize or reimburse for consult codes, effective Nov. 15, 2010. The notification, dated Aug. 15, 2010, was sent to physicians contracted with Aetna on a “current Medicare Physician Fee Schedule.” The policy change does not apply to physicians who are contracted with Aetna with a fee schedule based on a methodology other than the current Medicare Physician Fee Schedule. As previously reported in the May 2010 issue of CPR, Medicare is no longer recognizing inpatient and outpatient consultation codes. Effective Jan. 1, 2010, physicians must instead bill using E/M codes from the Office and Other Outpatient Services, Initial Hospital Care, and Initial Nursing Facility sections of the 2010 CPT. To assist physicians with this issue, CMA has published a Medicare consultation code billing guide. In addition, CMA has published a “Managed Care Consultation Code Quick Reference Guide,” which provides up-to-date information on which major payers in California have or will be changing their own payment policies as the result of this change. CMA’s consultation code billing guides are available free to members at the members-only website at www. cmanet.org/ces. Physicians are encouraged to carefully review all proposed amendments to health plan or medical group/IPA contracts. CMA has published “Contract Amendments: An Action Guide for Physicians,” which is designed to help physicians understand their rights and options when a health plan notifies them of a material modification to a contract, manual, policy, or procedure. CMA has also developed a simple worksheet to help physicians analyze proposed fee schedules and assess the impact fee schedule changes may have on physician practices based on commonly billed CPT codes. CMA RESOURCES: CMA’s “Managed Care Consultation Code Quick Reference Guide,” CMA’s “Medicare Consultation Code Billing Guide,” “Contract Amendments: An Action Guide for Physicians,” and CMA’s “Financial Impact Worksheet.”

November 2010 SAN DIEGO P HY SICIA N. o rg

practicemanagement

Did You Know? Has Your Contracted Health Plan or IPA Stopped Paying Claims?

CMA’s Center for Economic Services has recently received an increase in calls regarding physician concerns that a medical group/ IPA with whom they contract is experiencing financial difficulties. One of the symptoms of an insolvent health plan, IPA, or other payer is the failure to pay claims in a timely manner. Another indication of financial distress is a payer that cuts checks within the statutory timeframes but does not release the checks in a timely manner. If you are experiencing repeated payment delays, you should investigate the financial health of the payer. To help physicians monitor the financial health of their contracted payers, CMA has put together a “Payer Solvency Checklist.” This resource includes instructions on how to research and monitor the financial solvency of your contracted medical groups/IPAs and discusses options available to physicians in the event a payer stops paying claims. CMA RESOURCES: CMA’s “Payer Solvency Checklist,” CMA ONCALL document #0223, “Risk-bearing Medical Groups, Including IPAs: Regulation of Solvency,” document #1031, “Insolvency of Health Plan, IPA, or Other Entities That Contract With Health Plans (Pre-bankruptcy or Closure),” and document #0106, “Bankruptcy of IPAs or Health Plans.”

Have You Received Your eRx Incentive Payment?

Successful participants in the Medicare Electronic Prescribing for 2009 program should have received their lump sum payment from Palmetto GBA by Oct. 22, 2010. Paper EOBs associated with the payment contained the message “This is an eRx incentive payment.” Electronic remittances contained an indicator of LE to reflect an incentive payment, along with RX09 to identify the payment as the 2009 eRx incentive payment. If you have questions about the status of your eRx incentive payment, please contact the Palmetto GBA Provider Contact Center at (866) 931-3901. Physician feedback reports will be available on the Physician and Other Health Care Professionals Quality Reporting Portal at www.qualitynet.org/pqri starting the second week of November. For more information on an alternate way to receive the report, and for available resources for assistance with the portal or reports, please visit www.cms.gov/MLNMattersArticles/downloads/SE0922.pdf.

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CMA’s Center for Economic Services provides our members with up-to-date profiles on each of the major payers in California, including Aetna, Anthem Blue Cross, Blue Shield of California, CIGNA, Health Net, United Healthcare, Medicare/Palmetto, and Medi-Cal. Each profile includes key information on market penetration, a description of the plan’s dispute resolution process, as well as key contact information for payer medical directors, provider relations, and contracting-related issues. Don’t waste your time searching the Internet for this information. Payer profiles are free to members for download at www.cmanet.org/ces.

CMA Advocacy Results in Changes to United Coverage Determination Guideline

UnitedHealthcare recently proposed a coverage determination guideline that would have added an administrative burden to physician practices and potentially compromised patient care. The originally proposed guideline, which was to become effective Oct. 1, 2010, would have required physicians to submit not only written documentation, but also a CT scan and seven “high-quality color” photographs prior to performing rhinoplasty, septoplasty, and turbinate resection. In addition to the administrative burden, these requirements could have exposed the patient to unnecessary doses of CT radiation. After discussing the pitfalls of its proposed policy with CMA, United agreed to revise its guideline. The guideline no longer requires a CT scan if a patient refuses the scan or the physician believes it to be unnecessary. In such cases, United will accept detailed clinical documentation that adequately demonstrates chronic and consistent nasal obstruction that is unresponsive to medication. Additionally, the requirement for photographs has been eliminated for all cases except those in which there is a post-traumatic nasal deformity. The revised policy will be effective Dec. 1, 2010. For more information, including United’s revised guideline, visit http://bit.ly/91Qy0U.

Health Plan Provider Newsletters

To make sure that you are aware of important news from your contracting health plans, we encourage you to regularly read plans’ provider newsletters and bulletins. Follow the links below to access the current issues: • AETNA: www.aetna.com. Click on “Health Care Professionals” in the main menu, then on “News for Providers” in the left sidebar. • BLUE SHIELD: www.blueshieldca. com. Click on “I’m a Provider,” then on “Announcements” under “News and Features.” • CIGNA: www.cigna.com. Click on “Health Professionals” under “Customer Care” in the main menu, then scroll down and click on “Newsletters.” • ANTHEM BLUE CROSS: www.anthem. com/ca. Click on “Providers” in the main menu, then on “Professional Network Update” under “Spotlight.” • HEALTH NET: www.healthnet.com. Click on “I’m a Provider” and then “California.” Enter username and password, and then click “Online News.” • MEDI-CAL: www.medi-cal.ca.gov. Click on “Publications” in the main menu, then on “Provider Bulletins.” • MEDICARE/PALMETTO GBA: www. palmettogba.com/j1b. Click on “Publications” in the left sidebar, then on “Medicare Advisory.” • UNITED HEALTHCARE: www.unitedhealthcareonline.com. Click on “Tools & Resources” in the main menu, then on “Network Bulletin.” CMA RESOURCE: Find up-to-date profiles on each of the major payers in California at www.cmanet.org/ces.

{About CPR } CMA Practice Resources (CPR) is a free, monthly bulletin from the California Medical Association’s Center for Economic Services. This bulletin is full of tips and tools to help physicians and their office staff improve practice efficiency and viability. To sign up for a free subscription, visit www.cmanet.org/news/cpr.

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T: 925.249.9510 • E: info@amadorphysicianservices.com

SDCMS Tweets! Follow SDCMS on Twitter to keep abreast of the latest in health reform changes, regulatory news, scope of practice issues, practice management tips, and more!

November 2010 SAN DIEGO P HY SICIA N. o rg

fromsandiegocountyhealthleaders By Donald C. Balfour III, MD

Sharp Rees-Stealy Medical Group Delivering 21st-century Ideal Healthcare Note: Dr. Balfour’s article is one in an occasional series of articles from San Diego County’s healthcare leaders published in San Diego Physician. Opinions expressed are not necessarily endorsed by SDCMS or CMA. Founded in 1923, Sharp Rees-Stealy Medical Group is the region’s oldest multispecialty medical group, nationally known for superior clinical practices and recipient of numerous awards and recognition. One of the largest medical groups in the state, we have been committed since our inception to providing the finest in personalized medical care, where the health of our patients always comes first. We provide care at 19 locations throughout the region with 1,850 employees and more than 400 physicians representing virtually every medical specialty. In 2009, our medical group had more than 1 million patient visits, with about 70 percent of the population covered by one of several managed care health plans. In 2001 our leadership team set out on a

journey to transform our organization’s culture and unify our entire workforce to create a best-in-class healthcare system. The results of our efforts are broad, with breakthrough improvements in clinical performance, financial growth, and physician, employee, and patient satisfaction. Although our transformational improvement in reportable measures has gained the most attention, our greatest change has been in our culture, a measurement not tallied in national benchmarks. We have unified our workforce around a rededication to our patients, using systemic changes to positively impact the lives of others. Working as a team we have become the providers of care we had hoped to be when we joined this profession. We created six pillars of excellence representing the strategic focus areas of quality, service, people, finance, growth, and community to make targets concrete and assure execution of our strategic plan. We have achieved breakthrough results in each of the pillar focus areas. (See figure 1)

Figure 1: Key Results by Pillar of Excellence

In August 2008, the Commonwealth Fund issued the report “Organizing the U.S. Healthcare Delivery System for High Performance,” identifying six attributes of an ideal healthcare delivery system. Sharp Rees-Stealy’s redesign efforts incorporate each of the Commonwealth Fund’s attributes, and continue to be supported by the methods and processes helping us to achieve our vision. 1. EHR Information Access: We use a state-of-the-art EHR system to consolidate data for analysis and feedback, provide decision support, and engage patients in their healthcare. All primary care physicians, specialists, and in-network emergency rooms and hospitals share access to the system. Disease registries with robust data mining capture gaps in care for entire populations of patients. This has led to dramatic improvements in the multidisciplinary coordination and integration of personalized care for each patient. 2. Coordination of Patient Care: Our medical group assigns a primary care physician to every patient assuring a high level of continuity of care. In 2007 we developed the Continuity of Care Unit to capture integrated EHR data allowing nurses to monitor all patients’ post-hospital stays and after-emergency room discharges. Dramatic improvement in patient care resulted from the coordination of this critical transition across care settings.

PILLAR

RESULT

Quality

#1 in California’s P4P program for four consecutive years 2006–09, recognizing performance in clinical quality, patient experience, and information technology.

Service

Dramatic increase in patient satisfaction rates from 12th to 81st percentile on national Press-Ganey ratings.

People

Employee engagement index in the 99th percentile for healthcare organizations. Physician satisfaction has improved over 20%.

Finance

35% decrease in heart failure admissions resulting in over $1.5 million annual savings.

Growth

11.5% increase in patient visits.

3. Accountability Across the Care Team: We use consolidated EHR data to report patient outcomes by site, department, and individual physician, allowing for overall and individual review. This accountability and transparency drove the initial fundamental changes and continue to provide the basis for measuring progress. Shared behavior models, goals, and incentives reinforce the collaborative work environment in which all members of the healthcare team unite to provide the best healthcare.

Community

Tens of thousands of community volunteer hours logged by physicians and employees.

4. Ease of Access for Patients: A patient portal, mySharp, provides access to lab

S AN D I E G O P HY S I CI A N . or g N o v e m b e r 2010

results, prescriptions, patient/provider emessaging, and convenient online patient scheduling. A 24/7 telephone nurse advice line provides support, and patients have open access for same- or next-day primary care appointments. Diverse staff and physician backgrounds provide multicultural understanding and service in a wide range of languages to meet the needs of the communities we serve. 5. Accountability for Total Care: The collection of data, reporting, and analytics combined with our renewed focus on the patient experience has led to accountability for total patient care. Information systems allow close monitoring of key quality indicators and cost-of-care drivers. Regardless of funding source or type of insurance, our commitment to providing a consistent patient experience is our priority. Since more than 70 percent of the medical group’s revenue is full-risk capitation, business success demands financial accountability for the total cost of care. Physician quality and

service are reported with full transparency, institutionalizing peer pressure to improve performance. 6. Continuous Innovation and Learning: As we use more accurate data and analyze what achieves results, we have new opportunities to support continuous learning and system innovation. We allocate human and financial resources to leadership development, quality improvement, physician and staff coaching, and team building. As an organization we are now more accountable for quality results using selected sixsigma methodologies. These same processes are now used with a number of projects that support our pillars of excellence. We participate in state and national learning collaboratives and exchange best practices with other leading medical groups. At our quarterly leadership institute, we capture lessons learned and share successes from our organization and other healthcare environments and industries. We are proud of what we have become.

Performance, transparency, and accountability are fully integrated into Sharp ReesStealy’s culture. We are patients, families, physicians, healthcare administrators, nurses, allied health professionals, and staff who have come together, working together, helping and supporting each other to care better for patients and their families. Our journey continues as we find new and innovative ways to create the best place to work, the best place to receive care, and the best place to practice medicine.

{About the Author} Dr. Balfour, SDCMS-CMA member since 1978, has been president of the Sharp Rees-Stealy Medical Group (SRSMG) board of directors since 1985 and currently serves as the president and medical director. SRSMG includes more than 376 physicians representing 27 medical specialties at 17 medical centers throughout San Diego County, and provides comprehensive medical care to 140,000 HMO patients, including 14,000 seniors.

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November 2010 SAN DIEGO P HY SICIA N. o rg

DisasterPreparedness

patterns of

disease after natural disasters Time to Broaden Our Focus Robert E . Peters , PhD, MD

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Note: To read an extended version of this article, please visit SanDiegoPhysician.org. Infectious disease epidemics, with resulting high morbidity and mortality, commonly follow disasters, whether natural or the result of human activities. Large-scale disasters often result in associated social disruption, including reduced availability of healthcare services and/or access to the typically available healthcare infrastructure. After a survey of post-disaster circumstances from a community healthcare perspective, I suggest that we need to expect a potential epidemic of an infectious disease or diseases. Too often, the “disaster planning” focus of the healthcare infrastructure has the relatively limited focus of triage planning and largescale management of trauma patients. It must also include planning for highly likely, post-event infectious disease epidemic(s). Consider the case of a 51year-old previously healthy woman of Scandinavian descent. She was a victim of the southeast Asian tsunami. The initial medical problems included a deep cutaneous wound (Acinetobacter baumannii, Stenotrophomonas maltophilia, Achromobacter xylosoxidans) to her legs, multiple fractured pelvis, ruptured bladder (Enterococcus faecium) and pneumonia (Pseudomonas spp.). Two weeks later she developed a thigh abscess (Nocardia africanum).

Eight weeks later she developed altered mental status due to brain abscess (Scedosporium apiospermum). Three months later she had a persistent draining wound (Mycobacterium cheloniae) from the tibial region (osteomyelitis excluded). A healthy but immunologically naïve host from the other side of the world, massively inoculated with tropical organisms on top of severe trauma, will act like an immunocompromised host. But even local populations, subjected to trauma and massive inoculation, can experience large-scale infectious complications. How often do disasters result in infectious disease outbreaks? Experts disagree on both the incidence and the specific infectious agents involved. Definitive causal relationships can be difficult to confirm, as predisaster baseline surveillance is often weak to nonexistent. Postevent, population-based sur-

veillance may be a low priority in the initial weeks and months following disaster, yet difficult to accomplish at a later time. Lastly, origin of an outbreak is typically multifactorial. In order to consider a suggestion that infectious epidemic(s) should be anticipated for public health planning following a disaster, consider the following phases of a disaster. Think in terms of individual patients proximal to a disaster location and associated responses required by the healthcare infrastructure.

Too often, the “disaster planning” focus of the healthcare infrastructure has the relatively limited focus of triage planning and large-scale management of trauma patients. It must also include planning for highly likely, post-event infectious disease epidemic(s).

November 2010 SAN DIEGO P HY SICIA N. o rg

DisasterPreparedness

As we consider healthcare infrastructure planning programs for disaster circumstances, the goal of planning tends to intuitively gravitate to improving the health status of disaster victims one person at a time. We are beginning to realize that such planning is insufficient. Impact Phase: Zero to Four Days • Extrication/trauma. • Hypothermia/heat illness/ dehydration. • Early soft-tissue infections. Infectious complications in tsunami survivors often are the result of crushing or impaling injuries from wood, rock, concrete, or metal. Wounds become contaminated with tsunami water, soil, or particulate matter. Even minor wounds and abrasions could lead to overwhelming infection with Staphylococcus, Streptococcus, and water-borne organisms: Vibrio, Aeromonas, Pseudomonas, Burkholderia spp, and fungi.

• Post-Hurricane Katrina, a Dallas evacuation facility had a cluster of 30 adult and pediatric patients with MRSA. Following the same disaster, an increase in mortality was reported by CDC from Vibrio vulnificus and parahaemolyticus soft-tissue infections. Risk factors included wading in contaminated flood waters (60 percent of cases are wound infections) and 40 percent resulted from raw shellfish consumption. Contact with brackish salt water, prevalent in Gulf states. Necrotizing fasciitis may occur. Overall mortality is 40 percent — 20 percent in the subset with Vibrio from wounds. Another soft-tissue infection caused by Aeromonas hydrophilia is associated with brackish fresh water. This infection is associated with eating infected fish or with leech bites.

S AN D I E G O P HY S I CI A N . or g N o v e m b e r 2010

Post-impact Phase: Four Days to Four Weeks • Waterborne and foodborne illnesses from contaminated drinking water (cholera, bacterial dysentery, cryptosporidiosis, rotavirus, norovirus, typhoid and paratyphoid, giardiasis, hepatitis A and E or dermal/mucosal contact with flood waters (Leptospirosis). • Communicable respiratory infections. Predicting the most probable infections in a given disaster area is of course predicated on the pathogens known to be either endemic or most frequently observed during non-disaster time frames. Potential pathogens will probably include: Viral (Influenza, RSV, Adenoviruses) bacterial (Strep pneumoniae, Pertusis, Tuberculosis, Legionella, Mycoplasma pneumoniae), and diseases transmitted via the respiratory route (e.g., Measles, Varicella, Nisseria meningitides).

Recovery Phase: After Four Weeks • Diseases with longer incubation periods. • Vectorborne: malaria, Western/St. Louis encephalitis, dengue, yellow fever, and West Nile. For flooding disasters, there appears to be a complex relationship: Incidence may initially drop as flood waters wash away stagnant breeding sites for mosquitoes, but later, standing water pools may increase, with associated increasing incidence. Behavioral changes caused by disaster, such as sleeping outside, may result in additional vectorborne illnesses. • Exacerbations of chronic disease. We tend to focus on acute trauma, but prevention of chronic disease exacerbation is paramount. • Iatrogenic complications (e.g., transfusion-related infections). What are the variables to consider in post-disaster planning regarding infectious diseases? First, environmental considerations: cold climate favors airborne agents, and warm climate favors waterborne agents/vectors. Broadly speaking, winter favors influenza and summer favors enteroviruses. An important variable is, of course, endemic organisms. Infectious organisms endemic to a region will also be present after the disaster. Agents not endemic before the event are not as likely to create problems. Consider “normal” incidence observed of pathogens such as coccidiomycosis (valley fever)

or similar disease agents that may be periodic or minor problems during normal periods. An important parameter to consider, which varies as one moves from one geographical area to another, is population demographics. What is baseline immunity to specific diseases, population age (elderly or children), typically observed chronic diseases, malnutrition, diabetes, heart disease, etc.? As we consider healthcare infrastructure planning programs for disaster circumstances, the goal of planning tends to intuitively gravitate to improving the health status of disaster victims one person

at a time. We are beginning to realize that such planning is insufficient. Growing evidence from analysis of post-disaster data confirms that we must also plan for large-scale infectious disease outbreaks among the patients and cohorts of the disaster population, and the potential epidemics — if not anticipated and planned for — can overwhelm the healthcare system just at the point it is beginning to gain ground on care for the post-disaster trauma population. Disaster medicine planning must avoid situations where the healthcare infrastructure becomes overwhelmed. The

goal is improving the health of the largest possible number of persons post-event. That requires not only planning for trauma care of the individual, but also planning for potential epidemics of infectious disease following in the wake of the initial disaster.

About the Author: Dr. Peters, SDCMS-CMA member since 2000, is a family physician in private practice. He is a member of SDCMS’ GERM Commission, is secretary of SDCMS, is a member of the San Diego Academy of Family Physicians board of directors, co-chairs Sharp HealthCare’s Primary Care Conference, is a member of the infectious disease committee at Sharp Memorial Hospital, and is chairman of CMA’s Council on Ethical Affairs. Dr. Peters also serves as a consultant to the biomedical and pharmaceutical industry.

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Tracy Zweig Associates A

Are You Getting Your Reimbursement Issues Resolved? Have a question? Don’t know where to begin? Contact your full-time, SDCMS physician advocate, Marisol Gonzalez, free of charge, to get the answers to all your questions, at (858) 300-2783 or at MGonzalez@SDCMS.org.

REGISTRY

PLACEMENT

FIRM

Physicians

Nurse Practitioners Physician Assistants

Locum Tenens Permanent Placement V oi c e : 8 0 0 - 9 1 9 - 9 1 4 1 o r 8 0 5 - 6 4 1 - 9 1 4 1 FA X : 8 0 5 - 6 4 1 - 9 1 4 3

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November 2010 SAN DIEGO P HY SICIA N. o rg

DisasterPreparedness

Apocalypse!

Crisis! Disaster!

Pestilence!

Physicians Need to Know What to Do As Individuals and How to Work Within Their Healthcare System By s u s a n s h e pa rd

S AN D I E G O P HY S I CI A N . or g N o v e m b e r 2010

Living in the San Diego area, disasters are an ever-present reality — from potential mudslides, fires, or earthquakes. Improving health system preparedness to deal with terrorism and mass casualty events can seem overwhelming, but it should be one of our highest priorities. Without adequate planning, practice, and preparation, the consequences to those afflicted can become horrific. As part of the national commitment to improve health systems in support of patient safety, physicians need to know what they can do as individuals as well as how to work within their healthcare system. • Work with your local medical society, hospital, and other healthcare agencies involved in disaster preparation — accredited hospitals are required to plan and practice community-wide disaster drills based upon community-specific risks. • Be aware of your responsibilities as a medical staff member at hospitals where you have privileges. • Physicians and physician practices need to be involved with planning for the care of their patients to ensure critical services are not interrupted. This is especially true for patients with special needs, chronic diseases, the aged, and those with limited mobility. • Patients who will need to be in a special medical needs shelter should be identified to the emergency operation center (EOC) so that early transportation and shelter availability is ensured.

• Check with the home health agencies that are caring for your patients and their plans to adequately provide services in the home. • You may be called upon to be available to help staff shelters. The physician plays a key role in community preparedness. You may be the first to identify that a biological attack is taking place, as was the case in Florida with the first anthrax case in 2001. • Be familiar with the clinical manifestations, diagnostic tests, and treatment regimens for the major biological agents. • Understand your hospital’s incident command structure. ¤¤ Participate in hospital drills and community exercises.

• Maintain a relationship with the local health agency that is monitoring the health of the community and report suspected cases. The local health agency may be the primary source for treatment guidelines. A disaster plan for your office, including plans for communicating with staff and patients and resuming full operations following a disaster, can reduce recovery time. The plan would include: • Disaster planning checklist of items to consider as you plan to preserve assets and communicate with your staff and patients. It would be timed so that items are considered based upon priority and can be matched to weather-related information, such as in the case of hurricanes.

November 2010 SAN DIEGO P HY SICIA N. o rg

DisasterPreparedness

A disaster plan for your office, including plans for communicating with staff and patients and resuming full operations following a disaster, can reduce recovery time.

• Disaster recovery checklist with steps to follow upon your return from an evacuation. • Full-circle call tree and instruction, which is a directional plan of who will contact whom in the event of a disaster. • Instructions on setting up instant messaging groups at Yahoo.com to enable your staff to communicate when cells phones may not work. During the aftermath of Hurricane Katrina, one of the most problematic areas of recovery was with medical records. Water, fire, and even disruptions in electricity can affect the recovery of medical records. Loss

of records not only can disrupt care but can be compounded by the concerns about privacy issues and identify theft. • One of the most effective ways to minimize medical record continuity gaps is through the use of an electronic medical record and office management system that is web-based and HIPAAcompliant. • The Centers for Disease Control and Prevention have provided a method to provide patients with a personal medical information form that is a concise record patients can keep with them. This temporary record lists medical care and other

SDCMS

Does Your Office Manager Have an Ally She Can Turn To? Let your office manager and staff know that they have a full-time office manager advocate at SDCMS ready to help them with any questions they may have, free of charge. Contact Sonia Gonzales at (858) 300-2782 or at SGonzales@SDCMS.

S AN D I E G O P HY S I CI A N . or g N o v e m b e r 2010

member physicians receive

25% advertising in this publication.

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health information and can be adapted. It is not intended to replace hardcopy or the EMR but is an interim communication tool. The tool — known as Keep It With You — is available at bt.cdc.gov/ disasters/pdf/kiwy.pdf. • You may want to consider having an attestation of medical record loss or destruction on file for documents that were partially or completely destroyed as a result of a disaster. Planning for and responding to disasters are managed by multiple entities to include federal, state, and local governments; regional level, state, and local emergency management

authorities (EMA); hospitals accredited by the Joint Commission; and volunteer organizations, such as the Red Cross and Salvation Army. • Be familiar with your community. Ask the hospital you work in what your role is and how you fit into the plan. Accredited hospitals are required to work with the other agencies when developing their disaster preparedness plans and would be an excellent source of information. • Emergency physicians and occupational health physicians frequently have local organizations with planning activities. You can talk to your peers about their roles

Are You Squeezing All You Can out of Your Health Plan Contracts? SDCMS has endorsed Coastal Healthcare Consulting Group, Inc., a specialty consulting firm that assists clients with managed care contracting, contract negotiations, credentialing, revenue enhancement, and strategic planning. SDCMS members receive a free contracting analysis, a discount on hourly rates, and a package price on services for contract negotiations, including health plan contracts! Contact Kim Fenton, president, at (949) 481-9066 or at kimf@healthcareconsultant.org. Visit Coastal Healthcare Consulting Group online at HealthcareConsultant.org.

and activities. • Participate in the development of a community disaster plan and provide input into the state and local offices of emergency medical services and EMA. • Ask yourself these questions: ¤¤ Where should I go during a disaster? ¤¤ How will I be notified if I am needed to respond to a disaster? ¤¤ How will I be identified as a physician? ¤¤ How will my patients be transferred or discharged?

Your actions during a disaster will be predicated on the disaster plan, thus the need for familiarity with the plan. Once the disaster is recognized, the physician should institute office and home disaster plans and participate in the community or hospital predesigned plan. You can provide your patients with an emergency supply checklist and home disaster plan to promote their safety.

About the Author: Ms. Shepard is director of patient safety education for SDCMS-endorsed The Doctors Company.

Are You Writing off Bad Debt Unnecessarily? SDCMS has endorsed TSC Accounts Receivable Solutions, which has provided personalized, innovative collection and total accounts management services since 1992. This local, family-owned business’ management team has combined experience of more than 50 years in the healthcare billing and collection field. SDCMS members receive a 10% discount on monthly charges. Contact Catherine Sherman at (760) 6815012, or at csherman@tscarsolutions.com. Visit TSC online at TSCARSolutions.com.

November 2010 SAN DIEGO P HY SICIA N. o rg

DisasterPreparedness

7.2 a

Hits on Sunday, April 4, 2010 Observations From Imperial County By T h o m a s W. H e n d e r s o n

S AN D I E G O P HY S I CI A N . or g N o v e m b e r 2010

Mr. Henderson, in addition to being the executive director of the ICMS, is an administrator of a building that experienced extensive damage during the 7.2-magnitude earthquake that struck 20 miles southeast of Mexicali on Sunday, April 4, 2010. They received a $996,000 loan from the Small Business Administration for repairs. Following are a few of Mr. Henderson’s personal observations: • We were so lucky the earthquake happened on a Sunday. Lots of patient record cabinets fell over. The potential for injury to staff was huge due to their proximity to staff working areas. Anything on wheels rolled. Some equipment was heavy and could have caused serious injury. Wheeled equipment should either be locked or secured when not in actual use. • Everyone should ensure their hot water heaters are strapped. New laws require it, but older units may not be strapped. In fact, in our building one of the heaters broke its strap due to the magnitude of the earthquake. • Water pipes broke and folks were unaware of that due to the time lag between the earthquake and when individuals were able to check their offices. Owners had to get in touch with water removal services, which were swamped.

• We had 13 physicians displaced because the building could not be occupied. Doctors had to scramble to find places to move temporarily. ¤¤ Doctors had to reroute phone numbers or change phones; ads had to be placed in newspapers. ¤¤ Medical records had to be removed and stored. ¤¤ Leased equipment had to be returned, and access to the building for those companies had to be coordinated to ensure compliance with the city’s restrictions. ¤¤ Multiple issues, including the proper handling of medication samples, had to be resolved. This issue was important because the city initially imposed access exclusion to all except workers, later to all except those working to stabilize the building.

• SBA loans are available in disasters like this, and I can’t overemphasize how simple the disaster loan processing is compared to other loans, including loans for economic damages. • Owners were approached within days by individuals purporting to represent major construction companies. In one case we had an individual want to make a bid on repairs. A search revealed his licensed had been revoked. • Because access to the site was blocked for several days, doctors who did not have backup offsite had no access to any of their computer information. • Arranging to get fax lines moved was as difficult as getting temporary offices. Some docs had to change their fax numbers. • I spent a fair amount of time tracking down new locations and information to distribute to other members for referral purposes.

About the Author: Mr. Henderson is the executive director of the Imperial County Medical Society.

November 2010 SAN DIEGO P HY SICIA N. o rg

DisasterPreparedness

the

american

Red cross Seeking Local Medical Professionals

By j o e W. C a r v e r

As the American Red Cross moves forward into the new year, we continue to prepare for emergencies that can happen anywhere to anyone at anytime. Every year the Red Cross responds to more than 70,000 disasters, including approximately 150 home fires every day. The American Red Cross is one of the world’s most renowned humanitarian organizations, and it relies on volunteers to help with the mission of providing care and comfort to those affected by disaster. The scope and magnitude of disasters has created a unique opportunity for medical professionals to provide services in new roles. Traditionally, Red Cross medical volunteers support local hospital and emergency services response plans, extending the availability of medical services. This role is very effective when the disaster does not evacuate a large number of people remaining in their home locations or disrupt primary medical services. However, when large populations are being affected this way, a secondary disaster begins to occur in the safe evacuation locations. In addition, the displaced population overwhelms the community’s medical, infrastructure, transportation, waste, and security resources. Often, medical doctors from within the affected area may also find themselves evacuated and seeking shelter. Medical doctors who are not affected or a part of the affected area’s emergency response elements can work with American Red Cross relief operations to

provide triage units within Red Cross shelter facilities. Utilizing doctors’ experience in combination with Disaster Health Services (DHS) protocols could create a unique paradigm of “battle field” aid station triage providing major relief during critical evacuation. There are many ways health professionals can lend their services to disaster relief operations. Red Cross DHS volunteers not only provide medical services, but mental health and crisis counseling situations as well. For example, DHS volunteers provide health assessments and referrals for care, and assist victims in obtaining essential medications or equipment. With the generosity of more doctors, nurses, and other medical professionals, the Red Cross will be able to provide better relief for the hosting community’s medical services while offering better quality living and safety situations to those affected by disasters. The American Red Cross is now seeking local medical professionals to join us in our mission to provide relief to victims of disasters and help people prevent, prepare for, and respond to disasters. To learn about volunteer opportunities at your local American Red Cross, please visit SDARC.org or call (858) 309-1200. The American Red Cross greatly appreciates the continued support from health professionals and looks forward to expanding these partnerships in the future.

About the Author: Mr. Craver is CEO of the American Red Cross, San Diego/Imperial Counties chapter.

S AN D I E G O P HY S I CI A N . or g N o v e m b e r 2010

Purchase additional copies of the first annual SDCMS San Diego County Physician Directory. This resource lists contact information for every physician in the county.

SDCMS Member Price: $8 Nonmember Price: $16

To purchase your copy, email Editor@sdcms.org

November 2010 SAN DIEGO P HY SICIA N. o rg

“

Volunteering for Project Access ALLOWS ME TO GIVE BACK to the San Diego community where I have practiced medicine for 29 YEARS. I enjoy knowing that I am providing for people who would otherwise not be able to obtain needed medical care, and MAKE A DIFFERENCE in their lives. – Dr. Leslie Mark, Skin Surgery Medical Group, San Diego

“

”

I’m enjoying my new eyes and SEEING THE WORLD AGAIN in living color. Words are not enough to express my thanks and GRATITUDE to Project Access San Diego, may you have more power to help more people like me.

”

– Leonora, Recipient Cataract Removal on December 6, 2008, and April 24, 2010

project access

volunteerism made easy

LET THE SDCMS FOUNDATION HELP YOU HELP THOSE WHO NEED IT MOST Project Access San Diego is modeled after a successful, nationwide program being implemented in 50 cities around the country. The heart of the program is to assist low-income, adult San Diegans who do not have private or public health insurance to receive the medical care they need. The SDCMS Foundation has partnered with more than 16 community clinic organizations in the county to provide these services. Physicians set their own volunteer commitment and ideally see one patient per month in their office for free. Please contact Lauren Radano, Healthcare Access Manager, at (858) 565-7930 or at Lauren.Radano@SDCMS.org if you have any questions.

Volunteer online today at SDCMSF.org! 32

S AN D I E G O P HY S I CI A N . or g N o v e m b e r 2010

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classifieds office space OFFICE SPACE IN UTC: Full-time office in 8th floor suite with established psychologists, marriage and family therapist, and psychiatrist in Class A office building. Features include private entrance, staff room with kitchen facilities, active professional collegiality and informal consultation, private restroom, spacious penthouse exercise gym, storage closet with private lock in each office, soundproofing, common waiting room, and abundant parking. Contact Christine Saroian, MD, at (619) 682-6912. [862]

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 MEDICAL OFFICE OWNER/USER OPPORTUNITY — ADJACENT TO SCRIPPS MERCY HOSPITAL: Two-story medical building for sale, located on the corner of Lewis St. and 3rd Ave. at 233 Lewis Street, adjacent to Scripps Mercy Hospital. Property has tremendous foot traffic, a flexible floor plan, 10 offstreet parking spaces, and is elevator-served. Take advantage of this exclusive opportunity to own on-campus via SBA Financing (with as little as 10% down) for effectively less than renting in Hillcrest’s dense medical office submarket. For more information or to schedule a property tour, contact Nic Lyon or Evan Kovac at (858) 373-3100 or email Nic.Lyon@ MarcusMillichap.com. [859] NEW SPACE TO SHARE IN KEARNY MESA: Located directly across from Sharp Memorial Hospital in a Class A medical office building. The 2400ft2 space is perfect for a part-time or full-time, shared office arrangement. The reception area was designed to comfortably accommodate those with disabilities. Dual windows facilitate easy check-in. There are ample, built-in staff work stations. Staff also enjoy a private lounge. A furnished office and dedicated exam room are available for the physician. The office suite also includes a leaded room for minor procedures. Terms negotiable. Please contact carla.young@clyoungmdinc.com for more information. [857] MEDICAL OFFICE SPACE FOR RENT IN ENCINITAS: Convenient location five minutes from Scripps Encinitas Hospital. Close to 5 freeway. The 800ft2 space includes two spacious exam rooms, private consultation/doctor’s office, private bathroom, lunchroom, and a spacious waiting room shared with one other doctor. Very affordable rent. Office located at the corner of Encinitas Blvd. and Manchester Ave. Call (760) 519-0102 or email ktagdiri@gmail.com for more information. [855]

SCRIPPS RANCH OFFICE SPACE TO SHARE: Located at 10672 Wexford St. in San Diego with easy access to I-15. 4,000ft2 office with nine exam rooms (four available) and digital X-ray suite in a class A medical building. Office is currently occupied by an orthopedic surgeon looking to share space. Options available for space sublease or cost sharing of staff, X-rays, and office equipment. Practice currently uses CCHIT certified eClincalWorks EMR with e-prescribing. For more information, please contact Ian at (858) 5369500 or email at info@mcclurgmd.com. [852] DOWNTOWN OFFICE SPACE AVAILABLE: Family practice physician in downtown San Diego has office space available. Preferably a primary care physician, but open to any healthcare provider. If interested, please call (858) 270-7633. [735]

SHARE OFFICE SPACE IN LA MESA — AVAILABLE IMMEDIATELY: 1,400 square feet available to an additional doctor on Grossmont Hospital Campus. Separate receptionist area, physician’s own private office, three exam rooms, and administrative area. Ideal for a practice compatible with OB/GYN. Call (619) 463-7775 or fax letter of interest to La Mesa OB/GYN at (619) 463-4181. [648] OFFICE SPACE TO SHARE: Currently occupied by orthopaedic surgeon. Great location close to Scripps/ Mercy and UCSD Hospital. Looking to share with part-time or full time physician. Fully furnished, fully equipped with fluoro machine and 4 exam rooms and staff. (NEGOTIABLE) Please contact Rowena at (619) 299-3950. [804] PHYSICIAN POSITIONS AVAILABLE

OFFICE SPACE AVAILABLE IMMEDIATELY: Adjacent to Tri-City Medical Center and North Coast Surgery Center. Provide large consultation room, two exam rooms. Conditions are negotiable. Full or part time. Free parking. Easy access to 76 or I-5. If interested, please email jean@tricitycts.com or call (760) 726-2500. [840] OFFICE SPACE FOR LEASE: Medical Office space available 800–2,000ft2. Valet parking, walking distance to Mercy Hospital. To view call (619) 733-7497 or email crownpointbuilders@hotmail.com. [838] OFFICE SPACE IN HILLCREST: Office space available in Hillcrest at the Mercy Medical Building. Located directly across from Scripps Mercy Hospital. Excellent staff, state-of-the-art office and equipment. Please send letter of interest to KLewis@sdcms.org. [810] LUXURIOUS / BEAUTIFULLY DECORATED DOCTOR’S OFFICE NEXT TO SHARP HOSPITAL FOR SUB-LEASE: The office is conveniently located just at the opening of Highway 163 and Genesee Avenue. Lease price is very reasonable and appropriate for ENT, plastic surgeons, OBGYN, psychologists, research laboratories, etc. Please contact Mia at (858) 279-8111 or at (619) 823-8111. Thank you. [836] BUILD TO SUIT: Up to 1,900ft2 office space on University Avenue in vibrant La Mesa/East San Diego, across from the Joan Kroc Center. Next door to busy pediatrics practice, ideal for medical, dental, optometry, lab, radiology, or ancillary services. Comes with 12 assigned, gated parking spaces, dual restrooms, server room, lighted tower sign. Build-out allowance to $20,000 for 4–5 year lease. $3,700 per month gross (no extras), negotiable. Contact venk@cox.net or (619) 504-5830. [835] 3998 VISTA WAY IN OCEANSIDE: Two medical office spaces approximately 2,000ft2 available for lease. Close proximity to Tri-City Hospital with pedestrian walkway connected to parking lot of hospital, and ground floor access. Lease price: $2.20 +NNN. Tenant improvement allowance. For further information, please contact Lucia Shamshoian at (760) 931-1134 or at shamshoian@coveycommercial.com. [834] 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 10 half days per week. Located next to the Surgery Center. Receptionist help provided if needed. Contact Stephanie at (760) 753-8413. [703]

INTERNIST NEEDED: Group practice. Minimum 40+ hrs./week. Night call on as-needed basis. Competitive salary, non-negotiable. No medical/dental insurance covered. No retirement plan. No paid vacation. Contact by email at docsandiego@yahoo.com. [863]

MEDICAL DIRECTOR: Licensed physician for busy outpatient substance abuse program. Treatment for opiate/opioid addiction — MAT format — Methadone and Suboxone. 32 hours a week. San Diego and El Cajon locations. Contact Dennis Whitmyer at DWhitmyer@crchealth.com or at (619) 718-9890 INTERNAL MEDICINE, PART-TIME POSITION, PRIVATE PRACTICE, WONDERFUL JOB OPPORTUNITY!: Outstanding opportunity to work part time or more in a mature, premiere private practice setting in North San Diego County, outpatient only. This unique position blends the rewards of private practice and traditional continuity of care with scheduling flexibility. Perfect for any physician who wants to transition from the demands of a full-time position, or who wants to maximize job satisfaction in an extremely high quality work environment while still working part time. Contact (619) 248-2324 for more information. [861] PSYCHIATRIST OR FAMILY PRACTICE/PSYCHIATRY OR INTERNAL MEDICINE/PSYCHIATRY: Full-time position (40 hours per week) open at our behavioral health clinic in Escondido. The staff psychiatrist primarily provides evaluation and medication management services through psychiatric evaluation, diagnostic assessment, medication management, psycho-education, and follow-up. Candidates must have a current California medical license, DEA and CPR certifications. Graduation from a psychiatry residency is required. Please send CVs to Dr. Jim Schultz via email at jims@nhcare.org or fax to (760) 796-4021, “Attn: Psychiatry — Date”. [860] INTERNAL MEDICINE PHYSICIAN: Internal medicine physician to join a well-established turnkey practice located near Alvarado Hospital. New physician will take over existing practice, weekend call one in five weekends. Full laboratory, dexa machine, 2D echos, and vascular studies done in the office. Traditional inand out-patient practice. Benefits and salary leading to partnership. Interested candidates should contact

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.

S AN D I E G O P HY S I CI A N . or g N o v e m b e r 2010

Lydia Gormish at (619) 229-5055 and submit curriculum vitae to lydiagormish@cox.net. [853] PROFIL INSTITUTE FOR CLINICAL RESEARCH SEEKING CONTRACT PHYSICIAN: At Profil, we combine the careful and critical attitude of academic science with the professionalism of the bio-pharmaceutical industry. Located in Chula Vista, Profil Institute for Clinical Research is currently accepting applications for a highly qualified contract physician. Reports to medical director. Main purpose of job: Ensure the safety and wellbeing of human subjects; ensure integrity of study data; provide medical leadership and supervision for human clinical trials within PICR. Work side by side with a highly committed team proud of its contribution to diabetes and obesity research. Profil offers a competitive salary, excellent benefits, and career opportunities in a dynamic, quality-focused environment. For further information, visit SDCMS.org/classifieds/physician-positions-available. Forward resumes to hrpicr@profil-research.com. No faxes or phone calls, please. [851] PHYSICIANS NEEDED: Full-time, part-time, and perdiem opportunities available for family medicine, pediatric, and OB/GYN physicians. Vista Community Clinic is a private, nonprofit outpatient clinic serving the communities of North San Diego County. Must have current Calif. and DEA licenses. Malpractice coverage provided. Bilingual: English/Spanish preferred. Forward resume to hr@vistacommunityclinic.org or fax to (760) 414-3702. Visit our website at www.vistacommunityclinic.org. EOE/M/F/D/V [846] INTERNAL MEDICINE PHYSICIANS: SHARP ReesStealy Medical Group, a 350+ physician multi-specialty group in San Diego, is seeking full-time BC/BE internal medicine physicians to join our staff. We offer a first year competitive compensation guarantee, excellent benefits package, and shareholder opportunity after two years. Please send CV to SRSMG, Physician Services, 2001 Fourth Avenue, San Diego, CA 92101. Fax: (619) 233-4730. Email: Lori.Miller@sharp.com. [842] OBSTETRICIANS NEEDED: La Maestra Clinic is seeking to contract with obstetricians willing to do deliveries of our patients at Sharp Mary Birch, Scripps Mercy, or Grossmont Hospitals. We do all prenatal care, transfer to you at 36 weeks, then we resume care post-partum. No high-risk cases. Excellent opportunity! Interested? Contact David Priver, MD, OB/GYN Medical Director, at (619) 987-3092 or at dpriver@aol.com. [839] LOOKING FOR 1–2 NEUROLOGISTS TO JOIN OUR PRACTICE IN LA JOLLA: We are located on the campus of Scripps Memorial Hospital. This is a well-established (35+ years) practice. We have a strong referral base. Our practice treats neurodegenerative diseases with emphasis on dementias. We see a large number of movement disorder, stroke, and Botox treatment, as well as Parkinson’s disease. One of our physicians is the stroke director at Scripps Memorial Hospital, La Jolla. Outstanding earning potential and the option to expand into other areas is certainly a possibility. Email mrsbinx@hotmail.com. [837] PHYSICIAN POSITION WANTED PHYSICIAN POSITION WANTED: Female OB/GYN in solo practice for over 20 years in Southern California seeking part- or full-time position in San Diego area. Insured. Clean background. Please contact norplex@ hotmail.com. [833] NONPHYSICIAN POSITIONS AVAILABLE PROVIDER PRACTICE MANAGER: About Us: San Diego Hospice and The Institute for Palliative Medicine (SDHIPM) is one of the 10 largest communityowned, not-for-profit hospice programs in the nation,

caring for the 1,000 patients daily in their homes or other facilities in San Diego County. Our mission is to prevent and relieve suffering and to promote quality of life, at every state of life, through patient and family care, education, research, and advocacy. Position Description: The provider practice manager oversees all medical staff support, including administration, planning, budgeting, financial management, provider scheduling, and credentialing. Working in conjunction with the practice director, the provider practice manager ensures full and effective administrative and compliance support for the provider practice group. Works with IT, finance, and health information on documentation, billing, electronic medical record activities, and other activities of, and supports for, the provider practice group. Participates as appropriate in strategic and planning discussions related to provider and patient care services operating models and supports integration of direction. Education: Requires a bachelor’s degree, preferably in health administration or business administration. Experience: Must have at least three years of experience in managing the operations a physician practice group. Prior experience in a home health or hospice setting is preferred. Experience with electronic health records ideal. Must demonstrate ability to not only use computer systems effectively but also to employ them to improve processes. Familiarity with hospital and/or hospice regulations required. Position is full time, Monday through Friday. Shift is 8:00am to 5:00pm. sdhospice.org/ careers [858] LOOKING FOR A LICENSED PNPC: With two years experience for a pediatric office in Clairmont area. Part/full time. Call (858) 268-0702. Fax (858) 2680374. [856] WANTED CALIFORNIA-LICENSED CLS GENERALIST: For lead technologist for busy group practice. Must excel at multitasking and be able to supervise lab assistants and other CLS while performing patient testing. Will oversee day-to-day operations, including quality control, lab workflow, and troubleshooting. Instrumentation includes Dimension Expand and CellDyn. Strong technical background required. Two years plus experience preferred. Reports to lab director and technical consultant. Excellent benefits package. Salary commensurate with qualifications. Contact Lydia at (619) 229-5055. [845] PHYSICIAN ASSISTANT OR NURSE PRACTITIONER: We have an opening for a licensed midlevel practitioner (physician assistant or nurse practitioner) in our specialty practice. The successful candidate must be able to make focused patient assessments and have experience in clinical decision-making appropriate to a midlevel provider. We provide an environment of strong clinical support and access to supervising physician. We’re willing to make an investment in training the right candidate. The qualified candidate must be: graduate of an accredited program; current DEA certificate; Calif. license; Spanish speaking a plus; 2+ years of clinical experience. Please email cover letter, CV, and salary requirements to office@pacificsouthwestpain.com. [844] LOOKING FOR A MATURE, EXPERIENCED MEDICAL PRACTICE MANAGER: Twenty-hour-per-week position. Established nephrology practice with two physicians and a third physician in the office in another specialty. Duties: The manager must have computer practice management and EHR experience. The manager must be familiar with all state and federal regulations pertaining to medical office management. The manager has to be able to evaluate and direct the office staff. The manager must be able to communicate and work with the four physicians in the office (there is a locum physician). The manager must be able to hire and fire people in a legal and professional way. The office is currently re-tooling with Allscripts; this is

our software company as we move toward meaningful use. Dr. Ramenofsky’s wife is his account manager and works remotely. She is in charge of working with Allscripts to evaluate and re-tool the office to quality for the stimulus. The office manager will have to interact with her on a limited basis and then direct the office staff. Mrs. Ramenofsky also manages the hardware in the office, so that is one less duty the office manager has to perform. The entire office will re-train with the Allscripts academy onsite, the new manager will participate in this training for practice management and EHR. The manager will need to hold weekly or bi-weekly meeting with the staff to communicate and maintain high quality moral and work in the office. Contact Lauren Ramenofsky via her email: Buffmom1@aol.com. [843] MEDICAL ASSISTANT: Full-time medical assistant position available for general practice office. Four, 10hour day shifts: Monday, Tuesday, Thursday, Friday. Office closed on Wednesday. Experience required. Please fax resume with cover letter to (858) 7565952. If you have any questions, please call (858) 756-2340. [831] LOOKING FOR EXPERIENCED / LICENSED NURSE PRACTITIONER: Part time / full time, for a busy private primary care practice. Spanish helpful. National certification required. Location: Oceanside/Tri-City area. Compensation: competitive. The nurse practitioner will provide general medical care and treatment to patients in the office. Under the direction of physician: Performs physical examinations and preventive health measures within prescribed guidelines and instructions of physician. The nurse practitioner orders, interprets, and evaluates diagnostic tests to identify and assess patient’s clinical problems and healthcare needs. Records physical findings, and formulates plan and prognosis, based on patient’s condition. Discusses case with physician to prepare comprehensive patient care plan. Submits healthcare plan and goals of individual patients for periodic review and evaluation by physician. Prescribes or recommends drugs or other forms of treatment such as physical therapy, inhalation therapy, or related therapeutic procedures. May refer patients to physician for consultation or to specialized health resources for treatment. Call (760) 639-1204. Fax (760) 630-1252. Email ncmaoceanside@hotmail.com. [830] practice for sale

RANCHO BERNARDO MEDICAL WEIGHT LOSS PRACTICE FOR SALE $75,000: Practice uses OPTIFAST and counseling programs-can add other programs. Bariatric specialty not requiredOPTIFAST offers physician training. Patients see doctor or MA once week, get product, do labs, and attend lifestyle modification with counselors. Take over with no start-up issues, payments are cash/credit card – no insurance. Doctor’s other practice expanding, forcing sale. Great freeway access and parking. Easy transition with fully equipped office space, low rent, expert staff, website, etc. Call Diane 760-580-4423 or diane@healthfirstclinics.com MEDICAL EQUIPMENT SACRIFICE SALE: Slightly used, full-size hip and spine HOLOGIC Bone Densitometer. Price negotiable. Call (760) 703-0691. [755]

November 2010 SAN DIEGO P HY SICIA N. o rg

themedicalstudentperspective By Rachel Hogen, MS-II

A Summer at the Capitol

An Insider’s View Into the Daily Activities of Running Our Country

With health reform passing at the end of my first year of medical school, I decided to spend my summer interning at Capitol Hill in a congressman’s office in hopes of determining a physician’s place in the politics of healthcare. While I certainly did not find politics to be the most beautiful of decision-making processes at times, I accepted it as our current reality in hopes of learning something from my summer. In the end, I discovered a Capitol in need of the unified presence of physicians. I learned early on that congressmen are actually quite responsive to their constituents, as my fellow interns and I answered constituent calls and logged the mail and faxes each day. There is a constant eye toward what the constituents want. In fact, the desires of constituents seem to be the decisive factor in how the congressman votes each day. In addition, those constituents who make their interests readily apparent, or those constituents that are doing something beneficial for the district, seem to bear greater influence. For example, I discovered during my stay that while the congressman has limited stance on agricultural issues because there are no farms in the district, he is a proud advocate for facili-

S AN D I E G O P HY S I CI A N . or g N o v e m b e r 2010

tating the important advancements being made by the biotech industries in San Diego. Thus, I got to thinking how many doctors lived in the district, and, in combination with their patients, I envisioned their vast potential to positively influence the politics of each day. Their potential further amassed in my head when I realized that, whereas a district may lack farms or miners or fisherman, no district lacked doctors. The second thing I found particularly striking at the Capitol was the overwhelming workload of the congressmen and staffers. This has direct implications on how they treat physicians. It means that they regard doctors as doctors, and care little for their specialty of choice. They do not have the time to learn and track the needs of each specialty. Thus, I came to believe that the differences between specialties need to be worked out among doctors before they talk with the people in political power if doctors want to wield any power themselves. This applies to the physician research community as well. During a committee hearing regarding the best PTSD treatments to be adopted by the VA, I watched the committee chairman ask a discordant Duke neurosurgeon and physician specializing in hyperbaric oxygen therapy why they couldn’t talk to each other a bit before coming to talk to him. The last and most influential lesson that I took from my summer is the huge potential for physicians to become involved as educators in the formation of health policy. Physicians are seen by politicians as experts in the provision of healthcare. From my first day in the office, I was respected and utilized as a source of specialized knowledge in science and healthcare for merely deciding to em-

bark on the path to becoming a physician. As I said, congressmen and their staff are highly overworked. They are not capable of becoming experts on every issue, especially an issue as complicated as healthcare. The vast majority of their day is spent seeking guidance as to the best course of action to take — whether through lunch talks on healthcare reform, sharing information with other offices, or calling Health and Human Services. As recognized experts in their field, doctors need to be more available as a source of this guidance. Furthermore, the debates surrounding the Sustainable Growth Rate (SGR) in June led me to understand that guidance from physicians should be as productive as possible. As experts in their field, physicians should be a source of knowledge not only about the problems that physicians face, but also the problems that the provision of healthcare in the United States faces. For politicians, SGR is a budgetary issue. Most politicians agree that it’s important to adequately reimburse physicians, but when faced with reforming and fixing SGR, politicians are worried about the deficit. Their underlying concern is how healthcare spending is going to be limited in the future. As highly knowledgeable, educated, and practiced as they are, physicians should have an answer to this question, and they need to have an answer if they want to be effective in protecting their own interests. My summer in a congressman’s office gave me a brief insider’s view into the daily activities of running our country, and I found a much-needed place for physicians in the process. I met a Capitol that had not yet come to terms with the health reform legislation passed more than five months ago. I ate countless free sandwiches at lunch talks dedicated to deciphering the Patient Protection and Affordable Care Act (PPACA) and swaying congressmen and their staff on its implications. I experienced a Capitol asking, what did we pass? What does it mean? What do we do next? A Capitol yearning for a unified body of physicians with a clear and strong voice to help them find the answers.

{About the Author} Ms. Hogen, SDCMS-CMA member since 2009, is a second-year medical student at the UC San Diego School of Medicine.

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