July 2013 by San Diego Physician

San Diego Physician

official publication of the san diego county medical society july 2013

100 celebrates

years

Fraud

abuse and

What Physicians Need to Know to Comply With State and Federal Laws

â&#x20AC;&#x153;Physicians United For A Healthy San Diegoâ&#x20AC;?

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Contents july

Volume 100, Number 7

MANAGING EDITOR: Kyle Lewis EDITORIAL BOARD: Theodore M. Mazer, MD, James Santiago Grisolía, MD, Robert E. Peters, PhD, MD, David M. Priver, MD, Van C. Johnson, MD, Roderick C. Rapier, MD MARKETING & PRODUCTION MANAGER: Jennifer Rohr SALES DIRECTOR: Dari Pebdani ART DIRECTOR: Lisa Williams COPY EDITOR: Adam Elder

features FRAUD AND ABUSE

SDCMS BOARD OF DIRECTORS

OFFICERS PRESIDENT: Robert E. Peters, PhD, MD PRESIDENT-ELECT: J. Steven Poceta, MD TREASURER: William T-C Tseng, MD, MPH (CMA Trustee) SECRETARY: Mihir Y. Parikh, MD IMMEDIATE PAST PRESIDENT: Sherry L. Franklin, MD (CMA Trustee)

hat Physicians Need to W Know to Comply With State and Federal Laws CALIFORNIA MEDICAL ASSICIATION

CMA’s Center for Economic Services (CES) CALIFORNIA MEDICAL ASSICIATION

Addressing the Looming Primary Care Physician Shortage: An Interview With Dr. Leonard Glass

SAN DIEGO PHYSICIAN

departments 4

Briefly Noted: Calendar • Get in Touch • Featured Member • And More …

2013 White Coat Gala: SDCMS’s Presidential Dinner and Dance

Report From AMA’s Annual Meeting: June 2013

ALBERT RAY, MD

An Interview With Dr. Susan Kaweski

VIMAL NANAVATI, MD

Advice From a Recovering Control Freak: Learning to Become Proficient Delegators

HELANE FRONEK, MD, FACP, FACPH

22 Please Leave a Message: The Big Bang and Old Phone Numbers DANIEL J. BRESSLER, MD

24 Employee vs. Independent Contractor: Best Practices to Protect Your Business JENNY SMERUD, CPA

Frequent Malpractice Risks Faced by Office Practices Revealed in Survey

GEOGRAPHIC AND GEOGRAPHIC ALTERNATE DIRECTORS EAST COUNTY: Venu Prabaker, MD, Alexandra E. Page, MD, Jay P. Mongiardo, MD (A: Susan Kaweski, MD (CALPAC Treasurer)) HILLCREST: Gregory M. Balourdas, MD, Thomas C. Lian, MD (A: Sunny R. Richley, MD) KEARNY MESA: Jason P. Lujan, MD, John G. Lane, MD (A: Anthony E. Magit, MD, Sergio R. Flores, MD) LA JOLLA: Geva E. Mannor, MD, Wayne Sun, MD (A: Lawrence D. Goldberg, MD) NORTH COUNTY: James H. Schultz, MD, Eileen S. Natuzzi, MD, Michael A. Lobatz, MD (A: Anthony H. Sacks, MD) SOUTH BAY: Reno D. Tiangco, MD, Michael H. Verdolin, MD (A: Elizabeth Lozada-Pastorio, MD) AT-LARGE DIRECTORS Jeffrey O. Leach, MD (Delegation Chair), Karrar H. Ali, MD, Kosala Samarasinghe, MD, David E.J. Bazzo, MD, Mark W. Sornson, MD (Board Representative), Peter O. Raudaskoski, MD, Vimal Nanavati, MD (Board Representative), Suman Sinha, MD AT-LARGE ALTERNATE DIRECTORS Karl E. Steinberg, MD, Phil Kumar, MD, Holly B. Yang, MD, Perry N. Willette, MD, Samuel H. Wood, MD, Elaine J. Watkins, DO, Carl A. Powell, DO, Theresa L. Currier, MD OTHER VOTING MEMBERS COMMUNICATIONS CHAIR: Theodore M. Mazer, MD (CMA Vice Speaker) YOUNG PHYSICIAN DIRECTOR: Edwin S. Chen, MD RESIDENT PHYSICIAN DIRECTOR: Jane Bugea, MD RETIRED PHYSICIAN DIRECTOR: Rosemarie M. Johnson, MD MEDICAL STUDENT DIRECTOR: Jason W. Signorelli OTHER NONVOTING MEMBERS YOUNG PHYSICIAN ALTERNATE DIRECTOR: Renjit A. Sundharadas, MD RESIDENT PHYSICIAN ALTERNATE DIRECTOR: Erin Whitaker, 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 AMA ALTERNATE DELEGATE: Lisa S. Miller, MD

THE DOCTORS COMPANY

Physician Marketplace: Classifieds

24 2 j u ly 2013

San Diego Physician Celebrates 100 Years: April 1950

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.]

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/////////briefly ///////////////////noted ////////////////////////////////////////////////////////////////////// calendar SDCMS Seminars, Webinars & Events SDCMS.org

For further information or to register for any of the following SDCMS seminars, webinars, workshops, and courses, email Seminars@SDCMS.org.

Employee OSHA Training: Healthcare Facilities (seminar/webinar) AUG 15: 11:30am–1:00pm Cal MediConnect: What You Need to Know (seminar) AUG 22: 11:30am–1:00pm NOTE: Email your questions about the transition — to be answered during the seminar — to Marisol at MGonzalez@ SDCMS.org no later than Aug. 7!

Cma Webinars CMAnet.org/events Medicare Transition: MAC Jurisdiction E Implementation Overview AUG 7: 12:15pm-1:30pm HIPAA Compliance: The Final HITECH Rule AUG 21: 12:15pm–1:15pm Medicare: Proposed Changes for 2014 AUG 28: 12:15pm–1:15pm California’s Health Benefit Exchange: The Positives and the Perils of Contracting SEP 11: 12:15pm–1:15pm

“

Community Healthcare Calendar

To submit a community healthcare event for possible publication, email KLewis@ SDCMS.org. Events should be physician-focused and should take place in or near San Diego County. 30 Annual Primary Care Summer Conference AUG 2–4: Hilton San Diego Resort, 7:00am–12:00pm, $400 for physicians, 12 AMA PRA Category 1 Credits™, www.scripps.org/events/ primary-care-summerconference-august-2-2013 th

Journey Into Healing: The Chopra Center’s Mind-Body Wellness Workshop AUG 22–25: La Costa Resort & Spa, Carlsbad, $2,175– $1,675 (add promo code “MEDICAL” at checkout to receive special price), CMEs available) www.chopra.com/ programs/journey-intohealing/journey-into-healingaugust-22-25-2013# 4th Annual Percutaneous Catheter Ablation of Atrial Fibrillation: How to Incorporate This Therapeutic Option Into Your Practice AUG 24–25: Hilton La Jolla Torrey Pines • www.scripps. org/events/percutaneouscatheter-ablation-of-atrialfibrillation-august-24-2013 National End Stage Liver Disease Training and Treatment Update SEP 7: San Diego Marriott La Jolla • www.scripps. org/events/national-endstage-liver-disease-trainingprogram-and-treatmentupdate-august-10-2013

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

Injustice never rules forever.

”

— Seneca, Roman Philosopher (4 BCE – 65 CE)

4 j u ly 2013

get in touch

Patient Care Manager Rebecca Valenzuela at (858) 300-2785 or Rebecca.Valenzuela@SDCMS.org Patient Care Manager Elizabeth Terrazas at (858) 565-8156 or Elizabeth.Terrazas@SDCMS.org IT PROJECT MANAGER Rob Yeates at (858) 300-2791 or Rob.Yeates@SDCMS.org IT PROJECT MANAGER Victor Bloomberg at (619) 252-6716 or Victor.Bloomberg@SDCMS.org

/////////////////////////////////////////////////////////////////////////////////////////////////// Featured Member

legislator birthdays

Dr. Carlos J. Sanchez

Carlos J. Sanchez, MD, SDCMS-CMA member since 1974, received the Hispanic Physician of the Year Award at the 17th annual conference of the National Hispanic Medical Association in Washington, DC. In his acceptance speech, he succinctly spoke of his odyssey to become a doctor. Following are excerpts from his speech. I was born in the high Andes of Peru, raised in the steaming jungles of the Amazon without any schooling, medical care, or civilization around, except for nature that surrounded me as an open book. In those days I suffered all the diseases that one can think of, and I also saw misery all over. Somehow I ended up in the big city where I finished high school. Through the American movies, I saw on the big screen planes falling down in flames for the rights of other people and nations to recover their dignity and freedom from the dark forces of the enemy. Those were the days of the Second World War, and my thoughts went to that great country of the north — I knew I wanted to go there. Certain of my future and wishes, I was able to get a student visa, and, after a lengthy trip by air, car, and train, I arrived in the U.S., where I enrolled at Brigham Young University in pre-med. After five years of multiple rejections and without the existence of any minority programs, I was accepted at St. Louis University School of Medicine in Missouri, where I graduated in four years. I did my intern-

ship, and, soon after, I was drafted and served two years in the U.S. Navy as a medical officer during the Vietnam era. After a post in the desert, I was assigned to San Diego. After being discharged, I did my residency in pediatrics at UCSD. Not knowing where to go or where to practice, I opened an office in an underserved area of San Diego five miles from the border, where no one else wanted to go. I followed the words of wisdom of a medical school professor who used to say, “Do good and money will follow you,” and it certainly did for me. Soon after I was so busy that I had to construct a building and brought doctors to take care of the disadvantaged. As my success provided ample resources, I started to do what I told my medical school I would do: go and help the poor. For the last 30 years, I have continuously been doing yearly missions to far out places of the Amazon, the Andes, and the nations of Mexico and Brazil. It has been a beautiful journey and also a painful one. Those missions led me to writing my first book, The Soul of the Condor: A Forgotten Holocaust. Now in the sunset of my life, I ask myself, what have I done? Nothing but a drop of water in the diluvium of the mighty Amazon. In my moments of reflections, I began to write my second book, The Holocaust of All Times. Thus with a sense of deep humbleness I accept this honor you are bestowing on me, but I will accept it not as a Latino, for that I am not — the Pope is. I am not a Hispanic either — Marco Rubio is. I am an “Indian” who happens to have some Hispanic blood, and that makes me an Indo-American. So I receive this accolade as a mestizo in hopes that the so-called Hispanos and Latinos know that this is our ancestral continent, and that denying our roots is the cause of our misery in the so-called Latino or Hispanic population. Along with the other outstanding recipients, including Regina M. Benjamin, MD, the U.S. surgeon general, and Carlos M. Gutierrez, the former secretary of the U.S. Department of Commerce, Dr. Sanchez received a standing ovation. His books are for sale, with the proceeds going to SDCMS charitable projects. Please call SDCMS at (858) 565-8888.

One way to let your legislators know that you’re paying attention and that you vote is by wishing them a happy birthday! Councilmember David Alvarez (District 8) E: davidalvarez@sandiego.gov City Administration Building 202 “C” Street, 10th Floor San Diego, CA 92101 T: (619) 236-6688 • F: (619) 231-7918 Birthday: July 27 Assemblymember Toni Atkins E: (via website) asmdc.org/members/a76 Email: assemblymember.atkins@assembly. ca.gov Capitol Office: California State Assembly PO Box 942849 Sacramento, CA 94249-0078 Telephone: (916) 319-2078 Fax: (916) 319-2178 District Office: 2445 5th Ave., Ste. 401 San Diego, CA 92101 Telephone: (619) 645-3090 Fax: (619) 645-3094 Birthday: Aug. 1 Assemblymember Brian Jones Email: assemblymember.jones@assembly.ca.gov

Capitol Office: California State Assembly PO Box 942849 Sacramento, CA 94249-0071 Telephone: (916) 319-2071 Fax: (916) 319-2171 District Office: 10152 Mission Gorge Rd. Santee, CA 92071 Telephone: (619) 441-2322 Fax: (619) 441-2327 Birthday: Aug. 9 Senator Ben Hueso Email: senator.hueso@sen.ca.gov Capitol Office: State Capitol, Room 2054 Sacramento, CA 95814 Telephone: (916) 651-4040 Fax: (916) 327-3522 District Office: 303 H St., Ste. 200 Chula Vista, CA 91910 Telephone: (619) 409-7690 Fax: (619) 409-7688 Birthday: Sept. 2 SAN DI EGO PHYSICIAN.org 5

/////////briefly ///////////////////noted ////////////////////////////////////////////////////////////////////// SDCMS Foundation

SDCMS-CMA Membership

San Diego GYN Society Planning Major Gift to Project Access

Welcome New and Rejoining SDCMS-CMA Members!

The San Diego GYN

New Members

Society, which ceased operations in 2005, intends to turn over its residual treasury to the SDCMS Foundation’s Project Access. Its last elected officers, Arlene Morales, MD, and David Priver, MD, have con-

Marisol de la Cruz expressing her appreciation of Dr. Robert Eisenberg by presenting him with a painting during the 2012 White Coat Gala.

ducted extensive surveying of their OB/GYN colleagues and have determined that there is no substantial interest in reestablishing the society. This proposed contribution, which exceeds $40,000, will enable Project Access to provide much needed gynecological care to currently unfunded patients. Drs. Morales and Priver have decided that the donation of the funds to such 6 j u ly 2013

a worthy cause will reflect the very best caring instincts of their colleagues and will serve as a memorable and lasting legacy to the GYN Society. Ten percent of the more than 2,100 low-income, uninsured adults receiving specialty healthcare services through Project Access’s extensive physician volunteer network are women seeking gynecological care. “This contribution will greatly assist us in our work to meet the needs of women in our community,” says Stuart A. Cohen, MD, MPH, chair of the SDCMS Foundation. “We are most grateful to the gynecologists in the community for their commitment to Project Access as volunteers, and for this most generous contribution from the GYN Society.” One such patient is artist Marisol de la Cruz, who expressed her appreciation of her physician, Robert Eisenberg, MD, at the 2012 White Coat Gala by presenting him with a painting she had created. “GYN care profoundly improves the health of our patients,” adds Barbara Mandel, SDCMS Foundation executive director. “We are able to get women back to health, back to work, and caring for their families. That is what Project Access accomplishes.”

Aziz N. Ander, MD Neurology Oceanside (760) 631-3020 Brian D. Belnap, DO Physical Medicine and Rehabilitation Oceanside (760) 631-3020 Daniel D. Klaristenfeld, MD Colon and Rectal Surgery San Diego (619) 528-5000 Jon K. Ludwig, MD Emergency Medicine San Diego (619) 686-3800 Vi T. Nguyen, MD Pediatrics San Diego Remia S. Paduga, MD Clinical Neurophysiology Oceanside (760) 631-3020 Miguel A. Pena-Ruiz, MD Internal Medicine San Diego Jay Pyo, DO Physical Medicine and Rehabilitation San Diego (619) 532-6400 David W. Rosenthal, MD Nephrology San Diego

Lori B. Taylor, MD Pediatrics Del Mar Patrick A. Tellez, MD Allergy and Immunology San Marcos (760) 736-8689 Michael J. Zupancic, MD Sleep Medicine Oceanside (760) 631-3020

Rejoining Members Gilbert E. Boswell, MD Diagnostic Radiology San Diego (619) 532-8670 Jenna M. Lavina, MD Internal Medicine San Diego Jeanette Mendez, MD Gastroenterology San Diego (760) 436-9872 Nathan A. Miller, MD Pain Medicine Carlsbad (760) 753-7127

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SDCMS Membership

2013 White Coat Gala

SDCMS’s Presidential Installation Dance and Dinner

On Saturday, June 8,

2013, the San Diego County Medical Society (SDCMS) held its annual White Coat Gala at the Hyatt Regency La Jolla Aventine. Over 200 people joined in the festivities as Robert E. Peters, PhD, MD, was installed as the 144th president of SDCMS, and Sherry Franklin, MD, was recognized for her service as immediate past president. Honorable attendees included California Senators Mark Wyland and Marty Block, and California Assemblymembers Rocky Chavez, Brian Jones, Shirley Weber, and former Assemblymember Martin Garrick. The 2012 Presidential “Atlas” Awards, given each year by the outgoing SDCMS president, were presented to Roneet Lev, MD, longtime SDCMS member and chair of SDCMS’s Emergency Medicine Oversight Commission, and Tom Gehring, SDCMS CEO and executive director. The SDCMS Foundation / Project Access San Diego “Above and Beyond” Award was presented to Daniel “Stony” Anderson, MD, Sandra Freiwald, MD, Huathin Khaw, MD, Marco Tomassi, MD, and the Kaiser Permanente “Team Joel.” The SDCMS Foundation / Project Access San Diego “Spirit” Award was presented to Adam Fierer, MD, Eileen Natuzzi, MD, Mark Ransom, MD, Anesthesia Services 8 j u ly 2013

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Medical Group, and the Carlsbad Surgery Center Saturday Surgery Day team. Dr. Peters’ Acceptance Speech Friends, Family, Fellow Members, Honored Guests, Medical Society Staff: Thank you for joining us this evening for the annual succession of our San Diego County Medical Society’s officers — not a change in direction, but a change in the leadership working for our members and the community. This evening I would like to give special recognition — and thanks — to my family, my wife, Kathi, and our daughters, Christine and Julia, for their constant support. Every physician’s family understands better than anyone else what it

is like living and growing with a practicing physician, let alone with those of us who also add organized medicine to our load. Thanks, guys. It is my honor to accept the presidency of SDCMS, one of the best, if not the best, county medical societies in the United States. Aristotle stated, “We are what we repeatedly do. Excellence, therefore, is not an act but a habit.” In my experience, that quotation is a description of the San Diego County Medical Society. Excellence is exactly that, a “habit” for this organization. And it is my goal to continue that tradition. We face many challenges each year, but probably never more so than now. MICRA attacks, unwise scope of practice expansions, declining reimbursement, increasing overhead costs,

technology demands, the ACA and added reporting burdens, expanding populations of insureds and underinsureds, the list is longer than ever! Add to that the pending exit of significant experience from our physician population base due to the high number of physicians approaching retirement. And we as physicians and as organized medicine need to deal with all of these in order to preserve the practice of medicine and guard the welfare of those who entrust their health to us. In California and a few other states, dialogue among elected representatives is veering

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1. Dr. Robert Peters (L) with Senator Marty Block and guest, Julie McCabe. 2. Assemblymember Shirley Weber and Roxana Foxx. 3. (L–R) Former Assemblymember Martin Garrick, Dr. Sherry Franklin, and Karen and Jeffrey Dunham. 4. Dr. Robert Peters delivering his inaugural speech. 5. Dr. Robert Peters chatting with Senator Wyland before dinner.6. Assemblymember Brian Jones with his wife, Heather. 7. Assemblymember Rocky Chavez with his wife, Mary. 8. Dr. Robert Hertzka (L) with Nick Macchione, San Diego HHSA director, and his wife, Lisa. 9. Dr. Stuart Cohen (L) and Dr. Albert Ray (R) presenting the SDCMS Foundation / Project Access San Diego “Above and Beyond” Award to Dr. Daniel “Stony” Anderson and Dr. Sandra Freiwald.

SAN DI EGO PHYSICIAN.org 9

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toward potential expansion of so-called “provider” ranks via legal authorization of nonphysicians to provide primary care medical services to patients without physician supervision. This misguided effort to authorize nurse practitioners, optometrists, chiropractors, pharmacists, and podiatrists to act in an independent capacity, from diagnosis and triage decision-making to prescription writing, is falsely justified by the developing physician shortage and demands for access to care by newly insureds under the ACA. Instead of concern for the best quality and safety of care for the population, economics and expediency are driving such political discussions. We at SDCMS and CMA look at this differently: We fight to maintain the best care and expand access not by making non-doctors into doctors of medicine, but by carefully expanding the healthcare team 10 j u ly 2013

to allow everyone to work to the highest extent of their training and licensure while keeping the best educated and trained individual, the physician, at the head of the healthcare team. We are actively involved in each of these issues, working to model and guide the future for the benefit of the patient. We must be willing to step up and lead, defining a higher ground that minimizes disruption and diminution of the quality of patient care. We — as physicians — are the true “guardians” of patient care. That is our goal and mission as professionals with the greatest intensity of medical education and training. If not us, who? We must adapt to an everchanging practice environment, and we must help design and embrace new ways of delivering patient care, but we must also protect the quality of care delivered.

Our voices must be heard in the exam room, in San Diego, in Sacramento, and in Washington, DC. We must not allow needed changes to our healthcare delivery system to be made by politicians and/or by third parties without focusing them on patient needs and good medical practice, rather than a primarily economic focus. Too often the medical component

of patient care has not been the primary focus of legislated or insurance-forced change in healthcare delivery or payment systems. We are the last line to ensure that the focus is kept on best practices and medical care quality. Our oath of “First, do no harm” must extend to protecting the patient from the unintended consequences of policy-driven change.

10. Dr. Stuart Cohen (L) and Dr. Albert Ray (R) presenting the SDCMS Foundation / Project Access San Diego “Spirit” Award to (L–R) Dr. Mark Ransom, David Douglas, and Dr. Adam Fierer. 11. Dr. Franklin (L) presenting a 2012 Presidential “Atlas” award to Dr. Roneet Lev. 12. Dr. Sherry Franklin receiving a resolution from Senator Mark Wyland recognizing her for her outstanding work as SDCMS president in 2012–13. 13. Tom Gehring, SDCMS executive director, receiving a 2012 Presidential “Atlas” Award from Dr. Sherry Franklin, with Jennipher Ohmstede, SDCMS director of engagement, at left. 14. Dr. Sherry Franklin, SDCMS president for 2012–13, “passing the gavel” to Dr. Robert Peters, SDCMS president for 2013–14. 15. Current and former SDCMS presidents (L–R): Dr. Robert Peters, Dr. Stuart Cohen, Dr. Albert Ray, Dr. Susan Kaweski, Dr. Carol Young, Dr. James Hay, Dr. Sherry Franklin, Dr. Theodore Mazer, Dr. Robert Hertzka, and Dr. Ralph Ocampo. Tom Gehring at far right. Several presidents were making good-humored fun of Tom for his selection of sunglasses. 16. SDCMS medical students in attendance. Front row: Andy Huang and Marsha-Gail Davis. Back row (L–R): Evan Davidson, Christian Torres, Jason Signorelli, Ryan Nock, James Zhang, and Casey Williamson.

Can you recite the SDCMS vision statement? “Physicians united for a healthy San Diego.” More than at any time in the past, we must be united, protecting our profession and those we serve … our patients. Individually we may disagree on some details, on some issues, but we agree on consistently optimizing and improving, in the most economic fashion that can be accomplished, the quality of medical care for our patients. We have a duty and the capability, as well as credibility, to drive proposed positive changes and

to turn back those that may negatively impact patient medical care. From primary care to specialty care, from Scripps to Kaiser Permanente, Sharp to UCSD, whether solo practice or member of a large group, we are each first and foremost physicians. No one has greater experience, knowledge, or sensitivity to the reality of patient care issues under discussion than do we. We must be the vocal advocates for our patients. The Dalai Lama has been quoted saying, “To remain indifferent to the challenges we face is indefensible. If the goal is noble, whether or not it is realized within our lifetime is largely irrelevant. What we must do is persevere, and we must never give up.” Similarly, Dante said: “The darkest places in hell are reserved for those who maintain their neutrality in times of moral crisis.” And, for a more contemporary interpretation, Robert Langdon, in Dan Brown’s newest book, says: “In dangerous times, there is no sin greater than inaction.” Now, more than ever, it is up to us to protect the practice of medicine for the benefit of the patient, as we acknowledge that the world is changing. And I am honored, and humbled, as your new leader in these endeavors. I look forward to helping lead the charge! Thank you.

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american medical association

Robert Wah, MD, was elected AMA president-elect, and Ardis Hoven, MD, was installed as AMA president.

California Resolutions 1. Health Risks of Sitting (Res. 413): Adopted a resolution that asks that our AMA recognize that there are potential risks of prolonged sitting and encourage efforts by employers, employees, and others to make available alternatives such as standing work stations and isometric balls, and encourage educational efforts regarding ways to minimize this risk. 2. Monitoring for Radiation in Seafood (Res. 414): Adopted as amended a California resolution that asks that our AMA call for the United States government to continue to monitor and fully report the radioactivity levels of edible Pacific Ocean species sold in the United States that could reasonably have been exposed to radiation from the ongoing Fukushima disaster, with information about potential health implications of consuming such foods.

Report From AMAâ&#x20AC;&#x2122;s Annual Meeting June 2013 by Albert Ray, MD

12 j u ly 2013

3. Prevention of Falls Through Windows (Res. 415): Adopted as amended a California resolution that asks our AMA to support the use of window guards and devices that prevent windows from opening enough to allow a child to fall through, and to support public education regarding the risks of children falling through windows. 4. Public Education on Distracted Driving (Res. 416): Adopted a resolution that asks that our AMA support public education efforts regarding the dangers of distracted driving, particularly activities that take driversâ&#x20AC;&#x2122; eyes off the road. 5. Cannabis Decriminalization, Regulation, and Taxation (Res. 512): Referred a California resolution that asks our AMA to urge federal agencies to reschedule medical cannabis in order to encourage research leading to responsible regulation; decriminalize medical use of cannabis; build an appropriate public health regulatory framework for cannabis use; and facilitate dissemination of information about risks and benefits of cannabis use.

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6. Medication Collection “Take Back” Programs (Res. 513): Referred for decision a California resolution that asks our AMA to support medication collection or “take back” programs, funded in whole or in part by the pharmaceutical industry, that help keep unused medications out of the environment and out of the hands of potential overdose victims or drug abusers. 7. Revised Blood Donor Deferral Criteria (Res. 514): Adopted a substitute resolution for Res. 514 that asks our AMA to oppose the current lifetime deferral on blood donations from men who have sex with men, and express support for the use of rational, scientifically based deferral periods that are fairly and consistently applied to donors according to their level of risk rather than being solely based on sexual orientation. Adopted Resolves: • RESOLVED, that our AMA support the use of rational, scientifically based blood and tissue donation deferral periods that are fairly and consistently applied to donors according to their level of risk. • RESOLVED, that our AMA oppose the current lifetime deferral on blood and tissue donations from men who have sex with men. AMA Policies H-50.974 and D-50.997 were also rescinded. 8. Targeted Tuberculosis Testing of School Children (Res. 515): Adopted as amended a California resolution that asks our AMA to support efforts to replace universal tuberculosis testing of schoolage children with a TB risk assessment questionnaire, and support TB testing of school-age children based on the results of that TB risk assessment. 9. Early Treatment and Partner Services for HIV (Res. 516): Adopted as amended by addition a California resolution that asks our AMA to support programs raising physician awareness of the benefits of early treatment and of “treatment as prevention,” and the need for linkage of newly positive persons to clinical care and partner services.

Endorsed by

Other Key Actions: 1. Board of Trustees Report 30 — Future of the Interim Meeting of the House of Delegates: The AMA House of Delegates did not adopt Board Report 30, which rec-

14 j u ly 2013

ommended the elimination of the interim meeting of the House of Delegates. 2. Eligibility of Sugar-sweetened Beverages of SNAP: Adopted a resolution that asks that our AMA publish an educational brief to educate physicians about the effects of sugar-sweetened beverages (SSBs) on obesity and overall health, and encourage them to educate their patients in turn, that our AMA encourage state health agencies to include educational materials about nutrition and health food and beverage choices in routine materials that are currently sent to Supplemental Nutrition Assistance Program (SNAP) recipients along with the revised eligible foods and beverages guidelines, and that our AMA work to remove SSBs from SNAP. 3. Council on Science and Public Health Report 3 — Is Obesity a Disease? Our AMA adopted a report examining the definitions of obesity and disease, the limitations of those definitions, and arguments both for and against the classification of obesity as a disease. The possible implications for provider reimbursement, public policy, and patient stigma were also considered. Of central interest is the potential impact of classifying obesity as a disease on improving patient care and health outcomes. AMA Policies H150.953 and H440.866 are reaffirmed and Policy D440.971 rescinded. 4. Council on Science and Public Health Report 2 — Nanotechnology Safety and Regulation: Our AMA adopted a report that offers a brief overview of the current uses of nanotechnology, potential effects on human health and the environment, and regulation of nanomaterials. It recommends that our AMA (a) recognize the benefits and potential risks of nanotechnology; (b) support responsible regulation of nanomaterial products and applications to protect the public’s health and the environment; and (c) encourage continued study on the health and environmental effects of exposure to nanomaterials. This report was the product of a California Resolution from last year. Dr. Ray, SDCMS-CMA member since 1993, is, along with Lisa S. Miller, MD, an alternate delegate to AMA from San Diego. James T. Hay, MD, and Robert Hertzka, MD, are both delegates to AMA from San Diego. All four attended AMA’s June 2013 annual meeting.

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Physician Workforce

Addressing the Looming Primary Care Physician Shortage San Diego Physician Interviews Dr. Leonard Glass

Leonard W. Glass, MD, SDCMS-CMA member since 1972, is a University of Maryland School of Medicine graduate who trained in plastic and reconstructive surgery at the University of Michigan. He is certified by the American Board of Surgery and the American Board of Plastic Surgery. After a long career in private practice and as clinical professor of surgery at UC San Diego, Dr. Glass retired from practice eight years ago. San Diego Physician: There has been a great deal of concern regarding patient access when the Affordable Care Act gets to its next stage of enactment on Jan. 1, 2014. What can we expect? Dr. Glass: The shortage of primary care physicians has been well analyzed and doc16 j u ly 2013

umented. Now, with the Affordable Health Care Act expected to add 32 million insured people seeking a physician, the baby boomer generation adding more than 10,000 seniors every day to the ranks of those covered by Medicare, and an accelerating retirement rate of current physicians, the problem is exploding before our eyes. The current deficit of primary care physicians has been pegged at 33,000 and is expected to double over the next 12 years. As new private clinics continue to come online seeking to provide primary care, the competition among publicly funded clinics and private sector providers has intensified. Medical school capacity cannot be expanded in the foreseeable future at a rate that even begins to address the problem.

standardized patient competence assessment. The fact that competency will be demonstrated sets this program apart from traditional continuing medical education and adds confidence to the participant and employer after successful completion. PRR is the country’s only internet-based, online, affordable education service offered to physicians as a means of retraining. Moreover, it is the only program available for physicians to be retrained as an outpatient adult primary care physician from a previous specialty of any kind. All other retraining services simply bring physicians up to date in the specialty from which they had retired. The PRR curriculum is specifically designed to take any doctor, no matter their field of practice, and update their skills to allow them to return to practice in the specialty of primary care.

San Diego Physician: Are there any potential solutions? Dr. Glass: Dr. Stanley Pappelbaum and I, both former SDCMS members now retired from practice, began studying this impending crisis in the healthcare delivery system three years ago and have now co-founded a new company, Physician Retraining and Reentry (PRR), to begin addressing the issue. In collaboration with the UCSD School of Medicine, PRR utilizes the expertise of two national figures in teaching and practicing family medicine to design its curriculum. Doctors William Norcross and David Bazzo, both professors of family and preventive medicine at UCSD, have recruited other faculty members to write the educational material, exam questions, and develop a

San Diego Physician: Are there specific groups of physicians that are targeted for retraining? Dr. Glass: The program can work for any physician, but there is a cohort of physicians that may be very well suited for this program. The number of active, healthy, retired physicians is in the tens of thousands. PRR’s surveys indicate that a significant number of them are bored with recreational activities (think golf), would love to return to helping others as they did for so many years, and could use a modest financial boost. Moreover, the women among them, who retired early to raise a family, are also interested in returning as their children start maturing. As a whole, the group indicates that in returning to practice their priorities are: part-time work; no administrative duties; no nights or weekend call responsibility; and no financial obligations for rent, staff,

insurance, or other overhead items. Such positions are available on a permanent, regularly scheduled, part-time basis, working anywhere from one half-day up to three days a week. San Diego Physician: This seems like it may be a good fit. Dr. Glass: Herein lies the beautiful synergy between PRR and the rapidly growing critical need for adult primary care physicians. Such part-time, limited-responsibility positions exist today throughout the country, and the job placement division of PRR will guide its graduates to interviews for these jobs at no additional cost. The need and accompanying jobs are dispersed among community clinics (there are more than 7,000 federally funded clinics now seeing about 20 million patients a year), HMOs, college and university health clinics, medical schools, VA facilities, hospitalassembled primary care groups, and retail providers such as CVS and Walgreens. In addition to being positioned to earn from $25,000 to well over $100,000 annually, depending on hours worked, PRR graduates will receive approximately 100 hours of CME credits as well as a certificate of completion from UCSD. Perhaps most importantly, these individuals can be proud of their return to serving those in need, both by practicing medicine and becoming part of the solution to a national crisis. San Diego Physician: Thank you for the information. Is there a way to find out additional information about this program? Dr. Glass: To learn more about this innovative program and to see if it might be right for you or someone you know, please go to www.prrprogram.com or contact PRR at (858) 240-4647. SAN DI EGO PHYSICIAN.org 17

SDCMS Leadership

An Interview With Dr. Susan Kaweski

One in an Occasional Series of Interviews of SDCMS Physician Leaders by Vimal Nanavati, MD

Dr. Susan Kaweski, SDCMS-CMA member since 1983 and past president of SDCMS, is board-certified in plastic surgery, is currently an SDCMS geographic director from East County, and is treasurer of CALPAC, CMA’s political action committee. Dr. Kaweski was recently named a 2013 Healthcare Hero by the Grossmont Healthcare District; these awards are given to volunteers for their contributions to improve healthcare in East County. Dr. Nanavati: How long have you been a member of SDCMS? Dr. Kaweski: I have been a member since 1983. Dr. Nanavati: What brought you to SDCMS? Dr. Kaweski: I had been a plastic surgeon in the military and decided to embark on a private practice. I mistakenly thought that all I had to do was hang up my shingle, open my doors, and patients would flock to my office. Obviously, this didn’t happen. As I became a part of several hospital staffs, I learned that the County Medical Society could help me in several veins. I could network with other physicians who could possibly refer patients to me. I could obtain discounts for medical supplies, disability, liability, and car insurances, and on various services. They could help me in recruiting and hiring my office staff, as well as provide necessary updates and education for my staff. 18 j u ly 2013

Dr. Nanavati: You mentioned that you take advantage of some of the benefits of SDCMS. Can you name the benefits that you most like? Dr. Kaweski: I primarily use the educational benefits available to me and my office staff. There is an office manager course, a billing and coding course, EMR updates, and several other educational updates offered every quarter at the SDCMS headquarters and through video conferencing. I also take advantage of the numerous discounts available exclusively to Medical Society members. This includes discounts on medical and office supplies, AAA discounts, and a 5% discount on my medical malpractice insurance premiums. Dr. Nanavati: In your opinion, what three main changes in medicine today will impact the day-to-day functions of physicians the most? Dr. Kaweski: The Affordable Care Act is supposed to be fully operational in 2014. Physicians are concerned about the new law and how it will affect their incomes, their access to technologies, and their professional autonomy. Most of us feel that patient care will be negatively impacted and the doctor-patient relationship will be threatened as the decision-making authority is shifted to the government instead of to the physician. The Independent Payment Advisory Board (IPAB) brings the prospect of committee-based medicine much closer

to reality. This 15-person board will be charged with controlling Medicare spending by making payment and practice decisions that will oftentimes tie doctors’ hands. Similarly, the $10 billion Center for Medicare and Medicaid Innovation gives the HHS secretary and the CMS administrator enormous power not only to experiment with new payment and delivery systems, but to impose the results of the experiments without external verification. Reactions to these new constraints could vary. Physicians could choose to create boutique practices based on up-front payment from patients in order to avoid dealing with the government or insurances. Others will join large group practices that have more leverage with insurers and more staff to handle the increasing paperwork burdens. And some of us will retire early. So the supply of doctors may not be able to meet the demand of more patients. Dedicated professionals will lose their motivation to create new cures, techniques, or technology. Talented individuals will pursue something other than medicine. Dr. Nanavati: What would you change in medicine today that would have an immediate positive impact on the practicing physician? Dr. Kaweski: Physicians need to be remunerated fairly for their services in order to enable them to provide high-quality patient care. As reimbursements continue to plummet, there will be increased efforts

to consolidate and reduce costs. In the California Legislature, a number of bills have been introduced to have nonphysicians, such as nurse practitioners, physician assistants, optometrists, and psychologists, practice medicine without the ancillary guidance of a physician because of the cost. Should a patient be denied the right to access care by a physician because of cost? What happens when diagnoses are missed and patients suffer? The costs will ultimately increase. In addition, the SGR needs to be replaced with a new payment system, which is critical for ensuring access to medical care for beneficiaries of the Medicare program. The SGR is linked to the performance of the overall economy, yet the medical needs of individual patients do not shrink whenever the economy slows. When overall spending on services in the SGR exceeds the per capita gross domestic product, cuts to physician reimbursement are triggered. This skews the calculation of the SGR and triggers overly harsh reductions in physician reimbursement. The current SGR formula has led to reimbursements lagging behind the expansion of medical service that is scientifically valid

and appropriately expected by Medicare beneficiaries. Scheduled Medicare cuts in payments to physicians should be stopped. Physicians haven’t had a raise in 25 years! Congress must design a payment system that appropriately reflects the costs of practicing medicine and permits Medicare providers to continue delivering high-quality medical care to our Medicare beneficiaries. Dr. Nanavati: What advice would you give a medical student starting his or her first year? Dr. Kaweski: Work hard and diligently. Be compassionate to your fellow colleague, patient, and teacher. Stay open-minded and take as many electives as you can to get an excellent, well-rounded education. Enjoy and take time for yourself. Everyone needs a break. Stay active with other outside activities not related to medicine. Volunteer in your community. Dr. Nanavati: The work of the Medical Society board of directors and the executive committee is countless hours of uncompensated quality work on behalf of other physicians. This does not include travel and listening to testimony and draft-

ing resolutions for the House of Delegates at CMA. What keeps bringing you back year after year? Dr. Kaweski: We need to have a voice in order to make a difference. We must have consistent, regular, and collective efforts to advocate for our patients and fellow physicians to expand access to healthcare, stop the incursion of insurance companies and the government into the doctor-patient relationship, and improve the public health. It is vital that we are proactive in solution-building for the upcoming healthcare changes and how healthcare will be delivered in our community. We must weigh each proposal in light of the balance between cost and hoped-for advantages, the balance between clearly necessary and comfortably desirable, the balance between essential requirements and individual responsibilities, the balance between the actions of the moment and the future welfare, and the balance between local, state, and national programs. Dr. Nanavati, SDCMS-CMA member since 2005, is an SDCMS at-large director and board representative to SDCMS’s executive committee.

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Personal & Professional Development

1. Clearly define the task. Make sure that the person knows exactly what you want them to do. Be specific. Ask for their interpretation of the job so you know if you have the same vision. 2. When assigning tasks to a group, find out who is most interested in each one. Allowing people to work on projects in which they are genuinely interested improves the chance of success, especially if they have certain skills or experience to contribute. 3. Discuss what knowledge, skills, and equipment are needed for the task, and assess whether the person has them. 4. Determine what other resources are needed — people, equipment, access, technology, etc. — and facilitate that.

Advice From a Recovering Control Freak

Learning to Become Proficient Delegators

by Helane Fronek, MD, FACP, FACPh

20 j u ly 2013

Ah, those “lazy days of summer.” While we continue with our usual responsibilities, some of the other people in our lives see summer as a time to kick back. Our kids, home from school, may not be as interested in picking up after themselves or contributing to household chores as we might like. Staff members take vacations, leaving job responsibilities to others who may not have the same training or experience. We might try modeling the behavior that we want, using humor to encourage others to see what we think needs to be done, or even issue edicts. Frequently, we remain frustrated and lament the fact that things are not going our way. We often angrily give up and do things ourselves, adding to our own workload. As a recovering controlfreak, I can assure you that we can all learn to become proficient delegators. (If I can do it, so can you!) It’s a skill, like all those others we have mastered, and one worth developing. The truth is, most people want to feel accomplished, and they welcome the opportunity to be successful. So, the most important principle in delegating is to set the person up to achieve success. Try following these steps and see if you don’t lighten your load.

5. Describe the outcome you are expecting; exactly what will it look like when it’s completed to your satisfaction? Again, be very specific. 6. Specify when the task needs to be completed and how you will know it’s finished. 7. Outline the consequences, if it is completed by that date, and if it is not. This usually includes some reference to the goal of the task, its importance and relevance. 8. Ask for any final questions or considerations. Following these steps may initially feel awkward, but didn’t it feel that way the first few times you examined a patient? Try delegating something every day for a week. See how easy and natural it becomes. And then take a few minutes to decide what enjoyable things you will do with the time that you just freed up for yourself. Ah, those lazy days of summer! 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.

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POETRY AND MEDICINE

Please Leave a Message

The Big Bang and Old Phone Numbers by Daniel J. Bressler, MD

Cosmic Microwave Background

Radiation (CMBR) is the presence of electromagnetic energy, mostly in the microwave frequency, that is found uniformly throughout the universe. It is thought to be the residual radiation effect of rapidly expanding primordial matter. The discovery of this radiation is an essential piece of evidence for what has become known as the Big Bang Theory. The radiation sends us information from more than 13 billion years ago. It happened “then” and we learn about it “now.” Electromagnetic energy in all forms (radio waves, light waves, X-rays, etc.) spreads out in all directions, and, at least theoretically, it also spreads infinitely. When we say our cell phone is in or out of range of a signal (as in Verizon’s famous “Can you hear me now?” commercials), it refers to whether the antenna of the receiver has the sensitivity to pick up the information contained in the available waves. The waves are there, 22 j u ly 2013

however weak, in any case. But what happens to the voicemail, telephone conversations, ringtones, and other information that are contained on a mobile phone once the owner dies? All the information that has been previously transmitted is radiating infinitely to the far ends of space-time. Meanwhile, although Sprint may reassign the number, it often remains with its earlier link on the phones of friends and family who are not yet ready to remove one more physical bond with the deceased. And so it is on my phone where I see the face and number of a dear friend who recently departed for “parts unknown.” This poem is for her. Dr. Bressler, SDCMS-CMA member since 1988, is chair of the Biomedical Ethics Committee at Scripps Mercy Hospital and a longtime contributing writer to San Diego Physician.

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I call you on the telephone Expecting yet your voice I fumble past the dial tone But all I get is noise I’ve called to hear your speech again If only prerecorded To feel you within reach again From where you’ve teleported Do roaming charges still apply In the swirl of supernova? Is your iPhone lost amidst the sky In the cushions of God’s sofa? Is your number portable To n-dimensional space? Are galactic calls affordable From your transcendental place? I try to reach your old device I’m waiting for the beep I speed-dial past your death’s disguise And text you in my sleep.

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Practice Management

Employee vs. Independent Contractor

Best Practices to Protect Your Business by Jenny Smerud, CPA

Properly classified independent contractors can offer cost savings to a business through reduced employer payroll taxes and payroll administrative costs as well as reduced cash-flow burden of payroll tax deposits. However, misclassifying employees can subject the business to significant financial and business risk. Many agencies besides the IRS have an interest in the classification of workers. State agencies, such as the California Employment Development Department, and insurers providing workers’ compensation insurance have an interest in proper classification of employees. Worker classification also impacts eligibility for employee benefit plans. Misclassifying and thus excluding a worker from an employee benefit plan may jeopardize the tax status of the entire benefit plan. The worker classified as an independent contractor and not an employee may have 24 j u ly 2013

financial incentive themselves to challenge a classification to gain access to benefit plans or workers’ compensation insurance. This article will review the pitfalls to avoid and best practices to initiate in order to protect your business from the negative consequences of misclassifying employees. Many of the difficulties in classifying employees arise from the fact that there is no single definition of “employee.” The IRS has a 20-factor control test to help employers determine if the nature of the relationship between the employer and the worker qualifies the worker as an employee. Factors such as whether the business requires the worker to be trained, sets the hours of work, and sets the work location provide relatively straightforward tests.

But other factors, such as the continuity of the relationship and the integration of the worker into the operations of the business, are not as easily defined, and often depend on the facts and circumstances of the business operations. Broadly, in the case of an employee, the employer has the right to dictate the job that the worker is doing and how to do it. In an independent contractor relationship, the hiring business determines the desired result of the services but not the method of performing the services. Certain business practices point more directly to an employer-employee relationship instead of an independent contractor relationship. For example, the way a worker is paid for services can indicate a stronger

Broadly, in the case of an employee, the employer has the right to dictate the job that the worker is doing and how to do it. In an independent contractor relationship, the hiring business determines the desired result of the services but not the method of performing the services.

likelihood that the worker is an employee. Independent contractors are generally paid by the job or on a straight commission basis rather than hourly or weekly. If in analyzing the worker’s relationship to the business it is determined that the worker can be classified as an independent contractor, there are some steps a business can take to assert this position and minimize costs should the IRS examine and reclassify the worker. Put written independent contractor agreements in place for all independent contractors stating the intent to have an independent contractor relationship. Within the contract grant as many freedoms to the independent contractor as possible, including allowing the contractor to set their own working hours,

hire their own assistants, work for multiple other businesses, and provide their own tools and supplies. The agreement should have a fixed term and no unlimited automatic renewal provisions. The agreement can also ask the independent contractor to prove they have properly reported the income and should definitively state that the contractor is responsible for all state and federal employment taxes. Always file all required 1099 forms and tax returns on a basis consistent with the classification of the worker. Consistent treatment by worker and among workers is very important. All workers with similar positions should be classified in the same manner. Year to year, a single worker should also be classified consistently. If a

business mistakenly classifies workers in good faith and is found liable for employment taxes, the business can get relief through what is known as the Section 530 “safe havens.” At a minimum the relief provisions require that the business have a reasonable basis for the treatment, and that the business has been consistent in the classification of and reporting on individual workers and groups of workers. As such, it is a good practice to regularly review the census of employees and contractors to ensure that the business continues to maintain consistent practices. There are many good business reasons to classify a worker as an independent contractor and many cases when that classification is proper. Being aware of the potential consequences and performing careful analysis and due diligence in partnership with your professional tax adviser is a good investment of time and money to protect the business from potential liability. Ms. Smerud is a CPA with AKT, LLP, which is ranked in the top 100 accounting firms nationwide. AKT provides accounting, auditing, tax compliance, business valuation, international tax services, and management consulting to closely held businesses, nonprofit organizations, and individuals. Visit www.aktcpa.com for further information. SAN DI EGO PHYSICIAN.org 25

Risk Management

Frequent Malpractice Risks Faced by Office Practices Revealed in Survey by SDCMS-endorsed The Doctors Company — For more patient safety articles and practice tips, visitwww.thedoctors.com/patientsafety.

The most frequent malpractice risks medical office practices face are related to lab tests/referrals and scheduling/follow-up, according to a nationwide survey of practice environments conducted by The Doctors Company. The survey found that medical record documentation, medication management, and communication are other top areas of risk. Your office practice can follow these steps to lessen risks:

Lab Tests / Referrals and Scheduling / Follow-up: • Ensure that the office staff knows how to reconcile tests, referrals, and consult orders with the results when received, and have a process in place in case of discrepancy. • Communicate all test results to patients. • Don’t rely on a return appointment or a “hold” on a medical record as a reminder that a test was not performed or the patient was not contacted about results. • Tell patients to contact your office if they have not received test results by a specified date. • Send letters to patients who fail to follow up and cannot be reached by phone; file 26 j u ly 2013

all documentation in the medical record. • If using an electronic medical record, utilize the test-tracking capability. Medical Record Documentation: • Document allergy information in the same place on all medical records. • Keep a current list of all medications. • Maintain a current problem list with dates of problem identification, reviews, and resolutions. • Use the patient’s own words when documenting. • Indicate in writing or electronically that all results of tests, consultants, and referrals were reviewed. • Document all after-hours patient calls. Medication Management: • Ensure that the patient understands the reason for the medication, how to take it, and when to contact your office about side-effects. • Store medication samples, syringes, and prescription pads securely. • Label all syringes and administer medications immediately — and don’t leave them unattended.

• If you prepare medications to be used later, sign or initial the label and include the name of the medication, dosage, and date. • Maintain refrigerated medications at the correct temperature, and keep a record of who performs the checks and what was discarded. • Ask verbal orders to be repeated back. • Identify all high-alert medications, and follow guidelines to ensure they are ordered, stored, dispensed, and administered correctly. • Refer to your state law to determine which staff can call in new prescriptions and refills. Communication: • Document all advice in the patient’s record. • Ensure that a licensed provider responds when the patient’s question is outside the scope of office staff knowledge. • Document the level of understanding during the informed consent process. • Use open-ended questions. • Incorporate a standard communication protocol to enhance the handoff process and reduce errors of omission.

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Fraud and Abuse What Physicians Need to Know to Comply With State and Federal Laws by The California Medical Association

28 j u ly 2013

OIG Clarifies How to Disclose Healthcare Fraud Voluntarily Note: Throughout this article, you will find references to “CMA ON-CALL” documents. ON-CALL is the California Medical Association’s online health law library. ON-CALL documents are available free to members at www.cmanet.org/ cma-on-call. Nonmembers can purchase documents for $2 per page.

ost physicians strive to work ethically, providing high-quality medical care to their patients and submitting proper claims for payment. Unfortunately, the presence of some dishonest individuals has created the need for laws that combat fraud and abuse in the healthcare system. This trend has intensified with the passage of federal health reform legislation in 2010. The laws covering “fraud and abuse” have proliferated and broadly prohibit activities, some of which physicians may have in the past undertaken in good faith. Depending on the law, violations may be punishable by criminal and civil penalties, civil monetary penalties, payment suspensions, mandatory or discretionary exclusion from state and federally funded health programs, including Medicare, and other sanctions such as licensure actions or asset forfeitures. This article examines the most important fraud and abuse laws that apply to physicians. Anti-kickback Laws Both California and federal law prohibit kickbacks and fee-splitting by physicians and other healthcare providers. The federal anti-kickback statute prohibits knowingly and willfully offering, soliciting, paying, or receiving remuneration (essentially anything of value), directly or indirectly, in exchange for or to induce patient referrals for which payment can be made under a federal health program, or

The U.S. Department of Health and Human Services Office of Inspector General (OIG) has updated its “Provider Self-Disclosure Protocol,” in an attempt to make reporting potential fraud and returning overpayments less painful for practices and facilities. In 15 years, more than $280 million has been returned to federal health programs through a self-disclosure process, where physicians and hospitals voluntarily report instances of false Medicare billing, anti-kickback violations, or the like. In the new publication, OIG has provided more transparency about the process, including what is expected from physicians and how to have a successful resolution. The OIG document also details how to disclose certain types of fraud and abuse, such as false billing, employing an individual on the OIG exclusions list, and potential anti-kickback and physician self-referral violations. Physician practices uncovering instances of potential fraud can achieve a more favorable outcome when disclosing systemic problems voluntarily, rather than having them discovered by the government or brought to the government’s attention by a whistleblower. Practices face tougher penalties when the OIG initiates a fraud finding. The OIG Provider Self-Disclosure Protocol is available at https://oig.hhs.gov/compliance/selfdisclosure-info/files/Provider-Self-DisclosureProtocol.pdf.

to induce recommending or arranging for the purchase of items or services covered by a federal health program. The statute has been interpreted broadly to include any kind of compensation, and to apply so long as one purpose of the compensation is to induce referrals. Violation of the statute is punishable by a $25,000 fine and up to five years’ imprisonment and is grounds for exclusion from the Medicaid and Medicare programs. Violation of the statute also exposes the violator to civil monetary penalties. The statute and accompanying regulations, however, provide safe-harbor provisions that, if met, guarantee compliance with the law. The California law is similar to the federal anti-kickback statute. The California statute prohibits licensed healthcare professionals from offering,

accepting, or receiving consideration (in the form of money or otherwise) as compensation or inducement to refer patients, clients, or customers. Unlike the federal statute, which only applies to referrals of patients whose medical services are paid by a government healthcare program such as Medicare, the California statute applies to referrals irrespective of the payor (including commercial payors). While the California statute does not include regulatory safe harbors, it includes broad statutory exemptions, such as the payment of fair market value compensation for services other than the referral of patients. Violation of the law is a criminal offense that is punishable by up to one year in prison or fines of up to $50,000. For more information on anti-kickback laws, see California Medical Association (CMA) SAN DI EGO PHYSICIAN.org 29

A New Threat From an Old Fraud Law The Affordable Care Act (ACA) gives the government more power and dedicates more money to improving federal efforts against healthcare fraud, waste, and abuse. The ACA expands an old law, the False Claims Act (FCA), and places physicians’ business practices under the microscope like never before. The statute, enacted in 1863 during the Civil War, protects against the submission of fraudulent claims by government contractors and enforces strict penalties for such violations. The ACA expanded the reach of the law and made it easier for federal investigators to launch FCA cases against alleged violators. Of 2,309 civil and criminal cases — including FCA cases — opened in 2012 by the U.S. Department of Health and Human Services Office of Inspector General (OIG), 21% involved physicians, compared with about 15% in 2010, according to OIG data. Under the FCA, a violation occurs when a person knowingly presents, or causes to be presented, a false or fraudulent claim for payment; knowingly creates, uses, or causes a false record; or conspires with others to issue such a record or claim. For physicians, a broad range of scenarios puts them afoul of the FCA, including filing false codes for payment, making improper referrals, and participating in Medicare kickback schemes. Physicians can face treble damages (i.e., three times the amount of collections received as a result of the false claims) and civil fines for violating the FCA, a percentage of which might go to compensate whistleblowers who first alerted the government to the alleged fraud. Violations can also bring increased monitoring going forward or exclusion from government programs. While criminal health fraud enforcement has targeted hot spots such as California, Florida, New York, and Texas, FCA investigations have not been as geographically focused. The first step to complying with FCA requirements is to know what the rules are and how they apply to individual physician practices. The OIG provides general compliance guidance to all health professionals, but particular risk areas vary depending on industry circumstances. Physicians should implement written policies, procedures, and standards of conduct related to compliance expectations. Such documentation should identify how compliance issues are investigated and resolved in your practice, and it should include policies of non-intimidation and non-retaliation for employees who report potential violations. Promoting overall transparency and a culture of compliance also is important. Physicians should maintain detailed records and report any potential violations to authorities immediately, as and when appropriate. All levels of employees, from senior management to entry-level workers, should receive regular compliance training. For more information on avoiding fraud and abuse in the Medicare and Medicaid programs, visit the OIG website at https://oig.hhs.gov/compliance/ physician-education.

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Depending on the law, violations may be punishable by criminal and civil penalties, civil monetary penalties, payment suspensions, mandatory or discretionary exclusion from state and federally funded health programs, including Medicare, and other sanctions such as licensure actions or asset forfeitures. ON-CALL document #1151, “Prohibitions Against Kickbacks and Fee-Splitting.” ONCALL documents are available free to members in CMA’s online resource library at www. cmanet.org/cma-on-call. Nonmembers can purchase documents for $2 per page. Self-referral Laws, AKA “Stark” Laws and the Speier Act Both state and federal law prohibit physicians from referring patients for goods or services in which the physician or physician’s immediate family has a financial interest, with some exceptions. In general, federal selfreferral laws (known as the “Stark” laws) prohibit a physician from making a referral to an entity for the provision of certain “designated health services” (including hospital inpatient and outpatient services) if the physician has a financial relationship with the entity, unless the arrangement fits within an exception. If the self-referral prohibition applies and an exception is not applicable, the physician may not make a referral to the entity for designated health services covered by Medicare, and the entity may not, directly or indirectly, bill for any designated health services resulting from a prohibited referral. California also broadly prohibits physician self-referral of patients pursuant to the Physician Ownership and Referral Act of 1993, which is also known as the Speier Act. The California statute applies to all patients regardless of who pays for the healthcare services. California’s statute also provides a broad exception allowing physicians to refer patients

to a hospital with which they have a financial relationship so long as the hospital does not pay the physician for the referral and any equipment lease between the parties satisfies certain requirements. For more information on self-referral laws, see CMA ON-CALL document #1156, “Self-Referral Prohibitions (Federal and California).” Civil Monetary Penalty Law The federal civil monetary penalty law prohibits hospitals from knowingly paying, directly or indirectly, physicians to “reduce or limit services” provided to Medicare and Medicaid beneficiaries who are under the direct care of the physician. According to the U.S. Department of Health and Human Services Office of the Inspector General (OIG), which enforces the law, whether the services are medically necessary or prudent is irrelevant under the civil monetary penalty statute. The OIG also believes that payments to incentivize use of comparable but less expensive items (i.e., product substitution) violate the law because it limits choices. Violations are punishable by fines of up to $2,000 per patient, which can be assessed against both the hospital and the physician. While there are guidelines, exceptions, and safe harbors to the civil monetary penalty law, anti-kickback and selfreferral laws, this area of law is ripe for government enforcement. As such, it is critical that physicians obtain counsel with respect to any physicianhospital alignment arrangement. For more information, see CMA ON-CALL document #1103, “Fraud and Abuse (Fed-

eral and California Law),” and #0317, “Physician Alignment Models.” Antitrust Laws Antitrust laws prohibit conduct that has unreasonable anticompetitive effects. These laws generally prohibit conduct by or among two or more competitors, such as contracts, combinations, and conspiracies that unreasonably restrain trade, or by single entities that become so large that they become a monopoly. The basic objective of antitrust laws is to eliminate practices that unreasonably interfere with free competition so that each business has a fair opportunity to compete on the basis of price, quality, and service. These laws should be considered when physicians, hospitals, payors, and other providers integrate, collaborate, or otherwise coordinate their activities. Because of the important economic underpinnings reflected in antitrust laws, penalties for violating them are significant. Criminal violations of the Sherman Act, for example, are felonies punishable by imprisonment for up to three years and/or fines of up to $350,000 for individuals and $10 million for corporations per violation. A criminal conviction virtually assures civil liability. Judgments for civil violations often run in the millions, particularly since a private party can recover three times the amount of damages actually sustained and recover other costs and attorneys’ fees incurred in prosecuting the action — fees that often exceed a million dollars. Antitrust violations can arise, for example, if a physician-hospital alignment arrangement becomes so large that it is exercising substantial market power in the relevant area. Similarly, to the extent a hospital and physician organization are otherwise competing organizations, an alignment between them could conceivably be challenged as a restraint of trade unless they

are sufficiently integrated for purposes of the antitrust laws. For more information on antitrust laws, see CMA ON-CALL document #1000, “The Antitrust Laws: What Physicians Can Do.” For more information on antitrust laws as they relate to accountable care organizations (ACOs), see CMA ON-CALL document #0300, “Legal and Practical Considerations Concerning Accountable Care Organizations (ACOs).” Tax Exempt Status Tax laws are implicated when a hospital, or a 1206(l) medical foundation, is tax exempt pursuant to Internal Revenue Code §501(c)(3). Healthcare issues have received priority by Internal Revenue Service (IRS) enforcers for a number of years. In general, in order to qualify for tax exemption under Section 501(c)(3), an entity must be organized and operated exclusively for charitable purposes, with no part of its earnings going to the benefit of a private shareholder or individual. The IRS looks

to a number of factors when evaluating the qualifications of a healthcare organization for tax exemption. While the burdens of maintaining tax-exempt status, and liabilities for failing to do so, generally rest with the tax-exempt organization, penalties can also be imposed on private parties (which could include physicians if they are in a position of influence at a tax-exempt organization) who receive “excess benefits” in a transaction with a tax-exempt organization. Accordingly, physicians who exercise influence with a tax-exempt organization should be scrupulous in conducting business with that organization. For more information, see CMA ON-CALL document #0305, “Legal and Practical Considerations Concerning Medical Foundations.” Physicians are strongly urged to consult with qualified legal counsel because the requirements for qualification and maintenance of Section 501(c)(3) tax-exempt status are extremely detailed and complex.

While there are guidelines, exceptions, and safe harbors to the civil monetary penalty law, antikickback and selfreferral laws, this area of law is ripe for government enforcement. As such, it is critical that physicians obtain counsel with respect to any physicianhospital alignment arrangement.

Internet Coupon Sites May Put Physicians in Violation of State and Federal Kickback Laws In an effort to boost a medical practice, a number of physicians have begun offering discounts for their medical services through internet-based coupon companies (e.g., Groupon). While each deal varies, typically the physician agrees to give the coupon company a percentage of the revenue obtained by the physician from patients using the coupon (reports suggest as high as 50%) in return for the company’s promotion of the practice through various types of coupons or “daily deals.” The primary risk to physicians using such third-party coupon programs is that they may run afoul of state and federal anti-kickback laws that provide, among other things, that it is unlawful for a physician to offer any discount or other consideration as compensation or inducement for referring patients, or to split professional fees with a party who procures patients for, or refers patients to the physician. Even if the patients obtaining the benefits of such coupons are cash-based and non-insured, the activity may raise significant legal issues for physicians. Accordingly, physicians should act with great caution in this area and only after obtaining the advice of an attorney experienced in healthcare fraud and abuse laws. CMA has confirmed that the Medical Board of California is looking at this issue with respect to its legality under California’s Medical Practice Act. For more information, see CMA ON-CALL document #0104 “Practice Promotion Through Third-Party Coupons.” For general information on physician advertising, see CMA ON-CALL document #0102, “Advertising by Physicians.” For more information on the state and federal kickback prohibition, see CMA ON-CALL document #1151, “Prohibitions Against Kickbacks and Fee-Splitting.”

SAN DI EGO PHYSICIAN.org 31

CMA’s Free Reimbursement Helpline Physician members and staff can call CMA’s CES at (888) 401-5911 to discuss economic issues affecting their practice, including but not limited to billing and collections, coding and documentation, and managed care contracts.

CMA’s Practice Resources (CPR) Monthly Email Bulletin

CMA’s Center for Economic Services (CES) A Treasure Trove of Resources Available to Members by The California Medical Association

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CMA Practice Resources (CPR) is a free monthly ebulletin that focuses on critical payor and healthcare industry changes and how they directly impact the business of a physician practice.

CMA Hosted Practice Management Webinars CMA hosts a series of monthly webinars to educate physicians and staff on a range of topics from HIT to reimbursement issues — available for access-on-demand as well.

Practice Empowerment Toolkits CMA’s Got You Covered: A Physician’s Guide to Covered California, the State’s Health Benefit Exchange: Ensures physicians are aware of important issues related to exchange plan contracting. Taking Charge: Steps to Evaluating Relationships and Preparing for Negotiations: Guides physicians through the contract evaluation and negotiation / renegotiation process, and provides practical tips and tools to assist with the negotiation, implementation, and ongoing management of complex agreements.

Best Practices Toolkit: Offers a series of proven steps that solo and small-group practices can take to improve many facets of their practice, including the delivery of better-quality medical care.

Practice Empowerment Mini Toolkits / Informational Guides Medi-Cal Primary Care Physician Rate Increase FAQs: Answers the most commonly asked questions regarding the Medi-Cal primary care fee increases. TRICARE Transition Guide: What Physicians Need to Know: UnitedHealth Military & Veterans Services (UMVS) has taken over the contract held by TriWest. Managed Care Contracting: Objective analyses — though not exhaustive — of several health plan participating provider contracts. Designed to draw a physician’s attention to issues that may warrant further inquiry or clarification. Medicare E-prescribing Overview: Payment Incentives and Payment Reductions: Medicare’s eprescribing program provides incentive payments for physicians who e-prescribe and payment penalties for physicians who do not. Medicare Enrollment Guide for Individual Physicians: Guides new physicians through the Medicare enrollment process, and assists enrolled physicians who are making changes or who must revalidate their enrollment. Medicare Audit Guide: This guide does not cover all the audits that take place, but describes the audit activities currently taking place that may impact your practice.

Special Investigations Unit Audit Guide: Helps physicians understand their rights and responsibilities when it comes to health plan refund requests. FAQ About ACOs (Patient Handout): Explains for patients their rights in relation to accountable care organizations. Heritage California Accountable Care Organization (ACO) Physician FAQs: Helps physicians understand ACOs and ACO participation. Contract Amendments: An Action Guide for Physicians: Helps physicians understand their rights and options when a health plan notifies them of a material modification to a contract, manual, policy, or procedure. Payor Solvency Checklist: Helps physicians monitor the financial health of their contracted payors.

Payor Profiles Critical Information for Interacting With Aetna, Anthem Blue Cross, Blue Shield, Cigna, Health Net, Medi-Cal, Medicare, and United Healthcare: Important contact numbers, addresses, and links for quick reference for payor interactions. A/R Phone Call Follow-up Log Template Timely Access Regulation Guide: DMHC regulations require HMO patients be seen within certain timeframes for various levels of care, ensuring HMO networks of providers have the capacity and availability to provide care to enrollees in a timely manner.

“Know Your Rights” — One-page Summarizes of the CMA-sponsored Prompt Pay Legislation Timely Payment: Most payors are required to pay clean claims within specific timeframes, with California law further requiring health plans and insurers pay interest on claims unpaid within the required timeframe. Timely Filing Limitations: Timeframes for claim submission vary by payor and payor type, but state and federal laws set limits on the deadlines most payors may impose. Timeframes to Appeal: Appeal underpaid, delayed, or inappropriately denied claims as appropriate. Quick Guide for Appeals: Descriptions of some of the more common types of payor denials and how to respond to them. Identify and Report Unfair Payment Practices: Summarizes health plan / contracting medical group / IPA unfair payment practices prohibited by CMA-sponsored AB 1455. Filing a Formal Complaint With the Regulator: Quick reference guide to assist practices with identifying the appropriate regulator by plan type.

Other Educational Tools

Sample “Payor Termination: Material Modification to Contract” Letter: If the terms of a proposed contract are not acceptable or sustainable, physicians have the right to terminate their agreement with the payor prior to the effective date of changes. Physicians who wish to exercise their right to terminate their contract must do so in writing. Sample “Request for Copy of Complete Fee Schedule and Detailed Payment Rules” Letter: Health plans and their contracting medical groups / IPAs are required to disclose to contracting physicians the amount of payment for each and every service to be provided under the contract. Plans must also disclose the detailed payment policies and rules used to adjudicate claims. Sample “Request for Copy of Signed and Executed Contract, Complete Fee Schedule, and Detailed Payment Rules” Letter: Health plans and their contracting medical groups / IPAs are required to disclose to contracting physicians the amount of payment for each and every service to be provided under the contract. Plans are required to disclose this information initially upon contracting, annually, and upon the physician’s written request.

Sample “Patient Termination” Letter: If the terms of a proposed contract are not acceptable or sustainable, physicians have the right to terminate their agreement with the payor prior to the effective date of changes. Physicians who do this are encouraged to communicate their decision to their patients. SAN DI EGO PHYSICIAN.org 33

classifieds PHYSICIAN POSITIONS AVAILABLE NEW CAREER OPPORTUNITY: The GEO Group, Inc., has an opening for a medical physician in San Diego. If you are a skilled and experienced physician who is looking for a new challenge with an established and growing organization, join The GEO Group, Inc., team! GEO is the world’s leading provider of correctional, detention, and community re-entry services with 95 facilities, approximately 72,000 beds, and 18,000 employees around the globe. GEO employs top-notch talent, offers amazing benefits, and promotes safety. Apply online at www.jobs.geogroup.com. For information about GEO’s amazing benefits, visit http://jobs.geogroup.com/benefits.php. Contact Michele Dobos, senior recruiter, for more information at mdobos@geogroup.com. [151] FULL-TIME URGENT CARE PHYSICIAN: Busy practice in El Cajon, established in 1982, seeks a full-time physician. Please send CV to jeff@ eastcountyurgentcare.com or fax to (619) 4422245. [148] 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 (619) 992-5330 or email CV to drhunt@thehousecalldocs.com. [037] PART-TIME PHYSICIAN NEEDED FOR URGENT CARE IN SCRIPPS RANCH: Board-certified in family practice / IM or ER. PA considered with minimum of three years urgent care experience, DEA licence, and control substance class. Please email your CV to mdtodayurgentcare@ gmail.com or fax to (858) 622-1417. Please include references. [147] SHARP HEALTHCARE IS SEEKING A PHYSICIAN REVIEWER: For the medical direction of Authorization Review for Sharp Health Plan, and to ensure quality of care and appropriate utilization in the most cost-effective, appropriate, and professional manner. Must have an MD degree, current license, and five years minimum experience practicing primary care physician with knowledge of managed care and the process for prior authorization review required. To apply online, please visit http://bit.ly/10DvzMU. Sharp Experience is our unique, system-wide commitment to transforming the healthcare experience in San Diego by becoming the best place to work, practice medicine, and receive care. EOE. [143] SEEKING FULL-TIME BC/BE INTERNAL MEDICINE PHYSICIANS: Sharp Rees-Stealy Medical Group, a 400+ physician multi-specialty group in San Diego, is seeking full-time BC/BE internal medicine physicians to join our staff. We offer a first-year competitive compensation guarantee and an excellent benefits package. Please send CV to lori.miller@sharp.com or upload CV at https://home2.eease.adp.com/ recruit/?id=6795752. [136] PHYSICIANS NEEDED: Family medicine, pediatrics, and OB/GYN. Vista Community Clinic, a private nonprofit outpatient clinic serving the

communities of North San Diego County, has opening for part-time, per diem positions. Must have current CA and DEA licenses. Malpractice coverage provided. Bilingual English/Spanish preferred. Forward resume to hr@vistacommunityclinic.org or fax to (760) 414-3702. Visit our website at www.vistacommunityclinic.org. EOE/ MF/D/V [912] RECRUITING A CARDIOLOGIST TO VOLUNTEER ONCE A MONTH: The UCSD Student-Run Free Clinic Project is recruiting a cardiologist to volunteer once a month (Monday in downtown San Diego OR Wednesday evening in Pacific Beach). This is a unique opportunity to serve the community as well as teach the eager medical students that will become tomorrow’s physicians. If you are interested in learning more about this volunteer position, please contact Dr. Michelle Johnson at mlj001@ucsd.edu and / or visit our website at http://meded.ucsd.edu/freeclinic. [131] HIRING BC/BE PSYCHIATRISTS: Hiring BC/ BE psychiatrists for full-time, home call, and weekend rounding positions at award-winning Palomar Health. Competitive pay. Contact Susan Linback at (760) 739-2973 or send CV to susan. linback@palomarhealth.org. [130] PER DIEM PHYSICIANS: Imaging Healthcare Specialists is actively seeking per diem physicians to monitor patient examinations requiring contrast. Current openings are for Saturday and Sunday shifts. Applicants must be available a minimum of three weekend days per month and to work at multiple locations. For more information, please contact Brandy at (858) 658-6589 or email a copy of your updated CV / resume to careers@imaginghealthcare.com. [129] MEDICAL DIRECTOR: Part-time medical director needed for a medical spa in East County. Retired physicians welcome. Malpractice and salary will be paid. Please call Nancy at (619) 456-4555. [128] SEEKING BOARD-CERTIFIED PEDIATRICIAN FOR PERMANENT FOUR-DAYS-PER-WEEK POSITION: Private practice in La Mesa seeks pediatrician four days per week on partnership track. Modern office setting with a reputation for outstanding patient satisfaction and retention for over 15 years. A dedicated triage and education nurse takes routine patient calls off your hands, and team of eight staff provides attentive support allowing you to focus on direct, quality patient care. Clinic is 24–28 patients per eight-hour day, 1-in-3 call is minimal, rounding on newborns, and occasional admission, NO delivery standby or rushing out in the night. Benefits include tail-covered liability insurance, paid holidays/vacation/sick time, professional dues, health and dental insurance, uniforms, CME, budgets, disability and life insurance. Please contact Venk at (619) 504-5830 or at venk@gpeds. sdcoxmail.com. Salary $ 102–108,000 annually (equal to $130–135,000 full-time). [778] PRACTICE WANTED WE BUY URGENT CARE OR READY MEDCLINIC: 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]

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

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OFFICE SPACE / REAL ESTATE North Coast Health Center Office Space to Sublease — 477 El Camino Real, Encinitas: Beautiful office space available, 2100 square feet, at the 477/D Building. Occupied by vascular and general surgeons. Great window views and location with all new equipment and furniture. New hardwood floors and exam tables. Full ultrasound lab with tech on site, doubles as procedure room. Will sublease partial suite, one or two exam rooms, half or full day. 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 (858) 452-0306. [153]

CreekView Medical Park in Vista Quality Medical / Office Condos or Buildings / For Sale Lease. New sustainable construction near Tri-City Hospital, Healing Environment, Signage Available / Perfect opportunity for inpatient & overnight stay facility, assisted living, skilled nursing, educational, research, hospice, therapy, specialty hospitals, surgery centers, rehabilitation facilities, medical & dental offices & more! 1,494 - 48,268 SF Available 1910-1968 Via Centre Drive, Vista Visit www.creekviewmedical.com Call 760.431.4201

Scripps Ximed Medical Center Building Office Space to SubLease — La Jolla: 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, Scripps XiMed Medical Center Building is the office space location of choice for anyone doing surgeries at the hospital or seeking a presence in the La Jolla area. Support staff may be available if needed. Full ultrasound lab on site / procedure room. For more information, call Irene at (619) 840-2400 or (858) 452-0306. [154] OFFICE SPACE AVAILABLE IN SANTEE: We are located at 9456 Cuyamaca St., #102, Santee, CA 92071. There are 2 exam rooms and 2 doctors offices, private bathroom and a patients bathroom, kitchenette, large waiting room, a front office area, and a billing office area. Our parking lot is huge! It would be ideal for a psychiatrist or psychologist. Please email stacey.sdgi@gmail. com or call (619) 270-5665. Or contact Dr. A. Reddy at (619) 565-5138 or via email at areddyp. ca@gmail.com. [150] BANKERS HILL PRIMARY CARE AND RESEARCH OFFICE SPACE TO SUBLEASE: 50year established primary care practice and clinical research office with currently two internists has space to sublease to another primary care doctor (or two) to help curb overhead and help with acute overflow patients needs. Also can provide opportunity to get into clinical research. Contact Cindy at allmedgrp@hotmail.com. [146] SUBLEASE IN PRESTIGIOUS UTC BUILDING: Sublease beautifully appointed 2100-square-foot office in prestigious building in UTC, starting on July 1, 2014. Ideal for plastic surgeon, urologist, orthopedic surgeon, or pain specialist. Direct access to AAAASF-certified surgical center with

existing contracts with Blue Cross, UnitedHealthcare, workers' compensation, and Aetna. Fraxel repair laser, hand fluoro, endoscopic and powerassisted liposuction equipment available at premises. Please call or email Ines Ustare at (858) 4578686 or ines@solteromd.com. [145] OFFICE SPACE TO SHARE: Office space to share in National City with a well-respected physician who has been in private practice for 30 years. Office is about 900 square feet with two exam rooms and an additional office/multi-purpose space. Office is currently being used part-time, Monday through Wednesday, but hours are flexible to accommodate another part-time practice. Physician planning to retire within one year. Bilingual (English/Spanish) speaking helpful. If interested, please contact me at bpmedina@msn.com. [141] OFFICE SPACE AVAILABLE IN MISSION VALLEY: Seeking psychologist / psychiatrist or other similar provider for Mission Valley office space. Beautiful large room available in centrally located urgent care / family practice / occupational medicine practice. Psychologist or psychiatrist would be optimal provider, as we will be happy to refer you patients in need of your services — a winwin situation. Please contact Brenda at brenda@ missionvalleymedical.com or myself at drpohl@ missionvalleymedical.com, or on my cell at (619) 846-8156. Office is available on July 1. [140] OFFICES FOR RENT: UTC/La Jolla area, full-time office in 8th-floor suite with established psychologists and psychiatrists. In Class A building with pleasant view. Features include private entrance, staff room with kitchen facilities, active professional collegiality and informal consultation, private restroom, spacious penthouse gym, storage closet with private lock in each office, soundproofing, common waiting room, and abundant parking. Telephone Manuel D. Tobias, PhD, or Thomas J. Wegman, PhD, at (858) 362-8779. [139] LA JOLLA (NEAR UTC) OFFICE FOR SUBLEASE: Scripps Memorial medical office building, 9834 Genesee Ave. (great location by the front of the main entrance of the hospital between I-5 and I-805). Multidisciplinary group. Excellent referral base in the office and on the hospital campus. Please call (858) 455-7535 or (858) 320-0525 and ask for the secretary, Sandy. [127] 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 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] 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] 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 / WANTED NURSE PRACTITIONER: Needed for house-call physician in San Diego. Full-time, competitive benefits package and salary. Call (619) 9925330 or email drhunt@thehousecalldocs.com. Visit www.thehousecalldocs.com. [152]

professional attitude and appearance. 32 hours, Monday – Thursday. AS degree plus 2 years experience in a medical office. Contact Grace at (619) 297-4433, ext. 308. [144] NEED A PART-TIME NURSE PRACTITIONER: Apreva Hospice needs a part-time nurse practitioner for home hospice visits. Once a week at this time, but opportunity for more work available. Please email KLewis@SDCMS.org. [138] EXPERIENCED MEDICAL RECEPTIONIST FOR FULL-TIME EMPLOYMENT: My name is Ashley Richards. I recently moved to the San Diego area, and I am looking for employment. Collectively, I have 6+ years medical reception / management experience in optometry, audiology, and ENT offices. All included high call volumes, team work, EMR, insurance verification, and copay collections. References on request. Thank you. Cell: (805) 433-2983. Email: sff_mo@yahoo.com. [137] NORTH COUNTY PRACTICE SEEKS RNP: Multi-specialty practice in need of part- or fulltime RNP for growing practice. Prefer internal medicine / nephrology experience. Ehr experience a plus. Please send CV with references to rnpvacancy@gmail.com. [134] MEDICAL EQUIPMENT

NURSE PRACTITIONER NEEDED FOR LOCAL HOSPICE: Majority of visits are house calls. Flexible schedule. $53/hour. Mileage and cell phone reimbursement. Laptop provided. Part-time with full-time potential. Please send resume or CV to KLewis@SDCMS.org. [149] 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 email drhunt@thehousecalldocs.com. Visit www.thehousecalldocs.com. [038] MEDICAL RECEPTIONIST / SECRETARY: Cosmetic / plastic surgical practice in Bankers Hill. Must possess proper phone etiquette and have a

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 April 1950

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

C.M.A. Convention BuildMeeting rooms in the Conference and Palisades scienthe for ready made being are Park ings at Balboa n tific discussions and exhibits of the 79th Annual Sessio held be to is which ation Associ al Medic rnia of the Califo in San Diego April 30–May 3. Meetings of the C.M.A. House of Delegates will be beginheld in the Ball Room of the Hotel del Coronado, days third and first the on oon, aftern the in ning at 5:00 of the convention. Some 200 papers are to be read at the general and e sectional meetings. Five guest speakers from outsid by one and . C.M.A the by invited been have the state the the Section on Allergy. The five C.M.A. guests and y, Murph D. in Frankl are: s discus will they subjects MediM.D., dean of the University of Kansas School of “The cine, Kansas City, Kansas, guest of the president, and Concept of Continuation Education in Medicine,” M.D., Bell, T. E. ula”; Curric l Medica in New “What’s Mediprofessor of pathology, University of Minnesota s to Kidney the of n Relatio “The apolis, Minne l, cal Schoo atholPrimary Hypertension,” “What’s New in Histop “The ogy,” “The Pathology of Glomerulonephritis,” and M.D., Pathology of Diabetes Mellitus”; Warren H. Cole, l of Professor of Surgery, University of Chicago Schoo ’s Medicine, Chicago, “Intestinal Obstruction,” “What ce”; Jaundi uctive “Obstr and y,” Surger c Gastri New in al Jerome W. Conn, M.D., Associate Professor of Intern Ann l, Schoo al Medic an Michig of sity Univer Medicine, one Arbor, “The Metabolic Effect of ACTH and Cortis h throug es Diabet of ement Manag “The and in Man,” sor of Surgery”; and R. Gordon Douglas, M.D., Profes MediObstetrics and Gynecology, Cornell University rhage cal College, New York, “Management of Hemor in New ’s “What y,” Deliver and ncy Pregna Complicating rics Obstetrics,” and “Urinary Tract Infections in Obstet

36 j u ly 2013

and Gynecology.” Louis Tuft, M.D., Associate Profes ine, Medic of l Schoo sity Univer e Templ ine, Medic of sor y, will Philadelphia, the guest of the Section on Allerg y and Etiolog Its — titis Derma c “Atopi , papers two read ric Geriat the of ems “Probl Clinical Management,” and .” ement Manag l Clinica Their and atic Asthm In addition to the scientific meetings and exhibits, st number of technical exhibits that has ever greate the will been offered in connection with an annual session rConfe the of Hall t Exhibi the in booths 98 in shown be ence Building. More than 1500 physicians are expected to attend have the annual session, and hotels throughout the city Artime. some for ations reserv room ing receiv been speby n ortatio transp for rangements are being made not cial buses from the hotels to Balboa Park. For those been has ion provis ay, mid-d at wishing to leave the park Club, made for luncheon service in the former Officers’ ng. adjacent to the Palisades Buildi Admission to some of the meetings will be debe nied to anyone not wearing a badge. Badges may be on will which Desk, n tratio Regis the at ed obtain the first floor of the Conference Building. The Woman’s Auxiliary of SDCMS has arranged 30. for dinner and an evening of Jai Alai on Sunday, April transc specifi No le. availab be will games the for Passes buses portation has been arranged; however, Greyhound es. minut fifteen every border the for leave The local society has arranged for a golf tourna CounDiego San the at 1, May oon, aftern y Monda ment at the try Club, trophies for the winners will be awarded g. evenin that Ball ent’s Presid Other entertainment such as deep-sea fishing, bay will be trips, bus sightseeing trips, and visits to our zoo t. interes their ing arranged for those signify

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