February 2012 by San Diego Physician

official publication of the san diego county medical society february 2012

Reaching

8,500 Physicians

Every Month

“Welcome to the Presidency, Dr. Hay.”

James T. Hay, MD CMA President

Politics

Medicine

PLUS: PPACA: An Interview With Dr. Robert E. Hertzka Not Your Usual AMA Meeting Report

“Physicians United For A Healthy San Diego”

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strenghten your Practice at norcalMutual.coM Proud to support the San Diego County Medical Society.

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

this month Volume 99, Number 2

Managing Editor Kyle Lewis Editorial Board Van L. Cheng, MD, Adam F. Dorin, MD, Kimberly M. Lovett, MD, Theodore M. Mazer, MD, Robert E. Peters, 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)

features THE POLITICS OF MEDICINE 12 “Welcome to the Presidency, Dr. Hay.” by James T. Hay, MD

16 The Patient Protection and Affordable Care Act: An Interview by San Diego Physician

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) other voting members Communications Chair Theodore M. Mazer, MD (CMA Vice Speaker) Young Physician Director Van L. Cheng, MD Resident Physician Director Steve H. Koh, MD

26 Not Your Usual AMA Report

Retired Physician Director Rosemarie M. Johnson, MD

by Robert E. Hertzka, MD, James T. Hay, MD, Lisa S. Miller, MD, and Albert Ray, MD

Medical Student Director Beth P. Griffiths

OTHER NONVOTING MEMBERS Young Physician Alternate Director Renjit A. Sundharadas, MD Resident Physician Alternate Director Christina Pagano, MD Retired Physician Alternate Director Mitsuo Tomita, MD CMA President-elect James T. Hay, MD CMA Past Presidents Robert E. Hertzka, MD (Legislative Committee Chair), Ralph R. Ocampo, MD CMA Trustee Albert Ray, MD CMA Trustee (OTHER) Catherine D. Moore, MD CMA SSGPF Delegates James W. Ochi, MD, Ritvik Prakash Mehta, MD CMA SSGPF Alternate Delegates Dan I. Giurgiu MD, Ashish K. Wadhwa, MD

departments 4 Briefly Noted SDCMS Seminars, Webinars, and Events; CMA Weminars; Community Healthcare Calendar; Featured Member; Upcoming Legislator Birthdays; Get in Touch!; Are Online Coupons a Marketing Bargain?; Welcome SDCMS’ New and Rejoining Members! 10 Preteen Vaccine Week

An Opportunity for Health Education

34 Physician Marketplace Classifieds

36 Errata

San Diego County Physician Directory 2012 2 SAN DIEGO PHYSICIAN .org february 2012

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.]

“We call First Republic and instantly talk to someone who truly helps us with our account.” MICHAEL HALLS, M.D., F.R.C.S.(C), F.A.C.S. (LEFT), MUNISH K. BATRA, M.D., F.A.C.S. (RIGHT) CO-FOUNDERS, DOCTORS OFFERING CHARITABLE SERVICES (DOCS)

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feb ruary 2012 SAN DIEGO PHYSICIAN.org 3

brieflynoted featured member

calendar SDCMS Seminars, Webinars, & Events SDCMS.org/event

For further information or to register for any of the following SDCMS seminars, webinars, and events, visit SDCMS.org/event or contact Serena Sauerheber at (858) 300-2779 or Serena. Sauerheber@SDCMS.org. Tax Time (seminar / webinar) FEB 16 • 11:30am–1:00pm Collection Strategies (seminar / webinar) MAR 1 • 11:30am–1:00pm Surviving Economic Times: Avoiding Economic Lawsuits (seminar / webinar) MAR 15 • 11:30am–1:00pm Media Training (workshop) MAR 24 • 8:00am–12:00pm ICD-10 Training (seminar / webinar) MAR 29 • 11:30am–1:00pm Solo Practice Strategies for Docs (seminar / webinar) MAR 31 • 8:30am–11:00am SDCMS White Coat Gala (event) JUN 2 • 6:00pm–11:00pm

Cma Webinars

CMAnet.org/events

HIPAA Risk Analysis for Meaningful Use FEB 15 • 12:15pm–1:15pm Managing Difficult Employees and Reducing Conflict in the Practice MAR 7 • 12:15pm–1:15pm HIPAA Update 2012 MAR 21 • 12:15pm–1:15pm A Guide to Managing Upset and/or Difficult Patients APR 4 • 12:15pm–1:15pm Best Practices for Managing Your Accounts Receivable APR 18 • 12:15pm–1:15pm

Community Healthcare Calendar To submit a community healthcare event for possible publication, email KLewis@ SDCMS.org. Events should be physician-focused and should take place in or near San Diego County. Introducing New Technologies to Patient Care: The Promise and the Perils FEB 16 • UC San Diego Telemedicine and Medical Education Building, La Jolla • regonline.com/Register/Checkin. aspx?EventID=1012115 Cell Society: 2nd Annual Clinical Meeting (Register Now for a $100 Discount — Code: sdcms100) FEB 17–18 • Coronado Island Marriott Resort • xmedicacme. com/cell_society UC San Diego, Division of Plastic Surgery, Aesthetic Surgery Grand Rounds FEB 25 • 9:00am–12:30pm • UCSD Moores Cancer Center, Goldberg Auditorium, 3855 Health Sciences Drive, La Jolla, CA 92093 • RSVP to Amy Patterson at apatterson@ucsd.edu or (619) 543-6084 Sharp HealthCare’s 2012 Cardiology Conference for Primary Care Clinicians FEB 25 • Marriott Marquis and Marina, 333 West Harbor Drive, San Diego • Contact Stacey Hunt at (858) 499-4530 or stacey. hunt@sharp.com Safe Opioid Prescribing FEB 25–26 • Palm Springs • painmed.org/safeprescribing Timmy Global Health Mission Trip to Ecuador MAR 10–17 • Clinics Seeing Approximately 40 Patients per Provider per Day • timmyglobalhealth.org Topics and Advances in Internal Medicine MAR 12–16 • Catamaran Resort Hotel, Mission Bay • cme.ucsd. edu/internalmed

4 SAN DIEGO PHYSICIAN.org february 2012

Prescription Opioid Misuse Academy: The Dark Side of Prescription Opioids MAR 15 • An Educational Program of the American College of Medical Toxicology • Catamaran Resort Hotel, Mission Bay • acmt.net Topics and Advances in Pulmonary and Critical Care Medicine MAR 17–18 • Catamaran Resort Hotel, Mission Bay • cme.ucsd. edu/internalmed Emerging Markets and Global Health MAR 23 • San Diego Hilton Harbor Island Hotel • The recognition that the world’s health cannot be limited by geopolitical borders has emphasized the need for global health strategies. Yet, simultaneously, improving health in emerging markets provides both challenges and opportunities for policymakers and the private sector. The tenuous availability of resources and extant vulnerable patient populations and access needs are interfacing with growing economic strength and demand for healthcare products and services. As globalization becomes increasingly dominant in both issues of health and sovereign wellbeing, a forum to identify key issues in global health in these markets is needed to explore solutions that may serve as lessons for future developments in global public policy and health. • This is an invitation-only conference. If you are interested in attending, please contact Pam Tait, program administrator at The Institute of Health Law Studies, California Western School of Law, at (619) 515-1568 or at prt@cwsl.edu to reserve a seat. Hospital Medicine 2012 APR 1–4 • The Society of Hospital Medicine’s 15th Annual Meeting • San Diego Convention Center • See Page 29 for Details Sharon’s Ride Run Walk for Epilepsy 2012! APR 15 • De Anza Cove, Mission Bay Park • $25 for Adults / $10 for Ages 7–17 / Free for Ages 6 and Under • 7:30am-1:00pm • sharonsride2012.kintera.org

Bryan A. Liang, MD, PhD, JD SDCMS and CMA member since 2004, Dr. Liang, who is executive director of the Institute of Health Law Studies, California Western School of Law, and director of the San Diego Center for Patient Safety, UC San Diego School of Medicine, has been appointed to the Core Group, Global Drug Safety Roundtable of the Council on Foreign Relations. Dr. Liang has also been appointed to the American College of Chest Physicians Mass Critical Care Task Force, which will be revising the Consensus Statement on Critical Care and Disaster Management. Congratulations, Dr. Liang!

California Orthopaedic Association Annual Meeting APR 19–22 • Park Hyatt Resort, Carlsbad • www.coa.org/coaannual-meeting.html 15th Annual California Health Care Leadership Academy APR 27–29 • Disneyland Hotel, Anaheim • Models of healthcare financing and delivery will change as implementation of federal health reform kicks into high gear. What are the best options for

successful medical practice in the new environment? Hear from the experts and leaders of change, and attend a comprehensive slate of practice management seminars and workshops to position your practice for success. Details coming in January — stay tuned! 13th Annual Science and Clinical Application of Integrative Holistic Medicine NOV 2 • Hilton San Diego Resort

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

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3 employee Benefit Plans

SDCMS Contact Information

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5575 Ruffin Road, Suite 250, San Diego, CA 92123 T (858) 565-8888 F (858) 569-1334 E SDCMS@SDCMS.org W SDCMS.org • SanDiegoPhysician.org CEO • EXECUTIVE DIRECTOR Tom Gehring at (858) 565-8597 or Gehring@SDCMS.org COO • CFO James Beaubeaux at (858) 300-2788 or James.Beaubeaux@SDCMS.org DATABASE ADMINISTRATOR Janet Lockett at (858) 300-2778 or Janet.Lockett@SDCMS.org DIRECTOR OF MEMBERSHIP SUPPORT • 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 DIRECTOR OF COMMUNICATIONS AND MARKETING • MANAGING EDITOR Kyle Lewis at (858) 300-2784 or KLewis@SDCMS.org MEMBERSHIP ADMINISTRATIVE ASSISTANT Serena Sauerheber at (858) 300-2779 or Serena. Sauerheber@SDCMS.org OFFICE MANAGER • DIRECTOR OF FIRST IMPRESSIONS Betty Matthews at (858) 565-8888 or Betty.Matthews@SDCMS.org LETTERS TO THE EDITOR Editor@SDCMS.org GENERAL SUGGESTIONS SuggestionBox@SDCMS.org

3 outsourced Professional services (CFo, Controller) 3 organizational and Compensation structure 3 succession Planning 3 Practice Valuations 3 internal Control Review and Risk Assessment

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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

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feb ruary 2012 SAN DIEGO PHYSICIAN.org 5

brieflynoted 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: MARCH 7 State Senator Juan Vargas (District 40) E: (via website) sd40.senate.ca.gov/contact E: senator.vargas@sen.ca.gov Sacramento Office: State Capitol, Rm. 3092, Sacramento, CA 95814 T: (916) 651-4040 • F: (916) 327-3522 Chula Vista Office: 333 H St., Ste. 2030, Chula Vista, CA 91910 T: (619) 409-7690 • Fax: (619) 409-7688

BIRTHDAY: MARCH 17 State Assemblyman Ben Hueso (District 79) E: (via website) asmdc.org/members/a79 E: assemblymember.hueso@assembly.ca.gov Sacramento Office: State Capitol, PO Box 942849, Sacramento, CA 94249-0079 T: (916) 319-2079 • F: (916) 319-2179 Chula Vista Office: 303 H St., Ste. 200, Chula Vista, CA 91910 T: (619) 409-7979 • F: (619) 409-9270

BIRTHDAY: MARCH 24 State Assemblyman Martin Garrick (District 74) E: (via website) arc.asm.ca.gov/member/74 E: assemblymember.garrick@assembly.ca.gov Sacramento Office: State Assembly, Sacramento, CA 95814 T: (916) 319-2074 • F: (916) 319-2174 Carlsbad Office: 1910 Palomar Point Way, Ste. 106, Carlsbad, CA 92008 T: (760) 929-7998 • F: (760) 929-7999

BIRTHDAY: APRIL 13 U.S. Representative Susan Davis (District 53) E: (via website) house.gov/susandavis Washington, DC, Office: T: (202) 225-2040 • F: (202) 225-2948 San Diego Office: 2700 Adams Ave., Ste. 102, San Diego, CA 92116 T: (619) 280-5353 • F: (619) 280-5311

6 SAN DIEGO PHYSICIAN.org february 2012

Contributed by SDCMS-endorsed The Doctors Company

Are Online Coupons a Marketing Bargain? Discretionary services are an important source of income for many medical practices, and marketing is a key tool for bringing in new business. However, you should be wary of marketing with online and email coupons from social media sites such as Groupon and LivingSocial, which could get your practice into trouble. Social media coupon sites work by sending emails that entice customers to sign up for services — such as car detailing, photography sessions, or dermabrasion — at a reduced price. These sites receive payment based on the number of participants, bringing higher-thannormal customer volume for service providers. Physicians are also using these sites to promote their services. A search on Groupon revealed coupons offering $4,200 of liposuction for $999 in Southern California; discounts on a dental package of exam, X-rays, cleaning, and whitening; and nearly 50 percent off ultrasound facetightening therapy from a dermatologist. Some elements of this type of marketing should raise red flags with medical practices: • Exaggerated language in the offering — numerous sites use extreme exaggerations to garner attention.

• Lack of medical review — the only requirement for receiving the coupon is signing up, which means that services are offered to potential patients without regard to medical suitability. The payment structure is the primary concern in California and many other states, where laws prevent payments to physicians based on patient volume. Disobeying these laws can be punishable by prison time and/or $50,000 in fines. In Oregon, two medical boards have banned dentists and chiropractors from giving Groupon-style discounts. Before marketing your discretionary services, consider the following tips to help protect your practice: • Negotiate your marketing agreements with web-based companies to make it clear that services delivered are dependent on evaluation of the medical suitability of the prospective patient. • Review your marketing agreements to ensure that marketing services are not tied to patient volume. • Carefully review any marketing materials representing your practice for exaggerations, distortions, guarantees, or promises that may be hard to fulfill.

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feb ruary 2012 SAN DIEGO PHYSICIAN.org 7

brieflynoted Welcome SDCMS’ New and Rejoining Members! Welcome New Members! Farhana Ahmed, MD Internal Medicine San Diego Ali G. Alamar, MD Internal Medicine La Mesa (619) 461-3150 Richard T. Allen, MD Orthopaedic Surgery San Diego (619) 543-2542 Gus G. Atkins, MD Anesthesiology San Diego (858) 565-9666 Maneesh Bawa, MD Orthopaedic Surgery San Diego William J. Bigham, MD Ophthalmology Coronado (619) 435-8800 Douglas F. Brewster, MD Otolaryngology San Diego (858) 653-6936 Eric N. Bryant, MD Hospice and Palliative Medicine San Diego (619) 278-6425 Shrilekha M. Champaneri, MD Anesthesiology San Diego (858) 565-9666

Lynna P-S Choy, MD Anesthesiology San Diego (858) 565-9666

Ariel E. Feldstein, MD Pediatric Gastroenterology San Diego (858) 966-8567

Susan S. Laubach, MD Allergy and Immunology San Diego (858) 292-1144

Felipe D. Medeiros, MD Ophthalmology La Jolla (858) 822-4592

Sonya K. Christianson, MD Hospice and Palliative Medicine San Diego (619) 278-6425

Henry A. Ferreyra, MD Ophthalmology La Jolla (619) 471-9398

William D. Leonard, MD Anesthesiology San Diego (858) 565-9666

Katherine T. Morrison, MD Hospice and Palliative Medicine San Diego (619) 278-6425

Wolfram R. Forster, MD Diagnostic Radiology Oceanside (760) 721-6700

Krishelle T. Leong, MD Pediatrics San Diego (619) 278-6425

Lydia M. Grympa, MD Internal Medicine La Mesa (619) 528-5000

Yaohui Li, MD Anesthesiology San Diego (858) 565-9666

Korianne A. Haas, MD Anesthesiology San Diego (858) 565-9666

Kathy A. Ligon, MD Hospice and Palliative Medicine San Diego (619) 688-1600

John L. Gregory Reed, MD Anesthesiology San Diego (858) 565-9666

Jesus Lozano, MD Anesthesiology San Diego (858) 565-9666

Marianne C. Ries, MD Anesthesiology San Diego (858) 565-9666

Kris C. Lukauskis, MD Anesthesiology San Diego (858) 565-9666

Catherine M. Robertson, MD Orthopaedic Sports Medicine La Jolla (858) 657-8200

Eric L. Clark, MD Anesthesiology San Diego (858) 565-9666 Jeffrey R. Dangaran, MD Anesthesiology San Diego (858) 565-9666 Mark L. Dearden, MD Anesthesiology San Diego (858) 565-9666 Robert S. Dyer, MD Anesthesiology San Diego

Lori A. Hergan, MD Urology San Diego (858) 621-4090

Hisham N. El-Tayeb, MD Anesthesiology San Diego (858) 565-9666

Khanh T. Hoang, MD Anesthesiology San Diego (858) 565-9666

Sabrina G. Fabi, MD Dermatology San Diego (858) 657-1002

Royan N. Kamyar, MD Internal Medicine La Mesa (858) 829-7817

David W. Fabi, MD Orthopaedic Surgery San Diego (619) 299-8500

Tse-Sun Ku, MD Anesthesiology San Diego (858) 565-9666

Ladan Farhoomand, MD Anesthesiology San Diego (858) 565-9666

Keeran Kumar, MD Anesthesiology San Diego (858) 565-9666

8 SAN DIEGO PHYSICIAN.org february 2012

Cuong H. Luu, MD Internal Medicine San Diego Peter J. Martin, MD Otolaryngology San Diego William G. Maxwell, MD Anesthesiology San Diego (858) 565-9666

Brian S. Pazevic, MD Anesthesiology San Diego (858) 565-9666 Eileen R. Quintela, MD Anesthesiology San Diego (858) 565-9666

Jonathan B. Rosenthal, MD Anesthesiology San Diego (858) 565-9666 Jeffrey K. Sakihara, MD Anesthesiology San Diego (858) 565-9666

FREE With Your SDCMS Membership Daniel D. Sewell, MD Geriatric Psychiatry San Diego (619) 543-3772 Meera T. Shah, MD Pediatrics Chula Vista (858) 636-4300 Robert H-Y Shih, MD Anesthesiology San Diego (858) 565-9666 Heather L. Silverberg, MD Pediatrics Oceanside (760) 547-1010 Peter M. Sun, MD Internal Medicine La Jolla Clifford C. Tom, MD Anesthesiology San Diego (858) 565-9666 Co T. Truong, MD Anesthesiology San Diego (858) 565-9666 Fabian A. Von Posern, MD Anesthesiology San Diego (858) 565-9666 Barry Weinstein, MD Ophthalmology San Diego (619) 528-7100 Steven W. Zgliniec, MD Critical Care Medicine Escondido

Welcome Rejoining Members! Katherine H. Balazy, MD amily Medicine San Diego Corrie D. Broudy, MD Rheumatology Hillcrest Rebecca L. Gilbert, MD Anesthesiology San Diego (858) 565-9666 Randall L. Goskowicz, MD Anesthesiology San Diego (858) 565-9666 Heidi M. Meyer, MD Family Medicine San Diego Lester R. Mohler, MD Orthopaedic Sports Medicine San Diego (619) 291-8930 Dolores H. Pretorius, MD Diagnostic Radiology La Jolla (858) 543-3405 Akber M. Safi, MD Internal Medicine Poway (858) 485-6644 Steven M. Suydam, MD Anesthesiology San Diego (858) 565-9666 Mayer Tenenhaus, MD Plastic Surgery San Diego (800) 926-8273

» Free Attendance at SDCMS Seminars and Webinars All member physicians and their office staff attend SDCMS’ robust schedule of seminars and webinars held throughout the year free of charge. » Free Pictorial Membership Directory » Free Coding Hotline If you’re unsure about a code and need it verified, access SDCMS’ free coding hotline at Coding@SDCMS.org — provided by SDCMS-endorsed CHMB Inc. » Free CME From The Doctors Company » Free Classified Postings Place your classified ads (office space, physician positions available, nonphysician positions available, clinical trials, practice announcements, etc.) in San Diego Physician and online at SDCMS.org (members can post and manage their own ads) free of charge and for as long as you like! » Free Attendance at CMA’s Webinars Watch online presentations on important topics of interest and interact with legal and financial experts from the comfort of your home or office. » Free California Emergency Driving Emblem Don’t get stopped on your way to an emergency! Receive a free California physician emergency driving emblem and additional emblems discounted at $10. » Free Access to CMA’s Medical-Legal Library Are you getting all of your medical-legal and regulatory questions answered when you need them answered? CMA’s online library contains more than 4,500 pages of up-to-date legal information on a variety of subjects of everyday importance to practicing physicians. » Free San Diego County Physician Mailing List Make sure referring physicians can find you! Receive one free physician mailing list annually and a 50% discount on all additional mailing lists requested in the same year. » Free Listing in San Diego Magazine’s Annual “Health Annex” » Free Subscription to the DocBookMD App A smartphone platform designed by physicians for physicians, DocBookMD provides an exclusive, HIPAA-compliant professional network for on-the-go doctors to communicate, collaborate, and coordinate. » And More …

For further information, contact SDCMS at (858) 565-8888 or at SDCMS@SDCMS.org.

Mark D. Wiederhold, MD Internal Medicine San Diego (858) 642-0267

feb ruary 2012 SAN DIEGO PHYSICIAN.org 9

Public Health

Preteen Vaccine Week: Feb. 12–18 An Opportunity for Health Education

By Stuart A. Cohen, MD, and Robert E. Peters, PhD, MD

10 SAN DIEGO PHYSICIAN.org february 2012

There are more than 113,000 preteens ages 11 and 12 in San Diego County. They are at the age when they begin making important decisions and are ready to become more involved in their personal health. The decisions they make at this age set the foundation for a lifetime of healthy choices. Immunization is the most cost-effective form of healthcare delivery, and most vaccines are 85–100% effective at preventing disease. Preteen Vaccine Week, a California observance created to raise awareness of the importance of immunizations for “tweens” ages 11 and 12, is celebrated this year Feb. 12–18. There will be a strong public awareness campaign designed to educate parents and preteens about the importance of vac-

cinations, encouraging them to visit their physician, and giving you an opportunity to have an impactful conversation with them about their health. Immunization rates, most notably for teens and adults, have been on the decline due primarily to misinformation about the safety and efficacy of vaccines. Yet the CDC statistics demonstrate dramatic declines in vaccine-preventable diseases when compared with the pre-vaccine era. Many diseases previously eradicated in the United States are evident just a plane ride away, as we saw with the measles outbreak in 2008 and the most recent rise in pertussis. School-based varicella outbreaks are common, and influenza kills thousands every

lenges of growing up with their healthcare providers, such as eating right, standing up to peer pressure, drugs and alcohol, and other concerns. Physicians are reporting an increase in the number and severity of HPV cases in unimmunized young adults; immunization prior to sexual activity can prevent 70% of cervical cancer. Influenza contracted by a youth at school is easily spread throughout the family, increasing the likelihood of workdays missed, and putting both infants and older adults at greater risk of complications and even death. Without broad-scale vaccination, we will lose our heard immunity, which will have longterm public health consequences.

Immunization is the most cost-effective form of healthcare delivery, and most vaccines are 85– 100% effective at preventing disease.

year. The message to patients and parents should be clear: Vaccinations are safe, they do not cause autism or overwhelm the immune system, and vaccination is a community health prevention endeavor. Children are at higher risk by not having immunization (35 times more risk for measles, 5.9 times more risk for pertussis). As pertussis vaccination is now required of youth entering seventh grade (Assembly Bill 354), there will be increased opportunity for primary care physicians and pediatricians to discuss the importance of the other immunizations and other health issues with their young patients and their parents. This visit is a great opportunity for parents and preteens to discuss the chal-

The CDC Advisory Committee on Immunization Practices (ACIP) currently recommends that 11- and 12-year-olds receive, along with the Tdap vaccine, meningococcal vaccine, HPV vaccine, and the second chickenpox shot. All preteens are also recommended to receive an annual dose of flu vaccine. The California Department of Public Health further recommends that all vaccinated Californians 10 years and older receive a booster shot against pertussis. For those physicians engaged in pay-forperformance quality assurance programs with the IHA Consortium in California, part of the HEDIS measures used for tiering performance effective beginning 2011 includes immunization rates at ages 11–12. This February’s public awareness campaign is designed to reach parents, since they are the ultimate decision-makers for their children. Once parents and preteens are in your office, the opportunity for health education is yours.

Dr. Cohen, SDCMS-CMA member since 1988, is a pediatrician with Rady Children’s Primary Medical Group, vice chair (California District) of the American Academy of Pediatrics, and board president of the San Diego County Medical Society Foundation. Dr. Peters, SDCMS-CMA member since 2000, is a family medicine physician, member of SDCMS’ GERM Commission, current SDCMS treasurer and incoming president-elect.

Recommended Immunizations Shots that are recommended for 11- and 12-year-olds include: »» Meningococcal vaccine (MCV4) to protect against certain serious types of bacterial meningitis and other related infections. »» Tdap vaccine to help prevent tetanus, diphtheria, and whooping cough. All incoming seventh graders need proof of a Tdap vaccine before starting school. »» Human papillomavirus (HPV) vaccine series that can protect girls against cervical cancer (a cancer in a part of the reproductive system); boys should also be immunized. »» A second chickenpox vaccine. »» An annual flu vaccine. Resources for your practice: »» Preteen Vaccine Week page (downloadable materials, PSAs, and campaign kit): cdph.ca.gov/ programs/immunize/Pages/ PreteenVaccineWeek.aspx »» ACIP Childhood and Adolescent Immunization Schedule: cdc.gov/ vaccines/recs/schedules/childschedule.htm »» Vaccine Safety Information for Medical Assistants and Parents: immunizeca.org/what-we-do/ provide-vaccine-safetyinformation »» True stories of Vaccinepreventable Disease Survivors: shotbyshot.org

feb ruary 2012 SAN DIEGO PHYSICIAN.org 11

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12 SAN DIEGO PHYSICIAN.org february 2012

“Welcome to the Presidency, Dr. Hay.” By Jam es T. Hay, M D

“Your year starts at the close of the House of Delegates, Mr. President, and, oh, by the way, we have eight reporters who want to talk to you about your marijuana policy …” CMA’s board of trustees had three days earlier unanimously approved a new approach to the controversial substance, and I assumed that day that that was what my whole year was going to be about. Fortunately — or unfortunately — there are many other issues CMA is grappling with. 2012 will be the year the Supreme Court rules on the Affordable Care Act and on CMA’s lawsuit to stop the state from further reducing the already abysmal physician reimbursement for serving Medi-Cal patients. It will be the year the State Health Insurance Exchange, or the Administration, or the Legislature — at this point it isn’t clear which body will have this authority — determines what the basic benefit package will be for insurance plans that wish to participate in the market through the Exchange. And, because it is an election year, 2012 will be another year Congress fails to kill the SGR and create a realistic and equitable way to reimburse physicians for Medicare services.

To successfully address these and all the other issues on our plate, CMA must grow to be the organization of all California physicians, and, to do that, we need to rethink all of organized medicine’s business model. Other than that, it should be an easy year. The Exchange Since we expect this Congress to avoid any real Medicare reform and any substantial change to the current healthcare reform, we are now focused on the Exchange, which we know will have a tremendous impact on how we all practice. California’s AB 1602 (Perez) and SB 900 (Alquist) created an “active purchaser” model (as opposed to an open-market model now being adopted by many other states) with a small and powerful governing board that will decide what must be provided by plans that wish to sell to individuals and small-group employers through the Exchange. Health and Human Services Secretary Kathleen Sebelius enabled that power when she recently deferred the benefits determination to the states rather than setting a national standard. With a rich benefit package like those required now in California for

Knox-Keene plans, and by the 49 legislatively mandated service requirements for all plans, and with the constraints on premium that will be set by the Exchange and already by the federal law, the likelihood of Medi-Cal-like per-service reimbursement creates another terrible incentive for little or no physician participation and subsequently very limited access for the anticipated 12.8 million patients to be insured by the participating plans. Early feedback also suggests that many plans currently in the market may not participate in the first place. CMA is developing a coalition of stakeholders to address these concerns and to work to influence how the Exchange will affect our practices and our patients. The Exchange is sure to be one of the most historic changes in our industry that very likely, in its current configuration, will lead inexorably to a single-payer or all-payer system in California. Medicare and Palmetto Many physicians have received letters and are experiencing audits of their billing by our Medicare intermediary, Palmetto. feb ruary 2012 SAN DIEGO PHYSICIAN.org 13

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CMA is very concerned that the government’s attempt to find and eliminate fraud and abuse, which we wholeheartedly support, has spread a net far too wide and assumes guilt before innocence. By the time of this publication, CMA will have surveyed its members to assess the extent by which this audit practice has increased the hassle factor of caring for Medicare patients, analyzed what response we will make, and will have begun dialogue with Palmetto about our concerns. Clearly, physicians want their purposefully overbilling and illegally behaving peers to be found and stopped. We also want to be paid fairly and according to the rules already established by which we currently act, not downcoded arbitrarily by the government like we were by the plans we sued in the RICO lawsuits years ago. We also want to be presumed innocent and want any auditing that is done to be targeted to the ones more likely to be outliers. Failure in this effort will only further induce physicians to decrease or stop their participation in the Medicare program, especially as drastic SGR reductions continue to loom year after year.

CMA must grow to be the organization of all California physicians, and, to do that, we need to rethink all of organized medicine’s business model. Other than that, it should be an easy year.

The Business Model of Organized Medicine Physicians in recent years feel attacked from all sides by those who would control what we do and for how much. We are not victims, however, as we so often complain we are. We merely suffer the consequences of systems we designed ourselves. With so many geographic, specialty, generational, ethnic, and mode of practice differences, and with each of those having its own organization to argue for its members, and with so few physicians belonging to any 14 SAN DIEGO PHYSICIAN.org february 2012

of them in the first place, is it any surprise that large and coordinated efforts by others succeed at times we don’t? It is time we look at how CMA and the counties and the specialty societies and the medical groups and the ethnic and other special-interest groups of physicians are related. It is time we find what we have in common and more tightly align with each other, forgetting turf issues and remembering that every one of these organizations exists for the benefit of its physician members, not for the organization itself. It is time we get together for the good of the profession, which of course means for the good of our patients. Conclusion There are many other important issues, like public health initiatives, responding to the development of ACOs, protecting physicians and patients with fair peer review, developing a new state-supported Physician Health Program for those with potentially impairing illnesses, and so many more. I invite your ideas and opinions on any of them. I dealt only with a few here. Feel free to contact me at jthay@ ncfmg.com anytime. CMA is rolling out an entirely new and much expanded communication process to engage all California physicians in determining the future of our organization, our CMA business, but also of our very existence as Organized Medicine. We must grow and we will continue to succeed in the legislature and in the courts and in the public health because we are physicians and because it is our profession. SDCMS-CMA member since 1985, Dr. Hay is board-certified in family medicine, is current president of the California Medical Association (CMA), and past president of both the San Diego County Medical Society (SDCMS), and the SDCMS Foundation. Dr. Hay has practiced in North San Diego since 1978, when he founded North Coast FamilyMedical Group. He can be reached at jthay@ ncfmg.com.

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Dr. Robert E. Hertzka, who has a long history of working in the area of healthcare access, including being the chair of San Diegans for Health Care Coverage for the past 11 years (California’s largest bipartisan coalition supporting increased healthcare access), has been closely following the process that led to the passage and now initial implementation of the Patient Protection and Affordable Care Act, or PPACA. As a follow-up to his February 2011 interview with San Diego Physician, Dr. Hertzka sat down with us to discuss PPACA — the following is the transcript of that discussion. The opinions expressed by Dr. Hertzka do not represent the opinions of the San Diego County Medical Society or of the California Medical Association. We invite physicians to participate in this discussion by submitting their comments to Editor@SDCMS.org for possible publication in a future issue of San Diego Physician. 16 SAN DIEGO PHYSICIAN.org february 2012

The Patient Protection and Affordable Care Act An Interview By San Di ego Physician

San Diego Physician (SDP): When we last talked a year ago about the Patient Protection and Affordable Care Act (PPACA), it seemed clear that like any comprehensive piece of legislation, there were provisions that seemed positive and provisions that raised some concerns. What we want to do today is revisit some of those issues and concerns and see how we are doing. We want to first focus on the two major provisions of PPACA, i.e., the expansion of Medicaid and the creation of health insurance exchanges (HIEs), each of which is projected to cover approximately 16 million previously uninsured people. While they will not roll out until Jan. 1, 2014, they do represent — by far — the most consequential parts of the bill. Any indication of how they are turning out? Robert E. Hertzka, MD: Let’s start first with the Medicaid expansion. As you probably recall, it provides eligibility to all adults — children are already covered — at or below 138% of the federal poverty line

(FPL), which is currently about $11,000 for an individual and $22,000 for a family of four. Most people do not realize that childless adults in most states have no Medicaid eligibility even if they earn $0, so we’re talking quite literally about coverage for 16 million of the most impoverished adults in the nation. But demographics aside, so far there are at least four major, well-documented problems with the Medicaid expansion, and all four of these problems are unfortunately getting worse, not better, as 2014 approaches: 1. The number of new Medicaid enrollees that will arise from PPACA appears to have been significantly underestimated. I say this with confidence based on the experience of several states, most notably Colorado, which decided to ramp up early for PPACA’s implementation by expanding eligibility in 2010 to childless adults at or below 100% FPL. Well intentioned, but after just a few months, they had to pull the

plug on their program because it turned out that the number of people eligible for coverage was nearly three times as high and the cost of insuring them was almost nine times as high as what had been predicted. And it turns out that they are not alone. A similar program in Wisconsin designed to enroll 22,000 people in its first year had 137,000 sign up in the first four months. And earlier pre-PPACA Medicaid expansion efforts in both Indiana and Oregon also turned out to have far more people eligible than expected. This should really come as no surprise. Tens of millions of people in this country work at any number of jobs that pay them cash, and many of them do not bother to file tax returns. But with programs such as the ones in Colorado and Wisconsin, and as of 2014 in the entire country, everyone who submits a tax return listing — in the case of PPACA — $14,500 or less in income gets a free Medicaid card. The party line from PPACA proponents feb ruary 2012 SAN DIEGO PHYSICIAN.org 17

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is that we will “only” see about 16 million new adult Medicaid patients. I think not. Try 30 million, maybe more, with at least 3 million of them right here in California. 2. The abysmal payment rates for physicians, particularly in California. While PPACA provides enhanced primary care reimbursement in 2014, after one year all physician payment rates revert to baseline levels, which in California have just been reduced an additional 10% from what were already ridiculously low levels. And by the way, to add insult to injury, those 10% rate reductions in California were, in the end, actually supported by the Obama administration. Looking to 2015 and beyond, the

of our emergency rooms, which will actually end up driving up the wait times for services for all patients. We already know from every single study of emergency room usage in recent years that there is a disproportionate use of emergency rooms by Medicaid patients, far in excess of the utilization rates of the uninsured. How big an impact will this have post-PPACA? Well, one analysis by a former Congressional Budget Office director using RAND data concluded that PPACA’s Medicaid expansion would result in 13 million additional ER visits per year at a total annual cost of $7 billion. Another analysis from the National Center for Policy Analysis, a libertarian think tank, went one better, concluding that PPACA’s Medicaid expansion would result in 40 million additional ER visits per year. In California, where we are always teetering on the edge of an oncall emergency room crisis, this may well put us over; look for massive increases in costs for oncall stipends and strains on Emergency Associates (EA) program funds, assuming that all of our ERs even survive. And mind you, on a national level, we will be implementing a law that seems guaranteed to spike emergency visits — for many years if not forever — in an environment that has seen 27% of the nation’s emergency rooms close during the past 20 years.

But as 2014 looms, there is an amazing amount of confusion out there; no one really knows how PPACA’s HIEs will turn out. There has probably never been anything this big done by the federal government with so much uncertainty. national outlook for physician payment in Medicaid is that it is unlikely to get any better and will probably even get worse. 3. The abysmal access to physicians, particularly specialists, due in large part again to those abysmal payment rates. Last June, The New England Journal of Medicine published a survey of access to specialty care in Chicago for children with Medicaid and found it to be dismal, yet Medicaid access in pediatrics is actually much better than for adults. Looking to 2015 and beyond, the outlook for physician access for Medicaid patients is that it will definitely get worse, and with the specter of ever-decreasing reimbursement levels, no one seems to have much of a clue about how to provide meaningful access to these new adult patients. 4. The culmination of 1–3, which looks to be that these tens of millions of new Medicaid patients will cause a massive flooding 18 SAN DIEGO PHYSICIAN.org february 2012

SDP: You are not painting a pretty picture. Dr. Hertzka: There is nothing pretty about this. In fact, to many people, this massive Medicaid expansion, with only token efforts at providing new dollars or any increase in physician access, is enough reason to support repeal of the entire law, no matter how well the rest of it may work. SDP: Well, how about the rest of the law? How about the state-based Health Insurance Exchanges (HIEs) and the whole effort to expand private coverage? Still a good idea?

Dr. Hertzka: HIEs are still a great idea. Letting small employers and individuals coalesce into a large purchasing pool and having health insurers offer them products is a fine concept; it certainly works well for 8 million federal employees. And providing subsidies to help lower-income workers buy insurance is very popular, and was a cornerstone of the health reform plan developed at CMA when I was its president. But as 2014 looms, there is an amazing amount of confusion out there; no one really knows how PPACA’s HIEs will turn out. There has probably never been anything this big done by the federal government with so much uncertainty. SDP: What are some of the issues? Dr. Hertzka: First of all, even more dramatically than with the Medicaid expansion, we really have no idea how many people will be getting their private health insurance through these new HIEs. The original administration estimate was that it would be 19 million, while the nonpartisan Medicare Actuary originally projected 32 million. But on closer inspection, it now appears that both employers — and in some cases employees — will have substantial financial incentives to drop their existing health insurance arrangements in lieu of their state HIE. More recent surveys from management consultants such as McKinsey, Lockton and others suggest that as many as 55 or 60 million people will seek to utilize the HIEs, a number bigger than either Medicare or Medicaid, and all signed up virtually overnight in late 2013. This is not only a potential administrative nightmare, but it could also be very costly. If 50 million rather than 20 million people use the exchanges for their private coverage, the additional subsidies required by PPACA could add more than $1 trillion to the cost of the bill by 2019. SDP: Sounds daunting. Are the states ready for this? Dr. Hertzka: That would be nice. But it turns out that for a variety of political and policy reasons, many states have not even started setting up an HIE. The Obama administration may need to step in at the last min-

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ute in mid-2013 and set up an exchange in as many as 32 states; and, to date, they have been silent on just how they plan to do this, even refusing to comment when asked in a recent high-profile Washington Post article on this subject. And it gets worse. These exchanges need to be able to determine whether someone is eligible for Medicaid as opposed to a private plan, as well as the amount of subsidy

administration kicked that decision down to the states, adding a huge burden to the 18 states that are actually trying to set up an HIE. In fact, the director of the new Oregon HIE said in a public hearing that when he learned that he was now responsible for establishing his state’s essential benefits package, he felt like he had just been handed a “live grenade.”

Private physicians, that is to say physicians who are actually aware of the cash-in, cash-out part of their practice environment, have been majority opposed all along, and that has shown in every survey taken. Physicians, particularly those who do any emergency work, know that the Medicaid expansion is a disasterin-waiting. And given that the government has underfunded every physician access expansion for the past 50 years, there is scant optimism that PPACA will end up being good for physician practices.

that each person is qualified to receive. And health insurance companies have to design products to comply with the new requirements of either a state or federal government HIE, or both. All this requires sophisticated personnel and sophisticated IT, neither of which is what we tend to see with governmental health departments. Finally, a key challenge that the federal government was supposed to solve for states was the determination of a standard “essential benefits” package so that there would not be major variance in benefits between states; imagine if Medicare benefits varied widely from state to state, making some states a magnet for seniors. But, for reasons that seem to be political, the 20 SAN DIEGO PHYSICIAN.org february 2012

SDP: Why do you say that leaving the “essential benefits” decision to the states was political?

Dr. Hertzka: Not my words but that of awardwinning columnist and author Robert Samuelson, who recently wrote in his Washington Post column that by making the “decision to delegate to states the final decision on defining essential health benefits,” Health and Human Services Secretary Kathleen Sebelius will have a “special place in the history of the 2012 campaign” for having done her best “to make the Affordable Care Act disappear as a political liability for the president.” What he meant was that any federal determination on benefits would have been controversial and would have left the administration, and the president, open to criticism. So kicking the decision down to the states, which to most observers is bad policy, is actually, again per Robert Samuelson, a political “masterstroke.” SDP: You do not seem to have a lot of confidence that this administration can make PPACA work? Aren’t you being a little too cynical? Dr. Hertzka: I don’t really think so. PPACA, particularly when it comes to something like having 50 state HIEs fully up and running in less than two years, is truly trying

to design something that is just unprecedentedly huge from both a bureaucratic and a policy basis. What would give me confidence would be if the smaller and much simpler programs in PPACA were being implemented as projected. And there are in fact three much-praised and much less controversial programs to look at, all of which began in June of 2010: the highrisk pools, the small business tax credit, and the Early Retiree Reinsurance Program (ERRP). SDP: How are those three smaller programs working out? Dr. Hertzka: I believe that I mentioned the high-risk pools last year, projected to enroll 375,000 people by the end of 2010, and many more in 2011, but only 8,000 signed up by the end of 2010. Following some fairly massive additional premium subsidies, the program is up to 33,000 participants (6,000 in California), but has only spent 2% of its budget, despite offering what are now deeply discounted policies. Same with the small business tax credit. Touted routinely by PPACA proponents, as in “don’t repeal PPACA because you will take away a major new small-business benefit,” it now turns out that in 2011 only 309,000 individuals claimed the credit (only 7% of the administration projection of 4.4 million). The opposite, though, happened with the ERRP. Touted as a subsidy that would encourage employers who provide healthcare benefits to early retirees (ages 55–64), the $5 billion allocated is already all gone. No surprise, I suppose; the program was tailored to match existing union retiree benefit programs, which had no hesitation in accepting no-strings-attached federal dollars. Let me put this in perspective with a little analogy. Say that you are a city government with a large parcel of land that you would like to see turned into a housing development with hundreds of homes, some schools, a park, etc. You ask a prospective developer to build you three 2,000-squarefoot sample homes, but what actually gets built are two 200-square-foot huts and a 6,000-square-foot mansion, and the mansion has no plumbing and no roof. Would

you let that crew go ahead and build the rest of the development? Probably not, but that is what we are doing in PPACA by trusting the same governmental bureaucrats who misfired so badly on three simple programs to go out and create a massive HIE system that will almost overnight be responsible for providing health insurance to literally tens of millions of people. SDP: How about California? Our state government seems 100% committed to making PPACA a success, including passing the first-in-the-nation Health Insurance Exchange bill 16 months ago. Certainly things will work out here, yes? Dr. Hertzka: One would hope so, but I have my doubts. As I indicated earlier, with our worst-in-the-nation Medicaid reimbursements, we will probably be the state with one of the most problematic of the Medic-

aid expansions. And on the HIE side, yes, we now have an HIE created by state law. It has a fivemember board and staff, and, yes, they collectively have some experience with both public and private insurance, but it will be quite daunting over the next year and a half to set up all the required insurance options, including Medicaid options, for as many as 8 or 9 million people. And our Legislature put some problematic caveats into our HIE. It will have unchecked power to allow insurers in or out of the HIE and to regulate their rates, which sounds good but can be dangerous. The experience in states where regulators can keep a tight hold on insurance premium rates is that in the end the insurers just squeeze the physicians and hospitals even more. And mind you, with the Sebelius decision on essential benefits, we will likely be

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combining California’s generous health benefits (thanks to dozens of legislatively mandated benefits) with a politically appointed HIE board that will be capable of holding insurance rates artificially low. The only solution to that is to drive down physician and hospital payment levels even more, possibly to rates that will be near Medi-Cal levels. Finally, and perhaps most problematic, our state HIE law forbids insurers from offering lower rates to people outside of the exchange, even though there is a strong consensus that the people in the exchange, many of whom will have been uninsured and/or have some preexisting medical problem, will be sicker than those outside the exchange. Many believe that this is unworkable, and it has led to a situation where none of the state’s major insurers are 100% committed to participating in our state HIE. In fact, the entire 50-state

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feb ruary 2012 SAN DIEGO PHYSICIAN.org 21

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HIE process is looking so problematic that many commercial health plans are now setting up private HIEs outside of PPACA that will be directly competing with the fledgling government-backed HIEs. SDP: Last year you suggested that PPACA “may end up being a brick that is just smothered with tasty frosting, but the American people are being told that it is cake.” How do you feel about that analogy today? Dr. Hertzka: Last year I just suggested it, but now it seems to be the reality. Yes, there are more than a million otherwise uninsured kids ages 22–26 who are now on their parents’ policies, and we have banned rescissions and other abusive insurance company practices (which many states had already done). We have 33,000 people with preexisting conditions who now have good coverage, and a few dozen entities are splitting up $5 billion in “early retiree assistance” money. That’s the “tasty frosting.” But the core of PPACA, which is a combination of the Medicaid expansion and the pending HIEs, looks more and more like a brick to me

might just empower those who do not want to see any meaningful healthcare reform. That is what happened after the Clinton health plan debacle of 1994: Health reform as an issue was largely buried for 14 years even as many of the problems in the system got worse. SDP: But isn’t the individual mandate the key to holding the bill together? Dr. Hertzka: Certainly in theory it is, and if the Supreme Court rules that part unconstitutional, it will probably be a fatal blow to the entire bill. But you may remember from our discussion last year, the mandate in PPACA is so weak that it probably will not drive much behavior anyway. Since we spoke last year, and after a more detailed review from some of the medical students in my UCSD SOM health policy class, it now appears that only those earning between 133% and 250% FPL (roughly $14,500–$27,000) will even be at risk for the penalty, which in the first year would only be 1% of income ($145–$270). Compare that with what the cost of the policy will be, and the fact that a policy can be obtained as soon as any medical problem is identified, and it appears these penalties will probably have little effect.

Much is at stake in the 2012 elections, but perhaps nothing as much as the future of our healthcare system.

SDP: How does PPACA’s polling look these days? every day. I am not looking forward to 2014. SDP: What about the Supreme Court? They will be hearing arguments for and against PPACA in March and may rule it unconstitutional. Your thoughts? Dr. Hertzka: I can recite the legal arguments on both sides of the issue, but deciphering the Supreme Court is not my expertise. Frankly, as problematic as PPACA is, having the Supreme Court uphold it means that we will have to fix it and get it right, whether that means significant amendments or, in the parlance of the day, “repeal and replace.” If it is thrown out, that would probably be good short-term, but in the long run it 22 SAN DIEGO PHYSICIAN.org february 2012

Dr. Hertzka: Private physicians, that is to say physicians who are actually aware of the cash-in, cash-out part of their practice environment, have been majority opposed all along, and that has shown in every survey taken. Physicians, particularly those who do any emergency work, know that the Medicaid expansion is a disaster-in-waiting. And given that the government has underfunded every physician access expansion for the past 50 years, there is scant optimism that PPACA will end up being good for physician practices. SDP: How about the public? They were originally quite negative. How do they feel

today now that all the “frosting,” as you put it, is out there? Dr. Hertzka: “Frosting” notwithstanding, the public remains opposed to PPACA with amazing consistency. In the last 10 months there have been some 45 major national polls by Gallup, CBS, The New York Times, etc. When asked if PPACA was either a good thing or a bad thing, or something to be retained or repealed, all 45 polls said that it was a bad thing and/or needed to be repealed, and 40 of those 45 had at least a 10-point margin, and eight had a 20-point margin. Frankly, this is amazing, given that the vast majority of people want to see more health insurance company regulation and embrace ideas like 26-year-olds on their parents’ policies. The public, most of whom are insured, certainly does not understand what Medicaid is, let alone the magnitude of the proposed expansion and the likelihood of increased emergency room wait times. And they certainly remain largely clueless about the HIEs. Yet even though the public really has only heard about the “frosting” and knows next to nothing about the “brick,” only about 38% favor PPACA, and they seem to do so mostly because they are partisan Democrats who seem to support the president unconditionally. I would note that there is one exception to this polling trend, and that would be seniors, who have been and remain much more adamantly opposed, in the range of 70% opposed vs. 30% in favor. Seniors know that you cannot cut $530 billion out of Medicare without having some kind of negative impact on their care. SDP: Let’s finish up with a little politics. 2012 is turning out to be quite the election year, and it appears that you were correct when you said that the presidential election may turn out to be a referendum on PPACA. But that said, won’t it be a problem for Republicans if they were to nominate someone like Mitt Romney, who promoted something very similar to PPACA when he was the governor of Massachusetts? Dr. Hertzka: Actually not, but that will not stop his current primary competitors or President Obama in a general election from

saying it. I have spent plenty of time reading about “Romneycare,” and even brought in the head of the Massachusetts Health Exchange to San Diego for a well-attended townhall meeting in early 2009. To understand the core of the Massachusetts plan, you have to remember that for some time now, states have been “taxing” hospitals — with their consent — and then refunding their taxes back to them as “enhanced” Medicaid payments. They are “enhanced” because the federal government matches state Medicaid payments at 1:1 or 2:1, depending on the state. So in the end both the state and the state’s hospitals come out ahead. In Massachusetts, a state that played this “tax the hospital” game as well as anyone, by 2003 these “enhancements” had grown to literally hundreds of millions of dollars per year, which was being put into a fund that was used to pay for the hospital/ER care of the uninsured. Mitt Romney came in as governor and said that these hundreds of millions of dollars should be used instead to provide subsidies to help the uninsured become insured. To incentivize the “young invincibles,” he did use a mandate, but the key part of his plan was the reallocation of dollars and the creation of an exchange that, unlike the PPACA HIEs, did not dictate insurance rates and did not require a tax increase. Comparing “Romneycare” with PPACA, one sees no massive Medicaid expansion, no $800 billion tax increase, no $500 billion in cuts from Medicare, and no likely $1 trillion (if not $2 trillion) deficit after 10 years. As to the politics of it, Governor Romney seems to put it well when he says, “The president flatters me when he says that he modeled his health reform proposal after what we did in Massachusetts. But I wish that he had called me at some point because I would have told him not to raise taxes, not to raid Medicare, not to hand out 20 million Medicaid cards, etc.” The 2012 election will be brutal and close, and both candidates will have weaknesses, but if Governor Romney ends up being the Republican nominee and people think that he and President Obama will be indistinguishable on the healthcare issue, I think that they will be surprised at how sharp the contrast will actually be.

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SDP: Any last thoughts? Dr. Hertzka: We have raised some important issues, but at the risk of piling on, I have to note that we have only scratched the surface. PPACA has numerous other problematic provisions, one example being the Independent Policy Advisory Board (IPAB), which is on track to significantly reduce physician reimbursements in the name of “saving money” by the end of the decade. The IPAB actually has strong bipartisan opposition in the House of Representatives, but the Democratic Senate leadership and the president still support it, so, short of a major power shift in Washington, DC, this November, the IPAB is here to stay. And other “money savers” look like they will be anything but that. It is already clear that the much ballyhooed financial penalties for hospitals with high re-admission rates will just punish safety-net hospitals, as the data collected this year on high re-

admission rates show clearly that they are associated with poorly compliant patients. This is as opposed to the greedy hospitals and physicians that were portrayed by PPACA proponents as the bill was developed. Yet this provision stands. And it is the same story for the muchballyhooed disease management and care coordination projects. The Congressional Budget Office just released an analysis of the first 34 demonstration projects of this type, and almost all failed to save money; in fact, these programs were far more likely to increase than to decrease costs. So much for all those promised Medicare “savings” from PPACA. SDP: What can any one individual physician do about what looms with PPACA? Dr. Hertzka: The most important thing is to stay informed and to stay abreast of developments. CMA can really help here; no physi-

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cian organization is more on top of all this than the California Medical Association. Its officers, including San Diegans Jim Hay, MD (president) and Ted Mazer, MD (vice speaker), spend many days in DC on our behalf. And, at the staff level, CMA CEO Dustin Corcoran and CMA federal lobbyist Elizabeth McNeil are both fabulous advocates. Finally, if you have ever thought about getting involved politically, 2012 would be a great time to start. If you are a Democrat, take the time to educate the legislators you know and support about how problematic PPACA is and how much it needs to be significantly adjusted. And if you are a Republican, you should look into supporting some out-of-state Senate candidates (no real Senate race in California in 2012), as well as a presidential candidate who understands healthcare and can win. Much is at stake in the 2012 elections, but perhaps nothing as much as the future of our healthcare system.

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26 SAN DIEGO PHYSICIAN.org february 2012

Not Your Usual AMA Meeting Report By Robe rt E . H e rtz k a , M D, Jam es T. Hay, M D, Lisa S. Mille r , M D, and Albe rt R ay, M D

In mid-June of last year in Chicago, and again in mid-November in New Orleans, more than 1,000 physicians from around the country (including dozens of residents and medical students) debated a wide range of proposals, and as a result established and/or changed multiple policies for the American Medical Association (AMA). These changes have resulted in many thousands of man-hours and many millions of dollars spent on advocacy with a whole host of government agencies and regulators, as well as with private health plans, with hospitals, and with the media. Sounds like these meetings may have been a big deal. Or were they? The prevailing opinion among physicians seems to be that AMA, despite having far more staff and spending far more dollars on advocacy than any other physician organization by far, has lost influence from where it was decades ago — and even from 18 years ago — when it was at the center of a coalition

that stopped the Clinton healthcare plan in its tracks. Truth be told, we would agree that AMA is indeed less influential than it was 20 years ago. But we would also note that this loss of influence is not for any of the reasons that we hear bandied about in doctors’ lounges around town. Rather, as we will lay out in this article, it is for reasons that can be fixed and must be fixed because, as the uncharted waters of health reform loom ahead, the best thing that could happen for physicians is to restore that old AMA influence. Please read on. What we will discuss about AMA does not come from a random impression here or there. We speak as four experienced local representatives to AMA, one of whom has attended almost every semi-annual AMA meeting since 1988, and has had two leadership positions in AMA [AMPAC board 1996–2004 (chair 2002–04); Council on Medical Service (2008–present)].

The AMA that many of us grew up with had as its core mission the maintenance of the viability of the medical profession. What “viability” means may seem subjective in a changing medical practice environment, but it is actually not. For nearly 50 years, 98% of why physicians find themselves needing to collectively advocate for themselves can be linked to four core issues, which can be termed the “core four”: (1) seeking or protecting medical liability reforms such as MICRA; (2) blocking dangerous expansions of scope of practice; (3) dealing with almost invariably inadequate payments — and onerous regulations — from government health programs; and (4) protecting physician autonomy from being undermined by undue economic influences, which in most cases have been hospitals or hospital systems. And beyond advocacy for these core values, organizations like AMA at the federal level and the California Medical Asfeb ruary 2012 SAN DIEGO PHYSICIAN.org 27

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sociation (CMA) at the state level serve one other critical purpose: to collect and synthesize the views of the entire profession. This is critical, as decision makers such as our legislators in Sacramento and in Washington, DC, really do not want to try to sort through the myriad of views that arise from the various corners within medicine. When decision-making time comes, they are almost invariably seeking a single consensus viewpoint, and that viewpoint can only come from an AMA or CMA-type organization. It is hard to object to what we have outlined here. Who among us does not support meaningful tort reform? Or appropriate scope of practice levels for nonphysicians?

is CMA that has been the powerful consensus organization that has taken the lead in successfully protecting MICRA, in blocking almost all scope expansions, in going as far as the Supreme Court to block cuts to Medi-Cal, and, as recently as last summer, in blocking a proposal backed by one of the state’s most powerful labor unions that would have allowed widespread direct physician employment by hospitals. And there has been even more: CMA is singularly responsible for some of the most sweeping reforms of the health insurance industry, including major successes with racketeering lawsuits against the nation’s largest health plans. So what has happened on the federal level? Why do only 15% of America’s practicing physicians belong to AMA, whereas 60% or more belong to CMA and other state societies? Several reasons of course, but, far more than any other, the absolute number-one reason for decreased AMA membership has been that at the federal level physicians now overwhelmingly self-identify with their specialty, at the expense of identifying with the entire profession. That preference for specialty society membership should come as no surprise to most physician readers of this article, as there is more than a 90% likelihood that any given practicing physician is a member of his or her national specialty society, as compared to only a 15% chance that he or she is an AMA member. And why not? When most of us started our residencies, there were usually applications to our federal specialty societies all filled out and ready for signature, with no mention of AMA. More recently, that influence has started sooner, as there are now medical student organizations for many specialties just like there are pre-med organizations for undergrads, and many of these medical student organizations start recruiting on day one of medical school. Beyond self-identification, which is to say, having more in common professional-

Decision makers such as our legislators in Sacramento and in Washington, DC, really do not want to try to sort through the myriad of views that arise from the various corners within medicine. Who among us does not oppose the current payment mechanisms for Medicare (27% cut looming — again — on March 1, 2012) and Medicaid? And who among us would not oppose a surrender of our professional autonomy to bottom-line hospital managers, bottom-line insurance executives, or bottom-line government bean counters? And, finally, who among us could not support an organization that fights for us on all these core issues and can act as an impartial convener of the various perspectives within the medical profession, after which they can then advocate consensus positions, both legislatively and politically, on behalf of hundreds of thousands of us around the nation? It still works on the state level — and works well. In California, other than in Los Angeles County, which has had some unique problems within its medical society, the majority of practicing physicians are CMA members, and that number is growing. Most physicians seem to realize that it 28 SAN DIEGO PHYSICIAN.org february 2012

ly with fellow specialty members than with other physicians, breaking up into specialty groups has had an appeal on the policy level as well, particularly since the Medicare Resource-based Relative Scale (RBRVS) changes came about in Medicare in the late 1980s. Suddenly, specialty-specific payment and regulatory issues were a big part of congressional health policymaking, and it would seem that any given issue might best be handled by the focused specialty group most affected by the issue. We need to emphasize here that none of this is new. In fact, by the time the Clinton health reform debates of 1993–94 were under way, specialty societies had already reached their 90+% participation levels and were actively lobbying health issues, while AMA had already dipped well below a 30% membership level. However, despite that, AMA leadership and policy development were still dominated, as they had always been, by physicians representing state societies, i.e., physicians who looked at how policy proposals affected the profession as a whole. In that context, at that time, it was clear to most any physician looking at the “big picture” that the Clinton health reform proposal was not that well thought out and really did not fiscally “pencil out.” In fact, when the Clinton plan was rolled out in a nationally televised address in September 1993, every AMA member (in that pre-internet area) received a 14-page fax in twocolumn format comparing what was being proposed with AMA policy, highlighting discrepancies and problems. Along with hundreds of other physicians around the country, two of us used those talking points in local TV and radio interviews to raise some very appropriate concerns. Ultimately, due in large part to AMA’s opposition, with little additional input from the various specialty societies, the plan died without ever being voted out of a single congressional committee. So what happened between 1993–94 and today? Certainly the current health reform legislation, known as the Patient Protection and Affordable Care Act (PPACA), while different in detail from the Clinton plan, is similar in that few have ever thought that it really “penciled out.” Of course the private insurance reforms are popular, and in some

cases overdue, but a massive expansion of Medicaid in 2014 paid — after the first year — at current Medicaid rates? A massive yet dubious creation of 50 state insurance exchanges that will provide health insurance overnight to tens of millions of people? $530 billion cut out of an already deeply underfunded Medicare program? Why was the 2009 AMA silent on a proposal that seemed so fiscally dubious when they had been so out in front of something similar in 1993? We will declare first what it was not: It was not some evil deal to protect CPT revenue or any other AMA business line. That one is right up there with the Sept. 11 “truthers” on the far left or the Obama “birthers” on the far right — great conspiracy theory and great physician lounge chatter, but an idea based only on the fantasies of people who have never been to an AMA meeting or who in some cases are trying to derive personal financial

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benefit by trying to tear down AMA. Rather, we believe that the different way that AMA looked at this round of health reform was directly related to the changes it made in its governance structure in the late 1990s when it arguably “succumbed to reality” and began to dramatically influence the role of specialty societies. Physician organization governance actions, both state and federal, are largely determined, as they should be, by the delegates who attend the meetings. Locally elected and locally accountable, as we are, it may not be the most efficient system, but it is one that has stood the test of time. But the emergence of specialty-based thinking among physicians has challenged that model. If many physicians identify more with their specialty than with being from, say, San Diego, should there not be some delegates elected from specialty societies to represent that?

The answer is yes. At the state level, this has long been recognized, and there are in fact specialty society delegates in organizations such as CMA. But those delegates collectively have only about 15% of all the delegate votes, which is enough for meaningful input and can be enough to influence a decision, but which is never inherently decisive. So, in the overwhelming majority of circumstances, decisions are made — and officers are elected — by physicians who come to the meetings looking at the medical profession and the medical practice environment as a whole, i.e., the “big picture.” But AMA took a different path in the late 1990s: It chose to expand specialty society influence to the point where now fully half the delegates come from various specialty entities. This has had a profound influence on who is elected to various positions within AMA and, more importantly, its ability to

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make big-picture policy decisions. To the former, the issue of which physicians serve in leadership, we have been a witness to the transition. When Dr. Hertzka was appointed to AMPAC in 1996 and then served for eight years, of the nine physicians on that board, at any given time one there was a single-specialty representative while the remaining eight had served, were serving, or were about to serve as their state medical association president. Contrast that with the current AMA Councils, where as many as half of the 10 physicians serving on them are specialtysociety delegates. That same dynamic now applies to AMA’s board and, in recent years, even to the officers. Consider this numerical fact: In the AMA House of Delegates in 2012, the delegates representing hospital-based physicians will have more votes than the delegates representing California, and the primary care coalition of AAFP, ACP, and AAP will be able to outvote California and Florida combined. No state allows anything like this among their state delegations; this is

the big issues such as PPACA come up, the initial reaction from specialty societies large and small tends to be “as long as my funding stream appears fairly secure, I will not oppose.” Let’s be clear: These changes within AMA have been profound. Fewer than half of the +/- 500 voting delegates are elected from their communities. And among those from specialty societies, nearly 100 attend as single delegates representing miniscule societies with miniscule agendas (American College of Mohs Surgery, American Academy of Insurance Medicine, etc.). And many of these +/- 250 specialty delegates are salaried or academic or both, distancing them from the impacts of many major health reform initiatives. These delegates are truly fine people and fine physicians, but they are often not leaders who have been through the crucible of state politics, an experience that not only hones that “big-picture” view of the world, but that also sensitizes one to overpromised and underfunded government health programs. Now frankly, while these changes in delegate allocation were profound, they did not really matter much through 2008, as Republicans controlled Congress and/or the White House from 1994 to 2008. As a result, while there were some expansions of healthcare access (S-CHIP, Medicare Part D), there were no sweeping Clinton-like proposals with Republicans in charge. Enter 2009. A major sweeping health reform proposal favored by a new and charismatic Democratic president and huge Democratic congressional majorities. Most everyone in medicine wanted to give it a chance, but it became clear after about eight months that it was going to be done on the cheap. Medicaid expansions instead of private insurance premium support. An arbitrary cap of $900 billion over 10 years, despite a consensus among most observers and even most House Democrats that what they were trying to do would cost at least 50% more than that.

No wonder that many rank-andfile practicing physicians felt let down by AMA — yet the irony is that AMA only did what the physician representatives of the broad coalition of specialty societies wanted them to do.

exclusively an AMA phenomenon. So how is this a problem? Physician voices are still heard, just filtered through a specialty society (in fact, there are now more than 100 organizations that “represent physicians” that lobby Congress). The problem is that in Washington, specialty societies tend to play “small ball,” as in just protecting their piece of the pie and/or just trying to make their piece a little bigger, rather than thinking about how to keep the whole pie from shrinking, or even how to grow the pie. So, when 30 SAN DIEGO PHYSICIAN.org february 2012

State medical associations figured this out, and at least a dozen took early positions of opposition. And by the end of 2009, when the Senate version of the bill (which is what ultimately passed) was so obviously underfunded and so laden with antiphysician provisions (IPAB, etc.), even our historically left-leaning California Medical Association came out in opposition. And AMA? With half of the voting delegates coming from specialty societies, most of whom apparently feeling that (a) health reform was “inevitable,” but that (b) their specialty/academic niche was secure, little sense of opposition was evident. Instead, the public posture of AMA was one of how we would all “make history” by finally “doing the right thing.” What a change from 1994. Just look at PPACA in the context of the “core four” issues cited earlier: tort reform, never a chance of that; scope changes, all bad, as PPACA is the biggest federal nurse practitioner empowerment act ever devised; adequate funding, anything but — no one really believes that it will “pencil out” as currently structured; and protection of professionalism, hardly — the so-called “Accountable Care Organization” vision advanced by PPACA has already led to more physicians signing their professional lives over to hospital systems in the past year than the prior 50 combined. No wonder that many rank-and-file practicing physicians felt let down by AMA — yet the irony is that AMA only did what the physician representatives of the broad coalition of specialty societies wanted them to do. So what now? As prospects for PPACA success look bleaker by the month (see article on page 16), is there any change from AMA? None from the leadership, but the delegates, even with their inherent proPPACA biases, are getting restless. Last June they overruled the leadership by voting to put AMA in opposition to the new Independent Practice Advisory Board (IPAB), and then in November they took two more steps. One was to put AMA, however belatedly, in opposition to the implementation of the onerous ICD-10 coding system; the other was to adopt a set of policy principles designed to guide state medical associations as they deal with the creation and implementation of the health insurance

exchanges (HIEs) called for in PPACA. The latter action was important because if followed, it will put many states — and AMA — in opposition to a critical part of PPACA. The HIE guidelines in PPACA are so vague that they will allow states to create HIEs that are quite physician-hostile, but AMA can now step in and help states in which bad HIEs are being proposed. So the delegates are restless and are slowly putting AMA in more of a position to object to the worst of PPACA’s provisions. Whether that trend continues in future meetings — the next being June 2012 in Chicago — remains to be seen. Our bottom line: If you remember anything from this article, it should be that physicians will only be successful in the public policy arena to the extent that we are unified. As weakened as AMA may be, in almost all cases it remains the only organization that is listened to by both congres-

sional leaders and high-level administration officials as major policy decisions are made. When physicians walk away from AMA, they are only empowering our enemies. We would also emphasize that despite our strong feelings about the relative roles of state and specialty medical societies, none of us has considered quitting our specialty society. Our specialty societies provide great service to us from both an educational and a specialty-specific policy development standpoint. However, if you care about advocacy, we encourage you to remain a member of SDCMS/CMA/AMA and to consider rejoining AMA if you have quit. A stronger AMA is our best hope to survive the challenges that we as physicians face in the coming years. On a lighter and more positive note, the delegates from California have elected San Diego’s own Al Ray, MD, to be our statewide delegation chair. From the perspective of

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Drs. Miller, Hay, and Hertzka, Dr. Ray is a great choice. He is very much a “big picture” thinker who is looking out for all of us, and is interested in seeing that the influence of state medical associations be restored within AMA. In fact, with the support of CMA leadership, Dr. Ray has already initiated a series of meetings with other large-state physician leaders in Texas, New York, and Florida. Hopefully these meetings can be a springboard to seeing AMA become more influential again. As we like to say at AMA, “Together we are stronger.” Drs. Hertzka and Hay are AMA delegates, and Drs. Miller and Ray are AMA alternate delegates. Dr. Hertzka, Dr. Hay, Dr. Miller, and Dr. Ray are all past presidents of the San Diego County Medical Society. Dr. Hertzka is a past president of the California Medical Association (CMA), and Dr. Hay is CMA’s current president.

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

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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

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

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classifieds PHYSICIAN POSITIONS AVAILABLE ASSOCIATE MEDICAL DIRECTOR: San Ysidro Health Center, a federally qualified health center with nine medical clinics serving southern San Diego, is recruiting for an associate medical director. Will report to the chief medical officer with a dotted line relationship to the CEO. Works collaboratively to ensure SYHC continues to provide high quality, cost-effective healthcare. Leads efforts to increase healthcare access and enhance the patient experience. Provides some direct patient care (80% administrative, 20% direct patient care). Qualifications: Doctorate degree in Medicine (MD or DO) from accredited school of medicine; valid, current, unrestricted California medical license; BC in primary care specialty; minimum five years clinical/administrative practice in primary care setting; minimum five years as an associate medical director or clinical lead physician. Send resume to jobs@syhc.org. [005] GERIATRICIAN: Full-time position available at Neighborhood Healthcare in North San Diego County. This position provides comprehensive medical services for geriatric patients on continuing basis. Candidates must have current California medical license, DEA, and CPR certification. Please send CVs to Dr. Jim Schultz via email at JimS@nhcare.org or fax to (760) 796-4021 — “Attn: Geriatrician” must be included in the subject of your email or fax for your application to be considered. [010] CONTRACT PHYSICIAN: Profil Institute for Clinical Research is in need of three contract physicians for primarily weekend shifts. Requirements: One year of clinical experience in adult medicine and/or equivalent experience. License to practice medicine in California. Responsibilities: Perform medical histories, physical exams, and protocol-based assessments for qualification of subjects for studies. Admit, discharge, and monitor subjects including reviewing labs results, EKGs, and telemetry. Assess and manage adverse events and medical emergencies. Participate in safety and dosing assessments. Interested parties please email resumes to hrpicr@profilinstitute.com. If you have further questions, please contact Robyn Nielsen, recruitment manager, at (619) 419-2048. [007] PART- OR FULL-TIME PHYSICIAN OR PHYSICIAN ASSISTANT: Immediate opening for a part- or full-time physician or physician assistant in a busy internal medicine practice with two offices in La Mesa and El Cajon. This office uses EHR with speech recognition. The candidate should be willing to see patients at hospitals and SNF as well. Efficient, hardworking team-player with compassion towards patient care is expected. Compensation is competitive and commensurate with experience. Interested candidates can email CV to vprabaker@ yahoo.com, attention to Venu Prabaker, MD. [999] XIMED HOSPITALISTS, INC., LA JOLLA, CA: Prestigious, 350-physician multi-specialty group seeks experienced full-time hospitalists to be part of an established hospitalists program at Scripps Memorial Hospital, La Jolla. Board-certified internal medicine physicians with superior clinical skills and willing to work in a team environment. Excellent communication skills a must. Outstanding salary, bonus, and benefits. Please email CV to Yvonne Montelius, XiMED Hospitalists, at ymontelius@ ximedinc.com or fax to (858) 587-1642. [997] NEUROLOGIST: This practice is seeking a qualified neurologist to join our practice here in beautiful La Jolla. We are a well-established neurology practice with four physicians. We are located on and provide on call for Scripps Memorial Hospital, La Jolla campus. We have a large referral base with two HMOs and contract with numerous insurance companies. There is outstanding earning potential, and the opportunity to expand into other areas is certainly a possibility. On-call ratio is 1:4. One of our physicians is the stroke director at Scripps Memorial Hospital. Our practice treats neurodegenerative diseases with emphasis on dementias. We treat a large number of movement disorder, stroke, and Botox treatment, as well as Parkinson’s disease. If you know

anyone who would be interested in this excellent opportunity, please contact our office at or forward resumes to mrsbinx@hotmail.com. [995] INTERNAL MEDICINE, PRIVATE PRACTICE PART TIME: LIFE/WORK BALANCE! Unusual and exceptionally attractive private practice IM opportunity in beautiful North San Diego County. Stable, long-term, part-time position available with flexible scheduling. Collegial, single-specialty group, exceptional office staff, and above all very high-quality patient care set this far apart from many other situations. Outpatient only, paperless office, easy access from anywhere in the county. Multiple scheduling options available, making this very attractive for any physician wanting part-time only work or wanting to combine with other job opportunities. Outstanding way to experience private practice. Email CV to portofino3@aol.com or call (619) 248-2324. [993] 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 NEEDED: Family medicine, pediatrics, and OB/GYN. Vista Community Clinic, a private nonprofit outpatient clinic serving the communities of North San Diego County, has opening for part-time, per diem positions. Must have current CA and DEA licenses. Malpractice coverage provided. Bilingual English/Spanish preferred. Forward resume to hr@vistacommunityclinic. org or fax to (760) 414-3702. Visit our website at www. vistacommunityclinic.org. EOE/MF/D/V [912] 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 WANTED WE BUY URGENT CARE OR READY MED-CLINIC: We are interested in purchasing a preexisting urgent care or ready med-clinic anywhere in San Diego County. Please contact Lyda at (619) 417-9766. [008] residential REAL ESTATE

BANK OWNED - LA JOLLA ESTATE Price Reduction… $1,795,000 This sprawling Ranch-style home, with gorgeous pool & spa, commands almost a HALF ACRE of lushly landscaped grounds. Hidden at the end of this quiet West Muirlands cul-de-sac, you’ll find a magnificent family compound or entertainer’s dream! A privately gated, tree lined drive leads to the stately entry courtyard. Bright, spacious kitchen with newer stainless steel appliances. 5 bedrooms and 6 baths to accommodate a large family and guests. 4,656 square feet. Contact: Suzanne M. Giannella Broker Associate, Realtor®, CNE CA DRE #01770605 Pacific Sotheby’s International Realty 858.248.6398 suzanne.giannella@sothebysrealty.com www.sothebysrealty.com Each office is Independently Owned and Operated.

OFFICE SPACE / REAL ESTATE LOOKING FOR SPACE TO SUBLET: Please contact if you have office space available to sublet. Would specifically be interested in Poway, Escondido, Vista, North County, San Marcos, Sorrento Valley, Del Mar, etc. Prefer situation where we can use existing office staff. Contact sundhmail@yahoo.com. [011] LUXURIOUS / BEAUTIFULLY DECORATED DOCTOR’S OFFICE NEXT TO SHARP HOSPITAL FOR SUB-LEASE OR FULL LEASE: The office is conveniently located just at the opening of Highway 163 and Genesee Avenue. Lease price if very reasonable and appropriate for ENT, plastic surgeons, OB/GYN, psychologists, research laboratories, etc. Please contact Mia at (858) 279-8111 or at (619) 823-8111. Thank you. [836] NEW — EXTREMELY LOW RENTAL RATE INCENTIVE — EASTLAKE/RANCHO DEL REY: Two office/medical spaces for lease. From 1,004 to 1,381 SF available. (Adjacent to shared X-ray room.) This building’s rental rate is marketed at $1.70/SF + NNN; however, landlord now offering first-year incentive of $0.50/SF + NNN for qualified tenants and five-year term. $2.00/SF tenant improvement allowance available. Well parked and well kept garden courtyard professional building with lush landscaping. Desirable location near major thoroughfares and walkable retail amenities. Please contact listing agents Joshua Smith / Steve Dok, Grubb & Ellis, at (858) 875-3600. [006] POWAY / RANCHO BERNARDO — OFFICE FOR SUBLEASE: Spacious, beautiful, newly renovated, 1,467 sqft furnished suite, on the ground floor, next to main entrance, in a busy class A medical building (Gateway), next to Pomerado Hospital, with three exam rooms, fourth large doctor’s office. Ample parking. Lab and radiology onsite. Ideal sublease/satellite location, flexible days of the week. Contact Nerin at the office at (858) 521-0806 or at mzarei@cox.net. [873]

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 february 2012

TWO MONTHS FREE RENT: 1,215 SQ FT MEDICAL OFFICE NEXT TO POMERADO HOSPITAL: Office has furnished waiting area, front and back stations for four staff members, two exam rooms, a break room, private bathroom, and doctors’ office. Office is updated and 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. Negotiable rent. Please contact Olga at (858) 485-8022. [980] SAN DIEGO NORTH COUNTY OFFICE SPACE TO SHARE: Share reception, waiting area, and exam/consultation rooms in Class A medical building. Office is close to TCMC and all ancillary services. Flexible, P/T availability. Great opportunity for a North County satellite office. For more information, contact Anne at abilleter@ncim.net or at (760) 726-2180. [003] FOR SALE OR LEASE OR LEASE-OPTION: Coronado condo/office. California Plaza. 1001 B Ave., Ste. 100. Corner first floor, 900 sq. ft. Perfect doctor’s office. $375K. Owner will carry. Call (619) 997-3112. [002]

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] NONPHYSICIAN POSITIONS AVAILABLE FAMILY NURSE PRACTITIONER: Full-time position (40 hours per week) available in North San Diego County. The FNP provides healthcare services to patients under direction and responsibility of physician. Candidates must have a current FNP license, DEA and CPR certifications. Candidates must also specialize in geriatrics. Please send CVs to Dr. Jim Schultz via email at JimS@ nhcare.org or fax to (760) 796-4021 — “Attn: FNP-North” must be included in the subject line of your fax or email for your application to be considered. [009] PA/NP NEEDED IN VERY ACTIVE NEUROSURGERY 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. Motivated, as well as caring candidates, please send email with CV and references to armonia01@ me.com. [977]

REGISTERED POLYSOMNOGRAPHY TECHNICIAN; MEDICAL OFFICE ASSISTANT/FRONT DESK: AKANE Institute of Allergy, Asthma, and Sleep Medicine is a medical practice with our main office and sleep lab located in Scripps Ranch on Scripps Poway Pkwy off I-15. We provide specialty care for allergy, asthma, and sleep disorders. We are currently looking to recruit for the following positions: Registered Polysomnography Technician (RPSGT); Medical Office Assistant/Front Desk. We are looking for individuals who are technology savvy as we have a paperless office. We believe in providing stateof-the-art medical care and exceeding patient expectations. We are seeking applicants with previous experience, proven clinical skills, and friendly personality. Both part-time and full-time options are available with health benefits for full-time employees. If interested in joining our team, please contact us at akaneinstitute@gmail. com or at (858) 412-7362. [004] FT MEDICAL INSURANCE BILLER WANTED: Collections, A/R, with knowledge of full cycle billing. Verification of insurance benefits, and be familiar with electronic and paper billing insurance claim follow-up. Previous experience preferred. Send resume to mrsbinx@hotmail.com. [001] PART- OR FULL-TIME PHYSICIAN OR PHYSICIAN ASSISTANT (see #999 under “PHYSICIAN POSITIONS AVAILABLE”)

CLAIREMONT OFFICE SPACE TO SHARE: Currently occupied by two general internists. Great central location in Clairemont, halfway between Sharp Memorial and Scripps La Jolla hospitals. Office just recently remodeled. Free parking. Looking to share with specialty physician. Fully furnished. Terms negotiable. Please contact Gary at (858) 430-1651 for more details. [996] OFFICE SPACE TO SHARE: Currently occupied by orthopedic surgeon. Great location close to Scripps/Mercy and UCSD Hospital. Looking to share with part-time or fulltime physician. Fully furnished, fully equipped with fluoro machine and four exam rooms, and staff. (NEGOTIABLE) Please contact Rowena at (619) 299-3950. [804] FULL-AND PART-TIME OFFICE SPACE IN UTC with 8th floor view in suite with established psychologists and psychiatrists in Class A office building. Features include private entrance, staff room with kitchen facilities, active professional collegiality and informal consultation, private restroom, spacious penthouse exercise gym, storage closet with private lock in each office, soundproofing, common waiting room, and abundant parking. Contact Christine Saroian, MD, at (619) 682-6912. [862] SCRIPPS ENCINITAS CONSULTATION ROOM/EXAM ROOMS: Available consultation room with two examination rooms on the campus of Scripps Encinitas. Will be available a total of 10 half days per week. Located next to the Surgery Center. Receptionist help provided if needed. Contact Stephanie at (760) 753-8413. [703] 3998 VISTA WAY, IN OCEANSIDE: Two medical office spaces approximately 2,000 sq. ft. available for lease. 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] 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]

Increase Your Referral Business 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.

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

feb ruary 2012 SAN DIEGO PHYSICIAN.org 35

SDCMS-CMA MEMBERSHIP

Errata

San Diego County Physician Directory 2012 Please make the following corrections to your copy of SDCMS’ 2012 San Diego County Physician Directory, which was mailed with the December 2011 issue of San Diego Physician magazine: Please Delete Listings for the Following Physicians: • Asher Dean B MD • Gilles Alissa J MD Please Update Listing Information for the Following Physicians: • Chodos Marc D MD: T: 6194623131 F: 6194621731 A: 5565 Grossmont Center Dr, Bldg 3, Ste 256, LM 91941 N1: 1811094873 (ors) • SEROCKI JOHN H MD {ors} T: 8588241703 F: 8584556473 W: ljso.org A: 9834 Genesee Ave, Ste 228, LJ 92037 <Note: Dr. Serocki’s “955 Lane Ave.” address is a secondary practice address.> N1: 1679574743 [hs/ar/sm] • WEISS DANIELLE EVELYN MD {im/edm} T: 7607533636 F: 7604652332 W: centerforhormonalhealth.com A: 477 N El Camino Real, Ste D-200, EN 92024 N1: 1275731515 [mpd/os/ost/t] Our sincere apologies for the errors!

36 SAN DIEGO PHYSICIAN.org february 2012

We Celebrate Excellence – Theodore M. Mazer, MD CAP member and tireless champion for access to quality health care, for those in need

800-252-7706 www.CAPphysicians.com San Diego orange LoS angeLeS PaLo aLTo SacramenTo

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

Superior Physicians. Superior Protection. 37

may 2011 2012 SAN DIEGO P HY SICIA N. o rg 37 feb ruary SAN DIEGO PHYSICIAN.org

$5.95 | www.SANDIEGOPHYSICIAN.org PRSRT STD U.S. POSTAGE PAID DENVER, CO PERMIT NO. 5377

San diego County Medical Society 5575 RUFFIN ROAD, SUITE 250 SAN DIEGO, CA 92123 [ RETURN SERVICE REQUESTED ]

Richard E. Anderson, MD, FACP Chairman and CEO, The Doctors Company

We reward loyalty. We applaud dedication. We believe doctors deserve more than a little gratitude. We do what no other insurer does. We proudly present the Tribute® Plan. We honor years spent practicing good medicine. We salute a great career. We give a standing ovation. We are your biggest fans. We are The Doctors Company.

You deserve more than a little gratitude for a career spent practicing good medicine. That’s why The Doctors Company created the Tribute Plan. This one-of-a-kind benefit provides our long-term members with a significant financial reward when they leave medicine. How significant? Think “new car.” Or maybe “vacation home.” Now that’s a fitting tribute. The San Diego County Medical Society has exclusively endorsed our medical professional liability program since 2005. To learn more about our program for SDCMS members, including the Tribute Plan, call us at (800) 852-8872 or visit www.thedoctors.com/tribute.

Endorsed by

www.thedoctors.com 38Tribute SAN DIEGO PHYSICIAN.org february Plan projections are not a forecast2012 of future events or a guarantee of future balance amounts. For additional details, see www.thedoctors.com/tribute.