February 2013 by San Diego Physician

official publication of the san diego county medical society February 2013 San Diego Physician

celebrates

100 years

“Physicians United For A Healthy San Diego”

ANNOUNCING

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S A N D I E G O P HY S I CI A N .or g O c tob e r 2011

Special Mortgage Financing for Physicians Our special home financing program is designed to meet your needs as a physician for the purchase, refinance or construction of your primary residence. • Financing for single family homes available with low down payment up to $1,750,000. Refinances with high loan-to-values are also available • Private mortgage insurance is not required • One-Time Close Construction Loan - one application, one approval and one closing for both construction and permanent loans. For information on this special home financing program from BBVA Compass, give us a call today. Bryan Yaninek, NMLS #392774 Mortgage Banking Officer 719-499-9000 • bryan.yaninek@bbvacompass.com apply online at: bbvacompass.com/mortgages/byaninek

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8.4375x11_SMF Physicians AD.indd 1

11/17/11 11:59 AM

this month Volume 100, Number 2

features THE DEATH OF FEEFOR- SERVICe 24 The Death of Fee-for-Service 25 Surely, You Must Be Joking BY MICHAEL COURIS, MD 26 Fair and Balanced? BY EILEEN S. NATUZZI, MD 27 We’ve Had Enough BYRONALD FELDMAN, MD 27 Not Today and Not Tomorrow BY TED STEUER 28 Mural Dyslexia BY JOSEPH E. SCHERGER, MD, MPH 29 Fee-for-Service Will Continue to Grow! BY ROBERT PENDLETON, MD

departments

30 Neurology Solos in the Coalmine: Canaries Looking Good by Comparison BY JAMES SANTIAGO GRISOLÍA, MD

Calendar • Get in Touch • Real Estate Trends • Welcome New and Rejoining Members • And More …

Hillcrest: Theodore S. Thomas, MD (A: Gregory M. Balourdas, MD) Kearny Mesa: John G. Lane, MD, Jason P. Lujan, MD (A: Sergio R. Flores, MD) La Jolla: Geva E. Mannor, MD, Wynnshang “Wayne” Sun, MD (A: Matt H. Hom, MD) North County: Niren Angle, MD, Douglas Fenton, MD, James H. Schultz, MD (A: Anthony H. Sacks, MD) South Bay: Vimal I. Nanavati, MD, Michael H. Verdolin, MD (A: Andres Smith, MD)

Communications Chair: Theodore M. Mazer, MD (CMA SPEAKER)

14 Hurricane Sandy Underscores the Need for Physicians to Be Prepared for a Disaster

Young Physician Director: Van L. Cheng, MD Retired Physician Director: Rosemarie M. Johnson, MD Medical Student Director: Suraj Kedarisetty

by THE DOCTORS COMPANY

18 Power to the People: Each and Every One of Us

geographic and geographic alternate Directors East County: Alexandra E. Page, MD, Venu Prabaker, MD

other voting members

BY LARRY B. ANDERSON

by DANIEL J. BRESSLER, MD

SDCMS Board of Directors Officers President: Sherry L. Franklin, MD (CMA TRUSTEE) President-elect: Robert E. Peters, PhD, MD Treasurer: J. Steven Poceta, MD Secretary: William T-C Tseng, MD, MPH Immediate Past President: Robert E. Wailes, MD (CMA TRUSTEE)

At-large ALTERNATE Directors James E. Bush, MD, Theresa L. Currier, MD, Thomas V. McAfee, MD, Carl A. Powell, DO, Elaine J. Watkins, DO, Samuel H. Wood, MD, Holly Beke Yang, MD, Carol L. Young, MD

10 Data-driven Review Helps Tri-City Medical Center Reduce Readmissions

16 Undressed

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

At-large Directors Karrar H. Ali, MD, David E.J. Bazzo, MD, Jeffrey O. Leach, MD (DELEGATION CHAIR), Mihir Y. Parikh, MD (EXECUTIVE COMMITTEE BOARD REP), Peter O. Raudaskoski, MD, Kosala Samarasinghe, MD, Suman Sinha, MD, Mark W. Sornson, MD (EXECUTIVE COMMITTEE BOARD REP)

4 Briefly Noted

Managing Editor: Kyle Lewis

OTHER NONVOTING MEMBERS

by HELANE FRONEK, MD, FACP, FACPH

20 Breast Cancer Affects More Than Just the Breast by SANDRA CRAY

Young Physician Alternate Director: Renjit A. Sundharadas, MD Retired Physician Alternate Director: Mitsuo Tomita, MD SDCMS Foundation President: Stuart A. Cohen, MD, MPH CMA Past Presidents: James T. Hay, MD (AMA DELEGATE), Robert E. Hertzka, MD (LEGISLATIVE COMMITTEE CHAIR, AMA DELEGATE), Ralph R. Ocampo, MD CMA Trustee: Albert Ray, MD (AMA ALTERNATE DELEGATE) CMA Trustee (OTHER): Catherine D. Moore, MD CMA SSGPF Delegates: James W. Ochi, MD, Marc M. Sedwitz, MD CMA SSGPF Alternate Delegates: Dan I. Giurgiu MD, Ritvik Prakash Mehta, MD

22 Mindfulness in Clinical Practice: Our Patients, Ourselves 34 Physician Marketplace Classifieds

36 San Diego Physician Celebrates 100 Years

14 2 february 2013

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.]

Your Rhythm.

Leading-edge heart care. So you don’t miss a beat. Tri-City Medical Center leads the way when it comes to matters of the heart. Our state-of-the-art Cardiovascular Health Institute and da Vinci® robotic surgery options will keep you a step ahead. In fact, we’re ranked in the top 1% of hospitals nationwide for lowest heart attack readmissions. At Tri-City Medical Center, we believe as we progress, so does your health.

For more information, call (855) 222-8262 or visit TRICITYMED.ORG/HEART

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

For further information or to register for any of the following SDCMS seminars, webinars, or workshops, visit www.SDCMS. org/event or contact Jen at (858) 300-2781 or at JOhmstede@ SDCMS.org. The Leader’s Toolkit (workshop) MAR 16–17 • 8:00am–4:00pm, 8:00am–12:00pm Medicare 2013 and Beyond (seminar/webinar) MAR 21 • 11:30am–1:00pm Certified Medical Coder (course) MAR 22, 29, APR 5, 12, 19 • (8:00am–4:00pm Each Friday)

Cma Webinars

CMAnet.org/events

Practice Mergers: How to Successfully Merge Physician Practices FEB 27 • 12:15pm–1:15pm Fraud and Abuse MAR 6 • (TBD) Essentials for ICD-10-CM: Part 1 MAR 7 • (TBD)

Utilizing the New State Disability Insurance Online System MAR 13 • 12:15pm–1:15pm Essentials for ICD-10-CM: Part 2 MAR 14 • (TBD) EHR Selection: Top 10 Tips for Success MAR 20 • 12:15pm–1:15pm Essentials for ICD-10-CM: Part 3 MAR 21 • (TBD)

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. Aces for Health Golf Tournament FEB 28 • Del Mar Country Club, Benefitting the SDCMS Foundation’s Project Access San Diego • Call Nicole at (858) 5657930 or visit sdcmsf.org/golf The Future of Genomic Medicine MAR 7–8 • 7:30am–5:00pm • Robert Paine Scripps Forum • www.scripps.org/events/thefuture-of-genomic-medicine-vimarch-7-2013

Journey Into Healing: Ayurveda and Mind-Body Healing MAR 14–17 • Seminar Featuring Drs. Deepak Chopra and Andrew Weil • La Costa Resort, Carlsbad • www.chopra.com/jih-sdcms# Musculoskeletal Medicine for Primary Care Providers: A Symposium From UCSD Sports Medicine MAR 22–23 • 7:45am–4:45pm on the 22nd, 8:00am–4:20pm on the 23rd • Paradise Point Hotel, San Diego • ucsdsportsmedcme.com Volunteers Needed for RAM California Expedition (free medical, dental, and vision clinic) APR 4–7 • Riverside / Indio Fairgrounds • www.ram-ca.org 17th Annual Heart Failure 2013 APR 6 • Millennium Biltmore Hotel, Los Angeles • www. laheartfailure.com Mindfulness in Clinical Practice: Our Patients Ourselves MAY 11 • All-day CME (6.75hrs) Workshop • Presented by the UCSD Center for Mindfulness • cme.ucsd.edu/mindfulness/mcp_ workshop_051113_home.html RCMA’s “Cruisin Thru CME” — French Waterways: Highlights of Burgundy & Provence JUL 1–13 • Call RCMA at (800) 472-6204

SDCMS Member Physicians:

If you are interested in learning more about joining the San Diego Physician editorial board, please email Editor@SDCMS.org. 4 february 2013

get in touch Your SDCMS and SDCMSF Support Teams Are Here to Help!

SDCMS Contact Information 5575 Ruffin Road, Suite 250, San Diego, CA 92123 T (858) 565-8888 F (858) 569-1334 E SDCMS@SDCMS.org W SDCMS.org • SanDiegoPhysician.org CEO • EXECUTIVE DIRECTOR Tom Gehring at (858) 565-8597 or Gehring@SDCMS.org COO • CFO James Beaubeaux at (858) 300-2788 or James.Beaubeaux@SDCMS.org DIRECTOR OF ENGAGEMENT Jennipher Ohmstede at (858) 300-2781 or JOhmstede@SDCMS.org DIRECTOR OF MEMBERSHIP SUPPORT • PHYSICIAN ADVOCATE Marisol Gonzalez at (858) 300-2783 or MGonzalez@SDCMS.org DIRECTOR OF RECRUITING AND RETENTION Brian R. Gerwe at (858) 300-2782 or at Brian.Gerwe@SDCMS.org DIRECTOR OF MEMBERSHIP OPERATIONS Brandon Ethridge at (858) 300-2778 or at Brandon.Ethridge@SDCMS.org DIRECTOR OF COMMUNICATIONS AND MARKETING • MANAGING EDITOR Kyle Lewis at (858) 300-2784 or KLewis@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

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 Francesca Mueller, MPH, at (858) 565-8161 or Francesca.Mueller@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 RESOURCE DEVELOPMENT DIRECTOR Nicole Hmielewski at (858) 565-7930 or Nicole.Hmielewski@SDCMS.org IT PROJECT MANAGER Rob Yeates at (858) 300-2791 or Rob.Yeates@SDCMS.org IT PROJECT MANAGER Victor Bloomberg at (619) 252-6716 or Victor.Bloomberg@SDCMS.org

real estate trends

Commercial Real Estate: 2012 Year-end Review By Chris Ross

hile healthcare is undoubtedly a hot topic when it comes to politics, the U.S. economy, taxes, and technology, the industry is no less conspicuous when it comes to its ties to commercial real estate leasing and sales. The constant news articles, seminars, and table-side conversations at trade organization events all do their part in bringing plenty of attention to the niche of healthcare real estate. But there is a lot of smoke in the air, and it is important for you to determine — as a tenant or buyer — what is truly taking place in the market, and how it impacts you. The indicators are all over the map. North County Coastal is offering little in the way of concessions, while UTC is providing some of the largest tenant improvement allowances and rent abatement packages in the region. Medical condos in Poway are on the market at $375/SF, but there are units in Eastlake that cannot generate a showing at $150/SF. Many buildings have been sitting with significant vacancy for four years, yet a number of the better-located Class A medical condo and for-lease projects are nearly 100% occupied. Countywide vacancy is lower than what it was two years ago, yet a gradual drop in the average asking rate persists. On the surface, market rents appear to be moving in the wrong direction, but the trend is misleading. The steady decline is due to a flight to quality that has been

occurring in recent years as providers move out of old, sterile space into new, high-quality medical space. As such, a majority of the vacancy (which is directly tied to weighted-average asking rents) has shifted from Class A and B buildings to older Class C inventory. UTC saw tenants expanding and relocating from surrounding areas consistently in 2010 and 2011 but seemed to go quiet on us in 2012. However, things are not as they seem. There is a limited amount of quality medical office space in the submarket, particularly anything close to move-in ready, so there simply was not much movement and absorption netted out at just below zero. Conversely, Uptown/Hillcrest, which in recent years has been extremely stagnant, led the county in net absorption in 2012. Again, misleading. The completion of Sharp’s new 66,000-SF facility skewed the statistics.

It helps to take a closer look at the detailed trends across the county and in your specific submarket to get a better sense of where things are headed, some of which is provided within this article.

Construction Spotlight Sharp Rees-Stealy’s new, threestory, 66,365-square-foot medical building at 300 Fir Street was completed in October 2012. With its sustainable, energy-efficient design, it is the first LEED-certified medical office building in the county.

Submarket Snapshot: I-15 Corridor For many years, the I-15 Corridor submarket experienced single-digit vacancy and stable rental rates. During a 20-year span from 1987 through 2006, only one medical building was developed: the 56,000-squarefoot Sharp Rees-Stealy building on Via Tazon in Rancho Bernardo. Not a single multitenant medical building was

built during that time frame. In the late 2000s, a spike in vacancy was inevitable when the area’s MOB inventory witnessed a 73% increase as three buildings totaling 391,348 square feet were completed over a two-year span. Additionally, Scripps Clinic in Carmel Mountain Ranch expanded and relocated to a build-to-suit across the street in 2008, moving out of a 90,000-square-foot medical building on Innovation Drive that presently remains vacant. Today, however, a vast majority of that newly delivered space has been leased, and the former Scripps Clinic building — which comprises over half of the vacancy in the submarket — is in the process of being repositioned into a corporate headquarters facility. So while vacancy is technically at an elevated rate of 17.6%, it should see a dramatic drop to around 8% once that building is removed from the market (it will likely be leased to a corporate office user). Similarly, at $1.95 gross, the space Scripps vacated artificially holds down the weighted average rental rate. On paper, that number currently stands at $2.54, but it is about to spike up to $3.21 — second highest in the county. 4S Health Center was completed in November and currently stands at 84% leased — an indicator that well-located space in growing areas is in very high demand. There are no other medical office buildings currently planned or under construction in the I-15 Corridor. Mr. Ross is vice president of healthcare real estate services at Colliers International. He is a commercial real estate broker, specializing exclusively in medical office and healthcare facilities in San Diego County. He can be reached at (858) 677-5329 or chris.ross@ colliers.com. SAN DI EGO PHYSICIAN.org 5

brieflynoted SDCMS membership

Welcome Our New and Rejoining SDCMS-CMA Members! New Members Francesca D. Adriano, MD Family Medicine • San Diego

Nimish R. Dave, MD Anesthesiology San Diego • (619) 528-5000

Ejaz Ahmed, MD Internal Medicine • San Diego

Jason T. Davis, MD Nephrology San Diego • (619) 299-5298

Mary A. Ambach, MD Pain Medicine • San Diego

Tiffany A. Davis-Maltby, MD Family Medicine • San Diego

Andrew S. Baek, MD Anesthesiology San Diego • (619) 528-5000

Leeann K. Dohring, MD Family Medicine • La Mesa

Reema R. Batra, MD Internal Medicine La Mesa • (619) 644-4500 Lino O. Bautista, MD Internal Medicine • San Diego Scott L. Bluck, DO Family Medicine • San Diego Brook L. Brouha, MD Dermatology La Jolla • (858) 750-2983 Jason P. Brown, MD Cardiovascular Disease San Diego • (800) 290-5000 Dan S. Carpiuc, MD Family Medicine • San Diego Jeffrey J. Cavendish, MD Interventional Cardiology San Diego • (619) 528-5000 John A. Cella, MD Pediatrics • San Diego Hans Chin, MD Internal Medicine La Mesa • (619) 528-6111 Michael J. Clar, MD Surgery • San Diego Peter H. Custis, MD Ophthalmology • San Diego

6 february 2013

Donald A. Drew, MD Anesthesiology • San Diego Eric W. Edmonds, MD Orthopaedic Sports Medicine San Diego • (858) 966-6789

Carolene G. Madden, MD Family Medicine • San Diego Kevin G. Madden, MD Family Medicine Poway • (858) 675-3200 Thomas G. Maddox, MD Family Medicine • San Diego Scott R. Malkin, MD Internal Medicine • San Diego Maureen P. Marks, MD Family Medicine • San Diego Joseph E. De Joya Masbad, MD Anesthesiology • San Diego Jorge Mata, DO Family Medicine • San Diego Richard A. Mayer, MD Infectious Disease San Diego • (619) 287-7991 Michael A. Mikus, MD Sports Medicine San Diego • (800) 290-5000

Ai T. Quach, MD Internal Medicine San Diego • (858) 625-0785 Tryna M. Ramos, MD Family Medicine • San Diego Krishna K. Ratnam, MD Nephrology San Diego • (619) 528-5000 Neethi A. Ratnesar, MD Pediatrics • La Mesa Guy A. Ravad, MD Nuclear Medicine • San Diego Ahmed A. Salem, DO Internal Medicine • San Diego Eduardo Serna, MD Emergency Medicine • San Diego Anais B. Shannon, MD Family Medicine Carlsbad • (619) 528-5000 Cynthia L. Sierra, MD Family Medicine Chula Vista • (619) 691-7587

Lorraine A. Eubany, MD Internal Medicine • La Mesa

Connie B. Miller, MD Emergency Medicine San Diego • (619) 528-5804

Patricia Garcia, MD Anesthesiology San Diego • (619) 528-5000

Gevork Mosesi, MD Family Medicine San Diego • (619) 528-5000

Allison M. Tarplee, MD Family Medicine San Diego • (858) 678-8613

Carolyn A. Geanacou, MD Family Medicine • San Diego

Henry A. Ng, MD Family Medicine • San Diego

Marco J. Tomassi, MD Surgery • San Diego

Richard L. Hayes, MD Internal Medicine La Mesa • (619) 528-5000

Vanjah E. Norman, MD Thoracic Surgery San Diego • (858) 300-4747

Anthony T. Ton, MD Diagnostic Radiology San Diego • (619) 528-6226

Dung V. Huynh, MD Internal Medicine • San Diego

Robert R. Oakley, MD Gastroenterology • San Diego

Jennifer A. Kimble, MD Gastroenterology • San Diego

Douglas M. Olken, MD Family Medicine • San Diego

Danielle A. Towne, MD Obstetrics and Gynecology San Diego • (800) 290-5000

William C. Krauss, MD Emergency Medicine • San Diego

Michael A. Orosco, MD Anesthesiology • San Diego

David H. Kupferberg, MD Critical Care Medicine • San Diego Brent Lambert, MD Family Medicine San Diego • (619) 528-5000

Gowri Sivaraman, MD Family Medicine • San Diego

Hai T. Tran, MD Dermatology San Diego • (619) 528-5000

David C. Parra, MD Family Medicine • San Diego

Maria de Jesus VazquezCampos, MD Family Medicine • San Diego

David Poon, MD Surgery • San Diego

James Y. Youn, MD Sports Medicine • La Mesa

Sean T. Powell, MD Family Medicine • San Diego

Jordan I. Ziegler, MD Neuroradiology • San Diego

Rejoining Members Arthur A. Blain, MD Family Medicine San Diego • (619) 528-5000 Gabriela M. DiLauro, MD Obstetrics and Gynecology Escondido • (800) 290-5000 Angelica B. Espinoza, MD Family Medicine • San Diego Luis Esquenazi, MD Family Medicine • Carlsbad Charles A. Fleischer, DO Child and Adolescent Psychiatry El Cajon • (619) 299-9206 Adalberto R. Huerta, MD Family Medicine San Marcos • (800) 290-5000 Ramaiah Indudhara, MD Urology San Diego • (619) 299-5298 Hyunsoo Kim, MD Internal Medicine San Diego • (619) 528-5000 Christine M-G Lee, MD Family Medicine • San Diego George F. Longstreth, MD Gastroenterology San Diego • (619) 528-5000 Barry E. LoSasso, MD Pediatric Surgery Encinitas • (760) 634-4090 Majid Mani, MD Ophthalmology El Centro • (760) 352-7755 Norman H. Needel, MD Urology • San Diego Jeffrey S. Weissman, MD Internal Medicine San Marcos • (619) 218-5181 Alisa L. Williams, MD Obstetrics and Gynecology San Diego • (619) 299-3111 Joseph J. G. Yu, MD Endocrinology, Diabetes and Metabolism San Diego • (619) 528-5000

Policyholder Dividend Ratio* 49.2%

50% 39.4%

40% 29.3%

30%

38.1%

31.5% 25.6%

20% 10% 0%

11.8% 6.4%

2.2% 2007

2008

5.2% 2009

5.2% 2010

6.9%

7.1%

2011

2012

Med Mal Industry (PIAA Composite)

TBA

2013 MIEC

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brieflynoted

Featured Member

Daniel Einhorn, MD, FACP Dr. Einhorn, SDCMS-CMA member since 1984, has been involved with national leadership in endocrinology for over 20 years, and especially the past eight, being a past president of the American Association of Clinical Endocrinologists (2011) and now president of the American College of Endocrinology. Dr. Einhorn is also medical director of the Scripps Whittier Diabetes Institute and clinical professor of medicine at UCSD (voluntary). He says, “It has been a privilege to be part of creating guidelines for practice, graduate education, public awareness, and certification in endocrinology. It’s been a lot of fun, and I’ve made lasting friendships around the world.” 8 february 2013

SDCMS medical student members — joined by Dr. Robert Hertzka, SDCMS Legislative Committee chair, Dr. Sherry Franklin, SDCMS president, and Tom Gehring, SDCMS CEO — met with (top to bottom) Senator Joel Anderson, Assemblymember Toni Atkins, and Assemblymember Brian Maienschein during SDCMS’ annual Legislative Leadership Day trip to Sacramento.

“

Forty is the old age of youth, but fifty is the youth of old age.” (“Quarante ans, c’est la vieillesse de la jeunesse, mais cinquante ans, c’est la jeunesse de la vieillesse.)

”

— Victor Hugo, French Poet, Novelist, and Dramatist (1802–1885)

LESS IS MORE. Low Dose Che st Comparative Study Same patient is represented in each image

3/24/2011

4/18/2012

10 8 6 4 2

9.14 mSv

2.46 mSv

Pre Low Dose

Post SafeCT/Low Dose

We’ve lowered radiation doses in CT scanning by 50 to 90%. As reported by the American College of Radiology, Imaging Healthcare Specialists emerged at the forefront of significant dose reduction when compared nationally* to other imaging centers. We were the first outpatient imaging company in the nation to acquire SafeCT,™ an advanced technology for CT scanning that allows exemplary dose reduction while maintaining exceptional diagnostic quality. We custom tailor smart CT protocols according to individual patient size to ensure each patient’s safety.

*In metropolitan areas across the nation.

Our result—outstanding leadership in dose reduction and peace of mind.

T 866 558 4320

imaginghealthcare.com SAN DI EGO PHYSICIAN.org 9

Healthcare Systems

10 february 2013

Data-driven Review Helps Tri-City Medical Center Reduce Readmissions Heart Attack, Heart Failure, and Pneumonia by Larry B. Anderson, CEO, Tri-City Medical Center Trust the numbers. If you want to get better, if you want to provide the best care possible, if you want to achieve optimum outcomes, you’ve got to pay attention to the data. It is the canary in the mineshaft; it will tell you when you are doing something wrong — and, more importantly, when you are doing something right. At Tri-City Medical Center, it was the numbers (not so good) that prompted us to assess — and ultimately dramatically reduce — our 30-day readmission rates for heart attack, heart failure, and pneumonia. Readmission rates are a key quality indicator and are used by the Centers for Medicare and Medicaid Services to evaluate whether hospitals are doing a good job — and whether they should be penalized financially for falling short. There is perhaps no bigger challenge for hospitals than to keep patients from being readmitted. But Tri-City Medical Center did just that. Today, we are No. 1 in San Diego County and among the top 1% nationwide for reducing heart attack and heart failure readmissions. And we are among the top 3% in the state and nationwide for reducing pneumonia readmissions. How did we get there? At Tri-City Medical Center, we’ve taken several steps over the past several years to identify those areas where we can improve. With regards to heart care, we recognized that the best way to achieve optimum results was to get all parties involved in the treatment to sit at the table: hospitalists, cardiologists, case managers, interventional

radiologists, social workers, even the marketing department, as a consistent, cohesive message was key to all stakeholders. In addition to adopting a co-management structure, we also embraced best practices identified by the American College of Cardiology; if it proved successful elsewhere, it warranted review here. Our research led to the establishment of the Cardiovascular Health Institute (CVHI) in 2010. The institute employs a data-driven, clinically collaborative approach that has yielded gratifying results. Regarding the treatment and management of heart failure patients, who historically had the highest readmission rates, the institute does the following: A nurse rounds daily on all congestive heart failure patients to educate them about the disease and provide appropriate resources; and a cardiac nurse ensures a follow-up appointment has been scheduled within seven days after the patient is discharged. Other steps include: • Medication Management: This is one of the most important components of the program. If the patient fails to take their medication, they are more likely to be readmitted within 30 days. So we work very closely with the patient and their family to educate them regarding the importance of medication management. • Follow-up Appointments: We do not allow patients to leave the hospital without an appointment to see a primary care doctor within seven days. If the patient does not have a primary care doctor or can’t afford one, our staff ensures they

are seen through the institute’s clinic. And we follow up to make sure the appointment has been kept. • Once home, qualified patients participate in a 30-day Transition to Home Program. A nurse visits the patient at home and reinforces education and medication management. Some patients receive telemonitoring equipment that allows clinicians to track their blood pressure, weight, and heart rate. Dr. David Spiegel, a cardiologist practicing at Tri-City and SDCMS-CMA member since 1988, attributed the reduction in readmissions to the emphasis on ensuring a smooth transition from hospital care to office-based care by ensuring patients have follow-up appointments and that primary care doctors and specialists are provided with hospital documentation so they can continue treatment plans. “Where difficulties arise,” Dr. Spiegel says, “the CVHI runs follow-up clinics till the patients can access regular outpatient care.” Tri-City Medical Center also has similar measures in place to follow up with heart attack patients after they are discharged.

There is perhaps no bigger challenge for hospitals than to keep patients from being readmitted.

SAN DI EGO PHYSICIAN.org 11

Healthcare Systems

Figure 1: Heart Attack 30-day Readmission Rate

Tri-City Medical Center

U.S. Top 10% Rate

U.S. Average Rate

24 23

The overarching thread is collaboration. The institute could not succeed without buy-in from all the stakeholders, especially the doctors. We hold weekly conferences where doctors review cases, assess the treatment plan, whether it was successful and, if not, what we can do to affect a different outcome in the future. In addition to the CVHI, we are in the process of being recertified as a nationally accredited Chest Pain Center, the only one in San Diego County, and we are one of the county’s designated heart attack (STEMI) receiving centers. Both of these centers provided Tri-City with important data to manage heart patients and prompted some of the initial steps that helped to lower readmissions. Further, we review the data every month. To recap, the key ingredients necessary to reduce readmissions are: • Ensure accuracy of reporting; • Promote an evidence-based culture; • Evaluate the continuum for efficiency, effectiveness, and appropriateness; • Form strong physician partnerships to ensure alignment of goals. Identifying the cause(s) behind the high pneumonia readmission rates took us down a slightly different path. Hospital staff and physicians took a deep look at the data, which revealed that nearly half of the cases that were being documented as pneumonia were actually the more serious sepsis (SIRS) diagnosis. Here, the problem was documentation. We established a Code Sepsis response program, increased coding and documentation audits, implemented the St. John’s Sepsis Agent computer tracking program, and adopted an aggressive discharge plan to ensure patients are seen by a primary care physician within seven days after being discharged. Tri-City Medical Center will continue to evaluate ways to improve patient care. And as we advance, we will always remember to trust the numbers. Mr. Anderson has been chief executive officer of Tri-City Medical Center since 2009. He has transformed the Oceanside hospital from a financially ailing institution facing closure because of seismic deficiencies to a profitable operation in less than three years, and established Tri-City Medical Center as a leader in robotic and minimally invasive procedures. 12 february 2013

22 21 20 19 18 17 16 15

July 2009

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July 2011

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55 of 2,448

4 of 2,402

5 of 2,419

14 of 2,363

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9 of 205

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3 of 202

Figure 2: Heart Failure 30-day Readmission Rate

25 24 23 22 21 20 19 18

Tri-City Medical Center

U.S. Top 10% Rate

U.S. Average Rate

16 15

July 2009

July 2010

July 2011

July 2012

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202 of 3,881

155 of 3,904

103 of 4,025

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13 of 291

13 of 285

3 of 294

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Figure 3: Pneumonia 30-day Readmission Rate

Tri-City Medical Center

U.S. Top 10% Rate

U.S. Average Rate

24 23 22 21 20 19 18 17 16 15

July 2009

July 2010

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U.S. Rank

1,403 of 4,009

591 of 4,061

248 of 4,200

136 of 4,232

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103 of 294

45 of 288

14 of 294

8 of 290

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SAN DI EGO PHYSICIAN.org 13

Risk Management

Here are a few tips to help physicians with disaster preparedness.

Hurricane Sandy Underscores the Need for Physicians to Be Prepared for a Disaster by SDCMS-endorsed The Doctors Company — For more patient safety articles and practice tips, visit www.thedoctors.com/patientsafety.

Catastrophes such as the Hurricane “Superstorm” Sandy, the Japan earthquake, and Hurricane Katrina underscore the importance of proper planning for disasters by both physicians and healthcare systems. Preparedness is a continuous cycle of planning, organizing, training, equipping, rehearsing, and evaluating. ¶ Physicians should be involved in disaster preparedness to ensure that the best care is delivered to patients and that critical services are not interrupted, especially for at-risk individuals who may have special medical needs. Physicians also should be aware of the potential threat of medical malpractice liability when serving as a volunteer health professional during a natural disaster or other declared state of emergency. 14 feb ruary 2013

For your office plan:  Make sure your office plan includes: • A checklist of to-do items in case of an emergency. These steps should enable you to preserve your assets as well as communicate with your staff and patients. The list should be ordered by priority and can be designed to match up with specific weather-related information, such as in a hurricane. • A disaster recovery checklist with steps to follow upon your return from an evacuation. • A full-circle calling tree that provides directions on who will contact whom in the event of a disaster. • Instructions on setting up instant messaging groups to enable your staff to communicate when cell phones may not work.  Regularly revisit your office plan and review it with your staff.  Verify that home health agencies that are caring for your patients have plans to provide adequate services in case of a disaster. For your hospital’s plan:  Ask hospitals to define or redefine your role and responsibilities as a medical staff member during an emergency.  Understand your hospital’s incident/ disaster command structure and participate in drills and exercises. For your community’s plan:  Participate in the development of a community disaster plan.  Provide input to local entities such as Emergency Management Authorities, hospitals that are accredited by The Joint Commission, and volunteer organizations such as the Red Cross and The Salvation Army.  Work in concert with the lead organization coordinating disaster relief when volunteering to assist during or after a disaster.

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Poetry and Medicine

Undressed by Daniel J. Bressler, MD

16 february 2013

Undressed Before you get into bed tonight Take off all your clothes. All of them. Fold them neatly on the corner chair. Next: remove your watch and rings Your glasses and handsome silver chain Lay those casually by the clock radio. Now you are ready to begin. Peel off your skin from crown to toes The scars, wrinkles, and hair, distributed Like continents and islands on an ocean of integument. Hang this suit full length in the hallway closet Like a high school prom dress or formal tuxedo. But donâ&#x20AC;&#x2122;t stop. Now unlatch your organs from their skeletal hooks Sort them into piles named after your physiology classes: muscles, heart, lungs, digestive tract, nervous system and endocrine organs Arrange them neatly in that empty bottom dresser drawer. Almost there. Now shake down your bones like a wet dog fresh in from the rain. Shiver off each knuckle and phalanx, every tubercle and vertebra Shimmy loose the paired long bones of the legs and arms. Gather them all into the rectangular FedEx box You knew you were saving for something And slide it back under the bed for safekeeping. Youâ&#x20AC;&#x2122;re finally ready. Completely undressed. Now slide your no-body between the covers. You will find that with nothing to hold you back The earth has become your pillow And the universe your dream.

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

healthcare communit y. 3 income Tax Planning 3 Wealth Management 3 employee Benefit Plans

The so-called mind-body problem is a perennial of philosophical discussion. Is there an incorporeal entity — mind — that can exist independent from the body? While modern neuroscience seems to have answered this question in the negative by demonstrating through multiple experiments that consciousness is a “product” of the bits and parts of the brain, there remains the nagging question of whether we now or will ever know enough to put the question to rest. Science, at its best, stays humble in its conclusions. Scientifically, all we can allow is that, as of February 2013, there is no compelling experimental data to nullify the hypothesis that the mind and all its creations are manifestations of the brain. Certainly, the world’s religious and spiritual traditions are based, in part, on a very different interpretation of the problem. What, after all, are soul or spirit if not representations of the disembodied self, some mind without a brain giving rise to it. These traditions, besides drawing on the revelations of their founders, also tap into a deep and broadly shared intuitive sense that the spirit-self somehow inhabits a parallel plane of existence, that it mingles with the body but is not subsumed by it. The following poem, Undressed, plays with the idea of what’s left when we take away all the physical manifestations of the self. These physical parts make up the daily topics of a medical practice but don’t touch on the deepest sense of the person that the parts belong to. What if, after undressing from all the parts, there really is someone still there? What if? Dr. Bressler, SDCMS-CMA member since 1988, is chair of the Biomedical Ethics Committee at Scripps Mercy Hospital and longtime contributing writer to San Diego Physician.

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SAN DI EGO PHYSICIAN.org 17

Physician-Patient Communications

Power to the People

Each and Every One of Us by Helane Fronek, MD, FACP, FACPh

During his inaugural address, President Obama repeated the words, “We, the people,” many times. He evoked a sense of collective and personal responsibility, and encouraged us to use our power to enact change. So let’s examine the concept of power. If we want to have the practice, social conditions, and life that we want, we need to know how to be powerful enough to effect the decisions that will create or allow those things. Unfortunately, we often get confused by the definition of power 18 feb ruary 2013

that we have been taught to believe, that power implies “power over,” that someone or something must always have power over another. Instead, as Brene Brown reminds us in I Thought It Was Just Me (but it isn’t), “The Merriam-Webster Dictionary defines power as ‘the ability to act or produce an effect.’ Real power is basically the ability to change something if you want to change it.” While we frequently believe that power in any situation is finite — that the quest for power is a zero-sum game — power is often

unlimited. In addition, power can be created as we need it, and it is something that we can build with others. Brown goes on to explain that power requires three components: consciousness, choice, and change. Before we can create the life we want, we need to be aware of where our current situation falls short. This takes self-examination, a willingness to admit to our true feelings, and a methodical evaluation of which area(s) of our life do not feel fulfilling. Tools for this include the Wheel of Life and a list of values (you can find these tools at helanefronekmd.wordpress. com/tools-for-the-life-you-want). Once we discover the parts of our life that aren’t contributing to a feeling of satisfaction and fulfillment, we can begin to make some choices. When considering the possibilities, it’s best to be open to any idea, from the sublime to the ridiculous. Brainstorming with a friend or colleague can provide us with ideas we wouldn’t have considered ourselves. We often feel as if we have no options, since we are too quick to see why they wouldn’t work. So in this phase, write down every idea that comes up. If we find ourselves blocked, we can ask how we would want things to be if we had all the power in the world — if nothing were in our way. From these choices, select one or several that will move you toward a more fulfilling life. Then, it’s time to change. Since change is difficult, you may want to employ some help. Friends, colleagues, websites such as changeanything.com, or a professional coach can be useful in creating a plan, supporting your change efforts, and holding you accountable. Since success breeds success, define several steps along the path to your ultimate goal. Reaching these smaller goals provides the confidence and enthusiasm to continue. And as we consciously look at our life, define our choices, and make changes, we will truly become powerful in our own lives. Dr. Fronek, SDCMS-CMA member since 2010, is a certified physician development coach, certified professional co-active coach, and assistant clinical professor of medicine at the UC San Diego School of Medicine. You can read her blog at helanefronekmd.wordpress.com.

Physician Local San Diego

“think SDCMS FIRST!” Start by contacting SDCMS at (858) 565-8888 or at SDCMS@SDCMS.org.

SAN DI EGO PHYSICIAN.org 19

From the Patient’s Perspective

Breast Cancer Affects More Than Just the Breast Long After Treatment Is Finished by Sandra Cray, Lehigh Valley Vice President, PA Breast Cancer Coalition (www.pabreastcancer.org)

I became a statistic in 1995. Suddenly, I was one of those women I had read about for so many years. Yes, I became 1 in 8 women who were diagnosed with breast cancer. It was certainly not what I had planned for myself at that point in my life. Happily married, devoted mother, career-driven medical professional … those were my life descriptions. Now the one at the top of my list became breast cancer survivor. It is the title I am most proud of, and the one I worked the hardest to achieve. At the age of 36, I was diagnosed with breast cancer; it changed my life, as so many women have said before me. I often speak to groups across the country and describe my breast cancer experience as 20 february 2013

a positive in my life. Now, that’s not the typical analogy you will hear from a breast cancer survivor, but maybe I’m not the typical patient. I feel this disease chose me for a reason: I have the courage and the mouth to get out and talk about it. My message to an audience is to be your own advocate, arm yourself with ammunition and education on your disease, and ask questions … then ask more questions. Just as there are stages of cancer, there are stages of survivorship. Initially, the beginning stage of being a breast cancer survivor is relief. There’s relief when treatment is completed and you may feel you’ve almost earned the right to the term “survivor.” Then there’s the five-year mark,

which is often described as earning the survivor badge, and again at 10 years, 20 years, and so on. I must admit, as the years pass, I feel more and more like a survivor, but now there is a new term to call patients like me: long-term survivor. It’s a nice phrase, but does the medical community know what to do with us? I asked this question to a panel of physicians at the 2010 American Society of Clinical Oncology’s (ASCO) annual meeting in Chicago. The panel was discussing how best to follow up with cancer survivors and which specialty should take on this patient population. Much discussion took place about moving from the oncologist to the patient’s primary

care physician for follow-up. Then, should it be a physician, physician’s assistant, or nurse practitioner who actually examines the patient and discusses survivor issues? I marched up to the microphone and stated that while I appreciated this topic of discussion, I didn’t hear any plan to further decide where we fit and under whose care we should be. But, I stated, in the meantime we would continue to care for each other as we had in the past, on the Internet. There are a number of health issues that may arise with a long-term cancer survivor. The late effects of chemotherapy can be seen with cardiac, pulmonary, and musculoskeletal issues, just to name a few. Radiation has its own set of long-term effects on a cancer survivor. These are questions that are in the minds of cancer survivors every day. You undergo treatment to rid your body of the disease, but at what cost to your long-term health? Personally, I describe my disease of breast cancer as always being in my peripheral vision. As the years pass by and I wonder what is the meaning of this ache, or pain … could it be cancer related? My vision and urgent suggestion is for the future of long-term cancer survivors to have a medical professional specialty group formed to care for this patient population. There are a number of oncology physicians at or near the age of retirement who may be looking for a slower pace of practicing medicine. Why not have them serve the long-term cancer survivors? Perhaps a specialty could be formed within oncology for long-term cancer survivors and their needs. Or how about a physician’s assistant or nurse practitioner in each oncology group for this special patient group? It’s time to start thinking about the future, because the cancer survivor population is growing … thankfully!

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2/5/13 11:13 AM

Physician Wellbeing

Mindfulness in Clinical Practice: Our Patients, Ourselves A Daylong CME Workshop on May 11, 2013, at UCSD School of Medicine by Adele Josepho, MD (SDCMS-CMA Member Since 1989), Thomas Chippendale, MD, PhD (SDCMS-CMA Member Since 2004), Robert Bonakdar, MD (SDCMS-CMA Member Since 2005), Gene Kallenberg, MD (SDCMS-CMA Member Since 2005), Heidi Meyer, MD (SDCMS-CMA Member Since 2005)

22 february 2013

TrusT With the increasing demands of medical practice, physicians are experiencing unprecedented levels of job dissatisfaction and burnout, affecting our sense of identity and well-being as well as influencing the quality of care we provide, regardless of our specialty. Many of us feel overwhelmed by suffering, both our own and others’. A powerful approach to these challenges is to enhance the physician’s capacity for mindfulness. Mindfulness in medicine refers to the ability to be aware, in the present moment, on purpose, with the intentions of providing better care to patients and of taking better care of ourselves. Mindfulness is at the core of clinical competence and personal efficacy. “Mindfulness in Clinical Practice: Our Patients, Ourselves,” is a daylong CME workshop that will introduce participants to the skills needed for bringing mindfulness into clinical practice. Practicing medicine mindfully can result in decreased burnout, increased physician wellbeing, increased empathy, and enhanced patient-centered care. In addition, it may result in fewer errors, a greater sense of presence, the ability to see a situation from multiple perspectives before reacting, and greater satisfaction from work. The workshop will incorporate didactic and experiential learning to gain understanding of mindfulness, narrative medicine, and the application of appreciative inquiry in interpersonal dialogue. “Mindfulness in Clinical Practice” is designed and presented by Mick Krasner, MD, FACP, associate professor of clinical

medicine at the University of Rochester School of Medicine and Dentistry. Dr. Krasner, A UCSD School of Medicine graduate, practices internal medicine in Rochester, New York. He teaches medical students and trainees, and conducts research involving mindfulness. He was the project director of “Mindful Communication: Bringing Intention, Attention, and Reflection to Clinical Practice,” sponsored by the New York chapter of the American College of Physicians and reported in JAMA in September 2009. The curriculum guide developed by the Rochester team trains medical students and residents in mindful practice in medicine and is used in a number of training institutions in the United States and Canada. “Neuroscience of Mindfulness,” a one-hour special session presented by Thomas J. Chippendale, MD, PHD, director of neuroscience, Scripps Health, and assistant adjunct professor of neurology, UC San Diego, will discuss the growing literature on the neuroscience correlates of contemplative practices. The program is presented by the UCSD Center for Mindfulness and is supported by a consortium of institutions throughout San Diego County. Further information regarding the CME program and registration are available at http:// cme.ucsd.edu/mindfulness/mcp_workshop_051113_home.html. Lunch and 6.75 hours of CME are included. Parking is free. SDCMS members will receive a tuition discount as a membership benefit.

Practicing medicine mindfully can result in decreased burnout, increased physician wellbeing, increased empathy, and enhanced patientcentered care.

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Healthcare Financing

T h e Death of

Fee-for-

ervic

24 february 2013

The following are submissions San Diego Physician received in response to its call on the topic of â&#x20AC;&#x153;The Death of Fee-for-Service.â&#x20AC;?

— Michael Couris, MD, SDCMSCMA Member Since 2001, Is in Private Practice, Ophthalmology

Surely, You Must Be Joking

Until the individual has “skin in the game” and feels the consequences of his choices, the opportunity to pay for care at the time it is rendered remains the most feasible way to control costs.

he death of fee-for-service. Hardly. Expecting the hasty demise of the most basic of economic transactions is certainly premature. For thousands of years, mankind has bartered and exchanged items and services. Commerce later took place with the advent of coinage and ultimately to today, where transactions take place via fiat currency. Barring the complete outlawing of private medical care, like that attempted unsuccessfully in Canada (“Chaoulli v Quebec and the Future of Canadian Healthcare,” on www.thecourt.ca, Jan. 17, 2007), fee-for-service will be alive and well for some time to come. Even in the countries with a high degree of socialized medicine, a significant amount of healthcare is paid for directly by the patient or by third-party intermediaries on a fee-for-service basis. In fact, Forbes reports 11% of all care is transacted privately (“The Ugly Realities of Socialized Medicine Are Not Going Away,” on www.forbes. com, Dec. 21, 2012) in the United Kingdom. When our Canadian neighbors need medical treatment, they are often on the first plane to the United States, where they pay cash. Fee-for-service medicine is the predominant way physicians are compensated around the world, even in

countries where the government has heavy involvement, including Germany, France, and Japan (“Physician Payment: Current System and Opportunities for Reform”, by Nonnemaker et al, AARP Public Policy Institute, April 2009). In San Diego, about half of all physician services are transacted on a fee-forservice basis (Scripps Mercy Physicians Medical Group, Internal Study, December 2012). Three years into health reform, the vast majority of physicians are still being paid in the same manner they have been for the past 10 years, if not longer. Anyone practicing medicine for the last 25 years or so is likely experiencing déjà vu with all that is being bandied about, and will likely continue to do what he or she has been doing for the foreseeable future. Independent physicians who provide specialty and subspecialty care must be paid fee-for-service for unique, highly specialized care unless employed by a risk-bearing organization or a medical group. Accountable care organizations, independent practice associations, insurance carriers, and government payers will have to pay for episodic care and are still planning to pay feefor-service on a widespread basis, though modified fee-for-service reimbursement may go by other names like bundled payments and shared savings. The healthcare reform freight train runs right over and through primary care physicians. They can, however, choose to be paid on a fee-for-service basis if they desire. The practice of medicine is already risky and burdensome with e-prescribSAN DI EGO PHYSICIAN.org 25

— Eileen S. Natuzzi, MD, SDCMS-CMA Member Since 2010, Is in Private Practice, General and Vascular Surgeon

Healthcare Financing

Fair and balanced?

ing penalties, meaningful use penalties, quality measures, uncompensated mandates, and low-paying contract offers from payers, both public and private. Many will choose to operate outside these restrictions and return to a full fee-for-service mode. Though small in number now, many physicians will opt out or even disenroll from Medicare once the full force of penalties is realized. One need look no further than the contracts offered by the health insurance companies for Covered California — the nascent California Health Exchange — to see that fee-for service is alive and well. Various estimates are that anywhere from 30% to 50% of the healthcare administered by these plans will be on fee-for-service basis supported by preferred provider networks (Personal Communication, North American Medical Management/Optum), which is essentially fee-for-service with a discount. What should physicians do if they would like to continue to be paid fee-for26 february 2013

service? Develop specialized skills that few others possess. Practice where there is little to no competition. Adopt cash models of practice, especially in the primary care arena. Providing exemplary customer service above and beyond those participating in third-party payment schemes might also allow physicians to maintain feefor-service reimbursement. For many others, however, fee-for-service payment will simply mean going to work in the morning. From a larger perspective, there are many who predict fee-for-service will make a comeback after the politicians and bureaucracy acknowledge that the thirdparty payment system will continue to bust the budget and lead our country to economic ruin. Until the individual has “skin in the game” and feels the consequences of his choices, the opportunity to pay for care at the time it is rendered remains the most feasible way to control costs. It is a paradigm that has worked before. Many of us will be waiting and watching.

There is no financial reward for surgeons who make the appropriate decision to optimize medical treatment, maximize prevention measures, and follow patients expectantly.

ee-for-service payments, as we currently know them, cannot continue in our current healthcare economic crisis. Neither can excessive mark-ups of pharmaceuticals and medical devices. In surgical specialty care, there is an imbalance in what we are reimbursed for. Reimbursements for providing operative interventions are significantly higher than payments for managing patients non-operatively. This has the potential to promote lowering one’s threshold for recommending surgical treatment versus conservative management. This is especially pertinent when the expenses of running a practice outpace reimbursement rates. There is no financial reward for surgeons who make the appropriate decision to optimize medical treatment, maximize prevention measures, and follow patients expectantly. The old adage of “a chance to cut is a chance to cure” may be true, but under fee-for-service payments so is “a chance to cut is a chance to get paid.” We do not have a system that defines appropriate care for surgical conditions, leaving decisions on surgical or procedural care open to individual interpretation. Defining and adhering to appropriate care norms established by specialty care governing bodies will help in preventing unnecessary procedures from being performed. Adjusting non-intervention specialty care reimbursement will assist in maintaining a fair and balanced fee for service payment scheme.

— Ronald Feldman, MD, SDCMS-CMA Member Since 1975, Is in Private Practice, Gastroenterology

We’ve had enough (Reprinted letter to the editor, reacting to “The Private Practice Model of Medicine Must Survive” by Roseman B, Flake T, Kopen D. Gastroenterology & Endoscopy News, June 2012;63:40,44–46.)

am in agreement with everything said in the recent article on saving fee-for-service medicine. I would add, however, that physicians helped create the ever-expanding and largely physician-unfriendly regulated environment that we have today, and physicians will have to get themselves out of it. What began as an acceptance of small discounts in a supposed exchange for more patients (that never happened) and exploded into huge discounts; multiple, unfunded mandates by independent practice associations, health mainte-

nance organizations, insurance companies, and state and federal governments; markedly lower payments; and increased overhead has led to an overworked and underpaid U.S. physician aggregate. We physicians are the only essential part of medical care and the ultimate advocates for our patients. We need to look in the mirror and ask ourselves why we sign inadequate contracts and don’t have the pricing power in the market to cover our costs and make a reasonable profit. It’s time for physicians to say, “We’ve had enough.” As the current scheme du jour — now, accountable care organizations — fails to produce results and lowers our pay even more, we need to make better business decisions in the best interests of ourselves, our families, and our patients.

Physicians helped create the everexpanding and largely physicianunfriendly regulated environment that we have today, and physicians will have to get themselves out of it.

— Ted Steuer Is the Executive Director of Scripps Mercy Physician Partners and VIP Health Connect

Not Today and Not Tomorrow “Reports of my death have been greatly exaggerated!” — Mark Twain, 1897

ikewise, the demise of fee-for-service payment certainly seems greatly exaggerated! Several months ago, I studied the reimbursement trends in San Diego over the past few years. The bottom line of that study showed that the major payment change was the decrease in insurance coverage because of the economic downturn. There was no change in the ratio of patient reimbursement on fee-for-service vs. capitated payment. A San Diego County Medical Society study came to the same conclusion. Outside of California, fee-

for-service is the dominant payment mechanism. Futurist Ian Morrison points out in Understanding the Velocity of Change in Healthcare: “The key drivers of healthcare have different rates of change. Coverage expansion is on a two-to-threeyear timeline. Reimbursement reform is on a 10-year timeline.” Looking back at the last 20 years, many physicians have developed successful practices using fee-for-service medicine as the core of their practices. This won’t change today or tomorrow. The velocity of change is huge and the forces are complex. Nonetheless, it’s clear that: • Patients’ personal payment

SAN DI EGO PHYSICIAN.org 27

Healthcare Financing

A strong business opportunity remains for physicians to improve their success and satisfaction with fee-for-service healthcare.

responsibility for healthcare costs has increased and will continue to increase. Regardless of the causes for this increased personal financial responsibility, these are fee-for-service payments. • Fee-for-service payment is the most basic and straightforward payment mechanism. It is logical and transparent. • Self-insured payers typically utilize fee-for-service payment. • Elective healthcare services are frequently paid on a feefor-service basis. These elective services include many out-of-network healthcare services. • Mechanisms are needed to prevent unnecessary and inappropriate utilization. • Demand for care is increasing because of population aging and broadened eligibility regulatory changes. It’s difficult to project how increased demand will be managed, but it’s apparent that fee-for-service reimbursement, especially in the short-term, will be extensively utilized. 28 february 2013

The most critical components of reimbursement remain: 1. Rate of Payment: Regardless of the method of payment, the rate needs to be acceptable — the payment rate needs to meet or exceed the cost of service. Practices need to manage their costs and say “no” to contracts that don’t meet their needs. 2. Collections: Physicians need to improve collections and reduce the cost of collections. There are many resources available. These are basic business principles! Conclusion While the velocity of change is intense, reports of the death of fee-for-service payment are greatly exaggerated! Demand for medical care will undoubtedly increase with healthcare reform. A strong business opportunity remains for physicians to improve their success and satisfaction with fee-for-service healthcare.

— Joseph E. Scherger, MD, MPH, SDCMSCMA Member Since 2003, is Vice President of Primary Care and Academic Affairs at the Eisenhower Medical Center and Eisenhower Argyros Health Center in La Quinta

mural dyslexia

hat will die, or become rare, is fee-for-service in an independent private practice. Cash patients will continue to pay fee-for-service, so some practices such as cashonly primary care and plastic surgery will remain fee-forservice. Most medical care will become contracted or bundled, for good reason. The healthcare cost problem is well known and now universally accepted as a financial crisis. No longer can episodes of care such as a broken hip, heart attack, stroke, or even elective surgery such as a joint replacement have many separate small businesses charging what they can for their part of the care. Costs in such a non-system are uncontrollable, and there is excessive

administrative waste processing many claims from many providers. The new mantra in healthcare is value, quality care at controlled costs. The leading health systems in America are now contracting or bundling payment for services and taking risk based on the quality of care. Payers such as Medicare and private insurance see the benefits of this and rightfully will expect these systems of care in every region of the country. Do not fall victim to mural dyslexia, difficulty reading the writing on the wall. Join a system of care so that your services are valued and reimbursed appropriately. That will be more satisfying than your own billing office struggling to get paid just for your services.

— Robert Pendleton MD, PhD, SDCMSCMA Member Since 2003, Is Medical Director of Pendleton Eye Center

Fee-for-Service Will Continue to Grow!

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ormer Surgeon General C. Everett Koop observed that we demand three things from healthcare: high quality, immediate access, and low cost. More importantly, he stated that a healthcare system could be 11:22 AM

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FIRM

designed to achieve only two of these goals, at the expense of the third. Arguably, the U.S. healthcare system has evolved to favor quality and accessibility, at the “expense” of costs. We are a world leader in high-quality healthcare, and anyone, including illegal aliens, can access our current healthcare system just by walking into the ER. Assuming Dr. Koop’s observations are correct, our nation’s rejuvenated efforts to drive down healthcare costs and improve access by expanded insurance coverage will necessarily result in decreased quality of care. Already we know this to be true; as reimbursements continue their downward spiral, cost-containment has risen on the priority list in our offices, our surgery centers,

and even at our hospitals. The newest, best medication is the one that isn’t covered, or has the highest copay, often making it out of reach. Excisional biopsy of a suspicious skin lesion is considered by Medicare to be a non-covered, medically unnecessary service when the pathology “unfortunately” turns out benign. I thought I had good, inexpensive health insurance myself until I injured my shoulder. Only after an inconclusive arthrogram and written preapproval was my physician able to order the less-invasive, less-risky, less-painful, betterquality MRI that diagnosed the problem. After surgery, I learned that physical therapy of the shoulder was not a covered benefit under my plan. Believing my doctor’s recommendation for physi-

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Healthcare Financing

— James Santiago Grisolía, MD, SDCMS-CMA Member Since 1983, Is in Private Practice, Neurology

cal therapy was medically necessary, I paid for it myself. Similar scenarios will increase in frequency as cost-containment measures further erode quality of care. More and more people will be pulling out their wallets to purchase “concierge” services, “cosmetic” surgery, “experimental” treatments, dental implants, private hospital rooms, physical therapy, “premium” presbyopia correcting lens implants, upgraded joint implants, genetic testing, robotic surgery and dazzling, expensive new technologies, treatments, and medications yet to be invented. Cost containment and expansion of insurance coverage are squeezing out quality in our healthcare system. The feefor-service-only Harley Street in London flourished after the introduction of a single-payer system in the United Kingdom. In the foreseeable future, fee-for-service medicine in the United States will only continue to grow. 30 february 2013

More and more people will be pulling out their wallets to purchase “concierge” services, “cosmetic” surgery, “experimental” treatments, dental implants, private hospital rooms, physical therapy, “premium” presbyopia correcting lens implants, upgraded joint implants, genetic testing, robotic surgery and dazzling, expensive new technologies, treatments, and medications yet to be invented.

Neurology Solos in the Coalmine: Canaries Looking Good by Comparison

he rapidly aging U.S. population will demand more neurologic care for dementia, Parkinson’s, stroke, and other diseases of longevity. The failing brain requires active management, including aggressive acute stroke therapy, and active treatment for symptoms and underlying causes of many conditions that were untreatable only decades ago. Yet no specialty is more imperiled, caught between the worst economic straits of primary and specialty care.

Similar to primary care, the majority of neurology billing is based on evaluation and management (E/M) services. In 2010, CMS abolished Medicare inpatient and outpatient consultations (CPT 99241–99244 for outpatients, 99255–99255 for inpatients), reimbursing all consultants at the lower-paying H&P codes. However, like other predominantly E/M specialties, neurology has not received reimbursement increases designed to reward E/M services in primary care. For

example, the 2013 Medicare fee schedule increases reimbursements to primary care 4–7% by defunding many other specialties. Neurology’s share of this transfer will be a 7% decrease. Our American Academy of Neurology (AAN) argues that for many neurologic conditions, the neurologist is actually the principal care provider and should be reimbursed for coordinating care. As the AAN represents only neurologists, some 2% of U.S. physicians, their arguments of course fall on deaf ears. Neurologists may qualify for some medical home coordination projects under certain commercial insurers, but are not getting

the primary care upgrades. In the past, some neurology practices have enjoyed significant billing for EEG and EMG testing. Medicare destroyed EEG reimbursement many years ago, so that few neurologists maintain EEG labs in their private offices. The new 2013 Medicare schedule creates new CPT codes for EMG/NCS testing. According to an analysis by the AAN, the new codes result in a 30–60% drop in RVU (relative value units) for equal work. Few solo neurologists use technicians to perform EMG/NCS testing, so that physician time is directly involved in all aspects of neuromuscular testing.

Particularly in practices that emphasize neuromuscular testing, these changes will be devastating. Neurologists will be forced to reevaluate their practices. Despite the excitement of ongoing revolutionary changes in basic and applied neuroscience, many medical students will decide against neurology based on the financials. Given the increasing demand for neurology services, neurologists may be forced into concierge-type practices, which will preserve income for neurologists at the expense of access for rural and low-income patients, and any Medicare patient unwilling to pay concierge rates.

Given the increasing demand for neurology services, neurologists may be forced into conciergetype practices, which will preserve income for neurologists at the expense of access for rural and lowincome patients, and any Medicare patient unwilling to pay concierge rates.

Thank You SDCMS Member Physicians for Making All the Difference! SAN DI EGO PHYSICIAN.org 31

YOU HERO YOU ARE ARE OUR HERO thank youfor forgiving givingaccess accessto tohealthcare healthcare for those thank you those without! without!

San Diego County Medical Society Foundation’s Mission Is To Improve Health, Access San Diego County Medical Society Foundation’s Mission Is To Improve Health, Access To Care, And Wellness For Patients And Physicians Through Engaged Volunteerism. To Care, And Wellness For Patients And Physicians Through Engaged Volunteerism.

You are the Heart & Soul of Project Access San Diego YouThrough are the Heart & Soul of Project Access San Diego your support of our flagship program, Project Access San Diego, we have

Through your to support our1,850 flagship program, Project San to Diego, we have been able assist of over uninsured adults in ourAccess community improve their been able to assist over 1,850 uninsured adults in our community to improve health through access to specialty healthcare services. You have provided their over health through access to specialty healthcare services. You have provided $5.8 million in contributed healthcare services to community members sinceover our $5.8 million beginnings in contributed healthcare services to community members since our program’s in December 2008! program’s beginnings in December 2008! Thanks to more than 625 volunteer physicians providing specialty healthcare services Thanks to more volunteer physicians providing specialty healthcare to those whothan most625 need our help, we are getting people back to work, andservices able to care for their families. to those who most need our help, we are getting people back to work, and able to care for their families. Without the generous support and dedication of all of our physician volunteers, hospitals outpatient surgery imaging, labs, therapy,volunteers, and other Without the and generous support andcenters, dedication of all of physical our physician ancillary health providers, hundreds of hard-working but uninsured adults would go hospitals and outpatient surgery centers, imaging, labs, physical therapy, and other without care every year. Thank you for being a hero to our community! ancillary health providers, hundreds of hard-working but uninsured adults would go

without care every year. Thank you for being a hero to our community!

Get Involved

Diego County Medical Society Foundation needs you! Join us to volunteer for GetSan Involved

Project Access, or provide specialty consultations to primary care physician colleagues San Diego County Medical Society Foundation needs you! Join us to volunteer for through eConsultSD, our HIPAA-compliant, web-based system from the comfort of Project Access, or provide specialty consultations to primary care physician colleagues your home or office. Attend an event, assist us to recruit fellow physicians, or provide through eConsultSD, our HIPAA-compliant, web-based system from the comfort of educational opportunities for primary care physicians or medical students. Our first your home or office. Attend an event, assist us to recruit fellow physicians, or provide annual Golf Tournament is scheduled for Thursday, February 28, 2013 at Del Mar educational opportunities for primary care physicians or medical students. Our first Country Club; we hope you can join us! To register or for more information, go to annual Golf Tournament is scheduled for Thursday, February 28, 2013 at Del Mar sdcmsf.org/golf. Please consider making a contribution to SDCMS Foundation to Country Club; we hope you can join us! To register or for more information, go to support our efforts at www.sdcmsf.org, or call us at 858.300.2777. sdcmsf.org/golf. Please consider making a contribution to SDCMS Foundation to support our efforts at www.sdcmsf.org, or call us at 858.300.2777.

5575 Ruffin Road, Suite 250, San Diego, California 92123 p: 858.300.2777 f: 858.569.1334 n

Adam Fierer, MD Mark MD AdamRansom, Fierer, MD Mark Ransom, MD Expanding our model of care Expanding model of care Drs. Fierer andour Ransom practice and partner at the Carlsbad Surgery Center, Drs. Fierer and Ransom practice and one of the SurgeryOne facilities. partner at the Carlsbad Surgery Center, Seeing what an impact an ambulatory one of the SurgeryOne facilities. surgery can be for a person without Seeing what an impact anWorld ambulatory healthcare access in a Third surgery can be for a person country, Dr. Fierer approached without the healthcare access in a to Third World Carlsbad Surgery Center make country, Fierer the same Dr. impact at approached home. Now athe Carlsbad Surgery Center toa make semi-annual event involving growing the same impact anesthesiologists at home. Now a group of surgeons, semi-annual event involving a growing and other healthcare staff, we have groupable of surgeons, been to increaseanesthesiologists our capacity otherthe healthcare staff, we have toand improve health and change been to increase our most capacity the livesable of our community’s vulnerable. to improve the health and change themajority lives of of ourPASD community’s The patients most vulnerable. require just office consultations and 30% ofpatients patients Theprocedures. majority of PASD require or GIconsultations procedures, requiresurgery just office which occur during a30% Carlsbad or and procedures. of patients Kaiser Permanente Day, or require surgery or Surgery GI procedures, are accommodated partnering which occur duringataour Carlsbad or hospitals and outpatient surgery Kaiser Permanente Surgery Day, or centers throughout the year. are accommodated at our partnering Thank you to all of our physician hospitals and outpatient surgery volunteers-- you are all our heroes!! centers throughout the year. Thank you to all of our physician volunteers-- you are all our heroes!!

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classifieds PRACTICE ANNOUNCEMENTS NEW DERMATOLOGY PRACTICE: Board-certified dermatologist and dermatopathologist, Heidi Gilchrist, MD, practices medical dermatology for all age groups. She offers same-day and next-day appointments, including Saturdays, and accepts all major insurance plans. Dr. Gilchrist emphasizes a holistic and integrated approach to skin health and disease prevention, and she is open to patients who prefer natural or alternative approaches. She specializes in individualized care and spends at least as much time listening as she does talking. Cosmetic services are also available upon request. 345 Saxony Road, Suite 201, Encinitas, CA 92024; office (760) 230-2537; fax (760) 230-5386; gilchristdermatology.com; info@ gilchristdermatology.com. [100] PRACTICE FOR SALE INTERNAL MEDICINE PRACTICE FOR SALE: Established practice for 20 years; solid stable patient base. Clairemont area. Recently remodeled office space. Gross $550K per year. Call for details: (858) 344-2591. [102] PHYSICIAN POSITIONS AVAILABLE LOOKING FOR A BOARD-CERTIFIED FAMILY PHYSICIAN OR NURSE PRACTITIONER: Family medicine, private practice, part- or full-time coverage, North County San Diego. Looking for a board-certified family physician or licensed nurse practitioner who would like to join our small practice and provide personable, high quality, patient-centered care. Great position for someone who wants to practice medicine and make a difference. Flexible hours. Online access to EMR. We have a great team and would like to work with someone who can contribute to that experience. Please email CV to familypracticeNC@gmail.com. [111a] SEEKING DERMATOLOGIST: Established dermatology and cosmetic surgery practice in Encinitas is seeking a part-time to possible full-time dermatologist. We are currently looking for a dermatologist who is interested in doing general dermatology, dermatologic surgery, and possibly cosmetic procedures. Need physician with excellent patient rapport and interpersonal skills. Confidence and excellent surgical skills are key for this position. Compensation competitive! Please respond to this ad with cover letter and CV to dana@doctorlashgari.com. [109] PEDIATRIC PHYSICIAN — NORTH COUNTY HEALTH SERVICES, OCEANSIDE: Full-time lead pediatrician position in FQHC community health center. Please email your CV to Araceli Mercado at araceli.mercado@nchshealth.org or fax to (760) 736-8740. [108] PHYSICIAN OR NURSE PRACTITIONER: Physician or nurse practitioner to perform housecalls in North San Diego County Monday thru Friday. 10-12 patients per day. Please forward CV. Full time. Excellent time management skills required. Pager one week per month, no hospital rounds. Established patient base. Independent contractor position with great income potential. NP’s-home health experience a plus. Please respond by email only to mobiledoctor@sbcglobal.net. Thank you. [106a] PEDIATRIC PHYSICIAN — NORTH COUNTY HEALTH SERVICES, OCEANSIDE: Full-time lead pediatrician position in FQHC community health center. Please forward your CV to Araceli Mercado at araceli.mercado@nchshealth.org or fax to (760) 736-8740. [105] FULL-TIME FAMILY MEDICINE PHYSICIAN: The San Diego American Indian Health Center is seeking a BC/ BE full-time family medicine physician for an ambulatory care clinic. Clinic hours are Monday through Friday, 8:00am to 5:00pm. Light telephone call. No hospital duties. No weekends. Malpractice covered. Benefits. Disclaimer: Preference is given to qualified American Indian applicants in accordance with the Indian Preference Act of 1934 (Title 25, USC Section 472). Please email CV to Natalie Cadena at natalie.cadena@sdaihc.com. [904]

MID-CAREER PEDIATRICIAN: Great opportunity for a mid-career pediatrician with kind manner and strong entrepreneurial spirit to work FT/PT in small solo progressive practice. This position is a partnership track. Night call is minimal but must be willing to work some Saturdays and one evening/week to help grow the practice. Space available to expand. Nice mix of parents in great school area. Salary DOE. Nice, stable office staff with EMR. Send CV to cvp315@sbcglobal.net. [057] THREE CONTRACT PHYSICIANS: Profil Institute for Clinical Research is looking for three clinical contract physicians. Requirements: One year of clinical experience in adult medicine and/or equivalent + unrestricted California MD license. Research experience not necessary. Responsibilities: Perform medical histories, physical exams, admit, discharge, and monitor subjects, including reviewing labs results, EKGs and telemetry as part of clinical research trials. Weekend shift hours (Saturday) + occasional weekday shift. Interested parties please apply online at www.profilinstitute.com under “Career Opportunities” — search for position under “Contract Physician,” and apply to the job online. [097] CHIEF, MATERNAL AND CHILD HEALTH: The County of San Diego Health and Human Services Agency is seeking a qualified medical doctor to fill the position of chief, Maternal, Child, and Family Health Services (MCFHS) branch. The chief is responsible for the management and administration of public health programs that improve the health of mothers, children, and their families. For more information on the position, including minimum requirements and how to apply, please visit www.sdcounty. ca.gov. [092] ADULT PSYCHIATRIST — PART TIME: The County of San Diego’s Health and Human Services Agency is seeking a psychiatrist for 10-hour weekdays, part-time shifts for adult outpatient clinic work. Our psychiatrists work with a dynamic team of medical and nursing professionals to provide outpatient treatment, telepsychiatry, inpatient and emergency services, and crisis intervention. More information about psychiatrist positions can be found at www.sdcounty.ca.gov/hr. Interested candidates may contact Lita Santos at (619) 563-2782 or email a CV to lita.santos@sdcounty.ca.gov. [091] ADULT PSYCHIATRISTS: County of San Diego’s Health & Human Services Agency seeks FT/PT psychiatrists for key components in the Behavioral Health Division’s continuum of care. Our psychiatrists work with a dynamic team of medical and nursing professionals to provide outpatient treatment, telepsychiatry, inpatient and emergency services, and crisis intervention. More information about psychiatrist positions can be found at www.sdcounty.ca.gov/hr. Interested candidates can contact Gloria Brown at (858) 505-6525 or email CV and cover letter to gloria.brown@sdcounty.ca.gov, and Marshall Lewis, MD, Behavioral Health clinical director, at marshall.lewis@sdcounty.ca.gov. Please specify clinical area of interest. [090] SENIOR PHYSICIAN: The County of San Diego, Health and Human Services Agency’s HIV/STD/Hepatitis clinic has an immediate opening for a licensed physician with at least three (3) years of recent post-internship training or experience in internal medicine or as a general practitioner to manage a team responsible for planning and directing clinic services. Must be available to work flexible schedules at multiple sites, including some evenings is expected. Please read more about the senior physician job description, benefits, and application process at www.sdcounty.ca.gov/hr. Please include a copy of your CV along with your online application. For questions, please contact Gloria Brown, human resources analyst, at (858) 505-6525 or at gloria.brown@sdcounty.ca.gov. [088] MEDICAL DIRECTOR / PHYSICIAN / AND OTHER HEALTHCARE POSITIONS: Southern Indian Health Council is seeking a FT, board-certified physician, M–F, 8:00am–4:30pm. Must have current CA medical license, DEA license, ACLS, BLS. We offer: a competitive salary,

health benefits, vacation, holidays, sick, CME and license reimbursement, and malpractice coverage. Forward resume to tdentice@sihc.org or fax to (619) 659-3145 or website at www.sihc.org. Contact: tdentice@sihc.org or HR phone (619) 445-1188, ext. 308 or ext. 307 or HR fax (619) 659-3145. [048] OPPORTUNITY KNOCKS FOR BC/BE DERMATOLOGISTS: Live in one of the country’s most desirable locations and practice with a premier San Diego multispecialty medical group! Sharp Rees-Stealy Medical Group is looking for BC/BE dermatologists. Competitive first-year compensation guarantee, excellent benefits, and shareholder eligibility after two years. Unique opportunity for professional and personal fulfillment while living in a vacation destination. Please send CV to Physician Services, 2001 Fourth Avenue, San Diego, CA 92101. Fax: (619) 2334730. Email: Lori.Miller@sharp.com. [084] SUPERB INTERNAL MEDICINE PRACTICE OPPORTUNITY: The position is available in August of 2013. You will be joining one of the premier internal medicine groups in North County San Diego. No hospital work or ER call. Competitive salary including benefits plus the opportunity to begin a partnership track if desired. Beautiful office building, excellent staff, ideal for either first year in practice or for an experienced practitioner. Contact Jon LeLevier, MD, at (760) 310-2237 or Jeff Leach, MD, at (760) 846-0464 for more information. [081] FAMILY HEALTH CENTERS OF SAN DIEGO: JOIN OUR FAMILY! As we continue to grow, we currently have great career opportunities for: Family Practice Physicians; Internal Medicine Physicians; Internal Medicine / Pediatric Physicians. With 33 locations that include 13 clinics and growing, we offer a wide variety of flexible career choices for you to select from as well as a positive work environment, grateful patients, and a competitive salary and excellent comprehensive benefits packages. To talk to someone directly about provider careers at Family Health Centers of San Diego, please contact our Recruitment Supervisor, Anna Marie Jameson, at (619) 906-4591 or at ajameson@fhcsd.org. [046] PRIMARY CARE JOB OPPORTUNITY: Home Physicians (www.thehousecalldocs.com ) is a fast-growing group of house-call doctors. Great pay ($140–$220+K), flexible hours, choose your own days (full or part time). No ER call or inpatient duties required. Transportation and personal assistant provided. Call Chris Hunt, MD, at (858) 279-1212 or email CV to hpmg11@yahoo.com. [037] PHYSICIANS WANTED: Vista Community Clinic, a private, nonprofit clinic serving the communities of North San Diego County, has openings for part-time and per-diem positions. Five locations in Vista and Oceanside. Family medicine, OB/GYN medicine, pediatric medicine. Requirements: California license, DEA license, CPR, board certified, one (1) year post-graduate clinic experience. Bilingual English/Spanish preferred. Benefits: malpractice coverage. Email resume to hr@vistacommunityclinic.org or fax to (760) 414-3702. Visit website at www.vistacommunityclinic.org. EOE/M/F/D/V [035] 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]

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 february 2013

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] OFFICE SPACE / REAL ESTATE PROFESSIONAL SPACE FOR LEASE: La Jolla Office Space: Two private offices with shared reception, waiting area, and exam / consultation rooms in new office. Five exam rooms. On-site X-rays with tech available. Office is close to Scripps Memorial Hospital. In Golden Triangle between 805 and 5 freeways. Terms negotiable. Please contact Kathy Koppinger at (858) 678-0455. [113] FOR SALE: APPROXIMATELY 9,000 SF OFFICE BUILDING CLOSE TO HOSPITALS: Near Rady Children’s and Sharp Hospital. Right off Ruffin Road and Aero Drive intersection. Zoned medical. Standalone, single-story building. High-end, attractive property. LEED Certified Gold Core and Shell. Neighboring medical tenants in business park. With 10% down OWN FOR LESS than rent. Call Melissa Foster at CBRE at (858) 546-4658 or email her at melissa.foster@cbre.com for more information. [103] 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] SCRIPPS XIMED MEDICAL CENTER BUILDING, LA JOLLA: Office Space to sublease occupied by vascular and general surgeons. One room consult office available, with one or two exam rooms, to a physician or team. Located on the campus of Scripps Memorial Hospital, XiMed Building is the office space location of choice for anyone doing surgeries at the hospital or seeking a presence in the La Jolla area. Reception and staff available if needed. Full ultrasound lab onsite in office for anyone interested in this service. For more information, call Irene at (619) 840-2400 or at (858) 452-0306. [101] MEDICAL OFFICE SPACE FOR LEASE: Medical office space of 1,846 square feet located at 15721 Pomerado Road, Poway, CA 92064 in the Gateway Medical Center available for immediate lease. This recently remodeled facility has a shared waiting room, medical records storage area, front desk reception area, three exam rooms, nursing station, private office, shared bathroom. The larger space is shared with an internal medicine group and is blocks away from Pomerado Hospital. Imaging is located in an adjacent building. The lease rate is $1.69/SF NNN with a 3% annual increase. The NNNs are currently running $0.73/SF. Tenant will be responsible for pro rata share of utilities and janitorial in addition to NNNs. Great opportunity in this affluent community. Call Angie at (858) 605-9966. [065] MEDICAL OFFICE SPACE IN SANTEE: Beautiful calming space in an office/business park located adjacent to a major shopping center in Santee. Newer building (2007), and recently remodeled into a premier medical office. Plenty of free parking, and nice outside courtyard includes a fish pond. The available space (approximately 1200 sf) consists of 3 large exam rooms, medical assistant/lab area, office and a shared waiting area. Other half of space is occupied by a family physician. Rent is 2.50/sf and includes all utilities (electricity, internet, phone, security, water). Available 1/2/2013. Contact: santeemedicaloffice@yahoo.com. [099] 3998 VISTA WAY, IN OCEANSIDE: Four medical office spaces approximately 1,300–2,800 square feet available for lease. Close proximity to Tri-City Hospital with pedestrian walkway connected to parking lot of hospital, and ground-floor access. Lease price: $1.55+NNN. Tenant improvement allowance to customize the suites is available. For further information, please contact Lucia Shamshoian at (760) 931-1134 or at shamshoian@coveycommercial.com. [096]

NORTH COAST OFFICE SPACE TO SUBLEASE: North Coast Health Center, 477 El Camino Real, Encinitas, office space to sublease. Newly remodeled and beautiful office space available at the 477/D Building. Occupied by seasoned vascular and general surgeons. Great window views and location with all new equipment and furniture. New hardwood floors and exam tables. Full ultrasound lab and tech on site for extra convenience. Will sublease partial suite for two exam rooms and office work area or will consider subleasing the entire suite, totally furnished, if there is a larger group. Plenty of free parking. For more information, call Irene at (619) 840-2400 or at (858) 452-0306. [041] FULL- AND PART-TIME OFFICE SPACE IN UTC: in 8th floor suite with established neuropsychologists 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 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] 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, ECP Commercial, at (619) 442-9200, ext. 102. [006] POWAY / RANCHO BERNARDO — OFFICE FOR SUBLEASE: Spacious, beautiful, newly renovated, 1,467 sq-ft 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] SHARE OFFICE SPACE IN LA MESA: Available immediately. 1,400 square feet available to an additional doctor on Grossmont Hospital Campus. Separate receptionist area, physician’s own private office, three exam rooms, and administrative area. Ideal for a practice compatible with OB/GYN. Call (619) 463-7775 or fax letter of interest to La Mesa OB/GYN at (619) 463-4181. [648] BUILD TO SUIT: Up to 1,900ft2 office space on University Avenue in vibrant La Mesa / East San Diego, across from the Joan Kroc Center. Next door to busy pediatrics practice, ideal for medical, dental, optometry, lab, radiology, or ancillary services. Comes with 12 assigned, gated parking spaces, dual restrooms, server room, lighted tower sign. Build-out allowance to $20,000 for 4–5 year lease. $3,700 per month gross (no extras), negotiable. Contact venk@cox.net or (619) 504-5830. [835] SHARE OFFICE SPACE IN LA MESA JUST OFF OF LA MESA BLVD: 2 exam rooms and one minor OR room with potential to share other exam rooms in building. Medicare certified ambulatory surgery center next door. Minutes from Sharp Grossmont Hospital. Very reasonable rent. Please email KLewis@SDCMS.org for more information. [867] NONPHYSICIAN POSITIONS AVAILABLE LOOKING FOR A BOARD-CERTIFIED FAMILY PHYSICIAN OR NURSE PRACTITIONER: Family medicine, private practice, part- or full-time coverage, North County San Diego. Looking for a board-certified family

physician or licensed nurse practitioner who would like to join our small practice and provide personable, high quality, patient-centered care. Great position for someone who wants to practice medicine and make a difference. Flexible hours. Online access to EMR. We have a great team and would like to work with someone who can contribute to that experience. Please email CV to familypracticeNC@gmail.com. [111b] PHYSICIAN OR NURSE PRACTITIONER: Physician or nurse practitioner to perform housecalls in North San Diego County Monday thru Friday. 10-12 patients per day. Please forward CV. Full time. Excellent time management skills required. Pager one week per month, no hospital rounds. Established patient base. Independent contractor position with great income potential. NP’s-home health experience a plus. Please respond by email only to mobiledoctor@sbcglobal.net. Thank you. [106b] NURSE PRACTITIONER OR PHYSICIAN’S ASSISTANT: Established, busy pain management practice in Mission Valley is looking for a nurse practitioner or physician’s assistant, preferably experienced in pain management or family practice. Knowledge of controlled substance prescriptions and regulations is required. Interpretation of diagnostic tests and the ability to apply skills involved in interdisciplinary pain management is necessary. We offer a competitive salary and benefit package that provides malpractice coverage, CME allowance, as well as an excellent professional growth potential. Please email your curriculum vitae/resume to sdpainclinc@yahoo.com. [094] PHYSICIAN ASSISTANT OR NURSE PRACTITIONER: Needed for house-call physician in Coachella Valley (Palm Springs / Palm Desert). Part time, flexible days/ hours. Competitive compensation. Call (619) 992-5330. [038] MEDICAL EQUIPMENT ELECTRONIC TOUCH SCREEN MEDICAL CHECK IN SYSTEM FOR SALE: Eliminate staff interruptions and increase your office efficiency with this easy-touch patient sign-in kiosk in your waiting room. The average sign-in time for patients with a Medical Check In touchscreen kiosk takes fewer than 10 seconds. With this reduction in interruptions and the clear, organized communication of patient information to your receptionist’s computer, Medical Check In will reduce the time for the patient sign in process, reduce congestion for your reception area and save you money. Compatible with all electronic health records. Still under warranty. Cost for new Medical Check In is $2,500. Great price for this at $995. For more information please see medicalcheckin. com. Email KLewis@SDCMS.org. [982]

Place your ad here Contact Dari Pebdani at 858-231-1231 or DPebdani@sdcms.org

SAN DI EGO PHYSICIAN.org 35

San Diego Physician Celebrates 100 Years!

The Bulletin of the San Diego County Medical Society February 20, 1931

In celebration of 100 years of publication of San Diego Physician (formerly known as The Bulletin), we will be reprinting throughout the year excerpts from past issues, and we will devote our December 2013 issue to recognizing the achievements of the official “Bulletin” of the San Diego County Medical Society. If you would like to contribute in any way to our December issue, please email Editor@SDCMS.org. Thank you!

the bulletin The Specter Talk s From High Sou

rces

The specter facing the Medical profession today is — Social or State Medicine — and, try as we will to shut our eyes to it, he stands just around the corner. When he strikes it will affect us all for, sad as it is, the Medical profession has never stood as a unit. Much has been said in the last few years on this subject but when a member of the Presi dent’s cabinet comes out with inter views and articles such as have appea red in recent publicatio ns by Mr. Ray Lyma n Wilbur, Secretary of the Inter ior, our posit ion is extremely preca rious. In these articles Ray Lyma n Wilbur, M. D., states that while the A. M. A. is fight ing this proposition the members might just as well accept it for it is sure to come . That the cost of medi cal care of the great midd le class is all out of prop ortion to the earni ng capacity of this class. The answ er, as he sees it, is for the medical profession to do the work and pay the bills. Since when has Ray Lyma n Wilbur, M. D., and the Hoover admi nistration been so vitall y interested in the great common people? In watch ing the admi nistration activ ities for the past eighteen mont hs, your editor has failed to see wher e any actions have been taken in the interests of this supporti ng class of the nation, but a cry to cut the cost 36 february 2013

of medical care has an appeal and is good polit ics. If the Secretary of the Inter ior and the Hoover admi nistration are so interested in the interest of the common people why are they doing all in their power to turn over our natur al resources in the form of hydro-electric powe r, forest and oil reser ves, to private capital? It is the humble opinion of your editor (and you can’t hang a man for stating an opini on) that the Secretary of the Inter ior is again takin g his orders from the financial interests, this time in the form of the great indem nity insurance comp anies. These organ izations have got control of indus trial accident and have made millions out of it (at the expen se of the medical profession) and woul d now like to control all medical pract ice and pay the doctors what they see fit and incidental ly make more millions for their stock holders. If, or when this state arises, what is to becom e of the Medical profession — what incen tive will you and I have to do our best work. Love of our profession, yes — but incidentally we must make a living. What is to become of our medical colleges? Is a young man going to spend ten years to prepare himself to earn mechanic’s wages? Not unles s he is a bigger fool than most of the young men of today are. Face the issue men, and think it over. Your editor has shifted a load from his chest to your shoulders.

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