official publication of the san diego county medical society November 2011
From Lab TO Exam Room Life Sciences in San Diego With a Feature by Joe Panetta, President and CEO of BIOCOM, the Largest Regional Life Science Association in the World Page 18
“Physicians United For A Healthy San Diego”
“A” (ExcEllEnt) RAting
renewal rate
in a row of a.M. Best
of last
95
28
years
totAl DiviDEnDs DEclARED
$425M
or very satisfied
total years deClared dividend
Customers satisfied
32 34
93%
To make a calculated decision on medical liability insurance, you need to see how the numbers stack up—and there’s nothing average about NORCAL Mutual’s recent numbers above. We could go on: NORCAL Mutual won 86% of its trials in 2010, compared to an industry average of about 80%; and we paid settlements or jury awards on only 12% of the claims we closed, compared to an industry average of about 30%.* Bottom line? You can count on us. *Source: Physician Insurers Association of America Claim Trend Analysis: 2010 Edition.
strenghten your Practice at norcalMutual.coM Proud to support the San Diego County Medical Society.
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S A N D I E G O P HY S I CI A N .or g O c tob e r 2011
Our passion protects your practice
Octo ber 2011 SAN DIEGO P HY SIC I A N. o rg
1
thismonth Volume 98, Number 11
features LIFE SCIENCES
18 Easing Suffering, Saving Lives, Allowing Physicians to Provide Better Treatment by Joe Panetta 19 Late-stage Products in the San Diego
Life Sciences Pipeline by BIOCOM
22 Products Credited to Southern California’s Innovative Life Science Cluster by BIOCOM
24 Investing in Job Creation and Life-saving
Innovation by U.S. Rep. Brian Bilbray
26 OR Room: 007 — Developing Surgeries
With Fewer Incisions
28 Searching for New Ways to Diagnose
and Treat Brain Tumors
30 Principled Pioneering: Cardiologist Puts
Heart and Mind Into Collaborating for Benefit of Patients Worldwide
Managing Editor Kyle Lewis Editorial Board Van L. Cheng, MD, Adam F. Dorin, MD, Kimberly M. Lovett, MD, Theodore M. Mazer, MD, Robert E. Peters, 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
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: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) 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
other voting members Communications Chair Theodore M. Mazer, MD (CMA Vice Speaker) Young Physician Director Van L. Cheng, MD
4 Briefly Noted SDCMS and CMA Seminars, Webinars, and Events Cold and Flu Season Toolkit And More …
Resident Physician Director Steve H. Koh, MD Retired Physician Director Rosemarie M. Johnson, MD Medical Student Director Beth P. Griffiths
OTHER NONVOTING MEMBERS
8 Your Monthly Benefits Check-up
Young Physician Alternate Director Renjit A. Sundharadas, MD
Coding Question HIPAA 5010 Transition and More …
Resident Physician Alternate Director Christina Pagano, MD Retired Physician Alternate Director Mitsuo Tomita, MD CMA President-elect James T. Hay, MD
12 “This is a dumb question, but …”
by Jerry L. Bauer
16
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 CMA SSGPF Delegates James W. Ochi, MD, Ritvik Prakash Mehta, MD CMA SSGPF Alternate Delegates Dan I. Giurgiu MD, Ashish K. Wadhwa, MD
16 Yelp Yourself: Can One Bad Comment / Review Ruin Your Practice?
by The Doctors Company
34 Physician Marketplace
Classifieds
36 2 SAN DIEGO PHYSICIAN .org Novem ber 2011
36 Piano Lessons by Kevin P. Glynn, MD
Opinions expressed by authors are their own and not necessarily those of San Diego Physician or SDCMS. San Diego Physician reserves the right to edit all contributions for clarity and length as well as to reject any material submitted. Not responsible for unsolicited manuscripts. Advertising rates and information sent upon request. Acceptance of advertising in San Diego Physician in no way constitutes approval or endorsement by SDCMS of products or services advertised. San Diego Physician and SDCMS reserve the right to reject any advertising. Address all editorial communications to Editor@SDCMS.org. All advertising inquiries can be sent to DPebdani@SDCMS.org. San Diego Physician is published monthly on the first of the month. Subscription rates are $35.00 per year. For subscriptions, email Editor@SDCMS.org. [San Diego County Medical Society (SDCMS) Printed in the U.S.A.]
“They understand busy—make that super busy—people. No matter where we are, they make things easy.” DAVID JABLONS, M.D. (LEFT), CHIEF OF GENERAL THORACIC SURGERY PIERRE THEODORE, M.D. (RIGHT), THORACIC SURGEON & ASSISTANT PROFESSOR OF SURGERY UCSF MEDICAL CENTER
p r i vat e b a n k i n g
•
w e a lt h m a n ag e m e n t
•
b ro k e r ag e
•
trust
1-800-221-9333 • www.firstrepublic.com • new york stock exchange symbol: frc • member fdic brokerage services provided through first republic securities co., llc. member finra / sipc
3 3
sept August ember 2011 SAN DIEGO P HY SIC SICII A A N. N. o o rg rg 3 Novem b er 2011 SAN DIEGO PHYSICIAN.org Octo ber 2011 SAN DIEGO P HY
brieflynoted featured member
calendar SDCMS SEMINARS & WEBINARS SDCMS.org/event
Workplace Harmony JAN 18 • 11:30am–1:00pm Legislative Advocacy Training (workshop) JAN 21 • 8:00am–12:00pm EHR and Documentation Risk Issues JAN 25 • 6:30pm–7:30pm EHR and Documentation Risk Issues JAN 26 • 11:30am–12:30pm Certified Medical Coder Course JAN 27, FEB 3, 10, 17, 24 • 8:00am–4:00pm Are Your Contracts Healthy? FEB 1 • 11:30am–1:00pm HIPAA 5010 FEB 9 • 11:30am–1:00pm Tax Time FEB 16 • 11:30am–1:00pm
CMA WEBINARS CMAnet.org/calendar
Medicare 2012: Final Rules DEC 7 • 12:15–1:15pm Individualized Treatment Plans for Patients With Diabetes DEC 14 • 12:00pm–1:00pm
COMMUNITY HEALTHCARE CALENDAR 5th Annual UC San Diego Hands-On Endoluminal, Single Site, and NOTES Surgery Symposium DEC 1–3 • Hard Rock Hotel San Diego • cme.ucsd.edu/notes/ index.html
Doris Howell, MD
9th Annual Natural Supplements: An Evidencebased Update JAN 19–22 • Hilton San Diego Bayfront
Doris Howell, MD, retired SDCMS-CMA member (first joining in 1993) and pioneer of the modern hospice movement, was honored for her legacy on October 14 at the San Diego Hospice and The Institute for Palliative Medicine’s inaugural “Transforming Healthcare” awards program. Dr. Howell, founding member of San Diego Hospice and The Institute for Palliative Medicine, received the first Kaye Woltman Legacy award in recognition of her transformational contributions to the field of hospice care and palliative medicine. Dr. Howell was first introduced to the hospice concept as a young oncologist in 1968. She recognized its potential and embraced this radical departure from the way medicine had previously treating dying people and their families. Congratulations, Dr. Howell!
Brain Tumors: 2nd Annual Collaborative Care Conference JAN 21 • Catamaran Resort Hotel, San Diego • cme.ucsd.edu/ braintumors Timmy Global Health Mission Trip to Ecuador MAR 10–17 • Clinics seeing approximately 40 patients per provider per day. • www. timmyglobalhealth.org Topics and Advances in Internal Medicine MAR 12–16 • Catamaran Resort Hotel, San Diego • cme.ucsd.edu/ internalmed Prescription Opioid Misuse Academy: The Dark Side of Prescription Opioids MAR 15 • Catamaran Resort Hotel, San Diego • www.acmt.net Topics and Advances in Pulmonary and Critical Care Medicine MAR 17–18 • Catamaran Resort Hotel, San Diego • cme.ucsd.edu/ internalmed California Orthopaedic Association Annual Meeting APR 19–22 • Park Hyatt Resort in Carlsbad • www.coa.org/coaannual-meeting.html Sharon’s Ride Run Walk for Epilepsy 2012! APR 25 • De Anza Cove, Mission Bay Park • $25 Individuals/$50 Family/Phil’s BBQ Lunch included • 7:30am-1:00pm • sharonsride2012.kintera.org 13th Annual Science and Clinical Application of Integrative Holistic Medicine NOV 2 • Hilton San Diego Resort
2011 Military Healthcare Convention and Conference San Diego DEC 5–8 • www.militaryhealth careconvention.com
4 SAN DIEGO PHYSICIAN.org Novem ber 2011
legislator birthdays
One way to let your legislators know that you’re paying attention and that you vote is by wishing them a happy birthday! BIRTHDAY: NOV. 24 State Assemblyman Kevin Jeffries (District 66) E: (via website) arc.asm.ca.gov/member/66 E: assemblymember.jeffries@assembly. ca.gov Sacramento Office: California State Assembly, PO Box 942849, Sacramento, CA 94249-0066 T: (916) 319-2066 • F: (916) 319-2166 Murrieta Office: 41391 Kalmia St., Ste. 220, Murrieta, CA 92562 T: (951) 894-1232 • F: (951) 894-5053
BIRTHDAY: DEC. 7 U.S. Representative Duncan D. Hunter (District 52) E: (via website) hunter.house.gov Washington, DC Office: T: (202) 225-5672 • F: (202) 225-0235 El Cajon Office: 1870 Cordell Court, Ste. 206, El Cajon, CA 92020 T: (619) 448-5201 • F: (619) 449-2251
BIRTHDAY: DEC. 31 State Assemblyman Nathan Fletcher (District 75) E: (via website) arc.asm.ca.gov/member/75 E: assemblymember.fletcher@assembly. ca.gov Sacramento Office: California State Capitol, Rm. 2111, Sacramento, CA 95814 T: (916) 319-2075 • F: (916) 319-2175 San Diego Office: 9909 Mira Mesa Blvd., Ste. 130, San Diego, CA 92131 T: (858) 689-6290 • F: (858) 689-6296
you take care of the san diego communit y ’s health. we take care of san diego’s
healthcare communit y.
get in touch
3 income Tax Planning 3 Wealth Management
Your SDCMS and SDCMSF Support Teams Are Here to Help!
3 employee Benefit Plans 3 Profitability Reviews
SDCMS Contact Information
5575 Ruffin Road, Suite 250, San Diego, CA 92123 T (858) 565-8888 F (858) 569-1334 E SDCMS@SDCMS.org W SDCMS.org • SanDiegoPhysician.org
3 outsourced Professional services (CFo, Controller) 3 organizational and Compensation structure
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
3 succession Planning
Director of Membership DevelopmenT Janet Lockett at (858) 300-2778 or Janet.Lockett@SDCMS.org
3 Practice Valuations 3 internal Control Review and Risk Assessment
Director of Membership Operations and Physician Advocate Marisol Gonzalez at (858) 300-2783 or MGonzalez@SDCMS.org Director of Engagement Jennipher Ohmstede at (858) 300-2781 or JOhmstede@SDCMS.org
akt
Director of Communications and Marketing Kyle Lewis at (858) 300-2784 or KLewis@SDCMS.org administrative assistant Betty Matthews at (858) 565-8888 or Betty.Matthews@SDCMS.org
A KT LLP, CPAs and Business Consu LTAnTs
LETTERS TO THE EDITOR Editor@SDCMS.org GENERAL SUGGESTIONS SuggestionBox@SDCMS.org
SDCMSF Contact Information
5575 Ruffin Road, Suite 250, San Diego, CA 92123 T (858) 300-2777 F (858) 560-0179 (general) W SDCMSF.org EXECUTIVE DIRECTOR Barbara Mandel at (858) 300-2780 or Barbara.Mandel@SDCMS.org project access PROGRAM DIRECTOR Tanya Rovira at (858) 565-8161 or Tanya.Rovira@SDCMS.org RESOURCE DEVELOPMENT DIRECTOR Lauren Banfe at (858) 565-7930 or Lauren.Banfe@SDCMS.org Patient Care Manager Rebecca Valenzuela at (858) 300-2785 or Rebecca.Valenzuela@SDCMS.org Patient Care Manager Elizabeth Terrazas at (858) 565-8156 or Elizabeth.Terrazas@SDCMS.org
IT PROJECT MANAGER Rob Yeates at (858) 300-2791 or Rob.Yeates@SDCMS.org
CARL SBAD
ESCONDIDO
760-431-8440
S A N DIEGO
W W W.AKTCPA.COM ron mitchell, cpa director of health services
RMITCHELL@AKTCPA.COM
Give Us 5 Minutes and We’ll Give You a Benefits Check-up!
Call SDCMS at (858) 565-8888 to schedule a time Today!
Novem b er 2011 SAN DIEGO PHYSICIAN.org 5
brieflynoted Public health
CMA Foundation’s 2012 AWARE Provider Toolkit for the Cold and Flu Season by Carol A. Lee, Esq., President and CEO, CMA Foundation Healthcare providers know that antibiotics cure bacterial infections, not viral infections such as colds or flu, most coughs and acute bronchitis, sore throats not caused by strep, and runny noses. But some healthcare providers are still overprescribing antibiotics. We must continue educating the healthcare community, patients, and the public about when antibiotics work and when they do not. To aid in these efforts, the CMA Foundation’s Alliance Working for Antibiotic Resistance Education (AWARE) project has developed the 2012 AWARE Provider Toolkit for the cold and flu season. AWARE supports physicians’ efforts to promote appropriate antibiotic use, decrease the incidence of antibiotic resistance, and meet the HEDIS measures for the avoidance of antibiotic treatment in adults with acute bronchitis, as well as appropriate testing for children with pharyngitis. The 2012 AWARE Provider Toolkit contains educational resources for providers, as well as resources to educate patients: • 2012 Acute Respiratory Tract
6 SAN DIEGO PHYSICIAN.org Novem ber 2011
Infection Guideline Summary (Adult and Pediatric): A synopsis of appropriate diagnosis and antibiotic treatment of the most common respiratory infections. • Prescription Pad (available in English and Spanish): A handout offering over-thecounter treatments that can help alleviate symptoms of colds. • CDC Flyers: »»Careful Antibiotic Use: Cough Illness in the Well-appearing Child; Acute Cough Illness (Acute Bronchitis) (English only). »»Careful Antibiotic Use: Pharyngitis in Children (English only). • Patient Education Materials (available in English and Spanish): »»Health Tips: A handout providing tips to stay healthy, promoting proper antibiotic use, and encouraging frequent hand washing. »»Bronchitis and Other Cough Illnesses: Adult and pediatric handouts containing useful homecare options and prevention tips. »»I Choose … to Prevent Influenza! Adult and pediatric handouts containing information on influenza, how to prevent influenza, and what to do should one get sick. »»Feel Better Soon … Without Antibiotics! Adult and pediatric brochures that identify common symptoms and remedies that can provide symptomatic relief. • Medical Office Posters (available in English and Spanish): »»Feel Better Soon … Without Antibiotics! Adult and pediatric posters informing patients that viral infections cannot be treated with antibiotics. For more information about AWARE and additional materials regarding appropriate antibiotic use, please call the CMA Foundation at (916) 779-6620, email aware@thecmafoundation.org, or visit www.aware.md for additional clinical resources and patient education materials.
overcrowding
San Diego Hospital Emergency Department Overcrowding Summit On Oct. 27, the Sixth Annual San Diego Hospital Emergency Department Overcrowding Summit took place. The summit, which is hosted by SDCMS’ Emergency Medicine Oversight Commission, is chaired by Roneet Lev, MD, emergency medicine physician and SDCMS-CMA member since 1996. More than 200 emergency department physicians and nurses, hospital CEOs, EMS providers, and hospital personnel involved in throughput came together to discuss best practices that address ED overcrowding. Physician panelists discussed common obstacles that delay emergency patient admission as well as problem-solving ideas utilized at area hospital emergency departments to reduce ED door-todischarge/admission times. In addition to the panels, Bruce Haynes, MD, medical director for the County’s Emergency Medicine Services and SDCMS-CMA member since 2006, talked about our stroke and STEMI systems, current bypass trends, and lessons learned from the recent electricity blackout. Eric McDonald, MD, the County’s deputy public health officer and SDCMS-CMA member since 2010, spoke on the trends and impacts pertussis, listeria, STDs, falls, and influenza have had on our emergency departments over the years. The afternoon focused on emergency department redesign strategies and how to plan for the future of San Diego. For additional information about SDCMS’ Emergency Medicine Oversight Commission, contact James Beaubeaux at (858) 300-2788 or at James. Beaubeaux@SDCMS.org.
FAST. COMFORTABLE. ACCURATE. THAT’S HOW CANCER TREATMENT SHOULD BE. At San Diego Radiosurgery, we offer treatment using the Novalis Tx platform for image-guided radiosurgery. Novalis Tx incorporates advanced imaging, treatment planning, and treatment delivery technologies from Varian Medical Systems and BrainLAB, enabling fast, highly precise, non-invasive radiosurgery treatments for cancers and other conditions in the brain, head, neck and body. Novalis Tx is optimized to deliver radiosurgery in the shortest possible time, averaging 15 minutes, preventing errors due to minor movements during long treatments. Call or visit our website for more information. Palomar Medical Center Department of Radiation Oncology 555 East Valley Parkway | Escondido, CA 92025 760-739-3835 / SDRadiosurgery.com
San Diego Radiosurgery is a service of Palomar Medical Center.
Novem b er 2011 SAN DIEGO PHYSICIAN.org 7
Your Monthly Benefits
check-up Put Your SDCMS-CMA Membership to Work!
This Month:
✓✓ Coding Question ✓✓ HIPAA 5010 Transition ✓✓ Upcoming Seminars & Webinars ✓✓ Q&A With Your Physician Advocate ✓✓ Q&A With Your Office Manager Advocate ✓✓ Deadlines & Reminders
8 SAN DIEGO PHYSICIAN.org Novem ber 2011
THIS MONTH’S CODING QUESTION By Kimberly Sherman, CPC, CHMB (www.cahealth.com)
HIPAA 5010 TRANSITION
Your
Mon l y Benetfh s check-it up
Is Your Practice Ready? What Questions Should You Be Asking?
Question: Some physicians are asking for 58555 and 58120 when a hysteroscopy and D&C are performed as part of the same surgery. Is this allowed? Answer: 58555 is the CPT code for a diagnostic laparoscopy, and 58120 is a nonobstetric dilation and curettage. A typical diagnosis for these procedures would be menorrhagia, 626.2. While CCI edits allow these two procedures to be billed separately, they are bundled into the 58558 procedure and should not be unbundled. 58558 is “Hysteroscopy, surgical; with sampling (biopsy) of endometrium and/or polypectomy, with or without D&C.” Since CPT provides a single code that is a combination of the other procedures, the single code must be used. According to the Supercoder OB-Gyn Coding Alert 2002, “An auditor would likely view billing 58555 and 58120 separately as abuse and an attempt to unbundle the services to maximize revenues. … This could lead to demands for repayment or stiff penalties against your practice.” Please encourage your clients to always avoid unbundling when coding procedures.
UPCOMING SDCMS & CMA SEMINARS/ WEBINARS Don’t Forget: SDCMS members and their staffs attend free of charge all SDCMS and CMA seminars and webinars. See page 4 for a list of our January 2012 seminars and webinars.
Practice Management Vendor Questions (in-house billing): • Will your system allow us to report Health Payer ID number as mandated by PPACA (Patient Protection and Affordable Care Act)? • Will the software generate a 5010 compliant 837 claim or rely on some form of translation? If the latter, will you require a clearinghouse to do the translation? • How will you provide the 5010 update to our software? Will this be a regular download or version update? Do we need to schedule it now? • What version of the software must we be using to obtain this update? If we are on an older version, do we need to complete intermediate updates first? Third-party Billing Vendor Questions (ask your practice management vendor the following also): • Have you completed your testing for 5010? If the answer is NO, ask them to describe when they will have the testing complete. • Did you use a third-party to test your 5010 readiness? If so, ask them to provide you with the name of the company they worked with. • Were the following transactions tested for 5010 readiness: 837 claim forms; 835 RAs-receiving and processing; 270 eligibility and benefits inquiry; 271 eligibility and benefits response; 276 & 277 claim status and response; 278 referral authorization? • Will you provide updates to our underlying software so that we can correctly generate 5010 transactions? For example, we know that 5010 allows us to report 12 diagnosis codes per claim (up from the current amount of 8) while retaining the four code per line item limit. Will your software allow us to maintain a total of 12 ICD codes where appropriate? Additional Resources: • Recorded seminars available for viewing by SDCMS members and staff at SDCMS.org: “The Road to ICD-10” and “Are you Ready for the HIPAA 5010 Changes?” • CMA guide available for download by SDCMS members and staff at SDCMS.org: “Preparing for the New HIPAA 5010 Standards: A Guide for Physicians” • Informative article in the August 2011 issue of San Diego Physician: “Physicians Advised to Begin Preparing for New HIPAA 5010 Standards” • GetReady5010: Get Ready for HIPAA 5010 is an educational effort supported by AMA and other healthcare industry stakeholders to ensure a smooth and timely transition to the 5010 transactions. At www.getready5010.org you will find a number of physician resources, including free webinars on the testing of 5010 transactions. Still have questions? Think SDCMS First! Physicians can contact Marisol Gonzalez at (858) 3002783 or at MGonzalez@SDCMS.org. Office managers can contact your SDCMS office manager advocate at (858) 565-8888 or at SDCMS@SDCMS.org.
Novem b er 2011 SAN DIEGO PHYSICIAN.org 9
r u o Y y h t Mon l
s Benefkit -up
chec
Q&A WITH YOUR OFFICE MANAGER ADVOCATE
Q&A WITH YOUR PHYSICIAN ADVOCATE By Marisol Gonzalez, Your SDCMS Physician Advocate SDCMS member physicians are encouraged to contact Marisol with any practice or membership questions at (858) 300-2783 or at MGonzalez@ SDCMS.org. Question: I’ve always avoided online backups and maintained external hard drives at two or more different physical locations, but now I’m considering using an online backup service in addition to what I’ve been doing. Can you recommend a HIPAA-compliant online storage service? Submitted by a boardcertified psychiatrist. Answer: Whichever service you decide on, you should ask the company to provide written confirmation stating they are encrypting your data on their backup servers, and the encryption should be at least 256 bit Advanced Encryption Standard (AES) or higher. Neither Amazon nor Google will provide this, but websites Dropbox and Carbonite do provide this assurance. Question: How does overtime law work? For example, if I have an employee who clocks out at eight hours and two minutes, do I need to round up? Submitted by a board-certified dermatologist. Answer: This is considered insubstantial or insignificant periods of time — de minimis time — and generally does not need to be counted as overtime hours. There is no set time limit for what will be considered de minimis; however, the time worked must generally be fewer than seven or eight minutes, should not be a regular occurrence, and cannot always benefit the employer, i.e., it must “balance-out” over time.
10 SAN DIEGO PHYSICIAN.org Novem ber 2011
Office managers of SDCMS member physicians are encouraged to reach out to SDCMS’ office manager advocate — THINK SDCMS FIRST! — when you have a question or issue you need help with. Contact SDCMS at (858) 565-8888 or at SDCMS@SDCMS.org Question: What are the top five most important things to be thinking about with regard to HIPAA 5010 preparation for a solo practice with in-house billing? Submitted by the office manager of a solo practice physical medicine and rehabilitation physician. Answer: • Be sure to have sufficient cash-flow reserves for January–June 2012. If payers are overwhelmed by manual claims, you may see significant delays in payment. • Ask your practice management or integrated EHR vendor if they are ready for the changes and if they have completed their testing for 5010. Be sure to obtain their written implementation and testing plan. • Have a complete list of any new code sets you will need to use. IPAs are critical partners, so be sure to ask them questions too. • The most important question to ask your EHR vendor is: Will the software create a HIPAA-compliant transaction? Ask if they use a claim print image or some other type of translation software, or if they rely on a clearinghouse to do this. If the answer is yes, then plan now for problems. • Is your staff trained to collect additional information from patients needed on the claim form? Question: How does HIPAA 5010 affect the transition to ICD-10? Submitted by a board-certified internal medicine physician in a medium-size practice. Answer: HIPAA 5010 supports both the ICD-9 and ICD-10 code set structures. It is not possible to create or transmit electronic claims using ICD-10 codes without transitioning to HIPAA 5010. Please keep in mind that the HIPAA 5010 transition deadline is Jan. 1, 2012, and the ICD-10 deadline is October 2013. Although the ICD-10 deadline isn’t until 2013, practices should begin preparing for the transition now to avoid any reimbursement issues due to incorrect coding.
PRACTICE MANAGEMENT AND MEMBERSHIP DEADLINES & REMINDERS • ONGOING: TDC-insured SDCMS member physicians MUST satisfy their participation requirement ONCE EVERY TWO YEARS in order to continue receiving their TDC medical professional liability insurance premium credit. Contact Janet Lockett at SDCMS at (858) 300-2778 or at Janet.Lockett@ SDCMS.org. • DEC. 31: Reporting year ends for eligible professionals (eRx). • JAN. 1: $100 Three-year Commitment SDCMS-CMA Dues Discount Deadline • JAN. 1: SDCMS-CMA Membership Dues Deadline • JAN. 1: On Jan. 1, 2012, the HIPAA 5010 “implementation guide” standard will go into effect. This affects all of the HIPAA Standard Transactions, including the following pertinent transactions for most medical practices: electronic claims; electronic remittance advices; electronic requests for eligibility and benefit verification and the responses; electronic referral authorizations; and electronic claims status. The last major change was in October 2003, when the HIPAA transactions and code sets rule took effect. The 5010 changes reduce ambiguity in many of the transactions and provide for some very important new codes such as ICD-10. They also eliminate many of the situational codes while implementing requirements such as taxonomy codes on all claims. Medical practices should be preparing now for this change by ensuring your vendors (billing software, billing services, and clearinghouses) are ready and that your software is capable of generating a 5010 transaction. If your practice management systems are not compliant with HIPAA Version 5010 standards by Jan. 1, 2012, you will risk not getting electronic payments from Medicare or private insurers. • FEB. 29: Last day for eligible professionals to register and attest to receive incentive payment for calendar year 2011 (eHR).
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TODAY’S HEALTHCARE ATTORNEY FOR TOMORROW’S HEALTHCARE PROFESSIONAL.
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Call SDCMS at (858) 565-8888 to schedule a time Today!
Novem b er 2011 SAN DIEGO PHYSICIAN.org 11
Patient’s Perspective
“This is a dumb question, but …” by Jerry L. Bauer I don’t know how many times I’ve heard people say, “This is a dumb question, but ….” It has to be in the thousands. Almost everyone has used it once or twice, and most of us have used it often. I’ve heard it from a cashier at Safeway, a mechanic at BMW, a fireman, and more than one doctor or lawyer. The 23-year-old cashier asked it at childbirth classes. An oncologist asked it at the Volvo dealership when the mechanic was trying to explain traction control and when you should turn it on or off. I asked a question like it of my oncologist when I received my diagnosis of esophageal cancer. 12 SAN DIEGO PHYSICIAN.org Novem ber 2011
What we are actually attempting to say is, “You are the expert, and I need to learn what I must do to make these treatments as effective as possible, and deal with the side-effects at the same time.” I’ve been in sales all my life, and I have no idea what’s going to happen when I start putting these chemicals into my body. I have no idea what to expect when I spend 30 days on a table having X-rays shot into my body. I almost vomited hearing about the surgery I would be having and how my “plumbing” would be changed forever. The answers to the question are never
more important than today and all the days ahead for the person who has received the stunning news that “it” is cancer. That “thing” has been hiding inside his/her body and now he/she must face death much sooner than expected. Time has suddenly stopped! “I’m not ready for this” is what almost everyone says or at least thinks at that moment. “What’s next?” “How much time is left?” “Am I going to die?” “What will happen to my family?” “What do I do now, Doctor?” “You are the ‘expert’ on this; tell me what to do, please?” “I’m so confused.”
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Patient’s Perspective
From the time he said “cancer,” I began drifting into a fog that seemed to swirl all around me.
14 SAN DIEGO PHYSICIAN.org Novem ber 2011
I remember about five minutes of the 30–45 minutes we spent in our doctor’s office on Nov. 10, 2005. From the time he said “cancer,” I began drifting into a fog that seemed to swirl all around me; I didn’t know if I would be able to walk out of there. I was scared. My mother had died of cancer less than two months after her diagnosis and surgery. I was thinking, is this going to happen to me? I’m not ready. I just retired. I wanted to spend some quality time with my wife and family after working so many nights and weekends to be able to get to this point, and now it would all be lost. “What do I do now, Doctor?” “You are the expert; tell me what to do.” I was lucky because my doctor took the time that day to try to put me at ease and offer some hope. He always took time to talk, and it wasn’t always about my condition either. Many times it was about me, my family, or what was going on in my life. He was getting to know and deal with me as a person and as a patient. He also explained what was going to happen next, the reasoning for the protocol, side-effects I might experience, and measures I could take to relieve or reduce them. We communicated. I was really lucky to find him. As a patient advocate, volunteer, and speaker, I hear so many stories about how other people never
spend more than 5–7 minutes with their doctors. They come away with unanswered questions, most of them asking, “What questions should I be asking?” “I’m a secretary or an auto mechanic or a school teacher, not a doctor.” “I don’t know what questions to ask.” Last year I was at the American Society of Clinical Oncology convention and sat in on a seminar about how to get along with patients who are newly diagnosed with cancer. That’s where I heard the statement, “If they don’t ask, I don’t tell them much,” raise its ugly head. This became a good part of the discussion by the oncologists in the room. Somehow many doctors feel that if patients do not ask a question, it means they already know the answer. If I’ve never had cancer, how can I know which questions to ask? I thought everyone had learned the word “assume” has a terrible connotation about it. Evidently this is not true, at least with cancer patients. I have so many people tell me how little their doctors tell them about their condition. “I don’t know what to expect, but they know the side-effects with these treatments. Why don’t they prepare me for these things?” Please, for the sake of the auto mechanic who works on your car, the elementary school teacher who teaches your children math, or the checkout person at your grocery store, try a little harder to understand that in their eyes, you are the “expert” on cancer. Be proactive; take the needed time to educate us so we don’t have so many surprises during this journey. Communicate! Please! About the Author: Mr. Bauer is a fiveyear survivor of esophageal cancer; a patient advocate for the Arizona Cancer Center in Tucson, Ariz. (GI SPORE — esophageal cancer); sits on the steering committee for the National Cancer Institute (esophageal cancer); is a newcomer orientation host and outreach ambassador and speaker for the Wellness Community of Arizona in Phoenix; and has been nominated to be an NIH esophageal cancer patient advocate.
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Risk Management Unhappy patients rarely retract derogatory or even defamatory statements made online. Should you fight the commenters? Fighting defamation, at least in some cases, might make the situation worse. Even if disgruntled commenters desist, the defamation is in the public domain and will circulate again and again. Consider the following recent court case: A neurologist in Duluth, Minn., sued a family member of an unhappy patient for defamation because of a negative review written on a third-party website. The media picked up the story, multiplying the negative aspects of the case and presenting additional facts that were not supportive of the physician’s office staff. Ultimately, the case was dismissed by the judge, who declared that “the court does not find defamatory meaning, but rather a sometimes emotional discussion of the issues.” Fighting commenters on an Internet review site can escalate a poor interaction or outcome into a full-blown complaint to the state medical board — as it did in Texas, where anonymous commenters and complainants led to medical board actions. In response, physicians banded together and pushed the passage of a law that prevents the Texas Medical Board from considering anonymous complaints against physicians for disciplinary actions. Other states may take up the issue as well. If you should receive a negative or unfair comment or review online: • Avoid responding to the post. • Review the comment from the point of view of a patient. Can any information shared in the comment help improve the practice? • Trust that established, potential, or new patients will use their own intelligence and judgment when reading the post. To help maintain positive relationships with your patients, consider the following ideas: • Trust your patients and your practice. Don’t have patients sign “gag orders” preventing them from commenting
Fighting commenters on an Internet review site can escalate a poor interaction or outcome into a fullblown complaint to the state medical board.
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Can One Bad Comment or Online Review Ruin Your Practice? by The Doctors Company
16 SAN DIEGO PHYSICIAN.org Novem ber 2011
about their experience. This puts a therapeutic relationship onto a potentially adversarial footing. • Give patients a direct line to the practice through patient satisfaction surveys. Discuss the results in regular staff meetings and address any patient concerns. • Consider sending a letter to new patients after their first visit, thanking them for choosing the practice and stating that you hope to see them in the future. • Encourage satisfied patients to post their experience as well, to help balance the reviews. About the Author: SDCMS-endorsed The Doctors Company provides MediGuard® to its members at no cost to them: defense in the case of complaint procedures brought before state medical boards. For additional information, please visit www. thedoctors.com/mediguard.
Partial List of Additional Websites to “Yelp Yourself” at: www.angieslist.com www.bestdoctors.com www.bookofdoctors.com www.checkbook.org/patientcentral www.citysearch.com www.consumerhealthratings.com www.doctor.com www.doctordirectory.com www.doctorfeedback.com www.doctorline.com www.doctorscorecard.com www.doctorsdig.com www.doctortree.org www.dotellall.com www.drscore.com www.findadoc.com www.healthcare.com www.healthcarereviews.com www.healthgrades.com
www.hospitalcompare.hhs.gov www.justclicklocal.com www.kudzu.com www.mdnationwide.org www.medimundi.com www.mydochub.com www.physicianreports.com www.premierdoctors.com www.ratemds.com www.revolutionhealth.com www.suggestadoctor.com www.vimo.com www.vitals.com www.wellness.com www.whitecollarfinder.com www.yelp.com www.yourcity.md www.zocdoc.com
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Easing Suffering, Saving Lives, and Allowing Physicians to Provide Better Treatment
While Driving Down the Overall Cost of Healthcare By Joe Panetta
18 SAN DIEGO PHYSICIAN.org Novem ber 2011
//////////////////////////////////////////////// //////////////////////////////////////////////// For much of the world, the word “biotechnology” conjures the image of scientists in white lab coats, pipetting cells into a petri dish. To many physicians, the biotechnology industry means persistent sales reps who are always trying to persuade you to prescribe some new therapy, eating up valuable patient time. To countless patients around the globe, however, biotechnology means hope. Started in California 35 years ago, the biotechnology industry — now also referred to as the life sciences industry — is responsible for cutting-edge therapies that treat everything from cancer to HIV, diabetes, and superbugs such as C-difficile. More than 35 percent of the world’s biotech might is centered in California, largely in Southern California and the Bay Area. The Boston/Cambridge, Mass., region is the other of the world’s top three biotechnology clusters. The Southern California life-science cluster is one of the most robust in the world, employing more than 40,000 people in San Diego County alone. The cluster was born when technology was spun out of UC San Diego into a company called Hybritech, which created the PSA test for prostate cancer as its first big commercial product. The success and culture of Hybritech created a generation of entrepreneurs with the cash and connections to start new companies. That cycle of innovation — discoveries out of one of the region’s stellar research institutes or universities, licensed by an entrepreneur and developed into a product — is now in its fourth decade. And just recently, another San Diego company, Gen-Probe, which coincidentally was co-founded by Hybritech founder Dr. Ivor Royston, had a new prostate cancer test approved by the FDA. Minimally invasive spinal surgery techniques, devices to treat sleep apnea, and two first-in-class diabetes medications were also developed in Southern California. San Diego County is home to two of the world leaders in genetic sequencing technology, Life Technologies and Illumina, as well as the
Late-stage Products in the San Diego Life Sciences Pipeline: A Sampling Progensa PCA3: Currently under review by the FDA, the Progensa PCA3 assay detects the overexpression of a gene called PCA3 in urine. Studies have shown that PCA3 is highly overexpressed in the vast majority of prostate cancers, indicating that PCA3 may be a useful biomarker for the disease. Data show that the PCA3 assay is more specific to prostate cancer than the traditional serum prostate-specific antigen (PSA) test, thus decreasing the likelihood of false positive results. Developed by Gen-Probe, based in San Diego. Lorcaserin: After completing a pivotal phase-three clinical trial program for lorcaserin, an obesity drug, San Diego-based Arena Pharmaceuticals submitted a new drug application to the FDA for regulatory approval in December 2009. The FDA issued a complete response letter in October 2010, and Arena is now engaged in activities — in collaboration with its partner Eisai — to address the issues raised by the FDA as part of the company’s plan to submit a response to the CRL. Contrave: On Jan. 31, the FDA rejected Orexigen Pharmaceutical’s application to put its obesity drug, Contrave, on the market. The company has since revived its plans for the drug and said it will start a twoyear clinical trial of about 10,000 patients in the first half of next year, aiming to receive FDA clearance for Contrave in 2014. Bydureon: The onceweekly form of the type-2 diabetes drug Byetta, or exenatide, has received marketing authorization in Europe and is currently under review by the FDA. San Diego-based Amylin Pharmaceuticals has partnered on the drug with Eli Lilly & Company and Alkermes Inc.
Novem b er 2011 SAN DIEGO PHYSICIAN.org 19
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Allovectin: The first-line treatment for stage 3 and 4 melanoma, developed by San Diego-based Vical, is in phase-three clinical trials. VX-770: The FDA is reviewing an application for a new cystic fibrosis drug, VX-770, developed in San Diego by Vertex Pharmaceuticals. Asimadoline: A treatment for diarrhea predominant irritable bowel syndrome developed by San Diegobased Tioga Pharmaceuticals is in phase-three clinical trials and has been given fast-track recognition by the FDA. Aeroquin: A proprietary aerosol formulation of levofloxacin, developed by San Diego-based Mpex Pharmaceuticals for the treatment of cystic fibrosis, is in phase-three clinical trials.
Wanting to be near the innovation on which its future depends, several big pharmaceutical companies also have operations in the region, including Johnson & Johnson, Pfizer, Celgene, and Novartis.
J. Craig Venter Institute, and Synthetic Genomics, which are pushing the science of personalized medicine forward at amazing speed. The region also boasts among its neighbors life science giants Amgen, Genentech — which has a manufacturing facility in Oceanside — as well as Allergan in Orange County. Wanting to be near the innovation on which its future depends, several big pharmaceutical companies also have operations in the region, including Johnson & Johnson, Pfizer, Celgene, and Novartis. At this very moment, there are Southern California companies moving closer to bringing new drugs to market for cystic fibrosis, MRSA, obesity, and to salvage tissue damaged in a heart attack. It is this exciting, life-saving innovation that draws us to work each day at BIOCOM, the 20-yearold trade association representing Southern Cali-
fornia’s life-science industry. BIOCOM accelerates life-science innovation by providing its member companies with educational programs and networking events, capital development support, and a strong and unified voice for the industry in town halls, Sacramento, and Washington, DC. What keeps me up at night are the many obstacles preventing the industry’s life-saving innovation from reaching the patients who so desperately need it. These are the innovative products that ease suffering, save lives, and allow physicians to provide better treatment, while driving down the overall cost of healthcare. What many people do not realize is that it can take 12 years on average to bring a new drug to market, and that that process can cost as much as $1.2 billion. The majority of product candidates will fail before they even make it to market, making this industry a high-risk investment despite the crucial need for its products.
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//////////////////////////////////////////////// //////////////////////////////////////////////// Contributing further to the industry’s struggles is an inconsistent and risk-averse regulatory environment. BIOCOM’s 560 member companies share one thing in common: Their fate rests in the hands of the FDA, which must approve all their products for market. Without approval from the FDA in every stage of the commercialization process, nothing else about the company matters. But the inconsistency of the regulatory environment and a general atmosphere of risk aversion over innovation support have created a funding crisis for many companies. These are companies that have been central to the growth of the life-sciences industry over the past 20 years, an industry that has outperformed other sectors through past economic downturns. One example of the troubled regulatory environment is obesity medications. Despite the unmet need for such medications and obesity’s contribution to many other health problems, the FDA did not approve any one of three recent new drug applications for obesity
medications. San Diego companies developed two of those products. Both San Diego companies had met the bar originally set for them by the FDA. However, at review time, the FDA raised safety concerns that had never been raised with the companies and asked for additional expensive and time-consuming clinical trials. It’s essential that the FDA maintain a premium on patient safety while strengthening its commitment to innovation in order to maintain this country’s leadership in the life sciences, and to prevent even more of our companies from first commercializing their products in Europe, where the regulatory process has more clarity and consistency. In fact, a recent BIOCOM member survey showed that 59 percent of respondents were developing strategies to seek approval outside of the United States first. That means patients outside the United States will be the first to have access to American innovation. Another issue that BIOCOM has been fighting for
What many people do not realize is that it can take 12 years on average to bring a new drug to market, and that that process can cost as much as $1.2 billion.
TR-701: A treatment for acute bacterial skin and skin structure infections, developed by San Diegobased Trius Therapeutics, is in phase-three clinical trials. Uceris: Phase-three trials have concluded on a treatment for ulcerative colitis, developed by San Diego-based Santarus in partnership with an Italian company. Santarus hopes to submit a new drug application to the FDA in December. Rhucin: A therapy for the treatment of hereditary angioedema, an orphan disease that involves extreme and acute attacks of swelling, was developed by San Diego-based Santarus in partnership with a company in the Netherlands. Enrollment in phase-three clinical trials is expected to be completed in the third quarter of 2012.
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Products Credited to Southern California’s Innovative Life Science Cluster: A Sampling Dificid: Approved last May, Dificid is specifically indicated in adults for treatment of Clostridium difficile-associated diarrhea. Developed by Optimer Pharmaceuticals, based in San Diego. Incivek: Approved earlier this year, Incivek is a prescription medicine used with the medicines peginterferon alfa and ribavirin to treat chronic hepatitis C genotype 1 infection in adults with stable liver problems, who have not been treated before or who have failed previous treatment. Developed by Vertex Pharmaceuticals, which has a large research presence in San Diego. Rituxan: Rituxan is used alone or with other medications to treat certain types of non-Hodgkin’s lymphoma. It is used with another medication to treat the symptoms of rheumatoid arthritis in people who have already been treated with a tumor necrosis factor inhibitor. Rituximab is in a class of medications called biologic antineoplastic agents. It treats NHL by causing the death of blood cells that have multiplied abnormally. It treats rheumatoid arthritis by causing the death of certain blood cells that may cause the immune system to attack the joints. Developed by San Diego-based Idec Pharmaceuticals, which is now Biogen-Idec. Symlin and Byetta: In 2005, the FDA approved two firstin-class diabetes drugs developed by San Diegobased Amylin Pharmaceuticals. Symlin and Byetta are injectable medications that mimic the body’s natural hormones that help control blood sugar levels. Symlin is a replacement for amylin, a pancreatic hormone, while Byetta mimics the action of exendin-4, a hormone that interacts with glucagonlike peptide-1 in the body to help regulate blood sugar.
Ofirmev: The first and only intravenous formulation of acetaminophen to be approved in the United States is Ofirmev. The injection is indicated for the management of mild to moderate pain, the management of moderate to severe pain with adjunctive opioid analgesics, and the reduction of fever. Developed by Cadence Pharmaceuticals in San Diego. Aptima HPV and other assays: Approved earlier this month, the Aptima HPV assay is another test in San Diego-based Gen-Probe’s Aptima line of assays and equipment, which screens for the virus that causes cervical cancer. Other molecular diagnostics developed by Gen-Probe screen donated blood, assess immune response for transfusion, measure components of the coagulation pathway, help ensure transplant compatibility, and aid biomedical research/drug development. Ion Torrent: Carlsbadbased Life Technologies’ Ion Torrent line of genetic sequencing equipment includes the Personal Genome Machine, which promises to sequence DNA more quickly and at a lower cost than other sequencing technologies. In less than a year of Life Technologies’ commercial launch of the PG, the semiconductorbased instrument has become the best-selling next-generation sequencing machine in the world. IVUS and FM Products: San Diego-based Volcano Corp.’s IVUS and FM products are designed to allow physicians to better assess the severity and progression of atherosclerotic and structural heart disease and to help guide the appropriate therapy as an adjunct to conventional angiography for every patient’s unique presentation. IVUS (intravascular ultrasound)
22 SAN DIEGO PHYSICIAN.org Novem ber 2011
is a catheter-based system that allows physicians to acquire images of diseased vessels from inside the artery. FM (functional measurement) is a guidewire-based technology that analyzes pressure and flow parameters from inside of the vessel. These wires produce a simple, reproducible measurement, and are used in conjunction with angiography. The measurement provides physicians with specific clinical guidance to aid appropriate treatment. XLIF: The XLIF technique of less invasive spinal surgery allows a safe, reproducible direct lateral retroperitoneal approach to the intervertebral disc space. When coupled with nerve detection capabilities, also developed by San Diegobased NuVasive, surgeons get maximum access while minimizing the soft-tissue disruption that often occurs during open surgery. By allowing greater access to the disc space, a larger implant can be used, which indirectly decompresses nerves by restoring disc height. NuVasive developed XLIF in collaboration with Luiz Pimenta, MD, PhD, of São Paulo, Brazil. Alaris, Guardrails, and Pyxis: The Alaris System with Guardrails Suite MX software is the first and only smart IV medication safety system that can help protect every infusion to guard physicians and their patients from medication errors. The Pyxis MedStation analyzes clinical data and informs nurses when patients may be at risk for a potential adverse drug event, without adding extra steps to their workflow. By monitoring inpatient information, the pharmacy can expand surveillance efforts hospital-wide. Both product lines were developed in San Diego and are now owned by San Diego-based CareFusion. S9 Series CPAP Devices: Resmed, a San Diegobased company, developed numerous CPAP devices, masks, and other accessories that aid people diagnosed with sleep-related breathing disorders, such as sleep apnea.
on Capitol Hill is stable year-to-year funding for the National Institutes of Health (NIH). It is the grant money out of the NIH that allows the more than two-dozen research institutes and universities in Southern California to make the life-altering discoveries that the life-science industry then turns into products. Unstable NIH funding prevents the research institutes from hiring, purchasing equipment, or committing to long-term projects. Meanwhile, developing nations such as China have made long-term commitments to funding biomedical research with the intent of growing a modern healthcare system and biomedical industry. Another matter that concerns the biotechnology industry is also of direct interest to prescribers: follow-on biologics, which is the life-science industry’s approximate equivalent of generics. Follow-on biologics hold the promise of bringing down the cost of therapies. However, unlike traditional drugs, which have a simple chemical formula that can be replicated to create generics, biologics are very complex and often highly targeted organic structures that take much more time to develop. They also have a higher cost of commercialization. BIOCOM has long advocated that companies that invest the time and money in creating new biologics should have exclusive rights to the data they conducted on the product for a sufficient amount of time to recoup their investment. Otherwise, why would venture capital and others invest in trying to bring new products to market? As a part of the healthcare reform law, that period was set at 12 years, a term which enjoyed overwhelming bipartisan support. However, some people, including President Obama, have proposed reducing this data-exclusivity period. A reduction in this window would add yet another level of uncertainty to the development process, and would stifle innovation as fewer discoveries would be funded to commercialization. Diseases just outside of the “orphan” category would be particularly hard hit, as there might be less incentive to fully develop therapies targeted to smaller and midsize populations. There have also been issues in which we have been honored to work side-by-side with the physician community. One of these issues on which BIOCOM continues to lobby, even as I write this article, is Medicare Part B reimbursement. As you probably know too well, Medicare Part B reimburses physicians and other providers for services rendered on an outpatient basis. Due to innovations in treatment, increasingly this includes things like chemotherapy treatments and other
//////////////////////////////////////////////// //////////////////////////////////////////////// This year, BIOCOM actively supported SB 866, a bill that will create a uniform, statewide, non-formulary prior authorization request form. The legislation, which was signed into law, gives insurers two days to respond to a request; otherwise the prescription is deemed approved as written.
into law, gives insurers two days to respond to a request; otherwise the prescription is deemed approved as written. This year BIOCOM also supported legislation at the state level to eliminate “fail first” prescription coverage and to require equitable coverage of oral cancer treatments. The physician-patient relationship is the most important in healthcare. The life-science industry is committed to providing physicians the best tools possible to combat disease and chronic conditions. Working together, we can keep U.S. healthcare as the model for the rest of the world in terms of both innovation and outcomes.
therapies that not long ago required hospitalization. Some pennywise bean counters on Capitol Hill have identified Medicare Part B as a candidate for cuts, not understanding that this will increase the total cost of healthcare, not reduce it. BIOCOM has been active in Washington educating our lawmakers and their staffs on how shortsighted such a move would be, not to mention devastating for many patients. Closer to home, BIOCOM has also been in Sacramento advocating for issues of interest to the physician community. This year, BIOCOM actively supported SB 866, a bill that will create a uniform, statewide, non-formulary prior authorization request form. The legislation, which was signed Project4:Layout 1
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11:22 AM
About the Author: Mr. Panetta is president and CEO of BIOCOM, the largest regional life-science association in the world, representing more than 550 member companies in Southern California.
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Investing in Job Creation and Life-saving Innovation By Congressman Brian Bilbray Member of the House Energy and Commerce Committee
24 SAN DIEGO PHYSICIAN.org Novem ber 2011
Note: To read this article with references, please visit SDCMS.org.
The House Energy and Commerce Committee recently held a field hearing to find answers on the impacts that medical device and drug regulations are having on patients, jobs, and innovation. It was important for us to get out of Washington and hear from life-science-industry job creators on the challenges they are facing in this economy, and there was no better place to accomplish this than in San Diego. California is home to more than 2,000 biomedical companies that employ more than 260,000 people. The San Diego life-science cluster is one of the largest in the world, accounting for more than 24,000 jobs in our region. These jobs are threatened by Washington bureaucracy, unnecessary regulations, and a disturbing culture within the Food and Drug Administration (FDA). Joe Panetta, president and CEO of BIOCOM, declared at our hearing, “The current environment at the FDA is perceived by investors to be arbitrary and risk-averse. This environment has created a funding crisis for many small and midsize companies.” The United States has a long, arduous, and ambiguous regulatory process. The FDA has put up roadblock after roadblock for companies looking to expand their businesses and develop the next great medical breakthrough. For new drugs and biologics, average review times have increased up to 75 percent longer than in previous years. It is time for Congress to remove barriers to small miracles that save lives. The federal agency’s arbitrary and riskaverse attitude promotes uncertainty and has lead to a decrease in American investors who fear that the FDA’s policies will impede development. It is becoming more efficient and faster to innovate outside of the United States, where regulatory processes are more timely, predictable, and transparent. The FDA could use an attitude adjustment for the benefit of patients and American jobs. Patients view innovation differently than regulators because their lives depend upon it, which is why they should be allowed to participate in the FDA process. Conflict-of-interest rules should be reexamined so that the best and brightest reviewers can be recruited. Congress should work in other areas to make the research and development tax credit permanent and offer a temporary tax reduction that encourages the repatriation of foreign subsidiary earnings for companies who want to bring money back from overseas to invest in research and development. A recent report from President Obama’s Jobs
//////////////////////////////////////////////// //////////////////////////////////////////////// The San Diego region contains the best and brightest America has to offer within the lifescience community.
Council confirms that the inefficient and unpredictable nature of the FDA is causing America’s medical technology industry to lose its competitive edge. What this report fails to mention is that a $20 billion tax on innovative medical device companies buried within the so-called Patient Protection and Affordable Care Act (PPACA) is compounding the problems facing the industry. I introduced HR 734 to repeal this tax in February in order to protect the 112,000 medical device industry workers statewide and prevent the suffering of countless patients whose survival depends on innovation. I also recently introduced HR 3203, the Novel Device Regulatory Relief Act of 2011, to improve the FDA’s third-party review and inspection process by making it more efficient, transparent, and beneficial to the life-science industry that employs 24,000 people in the San Diego region. This is not a political issue. In our lifetime we
have had major success battling the AIDS epidemic because we changed how regulatory oversight is conducted. The bureaucracy in Washington was forced to approach the challenge differently, and, as a result, significant accomplishments were made that improved the livelihood of those infected with the virus. Since those breakthroughs, the barriers to efficiency have increased in size and number. The public and private sector research entities must work together to advocate for one another. The San Diego region contains the best and brightest America has to offer within the life-science community. Our innovative companies have the potential to turn the stagnant economic climate around while saving lives. Removing government barriers to job growth is necessary in any business, but in this industry it is also necessary so that pain can turn to healing, and despair to hope.
EMR is great for record-keeping but it’s not the answer to getting you paid or managing your claims.
About the Author: Congressman Bilbray represents California’s 50th congressional district. He is a member of the House Energy and Commerce Committee and is co-chairman of the House Biomedical Research Caucus.
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The following three articles — “OR Room: 007,” “Searching for New Ways to Diagnose and Treat Brain Tumors,” and “Principled Pioneering” — are collated and presented by Tom McAfee, MD (SDCMS-CMA member since 2004 and SDCMS board member) as examples of what is actually happening in the life sciences at our academic medical center.
OR Room: 007 Developing Surgeries With Fewer Incisions
In March 2008, surgeons at UC San Diego Health System were the first in the United States to remove a diseased appendix through a man’s mouth. The goal was to develop a novel operation that resulted in fewer incisions and shorter hospital stays for patients. Similar procedures followed to treat achalasia, cholecystitis, and obesity. Not without its critics, this approach is called natural orifice translumenal endoscopic surgery (NOTES). Instead of making 4–6 laparoscopic incisions in the abdomen, existing body openings, such as the mouth, are used to access and remove damaged organs. “The goal of these clinical trials is to advance surgical procedures for gallbladder and appendix removal so that incisions and scars may one day be eliminated,” said Santiago Horgan, MD (SDCMS-CMA member since 2010), chief of minimally invasive surgery at UC San Diego. “What we need is the right tools. To achieve an elegant design, we have to bring surgeons, engineers, and device manufacturers into the same room, at the same time, for product development.” The tools used to perform NOTES represent long articulating instruments that can be threaded down the esophagus or through the vagina to reach the abdomen. The tools must be multifunctional to cut and cauterize tissue, and to deploy staples, clamps, and stitches. The instruments also require integration with camera platforms. One incision in the bellybutton is made to insert a camera to monitor the procedure. Stryker was one of the first medical companies to collaborate with Dr. Horgan on cameras to
26 SAN DIEGO PHYSICIAN.org Novem ber 2011
see inside the gut. “Flexible technology is an integral part of the NOTES procedure,” said Eric Masingale of Stryker. “Surgeons need superior visualization so that the procedure is safe. The device industry and surgeons must continue to work together to further these technologies for the patient’s benefit.” Currently Stryker and Michael Bouvet, MD (SDCMS-CMA member since 2005), professor of surgery and director of endocrine surgery at UC San Diego, are working on developing a laparoscopic technique that uses fluorescent light to improve pancreatic cancer staging and treatment. UC San Diego researchers have compared a standard xenon laparoscope with a laparoscope using a light emitting diode (LED) source. Dr. Bouvet and his team took two antibodies that are commonly expressed by pancreatic cancer and tagged them with a fluorescent marker, thus making cancerous tumors in mice “light up” in colors of bright green or red. “Laparoscopy is used for staging in patients with cancer, often before we make a big incision,” said Dr. Bouvet. “Now we’ve made it even better with the LED light source. We modified it so you can see both the normal background of the anatomy plus the fluorescent tumor signal at the same time.” Interactions between surgeons and device manufacturers occur frequently in the newly opened Center for the Future of Surgery at the UC San Diego School of Medicine. Here surgeons, gastroenterologists, and manufacturers have access to 22 training stations equipped with $30 million in new technology. The largest surgery and endoscopic research and training center of its kind to open in the world, it features a “007” room where doctors can test tool prototypes. “We are ruthless in providing feedback,” said Dr. Horgan, Center for the Future of Surgery (CFoS) director. “By testing the products in the CFoS labs, we can weigh in on what materials will be used, grip strength, flexibility, and durability. When the tool does the job right, it can decrease the amount of time in the operating room, meaning less time for the patient under anesthesia.” Right now Dr. Horgan is experimenting with magnets to guide and position tools and cameras from outside the body. He expects the NOTES procedures to be adopted as standard of care in 2012. The CFoS is open to all surgeons, gastroenterologists, and nurses seeking training in a variety of emerging surgery techniques.
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Searching for New Ways to Diagnose and Treat Brain Tumors
28 SAN DIEGO PHYSICIAN.org Novem ber 2011
//////////////////////////////////////////////// //////////////////////////////////////////////// “I would love it if we had a reliable, non-invasive way to detect a malignant brain tumor,” says Bob Carter, MD (SDCMS-CMA member since 2011), professor at UC San Diego School of Medicine and chief of UC San Diego Health System’s Division of Neurosurgery. “Think of the benefit to the patient who would not have to undergo surgery for a biopsy.” This is not just some pipe dream. Dr. Carter has dedicated substantial time and effort to making this a reality. From 1992 until he came to UC San Diego in 2010, he worked with Harvard Medical School and Massachusetts General Hospital (MGH). Three years ago, while still in Boston, he was part of a research group at MGH that made the groundbreaking discovery of an RNA-based biomarker for glioblastomas in blood serum. The RNA content is contained in small membrane sacs known as microvesicles (or exosomes), which are released by the glioblastomas in sufficient numbers to cross the blood-brain barrier. One particular mutation, EGFRvIII, affects a growth factor receptor and is the biomarker that signals the presence of glioblastoma. The researchers’ findings were reported in the Nov. 16, 2008, issue of Nature Cell Biology. One of the surprising outcomes in this study, which involved 30 suspected glioblastoma cases, was that the blood analysis of two biopsies said to be free of the EGFRvIII mutation tested positive. It meant that the blood analysis was actually more accurate in diagnosing these tumor mutations, and, in the future, a blood- or CSF-based test could eventually augment tissue biopsies or provide critical tumor information when biopsies cannot be taken. The exosome technology might have remained an interesting laboratory discovery if not for MGH’s collaboration with Exosome Diagnostics Inc. A provisional patent covering this work was licensed exclusively to the company in 2008. Exosome, headquartered in New York with a subsidiary in Munich, Germany, raised $20 million in financing to commercialize exosome bio-fluid technology, including the blood-based diagnostic EGFR test. (Dr. Carter is not financially involved in Exosome Diagnostics, but he was named to its scientific advisory board in May of this year.) UC San Diego is now Exosome Diagnostics’ primary brain cancer partner, a partnership led by Dr. Carter. “Bob Carter is one of the most forwardlooking investigators in the field,” says James R. McCullough, CEO of Exosome Diagnostics. “I believe this type of public-private partnership represents the future of translational medicine. It is essential in moving new discoveries from the research bench to the patient’s bedside.”
UC San Diego and Exosome Diagnostics are now moving forward to launch large-scale clinical studies to look at key gene mutations and gene expressions associated with different brain cancers found in blood and CSF samples. This will involve multi-center trials with an international component. The exosome technology will be used not only to diagnose glioblastomas but to track their drug resistance and growth status over time. “Exosome bio-fluid technology helps us identify new drug-able biomarker targets and provides a real-time genetic snapshot of the disease process to the clinician for both diagnosis and prognosis,” says McCullough. This is just one of dozens of examples of collaboration in brain cancer research now in effect between UC San Diego and its industry and community partners. Dr. Carter and Dr. Santosh Kesari (SDCMSCMA member since 2010) are two of the co-leaders of the clinical Brain Tumor program at UC San Diego Health System. They and their faculty and research colleagues work closely with the Salk Institute, Sanford-Burnham Medical Research Institute, and The Scripps Research Institute (TSRI). Dr. Kesari, associate professor of neuroscience at UC San Diego School of Medicine and director of Neuro-Oncology at UC San Diego Moores Cancer Center, is involved in several translational research projects and more than a dozen clinical trials. In his translational research projects, his partners include Clarient/GE Healthcare and the National Brain Tumor Society. The companies involved in UC San Diego’s brain tumor clinical trials include Novartis, Merck, eTherapeutics, Adnexus/Bristol-Myers Squibb, Geron, Northwest Biotherapeutics, and a local San Diego company called Tocagen. These trials are both national and international in scope and involve collaboration with prestigious research facilities. For example, Dr. Kesari is collaborating with Brigham and Women’s Hospital in Boston to assess early response to chemotherapy using the radiotracer fluorothymidine positron emission tomography (FLT-PET) imaging of de novo glioblastoma multiforme (GBM). Dr. Kesari leverages his experience in surgery, chemotherapy, and radiation therapy and collaborates with his colleagues, community partners, and pharmaceutical and biotech companies to advance medicine to a new stage in the battle against brain tumors. “We’re working with tumor biomarkers, imaging biomarkers, and blood biomarkers,” says Dr. Kesari. “All of them help us personalize patient care.” A blood test to detect glioblastoma is a step in that direction.
It meant that the blood analysis was actually more accurate in diagnosing these tumor mutations, and, in the future, a blood- or CSF-based test could eventually augment tissue biopsies or provide critical tumor information when biopsies cannot be taken.
Novem b er 2011 SAN DIEGO PHYSICIAN.org 29
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Principled Pioneering
Cardiologist Puts Heart and Mind Into Collaborating for Benefit of Patients Worldwide
30 SAN DIEGO PHYSICIAN.org Novem ber 2011
Ask any cardiologist how he or she chose their profession, and the list of reasons, if not the reason, always includes “a desire to help people/patients.” That holds true for Anthony DeMaria, MD (SDCMS-CMA member since 2005), Judith and Jack White Chair in Cardiology at UC San Diego School of Medicine and founding director of the Sulpizio Cardiovascular Center. But Dr. DeMaria has turned that desire to help into tangible devices and therapies for heart patients. Because of Dr. DeMaria’s decades-long collaboration with industry, his patients — and eventually patients worldwide — often benefit from first-ever clinical trials with those cutting-edge devices and therapies. “There is enormous satisfaction in being able to help fashion a device or product,” says Dr. DeMaria. “I have had the opportunity to recommend changes or improvements and have had the unique experience of being the first to bring forth new information and knowledge behind leadingedge medical advances.”
//////////////////////////////////////////////// //////////////////////////////////////////////// Mass Casualty Care “We rely on early collaboration with academia to prove that we can do what we claim we do,” says Gunnar Trommer, PhD, vice president of marketing at Sotera Wireless, a San Diego-based medical device company. “Researchers, such as Dr. DeMaria — through independent, objective studies — provide that proof, and we are able to market, with confidence, a product that we believe can help the healthcare system and society.” Dr. DeMaria is studying Sotera’s “ViSi Mobile,” a wireless vital-signs monitoring system that can be used in the hospital but also on the battlefield or in a mass casualty situation, such as Hurricane Katrina, to assist clinicians with triaging and remote surveillance of patients. The device is worn by patients, and the information is streamed wirelessly and continuously to a clinician who can then monitor if the patients are deteriorating and who needs immediate care. If a warrior is wounded, medics in the field can immediately view and send information about blood pressure, heart rate, heart rhythm, respiration rate, oxygenation, body temperature, and — in the future — overall blood flow volume from that remote station to the nearest military medical facility. Medics will be able to receive immediate in-field advice and can begin the appropriate therapy, in the field, prior to transporting the patient, saving time and lives. “We use a three-part formula to determine success: clinical outcomes, economic benefit, and usability,” says Trommer. “‘Usability’ meaning that our product must be proven accurate, rugged, and able to support the workflow of clinicians who are working with the device or patients who are attached to the device.” Coloring the (T)issue For years, Dr. DeMaria’s lab has been doing research with ultrasound contrast agents, trying to identify the viability of those agents to produce a signal and, more importantly, to figure out how to convert that signal into meaningful information about heart function and performance. Lantheus Medical Imaging Inc. — a diagnostic imaging company and manufacturer of ultrasound agents — approached Dr. DeMaria for assistance
with clinical testing, to validate the agents’ efficacy and rule out the possibility of any side-effects. Dr. DeMaria enrolled participants and provided the company with an unbiased, scientifically sound study showing the product to be safe and effective. Taking that collaboration a step further, a San Diego company, Targeson, approached Dr. DeMaria with its line of contrast agents. Its products were well-established for use in basic research. Josh Rychak, PhD, Targeson co-founder and vice president of research and development, had an idea for how to manipulate the ultrasound micro-bubble contrast agents so that they would attach only to a certain compound on the inner surface of a blood vessel. After applying for and receiving an SBIR (small-business investment research) grant from the NIH, Rychak and Dr. DeMaria have just launched a study to determine if this new contrast agent can detect a diseased artery in the heart by detecting excess amounts of this compound. Stem Cell Through his collaboration with Angioblast Systems Inc. — a biotechnology company that specializes in the development and commercialization of therapeutic products for the treatment of cardiovascular diseases — Dr. DeMaria has already participated in a multi-center study of allogeneic stem cells (derived from the donor). The stem cells were injected directly into the hearts of participants suffering from very advanced heart failure. The small, phasetwo trial showed that injecting the stem cells was feasible, safe, and may help restore lost heart muscle. The company is assessing the feasibility of phasethree trial. Dr. DeMaria emphasizes that although these experiences are “energizing, and it is exhilarating to be at the forefront of optimizing new medical devices and therapies,” he always maintains his independence. “Independence is critically important. A physician-researcher’s greatest value to the company — and to society in general — is absolute independence and objectivity,” says Dr. DeMaria. “If the product or idea is ineffective, you have to be able to say that. Sometimes the most important thing you can do is to tell the company that the product isn’t worth pursuing.”
If a warrior is wounded, medics in the field can immediately view and send information about blood pressure, heart rate, heart rhythm, respiration rate, oxygenation, body temperature, and — in the future — overall blood flow volume from that remote station to the nearest military medical facility. Medics will be able to receive immediate in-field advice and can begin the appropriate therapy, in the field, prior to transporting the patient, saving time and lives.
Novem b er 2011 SAN DIEGO PHYSICIAN.org 31
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.
2
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.
3
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.
4
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 Banfe, resource development director, at (858) 565-7930 or at Lauren.Banfe@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) 300-2777 or Fax: (858) 569-1334
SDCMSF was formed as a separate 501(c)3 in 2004 by the San Diego County Medical Society.
32 S AN D I E G O P HY S I CI A N. or g A uber gu st 2011 32 SAN DIEGO PHYSICIAN.org Novem 2011
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to stand without help. His wife hovered in the corner, her eyes telling me she didn’t know what to do. I said, “Earl, time is short. I want to say thanks again for your patience with me during those Fridays when I used to dash in, late for my lesson, and having not practiced.” “I understood you were busy.” He looked up at me beneath eyelids drooping from morphine and mumbled, “Young doctor, starting out in practice.” I turned to his wife. “He’s as comfortable as can be. Hospice is doing a good job. You’re doing a good job. Just keep it up.
Call me anytime.” I put my hand on her shoulder and said, “I’ll come back again in a few days.” To myself I said, If he doesn’t die sooner. Earl and I shook hands; his bony grip dug into my palm, and I remembered his thumbnails had always been long, which I figured was to help reach octaves and tenths on the keyboard. Earl died nearly 20 years ago, but his gift to me endures. Many of life’s experiences have to be felt, not analyzed. Understanding this has made me a better husband, father, and physician. Sometimes late in the evening, when it’s quiet and I want to relax, I go to the piano and play melodies from those old Broad-
way shows Oklahoma, South Pacific, The Sound of Music, and My Fair Lady. I see notations on the score scribbled by Earl with a felt pen to help me choose the accompanying chords. The sheet music is stained and dog-eared from turning, but the pages are treasures to me. They remind me of a time when I was learning about myself and medicine and the world, a time when I realized that with a little help I could do it. I could make music. About the Author: Dr. Glynn, who is board-certified in internal medicine and pulmonary disease, has been a member of SDCMS-CMA since 2007. Novem b er 2011 SAN DIEGO PHYSICIAN.org 33
classifieds SERVICES OFFERED MED-LEGAL SERVICES, INC.: Providing scheduling and billing services for CA-licensed QMEs throughout California, looking for physicians of all specialties. Don’t have your QME license, that’s okay, we can help. We handle all of the paperwork so you don’t have to. Call today to sign up for a great way to earn extra income or expand your existing practice. Have a vacant room you need filled? Looking for a great way to meet the expense of owning your own office? Med-Legal Services, Inc., is interested in subleasing it out. For more information, call Ashley today at 1 (877) 823-3793. [988] CLINICAL TRIALS CLINICAL RESEARCH STUDY FOR OPERABLE BASAL CELL CARCINOMA (BCC): Do you have patients whom you would consider for participation in a clinical research study for operable basal cell carcinoma (BCC)? If so, please refer them to Skin Surgery Medical Group’s Research Department. The research team at the facility is conducting a clinical study involving an investigational drug that is designed to inhibit a key pathway in cells, known as the Hedgehog pathway, which may be involved in the development of basal cell carcinoma. In this clinical study, the investigational drug is an oral tablet. Enrolled participants will receive study-related medical evaluations and the investigational drug at no cost. They will be compensated for study participation. Patients are eligible if they are 21 years or older, have previously untreated operable basal cell carcinoma, meet other study specific criteria. For more information, call the Research Department at (858) 292-8641. [962] PHYSICIAN POSITIONS AVAILABLE GENERAL CARDIOLOGIST: Recruiting for a general cardiologist for busy cardiology practice. Must perform diagnostic cath. Board eligible/certified. California license required. Must possess excellent education and training in the United States. Please send resume to SDCardioJobs@gmail.com. [989] INTERVENTIONAL CARDIOLOGIST: Recruiting for well-rounded interventional cardiologist interested in both an office-based practice and hospital procedures. The individual should be well trained in all aspects of cardiology for diagnostic and therapeutic interventions, including cardiac, peripheral vascular disease, and renal vascular disease. Please send resume to SDCardioJobs@gmail.com. [990] BOARD-CERTIFIED FAMILY PRACTICE PHYSICIAN NEEDED: To cover hours at busy urgent care/family practice office in Carlsbad. Nights and weekend coverage needed, some day coverage available. Please fax CV to (760) 603-7719 or email CV to gcwakeman@sbcglobal.net. [985] INTERNAL MEDICINE OPPORTUNITY: Full-time, BC/ BE internist to join private practice in Escondido. Inpatient/outpatient care with hospitalist rotation. Competitive salary, malpractice, benefits, and partnership potential. CV to EIM2011SDP@gmail.com. [970] PHYSICIAN AND FAMILY NURSE PRACTITIONER 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 fulltime, board-certified physician and/or nurse practitioner Monday–Friday, 8:00am–4:30pm. Must have current CA and DEA licenses; computer skills. A competitive salary, health benefits, vacation, paid holidays, sick time, CME, licensing reimbursement, malpractice coverage offered. Forward resume to jobs@sihc.org or fax to (619) 4457976 or visit our website at www.sihc.org. Contact jobs@ sihc.org or HR phone (619) 445-1188, ext. 291, or HR fax (619) 445-7976. [969]
BC FAMILY PRACTIONER MD/DO WANTED TO JOIN OUR PRACTICE IN BEAUTIFUL CORONADO: Seeking FT family physician to join our practice before July 2012. There would be a salary assistance guarantee through a leading local IPA for first year and also a buy-in opportunity as well. The ideal candidate would be willing to share practice with one FT FP and PT FP in practice together and share call and expenses. There would be additional earning opportunities for PT inpatient hospitalist at local hospital as well. Hospital work is optional however. We provide a full range of pediatric and adult family medicine (but no OB). Our practice is well known and has a reputation of personal excellence and service to a wonderful community in an ideal location. Also there is very good earning potential as well. If seriously interested in this unique opportunity, please send your CV and references to donalddill@sbcglobal.net, Attn: Gloria Rivera, or call (619) 435-3155 or fax (619) 435-3158. [968] PHYSICIANS: North County Health Services is a Joint Commission-accredited FQHC, celebrating 40 years of service and serving more than 60,000 patients in multiple locations in North San Diego County. We have opportunities for BC/BE physicians for both full-time and per-diem positions. Spanish communication skills are helpful but not required. Compensation includes attractive salary, great benefit and retirement programs, malpractice, reimbursement for CME and licensure. This is an opportunity to make a difference in the lives of patients who are under or uninsured without having the expense of overhead or management concerns, and provides work-life balanced hours. NHSC loan repay may also be available. Email cynthia.bekdache@nchs-health. org or (fax) 760-736-8740. [966] PHYSICIANS NEEDE: 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] CHIEF MEDICAL OFFICER: Mountain Health and Community Services (MHCS) is an established, four-site, Federally Qualified Health Center serving both rural and urban medically underserved residents of San Diego County. A competitive salary, medical benefits, vacation, paid holidays, sick time, CME and licensing reimbursement are offered. Board-certified family practice and English/Spanish preferred. Position is 60% clinical and 40% administrative. Please send CV and salary requirements to tfindahl@mtnhealth.org or contact Tabitha at (619) 478-5254, ext. 30. Visit www.mtnhealth.org. [960]
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 full-time). [778] PRACTICE FOR SALE INTERNAL MEDICINE PRACTICE FOR SALE IN NATIONAL CITY: $318,000 yearly average gross earnings for the past three years. Office-based busy practice of 31 years on the busiest street of the city. Option to add hospital practice to the office practice, with the nearest hospital 1.6 miles close. Two other nearby hospitals are less than 7 miles. Easily accessible location right between two freeways, I-5 and I-805. $89,000–$99,000. Terms negotiable. Financing if needed. Call (619) 948-4946 anytime or (619) 449-4318 7pm–2am. [945] 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] PRACTICE WANTED WANTED PRIMARY CARE MEDICAL PRACTICE: Please send particulars to fax (858) 456-3581. [986] OFFICE SPACE / REAL ESTATE OFFICE SPACE TO SHARE: Office space to share in National City with a well-respected physician who has been in private practice for 30 years. Office is about 900 square feet with two exam rooms and an additional office/multi-purpose space. Office is currently being used part-time, Monday through Wednesday, but hours are flexible to accommodate another part-time practice. If interested, please contact me at bpmedina@ msn.com. [991]
Internal Medicine: SHARP Rees-Stealy Medical Group, a 400+ physician multi-specialty group in San Diego, is seeking a part-time BC/BE internal medicine physician 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. [951]
TIME SHARES FOR SALE: 1 week / year at the Pono Kai in Kauai, Hawaii. Price $18,000. (2 bed / 2 bath). 2 weeks / year at the Summer Bay in Las Vegas. Price $14,000 (2 bed / 2 bath). Try before you buy. Both can be used at this time, 1 week for 2 $1,500. If interested, please contact me at bpmedina@msn. [992]
Dermatology: SHARP Rees-Stealy Medical Group, a 400+ physician multi-specialty group in San Diego, is seeking a full-time BC/BE dermatologist 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. [950]
OFFICE SPACE IN ENCINITAS — 477 N. EL CAMINO REAL: 1,600 sq. ft. beautiful office occupied by a dermatologist. One or two rooms available. May have the space to yourself for a full day and some half days. Prime location in a multi-specialty four building complex with an outpatient surgery center. Close to Scripps Encinitas Hospital. Available immediately and staff available if needed. Great for solo physician or a small group seeking a presence in North County. Please contact Dana at (760) 436-8700. [987]
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]
PLEASE CONTACT IF YOU HAVE OFFICE SPACE AVAILABLE TO SUBLET: Will consider any area in greater San Diego but would specifically be interested in Poway, Escondido, Vista, North County, as well as East County/La Mesa. Prefer situation where we can use existing office staff. Contact sundhmail@yahoo. com. [983]
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. 34 SAN DIEGO PHYSICIAN.org Novem ber 2011
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]
Close proximity to Tri-City Hospital with pedestrian walkway connected to parking lot of hospital, and ground floor access. Lease price: $1.75 +NNN. Tenant improvement allowance. For further information, please contact Lucia Shamshoian at (760) 931-1134 or at shamshoian@ coveycommercial.com. [965]
MEDICAL OFFICE SPACE FOR LEASE, 1,215 SQ FT: Office has furnished waiting area, front and back stations for four staff members, two exam rooms, a break room, and doctor’s office. Office is updated and is ready for move-in. Located in a great medical/dental complex in Poway, close to Pomerado Hospital, on the border with Rancho Bernardo. Second floor. Elevator/stair access. Large, free patient parking area. Ideal for medical, complementary/alternative medicine, physical therapy, chiropractic, acupuncture, massage/body work, etc. Patients from Poway, Rancho Bernardo, Carmel Mountain, 4-S Ranch, Scripps Ranch, Escondido, Ramona, and surrounding areas. Affordable rent. Please contact Olga at (858) 485-8022. [980]
PRESTIGIOUS OFFICE SPACE IN THE SCRIPPS LA JOLLA XIMED BUILDING TO SHARE/SUBLET: This suite is currently a (+/-) 4,486 sq. ft. expansion to a dermatology office, offered at competitive lease terms. It offers several rooms that may be used as offices, examination or consultation rooms. Includes fully furnished, renovated reception/lobby area, janitorial services, access to common areas, sweeping views, onsite parking. Lessee is to verify all information prior to signing a lease. Located in the Ximed bldg. in Scripps Memorial Hospital in La Jolla. Interested parties call Kelley at (858) 3628800. [964]
CONSULTATION ROOM AVAILABLE: On the campus of Scripps Encinitas, close to 5 freeway. Private entry to wheelchair-accessible unit with soundproof walls, spacious waiting room shared with one doctor, BR with shower, reserved parking. Flexible sub-lease terms. To view the property (available now), please contact (760) 944-9263. [979] OFFICE SPACE TO SUBLEASE: At 754 Medical Center Court, Suite 101, Chula Vista, CA 91911. Close to Sharp Chula Vista Hospital. Includes one office and three exam rooms. If interested, please call (619) 994-4366. [978] SCRIPPS / XIMED BUILDING, LA JOLLA OFFICE SPACE TO SUBLEASE: Currently occupied by one fulltime and three part-time physicians. One office available plus one exam room. Receptionist space available for your employee. For more information, contact Mary at (858) 457-3270. [975] OFFICE FOR LEASE: Beautiful turnkey 1,800-squarefoot medical office space for sublease in Encinitas on El Camino Real with lighted signage and wall signage on El Camino Real. Ideal drive-by advertising. $80,000 worth of tenant improvements with in the last two years. Hardwood flooring, designer decorated and coordinated walls, cabinets, and counters. Five exam rooms and beautiful nursing and reception areas all perfectly appointed. Waiting room with leather couch matching designer furniture and credenza. Phone system, T-1 line, surround-sound muzac system, E-clinical version 9 EMR, new server, all offices fully furnished with new exam tables, computers, and Welch Allen oto/optho sets. 4,700 active primary care patients with healthy cash-based practice. Rent is currently $4,900 a month. Office hard assets and goodwill are negotiable. Physician could lease the space, buy the practice, or work as a guaranteed employee. Please contact Judith Rubin, MD, at judyr@nouveauhealth.net. [973] PATIENT INTERVIEW OFFICE: Patient interview office available on the campus of Scripps Encinitas Hospital, adjacent to Highway 5 Santa Fe exit. First floor, four office private suite, with two established psychiatrists, and one psychotherapist. Full- or part-time lease available. Use of front office staff negotiable. [971] HILLCREST OFFICE SPACE AVAILABLE: Office space available at the corner of 8th Avenue and Washington St. in Hillcrest. Approximately 3,000 sq. ft. 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] MEDICAL OFFICE SPACES FOR RENT/PRE-LEASE, NEW CONSTRUCTION, VERY AFFORDABLE: Very close to Grossmont Hospital and highways 8 and 125. New building being constructed at 5980 Severin Dr., La Mesa. Near corner of Severin Dr. and Amaya, just north of the Brigantine restaurant. Beautiful and functional design. Spaces from 950 to 1,500 sq. ft. available. Now leasing. Call Nathan at (619) 787-3422 or email hythams@att.net. [967]
SUBLET 1 OR 2 EXAM ROOMS AND PHYSICIAN OFFICE: Beautiful, new, spacious medical office suite located at 801 Orange Avenue, Coronado, CA 92118. Shared waiting room, break room, and reception area. Majority of suite is presently occupied by a specialty physician. Ample, free, covered parking provided. Close proximity for patient convenience. For more information, please contact Karen at (619) 437-4406. [963] SHARE OFFICE SPACE IN LA MESA: Available immediately. 1,400 square feet available to an additional doctor on Grossmont Hospital Campus. Separate receptionist area, physician’s own private office, three exam rooms, and administrative area. Ideal for a practice compatible with OB/GYN. Call (619) 463-7775 or fax letter of interest to La Mesa OB/GYN at (619) 463-4181. [648] 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] 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]
Increase Your Referral Business Contact Dari Pebdani at 858-231-1231 or DPebdani@sdcms.org
NONPHYSICIAN POSITIONS AVAILABLE NURSE PRACTITIONER/PHYSICIAN ASSISTANT/ NURSE MIDWIFE: North County Health Services is a Joint Commission-accredited FQHC, celebrating 40 years of service and serving more than 60,000 patients in multiple locations in North San Diego County. We have opportunities for certified family nurse practitioners and physician assistants and nurse midwives for both full-time and per-diem positions. Spanish communication skills are helpful but not required. Compensation includes attractive salary, great benefit and retirement programs, malpractice, reimbursement for CME and licensure. This is an opportunity to make a difference in the lives of patients who are under or uninsured without having the expense of overhead or management concerns, and provides work-life balanced hours. NHSC loan repay may also be available. Email cynthia.bekdache@ nchs-health.org or fax (760) 736-8740. [984] PA/NP POSITION: PA/NP needed in busy neurosurgery private practice. Candidate needs to be highly interested and motivated, as well as caring and flexible. Will be asked to conduct patient clinics, hospital rounds, and assist in surgeries. If interested, please send email with CV and references to armonia01@me.com. [977] PHYSICIAN AND FAMILY NURSE PRACTITIONER FOR AMBULATORY CLINIC: (see ad #969 under “Physician Positions Available”) MEDICAL EQUIPMENT USED X-RAY PROCESSOR FOR SALE: Kodak RP XOMAT, model #M6B, 90 second processor. Works great. Contact Lisa Sullivan at lisas@sdsm.net or by phone at (619) 229-3934. [992] ELECTRONIC TOUCH SCREEN MEDICAL CHECK IN SYSTEM FOR SALE: Eliminate staff interruptions and increase your office efficiency with this easy-touse patient sign-in kiosk in your waiting room. The average sign-in time for patients with a Medical Check In touch-screen kiosk takes fewer than 10 seconds. With this reduction in interruptions and the clear, organized communication of patient information to your receptionist’s computer, Medical Check In will reduce the time for the patient sign in process, reduce congestion for your reception area and save you money. Compatible with all electronic health records. Still under warranty. Cost for new Medical Check In is $2,500. Great price for this at $995. For more information please see medicalcheckin. com. Email KLewis@SDCMS.org. [982]
San Diego Physician is the only publication that is distributed to all 8,500 practicing physicians in San Diego County. Advertising is a cost-effective and profitable way to increase your referral business.
3998 VISTA WAY, IN OCEANSIDE: Two medical office spaces approximately 2,000 sq. ft. available for lease.
Novem b er 2011 SAN DIEGO PHYSICIAN.org 35
the art of medicine
Piano Lessons by Kevin P. Glynn, MD
My eyes went to the mass on the chest film: big, dense, and ugly, surely a lung cancer. I looked at my former piano teacher, my friend, sallow, emaciated, and withered. I felt as if a lump of lead had dropped into the pit of my stomach. Earl (not his real name) said, “My family doctor wanted me to see a lung specialist, and I told him I wanted you.” I faked a smile. “I appreciate the compliment. It’s been what, eight years?” He shifted in his chair. “Sorry. It hurts if I sit still very long. You still playing the piano?” “Not as much as when I took lessons from you. Maybe a few minutes a couple of times a week.” He brushed tobacco-stained fingers over his thick, yellow-brown mustache. “Still busy with your practice, eh?” “Yeah. Keeps growing. No shortage of patients. Something had to give. You remember.” “Too bad. The piano was good for you.” I chuckled. “Made me humble, that’s for sure. Learning chords didn’t come easy.” He managed a little laugh. “I still
remember when you came to me. You thought the music came from the piano. I couldn’t believe someone intelligent enough to get through medical school would think music came from a box of wires and hammers.” “Like it was magical,” I said, smiling. “You taught me a lot.” “I was always trying to get you to loosen up, to feel the music.” “You had that newspaper clipping taped to the wall. The one quoting Artur Rubinstein that if he didn’t have a couple of slips in a performance, he hadn’t given his best effort. That was an important lesson for me: Trying to be perfect leads to being mechanical.” I leaned forward and put my hands on my knees. I said, “I remember you teaching me to feel triplets. You’d say, ‘Put your hands on your knees. Now pat each kneecap while you count: one, two; one two three, one, two, one two three.’” “It wasn’t hard, was it?” Earl extended his hands, palms up. “They’re so weak I can’t even play anymore. I don’t know what’s causing that.”
I whispered, “I’m not sure either. For a professional pianist, that must be a problem.” As if the thought was too painful to discuss, he continued. “You were a challenge. You had been told you had no ear and I knew that was wrong. I wanted to prove that you could hear music and could carry a tune.” “I had been told since I was a little boy that I had no talent.” “I felt that if you could learn to play the piano, it would help you as a doctor.” “Oh? Why so?” Earl looked at me. “Music is the universal language. But you can’t create music by analyzing. You have to feel it.” He shrugged. “Doesn’t a doctor have to be in tune with his patients?” “Music did make me use my right brain.” I crossed my leg and sat back, laughing. “When I discovered I could play ‘Happy Birthday’ in any key without sheet music, I felt like I had climbed Mount Everest.” “Sure you did. That was why I kept you as a student.” “I thought it was because you expected I would become another Hoagy Carmichael.” He snorted. “I just wanted you to enjoy music.” I nodded and said, “And I did. And I still do. I’m grateful to you.” I paused for a couple of seconds. “So, let’s talk medicine. When did you get sick?” He shrugged. “I haven’t felt like eating for the last couple of months. Then I started coughing, and last week when the bleeding began I knew it had to be serious.” I felt that lead lump again but quickly regained my professional poise. “We should do some more X-rays, take a look down there, and figure out what’s going on.” “Whatever you think.” A biopsy showed the mass was lung cancer. Radiation therapy didn’t work, and he went downhill fast. Earl said he didn’t want to go back to the hospital and so I connected him with hospice. Two days before he died I made a house call and could hardly face him. His legs were so swollen he couldn’t put on pants. He sat in an easy chair, naked from the waist down, unable Continued on page 33
36 SAN DIEGO PHYSICIAN.org Novem ber 2011
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