February 2011

February 2011

OF F ICI A L P U B L IC AT ION OF

THE SAN DIEGO COUNTY MEDICAL SOCIETY

Reaching

8,500 Physicians

Every Month

Health

REFORM COME 2014

“PHYSICIANS UNITED FOR A HE ALTHY SAN DIEGO”

We fight frivolous claims.

We smash shady litigants.

We over-prepare, and our lawyers do, too. We defend your good name. We face every claim like it’s the heavyweight championship.

We don’t give up. We are not just your insurer. We are your legal defense army.

We are The Doctors Company.

Robert D. Francis Chief Operating Officer, The Doctors Company

The Doctors Company built its reputation on the aggressive defense of our member physicians’ good names and livelihoods. And we do it well: Over 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.

Endorsed by

B

S A N D I E G O P HY S I CI A N .OR G F EB RU A RY 2011

ARE yOU READy fOR EHR?

CHMB – The Choice for EHR & Successful Adoption Improved business performance starts with CHMB—ranked among the top providers in California for EHR Adoption & Implementation Services. Here’s why hundreds of physicians have selected CHMB for building and installing the Allscripts EHR application into their community practices: NatioNal aNd local ExpErtisE

• Established footprint with 1,000 community physicians and clinics statewide • Experts who know the full story– Hardware Selection & Procurement, Network Configuration, Application Support targEtEd solutioNs

• World Class Portfolio – Clinical and Business Solutions – Allscripts, Dell, Cox Business

“CHMB has been our trusted business partner for more than six years. It made perfect sense that when we decided to move forward with EHR in our practice, we entrusted our implementation of Allscripts to them as well. They have been there for us every step of the way!”

ElizabEth silvErmaN, md

Partner North County OB/GYN Medical Group

• Flexible approach to drive efficiencies and meet diverse needs, from multi-specialty and specialty, to single provider, to multiple providers • Innovative technology that delivers at the speed you need provEN rEsults

• Real Utilization – 95% of physicians are at Meaningful Use with CHMB EHR Services • Superior Support – 98% client satisfaction on CHMB Clinical & IT Services during implementation & on-going support • Outstanding ROI – 97% of physicians believe CHMB’s services met all expectations, including cost, training, implementation, and application optimization As your business partner, let us navigate your entire EHR project and create the right solution to fit your practice. Count on us to train you to use the EHR at its optimal level. It’s time to trade up to EHR and discover Meaningful Use with CHMB.

Call today for your fREE EHR Readiness Assessment!

Ron Anderson • 1.760.520.1340 Marianne Gregson • 1.760.520.1333

San Diego County — 1121 East Washington Ave., Escondido, CA 92025 Orange County — 7700 Irvine Center Drive, Ste 290, Irvine, CA 92618 760.520.1400 • 800.727.5662 • www.chmbsolutions.com

CHMB delivers tHe HigHest level of serviCe and expertise to ensure a swift, sMootH and suCCessful eHr CoMpletion.

FEBR UARY 2011 SAN DIEGO P HY SICI A N. O RG

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thismonth Volume 98, Number 2

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

features Health Reform Come 2014?

22 departments

22 Health Reform: It’s All About What Happens In 2014 Interview With Robert E. Hertzka, MD

16

SDCMS BOARD OF DIRECTORS OFFICERS PRESIDENT Susan Kaweski, MD PAST PRESIDENT Lisa S. Miller, MD PRESIDENT-ELECT Robert E. Wailes, MD TREASURER Sherry L. Franklin, MD SECRETARY Robert E. Peters, MD, PhD GEOGRAPHIC AND GEOGRAPHIC ALTERNATE DIRECTORS EAST COUNTY William T. Tseng, MD, Heywood “Woody” Zeidman,

MD (A: Venu Prabaker, MD) HILLCREST Niren Angle, MD, Steven A. Ornish, MD KEARNY MESA John G. Lane, MD, 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, Thomas V. McAfee, MD, Ben Medina, MD, James E. Bush, MD, Alan A. Schoengold, MD)

4 SDCMS Seminars, Webinars, and Events Mark Your Calendars!

OTHER BOARD MEMBERS

4 Community Healthcare Calendar

COMMUNICATIONS CHAIR Theodore M. Mazer, MD

6 Briefly Noted

ALTERNATE YOUNG PHYSICIAN DIRECTOR Kimberly M. Lovett, MD

YOUNG PHYSICIAN DIRECTOR Van L. Cheng, MD

SDCMS Medical Office Manager Bulletin Board, and More …

RESIDENT PHYSICIAN DIRECTOR Katherine M. Whipple, MD ALTERNATE RESIDENT PHYSICIAN DIRECTOR Steve H. Koh, MD RETIRED PHYSICIAN DIRECTOR Rosemarie M. Johnson, MD

8 SDCMS in the Community

ALTERNATE RETIRED PHYSICIAN DIRECTOR Mitsuo Tomita, MD

James Beaubeaux Receives 2010 “Outstanding Community Partner” Award

MEDICAL STUDENT DIRECTOR Adi J. Price CMA PRESIDENT-ELECT James T. Hay, MD CMA VICE SPEAKER OF THE HOUSE Theodore M. Mazer, MD

9 Get in Touch

Your SDCMS and SDCMSF Support Teams Are Here to Help!

10 What Has SDCMS-CMA Done for You Lately?

12 Let Your Legislators Know You're Paying Attention, and That You Vote!

16 Emergency Medicine

The State of San Diego’s Emergency Departments

by Roneet Lev, MD

20 Risk Management

EX-OFFICIO, NONVOTING BOARD MEMBERS CMA PAST PRESIDENTS Robert E. Hertzka, MD (LEGISLATIVE COMMITTEE CHAIR), Ralph R. Ocampo, MD CMA DISTRICT I TRUSTEES Albert Ray, MD, Robert E. Wailes, MD,

30

Sherry L. Franklin, MD CMA TRUSTEE (OTHER) Catherine D. Moore, MD, CMA SOLO AND SMALL-GROUP PRACTICE FORUM DELEGATES

Michael T. Couris, MD, James W. Ochi, MD ALTERNATE CMA SOLO AND SMALL-GROUP PRACTICE FORUM DELEGATE Dan I. Giurgiu, MD AMA DELEGATES James T. Hay, MD, Robert E. Hertzka, MD ALTERNATE AMA DELEGATES Lisa S. Miller, MD, Albert Ray, MD

Avoid Being Put on the RAC(k): Be Prepared for a Recovery Audit Contractor Audit

30 Two Exciting New SDCMS Member Benefits IronStone Bank and DocBookMD

34 Physician Marketplace Classifieds

36 A Dinosaur’s Story

A Few Words From an Old Doc

2

S A N D I E G O P HY S I CI A N .OR G F E B RU A RY 2011

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.]

FEBR UARY 2011 SAN DIEGO P HY SICI A N. O RG

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calendar

sdcms Seminars / Webinars / Events Free to member physicians and their staff. For further information, contact Sonia Gonzales at (858) 300-2782 or at Sonia.Gonzales@SDCMS.org, or visit SDCMS.org. Look to our January issue of San Diego Physician for a complete listing of SDCMS’ seminars, webinars, and events in 2011!

Identity Theft (seminar/webinar) Feb. 24 — Thursday 11:30am–1:00pm Legalities of Hiring (seminar/webinar) March 3 — Thursday 11:30am–1:00pm Media Training for Physicians (workshop) March 12 — Saturday 8:00am–12:00pm Medicare Updates (seminar/webinar) March 17 — Thursday 11:30am–1:00pm Outlook for Busy Docs (workshop) March 26 — Saturday 8:00am–11:30am Anticipating Retirement (seminar/webinar) April 7 — Thursday 11:30am–1:00pm Disciplinary Actions, Employee Terminations (seminar/webinar) April 14 — Thursday 11:30am–1:00pm Disclosure: Doing the Right Thing in the Right Way (seminar/webinar) April 27 — Wednesday 6:00pm–7:30pm Disclosure: Doing the Right Thing in the Right Way (seminar/webinar) April 28 — Thursday 11:30am–1:00pm

4

S A N D I E G O P HY S I CI A N .OR G F E B RU A RY 2011

community Healthcare Calendar “Cross-cultural Considerations in End-of-life Care” (CME monograph) Until Feb. 28 • cme.ucsd.edu/crosscultural

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

Right Care Initiative “University of Best Practices” Luncheon Series Feb. 7 • 12:30pm–2:30pm • UCSD Scripps Seaside Forum in the Robert Scripps II Room, 8610 Kennel Way, La Jolla 92037 • Contact Elizabeth Helms at lizhelms@chroniccareca. org or at (916) 300-8687

Emerging Molecular and Cellular Insights Into Heart Failure and Arrhythmias (13th La Jolla-International Cardiovascular Research Conference) March 11–13 • Hilton Torrey Pines Hotel, La Jolla • cme.ucsd.edu

San Diego County Meta-Leadership Summit for Preparedness Feb. 7–8 • Call (404) 523-1788, email summit@cdcfoundation.org, or visit metaleadershipsummit.org West Coast Geriatric Psychiatry Conference Feb. 16–19, 2011 • Catamaran Resort Hotel, San Diego • cme.ucsd.edu Cell Society — First Annual Clinical Meeting Feb. 18–19 • Estancia La Jolla Hotel and Spa • xmedicacme.com/cell_society

Topics and Advances in Pulmonary and Critical Care Medicine March 13–14, 2011 • San Diego Marriott, La Jolla • cme.ucsd.edu Annual San Diego Science Festival March 19–26 • Petco Park • sdsciencefestival.com 12th Annual UC San Diego Stroke Conference May 14 • cme.ucsd.edu/stroke To submit a physician-focused, San Diego County healthcare event for possible publication, email KLewis@SDCMS.org.

The The new new Bank Bank of of America America Doctor Doctor Loan Loan could be the right home loan for you. could be the right home loan for you.

If you are a licensed, practicing doctor or resident, dentist or other eligible medical If you are a licensed, doctorLoans®could or resident, help dentist otherthe eligible 1 professional, Bank of practicing America Home youormake movemedical to your next 1 professional, Bank of America Home Loans®could help you make the move to yourfrom next home. With our new Doctor Loan, you can count on clear information and guidance home.

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1

Restrictions apply.

An applicant must Restrictions apply.have, or open prior to closing, a banking relationship with Bank of America, which can be, at a minimum, a checking or savings account.

2Credit and collateral are subject to approval. Terms and conditions apply. This is not a commitment to lend. Programs, rates, terms and conditions are subject An applicant must have, or open prior to closing, a banking relationship with Bank of America, which can be, at a minimum, a checking or savings account. toCredit change notice.

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FEBR UARY 2011 SAN DIEGO P HY SICI A N. O RG

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brieflynoted

SDCMS Medical Office Manager Save the Dates THE BEST EVENTS AND SEMINARS FOR MEDICAL OFFICE MANAGERS!

ASK YOUR OFFICE MANAGER ADVOCATE!

Question:

How can I check if an electronic tified EHR health record (EHR) system is a “cer product”?

Answer:

PL) The Certified HIT Product List (CH ensive listing provides the authoritative, compreh that have ules mod of complete EHRs and EHR porary Tem been tested and certified under the by the Office Certification Program maintained lth IT (ONC). of the National Coordinator for Hea listed has ule mod Each Complete EHR and EHR ing and Test zed been certified by an ONC-Authori to rted repo Certification Body (ONC-ATCB) and are included ONC. Only the product versions that ONC Tempoon the CHPL are certified under the that the note rary Certification Program. Please list of certified CHPL is a “snapshot” of the current uently as products. The CHPL is updated freq to ONC. To rted repo are newly certified products it.hhs.gov. alth view the current lists, visit http://he

By Sonia Gonzales,

Your Off ice Manager Advocate 6

S A N D I E G O P HY S I CI A N .OR G F E B RU A RY 2011

✓ MARCH 3: “Legalities of Hiring” ✓ MARCH 17: “Medicare Updates” ✓ MARCH 26: “Outlook for Busy Docs” ✓ APRIL 7: “Anticipating Retirement” ✓ APRIL 14: “Disciplinary Actions, Employee Terminations”

✓ APRIL 27, 28: “Disclosure: Doing the Right Thing in the Right Way”

✓ MAY 5: “Best Practices in Revenue Cycle Management”

(858) 300-2782 Contact Sonia at s@SDCMS.org le za or at Sonia.Gon

SPECIAL FOCUS:

Office Managers C on

test!

Here’s your chance to win an iPod Touc h!

Please send your qu estions, comments , pictures, ideas … an ything that you woul d like to see on your SD CMS Medical Office Manager Bulletin Bo ard, to me, Sonia, at Sonia.Gonzales@ SDCMS.org, or call me at (858) 300-27 82. The first five ide as received will be ente red into a drawing to receive an iPod Touc h. The winner will be announced in the ne xt issue.

BENEFITS CORNERi-

er for a member phys Are you an office manag D S WEBSITE LOGIN AN cian and NEED SDCM t es qu ATION? Email your re RM FO IN D OR W SS PA CMS.org. to Sonia.Gonzales@SD ar for your practice!

Make 2011 the best ye most out of your Do you want to get the bership? Give me a call physician’s SDCMS mem ail me to learn how to at (858) 300-2782 or em th membership. save time and money wi

CODING CORNER

BY MICHELLE PENA, CPC, CHMB (CAHEALTH.COM)

Question: CPTs 11040 and 11041 are inactive for 2011; which codes do I use?

Answer: Effective Jan. 1, 2011, CPTS 11040 and 11041 are no longer valid. Codes 11042– 11047 have had revisions in their descriptions to allow for this code change, and CPT has added 11045, 11046, and 11047.

Wound debridements are reported by depth of tissue that is removed and by surface area of the wound. When reporting debridement of a single wound, report depth using the deepest level of tissue removed. In multiple wounds, sum the surface area of those wounds that are at the same depth but do not combine the sums from different depths.

• 11042: debridement, subcutaneous tissue (includes epidermis and dermis if performed); first 20 cm2 or less • 11045: each additional 20 cm2 • 11043: debridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue if performed); first 20 cm2 or less • 11046: each additional 20 cm2 • 11044: debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle, and/or fascia if performed); first 20 cm2 or less • 11047: each additional 20 cm2 Please be advised though that if active wound care is being provided, then CPTs 97597 and 97598 should continue to be used.

FEBR UARY 2011 SAN DIEGO P HY SICI A N. O RG

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sdcmsinthecommunity Kristin Garret, CHIP president and CEO, awards James Beaubeaux the “Outstanding Community Partner Recognition” award

James Beaubeaux Receives 2010

“Outstanding Community Partner Recognition” Award From CHIP

8

S A N D I E G O P HY S I CI A N .OR G F E B RU A RY 2011

The Community Health Improvement Partners (CHIP) awarded James Beaubeaux, chief operations and chief financial officer of the San Diego County Medical Society, its 2010 “Outstanding Community Partner Recognition” for “exceptional contribution and commitment to CHIP and its mission.”

CHIP, whose mission is to improve the health of all San Diegans through needs assessment, advocacy, education, and programs best accomplished collectively, is a collaboration of San Diego healthcare systems, hospitals, community clinics, insurers, physicians, universities, community-based organizations, and the County of San Diego, all of whom are dedicated to a common vision.

In 2011, Mr. Beaubeaux will chair CHIP’s Steering Committee, which oversees all of CHIP’s many programs throughout San Diego County.

2011 will also mark Mr. Beaubeaux’s fifth year as co-chair of CHIP’s San Diego County Childhood Obesity Initiative Healthcare Domain, and will see his co-chair responsibilities for CHIP’s 2010 San Diego County Needs Assessment come to a close.

Congratulations, Mr. Beaubeaux!

Get in

touch

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

healthcare communit y.

Your SDCMS and SDCMSF Support Teams Are Here to Help!

SDCMS CONTACT INFORMATION

3 income Tax Planning

5575 Ruffin Road, Suite 250, San Diego, CA 92123

3 Wealth Management

T (858) 565-8888 F (858) 569-1334

3 employee Benefit Plans

E SDCMS@SDCMS.org

3 Profitability Reviews

W SDCMS.org • SanDiegoPhysician.org CEO/EXECUTIVE DIRECTOR Tom Gehring at (858) 565-8597 or Gehring@SDCMS.org

3 outsourced Professional services (CFo, Controller)

COO/CFO James Beaubeaux at (858) 300-2788 or James.Beaubeaux@SDCMS.org DIRECTOR OF MEMBERSHIP DEVELOPMENT Janet Lockett at (858) 300-2778 or Janet.Lockett@SDCMS.org

3 organizational and Compensation structure

DIRECTOR OF MEMBERSHIP OPERATIONS AND PHYSICIAN ADVOCATE Marisol Gonzalez at (858) 300-2783 or MGonzalez@SDCMS.org

3 succession Planning

DIRECTOR OF MEDICAL OFFICE MANAGER SUPPORT AND OFFICE MANAGER ADVOCATE Sonia Gonzales at (858) 300-2782 or Sonia.Gonzales@SDCMS.org

3 Practice Valuations 3 internal Control Review and Risk Assessment

DIRECTOR OF ENGAGEMENT Jennipher Ohmstede at (858) 300-2781 or JOhmstede@SDCMS.org DIRECTOR OF COMMUNICATIONS AND MARKETING Kyle Lewis at (858) 300-2784 or KLewis@SDCMS.org BUSINESS MANAGER Nathalia Aryani at (858) 300-2789 or Nathalia.Aryani@SDCMS.org ADMINISTRATIVE ASSISTANT Betty Matthews at (858) 565-8888 or Betty.Matthews@SDCMS.org LETTERS TO THE EDITOR Editor@SDCMS.org GENERAL SUGGESTIONS SuggestionBox@SDCMS.org

akt A KT LLP, CPAs and Business Consu LTAnTs CARL SBAD

ESCONDIDO

760-431-8440

S A N DIEGO

W W W.AKTCPA.COM

RMITCHELL@AKTCPA.COM

SDCMSF CONTACT INFORMATION 5575 Ruffin Road, Suite 250, San Diego, CA 92123

ron mitchell, cpa director of health services

T (858) 565-8888 F (858) 560-0179 W SDCMSF.org EXECUTIVE DIRECTOR Kitty Bailey at (858) 300-2780 or Kitty.Bailey@SDCMS.org PROJECT ACCESS PROGRAM DIRECTOR Brenda Salcedo at (858) 565-8161 or Brenda.Salcedo@SDCMS.org

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HEALTHCARE ACCESS MANAGER Lauren Radano at (858) 565-7930 or Lauren.Radano@SDCMS.org

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advertising in San Diego Physician.

PATIENT CARE MANAGER Rebecca Valenzuela at (858) 300-2785 or at Rebecca.Valenzuela@SDCMS.org PATIENT CARE MANAGER Elizabeth Terrazes at (858) 565-8156 or at Elizabeth.Terrazes@SDCMS.org

25%

SDCMS member physicians receive

ns United “Physicia

diego” lthy san For a hea

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

FEBR UARY 2011 SAN DIEGO P HY SICI A N. O RG

9

sdcms-cma

By Susan Kaweski, MD, and Tom Gehring

What Have We Done for You

Lately?

February 1, 2011

Dear Physician: Periodically, we want to let you know “what SDCMS has done for you lately.”

Here’s a summary of how we’ve created value for our members since our last letter of September 2010.

ADVOCACY: • With a new governor traditionally sympathetic to the trial attorneys, we fully expect a run on MICRA, the law that keeps your malpractice rates reasonable.

We appreciate your dues dollars to help us prepare for the fight, and we will need “all hands on deck” when the war on MICRA starts.

• Two San Diego physicians were elected to CMA’s Executive Committee: Dr. Jim Hay, president-elect, and Dr. Ted Mazer, vice speaker.

• CMA’s intense lobbying was integral to the nationwide effort to stop the dra-

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S AN D I E G O P HY S I CI A N . OR G F EB RU A RY 2011

conian Medicare cuts. Even in a tough fiscal environment, we press for a GPCI solution in order to restore our Medicare rates to an urban cost-of-living multiplier (rather than the completely unfair and inaccurate rural multiplier) in every federal conversation.

• Through our local contacts and through CMA’s national connections, we are keeping a very, very close eye on the implementation through regulation associated with healthcare reform.

• Throughout San Diego’s healthcare community, the doctor’s perspective is being represented to make sure that physicians are considered part of the solution. We are part of the Community Health Improvement Partners (CHIP), First 5 Commission, childhood obesity, needs assessment, mental and behavioral health, Chamber of Commerce, Medi-Cal managed care, disaster preparation, and many other organizations striving for a healthy San Diego.

BENEFITS: • We have three significant new benefits: » IronStone Bank provides members no points on lines of credit and loans, ½ off points on commercial and construction real estate loans, free online banking, bank at work and courier service, waived ATM fees, and free first order of checks. » DocBookMD® provides a free iPhone, iPad, or iPod Touch application (and soon on Android) that allows total access to our directory (and soon all physicians in San Diego County) plus HIPAA-compliant doctor-to-doctor connectivity. » A pilot program that pays your annual dues for those doing business with an SDCMS-endorsed investment group — call us for details if you want to participate in the pilot.

• The Doctors Company, SDCMS’ endorsed professional liability carrier, offers a 5% members-only discount on

•

•

•

•

•

professional liability insurance. More than 800 SDCMS physicians saved nearly $500,000 as a result of this discount alone.

Our physician advocate, Marisol Gonzalez, and our office manager advocate, Sonia Gonzales, are an extension of your medical practice and provide “concierge care” service to you and your staff. Since our last communication, as an example, one of the 140 problems solved resulted in a two-doctor group’s obtaining $114,000 in held claims.

Check out our filled-to-the-brim educational seminar schedule — all but one free to members and their staff — at SDCMS.org/Event. So far on our 2011 calendar we have 33 educational opportunities to ensure that you and your staff get the most accurate and up-todate information available to keep your practice running smoothly. For information on our next few seminars — “Identity Theft,” “Medicare Updates,” and “HIPAA and HITECH Act Updates” — and for a complete list of SDCMS seminars and webinars, visit SDCMS.org/ Event. The next important courses are: » Media training or “Why Umm is not a Verb” (March 12 and July 16) » Outlook for Crazy Busy Docs (March 26) » The Leader’s Toolbox, a Micro-MBA in 12 Hours (May 20 & 21) » Financial & Legal Life Skills for (Financially & Legally Clueless) Docs (August 20) Does your office staff struggle with getting your aging reports under control?

Do you know if your claim follow-up procedures are effective? For the first time ever, we are offering a Certified Medial Insurance Specialist (CMIS) course at a 50% discount to members and their staff. Please visit SDCMS.org/Event for more information.

SDCMS’ endorsed partners offer members significant savings on the cost of insurance, accounting services, security prescription pads, billing solutions, IT support, computer hardware, contract negotiations services, practice management consulting, banking, legal services, and collections.

Are you getting your free annual phy-

sician mailing list, car insurance discounts, free classified ads, and free California Emergency Situation Driving Emblem?

ENGAGEMENT: • We continue to speak at general staff meetings and medical executive committees (we did 15 in the last five months); can we speak to yours?

• Ninety-five first-year medical students signed up as members at UCSD’s Medical Student Fair, bringing the next generation into organized medicine.

• We are hosting quarterly Retired Physician Society luncheons.

• We had 40+ young physicians at our YPS social and almost 65 physicians and guests at our first membership social of 2011!

COMMUNICATIONS: • Your monthly San Diego Physician speaks to and for all 8,500+ San Diego County physicians. Our bi-weekly, commercialfree e-newsletter, “News You Can Use” (NYCU), goes to 4,000+ physicians. If you’re not getting NYCU, send me an email at Gehring@SDCMS.org and we’ll sign you up.

• Your free classifieds in San Diego Physician reach 8,500+ physicians in San Diego County.

• San Diego County’s media outlets continued to turn to SDCMS when looking for the physician’s perspective on stories, including Blue Shield’s announcement that it plans to hike premiums by an average of 30%, the DMHC’s “timely access” regulations, polio’s continued existence, the role of nurse practitioners in the provision of healthcare, Doctors Express franchises opening up in San Diego County, and many more.

• You can now follow SDCMS on Twitter — go to twitter.com/SDCMS — and get the latest healthcare news and updates from SDCMS-CMA and respected media sources from across the country.

INFRASTRUCTURE: • We rewrote the entire SDCMS database and shifted it to the “cloud,” making it more accurate, more accessible, and less vulnerable in times of crisis.

• Since our last WHWDFYL, we launched version three of our website with a number of usability improvements and functionality enhancements: » You can join or renew online in under five minutes. » Members-only access to valuable toolkits, recorded seminars, FAQ database, and much more! » HIPAA-compliant doctor-to-doctor and (with permissions) patient-todoctor communication. » Online advocacy tool for physicians to affect and effect legislation critical to your practice. » Online posting of classified ads. » Online searching of SDCMS’ robust physician marketplace at SDCMS. org/Classifieds.

MEMBERSHIP: • We’ve increased membership from 2,579 in September 2010 to 2,652 today.

SDCMS is growing faster than any other large county medical society in California.

• As a result of continuing growth, we added to our board of directors (one in East County and an alternate in Kearny Mesa), plus an alternate at-large director.

What are you doing that you’d like us to know about? What more do you need us to be doing on your behalf? Contact us directly; our email addresses are President@ SDCMS.org and Gehring@SDCMS.org respectively.

Finally, we ask for your help in telling your nonmember colleagues what SDCMS-CMA are accomplishing. Please encourage nonmember physicians to join at SDCMS.org so that we can fulfill our vision of “Physicians United for a Healthy San Diego.”

Susan Kaweski, MD President, SDCMS

Tom Gehring CEO/Executive Director, SDCMS

FEBR UARY 2011 SAN DIEGO P HY SICIA N. O RG

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legislativeadvocacy

Physicians: Let Your Legislators Know You’re Paying Attention And That You Vote!

BIRTHDAY: APRIL 13

U.S. Representative Susan Davis (District 53) E: (via website) house.gov/susandavis Washington, DC, Office: T: (202) 225-2040 • F: (202) 225-2948 San Diego Office: 2700 Adams Ave., Ste. 102, San Diego, CA 92116 T: (619) 280-5353 • F: (619) 280-5311

BIRTHDAY: JUNE 20

One way to let your legislators know that you’re paying attention and that you vote is 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.

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BIRTHDAY: ?

State Assemblyman Brian Jones (District 77) E: (via website) arc.asm.ca.gov/member/77 E: assemblymember.jones@assembly.ca.gov Sacramento Office: California State Assembly, PO Box 942849, Sacramento, CA 94249-0077 T: 916-319-2077 • F: 916-319-2177 El Cajon Office: 500 Fesler St., Ste. 201, El Cajon, CA 92020 T: (619) 441-2322 • F: (619) 441-2327

BIRTHDAY: JANUARY 28

U.S. Representative Brian Bilbray E: (via website) bilbray.house.gov Washington, DC, Office: T: (202) 225-0508 • F: (202) 225-2558 Solana Beach Office: 380 Stevens Ave., Ste. 212, Solana Beach, CA 92075 T: (858) 350-1150 • F: (858) 350-0750

BIRTHDAY: FEBRUARY 11

State Senator Joel Anderson (District 36) E: (via website) cssrc.us/web/36 E: senator.anderson@sen.ca.gov Sacramento Office: California State Capitol, Rm. 2054, Sacramento, CA 95814 T: (916) 651-4036 • F: (916) 447-9008 San Diego Office: 1870 Cordell Court, Ste. 107, El Cajon, CA 92020 T: (619) 596-3136 • Fax: (619) 596-3140

12

S AN D I E G O P HY S I CI A N . OR G F EB RU A RY 2011

BIRTHDAY: MARCH 7

State Senator Juan Vargas (District 40) E: (via website) sd40.senate.ca.gov/contact E: senator.vargas@sen.ca.gov Sacramento Office: California State Capitol, Rm. 5035, Sacramento, CA 95814 T: (916) 651-4040 • F: (916) 327-3522 Chula Vista Office: 637 3rd Ave., Ste. A-1, Chula Vista, CA 91910 T: (619) 409-7690 • Fax: (619) 409-7688

BIRTHDAY: MARCH 17

State Assemblywoman Ben Hueso (District 79) E: (via website) asmdc.org/members/a79 E: assemblymember.hueso@assembly.ca.gov Sacramento Office: California State Capitol, PO Box 942849, Sacramento, CA 94249-0079 T: (916) 319-2079 • F: (916) 319-2179 Chula Vista Office: 303 H St., Ste. 200, Chula Vista, CA 91910 T: (619) 409-7979 • F: (619) 409-9270

BIRTHDAY: MARCH 24

State Assemblyman Martin Garrick (District 74) E: (via website) arc.asm.ca.gov/member/74 E: assemblymember.garrick@assembly.ca.gov Sacramento Office: California State Assembly, PO Box 942849, Sacramento, CA 94249-0074 T: (916) 319-2074 • F: (916) 319-2174 Carlsbad Office: 1910 Palomar Point Way, Ste. 106, Carlsbad, CA 92008 T: (760) 929-7998 • F: (760) 929-7999

State Assemblywoman Diane Harkey (District 73) E: (via website) arc.asm.ca.gov/member/73 E: assemblymember.harkey@assembly.ca.gov Sacramento Office: California State Assembly, PO Box 942849, Sacramento, CA 94249-0073 T: (916) 319-2073 • F: (916) 319-2173 Oceanside Office: 300 North Coast Highway, Oceanside, CA 92054 T: (760) 757-8084 • F: (760) 757-8087

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U.S. Senator Dianne Feinstein E: (via website) feinstein.senate.gov Washington, DC, Office: T: (202) 224-3841 • F: (202) 228-3954 • TTY/ TDD: (202) 224-2501 San Diego Office: 750 B St., Ste. 1030, San Diego, CA 92101 T: (619) 231-9712 • F: (619) 231-1108

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State Assemblyman Marty Block (District 78) E: (via website) asmdc.org/members/a78 E: assemblymember.block@assembly.ca.gov Sacramento Office: California State Assembly, PO Box 942849, Sacramento, CA 94249-0078 T: (916) 319-2078 • F: (916) 319-2178 Lemon Grove Office: Lemon Grove Plaza, 7144 Broadway, 2nd Floor, Lemon Grove, CA 91945 T: (619) 462-7878 • F: (619) 462-0078

BIRTHDAY: AUGUST 1

State Assemblywoman Toni Atkins (District 76) E: (via website) asmdc.org/members/a76 E: assemblymember.atkins@assembly.ca.gov Sacramento Office: California State Assembly, PO 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

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U.S. Representative Bob Filner (District 51) E: (via website) house.gov/filner Washington, DC, Office: T: (202) 225-8045 • F: (202) 225-9073 Chula Vista Office: 333 F St., Ste. A, Chula Vista, CA 91910 T: (619) 422-5963 • F: (619) 422-7290 Imperial Office: 1101 Airport Rd., Ste. D, Imperial, CA 92251 T: (760) 355-8800 • F: (760) 355-8802

BIRTHDAY: OCTOBER 3

State Senator Christine Kehoe (District 39) E: senator.kehoe@sen.ca.gov Sacramento Office: California State Capitol, Rm. 5050, Sacramento, CA 95814 T: (916) 651-4039 • F: (916) 327-2188 San Diego Office: 2445 Fifth Ave., Ste. 200, San Diego, CA 92101 T: (619) 645-3133 • F: (619) 645-3144

BIRTHDAY: OCTOBER 27

State Senator Mark Wyland (District 38) E: (via website) cssrc.us/web/38 E: senator.wyland@sen.ca.gov Sacramento Office: California State Capitol, Rm. 4048, Sacramento, CA 95814

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BIRTHDAY: NOVEMBER 1

BIRTHDAY: DECEMBER 7

U.S. Representative Darrell Issa (District 49) E: (via website) issa.house.gov Washington, DC, Office: T: (202) 225-3906 • F: (202) 225-3303 Vista Office: 1800 Thibodo Rd., Ste. #310, Vista, CA 92081 T: (760) 599-5000 • F: (760) 599-1178

BIRTHDAY: NOVEMBER 11

U.S. Senator Barbara Boxer E: (via website) boxer.senate.gov Washington, DC, 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: (619) 239-5719

BIRTHDAY: NOVEMBER 24

State Assemblyman Kevin Jeffries (District 66) E: (via website) arc.asm.ca.gov/member/66 E: assemblymember.jeffries@assembly.ca.gov Sacramento Office: California State Assembly, PO Box 942849,

U.S. Representative Duncan D. Hunter (District 52) E: (via website) hunter.house.gov Washington, DC, Office: T: (202) 225-5672 • F: (202) 225-0235 El Cajon Office: 1870 Cordell Court, Ste. 206, El Cajon, CA 92020 T: (619) 448-5201 • F: (619) 449-2251

BIRTHDAY: DECEMBER 31

State Assemblyman Nathan Fletcher (District 75) E: (via website) arc.asm.ca.gov/member/75 E: assemblymember.fletcher@assembly.ca.gov Sacramento Office: California State Capitol, Rm. 2111, Sacramento, CA 95814 T: (916) 319-2075 • F: (916) 319-2175 San Diego Office: 9909 Mira Mesa Blvd., Ste. 130, San Diego, CA 92131 T: (858) 689-6290 • F: (858) 689-6296

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15

emergencymedicine

By Roneet Lev, MD

The State of San Diego’s Emergency Departments

16

S AN D I E G O P HY S I CI A N . OR G F EB RU A RY 2011

Sharp Grossmont Hospital

7,790

Tri-City Medical Center

6,025

Rady Children’s Hospital, San Diego

5,742

Palomar Medical Center

Navy Medical Center San Diego

4,964

MONTHLY VOLUME JUNE 2009-JUNE 10

5,512

Sharp Memorial Hospital

Scripps Mercy Hospital

4,592

4,900

Sharp Chula Vista Medical Center

4,505

Scripps Memorial Hospital, Encinitas

3,093

Scripps Mercy Hospital, Chula Vista

UCSD Medical Center, Hillcrest

3,092

3,526

Paradise Valley Hospital

2,950

Scripps Memorial Hospital, La Jolla

2,592

2,366

Pomerado Hospital

Alvarado Hospital Medical Center

2,243

UCSD Medical Center, Thornton Hospital

1,921

Sharp Coronado Hospital

1,097

Fallbrook Hospital

Kaiser Hospital remains the highest-volume emergency department in the county, followed by Sharp Grossmont. Fallbrook and Sharp Coronado are the smaller emergency departments. In the past year, San Diego’s emergency department experienced a 3 percent increase in volume with 12 hospitals seeing an increase in patients.

8,250

How busy are San Diego’s emergency departments?

920

EMOC is the Emergency Medicine Oversight Commission, a commission of the San Diego County Medical Society (SDCMS). Members of the commission include emergency physicians, nurses, paramedics, county EMS officials, and San Diego’s hospital association. Each year EMOC sponsors the San Diego County Overcrowding Summit, bringing together physicians, nurses, administrators, San Diego and California healthcare leaders, and guest speakers in order to improve emergency care in San Diego. In preparation for the conference, an annual survey is obtained from all 19 emergency departments with 100 percent participation over the past five years. Some of the data shared are sensitive and competitive and therefore presented in a blinded fashion. Hospitals that gave the data know how they rank among their colleagues. Below are some interesting findings from the 2010 data. Complete survey results are available in PowerPoint format on the EMOC website, which can be found by searching “EMOC” at SDCMS.org.

San Diego Medical Center, Kaiser Foundation Hospital

EMOC’s Annual San Diego County Emergency Department Survey

Sharp Chula Vista Medical Center

Navy Medical Center San Diego

Palomar Medical Center

Alvarado Hospital Medical Center

Paradise Valley Hospital

Scripps Memorial Hospital, La Jolla

Rady Children’s Hospital, San Diego

an average of 3.5 hours for patients who get discharged. In the past four years, the LOS of admission for admitted patients has improved by an average of one hour. The LOS for discharged patients has remained stable and represents an acceptable range.

2,703

2,291

2,281

2,079

1,863

1,830

EMERGENCY DEPARTMENT IMPACT: ANNUAL VISITS/BED

Are emergency departments with higher uninsured patients more crowded than other emergency departments?

No. There is no correlation with payer mix and how impacted our emergency departments are in terms of emergency department visits per emergency department bed. Self-pay is a term used for uninsured patients. In San Diego the range of uninsured emergency department patients is 0–38 percent. The San Diego average is 16.2 percent. According to the 2009 U.S. census, 16.7 percent of the country’s population is uninsured.

It is a common misconception that the emergency departments are full of patients that are not sick and should be treated elsewhere.

Do emergency departments that have sicker patients have longer waits?

1,813

1,687

Sharp Coronado Hospital

1,646

National Average

1,600

UCSD Medical Center, Hillcrest

Tri-City Medical Center

1,538

1,546

UCSD Medical Center, Thornton Hospital

1,537

Pomerado Hospital

1,494

Fallbrook Hospital

1,380

Sharp Grossmont Hospital

Scripps Mercy Hospital

1,252

1,395

Sharp Memorial Hospital

1,225

San Diego Medical Center, Kaiser Foundation Hospital

1,151

769

Scripps Mercy Hospital, Chula Vista

Volume alone is not an adequate measure of how impacted an emergency department is. National standards have established guidelines that state emergency departments should not exceed 1,600 visits per emergency bed. Using this guideline, an impact factor was calculated using each emergency department’s reported monthly visits and its official bed capacity.

Scripps Memorial Hospital, Encinitas

How impacted are our emergency departments?

ranged from 0.38 percent to 6 percent with a median of 2 percent. The national average is 1.9 percent, so San Diego meets the standard. Over the years the LWOT statistic for the county has improved, going down from 3 percent to 2 percent, and with a high of 8 percent to 6 percent.

It should be stated that there is no correlation for hospitals that are impacted in terms of emergency department visits/ bed and other emergency department throughput efficiency measures such as LWOT. Hospitals can have high efficiency standards despite inadequate emergency department beds.

No. There is no correlation with acuity and LOS. The measure used for patient acuity is percentage of admission, so emergency departments that admit more patients presumably have sicker patients. The national average for admitted patients from the emergency departments is 11.7 percent.

San Diego has a much higher percentage of admitted patients at 18.9 percent, and, therefore, our emergency department patients are sicker than the national average.

Why do patients have to wait so long?

The higher number of LOS for admitted patients correlated with problems with inpatient bed availability. Inpatient bed availability and boarding of inpatients in the emergency department remains a bottleneck for many hospitals. The correlation for LOS in discharged patients is different for each institution. Psychiatric patients tend to have the longest length of stays. The range in different hospitals does not correlate with their total volume of patients.

How many patients get tired of the waiting room and leave the emergency department before seeing a doctor?

How long do you have to wait to get care in San Diego’s emergency departments?

It is not the sore-throat patient that is causing emergency department overcrowding.

One measurement of emergency crowding is LWOT, left without treatment, which measures how many patients get tired of waiting and simply leave before seeing a doctor or getting treatment. It has been stated that when an emergency department’s LWOT percentage is very high, the safety net for patient care access is broken.

In San Diego the percentage of LWOT

Length of stay (LOS) for those who need admission is generally longer for patients who get discharged. LOS is the ultimate measure of emergency department efficiency since this is what the patient experiences.

Patients who require admission wait an average of 5.5 hours in the emergency department before they get a bed upstairs.

The time in the emergency department is

It is a common misconception that the emergency departments are full of patients who are not sick and should be treated elsewhere. The Abaris Group published data on San Diego’s safety net as well as data from the California Emergency Department Diversion study. This showed that San Diego’s population is one of the lowest emergency department users of any place in California FEBR UARY 2011 SAN DIEGO P HY SICIA N. O RG

17

emergencymedicine and one of the lowest in the United States. It is assumed that this low utilization is due to the heavy managed care market and a relatively high availability of clinics.

The San Diego emergency department throughput data demonstrated that it is not the discharged patients who are bottlenecking the system, but the patients who require admission. When patients wait for admission for hours in the emergency department, it takes away valuable emergency department bedtime that could be used for treating additional patients from the waiting room, not to mention the fact that the admitted patients are not getting the level of care they would be as inpatients. The sore-throat patient may be crowding the waiting room, but is not crowding the emergency department beds.

Patient boarding in the emergency department is a problem that is debated heavily. It is measured differently at our hospitals.

One measurement used by the American College of Emergency Physicians is patients who remain in the emergency department

for two hours after an inpatient bed has been ordered. This data is available from 12 out of 19 emergency departments. Of these, seven hospitals have over 70 percent of admitted patients routinely remain in the emergency department waiting for a bed.

How has emergency department patient throughput changed in the past year?

The emergency departments were asked to compare their overall throughput over the past year. The results show that nine emergency departments have improved throughput, one declined, and nine stayed the same.

What are the on-call physician issues in San Diego?

The on-call physician shortage has been a topic of healthcare debate over the years.

San Diego has experienced fewer on-call issues than other areas because of our wellestablished trauma system. All area emergency departments know that they can call any trauma center, and they have an entire

panel of on-call specialists. EMTALA law mandates that a request for transfer must be accepted if a higher level of care is available.

Each year the emergency departments are surveyed on their on-call shortages. This year 10 out of 19 emergency departments stated that they had no on-call issues. This is a major shift compared to 2007 when all but three emergency departments experienced some form of on-call physician deficiency.

The biggest on-call problem for 2010 is ENT, with five emergency departments reporting problems in coverage.

Where do we stand in diversion of ambulance patients?

EMOC helped spearhead San Diego’s ambulance bypass guidelines. These guidelines have two rules: one, that patient requests to a particular hospital should be honored within safety measures; and two, that hospitals remain on bypass for only one hour and then come off to accept one more ambulance patient before they go on diversion again. Hospitals have agreed to

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take their own requested patients even if they are on bypass.

The paramedics are trained to honor patient requests for a specific emergency department when possible. This may not correlate with where the patient’s insurance, hospital, or physicians are, but what the patient requests.

Safety measures for this guideline follow county policies. Trauma patients do not get to choose their hospital. Acute-care patients with impending respiratory or cardiopulmonary compromise will be taken to the closest emergency department. A transport of longer than 30 minutes is not within 911 guidelines. A patient with an ST elevation MI diagnosed in the field will be taken to one of San Diego’s STEMI receiving centers.

In 2010, San Diego had the lowest rate of ambulance bypass of any other year. We also had a minimum number of patients bypassed who requested a specific facility.

Bypass data collected by San Diego County Emergency Medical Services is shared

with the hospitals on a monthly basis, and methods of improvements are discussed on a regular basis.

San Diego’s population is one of the lowest emergency department users of any place in California and one of the lowest in the United States.

Side Effects of the Emergency Department Survey The annual emergency department survey takes much cooperation, trust, and effort to collect, but has resulted in an unprecedented collaboration and education between our various emergency departments and hospitals. Guests at the Annual San Diego Overcrowding Summit comment on the amazing degree of information exchange that occurs in our competitive healthcare environment. The conference includes panels with emergency department di-

rectors and hospital CEOs that exchange ideas. One year a hospital mentioned faxing nursing reports for admission instead of waiting on the phone for verbal reports, and now seven hospitals are doing the same. We have shown changes in clinical treatment such as TIA and hypothermia over the years by bringing to the surface different standards of care. In 2010 methods of financial incentives for improved patient flow and alternative triage models were discussed. We should all be proud to live in a community where such cooperation and collaboration exists in improving emergency care.

About the Author: Dr. Lev, SDCMSCMA member since 1996, is the current director of operations for the Scripps Mercy Hospital Emergency Department, current chair of the SDCMS Emergency Medicine Oversight Commission (EMOC), and past president of the California chapter of the American College of Emergency Physicians (CAL/ACEP).

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riskmanagement

By The Doctors Company

Avoid Being Put on the RAC(k)

Be Prepared for a Recovery Audit Contractor Audit Any medical practice submitting claims to a government program, such as Medicare, may contend with a Recovery Audit Contractor (RAC). RAC audits are not one-time or intermittent reviews; they are a systematic and concurrent operating process for ensuring compliance with Medicare’s clinical payment criteria, documentation, and billing requirements.

The Medicare RAC program was signed into law by the Medicare Prescription Drug Improvement and Modernization Act of 2003 and made permanent by the Tax Relief and Health Care Act of 2006. Its

20

S AN D I E G O P HY S I CI A N . OR G F EB RU A RY 2011

purpose is to identify improper Medicare payments — both overpayments and underpayments — nationwide. In three years of RAC audits, almost a billion dollars in overpayments have been identified by the auditors.

The RACs use proprietary software programs to identify potential payment errors in such areas as duplicate payments, fiscal intermediaries’ mistakes, medical necessity, and coding. RACs also conduct medical record reviews. Implementing appropriate compliance plans now will reduce anxiety and uncertainty if you are subjected to an audit.

Assign a member of your staff the job of implementing a compliance plan, or consider hiring a contractor specifically for this task. The person who is responsible for implementing the plan should regularly: • Review denied claims categories during the RAC demonstration program.

• Keep abreast of notifications on the CMS website.

• Review the annual Office of Inspector General (OIG) Work Plan document to assist providers in determining potential areas of RAC audits.

• Monitor RAC progress at your regional

RAC (there are four). Each maintains a website posting information on new audit focus areas and the status of a provider’s audits.

• Perform an audit of your own billing practices — a snapshot audit may illustrate areas that need work.

If you are audited: • Before you send records to the auditor, be sure to review them in a “self-review.” Are there common themes? Are you coding with the correct documentation?

• Make copies of everything you send to the RAC auditor, and keep all of your documentation.

Here is information the person implementing the compliance plan should know: • Staying on top of the RAC audits is important, as there are multiple policies and procedures governing RAC audits.

The RAC can request a maximum of 10 medical records from a provider in a 45day period. The time period that may be reviewed has changed from four years to three years.

• Responses are time sensitive, and significant penalties may result if not handled properly. RAC contractors are paid on a contingency basis, which means they are only paid when they find either overpayments made by CMS or potential fraud by a provider.

About the Author: SDCMS-endorsed The Doctors Company provides its members with MediGuardSM core coverage, which protects against regulatory risks, including Medicaid and Medicare RAC allegations. MediGuardSM PLUS is an enhanced coverage available to members and includes higher limits and expanded features. For more information, visit www.thedoctors. com/mediguardplus.

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Health

REFORM IT’S ALL ABOUT WHAT HAPPENS IN 2014

22

S AN D I E G O P HY S I CI A N . OR G F EB RU A RY 2011

Dr. Robert E. Hertzka, who has a long history of working in the area of healthcare access, including being the chair of San Diegans for Health Care Coverage for the past 10 years (California’s largest bipartisan coalition supporting increased healthcare access), has been closely following the process that led to the passage and now initial implementation of the Patient Protection and Affordable Care Act, or PPACA. Dr. Hertzka recently sat down to discuss PPACA with San Diego Physician — the following is the transcript of that discussion. The opinions expressed by Dr. Hertzka do not represent the opinions of the San Diego County Medical Society (SDCMS) or of the California Medical Association (CMA).

SDCMS invites physicians to participate in this discussion by submitting their comments to Editor@SDCMS.org for possible publication in a future issue of San Diego Physician.

FEBR UARY 2011 SAN DIEGO P HY SICIA N. O RG

23

San Diego Physician: Everyone agrees that PPACA is a broad and sweeping piece of legislation — in fact, the most comprehensive health reform measure since Medicare and Medicaid in 1965. Everyone also agrees that, just like Medicare and Medicaid, it will need to be amended and adjusted over the years.

Nothing special about that. So why should people, and, in particular, why should physicians be concerned?

GOVERNMENT PROGRAMS THAT ARE OVERPROMISED AND UNDERFUNDED ARE HARD TO SUSTAIN, BUT, MORE SIGNIFICANTLY, THEY END UP PUTTING A PARTICULAR BURDEN ON PHYSICIANS BECAUSE WE ARE THE ONES WHO PICK UP THE PIECES WHEN THESE PROGRAMS FALL SHORT.

Dr. Hertzka: Those who have been involved in the health reform efforts of the past 20 years or so — I go back to the Prop 166 Steering Committee of 1992 — know that there are certain principles to follow if one is to be successful in expanding healthcare access. Chief among those is financial soundness: Does the program pencil out? Government programs that are overpromised and underfunded are hard to sustain, but, more significantly, they end up putting a particular burden on physicians because we are the ones who pick up the pieces when these programs fall short.

This is not just theory; just look at all the programs around us. Medicare has kept physician reimbursement essentially frozen for 10 years, while threatening ever-increasing cuts — the latest being in the 30–35 percent range at the end of 2011. Medicaid in California has also been essentially frozen for most everyone, other than obstetricians and pediatricians, for 25 years. And, at the same time, enrollment and eligibility for both of these programs has expanded. Much the same for healthcare for military dependents; when I started in practice, what was then CHAMPUS was a good payer, but now the new version (TRICARE) is linked directly to Medicare.

All of this is an overpromise/underfund phenomenon that has meant that the “books” for these programs are “balanced” on the backs of physicians. And, after a careful review of PPACA, many believe that it could easily end up being more of the same.

San Diego Physician: Points well taken. But, obviously, the

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S AN D I E G O P HY S I CI A N . OR G F EB RU A RY 2011

Obama administration and the Democrats in Congress who voted for PPACA disagree with you. They say that in 2014 PPACA will provide health insurance to 32 million of the currently uninsured in a financially sound manner. What could be wrong with that?

Dr. Hertzka: Clearly, on the face of it, expanding access to 32 million people in 2014 is wonderful. But, in fact, the reality of that “32 million newly covered” statistic is the heart of the problem. As proposed and touted, approximately half of those newly covered will be in an expanded Medicaid, and the other half will obtain coverage from the new health exchanges in the context of an individual mandate. Even putting aside the very serious constitutional issues that have been raised about both the Medicaid expansion and the individual mandate, both of these access expansions, as currently structured, are at best highly problematic, if not likely to fail.

San Diego Physician: How so?

Dr. Hertzka: Let’s look at the Medicaid expansion first. Most people, including physicians, are not aware that Medicaid, which was originally designed in 1965 to cover all low-income people, has actually evolved into a program largely for low-income pregnant women, low-income children, AIDS patients, and a smattering of other eligibility categories, including lowincome parents in some states. Contrary to popular belief, there is no inherent eligibility for non-elderly, childless adults — as many as 32 million of the currently 50 million uninsured are in fact such childless adults.

And while some low-income adults do get some kind of coverage (in California through a County Medical Services program), they find themselves in a program that pays at abysmal Medicaid rates. So while “covered,” they find that their access is limited to a smattering of primary care doctors and community clinics; specialty physician access for Medicaid patients, at least in California, is virtually zero. The combination of this limited ac-

cess to physicians with the nature of very low-income adults is that we see this population frequenting the emergency room at a rate far in excess of otherwise uninsured individuals.

By the way, this goes against a prevailing wisdom among the public that it is the uninsured who are the ones who crowd our emergency rooms. In fact, many of the uninsured shun the emergency room — the waits are long and the bills are huge. But once very low-income individuals are given Medicaid eligibility and realize that they are essentially immune from being billed for any healthcare expense, study after study shows that relatively few establish any kind of steady, cost-effective primary care access; rather they tend to seek episodic care in expensive emergency rooms at a rate two to three times that of the uninsured.

Effective Jan. 1, 2014, PPACA declares that all those below 133 percent of the federal poverty level (FPL, currently $11,000 for an individual, $14,000 for a

couple, and $22,000 for a family of four) are immediately eligible for Medicaid.

Most people would be shocked to realize that as many as 16 million people at or below that income level, if not more, make up such a large proportion of the uninsured.

But, more importantly, in the context of no real effort to improve primary care access other than a) a two-year increase in primary care payment rates in 2013 and 2014 (really only one year because the eligibility increase does not occur until 2014); and b) a series of threats to deputize nurse practitioners as primary care providers equivalent to physicians, it is predictable that we will see a flood of new emergency room visits and very little new comprehensive care.

Bottom line: A major new adult Medicaid expansion (unlike pediatrics, which has adapted and adjusted to Medicaid over decades) is not real healthcare access, but yet it is fully half of what PPACA purports to provide.

San Diego Physician: OK, but what about the other half? Those +/- 16 million are going to get solid, fiscally sound private insurance, yes?

Dr. Hertzka: Frankly, that looks problematic as well. Unlike the arguably blind hope and faith that went into the proposed Medicaid expansion, the underlying principles here are OK. The idea is to give uninsured individuals above 133 percent of FPL purchasing power by letting them buy partially subsidized private insurance through an insurance exchange, much like 5 million federal workers currently do. These many millions of people will now have the purchasing power of a large group and cannot be discriminated against for any preexisting conditions.

It all looks great in theory, combining the “carrot” of subsidized healthcare premiums with the “stick” of a penalty if insurance is not purchased.

But, as can be seen in Figure 1, the reality of the choices that people will probably

FEBR UARY 2011 SAN DIEGO P HY SICIA N. O RG

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make is different from what the Obama administration would lead us to believe.

Insurance subsidies will lower the cost of insurance for very low-income people to just 4 percent of income, but only to 8.05– 9.5 percent for low to moderate incomes, and not at all for those above 400 percent FPL (currently $44,000 for an individual and $88,000 for a family of four).

Meanwhile, the penalties paid by individuals will only be 1 percent of income when this rolls out in 2014, rising to 2.5 percent of income by 2016. This may sound substantial, but it is in fact far below the levels seen in the successful individual mandate models of the Swiss and the Dutch, where the penalties for not obtaining health insurance exceed the cost of the subsidized premium. Furthermore, under PPACA, those who do not purchase insurance and then become ill can buy the same subsidized insurance at that time.

Look carefully at Figure 1 and ask yourself if an uninsured individual scraping

by on $16,000/year will really pay $640 for health insurance if the penalty for not doing so is only $160, and they can get the insurance later if they need it anyhow? Or better yet, they can just work a bit less or report less income and get into the newly expanded Medicaid for free.

How about an uninsured individual living on $44,000/year? Will that individual really pay $4,180 for health insurance if the penalty for not doing so is only $440 and they can get the insurance later if they need it anyhow? Most think not.

San Diego Physician: OK, maybe the whole individual mandate/ insurance exchange model is a bit shaky.

But for the working uninsured, whose only current option is to buy insurance as an individual and thus be subject to individual underwriting, isn’t this still a major improvement?

Dr. Hertzka: Maybe so. But the authors of PPACA were so obsessed with this

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population and how they might or might not respond to various incentives and penalties that they forgot everyone else, namely the 170 million currently insured through their employers, the vast majority of whom are in a secure if increasingly expensive situation.

To get all the votes they needed from more centrist Democratic House and Senate members, PPACA’s authors limited the penalty on medium and large employers for failing to provide health insurance to only $2,000/employee, far less than what most currently pay to provide it. This has created a huge incentive for employers who currently provide insurance to stop doing so and just pay the fine, while sending their employees — by the millions — to the subsidized exchanges. Same for new and expanding companies: Their incentive is to never start providing health insurance in the first place. By 2014, many now believe that the number of people in the exchanges will not just be the 19 million projected by the Obama administra-

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FIGURE 1

Penalties and Premiums for the Individual

PENALTY: 2014/2016

PREMIUM

$16,000 (150% FPL)

$160/$400

$640 (4% of income)

$28,000 (250% FPL)

$280/$700

$2,254 (8.05% of income)

$44,000 (400% FPL)

$440/$1,100

$4,180 (9.5% of income)

$45,000 (>400% FPL)

$0/$0

Market Rate

PENALTY: 2014/2016

PREMIUM

$33,000 (150% FPL)

$330/$825

$1,320 (4% of income)

$55,000 (250% FPL)

$550/$1,375

$4,400 (8.05% of income)

$88,000 (400% FPL)

$880/$2,085 (max)

$8,360 (9.5% of income)

$90,000 (>400% FPL)

$0/$0

Market Rate

Penalties and Premiums for the Family of Four

tion (the vast majority of whom will have been previously uninsured), but more like 55 million, raising the cost of the necessary subsidies by an additional $1 trillion.

This alarm bell is being rung all over the country, as even a senior health policy analyst at the left-of-center Urban Institute has labeled this arrangement “unworkable and unfair.” And two-term Tennessee Governor Phil Bredesen — a Democrat no less — has published a detailed analysis of how Tennessee will be able to cut its health benefit costs for its state workers by as much as 40 percent. In this analysis, state workers are actually kept whole by having their state benefit costs replaced by some increase in wages, but, most importantly, by access to the substantial federal subsidies shown in Figure 1.

And it gets worse. Given the new projections of the additional tens of millions of workers — many of whom will be low-wage workers — being directed to the exchanges in combination with the weak penalties for not obtaining in-

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surance (see Figure 1 again), the future of all this actually looks more than a bit scary. A recent nonpartisan analysis by McKinsey and Co., an international consulting company, whose Center for U.S. Health System Reform is actually headed by a former special assistant to President Obama, suggested that after PPACA’s implementation, we may still have as many as 40 million uninsured. This, combined with as many as 20 million in a likely ineffective Medicaid expansion, gives us 60 million with little to no coverage — no better than where we are today — and, after spending, as much as 2 trillion dollars!

BY 2014, MANY NOW BELIEVE THAT THE NUMBER OF PEOPLE IN THE EXCHANGES WILL NOT JUST BE THE 19 MILLION PROJECTED BY THE OBAMA ADMINISTRATION, BUT MORE LIKE 55 MILLION, RAISING THE COST OF THE NECESSARY SUBSIDIES BY AN ADDITIONAL $1 TRILLION.

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S AN D I E G O P HY S I CI A N . OR G F EB RU A RY 2011

San Diego Physician: As of today, the Congressional Budget Office (CBO) maintains the position that PPACA actually saves money, even releasing a new report that concludes that repealing PPACA would cost taxpayers over $200 billion over the next 10 years. Why such a discrepancy with what you seem to be saying, which is that keeping PPACA in place is what would be costly?

Dr. Hertzka: The CBO has been and continues to be a reputable source of information, even if its director is chosen by partisans, most recently Democrats.

But what the CBO is most known for is making projections based on assumptions that are provided to it. In the case of PPACA, when it came time to project the costs of PPACA, the CBO was instructed by the Democrats in Congress to accept a long list of dubious assumptions, including that a) all physician reimbursement under Medicare would drop by 40 percent and stay there (actually making Medicare in the aggregate a worse payer than Medicaid); and that b) a wholly unprecedented $500 billion in cuts to other Medicare services, including $398 billion from hospitals, would be identified and successfully implemented. And, of course, they were directed to factor in 10 years of taxation but only six years of subsidy payments.

All that taken into account, the CBO was then able to project $143 billion in "savings" over 10 years and thus, of course, at this point an even larger “cost” should

PPACA be repealed. And don't forget, PPACA includes about half a trillion dollars in tax increases on various sectors of the health industry that are supposed to pay for all that will occur in 2014 and beyond — repealing all those taxes adds to the deficit.

In a broader context, it needs to be noted that an equally reputable source, the truly nonpartisan Medicare actuary, quietly issued a report just a few weeks after PPACA was passed and signed last March that was quite damning, concluding even then that PPACA would add to the deficit by some $311 billion over 10 years, and also that, if successful, the proposed cuts to hospitals could cause at least 15 percent of them to stop accepting Medicare patients in order to remain solvent.

So, as the “repeal” debate rages, we are left with two starkly different estimates: one that says that keeping PPACA in place will save us about $200 billion, and another that says that Medicare will not cut physician reimbursement by 40 percent, will not cut hospitals by $398 billion, and that many millions of the currently insured will end up seeking care from the exchanges, ballooning the cost of the federal subsidies by an additional $1 trillion between 2014 and 2019. Under that latter analysis, which actually makes more sense to me, repealing PPACA will actually save as much as $2 trillion over the next 10 years while leaving Medicare in better financial shape.

San Diego Physician: You have to admit that your take on all this is pretty negative. Do you have anything good to say about PPACA? Dr. Hertzka: Of course. First let me emphasize with enthusiasm that most of the various reforms to the private health insurance industry read like a CMA policy recommendation manual. In addition, on a conceptual level, subsidized highrisk pools for people with preexisting conditions, tax credits for small businesses to incentivize them to provide insurance to their employees, and additional relief for seniors with high drug costs are

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all good things.

But remember, PPACA was written by politicians, not policy people, so it was designed to front-load as many “goodies” as possible to give its proponents things to crow about. Many of those “goodies” are fine concepts and would likely be preserved in some form in any eventual “Repeal and Replace” effort. But the core of the bill and its $1 trillion cost ($2 trillionplus if the critics are correct) is all about what happens in 2014.

And even in 2014, some people will derive great benefit from the new health insurance exchanges, and even some of the new Medicaid patients will find themselves in a much better situation.

Unfortunately though, as PPACA is more thoroughly analyzed with each passing week, it appears that these people will be the exception more than the rule.

The bottom line about how to think about PPACA is that it may end up being a brick that is just smothered with tasty frosting, but the American people are be-

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San Diego Physician: What do you think is behind the public’s mood about PPACA, as every single survey done since last March shows that the number of those who favor repeal outnumbers those who favor keeping PPACA as is (or expanding it)?

Dr. Hertzka: It is hard to really know because the public knows almost nothing about the various policy points that I have just laid out in this interview, but think of what the percentage favoring “repeal” would be if they did: probably 60–70 percent.

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despite nonstop cheerleading from the White House and from many Democrats in Congress, nothing about PPACA is turning out as advertised. Only in the bubble of Washington, DC, can otherwise intelligent individuals believe that if we can just put “15 really smart people” together in a room, they could figure out — with precision — how 308 million people will respond to a dizzying array of new taxes, mandates, and regulations.

As just one recent example, it was estimated by the CBO — and even the truly nonpartisan Medicare Actuary — that

by December 2010, some 375,000 people would have enrolled in the new subsidized high-risk pools for the uninsured that were launched in June. However, the actual number was only 8,000, meaning that the projection was off by nearly 98 percent!

Beyond that general distrust of government, my sense is that, at a gut level, most people realize that there is probably not much in PPACA for them, and, in fact, the

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majority of people will actually end up paying more for the same, or less, coverage than they have now.

Consider the various insurance reforms, most of which have been and remain quite popular. Having your uninsured children still living at home stay on your policy until age 26 is a very reasonable idea, but it is projected to increase the cost of a family policy by $135/year.

Perfectly acceptable to most, but when you then add the ban on preexisting conditions for children, the removal of lifetime payout limits on policies, the ban on rescissions, and all the other reforms, we will have increased the cost of a family policy by about $1,000/year. That is probably still worth it, but I would guess that 70 percent or more of those currently insured believe that they will never derive much benefit from any of this.

And that is just the start. Let’s list just a few of the ways that PPACA provisions will increase the cost of existing private insurance:

• The various cuts and freezes in Medicare and Medicaid will accelerate what has already been substantial cost-shifting by physician and hospital providers to private payers.

• The weak individual mandate, even if not struck down by the courts as constitutionally excessive, will boost private premiums as all of those with major medical conditions will buy insurance (no more discrimination against those with preexisting conditions) while many millions of the healthy will wait until they get sick.

• As a perk for (high-propensity voting) seniors, some $80 billion in mandated price reductions for brand-name drugs will go toward shrinking Medicare Part D’s so-called “donut hole.” Great for seniors, but the rest of us will all pay that through our private premiums as Big Pharma will just cost-shift that $80 billion over to private plans.

• Various new direct taxes on the healthcare industry are also part of PPACA,

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including a tax on health insurers ($14 billion per year by 2017), a tax on pharmaceutical companies ($4 billion per year by 2017), and a new 2.3 percent tax on all medical devices. All of these costs — more than $20 billion per year — will again just be cost-shifted over to private plans.

• Finally, contrary to conventional wisdom, the proposed transition of the healthcare system to one based on so-called Accountable Care Organizations (ACO’s) may not save money, at least initially. The Obama administration has a documented obsession with blaming the health system’s ills on feefor-service physicians — in nationally televised appearances, the president himself cited first ENT surgeons taking out tonsils on a whim for cash, and then later blamed physicians as a class for “amputating the limbs of diabetics for $30,000” rather than managing their disease. This obsession is driving a hasty and frenzied consolidation

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SHOULD PPACA BE UPHELD, THE 2012 PRESIDENTIAL ELECTION WILL THEN LIKELY BE DECISIVE, AS THE REPUBLICAN NOMINEE WILL RUN AGAINST PRESIDENT OBAMA ON A PLATFORM OF “REPEAL AND REPLACE.” AND BY THAT 2012 ELECTION, THERE WILL BE A MUCH MORE SIGNIFICANT EMPHASIS ON THE “REPLACE,” AS VOTERS WILL WANT TO KEEP SEVERAL OF PPACA’S EARLY PROVISIONS, IN PARTICULAR THE PRIVATE INSURANCE INDUSTRY REFORMS.

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within the healthcare world, as hospital systems are growing and physicians are aligning with them. The problem is that there is plenty of evidence that the larger the health system, the harder bargain they drive, particularly with private insurers. Once again, this raises the cost of private insurance.

By the time all this kicks in, the average currently covered American, some 170 million people — still the majority of the country — will likely see their annual premium for family coverage go up $2,500/year or more just from PPACA provisions. Notably, CBO does not “score” this because none of this is government expense.

And so to sum up, in a political context, we are looking at the signature issue of a president who ran in 2008 on the promise that electing him would result in family premiums going down by $2,500, not up by $2,500. No wonder that repeal remains popular, and the Republicans picked up 63 House seats.

San Diego Physician: So what next?

Dr. Hertzka: In the big picture, not much right away.

By the time people read this, the House of Representatives will have repealed PPACA by a wide margin, including the votes of some House Democrats. But the Democratically controlled Senate will do little for now and wait, hoping that all this hoopla is just “Tea Party passion” that will settle down over time.

But if public opinion stays negative, they will have to do something, as many of the current Senate Democrats were either elected in 2006 as a protest of the Iraq War or in 2008 as part of the Obama wave election. They will face the voters again in 2012 and 2014 respectively and will need to show that they know that their constituents are concerned about PPACA. The courts will weigh in at some point

in the next two years, as the Supreme Court will likely opine on two separate issues: the constitutionality of the mandated Medicaid expansion and the constitutionality of the individual mandate.

Should PPACA be upheld, the 2012 presidential election will then likely be decisive, as the Republican nominee will run against President Obama on a platform of “Repeal and Replace.” And by that 2012 election, there will be a much more significant emphasis on the “Replace,” as voters will want to keep several of PPACA’s early provisions, in particular the private insurance industry reforms.

If Republicans retake the White House in 2012, the House of Representatives will almost certainly remain Republican, and the Senate will likely flip over to the Republicans as well, making it likely that PPACA will be replaced or significantly altered before the critical date of Jan. 1, 2014, which is when the Medicaid expansion, the mandate to buy insurance, and the substantial subsidies would all begin.

But if President Obama is reelected, PPACA will stand, and we will all watch what happens in 2014: Will PPACA shock its detractors and work successfully? Or will it be the reckless social experiment that its detractors believe it is, leaving us with a health system that is acutely destabilized and thus even more problematic than what we have now?

Stay tuned.

About the Author: Dr. Robert E. Hertzka, San Diego County Medical Society (SDCMS) and California Medical Association (CMA) member since 1980, served as SDCMS president in 1999 and CMA president in 2004–05. As CMA president, Dr. Hertzka led the effort that resulted in much of its current policies on healthcare access. At present Dr. Hertzka serves on the American Medical Association (AMA) Council on Medical Service, which does much of AMA’s health policy development.

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For information, contact Ed Muna at 619-702-5655, ed@lankfordsd.com www.pinnaclemedicalplaza.com 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] MEDICAL OFFICE SPACE TO SHARE: Three furnished exam rooms, one physician office, and one accessory room. Spacious reception area to share. Close to Alvarado Hospital. First floor with easy access. Large free patient parking area.

Very reasonable rent. Please call Dr. Fred Shahan at (858) 945-1162. [886] MEDICAL OFFICE SPACE AVAILABLE PART TIME TO SHARE IN SOLANA BEACH: Excellent location off I-5 by coast. Space includes three fully equipped exam rooms, waiting room, lunchroom, two bathrooms. Available all day Thursdays and other half days — flexible schedule. Great opportunity for a start-up practice that can’t fill a full-time schedule. Affordable rent and flexible arrangements. Call (858) 259-9708 or email solanabeachmed@sbcglobal.net for more information. [878] AVAILABLE CONSULTATION ROOM ON THE CAMPUS OF SCRIPPS ENCINITAS: Close to 5 freeway. Private entry to wheelchair accessible unit with soundproof walls. Spacious waiting room shared with one doctor. Bathroom with

shower. Reserved parking. Flexible sublease terms. To view the property (available January 1, 2011), please contact Beverly at (760) 944-9263 or email sdvi.office@gmail.com. [876] HILLCREST OFFICE SPACE AVAILABLE: Office space available at the corner of 8th Avenue and Washington St in Hillcrest. Approximately 3,000ft2. Surgical center building. Ample parking and freeway access. Proximity to Scripps Mercy Hospital. Contact Laura Hurshman at (619) 2995000 or at laura@sdhandcenter.com. [874] POWAY GATEWAY BUILDING OFFICE TO SHARE/SUBLEASE: Beautiful, newly renovated, ground floor, 1,467ft2, close to main entrance, spacious office in a class A medical office building. Close to Pomerado Hospital. Large windows, ample room, must see furnished office. Ample parking. Labs and radiology onsite in building.

Negotiable rent. Looking to occupy with another subspecialist who needs a satellite location for 1–2 days a week. Contact Maryam at (760) 518-8767 or email mzarei@cox.net. [873] OFFICE SPACE LA MESA: Office space adjacent to Grossmont Hospital. Up to 3,000ft2 for short-term sublease. Two consultation rooms, six exam rooms . Space can be sublet in whole or partially. Attractive rates. Inquiries to richrach57@gmail.com. [871] AVAILABLE CONSULTATION ROOM ON THE CAMPUS OF SCRIPPS ENCINITAS, CLOSE TO 5 FREEWAY: Private entry to wheelchair accessible unit with soundproof walls, spacious waiting room shared with one doctor, BR with shower, reserved parking. Flexible sublease terms. To view the property (available January 1, 2011), please contact Beverly at (760) 944-9263 or email sdvi. office@gmail.com. [868] SHARE OFFICE SPACE IN LA MESA JUST OFF OF LA MESA BLVD: 2 exam rooms and one minor OR room with potential to share other exam rooms in building. Medicare certified ambulatory surgery center next door. Minutes from Sharp Grossmont Hospital. Very reasonable rent. Please email KLewis@sdcms.org for more information. [867] PROFESSIONAL OFFICE SPACE TO SHARE OR LEASE: Part time, full time, flexible terms and incentives. Up to 1,400ft2 in a medical complex.

Near Alvarado Hospital, SDSU college area. Ample parking. High visibility street location. Ideal for any specialty or allied medical professionals.

Call (858) 243-2425. [733] 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]

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] OFFICE SPACE TO SHARE: Currently occupied by orthopedic 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] REAL ESTATE SURGICAL CENTER FOR SALE OR LEASE: Conveniently located in the El Cajon area off highway 125. Medicare- and AAAASF-certified, reception area, physician’s lounge, two operating rooms with C-arm, three recovery beds, medical gases, emergency back-up power. Ample parking and surveillance cameras on site, 2,400ft2.

Please call (619) 203-9831or email pain92120@ aol.com for details. [870] PHYSICIAN POSITIONS AVAILABLE PHYSICIANS NEEDED: Family medicine, pediatrics, and OB/GYN. Vista Community Clinic, a private, nonprofit, outpatient clinic serving the communities in North San Diego County, has openings for part-time and per-diem positions.

Must have current CA and DEA licenses. Malpractice coverage provided. Bilingual English/Spanish preferred. Forward resume to hr@vistacommunityclinic.org or fax to (760) 414-3702. [887] FAMILY PRACTICE PHYSICIAN: Three positions available. Full-time family practice or internal medicine/pediatrics in Temecula (physician: Temecula).

Full-time family practice or internal medicine in Escondido at clinic as well as at a skilling nursing facility (physician: Grand). Full-time family practice in Escondido (physician: Elm). All positions provide comprehensive medical services for members of family, regardless of age or sex, on continuing basis. Candidates must have current California medical license, DEA and CPR certifications. Please send CVs to Dr. Jim Schultz via email at JimS@ nhcare.org or fax to (760) 796-4021, Attn: Physician — Date. Please indicate which position (Temecula, Grand, or Elm) is desired. [884] LOOKING FOR PART-TIME PHYSICIAN: Active six providers, three physicians group looking for a part-time physician. Office located in the San Diego, Chula Vista area. Looking for a physician to permanently join our group. Family medicine and pediatrics (is preferred). This is a good opportunity for a younger physician to become full time and partner of this well-established (30-year) group.

The office is exceptionally well run and is very efficient and friendly. Please respond by email with CV to sharpgate@yahoo.com or contact our office manager, Connie Espinoza, at conniee4@ gmail.com for additional information. [882]

TO SUBMIT A CLASSIFIED AD, email Kyle Lewis at KLewis@SDCMS.org. SDCMS members place classified ads free of charge (excepting “Services Offered” ads). Nonmembers pay $150 (100-word limit) per ad per month of insertion.

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PHYSICIANS: RETIRED WITH LICENSE? WANT TO CUT BACK TO TWO DAYS? Alternative care office in Carlsbad Village looking for California-licensed MD for consultative work. Part time, excellent compensation. Contact James Gould at knewidea@gmail.com or at (760) 7033767. [880] SEEKING BOARD-CERTIFIED PEDIATRICIAN FOR PERMANENT FOUR-DAYS-PER-WEEK POSITION: Private practice in La Mesa seeks pediatrician four days per week on partnership track. Modern office setting with a reputation for outstanding patient satisfaction and retention for over 15 years. A dedicated triage and education nurse takes routine patient calls off your hands, and team of eight staff provides attentive support allowing you to focus on direct, quality patient care. Clinic is 24–28 patients per eight-hour day, 1-in-3 call is minimal, rounding on newborns, and occasional admission, NO delivery standby or rushing out in the night. Benefits include tail-covered liability insurance, paid holidays/vacation/ sick time, professional dues, health and dental insurance, uniforms, CME, budgets, disability and life insurance. Please contact Venk at (619) 5045830 or at venk@gpeds.sdcoxmail.com. Salary $ 102–108,000 annually (equal to $130–135,000 full-time). [778] GREAT FP OPPORTUNITY IN RAMONA: Immediate opening for CA-licensed physician in thriving family practice with small-town, rural atmosphere. We are flexible and friendly with excellent working conditions, loyal staff, and wonderful patients. No hospital work, easy call, attractive compensation package. Email fredarsham@hotmail.com. [807] PRIMARY CARE JOB OPPORTUNITY: Home Physicians (www.thehousecalldocs.com) is a fast-growing group of house-call doctors. Great pay ($140–$200+K), flexible hours, choose your own days (full or part time). No ER call or inpatient duties required. Transportation and personal assistant provided. Call Chris Hunt, MD, at (858) 279-1212 or email CV to hpmg11@yahoo. com. [801] SEEKING A FULL-TIME FAMILY PRACTICE PHYSICIAN FOR AMBULATORY CLINIC: Southern Indian Health Council is made up of board-certified physicians who are experts in primary care and health management. Working closely with a well-trained support staff, our medical providers have established a solid reputation of delivering quality outpatient care and a broad scope of services to individuals of all ages.

We are seeking a full-time, board-certified family practice physician, Monday–Friday, 8:00am– 4:30pm. Must have current CA and DEA licenses; computer skills. Malpractice coverage provided.

Forward resume to jobs@sihc.org or fax to (619) 445-7976 or visit our website at www.sihc.org.

Contact jobs@sihc.org or HR phone at (619) 4451188, ext. 291, or HR fax at (619) 445-7976. [866] 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 tradi-

tional 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]

FAMILY NURSE PRACTITIONER OR PHYSICIAN ASSISTANT: Two positions available. Fulltime position (40 hours per week) and part-time position (24 hours per week) open at our clinic in Temecula. The FNP or PA provides healthcare services to patients under direction and responsibility of physician. Candidates must have a current California PA or FNP license, DEA and CPR certifications. Please send CVs to Dr. Jim Schultz via email at JimS@nhcare.org or fax to (760) 796-4021, Attn: FNP/PA — Date. Please indicate which position (FT or PT) is desired. [885]

PRACTICE FOR SALE CARDIOLOGY MEDICAL PRACTICE: In practice since 1982. Very successful practice with 100% private pay PPO and Medicare population.

La Mesa area. No managed care. Practice demographics are middle to upper income. Practice includes equipment, including stress testing, echo, and nuclear camera. Both echo and nuclear programs are certified by ICAEL and ICANL (this is a requirement for being reimbursed by Medicare starting January 2012). Reason for sale is retirement. Will stay to introduce. Terms available. Inquiries to richrach57@gmail.com or to (619) 501-6858. Excellent opportunity. [872]

BILLING PERSON NEEDED: We are looking for a billing person to fill the position that we currently have open. Here are the requirements: full-time; Monday – Friday 8:00 – 4:30 with a half hour lunch; UTC area with free parking; busy orthopedic office, solo practice; full medical and dental benefits; must have minimum of five current years of workers’ compensation experience. Send resume with salary requirements to slevine@northcountyomg.com. [883] PART-TIME NURSE PRACTITIONER OR PHYSICIAN ASSISTANT: Busy family practice with strong geriatric population located in downtown is seeking full- or part-time nurse practitioner or physician assistant. Experience in EMR preferred.

Must be fluent in Spanish and English. Please fax resume to (858) 270-7633. [881]

NONPHYSICIAN POSITIONS AVAILABLE PSYCHOTHERAPIST: Full-time position (40 hours per week) open at our behavioral health clinic in Escondido. The staff psychotherapist does individual, family, and/or group psychotherapy with children and/or adolescents and/ or adults. Also designs, markets, conducts, and evaluates health promotion programs for smoking cessation, weight management, stress management, and other types of health promotion groups. Candidates must have PhD in psychology or counseling or a master’s degree in social work. Two years of experience is preferred.

Please send applications/resumes to Matt Holden, PhD, via email at MattH@nhcare.org or fax to (760) 796-4021, Attn: Psychiatry — Date. [888]

MEDICAL EQUIPMENT CHART RACKS FOR SALE: Three free-standing metal chart racks for sale in very good condition.

Each rack has nine shelves with four metal dividers per shelf. Dimensions are 36” wide by 92” tall by 13” deep. Each chart rack can hold approximately 575–625 charts, depending on size. These chart racks cost over $600 each brand new. Asking $375 or best offer. Email KLewis@SDCMS.org. [879]

INCREASE YOUR REFERRAL BUSINESS Contact Dari Pebdani at 858-231-1231 or DPebdani@SDCMS.org

San Diego Physician is the only publication that is distributed to all 8,500 practicing physicians in San Diego County.

Advertising is a cost-effective and profitable way to increase your referral business.

FEBR UARY 2011 SAN DIEGO P HY SICIA N. O RG

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adinosaur’sstory

By F. Bruce Kimball, MD

Medical Humor In med school dermatology class, the instructor discussed crab lice, saying they had eight legs. An eager student said, “No, six.” I imagine the instructor repeated that one every year.

At San Francisco County Hospital during my residency, the general surgeons planned an operation, a hemorrhoidectomy, on a male of middle age. First, to be thorough, a sigmoidoscopy was done. Unfortunately, the scope perforated the colon. A laparotomy repaired the opening. Everything went well until postoperative day 10 when the wound separated. The dehiscence was repaired. Finally, about hospital day 24, the patient was discharged. At the surgery conference someone asked about the hemorrhoidectomy.

“Ahhh, no, it was not done.”

In my day at Ann Arbor, we had several polio patients in Drinker respirators. These are large, airtight tanks surrounding the body except for the head, which protrudes through a snug foam collar.

I was ordered to move a patient to a new respirator. This involves turning off the

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breathing, pulling the patient’s head out of the collar, lifting him out of the tank, and placing him in the new one, quickly pushing his head through the new collar before he died from lack of oxygen.

The new collar was so snug his head got stuck halfway through. At this point an intern, the duty comic, said, “This is the tragedy of obstetrics: a persistent occiput posterior.” It’s a wonder the patient survived with all of us trying not to laugh.

I was fortunate to have six months in San Francisco on a busy trauma service, made more fortunate by an attending just back from WW II. He told us how he treated fractures of the calicle, notoriously difficult to hold in place, by applying a double shoulder spica, extending down each arm to the elbow.

As luck would have it, such a fracture came in that night. My assistant resident promptly placed the man in the double-shoulder spica and sent him home. The attending had neglected to tell us that his patients all had 24hour care in a military hospital. Our patient

was sent home. He had to be helped on to a streetcar. The motorman fished out the fare as the patient could not reach his pocket. At his apartment a neighbor unlocked the door.

Now it was bedtime and he couldn’t undress or tend to any ablutions. Somehow he managed to show up at the clinic next day, still dressed and soaking wet. The resident took a bit of ribbing over that incident.

On rounds one day I noticed a patient’s cast was loose. I ordered the intern to change it. The patient protested vigorously. Finally it came out that he liked it as it was because he had bottle of whiskey hidden in it.

A little humor doesn’t hurt.

About the Author: Dr. Kimball, who first joined SDCMS-CMA in 1957 and was editor of San Diego Physician (then known as The Bulletin of the San Diego County Medical Society) in 1960 and 1961, is now both a retired member and a retired orthopedic surgeon.

San Diego Physician is happy to publish a series of articles by Dr. Kimball under the rubric “A Dinosaur’s Story.”

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