June 2014

official publication of SDCMS june 2014

$12,500 / Year* Returned to Every Doctor’s Practice By the Member Physicians of SDCMS-CMA *on average

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June

Contents

Volume 101, Number 6

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 SDCMS BOARD OF DIRECTORS OFFICERS PRESIDENT: J. Steven Poceta, MD PRESIDENT-ELECT: William T-C Tseng, MD, MPH (CMA Trustee) TREASURER: Mihir Y. Parikh, MD SECRETARY: Mark W. Sornson, MD IMMEDIATE PAST PRESIDENT: Robert E. Peters, PhD, MD

features 12

$12,500 / Year Returned to Every Doctor’s Practice by the Member Physicians of SDCMS-CMA

8

BY THEODORE M. MAZER, MD

14

Increased Costs. Losing Trusted Doctors. Threatened Privacy. That’s What Happens When Lawyers Play Doctor

BY RICHARD THORP, MD

18

Federal Update: SGR • ICD-10 • GPCI

BY ELIZABETH MCNEIL

22 Governance Reform: CMA Envisions a New Future for Organized Medicine

BY STEVEN E. LARSON, MD, MPH

departments 4

Briefly Noted: Calendar • AllPhysician Social • Featured Members • And More …

8

Rediscovering Our Wanting: Balancing Interests Inside and Outside of Medicine

BY HELANE FRONEK, MD, FACP, FACPH

10

Planning a Vacation? Include Risk Management So You Can Relax

BY THE DOCTORS COMPANY

26

Physician Marketplace: Classifieds

GEOGRAPHIC AND GEOGRAPHIC ALTERNATE DIRECTORS EAST COUNTY: Venu Prabaker, MD, Alexandra E. Page, MD, Jay P. Mongiardo, MD, Alt: Susan Kaweski, MD (CALPAC Treasurer) HILLCREST: Gregory M. Balourdas, MD, Thomas C. Lian, MD, Alt: Thomas J. Savides, MD KEARNY MESA: Sergio R. Flores, MD, John G. Lane, MD, Alt: Anthony E. Magit, MD, Alt: Eileen R. Quintela, MD LA JOLLA: Geva E. Mannor, MD, Marc M. Sedwitz, MD, Alt: Lawrence D. Goldberg, MD NORTH COUNTY: James H. Schultz, MD, Eileen S. Natuzzi, MD, Michael A. Lobatz, MD, Alt: Anthony H. Sacks, MD SOUTH BAY: Reno D. Tiangco, MD, Michael H. Verdolin, MD, Alt: Elizabeth Lozada-Pastorio, MD AT-LARGE DIRECTORS Lawrence S. Friedman, MD, Karrar H. Ali, MD, Kosala Samarasinghe, MD, David E.J. Bazzo, MD, Stephen R. Hayden, MD, Peter O. Raudaskoski, MD, Vimal Nanavati, MD (Board Representative), Holly B. Yang, MD AT-LARGE ALTERNATE DIRECTORS Karl E. Steinberg, MD, Jeffrey O. Leach, MD, Toluwalase A. Ajayi, MD, Phil Kumar, MD, Wayne C. Sun, MD, Kyle P. Edmonds, MD, Carl A. Powell, DO, Marcella M. Wilson, MD OTHER VOTING MEMBERS COMMUNICATIONS CHAIR: Sherry L. Franklin, MD (CMA Trustee) YOUNG PHYSICIAN DIRECTOR: Edwin S. Chen, MD RESIDENT PHYSICIAN DIRECTOR: Jane Bugea, MD RETIRED PHYSICIAN DIRECTOR: Rosemarie M. Johnson, MD MEDICAL STUDENT DIRECTOR: Spencer D. Fuller OTHER NONVOTING MEMBERS YOUNG PHYSICIAN ALTERNATE DIRECTOR: Daniel D. Klaristenfeld, MD RESIDENT PHYSICIAN ALTERNATE DIRECTOR: Diana C. Gomez, MD RETIRED PHYSICIAN ALTERNATE DIRECTOR: Mitsuo Tomita, MD SDCMS FOUNDATION PRESIDENT: Albert Ray, MD (CMA Trustee, AMA Delegate) CMA SPEAKER: Theodore M. Mazer, MD CMA PAST PRESIDENTS: James T. Hay, MD (AMA Delegate), Robert E. Hertzka, MD (Legislative Committee Chair, AMA Delegate), Ralph R. Ocampo, MD CMA TRUSTEES: Robert E. Wailes, MD, Erin L. Whitaker, MD CMA SSGPF Delegate: James W. Ochi, MD CMA SSGPF ALTERNATE DELEGATES: Dan I. Giurgiu, MD, Ritvik Mehta, MD AMA ALTERNATE DELEGATE: Lisa S. Miller, MD

28

Colleagues

BY DANIEL J. BRESSLER, MD, FACP

22 2 j u n e 2014

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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10 /////////briefly ///////////////////noted ////////////////////////////////JULY /////////// /////////////////////////// calendar SDCMS Seminars & Webinars SDCMS.org

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

OSHA Update (seminar/webinar) JUL 10: 11:30am–1:00pm Consent and Abuse Reporting: Your Duties and Responsibilities (seminar/webinar) JUL 17: 11:30am–1:00pm Advocacy Training (workshop) JUL 19: 8:00am–12:00pm HIPAA Update (seminar/webinar) AUG 14: 11:30am–1:00pm

Workers’ Compensation Advanced Part 1: Tips and Tricks for Workers’ Compensation Billing AUG 5: 12:15pm–12:45pm Workers’ Compensation Advanced Part 2: Second Bill Review Plus Managing Third-party Billers AUG 12: 12:15pm–12:45pm Workers’ Compensation Advanced Part 3: Requests for Authorization, Dispensed Pharmaceutical and DMEPOS Billing for Workers’ Compensation AUG 19: 12:15pm–12:45pm

Community Healthcare Calendar

Cma Webinars CMAnet.org/events

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.

The Power of the Pen: The Physician’s Responsibility in Prescribing and Referring for Medi-Cal Patients JUN 18: 12:15pm–1:15pm

San Diego Academy of Family Physicians Symposium, Family Medicine Update: 2014 JUN 27–29 (www.sandiegoafp. org)

Recipe for Financial Success: Key Steps to Increasing Your Net Income JUL 16: 12:15pm–1:15pm

RCMA’s 10th Annual “Cruisin’ Thru CME” JUL 9–22 (www.rcmanet. org/Portals/17/04Events/ Flyer/2014Cruise.pdf)

What to Expect From a Medi-Cal Audit JUL 30: 12:15pm–1:15pm HIPAA Breach Notification and California Requirements JUL 31: 12:15pm–1:15pm

“

Summer Medical Academy JUL 14–25 (facesforthefuture. org/san-diego/san-diego.html) 31st Annual Primary Care Summer Conference AUG 1–3 (www.scripps.org/ sparkle-assets/documents/ primary_care_summer_2014. pdf)

A great secret of success is to go through life as a man who never gets used up.

4 j u n e 2014

”

— Albert Schweitzer, German/French Theologian, Organist, Philosopher, Physician, and Medical Missionary (1875–1965)

PHYSICIAN SOCIAL

All San Diego County Physicians: Join SDCMS for a networking opportunity and mixer on Thursday, July 10, from 5 to 8 p.m.! All physicians are welcome and encouraged to attend. Come mingle, socialize, and network with your fellow San Diego County physicians!

Complimentary hors d’oeuvres and drinks will be served! Our July 10 social will take place in East County near Grossmont Hospital. To RSVP, email your name and telephone number to Jen at JOhmstede@SDCMS. org. Questions? Call Jen at (858) 300-2781.

Featured Member SDCMS-CMA member Arthur “Tony” A. Blain IV, MD, FAAFP, MBA, finished his first ultramarathon (100 miles) in May, running in the seventh annual KEYS100, a point-to-point event beginning in Key Largo and ending in Key West. Congratulations, Dr. Blain!

/////////////////////////////////////////////////////////////////////////////////////////////////// PUBLIC HEALTH CHAMPIONS

SDCMS and SDCMS Foundation Honored as 2014 Live Well, San Diego!

2014 Public Health Champions L–R: Nick Macchione, San Diego County HHSA director, Dr. Steve Poceta, SDCMS president for 2014–15, Tom Gehring, SDCMS executive director, Dr. Wilma Wooten, San Diego County public health officer, Dr. Al Ray, SDCMS Foundation president, Barbara Mandel, SDCMS Foundation executive director, Dr. Rosemarie Johnson, SDCMS Foundation medical community liaison, Dr. Carol Young, SDCMS Foundation board member, County Supervisor Dianne Jacob, and Dr. Nick Yphantides, County of San Diego HHSA CMO.

The County of San Diego held its 13th Annual Live Well San Diego! Public Health Champion Awards Ceremony on April 11, 2014, recognizing achievements in public health services that protect and promote the health of San Diego County residents.

This year’s theme — “Public Health: Start Today! Today’s Public Health Professionals Are Helping Individuals and Communities Navigate the Changing World of Public Health” — celebrated the principles of Live Well San Diego!, the County’s 10-year vision to build healthy, safe, and thriving communities.

Both the San Diego County Medical Society (SDCMS) and the SDCMS Foundation were honored this year, the Foundation in particular for the work of its Project Access San Diego initiative, which has since 2008: • improved the health of 2,400 patients • saved 20 lives • reduced emergency department visits by 80% • reduced workdays missed by 75% • performed 682 surgeries and GI procedures • facilitated 7,463 specialty healthcare appointments • and received $8 million in donated care by physicians, hospitals, surgery centers, and ancillary healthcare providers.

Thank you to Wilma J. Wooten, MD, MPH, SDCMS-CMA member since 2006, the County of San Diego’s public health officer, and Nick Macchione, the director of the County of San Diego’s Health and Human Services Agency, for bestowing this honor on SDCMS and the SDCMS Foundation, and for their untiring efforts to protect and promote the health of San Diegans!

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Featured Member President Obama announced the appointment of Dr. Horacio Rodiles, SDCMS-CMA member since 1973, to the United States Section of the United States-Mexico Border Health Commission, a binational presidential commission co-chaired by the secretaries of health of the United States and Mexico. Dr. Rodiles is joining a diverse group of public health leaders committed to enhancing the health and wellbeing of border residents. Dr. Horacio Rodiles, who is a physician at the Balboa Nephrology Medical Group, a position he has held since 2006, was sworn in by Peter C. Lewis, U.S. Magistrate Judge, on May 6, 2014. Congratulations, Dr. Rodiles!

Endorsed by

SAN DI EGO PHYSICIAN .org 5

/////////briefly ///////////////////noted ////////////////////////////////////////////////////////////////////// SDCMS-CMA Membership

Ask Your Physician Advocate

Welcome New and Rejoining SDCMS-CMA Members!

SDCMS Member Question: We often have patients ask us to fill out forms on their behalf. These forms can be lengthy, and they can take up a lot of time. Is there any way we can charge them for this?

New Members

Answer: So long as the activity is not prohibited by law or a physician’s contract with a third-party payer, whether and how much a physician charges for filling out forms on behalf of a patient should be an individualized decision made by the physician. While many physicians charge their patients for this activity, some do not, and some charge only if they have to be completed prior to a visit.

Some charge only for complex forms, whereas others charge for all forms regardless of complexity.

For more relevant facts to consider, please see CMA ON-CALL document #7656, “Charging for Form Completion.” SDCMS-CMA members can contact your SDCMS physician advocate, Marisol Gonzalez, at MGonzalez@SDCMS.org to obtain this document.

Edward G. Arevalo, MD Child and Adolescent Psychiatry San Diego (858) 694-3900 Scott P. Bunner, MD Psychiatry San Diego (619) 692-8750 Yi-Ning Cheng, MD Pediatrics San Diego (619) 692-8600 Vijay K.N.C. Jayaprakash, MD Psychiatry El Cajon (858) 694-3900 Puja Chitkara, MD Rheumatology San Diego (619) 289-9145 Ernest V. De Guzman, MD Psychiatry San Diego (858) 694-3900 Brenda L.F. Rodriguez, MD Pediatrics El Cajon (619) 401-0404 Joan E. Friedson, MD Psychiatry La Jolla (858) 551-8171 Dauod M. Ghafari, MD Family Medicine El Cajon (619) 401-0404 Bruce L. Gillingham, MD, FAAOS Orthopedic Surgery Coronado (619) 532-6411 Bret E. Ginther, MD Emergency Medicine Fallbrook (760) 739-3000

6 J u n e 2014

Allan V. Hansen, MD Emergency Medicine La Jolla (760) 739-3000 Nasra S. Haroun, MD Child and Adolescent Psychiatry San Diego (619) 421-6900 James M. Huot, MD Family Medicine Borrego Springs (760) 767-5051 Beth A. Judge, MD Forensic Psychiatry San Diego (858) 694-3900 David I. Kaufer, MD Internal Medicine El Cajon (619) 401-0404 H. Susan Kower, MD Psychiatry San Diego (760) 967-4475 Michael S. Krelstein, MD Forensic Psychiatry San Diego (858) 694-3900 Karim I. Mohamed, MD Pediatrics Desert Hot Springs (760) 676-5240

Nathan A. Perrizo, DO Pain Medicine Encinitas (760) 941-7336 Ran Regev, MD Emergency Medicine Chula Vista (619) 502-5800 John A. Siefert, MD Emergency Medicine Coronado (619) 532-7427 Soheyla Talebimarandi, MD Psychiatry San Diego (858) 694-3900

Myres W. Tilghman, MD Infectious Disease Kathleen S. Moser, MD San Diego Public Health and General (619) 515-2300 Preventive Medicine San Diego Katherine Trintchouk, MD (858) 694-3900 Internal Medicine San Diego David Naimark, MD (858) 694-3900 Forensic Psychiatry San Diego Gary Tsai, MD (619) 531-3047 Psychiatry San Diego Anthony T. Nasser, MD (858) 694-3900 Family Medicine San Diego Laura A. Vleugels, MD (858) 694-3900 Child and Adolescent Psychiatry Armando Olivera, MD San Diego Family Medicine (858) 694-3900 El Cajon (619) 401-0404 Blake A. Wylie, DO Family Medicine Julian (760) 765-1223

Rejoining Members Timothy D. Bilash, MD Obstetrics and Gynecology La Jolla (858) 997-0212 Melissa E. Heart Deer, MD Psychiatry San Diego (619) 234-2158 Samuel O.T. Etchie, MD Psychiatry La Mesa (619) 303-8363 Rebecca L. Ferrini, MD General Preventive Medicine Santee (619) 596-6351 Frank B. Hamlett, MD Diagnostic Radiology San Diego (619) 234-3918 Amanda J.L. Holden, MD Emergency Medicine Valley Center (760) 739-3000 Sepi Mahooti, MD Anatomic Pathology San Diego (858) 552-8585 Violeta C. Martel, MD Internal Medicine Santee (619) 596-6351

Thomas J. Murphy, MD Obstetrics and Gynecology La Mesa (619) 463-0600 Paul A. Pyka, DO Obstetrics and Gynecology La Mesa (619) 463-9195 Alfredo Ratniewski, MD Internal Medicine Escondido (760) 871-0606 Robert E. Scott, MD Physical Medicine and Rehabilitation San Diego (858) 277-7123 Dean E. Sidelinger, MD Pediatrics San Diego (619) 685-2539 Bernard Wosk, MD Pediatrics Carlsbad (619) 401-0404 Nicholas J. Yphantides, MD General Practice San Diego (760) 737-2000

/////////////////////////////////////////////////////////////////////////////////////////////////// Board of directors

Congratulations to the Following Physicians for Being Elected to SDCMS’s Board of Directors!

President-elect: William T-C Tseng, MD Treasurer: Mihir Y. Parikh, MD

Auditing

Practice Management

Contracting

Relocation Management

Credentialing

Technological Advances

Billing Service

Secretary: Mark W. Sornson, MD At-large Director #1: Lawrence S. Friedman, MD At-large Director #5: Stephen R. Hayden, MD At-large Director #6: Peter O. Raudaskoski, MD At-large Director #8: Holly B. Yang, MD At-large Alternate Director #2: Jeffrey O. Leach, MD At-large Alternate Director #5: Wayne C. Sun, MD At-large Alternate Director #7: Carl A. Powell, DO At-large Alternate Director #8: Marcella M. Wilson, MD Young Physician Director: Edwin Chen, MD Young Physician Alternate Director: Daniel Klaristenfeld, MD

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Hillcrest Geographic Alternate Director #1: Thomas J. Savides, MD Kearny Mesa Geographic Director #1: Sergio R. Flores, MD Kearny Mesa Geographic Director #2: John G. Lane, MD La Jolla Geographic Director #2: Marc M. Sedwitz, MD La Jolla Geographic Alternate Director #1: Lawrence E. Goldberg, MD

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

SAN DI EGO PHYSICIAN .org 7

Personal & Professional Development

Rediscovering Our Wanting Balancing Interests Inside and Outside of Medicine

by Helane Fronek, MD, FACP, FACPh

Early in our training when we were trying to get to know each other, a medical school classmate asked, “What do you like to do?”

My answer was telling: “I used to like to read, I used to like to play music, I used to like to run ….” In the medical profession, studying and working had to come before playing if we wanted to become the professional we dreamed of becoming. For many years it didn’t matter what we wanted, and acknowledging what we desired was more painful and frustrating than going along with what 8 j u n e 2014

What fills your own vision of your perfect life, in 5, 10, or 15 years?

we thought we had to do.

When coaching clients who feel stuck and confused, I’ll often ask, “What do you want?” Almost every time, they respond, “That’s a great question!” My reply is always the same: It’s THE question.

That part of us that knows what we want has been buried for so long that we can feel disconnected from knowing what would make us happy or fulfilled. In Fierce Conversations, Susan Scott warns that we may eventually realize “that you have no discernible identity. … It’s not that

your credit card or Social Security number was stolen. It’s that an internal voice is whispering, ‘This isn’t you.’ Parts of you are failing to show up.” This makes it crucial for each of us to spend some time asking ourselves, “What do I really want?”

Journaling is one way of opening the conversation with ourselves.

In The Artist’s Way, Julia Cameron suggests we write three pages each morning before our day begins.

Dreams from the night before, thoughts filtered through our unconscious during the night, leftover concerns and ideas from the days before have an opportunity to rise to the page and be acknowledged. As busy professionals, we may not have time for three pages, but perhaps we do have time for one. A regular practice of writing can help us discover many of our wantings.

During a recent presentation on balancing your interests inside and outside of medicine, I asked the medical student attendees to imagine their perfect life. The room became quiet as they closed their eyes and visualized themselves 15 years in the future. There were many surprises as some students realized they valued a traditional, stable family life and others were excited by a career filled with cutting-edge research. What fills your own vision of your perfect life, in five, 10, or 15 years?

We work hard to improve our patients’ lives. Shouldn’t we also dedicate time to our own? To make sure we are living a life filled with activities we enjoy, relationships that nurture us, work that is meaningful and fulfilling? Each of us deserves to live the life we want, but creating it doesn’t happen without intention and action. As the wise Yogi Berra once said, “If you don’t know where you are going, you might wind up someplace else.”

The first step is to ask one question: “What do I really want?” And then listen for the answer.

Dr. Fronek, SDCMS-CMA member since 2010, is assistant clinical professor of medicine at UC San Diego School of Medicine and a certified physician development coach who works with physicians to gain more power in their lives and create lives of greater joy. Read her blog at helanefronekmd.wordpress.com.

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Risk Management

Planning a Vacation?

Include Risk Management So You Can Relax

Contributed by SDCMS-endorsed The Doctors Company. For more patient safety articles and practice tips, visit www.thedoctors.com/patientsafety.

Because liability never takes a holiday, your vacation plans should include medical coverage arrangements for your practice, particularly when you use locum tenens. The following tips will help reduce risks in your practice and promote the safety of your patients as you plan your vacation: • Review managed care contracts for relevant coverage requirements. Some managed care contracts contain very specific language on this topic and many contain indemnification clauses that could expose you to the liability of the covering physician (as well as breach of contract).

• Whenever possible, make secondary coverage arrangements. Confirm coverage arrangements via email or fax 10 j u n e 2014

with the locum tenens who are covering your practice in order to avoid misunderstandings, possible uncertainty of dates or timeframe, and exposure to abandonment.

• Ensure that the practice coverage arrangements include an understanding about patient billing practices in conjunction with any managed care contracts or plans.

• Choose covering physicians who share your medical specialty and have privileges at the same hospitals that you do.

• Determine if covering physicians carry professional liability coverage and the limits of such coverage. While asking these questions could be awkward, you may be required to ask under certain

managed care plans, provider agreements, and hospital bylaws.

• Before leaving on vacation, prepare a list of patients who are hospitalized or are in the midst of diagnostic workup, or who have special medical problems or needs. Give this information to the covering physicians and document any specific advice you provide.

• Inform the attending physicians or hospitalists of any hospitalized patients you are following about your coverage arrangements, and document the hospital chart to reflect these conversations.

• Advise your patients of the coverage arrangements, and give them the covering physicians’ names.

• Make each hospital where you have oncall responsibilities aware of the dates of your unavailability and the identity and phone numbers of the covering physicians. Give similar notice to your answering service and office staff.

Upon returning from vacation, promptly confer with all covering physicians. Document what you were told by the covering physicians about any significant developments in patients’ clinical course or treatment while you were away.

Consider implementing these fundamental loss-prevention measures for even brief periods when you are unavailable, such as observance of religious holidays, attending medical conferences, personal illness, or a long weekend. Unfortunately, vulnerability to claims is not diminished on these occasions.

90%

90% 90%

90% 90% SAN DI EGO PHYSICIAN.org 11

GPCI

$12,500 / Year* Returned to Every Doctor’s Practice By the Member Physicians of SDCMS-CMA

By Theodore M. Mazer, MD

* On Average

An Inequity Is Born What began in 1992 with a new Medicare payment system based on the cost to render physician services, i.e., RBRVS, quickly became mired in formulas tied to government policies both to support rural access to care and to group like-cost areas into payment localities. In some cases, the formulas undervalued urban cost differences in order to shift monies to support rural practices.

California was broken into multiple payment localities — using the initial formulas — to allow for accurate payments to physicians that reflected their geographic cost differences, while paying at levels that would sustain access to care for Medicare beneficiaries, in accordance with statutes requiring payments to meet these conditions.

A 1997 readjustment of RBRVS payment 12 j u n e 2014

areas resulted in some shifts in California, but by that time it was becoming apparent that the original payment locality groupings, which were based on data that hadn’t been updated for several counties that had become urbanized since the original data sets were collected, was resulting in highly inaccurate payments in counties like San Diego, Santa Cruz, Monterey, and others — and the problem was repeating itself in other states.

By 2000, several doctors and staff members at CMA had identified the growing problem, which was worsened by the gradual adoption of Medicare physician fee schedules by commercial payers, and even by IPAs and other medical groups. As Medicare payments grew more negatively out of line with increasing practice costs in the urban counties that had been placed in California payment locality 99, San Diego

included, efforts began to have the Health Care Financing Administration (HCFA) — CMS’s precursor — correct the growing problem by removing the urbanized counties from Area 99 and recalculating more accurate payments.

Unfortunately, in a tangle of Medicare rules and in a zero-sum game, any move to increase payments to these now underpaid counties would need to shift monies from other counties that would remain in Area 99. Thus began a protracted battle between CMA, Medicare, and the Department of Health and Human Services, and, eventually, Congress, and later lawyers in a class-action lawsuit.

The Long Battle Begins I became involved in the battle sometime in 2000, as chairman of CMA’s Committee on Medical Services, while at the same time a couple of doctors in Northern California — Drs. Ned Bentley and Larry DeGhetaldi — began working with their local legislators and CMA to try to get the problem corrected at their end of the state. Though we were only beginning to see the negative impact of the flawed Geographic Practice Cost Index (GPCI) payment formula in 2000, San Diego County would soon grow to be the most adversely impacted county not only in California but in the entire United States.

Unless San Diego and 13 other similarly situated and underpaid counties could be withdrawn from Area 99 (and Area 3 for Marin), the underpayments would continue. Other states, like Texas, had been granted changes to address similar concerns, but Medicare put California in the position of somehow having to solve Medicare’s own error by trying to find a solution wherein some counties would have to accept decreased payments in order to make other counties whole — a recipe for disaster.

In December 2001, while local efforts had begun in Santa Cruz County, I convened the first formal meeting on the GPCI inequities, and CMA gathered representatives from HCFA and Region IX Medicare, along with CMA staff and doctors from the affected counties. By the end of the meeting, we learned how the formula was made in error, what the impacts were, and, unfortunately, that there was no easy resolution to the problem.

Thus began a nearly 13-year campaign to obtain a ‘GPCI fix’ that would take all of us, primarily Drs. Bentley, DeGhetaldi, and myself, along with CMA staffer and lobbyist Elizabeth McNeil, on a journey of CMA resolutions, CMA Board of Trustee challenges, local and Washington, DC,

visits with legislators and legislative staffers, multiple House of Representative bills that died in December sessions year after year, broken promises by House Ways and Means leadership, and even a still ongoing lawsuit in which I — along with several counties and two other doctors — am a plaintiff against DHHS, seeking both prospective correction of and retrospective relief from the GPCI underpayments.

That lawsuit is still in process, since roughly 2007, and is now over $4 billion in retroactive underpayments.

Taking the Fight to the Legislature and the Courts The numbers guys, Drs. DeGhetaldi and Bentley, have already had incredibly important impact over the years by finding other errors in CMS calculations of annual updates that even CMS agreed with and corrected, avoiding onerous cuts to California physician payments. They, along with Ms. McNeil, have made numerous trips to DC, holding educational sessions for congressional staff that not only helped lead to a few bills that eventually failed — we call it Lucy pulling the ball away just as Charlie Brown was about to kick us a field goal — but also to what finally became the GPCI fix of 2014.

For my part, as GPCI King from San Diego (a moniker given to me locally for my obsession with resolving this issue), I worked hard to ensure that any fix would be applied fairly to all counties impacted by the broken formula, which, unfortunately, led to my fighting to delay an earlier proposal that would have helped my friends in Northern California but that would have left San Diego out and hoping for future relief. I continued to press the issue through CMA and with federal legislators and Medicare administrators.

Many of you reading this probably got tired of hearing me talk about how close we kept coming to resolving this problem year after year, and thought, like me, that I was passing time tilting at a windmill that would never fall.

As the legislative impasse continued, I, along with my fellow musketeers, decided that we needed to turn to the legal arena.

We eventually worked to gather several California counties to become plaintiffs on behalf of their local doctors and patients, and filed a class-action lawsuit seeking correction of the problem going forward and compensation going back, under the statute of limitations, to the early 2000s. As the suit progressed, fought by DHHS and Medicare, reprecontinued on page 16

Nonmembers: Thank Your SDCMS Member Colleagues!

This win is not any one person’s victory, but resulted from the concerted efforts of organized medicine, backing those who choose to take an active role.

For those readers who are already SDCMS-CMA members, your support and membership allows this kind of advocacy, often requiring persistence through the frustrating political and legal processes.

Nonmembers should recognize that while they may benefit from this work, they owe a thank-you to those whose membership shouldered the burden on all doctors’ behalves … and should reconsider their own decision not to be a member of SDCMS-CMA. The increased reimbursements that will ultimately result through both Medicare and commercial rate changes will more than pay for most physicians’ memberships year after year for those who are not yet nearing retirement. And the GPCI issue is but one of many that SDCMS and CMA advocate for year after year.

SAN DI EGO PHYSICIAN.org 13

no increased security standards to protect your personal prescription information from hacking and theft. Though the database already exists, it is underfunded, understaffed, and technologically incapable of handling the massively increased demands this ballot measure will place on it. This ballot measure will force the CURES database to respond to tens of millions of inquiries each year, something the database simply cannot do in its current form or functionality. A nonfunctioning database system will put physicians and pharmacists in the untenable position of having to break the law to treat their patients, or break their oath by refusing needed medications to patients.

Most concerning, the massive ramp-up of this database will significantly put patients’ private medical information at risk. The ballot measure contains no provisions and no funding to upgrade the database with increased security standards to protect personal prescription information from government intrusion, hacking,

ou may have heard that the trial-lawyer-sponsored ballot measure that aims to undermine the protections of the Medical Injury Compensation

By Richard Thorp, MD

That’s What Happens When Lawyers Play Doctor

Increased Costs. Losing Trusted Doctors.

Threatened Privacy.

*Please post in physician common areas*

micra

If this measure is approved by voters, malpractice lawsuits and payouts will skyrocket, adding “hundreds of millions of dollars” in new costs to state and local governments, according to an impartial analysis conducted by the state’s Legislative Analyst. Someone will have to pay, and that someone is providers, taxpayers, and consumers.

Most The California Medical Association (CMA) has joined a concerning, campaign coalition to oppose the massive the measure because it will ramp-up of this be costly for consumers and database will taxpayers, endanger patient access to quality healthcare, significantly and jeopardize the privacy of put patients’ our personal health informaprivate medical tion. This group, “Patients and Providers to Protect information Access and Contain Health at risk.

Costs,” is a diverse and growing coalition of trusted doctors, community health clinics, hospitals, family-planning organizations, local leaders, public safety officials, businesses, and working men and women formed to oppose this costly, dangerous ballot proposition that would make it easier and more profitable for lawyers to sue doctors and hospitals.

This measure would also have devastating effects on access to care for patients everywhere, but especially in rural areas and areas that are already underserved. Community healthcare clinics like Planned Parenthood and the Central Valley Health Network are already warning that this measure will cause specialists like OB/GYNs to reduce or eliminate services to their patients.

This measure could also cause doctors to leave the state, meaning thousands of Californians could lose access to their trusted doctors.

Over the next few months you’ll hear a lot of rhetoric from the proponents of the measure — but really, this is another example of specialinterest politics trying to fool the voters into thinking this is something that it’s not. Authors purposely added doctor drug testing to disguise their real intent behind the ballot measure: to increase lawsuits against healthcare providers, which will increase our healthcare costs and reduce access to quality healthcare. According to the Los Angeles Times: “The drug rules are in the initiative because they poll well, and the backers figure that’s the way to get the public to support the measure. ‘It’s the ultimate sweetener,’ says Jamie Court, the head of Consumer Watchdog” (Dec. 10, 2013).

This proposal also forces doctors and pharmacists to use a massive statewide database known as the Controlled Utilization Review and Evaluation System, or CURES, filled with Californians’ personal medical prescription information — a mandate our government will find impossible to implement, and a database with

Reform Act (MICRA) has officially qualified for the November ballot. ¶ In less than six months, on Nov. 4, 2014, these trial lawyers will ask voters to weigh in on “The Troy and Alana Pack Patient Safety Act,” an initiative that was carelessly thrown together without any concern for taxpayer pocketbooks, privacy, patients, or healthcare. If trial lawyers get their way, our state will be saddled with a costly threat to privacy that California simply cannot afford.

Y

Dr. Thorp is president of the California Medical Association (CMA).

theft, or improper access by nonmedical professionals.

The initiative is bad for patients, taxpayers, and healthcare as a whole, and there has never been a greater need for physicians to band together and fight for our patients.

As you can see, this initiative is fraught with problems and would prove detrimental to California’s healthcare system. I’m asking each of you to join the effort to defeat this costly threat to our state, and, in doing so, protect access to care and prevent higher costs for all California.

Together, I’m sure we will be victorious.

As we forge ahead to Election Day, it is more important than ever to make sure we are speaking as a unified, coordinated voice. If you haven’t done so already, please visit CMA’s website at www.cmanet.org/micra for the latest information, handouts, and to sign up as a campaign coordinator in your area. Please also visit the campaign website at www.stophigherhealthcarecosts.com to sign up to become an official opponent of this badly flawed measure.

From the website you can: • Sign up to add your name to the growing list of individuals and groups opposed to the MICRA ballot measure.

• Get important facts, downloads, and information that will help you spread the word about this costly measure • Be part of our outreach team. If you have direct patient contact, become part of our outreach team. Visit CMA’s MICRA resource page to sign up as a campaign coordinator here.

• Participate in message/media training.

The campaign is also looking for physicians interested in taking on a more public role speaking to community groups about why this ballot measure should be defeated.

Contact Molly Weedn at mweedn@cmanet.org for more information.

sented by the U.S. Department of Justice, it became apparent that the plaintiffs list needed to include practicing physicians, and I became a named plaintiff. That resulted in a most memorable trip to CMS headquarters in Baltimore, perhaps the most intensely secure campus I have ever entered.

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And indeed another short-term proposal did arise. But, thanks to our team in DC, and to some very important and longterm key legislators, a minor miracle occurred. With the assistance of Representative Sam Farr, representing California’s central coast, and our very own Representative Darrell Issa, the language of the GPCI fix from the overall SGR repeal bill was inserted into the last-minute SGR doc fix bill with agreement by both House and Senate leadership, and was eventually passed by both houses of Congress.

The GPCI fix, albeit a slow implementa-

PaLo aLTo SacramenTo

16 j u n e 2014 CAP_1402.indd 1

A GPCI Fix for California Secured … Almost In 2013, as bipartisan, bicameral legislation to eliminate the year-after-year “doc fixes” by repealing the SGR made its way through Congress, CMA was able, through the efforts noted above and through long-established relationships with our federal legislators, to insert language into the bill to fix GPCI for California (and eventually the rest of the nation) without negatively impacting other counties. CMA’s innovative method to fix the Medicare payment system, which has underpaid San Diego doctors by up to $30 million a year — compounded by similar underpayments by commercial payers following — alone was an incredible accomplishment.

In my last visit to DC in March of this year, we quickly saw that what could have and should have been a bipartisan repeal of SGR, which would have included our GPCI fix, was about to fall apart due to an inability for House and Senate leadership to find an agreeable means to pay for the very policy legislation they all supported.

Once again, we saw Lucy getting ready to pull the ball away from Charlie Brown just when we were going to score. We were even emboldened enough to pass out to key legislators pictures of our dear Peanuts friends, pleading with them not to block us from scoring once again. But the mood when we left DC was one of gloom, knowing that the SGR repeal, with our GPCI fix, appeared doomed, and another bill to kick the can down the road on SGR was likely to arise, leaving our GPCI fix on the floor.

2/5/13 11:13 AM

tion, is not a one-year kick of the can down the road, but rather a permanent solution for California, and will result in more accurate payments without negatively impacting the still-rural counties, while aligning payment adjustments for doctors with those for hospitals and serving as a model for eventual realignment of accurate payment for the nation.

President Obama quickly signed the SGR bill, locking in the GPCI fix, and, finally, after more than 14 years of work, resolving the issue on a prospective basis. Is it ideal?

No. But resolving this going forward will correct a longstanding problem, leading for instance to a 5–9% payment increase for San Diego doctors for Medicare services, and likely for all medical services where fees are predicated on the Medicare fee schedule. It will also allow CMA and others to refocus the resources and time given to this issue for many years into other areas of advocacy, including permanent repeal of SGR and development of new payment models.

Success at Last — With Lots of Help It has been a long and frustrating, though educational, journey. When I traveled last year to the La Mancha region of Spain, I felt at home looking for windmills to tilt at and feeling much like Don Quixote as I continued to fight the injustice of the GPCI impact on San Diego and other counties, and the injustice of delay after delay in resolving it. I hoped not to suffer the same fate of Don Quixote in the effort to tip the windmills over, despite Lucy’s showing up year after year. And here we are, finally having tilted at the GPCI successfully, with lots of help.

I may not be practicing long enough to fully benefit from what was finally accomplished, and the fate of the lawsuit seeking retroactive damages remains unknown. But as I said to Congressman Farr when presenting him a thank-you from SDCMS in May, I know the difficulty of fixing a problem in Medicare and I know that sometimes perseverance results in change. I also know that while I won’t be spending so much time being a GPCI King anymore, there are more windmills to tilt at, and I will be back working with these same persevering folks for the next battles.

The goals of advocacy are not necessarily for immediate or even personal gains, but to meet long-term needs of both physicians and the patients they serve, thus helping to preserve the profession for the future.

Dr. Mazer, SDCMS-CMA member since 1989, is past president of SDCMS and current speaker of CMA’s House of Delegates.

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California Medical Association

Federal Update SGR • ICD-10 • GPCI

by Elizabeth McNeil, Vice President of Federal Government Relations, CMA

T

he Wall Street Journal editors have called the Medicare SGR a “Greek tragedy.” For a decade, organized medicine has been working to repeal the flawed Medicare SGR fee-for-service payment formula and replace it with a new payment system.

Year after year, for one reason or another, Congress fails to eliminate the SGR and enacts a short-term patch to stop the SGR cut. But this year was going to be different.

The Congressional Budget Office (CBO) announced that the cost to repeal the SGR was at an all-time low of $116 billion compared to the $368 billion cost in 18 j u n e 2014

prior years. The House and Senate jointly introduced a bicameral, bipartisan bill (HR 4015/S 2000) to repeal the SGR and establish a reasonable new payment system. It passed out of three powerful House and Senate committees unanimously.

Nearly every physician organization in the country supported the bill. Political miracles were abundant. There was incredible momentum going into the final phase, where Congress would assign the funding sources.

And then the congressional leadership resorted to their partisan, dysfunctional, 3% approval rating behavior. The House and the Senate couldn’t agree to the Medicare slate of funding sources because it would force them to cut hospitals and pharma, and raise premiums on AARP seniors in an election year. So the House proposed to fund the SGR with a repeal of the ACA individual mandate. While it passed the House with Republican votes, it had no chance in the Senate. The Senate proposed to use unspent Afghanistan and Iraq military funding or not pay for it at all — equally unacceptable to the Republican leadership despite two Wall Street Journal editorials urging the House Republicans to “simply pass the bill and stop the pretense of fake-paying for it.” They were at a partisan impasse, got caught up in electionyear politics, and lost their political will.

Over organized medicine’s opposition to another short-term patch, on March 31, 2014, the night before the SGR cut, the House and Senate voted on the 17th patch in a decade. With the president’s signature, the bill took effect immediately and provides the following: • Stops the 24% Medicare physician payment cut for one year until April 2015.

• Provides a 0.5% payment increase through Dec. 31, 2014; 0% through April 1, 2015.

• Delays the burdensome ICD-10 coding system until October 2015.

• Permanently reforms the California physician payment localities. Over the next decade, it provides at least $400 million in payment increases to San Benito, Santa Cruz, Marin, Santa Barbara, San Diego, Monterey, Sonoma, Placer, El Dorado, Yolo, Sacramento, San Luis Obispo, Riverside, and San Bernardino.

It permanently holds the rural county physicians harmless from cuts.

While CMA opposed yet another patch, the silver lining is that California

physicians will receive a delay in the costly ICD-10 coding system and a substantial $50 million annual increase in geographic Medicare payments.

CMA, AMA, and almost every national specialty society and state medical association called upon Congress to return to the negotiating table to achieve permanent Medicare physician payment reform. A decade of patches had cost the taxpayers $150 billion — almost as much as the long-term reform bill. There had never been a better opportunity with the bipartisan committee agreement on the new payment system and the low price tag.

CMA, AMA, and others worked aggressively all year long to develop an agreeable new payment system. The proposed system provided payment updates, incentives for physicians to improve quality, efficiency, and coordinate care. It provided resources to help small practices transition to the new systems. It allowed large upside bonuses for alternative payment models. And it gave physicians the data to effectively manage their practices. It also repealed the SGR. It met most of CMA’s goals for payment reform.

CMA physician leaders worked tirelessly to improve the legislation and to bring

organized medicine to one unified position in support of the bicameral, bipartisan legislation, HR 4015 and S 2000, which unanimously passed the House and Senate committees in December 2013. The Energy Commerce Committee passed the first bipartisan version in July 2013. It was a truly Herculean effort, and, for the first time in a decade, Congress made real progress. But they failed to finish the job.

Whether it is the fate of a Greek tragedy, an evil spell cast upon physicians, or the difficult political and fiscal environments in the state capitol and Washington, DC, physicians continue to be challenged by public programs, such as Medicare and Medi-Cal. Despite CMA’s most valiant attempts to raise Medi-Cal reimbursement rates since the early 1990s, California’s remain last in the nation. Despite CMA’s and AMA’s aggressive advocacy since 2002, Medicare rates (while increasing) fail to keep pace with the growing costs to practice medicine.

Physicians will not be the “Greek tragedy.” The fight this year is not over.

We are too close. We have a bipartisan bill that we can carry forward. Physicians will regroup and broaden our coalition outside of medicine. We will immediately call upon

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While CMA opposed yet another patch, the silver lining is that California physicians will receive a delay in the costly ICD-10 coding system and a substantial $50 million annual increase in geographic Medicare payments.

the committed members of Congress from both parties, in both the House and the Senate, who have worked so hard over the past year to reach bipartisan agreement, to continue to persevere through the funding debate to get the bill passed. We will push the leadership to enter a real negotiation over the financing. And we will hold the 113th Congress accountable for delivering permanent Medicare reform. We must break their habit of patching the SGR. It is essential that we stabilize the Medicare program for physicians and their patients.

Thanks to the CMA physician leaders and physicians all across the state who fought and continue to fight for reform.

SAN DI EGO PHYSICIAN.org 21

California Medical Association

Governance Reform CMA Envisions a New Future for Organized Medicine

by Steven E. Larson, MD, MPH

C

hange is never easy, but oftentimes it is necessary, and even invigorating. The California Medical Association (CMA) is about to embark on a journey of change that will position our association as a nimble, proactive organization ready to lead the practice of medicine into a brave new world. In 2013, the CMA House of Delegates (HOD) approved a plan to reform the way our association is governed. Will it be easy? No. Will it be worth it? There is not a doubt in my mind.

22 j u n e 2014

In a nutshell, the reforms will make CMA more relevant and effective by focusing the association on, and bolstering its resources to address, the critical issues of universal importance to physicians.

By doing so, CMA will be better able to protect the interests of its physician members and, even more importantly, guide the future of our profession, not only in California but nationwide.

150 Years of Tradition For 150-plus years, CMA has been guided by the HOD, which meets once a year to set policies and direct resource allocation. This has led to a sometimes unwieldy 581-member HOD, a Board of Trustees numbering more than 50, a seven-member Executive Committee, and hundreds of other members serving as alternate delegates and in various capacities on dozens of councils, committees, sections, and mode-of-practice forums.

Over the years, there have been several task forces assigned to this subject. It wasn’t until this year, however, that the abstract discussions about “governance

reform” began to produce concrete results.

These discussions resulted in big questions. Does the HOD foster a reactive culture rather than a proactive one? Does it inhibit CMA’s ability to take quick action in a rapidly evolving healthcare environment?

While these questions were being asked, the HOD was spending most of its time on a growing number of resolutions that struggled to be assigned or implemented because of resource limitations.

The CMA Board of Trustees, realizing that a floundering governing style prevented the organization from quickly acting on issues of universal import to the membership and their patients, created a committee — the Governance Technical Advisory Committee (GTAC) — to look at this issue.

The GTAC confirmed what the executive committee had feared: The association was unable to quickly address universal issues that arose faster than the once-a-year HOD meetings could handle, and there were other inefficiencies in CMA’s governing bodies and processes.

And there was the cost. An independent

The Governance TAC Report The full report of the CMA Governance Technical Advisory Committee, as amended by the House of Delegates at its October 2013 meeting in Anaheim, is available for download on the California Medical Association website. To access the report, available to members only, visit www.cmanet.org/hod and click on the “documents” tab. The report begins on page 12 of the “Actions of the 2013 House of Delegates” document.

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study commissioned by CMA (an activitybased costing, or “ABC” study) found that CMA governance is far more resourceintensive than previously thought, accounting for almost one-third of CMA’s operating budget — an allocation that commensurately reduces resources available for advocacy and other member services.

The GTAC began its discussion of how to bring relevance, democracy, and costeffectiveness to governing the association.

It became clear to us that the rank and file members want more advocacy, while the delegates and trustees are heavily invested in leadership.

Tackling the Big Issues A proposal to reform CMA’s governing structure, put before the 2013 CMA HOD by the GTAC this past October, proposed that instead of a diffuse focus on many issues, the HOD take on a limited number of big issues — the most important, most pressing matters facing physicians and the practice of medicine.

CMA’s longstanding traditions of democratic participation and representative governance would continue; the difference, as envisioned by the GTAC, is that specific

issues that are of concern to a narrow spectrum of the membership would no longer command HOD’s limited time. Rather, the democratically elected Board of Trustees would act on those issues, as it already does on the increasing number of matters referred to the Board for action by a House that is aware of its policymaking constraints.

The HOD would continue to set policy on major issues, and its decisions would be informed through a year-round process not constrained by 15-minute limits on debate of recommendations developed in a rushed, overnight exercise, as is currently the case.

More focused expertise would be brought to bear in a more careful development of recommendations for action. Policy on other issues would realize the same benefits of a more careful and expert deliberative process throughout the year.

We would like to improve the discussion at the House of Delegates to deal with the big issues of the day and to utilize the valuable resources of our delegates for the collective development and direction of important policy matters. We believe this proposal has real potential for a robust discussion around issues that will impact all physicians.

The reforms would also open the discus-

sion to individual members who could continue to bring forth their ideas and proposals through a year-round resolution process provided for in the CMA bylaws. Such proposals would be studied, with recommendations acted on by the Board.

A year-round dialogue about timely issues should result in well-thought-out policy pieces that could be brought to the floor during HOD. Charting a Course for the Next 150 Years This year’s discussion and debate at HOD on governance reform has set the stage for the GTAC to make proposals to modify the bylaws to begin the changes needed to set CMA’s course for the next 150 years.

I am optimistic that this will result in an improvement for our entire organization. It will make CMA more effective in reaching the average member and give him or her a direct voice in policy, bringing broader input into our more difficult decisions.

Dr. Larson, a Riverside physician, has served as chairman of CMA’s Board of Trustees since 2011. He is also the chair of CMA’s Governance Technical Advisory Committee.

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Please email your CV in confidence for consideration to pbyrnes@andersonmedicalcenter.com. Compensation: Depends on Experience [224] SEEKING PER-DIEM PHYSICIAN: San Diego North County group looking for per-diem physician for busy urgent care. Family medicine physician preferred. Need coverage evening and weekends. Malpractice is covered. Please email CV to judy@cassidymg.com or fax to (760) 630-2558, Attn.: Judy. [222] SEEKING IM PCP: Growing multispecialty North County practice seeks internal medicine PCP. Please send CV and request for information to anon625@cox.net. [220] PHYSICIANS: Well-established, busy pain management practice in San Diego Mission Valley is seeking a staff physician, preferably experienced in pain management and/or family practice. Convenient location in a new and modern office setting. We offer a competitive salary, flexible work schedules, and a benefits package that provides malpractice coverage, CME allowance, as well as excellent professional growth potential. Please email your curriculum vitae/résumé in confidence to painclinicsandiego@gmail.com. [216] PEDIATRICIAN: To take over existing practice for Arch Health Partners, an award-winning medical foundation affiliated with the Palomar Health System in North San Diego County. M–F, 8:00am – 5:00pm. Send CV to catherine.jones@archhealth.org or fax to (858) 618.5820. [213] URGENT CARE PHYSICIAN — PER DIEM: Arch Health Partners is an award-winning medical foundation affiliated with the Palomar Health System in North San Diego County. Hours: 9:00am to 9:00pm. Send CV to catherine.jones@archhealth.org or fax to (858) 618.5820. [212] SEEKING A PART-TIME BC/BE INTERNAL MEDICINE PHYSICIAN: SHARP Rees-Stealy Medical Group, a 450+ physician multi-specialty group in San Diego, is seeking a part-time BC/BE internal medicine physician to join our staff at our Genesee location. We offer a first-year competitive-compensation guarantee and an excellent benefits package. Please email CV to lori. miller@sharp.com. [204]

LOOKING FOR A DERMATOLOGIST: Medical spa located in East County looking for a dermatologist who would like to buy into a very lucrative practice or willing to be a medical director. For more information, please call Dr. Shirin Dorin at (619) 456-4555. [238]

SEEKING A PART-TIME BC/BE INTERNAL MEDICINE / PEDIATRICS OR FAMILY MEDICINE PHYSICIAN: SHARP Rees-Stealy Medical Group, a 450+ physician multi-specialty group in San Diego, is seeking a part-time BC/BE internal medicine / pediatrics or family medicine physician to join our staff at our Carmel Valley location. We offer a first-year competitive-compensation guarantee and an excellent benefits package.

Please email CV to lori.miller@sharp.com. [205]

LOOKING FOR A RETIRED PHYSICIAN: Medical spa located in East County looking for a retired physician for a part-time position as a medical director. For more

FULL-TIME OR PART-TIME URGENT CARE PHYSICIAN: Busy practice in El Cajon, established in 1982, seeks a full-time and/or part-time physician. Good hours

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.

26 j u n e 2014

(mostly 9:00am–5:30pm weekday shifts with some weekends from 9:00am–4:00pm and closed on major holidays) plus good pay. Please send CV to jeff@eastcountyurgentcare.com or fax to (619) 442-2245. [161] 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. Visit www.thehousecalldocs.com. [037] 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, perdiem 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. EEO Employer/Vet/ Disabled/AA [912] SEEKING BOARD-CERTIFIED PEDIATRICIAN FOR PERMANENT FOUR-DAYS-PER-WEEK POSITION: Private practice in La Mesa seeks pediatrician four days per week on partnership track. Modern office setting with a reputation for outstanding patient satisfaction and retention for over 15 years. A dedicated triage and education nurse takes routine patient calls off your hands, and team of eight staff provides attentive support allowing you to focus on direct, quality patient care. Clinic is 24–28 patients per eight-hour day, 1-in-3 call is minimal, rounding on newborns, and occasional admission, NO delivery standby or rushing out in the night. Benefits include tail-covered liability insurance, paid holidays/vacation/sick time, professional dues, health and dental insurance, uniforms, CME, budgets, disability and life insurance. Please contact Venk at (619) 504-5830 or at venk@gpeds.sdcoxmail.com. Salary $ 102–108,000 annually (equal to $130–135,000 full-time). [778] OFFICE SPACE WANTED 3998 VISTA WAY, IN OCEANSIDE: Four medical office spaces approximately 1,300–2,800 square feet available for lease. Close proximity to Tri-City Hospital with pedestrian walkway connected to parking lot of hospital, and ground-floor access. Lease price: $1.75+NNN. Tenant improvement allowance to customize the suites is available. For further information, please contact Lucia Shamshoian at (760) 931-1134, ext.

13, or at shamshoian@coveycommercial.com. [234] HAND SURGEON LOOKING FOR PART-TIME OFFICE LOCATION: Looking for space to share in La Jolla to Del Mar areas. Limited space and time needs. Onehalf to one day per week. We have flexibility to accommodate your schedule and staffing. Please contact me at greg@thehanddoctor.com. [231] LOOKING FOR SUBLEASE: Subspecialist looking for space to sublease in the following locations: Encinitas / Carlsbad or Carmel Valley / Sorrento Valley / La Jolla / UTC. Would be able to move in May or later. Please contact sandiegodoctor23@yahoo.com with space location, availability, and type of arrangement (full or partial sublease, rooms / days available, etc.). [230] OFFICE SPACE AVAILABLE SCRIPPS XIMED MEDICAL CENTER BLDG, LA JOLLA — OFFICE SPACE TO SUBLEASE AVAILABLE: Vascular & General Surgeons have space available. One room consult office available, with one or two exam rooms, to a physician or team. Located on the campus of Scripps Memorial Hospital, The Scripps Ximed Medical Center is the office space location of choice for anyone seeking a presence in the La Jolla/UTC area.

Reception and staff may be available. Complete ultrasound lab on site for scans or studies. Full-day or halfday timeslots. For more information, call Irene at (619) 840-2400. [154]

NORTH COAST HEALTH CENTER, 477 EL CAMINO REAL, ENCINITAS, OFFICE SPACE TO SUBLEASE: Well-designed office space available, 2100 square feet, at the 477-D Bldg. Occupied by Vascular & General Surgeons. Excellent and central location at this large medical center. Nice third-floor window views, all new exam tables, equipment, furniture, and hardwood floors. 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 interest. Plenty of free parking. For more information, call Irene at (619) 840-2400 or at (858) 452-0306. [153] CLAIREMONT OFFICE SUITE AVAILABLE NOW FOR LEASE: 1,450ft2 office suite in medical office building centrally located in Clairemont. Second story suite in a new medical building, network wiring, with elevator access. Three exam rooms and a spacious consultation room. Current businesses on site include family practice, general dentist, and optometrist. Available month-to-month or long-term lease only $1.50ft2 gross lease. Call (619) 300-5139. [245] LA JOLLA (NEAR UTC) OFFICE FOR SUBLEASE OR TO SHARE: 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] NEW MEDICAL OFFICE SPACE AVAILABLE FOR SUBLEASE IN KEARNY MESA: Brand new office suite located at 3750 Convoy Street with nine exam rooms and digital X-ray, hi-speed wireless, free parking for patients and staff, conference room in building.

Several minutes from Sharp Memorial and Children’s Hospitals. Convenient freeway access to 163 and 805.

Multiple half-day clinics available. Please contact Lisa Vaughn at (858) 278-8300, ext. 210, for more information. [235] LA JOLLA OFFICE SPACE: Share reception, waiting area, and exam/consultation rooms with neurosurgeon and orthopedic surgeon in new office. Five exam rooms.

On-site X-rays with radiograph tech available. Office is close to Scripps Memorial Hospital. In Golden Triangle between 805 and 5 freeways. Terms negotiable. Please contact Kathy Koppinger at (858) 678-0455. [223] BANKERS HILL PRIMARY CARE AND RESEARCH OFFICE SPACE TO SUBLEASE: 50-year established primary care practice and clinical research office with currently two internists has space to sublease to another primary care MD (internal medicine or subspecialties / family practice) to help curb overhead and see acute overflow patients. Also can provide opportunity to get involved with clinical research. Flexible terms / space.

Free parking, close to hospital, easy access to freeways.

Contact Cindy at allmedgrp@hotmail.com. [146] POWAY OFFICE SPACE FOR SUBLEASE: Private exam room or rooms available for one day a week or more. Ideal for physician, chiropractor, massage therapist. Low rates. Email inquiries to kathysutton41@yahoo.com. [173]

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]

cense and ACLS certification. Please email or fax CV to (619) 569-2590. Visit www.DoctorsExpressSanDiego. com for more information. [229b] PHYSICIAN ASSISTANT OPENING: Well-established orthopaedic practice in San Diego County has an opening for an experienced, licensed orthopaedic physician assistant. Responsibilities include patient evaluation, diagnosis and treatment, in-office injections. This is a clinic-based position. We are considering both part-time and full-time candidates. Interested parties, email your CV with a cover letter including part-/full-time preference and salary range / requirements to lisas@sdsm. net (Word or PDF format only please). Thank you for your interest. [226] SEEKING PHYSICIAN ASSISTANT: Physician assistant needed on per-diem basis for busy urgent care in the San Diego North County area. Hours are evening and/or weekends. Please email CV to judy@cassidymg. com or fax to (760) 630-2558. [221] SEEKING PA / NP AND RN: Medical spa in the Del Mar / Solana Beach area is seeking PA / NP and RN. Should have experience with laser hair removal, IPL, CO2 laser, Botox and fillers, and sales. Positive attitude, ability to multitask, perform patient treatment, sales, consultations, effective communicator, work in a team environment, focused on client care, knowledge of lasers and laser theory, quick learner, self motivated. PA/NP will perform consultations and good faith examinations.

Minimum requirements: PA, NP, RN California license.

This is a part-time position, 1–2 days a week. Please email résumé / cover letter to synergyamasb@gmail. com or fax to (858) 259-0864. [219]

NONPHYSICIAN POSITIONS AVAILABLE / WANTED BEHAVIORAL HEALTH CONSULTANT: The behavioral health consultant, as part of the primary care treatment team, identifies, triages, and manages primary care patients with medical and behavioral health problems. In addition, the BHC will provide skill training through psycho-education and patient education strategies and develop specific behavioral change plans for patients. The BHC assists primary healthcare providers in recognizing and treating mental disorders and psychosocial problems, assists in detection of “at-risk” patients, and assesses the clinical status of patients referred by the PCP. Education / Certification: PsyD/ PhD in psychology or LCSW; CPR certification (including BLS). Contact Araceli Mercado at araceli.mercado@ nchs-health.org or at fax (760) 736-870. [244] SUPERVISORY RN — MISSION MESA PEDIATRICS: Under the direction of the health center director / practice manager, and in collaboration with the nursing services director, supervise the delivery of quality medical care with optimal efficiency and patient satisfaction.

Job Skills: Ability to relate to and work with people of all ages, social and ethnic backgrounds, and maintain patient confidentiality. Ability to work independently and as part of a team. Knowledge and Education: Current California state registered nurse license, current CPR certificate required. Bilingual (English / Spanish), baccalaureate level of conceptual thinking. Experience: Four or more year’s general nursing experience in ambulatory care, including one year supervisory experience.

Please apply at https://rew31.ultipro.com/NOR1021/ JobBoard/ListJobs.aspx. [241]

WOMEN’S HEALTH / WELLNESS OFFICE HAS SPACE AVAILABLE FOR SUBLEASE: Exam room, office, and/or shared staff optional. Fully furnished exam rooms available and ready for use. Location features onsite billing, reception, medical assistants, potential use of in-office procedure room, and a rooftop lounge.

If you are interested, please reply with the heading “Space for Sublease” outlining the details of space and/ or staff use desired, with your contact information, and we will contact you to set up a showing. Reply to Mrs. Kim at cvwh858@gmail.com. [217]

LOOKING FOR PRACTICE MANAGER POSITION: Extensive healthcare management experience, motivated and highly driven to succeed. Documented ability to expand medical practices, establish rapport at all levels of an organization, and build trust with professionals and staff of varied backgrounds. Excellent communication, time management, and education skills. Successful implementation of EMR systems, training staff and physicians. Contact Kathy Fischer at (231) 740-2286 or at kathyfischer1@aol.com. [240]

MEDICAL OFFICE SPACE AVAILABLE FOR SUBLEASE IN LA JOLLA: 9834 Genesee Avenue, Suite 400 (Poole Building). Steps away from Scripps Memorial Hospital, La Jolla. Please contact Seth D. Bulow, MD, at (858) 622-9076 if you are interested. [215]

BOARD-CERTIFIED PHYSICIANS, PHYSICIAN ASSISTANTS, AND NURSE PRACTITIONERS NEEDED FOR URGENT CARE: Part-time positions available but a full-time opportunity may be offered to the right candidate. Must possess a current California medical li-

PART-TIME OB-GYN NURSE PRACTITIONER: Busy established OB-GYN office in La Jolla seeking a parttime OB-GYN nurse practitioner. Please email resume to ljpp36@sbcglobal.net. [214] SEEKING NURSE PRACTITIONER: Independent pediatrics private practices in Poway and La Mesa seeking nurse practitioner (preferably pediatrics experienced) for maternity coverage in April and July for 10–12 weeks or more. Poway is for 2–3 days per week; La Mesa is for 1–2 days per week. Appointment may be extended depending upon each situation, i.e., if original provider returning to full-time, part-time care or not at all. Please contact Venk Adigopula at (619) 504-5830 with queries about the two positions or email resume and interest letter to venk@gpeds.sdcoxmail.com (La Mesa) or venk@vvpeds.com (Poway). [211] NURSE PRACTITIONERS AND PHYSICIAN’S ASSISTANTS: Established, busy pain management practice in San Diego Mission Valley is looking for a nurse practitioner and physician’s assistant, preferably experienced in pain management or family practice. Knowledge of controlled substance prescriptions and regulations is required. Interpretation of diagnostic tests and the ability to apply skills involved in interdisciplinary pain management is necessary. We offer a competitive salary and benefits package that provides malpractice coverage, CME allowance, as well as excellent professional growth potential. Please email your curriculum vitae/résumé to painclinicsandiego@gmail.com. [210] PHYSICIAN ASSISTANT WANTED FOR SPORTS, SPINE, AND ARTHRITIS REGENERATIVE MEDICINE PRACTICE (ENCINITAS): Please reply with resume, letter of interest, and salary requirements to ssbunyak@hotmail.com. [199] NURSE PRACTITIONER: Needed for house-call physician in San Diego. Full-time, competitive benefits package and salary. Call (619) 992-5330 or email drhunt@thehousecalldocs.com. Visit www.thehousecalldocs.com. [152] PHYSICIAN ASSISTANT OR NURSE PRACTITIONER: Needed for house-call physician San Diego. Parttime, flexible days / hours. Competitive compensation.

Call (619) 992-5330 or email drhunt@thehousecalldocs.com. Visit www.thehousecalldocs.com. [038]

SAN DI EGO PHYSICIAN.org 27

POETRY AND MEDICINE

Colleagues

Colleagues

Marcus Welbys, Doogie Howsers Crisp white coats and khaki trousers

by Daniel J. Bressler, MD, FACP Comparisons are inevitable.

We learn new facts in the comparative context of old ones. If you meet someone named Donna, she will call to mind, consciously or not, the Donna you know from a book, a movie, a television show, or from “real life.” A short, bald man with a Central European accent will inevitably remind you of someone you’ve met in real or fictional encounters.

As doctors we belong to a group that has been widely represented in fiction. Some little bit of House’s brilliance, Quinn’s dependability and Lecter’s sadism all adhere to our mantle in the public imagination. However we fight prejudgment in all its forms, some amount of it is inevitable. “You doctors … ” is a phrase I’ve heard from patients many times in my career. I’m sure it ricochets around in all of their (and our) minds more often still. Try to not finish a sentence that begins, 28 j u n e 2014

“You lawyers” or “You Swiss” or “You golfers.” We all do it. We draw inferences based on a few examples.

Our better nature (and our scientific medical training) prevents us from inappropriately drawing broad conclusions from limited sample sizes (the N=1 experiment being the most prominent), but cultural associations often fly below the radars of our better nature and our statistical reality checks.

Just know this: Whenever we meet a patient, he has met us before, or so he imagines. So be prepared.

Perhaps you can find in the club of your fictional colleagues some tools and traits that help you to connect, to persuade, and to heal.

Dr. Bressler, SDCMS-CMA member since 1988, is chair of the Biomedical Ethics Committee at Scripps Mercy Hospital and longtime contributing writer to San Diego Physician.

Dr Quinn, Dr Zhivago Elsewhere’s Boston, Hope’s Chicago Dr Jekyll, Dr Who Dr Me and Dr You

Whenever we meet a patient, he has met us before, or so he imagines.

Dr Lecter, not benign Paging Doctor Frankenstein Beverly Crusher, Bones McCoy James Kildare, that Golden Boy Medicine Women, Chanting Shamans Specialized in chasing demons ER’s hustle and House’s sneer Make medical mysteries disappear Whatever doctor you might be They’ve seen on Grey’s Anatomy Though called “initial office visit” You’ve met before (just not explicit)

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