June 2011 by San Diego Physician

June 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

Patient / Consumer

Safety

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

S A N D I E G O P HY S I CI A N .or g june 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.

june 2011 SAN DIEGO P HY SICI A N. o rg

thismonth Volume 98, Number 6

features PATIENT/CONSUMER SAFETY

20 Your Medical Practice, Your Patients, and Direct-to-Consumer Genetic Testing by Robert E. Peters, PhD, MD 24 Partnership for Patients: Attempted Progress for Improved Patient Safety by Bryan A. Liang, MD, PhD, JD, and Kimberly Lovett, MD

26 Most Frequent Patient Safety/Risk Management Issues Identified in Our Closed Claims: Results of Our 2010 Site Surveys by Robin Diamond, JD, RN

28 Social Media and Drug Advertising:

Information and Warnings for Physicians and Patients by Bryan A. Liang, MD, PhD, JD, and Timothy Mackey, MAS

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

SDCMS Board of Directors Officers President Robert E. Wailes, MD (CMA Trustee) President-elect Sherry L. Franklin, MD (CMA Trustee) Treasurer Robert E. Peters, PhD, MD Secretary J. Steven Poceta, MD Immediate Past President Susan Kaweski, MD geographic and geographic alternate Directors East County William T-C Tseng, MD, Heywood “Woody” Zeidman,

MD, Kimberly M. Lovett, MD (A:Venu Prabaker, MD) Hillcrest Theodore S. Thomas, MD, Steven A. Ornish, MD, Jason P. Lujan, MD (A:Gregory M. Balourdas, MD) Kearny Mesa John G. Lane, MD (A:A: Marvalyn E. DeCambre, MD, Sergio R. Flores, MD) La Jolla Gregory I. Ostrow, MD, Wynnshang “Wayne” Sun, MD (A: Matt H. Hom, MD) North County James H. Schultz, MD, Douglas Fenton, MD, Niren Angle, MD (A: Steven A. Green, MD) South Bay Vimal I. Nanavati, MD, Mike H. Verdolin, MD (A: Andres Smith, MD)

other voting members Communications Chair Theodore M. Mazer, MD (CMA Vice Speaker)

4 Community Healthcare Calendar

Young Physician Director Van L. Cheng, MD Resident Physician Director Steve H. Koh, MD

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

12 Everything Changed the Day I Married a Solo Physician: A Year in the Life …

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

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, Peter O. Raudaskoski, MD, Mihir Y. Parikh, MD, Suman Sinha, MD (A: Carol L. Young, MD, Thomas V. McAfee, MD, Ben Medina, MD, James E. Bush, MD, Samuel H. Wood, MD, Elaine J. Watkins, DO, Carl A. Powell, DO, Theresa L. Currier, MD)

departments

8 Get in Touch Your SDCMS and SDCMSF Support Teams Are Here to Help!

Managing Editor Kyle Lewis

Retired Physician Director Rosemarie M. Johnson, MD Medical Student Director Adi J. Price

OTHER NONVOTING MEMBERS

Young Physician Alternate Director Renjit A. Sundharadas, MD Resident Physician Alternate Director (OPEN) Retired Physician Alternate Director Mitsuo Tomita, MD Medical Student Alternate Director Elizabeth P. Griffiths CMA President-elect James T. Hay, MD CMA Past Presidents Robert E. Hertzka, MD (Legislative Committee Chair), Ralph R. Ocampo, MD CMA Trustee Albert Ray, MD CMA Trustee (OTHER) Catherine D. Moore, MD Delegates Stuart A. Cohen, MD, Lisa S. Miller, MD, David Priver, MD CMA SSGPF Delegates Michael T. Couris, MD, James W. Ochi, MD CMA SSGPF Alternate Delegates Dan I. Giurgiu, MD, Ashish Wadhwa, MD

by Steve Nottoli

16 Health Butler: Your Personal Health Assistant by Murray A. Reicher, MD, FACR

18 Medi-Cal Provider Incentives: Does Your Practice Qualify? by Rob Yeates

34 Physician Marketplace Classifieds

36 Medicare and Gettysburg by Melvyn L. Sterling, MD

18 2

S A N D I E G O P HY S I CI A N .or g june 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.]

june 2011 SAN DIEGO P HY SICI A N. o rg

calendar

sdcms Seminars / Webinars / Events

community Healthcare Calendar Cardiomyocyte Regeneration and Protection June 20–21 • Hilton Torrey Pines, La Jolla • www.abcam.com Family Medicine Update: 2011

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.

June 24–26 • Paradise Point Hotel in Mission Bay • www.sandiegoafp.org

Asthma Camp June 26–July 1 • www.asthmasandiego.org Hugh Greenway’s 28th Annual Superficial Anatomy & Cutaneous Surgery July 11–15 • Del Mar Marriott • cme.ucsd.edu/ superficialanatomy

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

Medicare Incentive Programs (seminar/webinar) Thursday, June 16, 11:30am–1:00pm Risky Business: Avoiding Common Medical Malpractice Concerns in a Busy Office (webinars) Wednesday, July 6, 6:30pm–7:30pm, or Thursday, July 7, 11:30am–12:30pm SDCMS Pool Party & BBQ (membership social) Saturday, July 9, 3:00pm–7:00pm

OSHA Updates (seminar/webinar) Thursday, Aug. 11, 11:30am–1:00pm Focus on Payor Contracts With ACO Guidelines (seminar/webinar) Thursday, Aug. 18, 11:30am–1:00pm Financial and Legal Life Skills for (Financially and Legally Clueless) Docs (workshop) Saturday, Aug. 20, 8:30am–11:30am

S A N D I E G O P HY S I CI A N .or g june 2011

CMA Webinars & Events Best Practices for Working Your Account Receivable Reports Wednesday, June 15, 12:15pm–1:15pm

EHR: Selecting the Right System for Your Practice Wednesday, June 29, 6:15pm–7:15pm

Key Account Receivable Indicators Physicians Need to Know Wednesday, June 15, 6:15pm–7:15pm

Collections: Get Paid Now Wednesday, July 6, 12:15pm– 1:15pm, 6:15pm–7:15pm Writing Effective Appeals Wednesday, July 20, 12:15pm–1:15pm

Visit CMAnet.org/calendar

ProjECTcomPassion Have you ever considered going on a medical mission trip? Project comPassion offers you the opportunity to do short term medical mission trips around the world. This multi-denominational Christian organization will provide the supplies and make all the travel arrangements for you to spend 8-12 days using your skills to treat the underserved in developing nations. Each trip brings various medical professionals together to work as a team in an outpatient setting in remote villages. Every trip is a life-changing experience.

Visit www.projectcompassion.org for more information and to join one of our trips 11315 rancho Bernardo road, Suite 146, San Diego, CA 92127 858.485.9694 • info@projectcompassion.org Project Compassion is a Non-Profit, Multi-Denominational, 501(C)3 Charitable Medical Relief Organization Incorporated in the State of California since 1992.

No down payment for home mortgages up to $1 million Our special home financing is designed to meet your needs as a physician for the purchase of your primary residence. • Financing available with no down payment – up to $1,000,000. Expansion of loan-to-value ratios for loan amounts up to $1,750,000. • Private mortgage insurance is not required – save thousands over the life of the loan

• Single family homes, townhomes, lofts, and condominiums are eligible • Student loans that are deferred for 12 months are not counted in qualifying ratios. Refinances with high loan-to-values are also available.

For information on this special home financing program from BBVA Compass, give us a call today. Bryan Yaninek, Mortgage Banking Officer 719-329-3256 • bryan.yaninek@bbvacompass.com apply online at: www.bbvacompass.com/mortgages/byaninek

All loans subject to approval, including credit approval. Eligible properties must be located in Alabama, Arizona, California, Colorado, Central Florida, North Florida, New Mexico or Texas where BBVA Compass has a market presence. BBVA Compass is a trade name of Compass Bank, Member FDIC.

brieflynoted

SDCMS Medical Office Manager ASK YOUR OFFICAETE! MANAGER ADVOC

Prescriptions Without Office Visits & eRx

ion or calls to refill a prescript Question: If a patient ated office ass ion and there is no oci requests a new prescript will this t, ues req in d to the phonedvisit (encounter) relate Program ive ent Inc ng onic Prescribi count toward the Electr (eRx)? cribing y for reporting the e-pres Answer: No. To qualif cian Fee ysi a covered Medicare Ph measure, there must be ing peort rep furnished during the Schedule (PFS) service scribed, pre lly ica on scription is electr riod at the time the pre omiden re’s asu me specified in the which meets the coding nter do not erated without an encou nator. Prescriptions gen Please refer to lusion criteria for eRx. meet denominator inc service codes asure specification for the appropriate eRx me ation, visit tor. For further inform found in the denomina http://sdc.ms/4U.

R BENEFITS CORNE ition?

Looking to Fill an Office Pos

SDCMS membership is One of the benefits of e ified ads free of charg the ability to post class n icia d in San Diego Phys online at SDCMS.org an ail ad or to learn more, em magazine. To post an rg. S.o CM SD me at Sonia.Gonzales@

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 june 2011

SPECIAL FOCUS: Medicare Reprocessing Some 2010 Claims

CMS has instructed contractors to begin to reprocess claims affected by the Affordable Care Act of 2010 and corrections to the 2010 Medicare Physician Fee Schedule (MPFS) in March. These changes were implemented April 1, 2010, with an effective date retroactive to Jan. 1, 2010. Palmetto GBA is identifying the impacted claims and began the reprocessing of claims for California in March 2011. Due to the retroactive effective dates of these provisions and the MPFS corrections, a large volume of claims will be reprocessed. No action will be needed by most physicians to receive any applicable adjustment; however, for any claims submitted with billed charges lower than the revised 2010 fee schedule amount, you will need to request a reopening from Palmetto GBA using the Redetermination/Reopening Request form found at http://sdc.ms/4V. This reprocessing of claims may result in underpayments or overpayments. Physicians may choose to collect the additional co-payment that may be due, or waive it. The Office of Inspector General (OIG) has developed favorable policy related to waiving beneficiary cost-sharing amounts attributable to retroactive increases in payment rates resulting from the operation of new federal statues or regulations. Both the CMS notice and OIG policy can be found at the CMA Practice Resources webpage, http://sdc.ms/4V. You can also view SDCMS recorded webinar “Medicare Updates” at http://sdc.ms/4W.

Save the Dates

The Best Even Seminars/W ts and ebinars ✓ JUNE 16: Medica re

✓ JUly 6/7: Risky Bu Incentive Programs

Common Medica siness: Avoiding l in a Busy Office Malpractice Concerns ✓ AUG 11: OSHA Upda ✓ AUG 18: Focus on Pates yor Contracts With ACO Guidel ines

IMPORTANT! Silent PPOs

Question: I am receiving denials from Medicare for CPT 64405 indicating that the maximum number of services has been exceeded. When I called CMS, they said that this was based on the Medically Unlikely Edits. Where are these, and can I appeal these denials?

Contact Sonia at (858) 300 -2782 or at Sonia.Gonzales@SDCM S.org

How Do I Detect a Silent PPO?

• STEP 1: Review your PPO contracts. Examine all your PPO contracts and their lists of “other payors.” Be aware of contract provisions that authorize the PPO to sell, rent, or otherwise allow other payors to access your discounted rates. If your contract authorizes this activity, request a list of the PPO’s “other payors.” • STEP 2: Review EOBs carefully. If you do not contract with the managed care organization identified on the EOB, or if your contract with the managed care organization does not authorize Silent PPO activity, you should challenge the discount in writing to the payor. • STEP 3: Crosscheck EOBs against your PPO contract. Check the contracted payor’s list of “other payors” to determine if the discounting entity has legitimate access to your discounted rates. • STEP 4: Appeal all unauthorized discounts. Physicians should appeal all claims that have been inappropriately repriced. See CMA ON-CALL document #1907, “Silent PPO (Unfair Discounting) Action Guide,” for sample demand letters and letters of appeal.

Become a l Certified Medeica Complianc s! Officer in 5 Day

: Limited At tendance CMS SD e! bl la ai Only 40 Seats Av nted Rate and ou Members Get Disc Opportunity! tio First Registra n

Answer: The Medically Unlikely Edits (MUEs) are edits developed by Medicare to reduce claims paid in error. An MUE is the maximum number of units for a CPT/ HCPCS that a provider would typically provide for a beneficiary on a single date of service. The list of CPTS/HCPCS and their associated MUE values can be found on the CMS website. Denials for services based on MUE edits can be appealed as instructed by the local carrier. A request to have the MUE value changed can be submitted for review to Correct Coding Solutions as well. Medicare has published a guide as well regarding the different claim review programs, MR, NCCI Edits, MUEs, CERT, and RAC. It is simple and comprehensive with information that will empower practices to become part of the editing process. For more information, see the National Correct Coding Edits page at http://sdc.ms/4X and the Medicare Claims Review Programs at http://sdc.ms/4Y.

althcare ysicians and other he e. No longer can ph nc lia mp co ce from cti for al pra tic are cri e to safeguard the The next five years ill sets of complianc sk es availsic ba urs co on y ng rel ini ff sta most critical tra the of providers and their e on g cin un no Medical Compliance ations. SDCMS is an e five-day Certified Th audits and investig ff. sta ir the d an (8 a.m.–5 p.m. each SDCMS members d Oct. 19, 20, and 21 able exclusively for an , 23 d an 22 pt. ough Se ) will be held viously certified thr Officer course (CMCO If you have been pre 5. ,43 $1 is es ers lud mb SDCMS me The course inc day). Course fee for unted rate of $1,275. minre is a further disco the ), OM rtification exam, ad CM ce IS, the CM d PMI (CMC, m instruction, an roo ss call or cla t of en ys ev da rg/ e ials, fiv e visit SDCMS.o instructional mater re information, pleas mo r Fo . 21 t. rg. Oc S.o of CM n oo nzales@SD istered on the aftern email me at Sonia.Go at (858) 300-2782 or s, ale nz Go nia So , me

june 2011 SAN DIEGO P HY SICI A N. o rg

brieflynoted

BIRTHDAY: JUNE 20 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

Let Your Legislators Know You’re Paying Attention, and That You Vote! 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. Please fax or email if possible.

BIRTHDAY: JUNE 22 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 BIRTHDAY: JUNE 28 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

Get in

touch

Your SDCMS and SDCMSF Support Teams Are Here to Help! SDCMS Contact Information 5575 Ruffin Road, Suite 250, San Diego, CA 92123 T (858) 565-8888 F (858) 569-1334 E SDCMS@SDCMS.org W SDCMS.org • SanDiegoPhysician.org CEO/Executive Director Tom Gehring at (858) 565-8597 or Gehring@SDCMS.org COO/CFO James Beaubeaux at (858) 300-2788 or James.Beaubeaux@SDCMS.org Director of Membership DevelopmenT Janet Lockett at (858) 300-2778 or Janet.Lockett@SDCMS.org Director of Membership Operations and Physician Advocate Marisol Gonzalez at (858) 300-2783 or MGonzalez@SDCMS.org director of medical office manager support and Office Manager Advocate Sonia Gonzales at (858) 300-2782 or Sonia.Gonzales@SDCMS.org 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

Pros and Cons of C Corps vs. S Corps C Corp

S Corp

Double taxation on profits. Income is taxed at the corporate level; profits distributed as dividends are taxed at the individual level. Can reduce double tax by bonusing the income rather than taking a dividend.

Profits are passed through directly to shareholders, escaping corporate-level tax. Can take distributions from corporation tax free (subject to change — currently there is a bill in Congress proposing distributions to be subject to payroll taxes).

Dividends

Dividends paid by a C corporation are generally taxed to the individual at the same rate as long-term capital gains, 15 percent.

S corporation earnings passed through to a shareholder are taxed as ordinary income.

Ordinary Losses

C corporation losses are not passed through to shareholders. Losses can be deducted only at the corporate level as NOL carrybacks and carryforwards.

Losses are passed through directly to shareholders. Current-year losses are deductible up to the shareholder’s basis in S corporation stock and loans to the S corporation.

Capital Gains

Taxed at same rate as ordinary income (most likely 35 percent for doctors).

Pass through to shareholders and are eligible for favorable capital gain tax rates for individuals.

Capital Losses

Allowed only to the extent of capital gains. Net capital losses are carried back three years and forward five years.

Pass through to shareholders. Capital losses are deductible subject to limitation on the shareholder’s return. (Cannot show more than $3,000 in losses per year.)

Fringe Benefits

Few restrictions.

Restrictions for shareholders who own more than 2 percent of the corporation’s stock.

Taxation

S A N D I E G O P HY S I CI A N .or g june 2011

GENERAL SUGGESTIONS SuggestionBox@SDCMS.org

SDCMSF Contact Information 5575 Ruffin Road, Suite 250, San Diego, CA 92123 T (858) 565-8888 F (858) 560-0179 W SDCMSF.org EXECUTIVE DIRECTOR Barbara Mandel at (858) 300-2780 or Barbara.Mandel@SDCMS.org project access PROGRAM DIRECTOR Brenda Salcedo at (858) 565-8161 or Brenda.Salcedo@SDCMS.org Healthcare Access Manager Lauren Radano at (858) 565-7930 or Lauren.Radano@SDCMS.org 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 IT PROJECT MANAGER Rob Yeates at (858) 300-2791 or Rob.Yeates@SDCMS.org

Nosocomial MRSA Transmission and Infection May be Reduced by a Program of Universal Nasal Surveillance, Contact Precautions, and Hand Hygiene DynaMed EBM Series By Dyna Med Edit oria l Team Healthcare-associated methicillin-resistant Staphylococcus aureus (MRSA) infections continue to be a serious problem in hospitals around the world, causing thousands of deaths every year. Many institutions have enacted containment programs to reduce the rate of MRSA infections. A new study reports on the efficacy of one such strategy implemented at all Veterans Affairs (VA) acute care facilities in the United States. The VA “MRSA bundle” includes universal nasal surveillance for MRSA colonization in patients, contact precautions for patient carriers of MRSA, procedures for hand hygiene, and an institutional culture change making all personnel coming in contact with patients responsible for infection control. A total of 1,934,598 hospital admissions, transfers, or discharges (365,139 to intensive care units [ICU]) were analyzed from inception of the program in October 2007 through June 2010. During a two-year period preceding the

MRSA bundle program, there were no significant differences in monthly rates of MRSA infections in VA ICUs. Following implementation, the monthly MRSA infection rate fell significantly from the beginning of the program to the end of the study period (level 2 [midlevel] evidence). Rates per 1,000 patient-days decreased from 1.64 to 0.62 for ICU patients (p < 0.001) and from 0.47 to 0.26 for non-ICU patients (p < 0.001). Rates of MRSA transmission also fell from 3.02 to 2.5 for ICU (p < 0.001) and 2.54 to 2 for non-ICU (p < 0.001). Over the study period, screening rates increased from 82 percent to 96 percent at admission and from 72 percent vs. 93 percent at transfer or discharge (N Engl J Med 2011 Apr 14;364(15):1419). A new cluster-randomized trial evaluated a similar program including surveillance and expanded use of barrier precautions in 18 ICUs for six months (N Engl J Med 2011 Apr 14;364(15):1407). In that trial, there were not

significant reductions in either MRSA colonization or infection (study also investigated vancomycin-resistant enterococcus infections). There were a number of important differences between the two studies. The VA study was of longer duration, allowing time for changes in behavior to take full effect. Also, the VA study included hospital-wide surveillance, while the other was limited to ICUs. It is possible that infection control practices in the ICU setting were already sufficient to minimize infection rates, such that additional improvement could be hard to demonstrate. For more information, see the nosocomial methicillin-resistant Staphylococcus aureus (MRSA) infection topic in DynaMed at www. ebscohost.com/dynamed. About the Author: The DynaMed Editorial Team includes physicians, other clinicians, and scientists who systematically monitor the literature using a seven-step, evidence-based methodology. DynaMed provides the best available evidence to healthcare professionals at the point of care. DynaMed (ebscohost.com/ dynamed) is updated daily, is advertisementfree, and is published by EBSCO Publishing.

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june 2011 SAN DIEGO P HY SICI A N. o rg

brieflynoted

Welcome Our New and Rejoining SDCMS-CMA Members new Members Babak Abedi, MD Anesthesiology • La Jolla Sunil Jeram Advani, MD Radiation Oncology • La Jolla • (800) 926-8273 Tara Mine Akashi, MD Internal Medicine • San Diego

Mason Xuan Dang, MD Anesthesiology • San Diego • (619) 543-9814 Stephen Michael Daquino, DO Sports Medicine • Ramona • (760) 789-2629 David Lee Daugherty, MD Surgery of the Hand • Oceanside • (760) 724-5173

John Robert Alm, MD Emergency Medicine • Vista

Charles Deng, MD Emergency Medicine • Escondido • (760) 739-3300

Hala Mahmoud Amr, MD Family Medicine • Oceanside

Magdalene Annette Dohil, MD Dermatology • San Diego

Ruchita Asudani, MD Internal Medicine • San Diego

Paul Burbank Dohrenwend, MD Emergency Medicine • San Diego • (619) 528-7185

Brian Kiyoshi Barrozo, MD Internal Medicine • San Diego Kala R. Bhasker, MD Family Medicine • Vista • (760) 941-9002 Reshma G. Bhat, MD Psychiatry • San Diego Timothy Daniel Bilash, MD Obstetrics and Gynecology • Solana Beach Susan Kay Bodtke, MD Family Medicine • San Diego • (619) 688-1600 Bradley Blake Bower, MD Internal Medicine • Vista Cheryl J. Boyd, MD Pediatrics • Escondido Nelson Nghi Khac Bui, MD Family Medicine • La Mesa Colleen J. Campbell, MD Emergency Medicine • San Diego • (800) 926-8273 Bob S. Carter, MD Neurological Surgery • La Jolla • (800) 926-8273 Jaime Chen, MD Gastroenterology • San Diego • (800) 290-5000 Natalia Yurievna Cherepnina, MD Critical Care Medicine • La Mesa • (619) 460-1441 Jeffrey Paul Chisdak, MD Anesthesiology • San Diego • (858) 565-9666 Kiyon Chung, MD Cardiovascular Disease • San Diego Ariel Alexander Cortes, MD Family Medicine • San Diego Michelle Balow Crosby, MD Ophthalmology • Encinitas • (760) 943-7141

Jamin Albert Eiseman, MD Geriatric Medicine • San Diego Neil Norman Finer, MD Neonatal-Perinatal Medicine • San Diego • (619) 543-3759 Ira Bruce Fishman, MD Internal Medicine • San Diego • (209) 223-3749 David Parker Folsom, MD Psychiatry • San Diego Allan Gamagami, MD Surgery • San Diego • (858) 616-8200 Mark Vernon Garbutt, MD Ophthalmology • Coronado • (619) 435-4662 Diana Breister Ghosh, MD Plastic Surgery • San Diego • (619) 286-6446 Robert Gareth Gish, MD Gastroenterology • San Diego • (619) 543-2675 Anupam Goel, MD Internal Medicine • San Diego • (619) 471-9398 Michael Everett Gottschalk, MD Pediatric Endocrinology • San Diego • (858) 966-4032 Maria Kristina Gray, MD Pediatrics • San Diego Ian Roger Grover, MD Undersea and Hyperbaric Medicine • San Diego • (800) 926-8273 Gabriel G. Haddad, MD Pediatrics • San Diego James Small Hagood, MD Pediatrics • San Diego • (858) 966-5846

S AN D I E G O P HY S I CI A N. or g june 2011

Jane C. Burns, MD Pediatrics • San Diego • (858) 966-5961

Melinda E. Nevins, DO Family Practice (and OMT) • San Diego

Raminder Kaur Saluja, MD Ophthalmology • San Diego

Russel Arnold Buzard, DO Family Practice (and OMT) • Escondido • (760) 745-2000

Robert O. Newbury, MD Pediatric Pathology • San Diego • (858) 966-5944

Tim Mark Saylor, MD Emergency Medicine • San Diego

Mary Beth Casement, MD Pediatrics • Oceanside • (760) 631-3226

Sung Min Park, MD Pediatric Pulmonology • San Diego • (858) 966-5846

Matthew Abraham Silver, MD Emergency Medicine • San Diego

Deryien N. Chen, MD Family Medicine • Vista • (760) 806-5400

Richard Petyn, MD Internal Medicine • San Diego

Brett Henry Holko, DO Internal Medicine • Bonita

Michael Jerome Singleton, MD Anesthesiology • Oceanside

Brian Vuong Tran Chu, MD Pediatrics • San Diego • (800) 290-5000

Hetal H. Hosalkar, MD Anesthesiology • San Diego • (858) 565-9666

Theresa Roche Sloma, MD Anesthesiology • San Diego • (858) 565-9666

Wolfgang Dillmann, MD Endocrinology, Diabetes, and Metabolism • La Jolla

Anoop Karippot, MD Sleep Medicine • San Diego • (858) 863-7533

Matthew Stanley Smelik, MD Family Medicine • San Diego

John M. Dodge, MD Internal Medicine • San Diego • (619) 278-3300

Megan Elizabeth Hamreus, DO Family Medicine • San Diego • (619) 260-7125

Alexander Charles Salloum, MD Vascular Surgery • Escondido • (760) 739-7666

Patrick Thomas Healey, MD Anesthesiology • San Diego • (858) 565-9666 Jason R. Hess, MD Cosmetic Plastic Surgery • San Diego • (619) 299-7467 Mary Lenora Hilfiker, MD Pediatric Surgery • San Diego • (858) 966-7711

Jonathan Kei, MD Emergency Medicine • San Diego Frances Eun Kim, MD Anesthesiology • San Diego • (858) 565-9666 Albert R. La Spada, MD Clinical Genetics (M.D.) • La Jolla • (858) 966-8567 Erin Fritz Lawson, MD Pain Medicine • La Jolla • (800) 926-8273 Duc Thanh Le, MD Internal Medicine • San Diego Minh Van Le, MD Emergency Medicine • San Diego Robert Hon Kwong Mak, MD Pediatrics • San Diego • (858) 966-8052 Kristina Lynne Maletz, MD San Diego Jonathan Koon Lok Mau, MD Emergency Medicine • San Diego Shannon Elizabeth Metzger, MD Pediatrics • San Diego • (858) 636-4300

Charles Raymond Smith, MD Neurology • La Jolla • (858) 554-8202 Audrey Fallon Stephan, MD Cardiovascular Disease • San Diego Farzin Tayefeh, MD Anesthesiology • La Jolla Thomas Tellez, MD Emergency Medicine • San Diego

Nicole Hisam Gorton, MD Pediatrics • San Diego

Kyle Anthony Tokarz, DO Anesthesiology • San Diego

Gregory Phillip Imler, MD Surgery • San Diego • (858) 616-8200

Elahe Toulouie, MD Internal Medicine • San Diego • (619) 993-8996 Mildred J. Wessigk, MD Internal Medicine • San Diego • (858) 552-8585 Marin Feldman Xavier, MD Medical Oncology • San Diego Stanford Yee, MD Internal Medicine • San Diego Peter Donald Yorgin, MD Pediatric Nephrology • San Diego • (858) 966-8567

James Alan Moore, MD Emergency Medicine • San Diego • (310) 379-2134

Rejoining Members

Seong H. Ra, MD Anatomic Pathology and Clinical Pathology • San Diego • (619) 297-490

Barry Herschel Goldberg, MD Pediatric Nephrology • Carlsbad • (760) 726-6310

Billie E. Green, MD Internal Medicine • San Diego • (858) 483-1720

Jill Marie Meyer, MD Nephrology • San Diego • (619) 299-5298

Michael Henderson Owens, MD Internal Medicine • San Diego • (858) 614-1590

John E. Gaidry, MD Internal Medicine • San Diego

John Carlos Thompson, MD Nephrology • San Diego • (619) 299-5298

Adam Carl Zweig, MD Internal Medicine • San Diego • (619) 245-2350

Alyssa Amerina Nash-Goelitz, MD Dermatology • La Jolla • (858) 454-8811

Lawrence F. Eichenfield, MD Pediatric Dermatology • San Diego • (858) 966-6795

John K. Agostino, MD Family Medicine • San Diego Wayne Roy Anderson, MD Family Medicine • La Mesa • (619) 670-5400 John F. Bastian, MD Allergy and Immunology • San Diego • (858) 966-5961 Lynne M. Bird, MD Clinical Genetics (MD) • San Diego • (858) 966-5840

Jean Antoine Rizkallah, MD Family Medicine • Chula Vista • (619) 691-1990

John S. Bradley, MD Pediatric Infectious Diseases • San Diego • (858) 966-7785

Marc Kevin Rubenzik, MD Dermatology • San Diego • (800) 290-5000

Steven C. Brotman, MD Family Medicine • San Diego

Donald B. Kearns, MD Otolaryngology • San Diego • (858) 309-7701 Gail R. Knight, MD Neonatal-Perinatal Medicine • San Diego • (858) 576-5818 Cynthia L. Kuelbs, MD Pediatrics • San Diego • (858) 966-5841 John J. Lamberti, MD Thoracic Surgery • San Diego • (858) 966-8030 Hai Minh Le, MD Internal Medicine • Vista • (760) 806-5540 Michael L. Levy, MD Neurological Surgery • San Diego • (858) 966-8574 William J. Lewis, MD Neurology With Special Qualification in Child Neurology • San Diego • (858) 966-5819 Timothy E. Lindamood, MD Family Medicine • Vista • (760) 806-5431 Howard S. Lyon, MD Internal Medicine • San Diego Telesforo A. Molina, MD Family Medicine • Vista John W. M. Moore, MD Pediatric Cardiology • San Diego • (858) 966-5855 Thomas J. Naegeli, MD Family Medicine • Escondido • (760) 745-2000

Seth M. Pransky, MD Otolaryngology • San Diego • (858) 309-7701 Richard R. Ricci, MD Family Medicine • Escondido • (760) 745-2000 Jonathan Ellis Rivkin, MD Internal Medicine • Oceanside William D. Roberts, MD Pediatric Hematology-Oncology • San Diego • (858) 966-5811 Philip A. Sanderson, MD Family Medicine • San Diego Colin A. Scher, MD Ophthalmology • Escondido • (760) 737-0197 James Burr Shaw, MD Pain Medicine • Vista • (760) 734-1800 Kusum Sinha, MD Family Medicine • Oceanside Stephen A. Spector, MD Pediatric Infectious Diseases • La Jolla • (858) 534-7055 Jamie L. Switzer, DO Family Medicine • Encinitas • (760) 901-5180 Doris Trauner, MD Neurodevelopmental Disabilities • San Diego • (858) 966-5819 Josefina Trausch, MD Internal Medicine • Chula Vista • (619) 472-1000 Russell Ronald Zane, MD Family Medicine • Oceanside • (760) 967-4900 Maryam Zarei, MD Allergy and Immunology • Poway • (858) 521-0806 Rodrigo J. Fernandez, MD Nephrology • San Diego • (619) 299-5298 William J. Padilla, MD Family Medicine • Chula Vista • (619) 422-1324 Michael J. Sebahar, MD Pain Medicine • Carlsbad • (760) 753-7127 Frederick Youchong Fung, MD Medical Toxicology • San Diego • (619) 446-1510 Sandra Lynn Perez-McCraw, MD Pediatrics • National City • (619) 267-1022 Charles John Sarosy, MD Cosmetic Surgery • La Mesa • (619) 697-1325

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

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we take care of san diego’s

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SDPs Must Enroll in Medi-Cal Managed Care Plans Beginning June 1, 2011

3 income Tax Planning 3 Wealth Management

Starting June 1, 2011, most seniors and persons with disabilities (SPDs) must enroll in and get their healthcare from a doctor in a Medi-Cal Managed Care Plan. This will affect SDP enrollees with only Medi-Cal coverage — this is not for dual-eligibles who also have Medicare. For convenient lists of Q&As and consumer Q&As on the topic, please visit SDCMS. org and type in “Seniors and Persons With Disabilities” in the search field at the top of the homepage.

3 employee Benefit Plans 3 Profitability Reviews 3 outsourced Professional services (CFo, Controller) 3 organizational and Compensation structure 3 succession Planning

SDCMS-CMA Members Dropped April 2011 Sonal Agrawal MD Behrooz A. Akbarnia MD Erick H. Alayo MD Mihaela Beloiu MD Christian Derek Bentley MD Robert Michael Biter MD Douglas G. Bolitho MD Denise Andrews Brownlee MD David William Brunsting MD Richard Parks Burruss MD Andrew James Busby MD Jeffrey J. Buyse MD Phillip Michael Cacheris MD Edward Chen Chao DO Bryan K. Chen MD Connie Hong Chen MD Frederick W. Close MD David W. Cloyd MD Rafael Enrique Cuellar MD Houman Dahi MD Michael Charles Devereaux MD Juan Carlos Deza MD Gabriela Moreno DiLauro MD Howard C. Dittrich MD Rolf Richard Drinhaus MD Thomas W. Eastman DO Shaw Shahriar Eslamian MD Enrique Espinosa-Melendez MD Ramin Hamdy Farsad MD Richard L. Fassett MD Alissa Jean Gilles MD Karen Gordon MD Mary L. Grebenc MD Eric Neal Greenberg MD Joseph L. Grzeskiewicz MD Aireen Lugue Gutierrez MD John Ralph Harper MD Rachelle Monastra Hippen MD James Newton Ho MD Robert A. Houghton MD Elizabeth Ann Hourihan MD Mathew S. Isho MD Steven M. Jaeger MD Cheryl Lynn Jennett MD David Alexander Kaminskas MD Radmila Kazanegra MD Julie Anne Keeler DO Shahin Keramati MD Byron F. King MD Roya Kohani MD Stephen M. Krant MD

Lisa Cecilia Krijger MD Sarmistha Kumar DO Anand Srinivas Kunda MD Trang Dang Thu Le MD Lynn Lucille Leventis MD Ronald M. Levin MD Paul C. Liederman MD Binh Cam Lieu MD Stacey Lin MD Gene Ma MD Afsaneh Maghsoudy MD Monique Lenore Manganelli MD Frank Lee Mannix MD Chris P. Matthews DO Alex J. Mercandetti MD Nathan Arthur Miller MD John E. Milner MD Mansour Mofidi DO Ahmad Shah Mohammad MD William Mohlenbrock MD Coleman A. Mosley MD John Naitoh MD Robert Wetherell Orr MD William Brooks Paxton MD William David Petras DO Lon S. Poliner MD Ravindra Prabhu MD Irina F. Proshkina MD Manorama Reddy MD Elise A. Reed DO Xing-Jian Ren MD Joseph R. Resnikoff MD Nena Magdalena Rocha MD Bobak Salami MD Ali Salami MD Gail Celia Salganick-Erfani MD Robert A. Schaffer MD Fred W. Schnepper MD Christopher P. Sebrechts MD Reyzan E. Shali MD Vicktoria Gaylen Shuffelton DO Stacy R. Smith MD Ken Andrew Stanley MD Geoffrey Feher Sternlieb MD Jo Ann Lee Stewart MD Paul E. Tornambe MD Jonathan Seth Wilensky MD Calvin K. Wong MD Yin-Vui Yong MD Carla Lee Young MD

3 Practice Valuations 3 internal Control Review and Risk Assessment

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SDCMS Member Physicians

You, your spouse/significant other, and your children are cordially invited to attend our July 9 SDCMS pool party and BBQ (3–7pm)! Contact Jen at JOhmstede@SDCMS.org or at (858) 300-2781 with questions or to RSVP.

Hope to see you there!

june 2011 SAN DIEGO P HY SICIA N. o rg

practicemanagement

Everything Changed the Day I Married a Solo Physician A Year in the Life … By Steve Not toli

I will admit to having seen and read magazine, newspaper, and errant trade journal articles — left behind on airplane seats — over the past few years that spoke to the demise of the solo/small-group physician practice, with their extinction a minor impact on the healthcare ecosystem. Well, like most patients and outsiders to healthcare, I felt little if any concern and continued on my way, a corporate executive whose title, he believed, made him important, whose daily concern was how many airline miles he had amassed, and whose job was terribly difficult and stressful. All of that changed one day when I married — yes — a physician in solo, private practice. It soon became clear to me that my corporate gig was downright cushy compared to

It soon became clear to me that my corporate gig was downright cushy compared to that of a solo/small-group physician. that of a solo/small-group physician. What I did and produced in my corporation’s marketplace was generally important, but what solo/small-group physicians provide in their marketplace matters far more than I or the balance of patients in this country realize. Armed with this I set out to decide for myself if solo/small-group practice extinction is inevitable. Here is what I learned, recognizing that these are generalizations of themes:

S AN D I E G O P HY S I CI A N. or g june 2011

• Solo/small-group physicians are expected to run a business, manage staff, stay current on technology, navigate cleverly designed business process mazes in place at insurance companies and managed care organizations, stay one step ahead of a litany of regulations and laws written by teams of lawyers, attempt to participate in scores of meetings, and some even must log literally hundreds of car miles between hospital, office, SNF, LTAC, clinic, etc., and then put in 50 to 60-plus hours of patient care time. • Solo/small-group physician financial consultants tend to underplay the significance and importance of key financial instruments, such as MTD P&L, YTD P&L (month-to-date profit and loss, year-todate profit and loss), balance sheet summary, statement of cash flow, and monthly/YTD operating expense breakdown as a percentage of gross revenue. • Solo/small-group physician offices that outsource billing tend to have higher uncollected receivables and billing write-off adjustments against charges. • Solo/small-group physician offices tend to be heavily manual-process-based, susceptible to higher-than-normal error rates, and have substantially long value stream cycle times1 from patient encounter to receivable collected and deposited. • Solo/small-group physicians have difficulty gaining economies in many aspects of their business, which ultimately contributes to higher operating costs and lower contribution margins. • The bulk of the pressure for revenue and income rests largely if not entirely with the physician vs. the practice as a whole. • Solo/small-group staff are historically expected to understand many facets of the business but lack real depth in the same areas. (This is an understood tradeoff as specialty resources are a luxury in a small practice.) • Solo/small-group physicians tend NOT to have a culture that seeks out other solo/ small-group physicians to share office ideas, best practices, or contracting strategies, and to compare operating costs, etc. The same can be said largely about those offices that have office managers. Analyzing what I learned made it clear

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practicemanagement

that any business — not just a medical practice — faced with these types of hurdles/ challenges if left unchecked would have immense difficulty sustaining itself. However daunting these obstacles seem, there are ways to overcome many if not all of them. But to do so requires some sound business experience, a solid plan, and a willingness to change.

The plan once created was challenging, and it took the entire practice almost one full year to complete the majority of its elements. I openly admitted to the physician and staff that I had no practical healthcare experience, but that my 20-plus years in industry and manufacturing should at least help us develop and implement a plan to neutralize or overcome some if not many of these obstacles and get the practice moving in the right direction. In spite of my lack of healthcare experience, I was still offered the unpaid position of controller, and, upon acceptance, I donated the suit, tossed the frequent flyer card, and turned in the BlackBerry. The plan once created was challenging, and it took the entire practice almost one full year to complete the majority of its elements. Looking back, it became pretty clear that the following fundamentals were key to our success as we worked toward the plan goals: • Without question, create and distribute monthly key financial statements to help better predict, plan, and analyze revenue, expenses, cash flow, and balance sheet activities. If your accountant tells you this is unnecessary, find another accountant. • Establish a robust and aggressive contracting and receivables management program — follow the money and seek out a contracting ninja: »» Contracting: The health plans and insurers all employ contracting specialists to ensure their interests are protected — do the same from your side2. Also, take the offensive: Understand your

S AN D I E G O P HY S I CI A N. or g june 2011

•

leverage points and exploit them when and where you can in the contracting process. »» Receivables: Sending accounts to collections or even small claims does not in any way tarnish one’s image as a physician. You have honored your profession by providing great care; keep insurers and health plans honest by using regular, pointed payment communications supported by Knox-Keene and DMHC standards, and do not accept that you must write off substantial amounts of patient billing! Patients’ failure to understand their insurance, failure to grasp that a “healthcare deductible” is exactly what it means, failure to pay their bill even after they’ve cashed the insurer’s check or, better yet, failure to pay “because my doctor is rich” are generally very good examples of “a lack of personal responsibility” and should earn a trip to the collections office or small-claims court without passing Boardwalk, Park Place, or GO! Understand, embrace and deploy “lean” across the practice and for all. Value Stream1 map your entire practice process — on a big wall where everyone can view it — from patient front office to money in the bank. Based on your Value Stream map: (i) Identify key areas for improvement (this will become your project plan for the year); (ii) Look for processes where you can use technology to replace manual process/ touch points; (iii) Pinpoint areas where lots of error occurs (install a tracking system, pareto the data, and set up improvement plans in high volume risk error corridors); and (iv) From your Value Stream map, calculate your “Total Cycle Time”3 and compare against your Payroll Cycle Time. (This so that employees can see how long it takes the practice to get paid vs. how long it takes the employees to get paid!) Next, measure, measure, measure. It has been said, “If you measure it, people will work toward it,” and “If you measure and post for all to see, results toward those same measures will double.” Create and post a practice scorecard! A scorecard is the adult version of the report

•

card we got as kids. Report cards went on the refrigerator. The scorecard goes on the biggest board you can put on a prominent wall. Invest in training and lots of it, but require the staff to create their own development plan based on what they do and what is core to their function. Physicians should not shoulder the entire burden for revenue and/or profitability. Revenue cycle management, operating cost control, alternative revenue creation (example: If you bill in-house, do you have capacity to bill for another solo physician?), etc. should be owned by the office. Install some type of incentive or profit share plan if you can that ties to practice profitability, increased output, and error reduction. The key here is to move the culture from “Here to pick up a paycheck” to “How can WE make more.” Utilize consultants strategically in the areas of contracting, IT, outside billing review, and practice and risk management. Focus and engage consultants who recommend and implement for you, while training your office to sustain. It’s easy to visit for a day, ask for scores of templates and/or surveys to be completed, and then make suggestions, but for solo/ small-group practices, the value and need for help is in the work plan creation, milestone identification, and implementation. If using an outside biller, create a scorecard for them in the same manner you have for staff. Place the responsibility on the biller to update the scorecard, and require they provide you with the scorecard at the time they give you the monthly invoice. Lastly and most importantly, solo/smallgroup physicians must seek out other solo/small-group physicians for better ways of doing things. While I understand practice specialty differences may mean some process or practice elements may vary from one office to the next, the number of common denominators that exist between practices is more substantial than most know. Force yourself and/ or key staff to cultivate a small circle or focus group of solo/small-group resources to meet monthly/quarterly. I am quickly approaching my one-year

anniversary, and as a result of what I’ve learned, here is what I now believe: • There may not be a more difficult job or role anywhere in this country than that of a solo/small-group physician. • Anyone who has endured medical school, internship, residency, board certification, fellowship, and has committed a lifetime to the care of others is deserving of being referred to as physician/doctor, NOT provider! • Staff and employees of solo/small-group physician practices need to step up and carry some or more of the load. If they can’t or won’t, there are others who will. • Solo/small-group practices can survive and thrive if they are willing to: (i) learn about and adopt some key business practices long in use by other industries; (ii) band together in coalition form and share information; (iii) take advantage of, utilize, and lean heavily on resources

such as SDCMS and CMA to supplement your limited resources; (iv) choose wisely the consultants you select and use; and (v) take the time to create a plan and follow it. • Assuredly, most if not all patients and most staff do not have any idea how important solo/small-group physician(s) are to the healthcare ecosystem, and without them there will be a seismic shift in the quality of care offered and received. • Lastly, it is important not to believe all that you read: Extinction is not inevitable; it’s a choice. While I am certain we have made some missteps this past year, and some things could have returned better results, I believe the practice is pointed in the right direction. For me, it has been a life-changing event, and I’m not quite sure how one returns to “generally important” after having become part of something “that matters.”

Notes: 1. Value Stream Mapping: A sophisticated flowcharting method that uses symbols, metrics, and arrows to help visualize processes and track performance. This method helps determine which steps add value and which do not. 2. Our use of Coastal Healthcare Consulting proved to have the greatest rate of return per dollar spent on consultants. 3. Total Cycle Time: The time that elapses from the beginning to the end of a process or value stream.

About the Author: Steve is a long-time corporate executive who has managed supply chains and manufacturing facilities on a global scale for a number of large, Fortune 500 companies. Dr. Roxanne Hon, Steve’s spouse and boss, is a second-generation East County solo practitioner and an SDCMS-CMA member since 2010. Steve can be reached at nottoli66@gmail.com or at (619) 379-0008.

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june 2011 SAN DIEGO P HY SICIA N. o rg

preventivehealth

Health Butler Your Personal Health Assistant By Murray A. Reicher, MD, FACR

We are all familiar with the old adage, “an ounce of prevention is worth a pound of cure,” but when it comes to our health, most Americans do a poor job of taking care of themselves. Increasingly, individuals, employers, and government agencies are recognizing the need for consumer-driven preventive healthcare. Preventive healthcare can be divided into three main categories: healthy habits, immunizations, and medical screening procedures. However, according to Dr. Danielle Reicher, co-founder of San Diego-based Health Butler, LLC, we all suffer from generally low compliance with even the most widely understood health prevention measures. Examples include our high national obesity rate, exceeding 35 percent in some

S AN D I E G O P HY S I CI A N. or g june 2011

ler periodically emails each user a reminder, health scorecard, and health challenge, as well as a health-related blog. Any individual can track his or her compliance score and any sponsor (such as an employer or healthcare provider) can easily view the aggregate performance of their affiliated group (for groups of 15 or larger). For individuals, it’s a great tool for self-empowerment, and for employers, it’s a great way to understand their employee’s health and prevention status (as a group) without violating any personal confidentiality. Health Butler aims to provide San Diegans the health literacy and motivation they need to take better care of themselves and to receive better care from their doctors. The Health Butler site contains no advertising, and all recommendations are referenced. The content is all written by physicians. In fact, Health Butler now appears on the SDCMS website as a link, having been adopted by the SDCMS as its web-resource for preventive healthcare.

Health Butler is a privately held states, our low mammography compliance rates, now less than 60 company, founded by physicians, percent, and our low colonoscopy including SDCMS members Danielle compliance rates, now less than 45 Reicher, MD, Murray Reicher, MD, and percent. their UCSD medical student son, Joshua Dr. Reicher co-founded Health Reicher. Health Butler has emerged at a Butler to provide individuals and healthcare providers with updated time when there is a growing consensus and credentialed preventive healththat self-empowered preventive health care information. The Health Butler is the key to both wellness and the website — www.healthbutler.com control of healthcare costs. — not only provides easily understood information, but also lets users confidentially and quickly view a About the Author: Dr. Reicher is a boardlist of their required medical screening procertified diagnostic radiologist and fellow of cedures, track their preventive health comthe American College of Radiology, and an pliance, and track their key healthy habits. SDCMS-CMA member since 1987. To provide further motivation, Health But-

june 2011 SAN DIEGO P HY SICIA N. o rg

healthinformationtechnologies

If you are interested in learning more about CalHIPSO or in signing up, please visit the CalHIPSO website at www.calhipso.org or contact Rob Yeates at the SDCMS Foundation at (858) 300-2791 or at Rob.Yeates@SDCMS.org.

Medi-Cal Provider Incentives Does Your Practice Qualify? By Rob Yeates

S AN D I E G O P HY S I CI A N. or g june 2011

Under the provisions of the American Recovery and Reinvestment Act of 2009 (ARRA, or the “Stimulus Act”), providers are eligible for financial incentives for demonstrating “meaningful use” of an electronic health record (EHR) system. Providers can qualify for incentives either through the Medicare program or through the Medicaid/Medi-Cal program. This article is intended to help providers determine if they qualify for Medi-Cal provider incentives.

Eligibility Rules While most Medicare providers will qualify for some incentive payments, Medi-Cal providers will only qualify if they fall into one of three categories: 1. Thirty percent of their patient volume is Medi-Cal patients. 2. Pediatricians will qualify if 20 percent of their patient volume is Medi-Cal patients. However, pediatricians who fall between 20 and 30 percent of patient volume will only qualify for two-thirds of the total incentive. 3. For providers who practice in a Federally Qualified Health Center (FQHC), 30 percent of their patient volume is “needy individuals” (Medi-Cal, Healthy Families, sliding scale, or uncompensated care). The federal government, through the regulatory process, has clarified how providers are to calculate their patient volume for determining whether they are eligible. These rules are outlined below. Calculating Patient Volume Providers can demonstrate that they are eligible for Medi-Cal incentives by tracking their patient volume for a 90-day period of their choosing. In general, the patient volume requirements are calculated as a percentage of total patient encounters during that 90-day period. The formula is: “Total Medi-Cal Patients Seen” divided by “Total Patients Seen” multiplied by 100. If the resulting percentage is more than 30 percent (or 20 percent for pediatricians), then

the provider qualifies for incentives in the Medi-Cal program. Providers practicing in an FQHC would use the same formula but would include all “needy individuals” in the numerator of the fraction. Special Rules for Medi-Cal Managed Care Providers who contract with Medi-Cal Managed Care plans will use a slightly different formula for calculating their patient volume. The federal government will allow providers in a managed care arrangement to consider patients assigned to their patient panel by the plan. The formula providers in this situation will use is: (“Medi-Cal Patients Assigned to the Provider” plus “All Other Medi-Cal Patients Seen by the Provider” divided by “Total Patients assigned to the Practice plus All Other Patients Seen by the Practice” multiplied by 100. A provider in an FQHC would count all needy individuals, not just Medi-Cal recipients, in the numerator of the equation. Definition of Medi-Cal Patients For both the fee-for-service and managed care Medi-Cal providers, Medi-Cal patients also includes anyone covered by a state Medi-Cal waiver, such as the Family PACT program and those covered by both MediCal and Medicare (“dual eligibles”). Providers who are not in an FQHC cannot count patients covered by Healthy Families, Access for Infants and Mothers (AIM), a county coverage initiative, the County Medical Services Program (CMSP), or any other state or local program. Timelines and Next Steps The State of California is currently finishing the process of designing the Medi-Cal EHR Incentive Program so that it can be submitted for federal approval. Final details of the program will be available in the summer of 2011. Early in 2011, the federal government will begin asking providers to choose whether they will access the Medicare incentive program or the Medi-Cal program. Therefore, providers should begin assessing their practices now, to determine whether they will qualify for the Medi-Cal Program. About the Author: Mr. Yeates is the IT project manager for the SDCMS Foundation.

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Patient / Consumer Safety

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S AN D I E G O P HY S I CI A N. or g june 2011

As physicians, we need

to be aware of the directto-consumer model for genetic testing, and we need to be prepared to respond to patient inquiries. The increasing desire of our patients to know and to “control” more and more of their medical management issues has increased the demand for direct-to-consumer testing, including genetic testing. Consumers are interested, of course, in determining their respective potential risk of developing certain illnesses. Is a future child at greater than normal risk for a given genetic disease? Is the person more susceptible to environmental risk of exposure? Does he or she potentially respond (or not respond) to a given drug or drugs you may prescribe differently than does a “normal person.” The list continues to grow of the potential value to a medical consumer as advances continue. Increasing knowledge regarding the number of genes identified as playing roles in complex disorders such as Alzheimer’s, cancer, cardiovascular disease, and diabetes continues to increase patient interest in genetic testing. Public awareness began to increase in late 2008 on the heels of articles in Time magazine, for example, that hailed the “retail DNA test” as the “invention of the year.” That same year the journal Nature declared 2008 as “the year in which personal genomics goes mainstream.” This has led to multiple companies following a business model that promotes and markets genetic tests and/or a “personalized genetic profile” directly to the public. The issue is not should this be done or will this be done — it is being done, and as physicians we need to be aware of this rapidly changing “genetic testing” landscape. What is direct-to-consumer (DTC) genetic testing? DTC genetic testing comprises genetic tests and services that are advertised directly to consumers, that are purchased through nonprescription required consumer-initiated requests, and that provide test results directly to the ordering consumer. The consumer’s healthcare provider is not involved — unless he or she receives questions from a patient — before or after such tests may have been, or may be, ordered. As you have probably noticed, many pharmacies currently offer home DNA paternity tests off the shelf, sold alongside tests to measure blood sugar levels, predict ovulation, ascertain

pregnancy, or to detect illegal drugs in the urine. In May 2010, Walgreens announced the availability of tests intended to detect genetic diseases. (Sometimes these are, in fact, specimen collection kits and not test kits; the result, however, is the same: The specimen is sent to the lab by the consumer and the results are reported directly to the consumer.) The U.S. Food and Drug Administration ruled, at least initially, that these genetic testing kits could be sold over the counter because the specimen collection kits do not fit the definition of a medical device that would require FDA clearance prior to sale. Direct-to-consumer genetic tests were initially categorized by the FDA as in the same category as laboratory-developed tests. There remains, however, considerable discussion of these OTC-offered testing services and at least some “regulatory” gray area still under discussion. The FDA is to report soon its view of the regulatory oversight appropriate for OTC genetic testing. Additional regulatory requirements are anticipated for most direct-to-consumer test offerings, including genetic tests. Members of the House Committee on Energy and Commerce have raised questions about the reliability of DTC tests in general, and in so doing have called attention to such tests, so additional regulatory scrutiny would not be a surprise. At the moment, however, over-the-counter genetic testing services, with results provided directly to the consumer, are available. Over the counter, or directto-consumer, genetic testing raises a number of potential medical and social issues, some of which are unique to genetic-level testing. What are an individual’s rights and responsibilities regarding genetic test results that may have an impact on other family members as well as the overall social, emotional, and economic wellbeing of the individual and/or family? Privacy, in particular, has become a matter of enormous concern to medical ethicists, policymakers, and the general public regarding genetic test results. The Genetic In-

What are an individual’s rights and responsibilities regarding genetic test results that may have an impact on other family members as well as the overall social, emotional, and economic wellbeing of the individual and/or family?

june 2011 SAN DIEGO P HY SICIA N. o rg

Patient / Consumer Safety

formation Nondiscrimination Act (GINA), which took effect in November 2009, is intended to protect individuals against undesired access to and potentially adverse use of genetic information by entities such as health insurers or employers. At this time it is not clear if GINA will extend to genetic information that an employer might request as part of a voluntary workplace wellness program. HIPAA does not include results obtained by a consumer from a DTC testing company. Consumers are unlikely to be aware of this technicality, making it crucial that a DTC customer understands privacy policies, including rules regarding the sale and disclosure of one’s data, use of the data in research, and under what circumstances those rules can be changed. DTC genetic testing companies, via Internet promotion and access, can potentially serve a diverse market that ignores reliance on the checks and balances of the traditional healthcare system. Do genetic testing companies (OTC or DTC) have a therapeutic relationship with their customers? Are they “practicing medicine”? What should their responsibilities, if any, be beyond mailing out the results of a genetic test? If genetic counselors are offered, does that create (or imply) a medical patient relationship? Not surprisingly, DTC genetic testing companies maintain that it is not their intent to practice medicine or to enter into a therapeutic relationship with their clients.

In China, it is reported that for approximately $900, parents in Chongqing can send their children — ages 3–12 years — to a fiveday camp that includes comprehensive DNA testing to identify and determine the child’s “gifts and talents” so that the parents can focus on those strengths from an early age.

Direct-to-consumer genetic testing companies generally advise their customers to discuss their individual test results with their healthcare provider. The typical provider may or may not be prepared to interpret the results of a test “panel” he or she may see for the first time, with minimal context or background perspective of that patient’s results

or the credibility of the test panel itself. The OTC test customer’s physician may have neither the context nor the expertise required to discuss the results of an esoteric panel that may propose to indicate subtle genetic predispositions or risks. A 2008 online survey of 1,880 physicians (including internists, pediatricians, obstetricians/gynecologists,

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and family physicians) found that fewer than half (42 percent) were even aware of the scale and scope of available OTC genetic testing. These physicians were asked to rate five medical information resources. Journal articles scored highest (96 percent) among respondents, followed by information from government agencies (83 percent), other physicians (80 percent), professional organizations (74 percent), and medical websites (62 percent). Only 2 percent considered media a trusted source, yet when asked where they were most likely to get information about DTC genetic testing, respondents overwhelmingly cited that the source would be public media, reflecting the paucity of information available from the more trusted sources (at least to the awareness of this survey group). The medical value of genetic testing in certain clinical settings is both well understood and growing in frequency of use. Direct-to-consumer genetic testing may become a meaningful contribution to information for a given individual as well as a meaningful component of the healthcare system. The potential for abuse of such easily available genetic testing is dramatic, however. In China, it is reported that for approximately $900, parents in Chongqing can send their children — ages 3–12 years — to a five-day camp that includes comprehensive DNA testing to iden-

tify and determine the child’s “gifts and talents” so that the parents can focus on those strengths from an early age. According to the director of the Chongqing Children’s Palace, “Nowadays, competition in the world is about who has the most talent. They can give Chinese children an effective scientific plan at an early age.” The ethical questions regarding such testing are rather immediately evident. Clearly, individual physicians, the institutions of medical education, and medical professional societies need to engage fully in this matter, and immediately so. “Gatekeeper” physicians in particular must rapidly increase their respective knowledge and awareness of genetic testing’s being offered direct to the consumer so the medical professional can discuss the pros, cons, and limitations of such direct-to-consumer genetic tests. About the Author: Dr. Peters, SDCMS-CMA member since 2000, is a family physician in private practice. He is treasurer of SDCMS, sits on SDCMS’ GERM Commission, co-chairs Sharp HealthCare’s Primary Care Conference, is chair of CMA’s Council on Ethical Affairs, and sits on the San Diego Academy of Family Practice board of directors. Dr. Peters also serves as a consultant to biomedical and pharmaceutical companies and is involved in vaccine clinical trials (investigator).

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Patient / Consumer Safety

Partnership for

patients Attempted Progress for Improved Patient Safety B y B r yan A . Liang , M D , P h D , J D , and Kimbe r ly Love t t, M D

On April 12, 2011,

the Centers for Medicare and Medicaid Services (CMS) announced a new patient safety initiative: the Partnership for Patients. This program is designed as a set of initiatives aimed at creating awareness, introducing incentives, implementing standardized quality measurements, and establishing and executing proven interventions. The program will start by focusing on nine types of medical errors/complications where the potential for dramatic reductions in harm rates has been demonstrated by pioneering hospitals and systems across the country, including preventing adverse drug reactions, pressure ulcers, and surgical site infections. The Partnership will be based on pilot projects, with approximately $500 million available to community-based organizations offering compelling models for reducing readmissions, and $500 million to organizations to help promote best-practice interventions to reduce hospital-acquired conditions. Participation is voluntary. According to CMS, the Partnership for Patients effort would theoretically reduce hospital-acquired conditions by 40 percent and readmission rates by 20 percent by 2013. Particularly in the context of recently published government reports and academic articles suggesting higher rates of adverse events than

S AN D I E G O P HY S I CI A N. or g june 2011

previously estimated, Partnership for Patients is a potential step forward for patients and patient safety. Indeed, recent findings have suggested adverse events up to 10 times that of previous estimates and up to one-third of inpatients suffering negative impact from medical errors during their hospital stay. Notwithstanding the theoretical benefits of Partnership for Patients, the initiative will not require public reporting of individual hospital performance, as originally conceived for inclusion in the project. Rather than having each facility report results on reaching quality and safety targets, only aggregate goals and figures are to be used in the effort. Consequently, potential strides for improvement of transparency and accountability in patient safety have been thwarted. Transparency, however, is critical to any improvement in the patient safety realm, as is patient engagement in the process as a member of the safety team. The patient safety literature abounds with studies demonstrating that the current culture of secrecy and opacity within the healthcare system remains a barrier to improving medical errors and patient safety. The Institute of Medicine has reported that one of the 10 pillars imperative to crossing the chasm that separates the current state

of healthcare quality and where we should be is transparency. Taken directly from the Institute of Medicine report synopsis: Transparency is necessary. The system should make available to patients and their families information that enables them to make informed decisions when selecting a health plan, hospital, or clinical practice, or when choosing among alternative treatments. This should include information describing the system’s performance on safety, evidence-based practice, and patient satisfaction. (Kohn LT, et al. Crossing the quality chasm: a new health system for the 21st century. A report of the Committee on Quality of Health Care in America, Institute of Medicine. Washington, DC. National Academy Press; 2001. Report Brief available at www.nap.edu/html/quality_chasm/reportbrief.pdf). Hence, any publicly funded safety initiative should provide for individual hospital accountability through widely available public information about quality and safety measures within that facility. Moreover, public reporting of patient experience and satisfaction scores to demonstrate a facility’s responsiveness to patients as the true center of the delivery process is imperative to achieving patient-centered care and informed consumer choice. However, it is exactly these key indicia that have been removed from the initiative. Last year, when the initiative was supposed to be announced, both “retail” consumer groups and “wholesale” large employer customers indicated that public reporting was essential for individual hospitals to drive accountability and to supplant public value-based purchasing efforts with private-sector approaches. Indeed, the administration solicited large employers (although not patients) for input regarding the initiative and tying payments to attainment and reporting of quality measures. However, instead of integrating input from stakeholders and promoting accountability by designing hospital reporting systems that fulfill transparency, quality, and safety information needs, CMS has instead taken the politically expedient approach of eliminating public reporting from the patient safety initiative altogether. Removing the aspect of the policy that would actually create transparency may have eliminated the muscle from the concept. With the continuous and increasing flow of information depicting the poor state of patient safety outcomes typical in the United States, a focus on greater accountability and greater transparency is needed, not continued acceptance of an opaque health system woefully bereft of transparent information that might facilitate consumers to make informed choices about where they receive care. Moreover, publicly reported scores at the Hospital Compare website — hospitalcompare.hhs.gov — demonstrate that hospitals are receiving an F grade (scores of 55 percent or lower) for patients willing to recommend the facility to others, indicating an even greater need for individual hospital information. Patient access to safety, quality, and satisfaction information about individual institutions is the only road to informed consumer choice and thus improved accountability and competition. Partnership for Patients does represent a “feel-good” approach to improving patient safety, but, in the long run,

transparency is going to be a necessary ingredient to achieving those safety goals. Facilities that perform well, that are open and transparent about their quality and safety, and that are truly patient centered, are ultimately indirectly penalized by the failure to reward their efforts under this new CMS initiative. Patients who want and are entitled to key, important, and needed information about quality and safety of particular facilities are directly penalized by the absence of a transparency requirement under the CMS initiative. And the health delivery system, which is driven by incentives created by public policy decisions, is placed deeper into the shadows of opaqueness that have created the current state of affairs in United States healthcare delivery. CMS should reconsider its approach. Any patient safety program must include public reporting of individual facility performance in quality and safety, including defined metrics coupled with patient experience scores. Patient safety advocates must push for such reporting as a minimum basis for transparency and accountability. Furthermore, innovative hospitals with outstanding quality and safety outcomes should not wait for CMS to improve its approach. These facilities should be trumpeting their transparency in open reporting of their patient safety and quality improvement activities. They should aggressively advertise their own high scores and make direct comparisons to competing facility-reported outcomes using Hospital Comparisons. This would represent a somewhat more comprehensive approach for creating accountability for facilities that hide behind a protected veil despite relatively high numbers of medical errors and poor patient satisfaction. In sum, if the Partnership for Patients program reaches its projected goals for readmission reductions and hospital-acquired conditions reductions, it would represent a great improvement in patient safety. But without a mechanism to involve competition and consumer choice based upon publicly reported scores, the projected improvements are likely overestimates, at best.

Recent findings have suggested adverse events up to 10 times previous estimates and up to onethird of inpatients suffering negative impact from medical errors during their hospital stay.

About the Authors: Bryan A. Liang, MD, PhD, JD, is Shapiro Distinguished Professor of Health Law and executive director, Institute of Health Law Studies, California Western School of Law; and professor of anesthesiology and director, San Diego Center for Patient Safety, UCSD School of Medicine. Kimberly Lovett, MD, SDCMSCMA member since 2006, is attending physician, Kaiser Permanente, and lecturer, UCSD School of Medicine.

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Patient / Consumer Safety

In 2010, we provided personalized support with 525 patient safety site surveys. These were conducted across a range of practice environments around the country — from small office practices to large integrated delivery systems, hospitals, and outpatient facilities, such as surgery centers. Our national scope gives us unparalleled insight into critical trends in every region of the country. This unique perspective guides us in creating clinical tools and programs that help our members identify risk and improve patient safety. In 2010, we improved the discipline, rigor, and potential for system-wide learning with the introduction of our Interactive Guide for Office Practices, an innovative tool based on the most frequent patient safety/risk management issues identified in our closed claims.

What Did We Find?

Of the 15 categories in the Interactive Guide for Office Practices, medical record documentation was the category with the most frequent patient safety/risk management issues. A total of 266 surveys — more than half of the 525 site surveys — had at least one issue related to this category. Top findings within this category included the failure to document allergy status in the same location in each record and the lack of a problem list or a list of current medications. We found that two combined categories — lab tests/referrals and scheduling/follow-up — came a close second with issues in 234 of the surveys. Although the categories are individually ranked fourth and fifth, they are so closely related that a finding in one typically leads to a finding in the other. The findings included a failure by the practitioner to review and sign all test results; no follow-up for missed appointments; and no tracking system to ensure that the ordered test was performed, the report

S AN D I E G O P HY S I CI A N. or g june 2011

received, the patient informed, and appropriate follow-up accomplished. The third category identified medication management as an issue in 195 of the surveys. The issues in this category included medications that were drawn up in unlabeled syringes, absence of a system for storing and managing sample medications, and failure to ask patients for an updated list of current medications. The fourth category identified confidentiality and privacy as an issue in 137 surveys. Examples of these findings are failure to secure medical records after hours and failure to obtain consent to leave messages on the patient’s answering machine.

Risk Tips for the Top Four Categories

1. Medical Record Documentation (an issue in 51 percent of surveys): • Document allergy information in the same place on all medical records. If the patient has no allergies, document no known allergies (NKA). • Maintain a current list of medications, including herbal supplements and over-the-counter medications. • Maintain a current problem list with dates of problem identification, reviews, and resolutions. • Use the patient’s own words when documenting. This is not only more informative to other physicians or staff but it also lends more credibility in the event of a legal proceeding. • Make sure all pages are organized and that all forms are completed; do not use sticky notes or other loose papers for charting. • Always indicate in writing or electronically that all results of tests, consultants, and referrals were reviewed, and maintain the reports in the same place in all medical records. • Document all after-hours patient calls in the medical record.

2. Lab Tests and Referrals/Scheduling and Follow-up (an issue in 45 percent of surveys): • Ensure that all members of your office staff know how to reconcile tests, referrals, and consult orders with the results when received. If a discrepancy occurs, have a process in place to remedy it promptly before an adverse event occurs. • Do not rely on a return appointment or placing a “hold” on the medical record to act as a reminder that a test was not performed or the patient was not contacted about results. • Communicate all test results to patients, including those that are within normal limits (WNL). • Engage the patient in following up for test results. Tell the patient to contact your office if he or she has not received results from you or your office staff by a specified date. • Use a recall system for those patients who are regularly seen. • Send letters to patients who fail to follow up and cannot be reached by phone; file all documentation and copies of letters in the medical record. • If using an electronic medical record, utilize the test tracking capability as designed. 3. Medication Management (an issue in 37 percent of surveys): • Take time to make sure the patient understands the reason for the medication, how to take it, and when to contact your office if the patient experiences side-effects. Use repeat-back or teach-back techniques to confirm the patient’s understanding. • Store medication samples, syringes, and prescription pads securely. • Do not maintain unlabeled syringes, and do not leave them unattended. The medication should be immediately administered by the person who prepared it. • If you prepare medications to be used later, make sure the person preparing the medication signs or initials the label and includes the name of the medication, the dosage, and the date.

• Ensure that medications requiring refrigeration are maintained at the correct temperature by keeping a record of who performs the checks and what was discarded. • Ask the person receiving a verbal order to repeat back the order after he or she has written it. • Identify all high-alert medications kept in your practice, and follow guidelines to ensure they are stored, ordered, dispensed, and administered correctly. Refer to the Institute for Safe Medication Practices website at www.ismp.org for more information on this topic. • Refer to your state law to determine which staff can call in new prescriptions or refills. For example, medical assistants should not call in new prescriptions. 4. Confidentiality and Privacy (an issue in 26 percent of surveys): • Provide education to all staff and practitioners on the requirements of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) on an annual basis. • Use business associate agreements with vendors that have access to patient information. • Do a personal check of areas within your office where conversations with patients can be overheard by others. Pay particular attention to whether a conversation in one treatment room can be heard in the next room. • When faxing patient information, use a cover sheet that includes confidentiality language and provides contact information if a fax is received in error. • Always knock before entering a treatment room. Make sure you do not leave a treatment door open when a patient is present. • Do not leave messages on a patient’s voice mail unless you have been given specific permission to do so by the patient. About the Author: Ms. Diamond is AHA fellow, patient safety leadership and Department of Patient Safety senior vice president for The Doctors Company.

Most-prevalent Risks Identified in Selected Specialties Family Practice • Medical Record Documentation: 59% • Lab Tests and Referrals/Scheduling and Follow-up: 57% • Medication Management: 30% • Confidentiality and Privacy: 17%

Orthopedics • Medical Record Documentation: 65% • Lab Tests and Referrals/Scheduling and Follow-up: 49% • Medication Management: 40% • Confidentiality and Privacy: 30%

OB/GYN • Medical Record Documentation: 79% • Lab Tests and Referrals/Scheduling and Follow-up: 85% • Medication Management: 46% • Confidentiality and Privacy: 46%

Pediatrics • Medical Record Documentation: 10% • Lab Tests and Referrals/Scheduling and Follow-up: 5% • Medication Management: 82% • Confidentiality and Privacy: 8%

Plastic Surgery • Medical Record Documentation: 64% • Lab Tests and Referrals/Scheduling and Follow-up: 44% • Medication Management: 33% • Confidentiality and Privacy: 41%

Internal Medicine • Medical Record Documentation: 65% • Lab Tests and Referrals/Scheduling and Follow-up: 58% • Medication Management: 48% • Confidentiality and Privacy: 26%

june 2011 SAN DIEGO P HY SICIA N. o rg

Patient / Consumer Safety

Social Media and

Drug Advertising Information and Warnings for Physicians and Patients B y B r yan A . Liang , M D , P h D , J D , and Timo t hy M ac k ey, M A S The Internet has rapidly developed, with users moving from passive information using read-only “Web 1.0” technology to interactive, tailored relationships using “Web 2.0” technology. This includes social networking sites and other interactive systems that have created new direct-to-consumer advertising (DTCA) marketing opportunities that transcend geopolitical borders. Currently, the FDA has not issued guidelines on this type of drug marketing. However, drug advertising using the Internet may have a presence already. Physicians should counsel their patients on the challenges of social media drug advertising.

Social Media Marketing: Pharmaceutical Companies

There are several means by which social media marketing may occur. Pharmaceutical companies may, of course, develop corporate webpages that market products or provide health information directly to the public. However, with Web 2.0 technology, these webpages may also serve as launch points for access to the entire panoply of social media platforms. The spectrum of social networking tools used by drug companies is as broad as those available, including Facebook pages, Twitter accounts, blogs or RSS feeds, dedicated YouTube channels, and iTunes store applications sponsored by drug companies. These are accessible globally. Furthermore, these social media efforts can incorporate DTCA promotion strategies, including patient testimonials and product information, as well as extend their influence through hosting of direct-to-consumer media online and linking to favorable research data. The potential reach of social me-

S AN D I E G O P HY S I CI A N. or g june 2011

dia marketing is enormous, allowing for interactive marketing to millions of potential consumers globally. Some of these social media efforts may be presented as “neutral” information, despite being corporate-sponsored. This is particularly true when it employs third parties, e.g., bloggers, “consumer opinion leaders,” or other paid individuals/companies to promote products without disclosure; moderated forums/sites that appear interactive but only offer one-sided communication; and “unbranded websites” without sponsorship disclosure.

Social Media Marketing: Illicit Sales

There is also a nefarious parallel set of social media marketers selling drugs. The Internet is rife with rogue online pharmacies using marketing tools as their primary vehicle. These illicit drug sellers, for example, have used sponsored links and search engine shopping pages before they were stopped. Now they have transitioned to Facebook and Twitter, with direct links to sites that will sell purported drugs without a prescription. In fact, some of these sites are impossible to differentiate from the actual manufacturer’s. Social media marketing has emerged as an unregulated marketing tool for legitimate and illicit sources alike, and consumers lack insight on whether such information is valid or not.

Implications

Because more than half of U.S. adults and hundreds of millions worldwide use the Internet for health information, it is unsurprising companies have moved into this area for marketing us-

ing eDTCA2.0 tools, spending an estimated $1 billion. What this means, on one level, is that social media marketing of drugs directly to patients may not be limited to the United States or New Zealand. Social media marketing has globalized DTCA to anyone, anywhere with Internet access. Rapid social media development may place the FDA even further behind in attempting to regulate both DTCA and illegal online sales, while global DTCA prohibitions are being emasculated. Patient safety may also be compromised. Drug advertisements show suspect quality with the overemphasis of benefits, so patients may not adequately assess risk. Furthermore, marketing focus on high volume and/or chronic disease drugs may place vulnerable patients at risk, perhaps disproportionately, because blockbuster drugs are most heavily marketed early in product lifecycles when safety profiles are incomplete. Heavily promoted DTCA drugs have, in fact, been associated with safety advisories and blackbox warnings. U.S. safety concerns may become global health concerns under eDTCA2.0. Patient safety is also clearly undermined by illegal online pharmacy social media use. The clear risk is that patients may be purchasing drugs without professional oversight, that are unapproved, and/or those with safety concerns, assuming

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Drug advertisements show suspect quality with the overemphasis of benefits, so patients may not adequately assess risk. Furthermore, marketing focus on high volume and/ or chronic disease drugs may place vulnerable patients at risk, perhaps disproportionately, because blockbuster drugs are most heavily marketed early in product lifecycles when safety profiles are incomplete.

authentic drugs. But online pharmacies have also been found to sell counterfeits and tainted drugs, resulting in patient death and injury. These rogue sellers have been extremely nimble, and it is no surprise they have adapted to Web 2.0 technology. This magnifies the importance of public health regulatory body warnings about purchasing drugs online and obtaining information from trusted sources. Social media marketing use by companies and illicit online pharmacies may inappropriately increase demand and compound harm by permitting self-prescribing and direct, illegal purchase. And because search engines drive consumers to content, interactive social media may receive higher traffic due to repeat use or other website links. It will appear higher in search results with

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june 2011 SAN DIEGO P HY SICIA N. o rg

Patient / Consumer Safety concomitant higher impact, allowing it to become a dominant source of health information, potentially displacing healthcare professionals.

Physicians and Patients

It is critical for physicians and patients to be well versed in Internet drug sales, their risks, and their benefits. Patient safety must be paramount. Not only have traditional pharmaceutical manufacturers entered into the social media marketing arena, but also drug sellers acting illegally online. Several areas bear emphasizing for physicians and patients: 1. Physicians and patients should heed the warnings from the FDA and other international regulatory and public health bodies and strongly warn and guard against drug purchasing online. Only purchase from National Association of Boards of Pharmacy Verified Internet Pharmacy Practice Sites (www.nabp.net/programs/accreditation/ vipps/find-a-vipps-online-pharmacy). 2. Physicians should counsel their patients as to the risks of online drug purchasing and other nontraditional sites of drug access. In particular, social media and other interactive sources of information should be viewed with suspicion. 3. Physicians should counsel patients to use only trusted

sources of information online. Avoid any nonofficial sites, and rely only on trusted specialty or other formal information source not selling products. 4. Physicians should counsel patients to know what drugs they are taking, and know their options for obtaining them safely. Using checklists such as the SAFE DRUG checklist, keeping a medication diary with patient impressions and reactions to each drug, and having information on low cost/no cost drug programs can assist patients to be partners in medication safety (available at safemedicines. org). Overall, social media marketing of drugs represents a significant challenge. The evolution in these and future forms of pharmaceutical marketing will not wait for regulation. Both licit and illicit industry will continue to innovate and move forward in a rapidly changing Internet environment. Physicians must be knowledgeable about these risks so as to best advocate for patients and patient safety. About the Authors: Dr. Liang is executive director of the Institute of Health Law Studies, California Western School of Law. Mr. Mackey is senior research associate, Institute of Health Law Studies, California Western School of Law.

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Is Outsourcing Your Billing the Solution? CHMB Solutions provides outsourced medical billing, revenue cycle management services, information technology support, and hardware solutions to physician practices, clinics, and multi-specialty organizations. SDCMS members receive a 50% discount on startup fees and a $33 per-physician-per-month services credit, 10% off of outsourced IT support, 10% off of already discounted Dell hardware solutions, and a free coding hotline. To learn more, contact Ron Anderson at (760) 520-1340 or at randerson@chmbsolutions.com. Email your coding questions to SDCMS at Coding@SDCMS.org. Potential Benefit Value: $1,000!

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Looking for a way to give back to the community? The San Diego County Medical Society Foundation’s (SDCMSF) mission is to address the unmet San Diego healthcare needs of all patients and physicians through innovation, education, and service. SDCMSF is proud to partner with volunteer specialty physicians and nearly 100 community clinics in the county who provide primary care services for the medically uninsured and underserved. These clinics have little to no access to specialty care for their patients and need your help!

Opportunities for Physicians 1

Volunteer for Project Access San Diego:

If you are a specialist in private practice in San Diego, please consider joining more than 180 specialists in the county by seeing a limited number of uninsured adult community clinic patients in your office for free. Project Access coordinates all aspects of care so your volunteerism is hassle-free for you and your office staff.

Volunteer for eConsultSD:

eConsultSD allows primary care physicians from the community clinics in San Diego to articulate a clinical question to a specialist and receive a timely response in a HIPAA-compliant, web-based portal. eConsultSD is an easy way for busy specialist physicians to give back to the community who are not able to provide direct patient care.

Obtain a Volunteer or Paid Position at a Local Community Clinic: SDCMSF is happy to connect specialist physicians with a community clinic that needs your services on site. This opportunity involves traveling to a clinic within San Diego County as your schedule permits.

Make a Contribution:

SDCMSF needs your support to care for the medically underserved in our community. Please consider making a contribution of any size to support the Foundation’s efforts. Contributions can be made online at SDCMSF.org or sent to the San Diego County Medical Society Foundation at 5575 Ruffin Road, Suite 250, San Diego, CA 92123. Thank you for your support!

Thank you for your dedication to the medically underserved. If you are interested in any of the opportunities above, please contact Lauren Radano, program manager, at (858) 565-7930 or at Lauren.Radano@SDCMS.org. The San Diego County Medical Society Foundation is a 501(c)3 organization (Tax ID # 95-2568714). Please visit SDCMSF.org for more information. Telephone: (858) 565-8888 or Fax: (858) 569-1334

SDCMSF was formed as a separate 501(c)3 in 2004 by the San Diego County Medical Society.

S AN D I E G O P HY S I CI A N. or g june 2011

Professional Services Nova Communications

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Sexuality Clinic of San Diego Cognitive/behavioral/psychodynamic therapy allows for understanding and treatment of sexual dysfunction, sexual addiction, and mental health problems. Relationships with others kindle thoughts in our minds about one’s self. The dramas are powerful and maintain their status at various levels of one’s psyche resulting in sexual and psychological turmoil. The therapeutic relationship with Dr. Silbert rn,cns,phd,faacs, promotes healing by trusting expression and freedom of the authentic self.

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TriVant Custom Portfolio Group, LLC TriVant provides institutional-level wealth management to investors with assets $200,000 and above. Looking for better portfolio management? We can help. Contact Dan Laimon in San Diego for your complimentary portfolio analysis.

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Looking for a cost-effective way to reach 8,500 physicians each month? Place your message here in the Professional Services page of San Diego Physician magazine. Rates starting at $250 for a six time contract. Contact: Dari Pebdani 858.231.1231 or DPebdani@sdcms.org

Your Contact Info Here june 2011 SAN DIEGO P HY SICIA N. o rg

classifieds PRACTICE ANNOUNCEMENTS ZAVARO CARDIOVASCULAR INSTITUTE IS MOVING MAY 1, 2011!:Our new address is: 300 S. Pierce St., Ste. 102, El Cajon, CA 92020-4124. Phone: (619) 668-4700. Fax: (619) 668-0049. [924] PHYSICIAN POSITIONS AVAILABLE PHYSICIAN WANTED: ENT practice looking for board-certified/eligible otolaryngologist to join office and quickly achieve ownership. Located in central San Diego County. Full office with typical ENT equipment, including endoscopy. Position to befilled by Sept 2011. Terms available. Email KLewis@SDCMS.org. [936] PHYSICIAN RESEARCH (206507): Seeking a research physician to work with the DoD’s Infectious Disease Clinical Research Program (IDCRP) at the Naval Medical Center in San Diego, CA. IDCRP is a collaborative program among the Uniformed Services University (USU), NIH-NIAID, the U.S. Military, and the Henry M. Jackson Foundation for the Advancement of Military Medicine (HJF). Applicant will be responsible development, direction, and execution of clinical research protocols related to infectious diseases including HIV/sexually transmitted infections, respiratory infections, travel/deployment-related infections, trauma infections, skin and soft tissue infections, and other infectious disease threats to the military population. Must have thorough knowledge of clinical medicine and knowledge of research tasks; knowledge of medical science and development of clinical research programs; experience in design of clinical research trials; excellent communication, interpersonal, and presentation skills. Must have an MD or DO degree and ID Fellowship training, plus two years each of clinical research and ID specialty patient care. Must have licensure to practice medicine within the continental United States; Board certified or board eligible for certification in the specialty associated with the clinical research program. Please apply online at www.hjf.org/careers/search.html Job No: 206507. HJF offers a competitive salary and generous benefits package. AA/EEO [935] PSYCHIATRIST, WEEKEND, AND PER DIEM: Palomar Pomerado Health is seeking board-eligible / board-certified psychiatrists to take weekend call or per diem weekday work at Palomar Medical Center and Pomerado Hospital. Weekend duties include pager call from home, rounding at both inpatient units, and performing consultation to the medical surgical floors. $3,000 / weekend. Contact Jason Keri MD, at (619) 299-4374. [934] FAMILY PRACTICE PHYSICIAN: Family practice clinic located south of San Diego is seeking a family practice physician. This is a fully renovated, familyfocused office with cutting-edge equipment and close access to specialists and additional services (MRI, CT, X-ray, pharmacy …). The ideal physician would be one who wants to serve the low- and middle-income patient population and provide personalized, timely care that meets the standards of excellence set by the practice’s current physicians. Four days / nine hours a day, Monday–Thursday. Twenty-four-month partnership track. No call. BC/BE Spanish speaker strongly preferred. Contact Nick Glover at (503) 443-6008, ext. 131, or email nickg@uhcsolutions.com. [932] SAN DIEGO, NORTH COUNTY: Our busy urgent care is in need of locum tenens family practice physicians for evenings and weekends. Hours are 5–9 pm, Monday through Friday, 9am–5pm on Saturdays, and 10am–4pm on Sundays. Malpractice coverage is provided. Please send your CV to judy@cassidymg. com or call (760) 630-5487 for additional informa-

tion. You may also fax your CV to (760) 630-2558, attention Judy. [929] FAMILY MEDICINE: SHARP Rees-Stealy Medical Group, a 400+ physician multi-specialty group in San Diego, is seeking full-time BC/BE family medicine physicians to join our staff. We offer a first-year competitive compensation guarantee and excellent benefits package. Please send CV to SRSMG, Physician Services, 2001 Fourth Avenue, San Diego, CA 92101. Fax: (619) 233-4730. Email: lori.miller@sharp.com. [928] FULL-TIME OPENING FOR A MEDICAL LEADER TO JOIN OUR EMPLOYEE HEALTH CENTER LOCATED IN SAN DIEGO: As part of Walgreen’s Health and Wellness division, Take Care Employer Solutions manages worksite-based health and wellness services. The company combines best practices in healthcare and the expertise and personal care of our trusted community of providers to deliver access to high-quality, affordable, and convenient healthcare to all individuals. We operate onsite employee health centers, pharmacies, and fitness centers for many of the country’s largest corporations and federal agencies. We currently have a full-time opening for a medical leader to join our employee health center located in San Diego. The medical leader is responsible for the medical leadership, clinical oversight, and patient care for a specific health center. Please visit takecarejobs.com and enter the search term “San Diego” for further information and to apply. [927] FAMILY PRACTICE PHYSICIANS NEEDED: Fulltime and part-time. Days, nights, weekends available. Fax CV to La Costa Urgent Care and Family Practice at (760) 603-7719. [925] SEEKING A MEDICAL DIRECTOR/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 medical director/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) 445-1188, ext. 291 or HR fax at (619) 445-7976. [918] CONTRACT PHYSICIAN: Provides medical leadership, oversight, and management of human clinical trials while ensuring the integrity of the studies and the safety and wellbeing of human subjects. Performs duties in accordance with company’s values, policies, and procedures. For further details, visit www.profilinstitute.com and click on “Current Job Opportunities.” [917] SATURDAY /PER DIEM PHYSICIANS: Independent diagnostic imaging facility seeks physicians to monitor patient examinations requiring contrast. Various Saturday shifts available on an ongoing basis, scheduled 8am–5pm. Please contact Heidi at (858) 6586577 for more information. [915] PHYSICIANS NEEDED: Family medicine, pediatrics, and OB/GYN. Vista Community Clinic, a private nonprofit outpatient clinic serving the communities of North San Diego County, has opening for part-time, 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. Visit our website at www.vistacommunityclinic.org. EOE/MF/D/V [912]

PHYSICIAN: Multiple positions available at our family practice clinics in Escondido and Temecula. Seeking pediatricians, family practice, and internal medicine physicians. 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 certification. Please send CVs to Dr. Jim Schultz via email at jims@nhcare.org or fax to (760) 7964021 “Attn: Physician.” [907] PEDIATRICIAN OR PEDIATRIC NURSE PRACTITIONER: Part-time position (four days per week) provides comprehensive medical services for pediatric patients. Candidates must have a current California medical or NP 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: Pediatrician — Peds.” [909] 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) 504-5830 or at venk@gpeds.sdcoxmail.com. Salary $ 102–108,000 annually (equal to $130–135,000 fulltime). [778] 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] PRACTICE FOR SALE INTERNAL MEDICINE PRACTICE FOR SALE: Beautiful beach weather, established 27 years with excellent reputation. Two exam rooms. Free-standing building. Main street corner location. Great visibility. Office shared with another physician. Patient parking. 2010 gross: $483K. Asking $245K. 100% financing available. Please contact ProMed at (888) 277-6633 or at info@promed-financial.com, or visit www.promed-financial.com. [906] CLINICAL TRIALS DO YOUR PATIENTS NEED TO LOSE WEIGHT AND REDUCE THEIR RISK FACTORS?:If so, please refer them to UCSD’s Healthy Road to a Healthy Heart study. Patients are eligible if they are/have: BMI between 30 and 45; 25–70 years old; at least one cardiovascular risk factor (HTN, stabilized type 2 diabetes, metabolic syndrome, smoker); English or Spanish speaking; willing to attend health coach and measurement sessions at a participating doctor’s office; a stable phone; not pregnant or plan to be during the two-year study period. For more information, call (858) 534-9333 or 1 (866) 667-7223. [919]

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

S AN D I E G O P HY S I CI A N. or g june 2011

OFFICE SPACE / REAL ESTATE 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. [938] 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 IN EASTLAKE AREA: Currently occupied by owner, family physician. Great location close to Sharp Chula Vista Hospital. Beautiful new building with ample parking. Procedure and exam room available. If interested please call Norma (office manager) at (619) 946-4073. [931] 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] ENCINITAS: Beautiful, completely renovated office available for sublease two days per week. Four exam rooms, generous waiting area, and bathroom. Perfect for specialist, lots of primary care physicians on campus. Located at the largest outpatient health center in coastal North County. Surgery center, pharmacy, lab, and radiology onsite with ample free parking. Go to ochiphotos.com/office for photos and floor plan. Contact jwochi@yahoo.com or (858) 792-4800 for more information. [926] SCRIPPS/XIMED BUILDING, LA JOLLA, OFFICE SPACE TO SUBLEASE: Occupied by vascular and general surgeons. One room office available, with one or two exam rooms, to a physician or team. Located on the campus of Scripps Memorial Hospital, Ximed Building is the office space location of choice for anyone doing surgeries at the hospital or for anyone seeking a presence in the La Jolla area. Reception and staff available if needed. Full ultrasound lab on site in office for anyone interested in this service. For more information, call Irene at (619) 840-2400 or at (858) 452-0306. [921] NORTH COAST HEALTH CENTER, ENCINITAS, OFFICE SPACE TO SUBLEASE: Newly remodeled and beautiful office space available at the 477 Building. Occupied by seasoned vascular and general surgeons. One office and two exam room available. Great window views and location with all new equipment and furniture. Full ultrasound lab and tech on site for extra convenience. New hardwood floors and exam tables. Staff available for an add-in if needed. Plenty of free parking. For more information, call Irene at (619) 840-2400 or at (858)-452-0306. [922] 1,100 SQUARE FOOT SUITE FOR RENT IN CHULA VISTA MEDICAL CENTER COURT CHULA VISTA, CA 91911: +/- 1,100 sq. ft. medical office. Full-service pharmacy conveniently located in adjacent suite. Directly across the street from Sharp Chula Vista Medical Center. Ancillary services such as laboratory and radiology, physical therapy available within walking distance. Close to public transportation. Easy access to I-805 via L Street. Great floor plan with three exam rooms, waiting room, two restrooms, kitchen, file area, reception, and doctor’s office. Contact Tracy Clarke at (858) 458-3339 or at (619) 726-7335. [920]

LUXURIOUS / BEAUTIFULLY DECORATED DOCTOR’S OFFICE NEXT TO SHARP HOSPITAL FOR SUB-LEASE OR FULL LEASE: The office is conveniently located just at the opening of Highway 163 and Genesee Avenue. Lease price is very reasonable and appropriate for ENT, plastic surgeons, OB/GYN, psychologists, research laboratories, etc. Please contact Mia at (858) 279-8111 or at (619) 823-8111. Thank you. [836] SUBLET ~ 2 EXAM ROOMS AND PHYSICIAN OFFICE: Beautiful new spacious medical office suite located at 501 Washington St., San Diego 92130, contiguous to Vibra Hospital and across from Scripps Mercy Medical Campus in a Class A office building. Shared waiting room, break room, receptionist area included. Currently office suite is occupied by seasoned primary and specialty physicians. Ample parking, freeway access to interstates 5/163/8, ancillary services are in close proximity for patient convenience. Please contact Ms. Betterton or Dr. Carla Fox at (619) 299-2570. [914] OFFICE SPACE TO SHARE FOR RENT OR LEASE: Adjacent to Tri-City Medical Center and North Coast Surgery Center. Provide large consultation room, two exam rooms, fax, copier, wireless. FREE parking. Conditions are negotiable. Full or part time. Easy access to 78 or I-5. If interested, please email jean@ tricitycts.com or call (760) 726-2500. [911] 3998 VISTA WAY IN OCEANSIDE: Two medical office spaces approximately 2,000ft2 available for lease. Close proximity to Tri-City Hospital with pedestrian walkway connected to parking lot of hospital, and ground floor access. Lease price: $2.20 +NNN. Tenant improvement allowance. For further information, please contact Lucia Shamshoian at (760) 931-1134 or at shamshoian@coveycommercial.com. [834] OFFICE SPACE IN HILLCREST: Office space available in Hillcrest at the Mercy Medical Building. Located directly across from Scripps Mercy Hospital. Excellent staff, state-of-the-art office and equipment. Please send letter of interest to KLewis@ sdcms.org. [810] BUILD TO SUIT: Up to 1,900ft2 office space on University Avenue in vibrant La Mesa/East San Diego, across from the Joan Kroc Center. Next door to busy pediatrics practice, ideal for medical, dental, optometry, lab, radiology, or ancillary services. Comes with 12 assigned, gated parking spaces, dual restrooms, server room, lighted tower sign. Build-out allowance to $20,000 for 4–5 year lease. $3,700 per month gross (no extras), negotiable. Contact venk@cox.net or (619) 504-5830. [835] 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) 299-5000 or at laura@sdhandcenter.com. [874] 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] 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, com-

mon waiting room, and abundant parking. Contact Christine Saroian, MD, at (619) 682-6912. [862] 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] NONPHYSICIAN POSITIONS AVAILABLE FULL OR PART-TIME NURSE PRACTITIONER OR PHYSICIAN ASSISTANT: Busy family practice with stronggeriatric 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. [939] FULL-TIME OFFICE MANAGER/BILLER: Dr. Marc Kramer has a full-time office manager/biller position open. The ideal candidate would need to be a strong leader with great communication skills and a strong background in billing. Practice location is in La Jolla. Please fax resumes to (858) 457-0049. [933] SAN DIEGO, NORTH COUNTY: Our busy urgent care is in need of per diem physician assistants for evenings and weekends. Hours are 5–9 pm, Monday through Friday, 9am–5pm on Saturdays, and 10am– 4pm on Sundays. Malpractice coverage is provided. DEA certificate is necessary. Please send your CV to judy@cassidymg.com or call (760) 630-5487 for additional information. You may also fax your CV to (760) 630-2558, attention Judy. [930] FULL-TIME TEMP ADULT NURSE PRACTITIONER NEEDED: Full-time temporary NP position available for coverage of current office NP maternity leave in May for 10 weeks. Busy internal medicine practice located adjacent to Scripps Mercy Hospital. Clinical experience, furnishing number and EMR experience required. Spanish speaking a plus but not required. Based on performance, scheduling needs and ability to build a patient base, there is the potential for continued work upon the return of the current office NP. Contact Kyle Lewis at KLewis@SDCMS.org. [916] NURSE PRACTITIONER: With physician supervision, provides medical oversight and management of human clinical trials while ensuring the integrity of the studies and the safety and wellbeing of human subjects. Performs duties in accordance with company’s values, policies, and procedures. For further details, visit www.profilinstitute.com and click on “Current Job Opportunities.” [913] FAMILY NURSE PRACTITIONER OR PHYSICIAN ASSISTANt: Two positions available. Full-time 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. [908] 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]

june 2011 SAN DIEGO P HY SICIA N. o rg

humor/opinion

Medicare and Gettysburg By Melvyn L. Sterling, MD, MACP, FA AHPM Two score and not yet seven years ago, our Congress brought forth on this continent a new program, conceived in compassion and fiscal responsibility, and dedicated to the proposition that all our elderly should be cared for without intrusion by government. Now we are engaged in a great civil war, testing whether that program, or any program so conceived and so dedicated, can long endure. We are met on a great battlefield of that war. We have come to mourn the impending death of that program, as the government that created that program intrudes, controls, and destroys that program. It is altogether fitting and proper that we should do this. But, in a larger sense, we cannot abdicate, we cannot allow the care of our patients to be so poorly served by an unknowing government. The dedicated physicians, living and dead, who struggled these many years to serve our patients deserve better, as do the legions of patients whose lives have been saved, pain relieved, depression lifted. The world will little note nor long remember what we say here, but it

S AN D I E G O P HY S I CI A N. or g june 2011

can never forget what they did here. It is for us the practicing, rather, to be dedicated here to the unfinished work which they who fought since 1965 have thus far so nobly advanced. It is for us to be dedicated to the great task looming before us — that from our colleagues, our mentors, and our patients, we take increased devotion to that cause for which they gave their best efforts in the service of our patients — that we here highly resolve that those years of dedication shall not be in vain — that healthcare by the doctors, for the people, shall not be destroyed by our government. That this nation’s healthcare, under God, shall have a new birth of freedom — and that healthcare of the people, for the people, unobstructed by government, shall not perish from the earth. About the Author: Dr. Sterling is a Master of the American College of Physicians and a fellow of the American Academy of Hospice and Palliative Medicine.

We Celebrate Excellence – Calvin Lee, MD CAP Member, Internationally Renowned Violinist, and Dedicated Philanthropist

800-252-7706 www.cap-mpt.com/physicians San Diego orange LoS angeLeS PaLo aLTo SacramenTo

For over 30 years, the Cooperative of American Physicians, Inc. (CAP) has provided California’s finest physicians, like general surgeon Calvin Lee, MD, with superior medical professional liability protection through its Mutual Protection Trust (MPT). Physician owned and physician governed, CAP rewards excellence with remarkably low rates on medical professional liability coverage – up to 40 percent less than our competitors. CAP members also enjoy a number of other valuable benefits, including comprehensive risk management programs, best-in-class legal defense, and a 24-hour CAP Cares physician hotline. And MPT is the nation’s only physician-owned medical professional liability provider rated A+ (Superior) by A.M. Best. We invite you to join the more than 11,000 preferred California physicians already enjoying the benefits of CAP membership.

Superior Physicians. Superior Protection. may 2011 SAN DIEGO P HY SICIA N. o rg

$5.95 | www.SANDIEGOPHYSICIAN.org San diego County Medical Society 5575 RUFFIN ROAD, SUITE 250 SAN DIEGO, CA 92123 [ RETURN SERVICE REQUESTED ]

PRSRT STD U.S. POSTAGE PAID DENVER, CO PERMIT NO. 5377

Why choose between national resources and local clout? In California, The Doctors Company protects its members with both. With nearly 55,000 member physicians nationwide, we constantly monitor emerging trends and quickly respond with innovative solutions, like incorporating coverage for privacy breach and Medicare reviews into our core medical liability coverage. Our over 20,000 California members also benefit from significant local clout provided by long-standing relationships with the state’s leading attorneys and expert witnesses, plus litigation training tailored to California’s legal environment. This uncompromising approach, combined with our Tribute® Plan that has already earmarked over $106 million to California physicians, has made us the leading national insurer of physician and surgeon medical liability. 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 us at (800) 852-8872 or visit us at www.thedoctors.com. Richard E. Anderson, MD, FACP Chairman and CEO, The Doctors Company

Endorsed by

S AN D I E G O P HY S I CI A N. or g august june 2011 2010

We relentlessly defend, protect, and reward the practice of good medicine.