December 2014 by San Diego Physician

official publication of SDCMS December 2014

Cal MediConnect Is There a Doctor on Board?

“Physicians United for a Healthy San Diego”

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Contents

Volume 101, Number 12

EDITOR: James Santiago Grisolía, MD MANAGING EDITOR: Kyle Lewis EDITORIAL BOARD: Sherry L. Franklin, MD, James Santiago Grisolía, MD, Theodore M. Mazer, MD, Robert E. Peters, PhD, MD, David M. Priver, 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 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

features Cal MediConnect: Is There a Doctor on Board?

Introduction

BY JAMES SANTIAGO GRISOLÍA, MD

Physician FAQ

BY THE CALIFORNIA MEDICAL ASSOCIATION

The Duals’ Medical Justice Dilemma

BY MANUEL PUIG-LLANO, MD, FACS

orking Together to Improve W Members’ Quality of Life BY J. MARIO MOLINA, MD, AND RICHARD CHAMBERS

departments 4 Briefly Noted: Calendar • 2014 Office Manager of the Year • Volunteer Opportunities • And More … 6 Last Month, 68% of Californians Voted No on 46 … 8

“ Get me a doctor!” In-Flight Emergency BY DEVESH VASHISHTHA, MSII

I gnore AMA at Your Own Peril: AMA Interim 2014 Report

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

BY JAMES T. HAY, MD

Physician Marketplace: Classifieds

8 2 decem b er 2014

What’s Still Here? BY HELANE FRONEK, MD, FACP, FACPH

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

office manager advocacy

SDCMS Seminars & Webinars SDCMS.org

Congratulations, Sheila A. Hendry, PhD, SDCMS’ 2014 Office Manager of the Year!

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

Cma Webinars and Events CMAnet.org/events

Nominated by Dr. Wendy M. Buchi, SDCMS-CMA Member Since 1995

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. 12th Annual Natural Supplements: An Evidencebased Update JAN 16–18 (www.scripps.org/ events/12th-annual-naturalsupplements-january-15-2015) Pregnancy and Lactation in Women With Autoimmune Diseases: Sharing Knowledge Across Disciplines FEB 6–7 (cme.ucsd.edu/ plwad) Bridging the Hearts & Minds of Youth: Mindfulness and Compassion in Clinical Practice, Education, and Research FEB 27–MAR 1 (cme.ucsd. edu/bridging)

“

I honestly cannot imagine a better person to run a medical office. Period. I hesitate to call her an office manager since she is really so much more than a manager: administrator, clinical laboratory director, research coordinator, mediator, friend, and she can put her jeans on and scrub the floor with a Brillo pad if that’s what needed at the moment. Sheila Hendry came to IGO Medical Group in 1986 shortly after finishing her post doc training in cellular immunology at UCSD. She set up the andrology program and clinical laboratory and started the in vitro fertilization lab when we moved to our current location in 1988. Under Sheila’s guidance, IGO had the first IVF pregnancy in San Diego. IGO changed with the times and was managed by UCSD, as well as by several different highly recruited administrators. Although Sheila was the laboratory director during this time, she did any and every project that was handed to her. If we needed something done, we gave it to Sheila, as it would certainly be done thoroughly and extremely well. We realized that, in Sheila, we had a multitalented, immensely competent and organized person who could do so much. Sheila took over as our administrator in 2004 and the practice has done amazingly well ever since. We now have 11 obstetricians and gynecologists, two nurse practitioners, a clinical labora-

tory, andrology, a mammography and bone densitometry department, an active clinical research program, three ultrasound techs, and a total of 40 employees. Sheila oversees the supervisors of each department, remains the laboratory director and is the clinical research coordinator. She handles all personnel issues, substitutes in any department that needs help, and is always coming up with new ideas. Under Sheila’s direction, IGO has become much more efficient, much less wasteful, and more profitable. Sheila has aligned IGO Medical Group with the SDCMS, and with their help, has streamlined the practice and saved money. She has brought the available SDCMS resources to our practice in the form of speakers, and has used SDCMS recommendations for everything from accountants to attorneys, EMRs, billing companies, and insurance questions. In her 27 years at IGO, Sheila has adapted as the practice evolved. Although she was hired as the laboratory director to set up the clinical and IVF laboratory, she has grown with the practice, taken on any challenge, and, with her ability to see the big picture, has been instrumental in making IGO what it is today. She epitomizes the spirit of the independent medium-size group practice in which everyone has to chip in to do whatever is needed at the time to keep the practice running well. Sheila is an inspiration to all of us.

Sheila took over as our administrator in 2004 and the practice has done amazingly well ever since.

quote of the month

Nothing you do for children is ever wasted. They seem not to notice us, hovering, averting our eyes, and they seldom offer thanks, but what we do for them is never wasted.

4 decem b er 2014

— Garrison Keillor, Author, Storyteller, Humorist, and Radio Personality (born 1942)

/////////////////////////////////////////////////////////////////////////////////////////////////// giving back

PHYSICIAN VOLUNTEERS NEEDED! Email Your Physician Volunteer Opportunities to Editor@SDCMS.org

Volunteer Specialty Physicians Needed for Project Access for the following specialties: pulmonology, urology,

neurology, and sleep study. We are seeking these specialists throughout all regions of San Diego. Commitment can vary by practice. The mission of Project Access is to improve community health, access to care for all, and wellness for patients and physicians through engaged volunteerism. Help us help the most vulnerable population seek care. For more information, please call Ana Seda at (858) 565-8161 or email Ana.Seda@SDCMSF.org, or visit our website at www.sdcmsf.org. [282] Family Medicine/General Internal Medicine Physicians Needed: Excellent

family medicine and general internal medicine community docs to serve as role models and teachers to UC San Diego first- and second-year medical students in their Ambulatory Care Apprenticeship Program. This is a longitudinal oneafternoon-every-other-week clinical experience that extends from the beginning of medical school to the end of the second year, approximately 25 sessions in all. The goals are to allow students to practice history-taking and physical examination

skills, learn what primary care is all about, and develop a nurturing student-mentor relationship with a positive, enthusiastic practicing primary care physician in the community. Join us! Call Rusty Kallenberg, MD, at (619) 838-8047 or email gkallenberg@ucsd.edu. [281] Humanitarian Teams Need Medical Volunteers For Haiti: The Seattle-King

County Disaster Team, a US-based nonprofit, is looking for physicians for one week primary care medical clinics in rural Haiti in February and June 2015. Seattle-King County Disaster Team has been operating these clinics since 1998. It coordinates all in-country travel and logistics. Please contact Bob Downey at (619) 905-7157 or at labboy@earthlink. net if you are interested in applying. UCSD PACE Program Is Recruiting Practicing Physicians Above Age 50 for a PACE Aging Physician Assessment (PAPA) Pilot Study: Anyone interested in

participating should contact Patricia Reid, MPH, at (619) 471-0569. David E.J. Bazzo, MD, Director, PACE Fitness for Duty Program, is heading this effort. Compensation for your time is offered.

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SAN DI EGO PHYSICIAN.org 5

Last Month, 68% Voted No on 46 Becau

Raised a Massive War Chest

Assembled an Exceptional Campaign Team

Built a Broad and Deep Coalition

CMA’s initial $5 million pledge convinced coalition partners — hospitals, dentists, medical malpractice carriers, and others — to join and to contribute.

“Tour de Force” Performances From Both Richard E. Thorp, MD, CMA President, and Dustin Corcoran, CMA CEO

Business, Labor, Local Government, Community Clinics, Planned Parenthood, ACLU, NAACP, Taxpayers, Teachers, Firefighters — Nearly 800 Organizations in Total Across California

Highly Influential External Consultants From Both Sides of the Aisle

Natural Alliance Between Lawyers and the Democratic Party Neutralized

SDCMS convinced San Diego hospital medical staffs and medical groups to contribute nearly $1 million — after the California Hospital Association’s 2:1 match!

Brilliant Campaign Managers

It took $60 million to defeat Prop. 46.

A Coherent and Effective CMA Team

Ask Yourself: What W Medicine Look Like If 6 decem b er 2014

% of Californians use SDCMS and CMA …

Conducted Extensive Polling and Focus Groups

Conducted a Flawless Air Game

And a Flawless Ground Game

Consistent and Unified Messaging, Trained Physician Spokespeople, Extreme Message Discipline, No Mistakes

SDCMS Coordinated the Local and State Efforts for San Diego County Energized San Diego Physicians

“No on 46” Message Communicated Daily on Newly Created Twitter, Facebook, Google+, and YouTube Social Media Platforms Myriad “No on 46” Traditional Media Campaign Ads, Recordings, Visuals, and News Releases “No on 46” Endorsements by Every Major Editorial Board in California

Would f We Hadn’t?

Immeasurable “No on Prop. 46” Buttons, Lab Coat Cards, Brochures, Waiting Room Posters, Yard Signs, and Bumper Stickers Distributed Hundreds if Not Thousands of Individual San Diego Physicians Talked to Voters About the Deception and Trickery Behind Prop. 46, Resulting in 72% of San Diegans Voting NO — 5 Points Better Than Statewide SDCMS Spoke at Every Medical Staff Meeting to Inform and Motivate a San Diego-wide Response SAN DI EGO PHYSICIAN.org 7

MEDICINE’S FUTURE

Email your “Is there a doctor on-board?” stories to Editor@SDCMS.org.

“Get me a doctor!” In-Flight Emergency

by Devesh Vashishtha, MSII, UCSD School of Medicine

8 decem b er 2014

For me, this past summer was the so-called “last summer” between the first and second years of medical school. I was quite exhausted after a full year of exams, and I decided to spend the summer months getting some good old-fashioned rest and relaxation. I spent time with my family, and I also planned a trip to Trinidad for a weeklong retreat in Indian spiritual philosophy. The day of the trip came in late July, and I left home in good spirits. I had already been on break for six weeks, and I was looking forward to leaving California for a bit. The journey to Trinidad was in two legs: from San Diego to Houston, and from Houston to Port of Spain. My first flight passed without much difficulty. The second flight, however, was far more interesting. I was sitting on the right side of the plane, toward the back. I remember feeling somewhat drowsy, and I took a series of naps for the first couple hours of the flight. I was listening to music and staring at my desktop background when I noticed a commotion on my left. Across the aisle from me was a man sitting with his wife. They

Then it hit me. At that moment, I was the most senior medical authority in the situation. At that moment, I was responsible for this woman’s life.

seemed to be from Trinidad but of Indian origin, and the airline hostesses were leaning over the woman, asking frantic questions. Thinking it could be a medical emergency, I unbuckled my seat and stood up. “Hello? I’m a medical student. Is there anything I can do to help?” Without a word, the hostesses made room for me. I stepped into the row, and was rendered speechless for a few seconds. There could be little doubt about it. I was seeing a seizure for the first time in my life. She was a heavyset woman, with bright-red lipstick, and her entire upper body was shuddering. Her eyes were rolling in her sockets and saliva was coming out of her mouth. I stood there, mesmerized by what was in front of me. My mind started reeling. “What should we do?” asked one of the hostesses. The husband looked expectantly at me. Other passengers in the plane had turned their heads and were staring openly, unable to contain their curiosity. Then it hit me. At that moment, I was the most senior medical authority in the situation. At that moment, I was responsible for this woman’s

life. I paused a moment and thought. What was the right course of action for a seizure? I couldn’t remember learning anything about this. I closed my eyes and remembered something: During the first few weeks of medical school, we had all received CPR training. The first thing I needed to do was check if her heart and lungs were working. This would help me rule out CPR. “I’m going to check her pulse and breathing. See if you can get me a doctor.” The hostesses nodded, and one of them left to make a request for any physicians who were on-board. I checked the radial arteries at the wrist first. No pulse. I then went to her carotids in the neck. Thankfully, I could feel a pulse there. I watched her chest and saw that she was breathing OK, although her husband was shaking her neck back and forth. I told him to hold her head still and upright, and then I looked back at the hostess. They still hadn’t made a request for any physicians on-board. “Get me a doctor!” I yelled frantically. I had checked that the woman was not dying, but my knowledge of what to do with seizures was severely limited. I remembered something about waiting them out, but I didn’t want to take any chances. What if she was having an acute neurological problem? She could be dying and I had no idea what to do. Finally, I heard a voice over the intercom: “We have a request for any doctors on-board. There is a medical emergency in row 37. Would any doctors please report immediately.” I looked around and saw that nobody had stood up, although everybody’s eyes were on me. I stared at the back of a seat, biding my time. The woman’s body continued to convulse, her eyes continued to roll, and her mouth continued to drool. Her husband did his best to hold her neck upright and wiped her mouth with a napkin. Her lipstick left a smudge. Just as I was losing hope, a large, balding man stood up from near the front of the plane. He had frizzy patches of orange, unkempt hair and thick, grimy glasses. I would have had trouble believing he was a doctor, although he was making a beeline for

my row. He looked over the situation once and asked me what was going on. I explained that this woman was having a seizure, and that her heart and lungs were still working. He nodded and I got out of the way, letting him take over. The first thing he did was ask for a first aid kit, from which he pulled out an ammonia smelling salt to help the woman wake up. When this didn’t work, he asked for supplemental oxygen and requested that her husband hold the mask. He looked over at me, and said the only words I would hear him say for the entire flight. “She should get up soon. We will just wait.” And that was exactly what we did. The doctor went back to his seat, and I sat back down in mine. The hostess came by my row and thanked me for my help. She referred to me as “doctor,” and I didn’t bother correcting her. I waited, on edge, hoping that this doctor knew what he was doing. Was he even a doctor? I decided to be patient and put faith in him. After all, what choice did I have? After a very long 10 minutes, I noticed movement to my left. The woman was beginning to wake up! I watched as her husband closed his eyes, perhaps thanking God for this good fortune. The hostesses came over to confirm that she was OK. I breathed a sigh of relief and went back to listening to music. The doctor who had helped looked back at one point, and I flashed him a thumbs-up. We had successfully cared for our in-flight patient! A couple of hours later, the plane landed. I exited the airport and called for a taxi, and as I waited I replayed the events of the flight in my head. I had helped in a medical emergency! I stepped into the cab and introduced myself to the driver. His name was Thomas, and he spoke with a beautiful, lilting Trinidadian accent. “So, you gonna be a doctor, huh?” “Yep, at least that is the plan.” “The plan? No, sonny. You gonna be a doctor. Dis is very important you know. Doctors help people. You gonna help people too.” “I guess so. Medical school is pretty exhausting, Thomas.” “You gonna make a good doctor. Keep studying.” SAN DI EGO PHYSICIAN.org 9

AMA

Ignore AMA at Your Peril

AMA Interim 2014 Report 10 decem b er 2014

James T. Hay, MD, SDCMS-CMA member since 1979, and Robert E. Hertzka, MD, SDCMS-CMA member since 1984, are both delegates to AMA. Albert Ray, MD, SDCMSCMA member since 1984, and Lisa S. Miller, MD, SDCMS-CMA member since 1992, are both alternate delegates to AMA. Every day our AMA affects physicians, our practices, and our patients whether weâ&#x20AC;&#x2122;re paying attention to the AMA or not. Actions and activities at the recent Interim meeting of the House of Delegates (HOD) in Dallas should be important to know about: 1. The proposed revision of our code of ethics; 2. The ethical policy on physiciansâ&#x20AC;&#x2122; rights of personal conscience; 3. Advocacy efforts to change or delay implementation of meaningful use and ICD-10; 4. Public health issues, including Ebola; and

Member of the AMA or not, we all sign medical staff bylaws, health plan contracts, and employment contracts, most of which include a clause requiring us to abide by the ethical standards developed by AMA’s Council on Ethical and Judicial Affairs (CEJA). the concern of many delegates, including those from California, that that prescriptive language might create a legal cause of action against physicians who, for whatever clinical or circumstantial reason, might not be in 100% compliance. Consequently, the report was referred back to CEJA for further discussion and review. AMA members are welcome to review and comment on the proposed “Code” on AMA’s website: www.AMA-Assn.org. Physicians’ Leeway to Use Personal Beliefs When Caring for Patients? CEJA reports can be exceedingly helpful in guiding physician practices, and, at this meeting, the HOD adopted CEJA Report 1, “Physician Exercise of Conscience” (also available on the website). It examines the implications for patients, physicians, and the medical profession when conflicts arise between a physician’s professional commitments and his/her deeply held personal moral beliefs. It offers guidance on when a physician’s professional commitments should outweigh personal beliefs, as well as when physicians should have freedom to act according to the dictates of conscience while still protecting patients’ interests.

5. An excellent review of the implications of multistate compacts and telemedicine. This is a summary of just a few things from that meeting. Physicians Are Bound by AMA’s Code of Ethics Member of the AMA or not, we all sign medical staff bylaws, health plan contracts, and employment contracts, most of which include a clause requiring us to abide by the ethical standards developed by AMA’s Council on Ethical and Judicial Affairs (CEJA). Jokingly referred to as the “Supreme Court of medicine,” CEJA is a panel of ethicists appointed by AMA who are, while in office, banned from participation in AMA’s political process. At this meeting a thorough review of the entire many-volume “Code” was presented for adoption as revised. Language in the proposed revision included many instances of what physicians “should” or “should not” do, raising

Fighting Hassle Factors Our AMA’s strategic plan, adopted just three years ago, is focused on only three main goals, and includes a major effort to improve physician satisfaction and success in medical practice. Many actions at this HOD reflect that focus, including a strong push to delay or kill the implementation of ICD-10. In his presidential address, Robert Wah said he and AMA leadership were dedicated to continuing this fight at CMS, and, if necessary, with a legislative strategy to force CMS to change their plan to impose this onerous and costly unfunded mandate on the medical profession. The HOD also adopted Resolution 204 that asked AMA to seek reimbursements to physicians by payers and government if the implementation proceeds as planned. And a grassroots effort started by several individuals during the meeting led to a letter-writing campaign to members of Congress to at least delay ICD-10. Many resolutions dealt with concerns about maintenance of certification and proposals being considered by state licensing boards for maintenance of licensure.

And several others addressed the difficulties arising from the need to meet new and mostly unachievable meaningful use standards or pay penalties. Some asked AMA to seek delay or modification of the standards and ease the burden on physicians attempting to comply. Interstate “Compacts” and Telemedicine: Will Out-of-state Doctors Who Don’t Meet the Standards You Do Treat Your Patients in the Future? The Federation of State Medical Boards has developed a process for states that are willing to enter into contracts (Compacts) with each other to license out-of-state doctors to treat patients in their states, presumably mostly by telemedicine. Many questions arise as to who regulates these doctors, what standards (of which state) must they meet, and where would disciplinary and liability issues be handled if states agree to such “compacts.” Board of Trustees (BOT) Report 3 is an excellent review of the issues surrounding this subject and informs physicians of the implications if and when their state joins one. See BOT Report 3 on the website as well. Doesn’t AMA Pay Attention to Public Health? Every session of the HOD, annual and interim, addresses many resolutions and discussions of population and public health. After all, the mission of the AMA includes “improvement of the public health.” This meeting was no different and dealt with policy development about e-tobacco use, controlled substance prescribing, improving immunization rates, and CPR training. Of particular interest was a presentation about Ebola and the U.S. response to it, including the one in the city where we met, Dallas. As most of us know by now, the disease is deadly, but minimally infectious until the patient has rising fevers. Casual contact with someone with no or low-grade fever is very unlikely to result in infection. Breakouts in Africa date back many decades and there is considerable literature on the disease. Conclusion Your AMA delegates are glad to hear from you, hear your concerns, and get your feedback. AMA is your voice nationally that represents all physicians. SAN DI EGO PHYSICIAN.org 11

DUAL-ELIGIBLES

Cal MediCon

12 decem b er 2014

his year, Cal MediConnect (CMC) hit many practices like a thunderclap, confusing patients and office staff, disrupting continuity of care and practice cash flow. This hot-button issue crystallizes the dilemmas of a health system in transition, with tradeoffs between liberty vs. value, individual control vs. system integration. We present a variety of perspectives on this issue, including a piece by Maria Puig-Llano and Dr. Manuel Puig-Llano, highlighting the impact of change on vulnerable Medi-Medi patients (so-called “dual eligibles” or “duals”), who are often frail, unsophisticated, or of limited English. We also present FAQs from CMA, with valuable guidance for impacted practices. As well, we have a piece by Dr. Mario Molina and Richard Chambers of Molina Healthcare, outlining the potential advantages of the new system. The 2012 California state budget mandated a “pilot project” placing nearly one half million duals into HMOs across eight counties, including San Diego. State pressures for this program are primarily economic, but Mr. Chambers and Dr. Molina make the quality and value case that integrated care teams will better meld social service and medical care, cutting hospitalizations and SNF placements, keeping fragile patients at home longer. On the other side, despite 15 years of planning, implementation was opaque and seemingly abrupt, leaving patients, family,

and medical providers uncertain re: insurance status or procedures. The “opt out” forms gave no clue that opting out was even a possibility, and the “passive” enrollment really meant that patients were actively enrolled unless they actively opted out. CMA provides FAQs to help with these issues. Primary care offices that sign with the CMC products hopefully will experience increased value and revenues, but many specialists will experience a loss of control, loss of patients and revenue. Will the promises of better care coordination bear fruit? Coordination will have to morph into something more sophisticated and pro-active than simple denial of care. As your Medical Society, we provide the common ground where all physicians can meet, from solo docs like me to members of the largest multispecialty groups. And, collectively, we stand for true quality and value, not simply more paperwork and denials. Hence the SDCMS vision: “Physicians UNITED for a healthy San Diego.” Medicine is subject to the same economic and social pressures that closed momand-pop bookstores in favor of Amazon, Thriftbooks, and Costco. But on my way to visit family, I found irreplaceable Christmas presents in our airport Warwick´s and an African-American bookstore at Atlanta’s Hartsfield-Jackson. Solo and small-group docs will best survive in this economy by reinventing ourselves and offering the most personal, individualized service to wow Yelp and Healthgrades, while considering niche medical markets with special needs or interests. And all physicians should work together to push the insurers for better coordination of care, and less paperwork for providers, to achieve genuine value for our patients.

As your Medical Society, we provide the common ground where all physicians can meet, from solo docs like me to members of the largest multispecialty groups. And, collectively, we stand for true quality and value, not simply more paperwork and denials. Hence the SDCMS vision: “Physicians UNITED for a healthy San Diego.”

Introduction

nnect

by James Santiago Grisolía, MD, Editor, San Diego Physician

SAN DI EGO PHYSICIAN.org 13

DUAL-ELIGIBLES

Cal MediConnect Physician FAQ What You Need to Know About Keeping Your Patients and Billing for the DualEligible Population by the California Medical Association

14 decem b er 2014

n an effort to save money and better coordinate care for the state’s low-income seniors and persons with disabilities, the 2012 California state budget authorized a three-year demonstration project, the Coordinated Care Initiative (CCI). The Centers for Medicare and Medicaid Services (CMS) approved the memorandum of understanding (MOU) between the State of California and CMS on March 27, 2013. CCI contains two main components: 1. Cal MediConnect, which transitions individuals who are eligible for both Medicare and Medi-Cal (dual-eligibles) away from fee-for-service and into managed care, and 2. integration of long-term supports and services into managed care. The Cal MediConnect program transitions dual-eligibles into managed care and allows them to receive medical, behavioral, long-term supports and services, and homeand-community-based services coordinated through a single health plan.

Cal MediConnect was approved in eight counties: Alameda, Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Mateo, and Santa Clara. No more than 456,000 individuals will be allowed to enroll into Cal MediConnect. Los Angeles’ enrollment will be capped at 200,000.

QUESTION 1: When will the Cal MediConnect demonstration begin? The demonstration project start date varies by county. Some counties began with a voluntary enrollment period prior to the start of passive enrollment. [“Passive” enrollment means that if a patient does not proactively select a health plan, he or she will be “passively” enrolled into a plan selected by the California Department of Health Care Services (DHCS).] Once the passive enrollment period begins, dual-eligible individuals in all counties except San Mateo will be automatically enrolled over a 12-month period based on

birth month. (San Mateo had a hard start date of April 1, 2014, rather than a 12-month rollout.) Notification will be made to participants by birth month at the 90-, 60-, and 30-day periods prior to “passive” enrollment. Patients who do not select a health plan after all three notices will be “passively enrolled” into a plan selected by DHCS. For a list of the start dates by county and plan, see CMA’s “Duals Passive Enrollment Timeline” at www.cmanet.org/duals.

QUESTION 2: Will dual-eligibles be required to enroll into a Cal MediConnect plan? Dual-eligible patients in the eight affected counties have the option of opting out of a Medicare managed care plan and staying in fee-for-service Medicare, but there is no ability to opt out of enrollment in a MediCal managed care plan. Participation in a Medi-Cal managed care Cal MediConnect plan is required in order to receive all MediCal health benefits, including long-term services and supports. Beneficiaries will be sent a unique “Health Plan Choice Form,” found in the middle of the Plan Choice booklet. The choice form will give beneficiaries the opportunity to opt in or out of the Cal MediConnect program. Patients who choose to opt out of the demonstration and remain with fee-for-service Medicare can do so at any time and their feefor-service coverage will be effective in the following month. Those who wish to opt out or switch to another plan can contact Health Care Options at (844) 580-7272.

QUESTION 3: Are there any dualeligible individuals who are excluded from Cal MediConnect? Yes. Certain dual-eligible populations will be excluded from Cal MediConnect, including but not limited to: • individuals under age 21, • individuals with other private or public health insurance, • individuals receiving services through a regional center, state developmental center, or intermediate care facility for the developmentally disabled, • most individuals with a share of cost, • individuals residing in a veterans home, • individuals in the following rural zip codes: °° San Bernardino: 92242, 92267, 92280, 92323, 92332, 92363, 92364, 92366, 93592, and 93558. °° Los Angeles: 90704 °° Riverside: 92225, 92226, 92239 • individuals with a diagnosis of endstate renal disease at the time of enroll-

ment, except in San Mateo and Orange counties. For a complete list of the Cal MediConnect exclusions, visit the CalDuals website at www.calduals.org/wp-content/uploads/2012/08/CCI-Participating-Populations_November2013.pdf.

QUESTION 4: How can my patients opt out of Cal MediConnect? Federal guidelines require that individuals be allowed to opt out of passive enrollment verbally, as well as in writing. Beneficiaries can opt out by doing the following: 1. Call 1-800 Medicare. 2. Call Health Care Options at (844) 5807272. 3. Fill out the state’s “Health Care Choice Form,” which provides two options: a. Beneficiary can enroll in a combination Cal MediConnect plan (Medicare and Medi-Cal benefits from the same plan); b. Beneficiary can elect to keep original fee-for-service Medicare and enroll only in a Medi-Cal managed care plan for their Medi-Cal benefits. Patients should receive their choice form within the Plan Choice booklet shortly after receiving the 60-day notice. CMA has created sample letters for physicians to provide to patients on their options with the Cal MediConnect program, including information on whether the physician participates with any of the Cal MediConnect plans that can be customized by the practice, available at www.cmanet.org/ issues-and-advocacy/cmas-top-issues/calmediconnect.

QUESTION 5: Will I be able to keep my patients? Yes, there are a number of scenarios in which you will be able to keep your patients, even if you do not contract with their Medi-Cal managed care plan. Physicians with Medicare fee-for-service patients do not need to be contracted with Medi-Cal managed care plans to continue to see their dual-eligible patients. However, these patients will need to opt out of Cal MediConnect to continue receiving services under original fee-for-service Medicare. Again, if a patient opts out of Cal MediConnect, they will still be required to join Medi-Cal Managed Care plan in order to receive their Medi-Cal health benefits. Patients who don’t opt out and are enrolled in a Cal MediConnect plan will generally need to receive their care from physicians who contract with their Cal MediConnect plan. For more information on participating with a Cal MediConnect plan,

visit www.calduals.org/wp-content/uploads/2014/09/PhysToolkit_Contractingwith-Cal-MediConnect-Plans_09.17.14. pdf. Finally, even if a patient is enrolled in a Cal MediConnect plan with which the physician does not contract, the patient has the option to opt out or change plans at any time. Decisions to opt out are effective the next month.

QUESTION 6: If my patient selects a plan in which I am not contracted, can I continue to see the patient? If your patient elects a Cal MediConnect plan for their Medicare and Medi-Cal benefits with which you are not contracted, you may be able to continue to see the patient for a limited period of time, under the continuity of care rules. Under the Cal MediConnect continuity of care rules, once patients are enrolled in a Medi-Cal managed care plan, they can continue to see a physician with whom they have an existing relationship, even if the physician is not contracted with the plan, for up to six months for Medicare and up to 12 months for Medi-Cal services if certain criteria are met: • Medicare Services: °° Patient demonstrates they have seen the out-of-network physician at least twice in the previous 12 months °° Physician must be willing to accept payment from the plan at Medicare rates °° The plan would not have otherwise excluded that physician from its network due to quality or other concerns • Medi-Cal Services (1): °° Patient demonstrates they have seen the out-of-network physician at least twice in the previous 12 months °° Physician must be willing to accept payment from the plan based on the plan’s reimbursement rate or MediCal rate (whichever is higher) °° The plan would not have otherwise excluded that physician from its network due to quality or other concerns A preexisting relationship with the outof-network physician may be established by the plan using Medicare data or by documentation from the provider or enrollee.

QUESTION 7: Can I request continuity of care on behalf of my patients? DHCS implemented new continuity of care rules in September that make it easier for patients to continue receiving needed care from out-of-network physicians without interruption. The new rules state: SAN DI EGO PHYSICIAN.org 15

1. Providers can request continuity of care for their patients under the duals demonstration project. Previously, only the patient could initiate such a request. This new rule will help beneficiaries who have difficulty navigating the healthcare system so they can maintain their provider for up to 12 months. 2. Continuity of care requests can be made via telephone, and plans will be prohibited from requiring beneficiaries to submit a request through a paper form. 3. Continuity of care requests must be processed within three days if there is a risk of harm to the beneficiary. Urgent requests will be processed within 15 days, and all other requests are to be processed within 30 days. 4. Providers or the beneficiary can now request continuity of care after the service has been delivered — ensuring payment for treatment. To qualify, the request must be received within 20 business days of the first service following the beneficiaries’ enrollment in Cal MediConnect. Once a beneficiary is approved for continuity of care, providers must work with the health plans to ensure compliance with the plan’s utilization and management policies. These changes in continuity of care do not apply to providers of DME, transportation or ancillary services.

QUESTION 8: Who do I bill and what are the reimbursement rates? For patients who opt to keep their fee-forservice Medicare coverage, physicians will continue to bill fee-for-service Medicare as they have in the past. There is no change in what fee-for-service Medicare will pay, which is generally 80% of the Medicare allowed amount. It should be noted that no change has been made to the rules governing the billing of the 20% Medicare copay for dual-eligible patients. It continues to be unlawful to bill dual-eligible patients. In limited circumstances, Medi-Cal may cover Medicare coinsurance and copays. Such “crossover” claims for Medicare coinsurance and copays should be sent to the patient’s Medi-Cal plan (see Payment for Medicare Physician Services Under the CCI fact sheet for more information). Patients who do not opt out and are enrolled in a Cal MediConnect plan for their Medicare and Medi-Cal benefits generally need to receive their care from physicians who participate in the Cal MediConnect plan network. The exception to this rule is if continuity of care is approved (see previous question for a discussion of the Cal MediConnect continuity of care rules). Physicians who participate in the patient’s Cal MediConnect plan will seek pay16 decem b er 2014

County (2)

ALAMEDA

Cal MediConnect Plan Name

Medi-Cal Managed Care Plan Name

Alameda Alliance Complete Care

Alameda Alliance

Anthem Blue Cross

Anthem Blue Cross Kaiser Permanente

Health Net Cal MediConnect

Health Net

Molina Dual Options

Molina Health Plan

L.A. Care

CareMore

Anthem Blue Cross

Care 1 Cal Mediconnect Plan

Care 1st Health Plan

LOS ANGELES st

Kaiser Permanente IEHP Dual Choice RIVERSIDE & SAN BERNARDINO

Inland Empire Health Plan

Molina Dual Options

Molina Health Plan Kaiser Permanente Health Net

Care 1 Cal MediConnect Plan

Care 1st Health Plan

Health Net Cal MediConnect

Community Health Group

CommuniCare Advantage

Health Net

SAN DIEGO

Molina Dual Options

Molina Health Plan Kaiser Permanente

SANTA CLARA

Santa Clara Family Health Plan Cal MediConnect

Santa Clara Family Health Plan

Anthem Blue Cross

Anthem Blue Cross Kaiser Permanente

ment directly from that managed care plan or whomever the plan delegates to (i.e., IPA or medical group) and will be reimbursed based on the terms of their contracts. For more information on rates and payment rules, please see the CalDuals “Payment for Medicare Physician Services” fact sheet.

QUESTION 9: If my patient opts out and remains with the fee-for-service Medicare, will the crossover claim automatically forward to the MediCal managed care plan? Probably not. According to the CalDuals website, “Most Medi-Cal plans are not yet participating in this automated process.” For a list of which plans receive crossover claims automatically and for more information, see the CalDuals fact sheet, “How Physician Crossover Claims are Processed for Beneficiaries in Medi-Cal Managed Care Plans.” If the patient’s plan is not yet participating in the automated crossover claim process, the practice will need to submit a claim to the crossover plan in order to be paid any amount due.

QUESTION 10: If my patient opts out and remains with fee-for-service Medicare, do I need to be contracted with the patient’s Medi-Cal managed care plan to receive deductible and coinsurance payments? No. According to the CalDuals website, physicians do not need to be part of the Medi-Cal plan’s network to have crossover claims processed and paid. For more information, see the CalDuals fact sheet “Providing Fee-for-Service Medicare Services to Dual-Eligibles in Medi-Cal Plans.”

QUESTION 11: If my patient opts out and remains with fee-for-service Medicare, can the Medi-Cal managed care plan require an authorization? No. The CalDuals website confirms that if a patient opts out and remains with fee-for-service Medicare, the Medi-Cal managed care plan cannot require authorizations for physician services as the secondary payer (see the CalDuals “Overview of the Coordinated Care Initiative” fact sheet).

QUESTION 14: Where can patients and physicians report continuity of care or other problems? Patients who have concerns with continuity of care can call the number on the back of their ID cards to talk with the Medi-Cal managed care plan. Additionally, patients with questions or concerns about continuity of care to their Medi-Cal managed care plan can also contact the Dual Demonstration Ombudsman by phone at (855) 501-3077. While the Ombudsman’s Office was created to assist patients, CMA has confirmed that physicians can report concerns to the ombudsman as well. Patients also have the ability to appeal a plan’s continuity of care decision by contacting DHCS for a State Fair Hearing or the DMHC for an Independent Medical Review. If you cannot find relief from the plan, the following are also options: • HICAP-Elder Law and Advocacy: (858) 565-8772 • Office of the Patient Advocate: (866) 466-8900 References: 1. This policy does not apply to IHSS providers, durable medical equipment, medical supplies, transportation, or other ancillary services. 2. Orange County health plan involvement is currently under review and beneficiaries are not scheduled to begin receiving materials until July 2015. San Mateo implemented passive enrollment for all dual-eligibles into Health Plan of San Mateo Care Advantage Cal MediConnect.

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QUESTION 13: What options are available for Cal MediConnect patients who are having trouble finding in-network providers and/ or facilities to provide care? Patients who are having trouble accessing an in-network physician or facility are encouraged to contact DMHC’s Help Center at (888) 466-2219.

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QUESTION 12: How do I identify a Cal MediConnect patient versus regular Medi-Cal managed care patient? Prior to delivering services, you or your staff will determine eligibility in the AEVS system. The AEVS eligibility information will contain the name of the patient’s plan. The Cal MediConnect plans will each have a unique name as compared with the standard Medi-Cal managed care plans. Practices are encouraged to familiarize themselves with the Cal MediConnect plans in their county (see table at left).

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SAN DI EGO PHYSICIAN.org 17

DUAL-ELIGIBLES

Cal MediConnect The Duals’ Medical Justice Dilemma — An Ophthalmology Office’s Experience in the South Bay by Manuel Puig-Llano, MD, FACS

18 decem b er 2014

he elderly very poor are known in legal and political sectors as “dual-eligibles” or “duals” because they qualify for Medicare due to age or infirmity, and Medicaid due to poverty — thus the more frequent designation of “Medi-Medi’s” (M-M) in the medical community.

The duals, in our experience running a small ophthalmology practice in the South Bay, were the uninsured working poor for their productive years and had little or no access to healthcare and preventive services. The duals comprise 21% of the Medicare patient population, but 36% of the total Medicare costs, and 15% of the Medicaid population, accounting for 39% of the total Medicaid costs. In no field is the price of ignoring prevention higher than in healthcare. The diabetic,

who is diagnosed late in the disease process, can easily incur a million dollars in expenses over 10 years: from dialysis to retinal surgery to amputation. The cost in human suffering is infinitely higher. Whereas the same patient, with preventive services, including physician visits, podiatry visits, medications, laboratory studies, diabetic education, and nutrition counseling, would only cost $50,000 over the same timeframe. In our office, elderly duals are immigrants who have a low education level, speak little or no English, may be illiterate in their native language, and tend to be suggestible and fearful of government. No group better exemplifies the meaning of the word “disenfranchised” and is less able to defend themselves. Due to the high cost of caring for dualeligibles, they have been the focus of government scrutiny for more than 20 years. Politicians want to control or decrease expenditures, and the easiest way is to cap costs by assigning the duals to a Medicare HMO. The health insurance companies want the dual patients, who are capitated at $1,000 to $1,500 per month, because the duals will not be demanding and have difficulty filing grievances. In 2007, CalOptima, Orange County’s nonprofit Medi-Cal managed healthcare plan, decided to start a Medicare HMO and oblige all duals to participate. Satinder Swaroop, the Fountain Valley cardiologist and then president of the Orange County Medical Association, joined forces with CMA and designed an “opt out” form that was approved by the Department of Health Care Services (DHCS) and CalOptima. The form was placed prominently on the OCMA and CMA websites. By the start date, 80% of the Orange County duals had “opted out.” A small section of the Affordable Care Act of 2010 granted financing for a “Federal Coordinated Health Care Office”(FCHCO) that would be “Supporting State efforts to coordinate and align acute care and long-term care services for dual-eligible individuals.” It was decided that FCHCO would fund “duals demonstration projects.” California had already created a Coordinated Care Initiative (CCI), which, with FCHCO grants, morphed into Cal MediConnect (CMC). Judith Solomon at the Center on Budget and Policy Priorities wrote a 2012 article, “Moving Dual Eligibles Into Mandatory Managed Care and Capping Their Federal Funding Would Risk Significant Harm to Poor Seniors and People With Disabilities.” Judith says, “Some past efforts to change the way care is delivered for this population have resulted in harm to vulnerable low-income beneficiaries.”

California’s Department of Health Care Services (DHCS) requested that 468,000 patients, half of the state’s duals, enter Cal MediConnect (CMC) by May of 2015. Thirtyseven organizations, including the California Medical Association (CMA) and the National Senior Citizens’ Law Center, requested that a smaller pilot be performed.

There have been many small-scale dual pilot programs over the years. The Kaiser Family Foundation Center on Medicare Policy published “Best Bets for Reducing Medicare Costs for Dual Eligible Beneficiaries: Assessing the Evidence” in 2012. This extensive report suggests that successful duals’ plans have to be customized for each patient population. The Program for All-Inclusive Care for the Elderly (PACE), the Minnesota Senior Health Options, the Wisconsin Partnership Program, and Evercare were cited for success in reducing hospitalizations, but the capitated rates were set higher than traditional feefor-service costs. Only two plans, the Commonwealth Care Alliance’s Disability Care Program and the SCAN Health Plan, reduced hospitalizations and spending, but the number of participants limited the applicability. California’s Department of Health Care Services (DHCS) requested that 468,000 patients, half of the state’s duals, enter Cal MediConnect (CMC) by May of 2015. Thirtyseven organizations, including the California Medical Association (CMA) and the National Senior Citizens’ Law Center, requested that a smaller pilot be performed. CMC is a voluntary program. However, duals who do not properly fill out the Health Plan Choice Form (HPCF), either to choose a plan with all their established physicians or to opt out of CMC and keep their regular Medicare, will be passively enrolled in CMC. The HPCF is very confusing. Many duals have difficulty filling out this form. SAN DI EGO PHYSICIAN.org 19

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In addition, the duals are informed about CMC via the postal system. In January 2014, Kathryn Kietzman, from the UCLA Center for Health Policy Research, wrote “Disconnected? Challenges of Communicating Cal MediConnect to Low-Income Older Californians,” which posits that the elderly duals should be informed about CMC by an unbiased, in-person “navigator” such as those used by the ACA because most duals would not be able to read, let alone understand, the mailed materials. The other players in this dual perfect storm are the health insurance companies and their independent brokers. A dual-eligible in CMC is worth from $1,000 to $1,500 per month to a Medicare managed care plan. To entice the PCP, the plans offer high capitated rates of $120 per month, twice the national capitated rates for non-dual Medicare Part C plans. According to the March 27, 2013, memorandum of understanding between the Centers for Medicare and Medicaid Services (CMS) and the California Department of Health Care Services (DHCS), CMC health insurance plans must use the Medicare database to assign “passively” enrolled duals to their established primary care physician. This has not happened in the South Bay area of San Diego. In our view, the result is that the traditional Medi-Medi primary care physician (PCP) now has fewer patients and does not know how to change the patient’s status so he/she receives the Cal MediConnect capitated fee. We have seen that health insurance brokers offer to make sure that the dual is correctly assigned if the primary care physician provides the broker with a list of his/her patients with addresses and phone numbers. Now the physician’s dual patients are in a Medicare Advantage plan, not Cal MediConnect. We have seen another layer of confusion when the specialists, again with helpful health insurance brokers, sign the duals into yet another plan in which the PCP may not participate. One of our patients has been in three plans since May 1! We’ve seen multiple examples of unethical — perhaps illegal — conduct on the part of brokers. The duals at a South Bay Adult Day Care Center, most of whom have Alzheimer’s disease and are legally incompetent, were signed up by a broker into a non-CMC Medicare HMO. We referred the daughter of Mrs. R., a patient at SBADCC, to the CMC ombudsman. A patient from the Regional Center, D.K., who is exempt from CMC, as well as her companions in a board and care facility, were signed up into Medicare HMOs. Endstage renal disease patients, exempt from CMC, have unknowingly been signed up by health insurance brokers at their dialysis center. The only way to describe the situation is pandemonium. The brokers know that

The duals are again at risk of ending up with no access to healthcare or limited healthcare due to the confusion. As you might imagine, specialists are reluctant to care for duals because payment is so uncertain.

their ability to sign up duals, at $300 to $500 per person, ends in December, so there is a “feeding frenzy.” The duals are again at risk of ending up with no access to healthcare or limited healthcare due to the confusion. As you might imagine, specialists are reluctant to care for duals because payment is so uncertain. Due to the lack of response from DHCS, the Los Angeles County Medical Association, a group of not-for-profit day care centers, and several other litigants filed an injunction to stop CMC, citing the defective enrollment procedure, the HPCF, inadequacy of the specialist network, and the inappropriate role of the insurance agents. The Sacramento Superior Court denied the injunction on July 1 and August 7, but an appeal is scheduled for later this year. Another perspective may be found in an article written by Craig Kliger, MD, the executive director of the California Academy of Eye Physicians and Surgeons (CAEPS), on Sept. 17, 2014, for the RealClearPolicy blog: “California’s Unwitting Health Care Guinea Pigs” (www.realclearpolicy.com/ blog/2014/09/17/californias_unwitting_ health_care_guinea_pigs_1078.html). It is time for physicians to stop being the pawns of the healthcare industry and take a leadership role in the future of a real American healthcare system, where the patients and their providers are the principal focus, not the profits of corporations. Politicians, economists, and insurance company CEOs are creating programs like Cal MediConnect without understanding the complexity of caring for specific groups of patients. Physicians can start by becoming more aware of injustice in medicine and actively champion just causes by educating and influencing legislators. Remember, if the duals’ rights are taken away today, what could happen tomorrow?

Dr. Puig-Llano, SDCMS-CMA member for 31 years, is board-certified in ophthalmology.

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DUAL-ELIGIBLES

Cal MediConnect was designed to provide care coordination for dualeligible beneficiaries as one organized delivery system to help them access medical and behavioral care as well as community resources.

Cal MediConnect Working Together to Improve Members’ Quality of Life BY J. MARIO MOLINA, MD, AND RICHARD CHAMBERS

hange can be difficult, but it can also be necessary. Sometimes change can lead to a better outcome. The Cal MediConnect (CMC) program is an example of just that. CMC was designed to improve care coordination for dual-eligible beneficiaries — those who qualify for both Medicaid and Medicare. Members are provided with medical and behavioral health, long-term institutional, and home- and communitybased services all through one organized delivery system. In addition, CMC helps members live independently by receiving appropriate care in their homes and communities rather than in institutional care. In order to operationalize the goals of CMC, companies like Molina have developed integrated care teams. These teams coordinate effective communication among beneficiaries, their family members, and other caregivers to determine together the 22 decem b er 2014

right approach to care in the right setting at the right time. A tool used to help the integrated care teams work with members is the health risk assessments (HRA) that are conducted with each member. The HRA identifies the appropriate resources (social services, behavioral health, transportation, etc.) needed to manage each member’s care. For lack of a better term, the HRA is the plan used by health companies to coordinate all the care the members need. Years to Get Here The healthcare system is difficult to navigate for even the most educated. But for those with complex conditions, such as dual-eligible members, the process can be even more challenging. This is made even more difficult when the member needs to access services through two different programs that are funded by different government agencies. This fragmented and disjointed

system results in confusion, disruption in care, inappropriate utilization, and unnecessary costs. It was for these reasons that state and federal agencies initiated CMC. But CMC wasn’t born overnight. For more than 15 years, San Diego County’s Office of Aging and Independent Services pushed to launch a duals pilot program. Stakeholders including health plans, physicians, advocates, and county leaders have been meeting regularly for years to promote integrated programs and, over those years, made many improvements in coordination and communication between all of the stakeholders within San Diego. When CMC became a reality, this group was ready to build on those efforts. The Coordinated Care Initiative (CCI) Advisory Committee was established out of this stakeholder group to gather recommendations on CMC operations, benefits, access to services, adequacy of grievance processes, and consumer protections. Much of the information shared at the committee meetings was weaved into the CMC program, and these meetings continue to provide a forum to solve problems and share best practices. Not only has California been pursuing different approaches to managing the dual population, but other states have seen success by coordinating care for their dual-eligible populations. In 2004, its first year of operation, Massachusetts’ Senior Care Options (SCO) program was able to keep individuals in the community by reducing nursing home utilization, avoiding unnecessary hospitalization, and reducing readmission rates. Care management played and continues to play a big part in reducing unnecessary care and keeping members healthy. SCO plans are required to provide a primary care locus, individualized care plans, centralized enrollee records, and a primary care team for those with complex care needs.

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Strong Consumer Protections To ensure strong consumer protections are in place, the CMC program is closely monitored by both state and federal agencies. In order to participate in the CMC program, health plans are required to provide appropriate and comprehensive care to their members. This means that health plans cannot take away any covered benefits that are required by the state and federal agencies. In addition, health plans do not have the option of exiting a market during their three-year contract. This ensures continuity of care for members. Finally, dual-eligible beneficiaries cannot be “tricked” into participating in CMC by agents who go door to door to enroll members. Health plans are prohibited from sending brokers to potential members’ homes. Instead, the CMC program requires that dual-eligible beneficiaries proactively request more information. And, to further protect beneficiaries, health plans must refer these potential members to the CMC program to enroll. Finally, for physicians who are wary of a varied payment structure under CMC, it’s important to know that the overwhelming majority of physicians will get paid at least their current fee-for-service rate.

Coordinated Care Through a Voluntary Program Cal MediConnect truly is a voluntary program. Yes, members are passively enrolled. This means that the state will automatically assign eligible individuals into a participating health plan. However, if an individual does not want to be enrolled, the individual merely notifies the state. The main idea here is that the beneficiary has the right and opportunity to choose not to join a coordinated health plan and keep his/her Medicare benefits separately. Also, beneficiaries are able to change health plans at any time. This is different from other programs where there are lock-in periods in which members cannot make any changes. Some fear that the CMC program will leave dual-eligible beneficiaries without any healthcare at all. However, there is no circumstance or scenario where beneficiaries cannot or would not receive their entitled healthcare benefits. The intent of the program is not to deter members from gaining coverage, but rather to help better coordinate their care in an effective and appropriate manner. With CMC, members now have more choices than before, including increased access to benefits like dental,

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transportation, and in-home supportive services by choosing a coordinated care plan. Working Together to Change How we Care for Our Most Vulnerable Citizens Change doesn’t come easily or alone. Neither physicians nor health plans nor community agencies can take care of the sickest and neediest members of our community alone. We may disagree about how we got here. We may still want to lobby for change. And we may have differing opinions when it comes to providing care. But we can all agree that better care coordination will improve health outcomes and drive down the high costs of medical care. The Cal MediConnect program has already begun, so now is the time to work together to help these beneficiaries benefit from the change. Dr. Molina, SDCMS-CMA member for 23 years, is president and CEO of Molina Healthcare. Mr. Chambers is president of Molina Healthcare of California. If you are a physician in the area, please feel free to contact Molina Healthcare at (858) 614-1580 should you have any questions or if you would like to partner with us.

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classifieds PHYSICIAN POSITION WANTED LOOKING FOR PART-TIME FAMILY PRACTICE POSITION: D. (Doyle) Eugene Johnson, family physician with a wealth of experience, looking for part-time position, preferably in North County. Have been a full-time practicing certified family physician for 50+ years and would like to continue seeing patients part-time. Had one of the largest solo family practices in San Diego for 25+ years. Excellent references! Continually certified in family practice, ACLS, BLS, regularly use computerized records. Will consider locum tenens. Please email d.eugenejohnsonMD@gmail.com with particulars. [301] PHYSICIAN POSITIONS AVAILABLE FAMILY MEDICINE and GENERAL INTERNAL MEDICINE PHYSICIAN OPPORTUNITIES: Kaiser Permanente is seeking physicians who are interested in positions ranging from per diem to full-time to join our team. We have opportunities throughout the County of San Diego, so, if interested, please submit your CV to david.h.horton@ kp.org or call (619) 528-7991. [304] PSYCHIATRISTS NEEDED: Part-time or full-time psychiatrists needed to work at San Diego County jails. Work as an independent contractor with very competitive pay. Contact Steve at steve@cpmedgroup.com or at (619) 885-3907. [302] SEEKING FAMILY MEDICINE AND INTERNAL MEDICINE PHYSICIANS: Sharp ReesStealy Medical Group is seeking full-time or half-time (job share) BC/BE family medicine and internal medicine physicians to join our staff. We offer a first year competitive compensation guarantee and an excellent benefits package. Please send CV to SRSMG, Physician Services, 300 Fir Street, San Diego, CA 92101. Fax: (619) 233-4730. Email: lori.miller@sharp.com. [299] SUPERB INTERNAL MEDICINE OPPORTUNITY: Internist (BC, BE) coastal North County available July 2015. Single specialty seven physician internal medicine group, well established and respected. With 30 years in the community, outpatient care only, minimal call, salary guarantee, income well over median range for internal medicine. Send CV to pkljol51@aol.com or call (760) 846-0464. [297] GENERAL, FAMILY, OR INTERNAL MEDICINE PHYSICIAN NEEDED IMMEDIATELY: This opening is an independent contractor position. We are a house call practice located in beautiful North San Diego County. We will also provide paid training on our EMR. 8–5 Monday–Friday, 10–12 patients per day and on-call pager 1 week every 3 weeks, telephone call only. No rounds or hospital duties. If interested please submit your CV to julie@sandiegomobiledoctor.com. We are very anxious to fill this position and we look forward to hearing from YOU! No agencies please. [286] RECRUITING FOR A FULL-TIME FP OR IM PHYSICIAN: San Diego Family Care is recruit-

ing for a full time family practice or internal medicine physician interested in working in a federally qualified community health center (FQHC) in the Linda Vista area of San Diego. The position requires at least a 32-hour/week commitment. Must be flexible and team oriented. May be required to work an evening or Saturday on occasion or, if preferred, could be part of regular scheduled rotation. Salary commensurate with experience and great benefits. Requirements include current California and DEA licenses / CPR certification, plus good standing with respective board / association. Candidates may be eligible to apply for federal loan repayment. If interested, please send CV to awalton@lvhcc.com. [284] PHYSICIANS WANTED FOR OUR GROWING ORGANIZATION: Full, part-time, or per-diem flexible schedules available at locations throughout San Diego. A national leader among community health centers, Family Health Centers of San Diego is a private, nonprofit community clinic organization that is an integral part of San Diego’s healthcare safety net. Since 1970, our mission has been to provide caring, affordable, high-quality healthcare and supportive services to everyone, with a special commitment to uninsured, low-income, and medically underserved persons. Every member of our team plays an important role in improving the health of our patients and community. We offer an excellent, comprehensive benefits package that includes malpractice coverage, NHSC loan repay eligibility, and much, much more! For more information, please call Anna Jameson at (619) 906-4591 or email ajameson@fhcsd. org. If you would like to fax your CV, fax it to (619) 876-4426. For more information and to apply, visit our website and apply online at www.fhcsd.org [046] PRIVATE PRACTICE, PART-TIME IM/FP OPPORTUNITY: Unusual and exceptionally attractive private practice, primary care opportunity in beautiful North San Diego County. Well-established, collegial, single-specialty internal medicine group with >30 years in the community, exceptional office staff, and very high quality patient care set this far apart from many other situations. Option for 1–2 days/week with flexible scheduling; very attractive opportunity as an add-on to other part-time work. Interested in board-certified IM or FP applicants with EHR experience. Please email CV to portofino3@aol. com or call (619) 248-2324. [263] 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 license and ACLS certification. Please email or fax CV to (619) 569-2590. Visit www.DoctorsExpressSanDiego. com for more information. [229a] PRIMARY CARE JOB OPPORTUNITY: Home Physicians (www.thehousecalldocs.com) is a fastgrowing 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 assis-

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 decem b er 2014

tant provided. Call Chris Hunt, MD, at (619) 9925330 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, 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. 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] PRACTICES FOR SALE DERMATOLOGY SOLO PRACTICE FOR SALE: Mature physician is retiring December 2014 after practicing 36 years in coastal San Diego County on the campus of Scripps Memorial Hospital, Encinitas, California 92024. Professional services provided have been medical dermatology and minor dermatologic surgery. Doctor has limited his patient base to original Medicare and fee for service. New owner could add managed care and cosmetic services if desired. Office space is leased from Scripps Real Estate. Turnkey sale could be arranged. Reply to email class259@hotmail.com or cell phone (760) 666-0571. [275] OFFICE SPACE AVAILABLE MEDICAL FACILITY AVAILABLE FOR SUBLEASE: Seeking physicians in the fields of orthopedic surgery, sports medicine, primary care, rheumatology, and physical medicine and rehab to sublease a 3,101ft2 office in Sorrento Valley. Built in 2013, the facility includes five exam rooms, a treatment room, onsite X-ray machine, large conference room, doctor’s office, nurses’ station, receptionists’ station, large waiting room, break room, two staff work rooms, and a restroom. The office is also adjacent to a DME supplier and physical therapist and is situated directly above an outpatient surgical center. Rates are negotiable with the terms of the lease. For more information, please contact Jeff Craven at jeff@ sdmoiortho.com or at (858) 245-9109. [300] ALISO VIEJO — 5 JOURNEY: Multi Tenant Medical Building with highly successful medical and dental practices. 4,360 sf ground floor. $2.90 PSF NNN. Beautifully designed. Tenant

Improvement Allowance to customize suite is available. For further information please contact Lucia Shamshoian @ 769-931-1134x13 or Shamshoian@coveycommercial.com. [298] AVAILABLE IMMEDIATELY: 14ft x 12ft sunny room in a four-room office suite shared by a physician, several chiropractors, and an acupuncturist. Located upstairs in Cardiff Town Center at the corner of San Elijo Avenue and Birmingham Drive one-half mile off I-5 and across Coast Highway 101 from San Elijo State Beach. Take advantage of Seaside Market, numerous restaurants, a post office, and a public library either onsite or across the street. Call (760) 436-7464. [294] 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. [288] 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) 3200525 and ask for the secretary, Sandy. [127] 3998 VISTA WAY, IN OCEANSIDE: Four medical office spaces approximately 1,300– 2,800SF 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] SPACE AVAILABLE FOR BOARD-CERTIFIED INTERNIST interested in developing an East County practice. Contact Debbie at debbiepmid@yahoo.com or at (619) 287-7991. [283] BANKERS HILL PRIMARY CARE / HEALTHCARE PROFESSIONAL & RESEARCH OFFICE SPACE TO SUBLEASE: 50-year established primary care practice and clinical research office, with currently two internists, have space to sublease to another primary care or primary care / subspecialist, or other independent healthcare professional, to help curb overhead and, if primary care, help with acute overflow patients’ needs. Also can provide opportunity to get into clinical research. Contact Jeff at crf@att.net. [265] DEL MAR / CARMEL VALLEY MEDICAL OFFICE TO SHARE: Available immediately. Class A medical building. 1,000SF. Two treatment / consultation rooms / office reception / photography room / break room. Full or shared occupancy. Unlimited free parking. Call (858) 481-4888 or email mobyrne61@ gmail.com. [252]

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. Fullday or half-day 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, 2,100SF, 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] 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] POWAY / RANCHO BERNARDO — OFFICE FOR SUBLEASE: Spacious, beautiful, newly renovated, 1,467SF 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 1,900SF 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: Two 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 PSYCHIATRIC NURSE PRACTITIONER: Part- or full-time psychiatric nurse practitioner needed to work at San Diego County jails. Work as an independent contractor with very competitive pay. Contact Steve at steve@ cpmedgroup.com or at (619) 885-3907. [303]

SEEKING NURSE PRACTITIONER: Internal medicine, part-time position available. Seeking nurse practitioner with primary care and EHR experience. Private practice located in beautiful North San Diego County, single specialty group, collegial work environment. Please contact (619) 248-2324 or email resume to portofino3@aol.com. [296] PA NEEDED FOR DERMATOLOGY AND COSMETIC SURGERY PRACTICE IN ENCINITAS: Experience in general dermatology a must! Applicant must be knowledgeable in diagnosing and treating common dermatologic conditions, possess excellent interpersonal skills, be a caring and empathetic provider, and possess the highest of ethical standards. Being a team player and having a positive attitude is essential for success! Please send your CV and salary history to dana@doctorlashgari.com. We look forward to hearing from you! [290] 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. [289] NURSE PRACTITIONERS WANTED FOR OUR GROWING ORGANIZATION: See ad #046 under “PHYSICIAN POSITIONS AVAILABLE.” 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 license and ACLS certification. Please email or fax CV to (619) 569-2590. Visit www.DoctorsExpressSanDiego.com for more information. [229b] NURSE PRACTITIONER: Needed for housecall 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. Part-time, flexible days / hours. Competitive compensation. Call (619) 9925330 or email drhunt@thehousecalldocs. com. Visit www.thehousecalldocs.com. [038] NONPHYSICIAN POSITIONS WANTED RECENTLY GRADUATED CERTIFIED MEDICAL ASSISTANT SEEKS PART-TIME POSITION IN NORTH COUNTY SAN DIEGO: Experienced in wound care, plastic surgery, orthopedics, surgical settings. Very knowledgeable, hard-working, dependable, team player, superb patient rapport, willing and eager to learn. Special interests in surgical setting or urgent care. Available afternoons or nights. Excellent references! Contact Carol at (442) 444-0621 or at cameer@juno.com. [293]

SAN DI EGO PHYSICIAN.org 27

Personal & Professional Development

How different could the experience have felt, she wondered, if she were able to accept that something had been lost, but still appreciate what was remaining?

What’s Still Here? by Helane Fronek, MD, FACP, FACPh

Medical training teaches us to become keen observers. We notice things about our patients as soon as we walk in the room: shortness of breath, anxiety, pain. We notice changes since their last visit: weight loss, new bruising, rapid aging. We usually focus on what is different, frequently on what has been lost. Our patients, as well, most acutely feel what has been lost. “Why can’t I run anymore without my knee swelling up?” they ask. “Why can’t I remember things the way I used to?” they lament. Life often feels like a series of losses and attenuations. 28 decem b er 2014

Recently, a caring aesthetician I know shared her sadness that one of her longstanding clients, a brilliant professor, had developed Alzheimer’s disease. The client had become increasingly confused and could no longer remember her. Although they had a pleasant conversation during the woman’s treatment, the aesthetician was distraught over the change in her client’s mind and their relationship. A very insightful medical student provided a different perspective on the experience of loss. As her grandmother developed increasingly severe dementia, the student

also focused only on what was no longer there. Early on, while Grandma remembered who she was, she was frustrated by the repeated questions and inability to remember her answers. Later, although they could still carry on a meaningful conversation, she felt hurt that Grandma could no longer remember who she was. In the latter stages, she was saddened that Grandma was no longer able to converse, although they could still sit and hold hands. In each stage, she focused only on what was gone — and not on what was present. How different could the experience have felt, she wondered, if she were able to accept that something had been lost, but still appreciate what was remaining? As the holidays approach, with the many festivities that frequently leave us feeling overwhelmed, can we decide to look at our life, even momentarily, through the lens of appreciation? Can we view each circumstance realistically, not sugarcoating our difficulties and losses, but acknowledge and focus on the goodness that still exists in our lives? As the wise saying goes, “Happiness is not having what you want, but wanting what you have.” Psychology Today cites studies that show that when we deliberately cultivate gratitude, we increase our well-being, levels of energy, optimism, and empathy. What a gift for ourselves, and for all those we come in contact with! As we celebrate the holiday season and begin a new year, let’s consciously notice not just what has been lost but what we still appreciate and cherish in our lives. It might be the most important skill of observation we can develop. 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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