January 2017 by San Diego Physician

January 2017 official publication of SDCMS

Congress’s Plan to Repeal and Replace the ACA … Page 20

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January 2017

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Contents

Volume 104, Number 1

EDITOR: James Santiago Grisolía, MD MANAGING EDITOR: Kyle Lewis EDITORIAL BOARD: James Santiago Grisolía, MD • Mihir Parikh, MD • Robert E. Peters, MD, PhD • J. Steven Poceta, MD MARKETING & PRODUCTION MANAGER: Jennifer Rohr SALES DIRECTOR: Dari Pebdani ART DIRECTOR: Lisa Williams COPY EDITOR: Adam Elder OFFICERS President: Mihir Y. Parikh, MD President-elect: Mark W. Sornson, MD Secretary: David E. J. Bazzo, MD Treasurer: James H. Schultz Jr., MD Immediate Past President: William T-C Tseng, MD, MPH (CMA Trustee) GEOGRAPHIC and GEOGRAPHIC ALTERNATE DIRECTORS East County: Susan Kaweski, MD (Alt) • Jay P. Mongiardo, MD • Venu Prabaker, MD • Kosala Samarasinghe, MD Hillcrest: Gregory M. Balourdas, MD • Kyle P. Edmonds, MD (Alt) • Thomas C. Lian, MD Kearny Mesa: Sergio R. Flores, MD (Board Rep) • John G. Lane, MD • Anthony E. Magit, MD (Alt) • Eileen R. Quintela, MD (Alt) La Jolla: Geva E. Mannor, MD, MPH • Marc M. Sedwitz, MD • Wayne C. Sun, MD (Alt) North County: Neelima V. Chu, MD (Alt) • Michael A. Lobatz, MD • Patrick A. Tellez, MD South Bay: Maria Carriedo, MD (Alt) • Reno D. Tiangco, MD

feature

Congressional Plan to Repeal and Replace the ACA Is Not Clear

BY ELIZABETH MCNEIL

departments 4

Briefly Noted: Calendar • History Thumbnails • Member Benefits • Office Manager Advocacy • Physician Socials • And More …

Telemedicine for Everyone

BY CHRISTOPHER P. SCHMIDT, MD

18 CMA’s Unseen Legislative Battles: AB 533 vs. AB 72 BY PETER BRETAN, MD, FACS 21

CMA Practice Tip of the Month

BY HELANE FRONEK, MD, FACP, FACPh

ew Health Laws for 2017: N Significant New California Laws of Interest to Physicians

Y THE CALIFORNIA MEDICAL B ASSOCIATION

Make 2017 a Year of Satisfaction and Joy!

Planned Parenthood: Celebrating 100 Years of Empowering Women, Building Healthy Communities, and Advancing Reproductive Freedom and Healthcare as a Basic Human Right

BY PHILIP J. DIAMOND, MD

Watch for the Signs: Screen All Patients for Suicidal Thoughts

BY ROBIN DIAMOND, MSN, JD, RN

January 2017

AT-LARGE and AT-LARGE ALTERNATE DIRECTORS Lase A. Ajayi, MD • Karrar H. Ali, DO, MPH • Steven L-W Chen, MD, MBA (Alt) • Stephen R. Hayden, MD • Vimal I. Nanavati, MD (Alt) • Alexexandra E. Page, MD • Robert E. Peters, MD, PhD (Alt) • Carl A. Powell, DO (Alt) • Peter O. Raudaskoski, MD • Albert Ray, MD (Alt) • Thomas J. Savides, MD • Karl E. Steinberg, MD (Alt) • Erin L. Whitaker, MD (Alt) • Marcella (Marci) M. Wilson, MD (Alt) • Holly B. Yang, MD (Board Rep) • Nicholas J. Yphantides, MD OTHER VOTING MEMBERS Communications Chair: J. Steven Poceta, MD Delegation Chair: Robert E. Peters, MD, PhD Young Physician Director: Edwin S. Chen, MD Resident Physician Director: Michael C. Hann, MD Retired Physician Director: Rosemarie M. Johnson, MD Medical Student Director: David Li OTHER NONVOTING MEMBERS Young Physician Alternate Director: Heidi M. Meyer, MD Resident Physician Alternate Director: Zachary T. Berman, MD Retired Physician Alternate Director: Mitsuo Tomita, MD SDCMS Foundation President: Albert Ray, MD (Delegation Vice Chair) (At-large AMA Delegate, Appointed by CMA) Delegation Chair: Robert E. Peters, MD, PhD CMA President-elect: Theodore M. Mazer, MD (At-large AMA Delegate, Appointed by CMA) CMA Past Presidents: James T. Hay, MD (AMA Delegate) • Robert E. Hertzka, MD (Legislative Committee Chair, At-large AMA Delegate, Appointed by CMA) • Ralph R. Ocampo, MD CMA Trustee: Bob E. Wailes, MD AMA Alternate Delegate: Lisa S. Miller, MD

Put Your SDCMS-CMA Membership to Work!

Physician Marketplace: Classifieds

Honey of Your Hive BY DANIEL J. BRESSLER, MD, FACP

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.]

Presenting Sponsor: THE DOCTORS INSURANCE AGENCY Bob DeSimone

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/////////Briefly /////////////////Noted //////////////////////////////////////////////////////////////////////// calendar

HISTORY THUMBNAILS

Ignaz Philipp Semmelweis (July 1, 1818 – Aug. 13, 1865) By Ralph R. Ocampo, MD, FACS

SDCMS-CMA CALENDAR

For further information or to register for the following events, contact Jen at (858) 300-2781 or at JOhmstede@SDCMS.org. How to Manage Your Professional Reputation Online (webinar) FEB 8: 12:15pm–1:15pm Physician Networking Opportunity & Mixer (social) FEB 9 at B.J.’s Brewhouse in La Mesa CMA Legislative Advocacy Day (conference) APR 18 at the Sheraton Grand in Sacramento Western Health Care Leadership Academy (conference) MAY 5–7 at the Marriott Marquis San Diego Marina

HEALTHCARE CONFERENCES

To submit a community healthcare event for possible publication, email Editor@SDCMS. org. Events should be physician-focused and should take place in or near San Diego County.

Structural Heart Intervention and Imaging 2017: A Practical Approach FEB 8–10 at the San Diego Marriott La Jolla

January 2017

Natural Supplements: An Evidence-based Update FEB 10–12: at Paradise Point Resort, San Diego Practicing Physician’s Approach to the Difficult Headache Patient FEB 17 at the Omni La Costa Resort & Spa Landmark Clinical Trials Revisited: 3- and 5-Year Results FEB 24 at the La Valencia Hotel SDCMS Members Receive 50% off Registration Fee — Email Editor@SDCMS. org for the Promo Code Before Registering Coalition for Compassionate Care of California Annual Summit MAR 13–14 in Sacramento Biomarker Summit 2017 MAR 20–22 at the Hilton San Diego Resort & Spa New Treatments in Chronic Liver Disease MAR 31–APR 2 at the Estancia La Jolla Hotel Clinical Advances in Heart Failure and Arrhythmias APR 28–30 at the Loews Coronado Bay Resort in Coronado

Jakob Kolletschka, a close friend of Ignaz Semmelweis, died of sepsis after cutting his finger during an autopsy in 1847. In Vienna, Semmelweis noted differences in puerperal fever mortality between obstetrician and midwife deliveries of 13% and 2% respectively. By hand washing with chlorinated lime before delivery, Semmelweis eliminated the difference in death rates and proved that contamination was a principal cause of perinatal mortality. It took another 40 years for Pasteur and Koch to define the nature of the contaminants. Dr. Semmelweis was maligned by almost all his colleagues. Even the famous Dr. Rudolf Virchow derided his claims. Semmelweis responded acerbically to criticism from all quarters for decades and was finally confined to a mental hospital for real or imputed psychosis. Two weeks after admission, he was placed in a straitjacket, purged, and finally beaten. He died. The autopsy gave pyemia as the cause of death, the apparent result of the beating by several guards. No records were preserved from San Diego’s first two “Boards of Health” (1850 and 1869), nor is there any emphasis on hand hygiene in the first records available from 1888 (The Journal of San Diego History, Vol. 48, No. 4, Fall 2002, by Gregg R. Hennessy and Michael Kelley, MD). The County of San Diego and its Department of Environmental Health, Food, and Housing Division now rigorously control practices in all eating facilities, including those in hospitals. Hospital-acquired infections are the fifth most common and fourth most expensive hospital-acquired conditions (HAC). Seven hundred twenty-one hospitals are repeat offenders, and incurred penalties of a 1% reduction in overall payments from CMS. Revisions are forthcoming to the current Affordable Care Act. To contain current runaway costs, it is likely that existing HAC standards will be further tightened. The best response to tightening hospital performance criteria is to anticipate them and also serve patients better. Our entire county should be motivated to use more effective hand hygiene in hospitals, schools, and at the workplace. And one final last word: Please keep your fingers out of and off your nostrils when caring for the young and immune deficient. For more resources, see Brevis.com.

“

Be at war with your vices, at peace with your neighbors, and let every new year find you a better person.

”

— Benjamin Franklin (1706–1790)

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/////////Briefly /////////////////Noted //////////////////////////////////////////////////////////////////////// OFFICE MANAGER ADVOCACY

Congratulations, Doris Castillo, SDCMS’s 2016 Office Manager of the Year!

L–R: Jay Grove, MD, Adam Fierer, MD, Doris Castillo, and Karen Hanna, MD, of Minimally Invasive Surgeons of North County (misnorthcounty.com).

Nominated by Dr. Karen Hanna, four-year Member of SDCMS-CMA: A little over two years ago, I retired from the U.S. Navy and joined two other general surgeons who were each leaving their prior practices to start a whole new practice in North County. We had to start from the ground up as we had no office space, no equipment, no employees, and certainly no processes in place. On the recommendation of one of my new partner’s wife, we hired Doris Castillo for our office manager. For 14 years Doris was a “program support supervisor” for a nonprofit program that dealt primarily with behavioral health; however, the program was soon going to be unfunded. She had

some medical billing and Medi-Cal experience, and certainly experience as a supervisor, but not specifically as a medical office manager. Despite her lack of experience, she was by far the best decision we have made in our new practice. She successfully got us started at a temporary location while we built our clinic, oversaw the hiring of our additional staff, researched, recommended, and navigated everything from who to use as our payroll, to who to use for medical supplies, housekeeping, etc. She diligently worked out all of our processes from answering phones to check-in and -out, follow-up phone calls, and the list goes on. She continues to

research and make changes to some of our vendors and processes with a true “quality improvement” attitude. In addition, Doris is amazingly frugal. Since we were just starting out and having to purchase everything, including office furniture, she used discount warehouses, coupons, and discount programs with companies such as Office Depot to obtain quality but inexpensive items. I am certain we would never have financially survived without her. She did all of this while endearing herself to our employees, all of whom have remained except one that moved away. I asked them for their input and several mentioned she was “by far the best boss,” in addition to comments such as “she makes us feel important and appreciated,” “she listens,” “approachable,” and “always figures out a way to fix any problem.” Not to say that she is too nice. We are extremely pleased with our employees and feel the excellent job they do is in a large part due to Doris’s guidance. She disciplines when necessary but very fairly. She is incredibly dedicated to her job and to our success. For example, we eventually bought our own building and built our clinic. Recently, in the evening, after clinic hours, a provider subletting our clinic discovered a significant roof leak into one of the exam rooms — it was raining and the water was really flowing in. The surgeons were all either out of town or on call and, without being asked, Doris and her husband rushed to the clinic, obtained and placed large garbage cans to catch the water, cleaned up, moved the furniture out, and Doris had her husband go up to the roof to attempt to find and/or control the leak. That is just one example of many times Doris has gone above and beyond. I hope you will consider her for the Outstanding Medical Office Manager because we certainly feel that way about her.

join the fun! Please join your physician colleagues on Thursday, Feb. 9, for SDCMS’s next physician networking opportunity and mixer from 5:30 p.m. to 8 p.m. at B.J.’s Brewhouse in La Mesa. Come mingle, socialize, and network with your colleagues, and be sure to bring your spouse/significant other — complimentary hors d’oeuvres and drinks will be provided. RSVPs are required, so register soon at SDCMS.org — and do spread the word by letting your colleagues know to join us as well. If you have any questions, contact Jen at JOhmstede@SDCMS.org or at (858) 300-2781.

January 2017

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We know how busy you are and how valuable your time is. That’s why we’re oﬃcially inviting you to NOT attend our No Ball At All Gala in February. Let us clarify: this is a virtual gala. No tux or ballgown. No babysitter or chicken dinner. But how about movie tickets? You can beneﬁt those in need of healthcare services, from the comfort of your home or wherever you would like to be. Your gift of $100 or more made for No Ball at All (now through February 28) will earn you two movie tickets at the luxury theater, The Lot, in downtown La Jolla or Liberty Station.

Thank you for participating in our No Ball At All Gala – your donation will go directly to where it is needed, providing healthcare services to uninsured, low income community residents who most need your help.

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P e r s o na l & P r o f e s s i o na l D e v e lo p m e n t

Make 2017 a Year of Satisfaction and Joy! by Helane Fronek, MD, FACP, FACPh

January 2017

It’s natural to view the New Year as a beginning — we’ve “turned the page.” We vow that this year will be different. We’ll lose the weight we’ve added over the years, keep up on our journals, or take that trip we’ve been dreaming of. Unfortunately, if past results do determine future performance, we’ll end 2017 as we started it. Many of us will feel disappointed in our ability to create the life we want to be living. Part of our difficulty in changing lies in the misconception that we just need to do something differently. We simply need to join a gym, put our journals where we’ll see them, or call a travel agent. But this focus misses two important steps: connecting to our motivation, and becoming the person we dream of being, i.e., the person who actually does those things. We can start by creating a list of the things we wish to do in the coming year. For each, take some time and ask yourself why it’s important to you. What will change in your life — or the lives of those you care about — if you accomplish this?

Imagine 2017 is nearing an end and you have accomplished your goals. What’s important about this change? Keep asking yourself this question until you hit the bedrock of a core value of yours. Is weight loss really about becoming fit so you will be healthy enough to play with your grandchildren? Will staying current on journals reinvigorate your approach to patient care? Would this trip restore the sense of adventure that’s been missing in your life? Connecting to your true motivation for each activity — perhaps placing a visual reminder of it where you’ll see it regularly — will help you stay engaged. And now imagine that 2017 is nearing an end and you have accomplished your goals. Picture yourself in your mind: playing with your grandchildren, using your new knowledge to solve the mystery of a patient’s concern, or smiling as you look at photos of your trip. What do you look like? How are you different? Are you more confident, more engaged in your specialty, more open to new adventures and ideas? Imagine being that person, starting right now. Spend time each day feeling that you are this “new you.” We often struggle to make changes because they conflict with what we actually want, or who we feel we are. If we don’t understand what’s important to us about a particular goal, it’s more likely to feel like another “should” in our life. And if we believe we’re someone who can never lose weight, that keeping up is hopeless or just too overwhelming, or we feel too mired in the stresses of life to consider taking time off, our new plans may feel as if they don’t belong to us. So let 2017 be a “new year” as we connect with what’s really important and with who we want to become. And let this practice propel us to accomplish the goals that will make 2017 a year to remember with satisfaction and joy. Dr. Fronek, SDCMSCMA 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.com.

CMA Member Help Line! Be it legal information, help with a problematic payor, or details about your member benefits, call CMA’s Member Help Line: (800) 786-4262

SAN DIEGO PHYSICIAN.org

acc e s s to ca r e

Planned Parenthood Celebrating 100 Years of Empowering Women, Building Healthy Communities, and Advancing Reproductive Freedom and Healthcare as a Basic Human Right by Philip J. Diamond, MD

January 2017

As a practicing Ob-Gyn for 25 years, I have dedicated my professional life to keeping the women and families of San Diego healthy, informed, and safe. And as a longtime supporter and new board member at Planned Parenthood of the Pacific Southwest (PPPSW), the foremost provider of high-quality reproductive healthcare for San Diego, Riverside, and Imperial counties (and the second-largest Planned Parenthood affiliate in the United States), Iâ&#x20AC;&#x2122;m proud to say that few organizations do more to prevent unintended pregnancy, empower youth, and drive health equity. Many of the 138,000 distinct patients who visit our 17 health centers each year depend on Planned Parenthood not just for family planning services and preventive care, but for their basic primary healthcare needs. For the most part, these patients are female (88%), young (69% between the ages of 18 and 29), low-income, and uninsured (66%,

a drop from 87% in 2013 that is attributable to the Affordable Care Act). No matter their background or ability to pay, regardless of the language they speak or their immigration status, these patients receive the highest quality of compassionate care. We all know these services are in demand, but many will be surprised to learn just how essential a role PPPSW plays in the region’s safety net system: One in three San Diego households — and one in four Riverside households — is home to a former or current PPPSW patient. Appointments are available for most services within one or two days, walk-ins are accommodated, and no one is turned away. Staffed by bilingual professionals, PPPSW’s 17 unique health centers reflect the diverse needs of their communities, including dense urban areas such as City Heights and Chula Vista, and rural areas such as the Coachella and Imperial valleys. It’s a disservice to women that Planned

Parenthood has long been a convenient political football, subject to malicious, sometimes violent attacks by those who mistakenly think the organization is defined by a single word: abortion. And while Planned Parenthood will always safely and legally provide — and continue to destigmatize — this important service to women, the vast majority of patients who access care at its local health centers are seeking basic primary healthcare, including blood pressure screening, breast health screenings, contraception, STI testing and treatment, and health counseling. Few people know that Planned Parenthood is one of California’s leading providers of cervical cancer screenings; the local affiliate performed more than 15,000 pap tests last year, as well as colposcopy, LEEP procedures, and HPV treatments. People may know that Planned Parenthood is responsible for delivering comprehensive sexual health education to thousands of local at-risk youth, providing them with the tools they need to make smart choices about their health and their future. However, few know that the organization also trains teachers, resident physicians, parents, and other youth-serving professionals on how to provide medically accurate, age-appropriate education. The teen birth rate in California has decreased nearly 60% over the past 20 years. This is a credit to California’s laws requiring school-based sex education to be comprehensive and medically accurate; the Family PACT program; improvements in contraceptive use; and increased use of the most effective contraceptives, such as long-acting, reversible contraceptive methods. Locally, Planned Parenthood has been integral to these successes, providing accessible family planning services for youth and effective adolescent pregnancy prevention programs. This year, Planned Parenthood celebrates 100 years of empowering women, building healthy communities, and advancing reproductive freedom and healthcare as a basic human right — one that is dispensed freely and without judgment to every person. That’s what Planned Parenthood is all about: Care, no matter what. I look forward to seeing Planned Parenthood launch its second century with as much passion, courage, and conviction as its first, and hope that I can count more and more fellow physicians as ardent supporters of this transformative organization. I support women. I trust women. And I’m proud to stand with Planned Parenthood.

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RIS K M A N AG EME N T

Watch for the Signs Screen All Patients for Suicidal Thoughts by Robin Diamond, MSN, JD, RN

Note: In addition to her legal experience, Robin Diamond has a master’s degree in psychiatric nursing from Vanderbilt University. The suicide of a patient is a tragedy for any physician. Patients with suicidal thoughts or ideation appear occasionally in physician encounters. The Joint Commission recently noted that the rate of suicide is increasing, and suicide is now the 10th leading cause of death in the United States (1). Most people who commit suicide received healthcare services in the year prior to death, usually for reasons other than mental health issues or suicidal thoughts. It’s a strong reminder that any patient — no matter what issue is being treated and in any setting — could be

January 2017

at risk for suicide. The patient’s wellbeing should be the primary concern, but physicians also must consider the potential legal liability that can come from failing to adequately screen patients for suicide risk and taking the proper steps when needed. The remorse a physician may face over missing signs can be compounded by legal action claiming the physician is accountable for the patient’s demise. A consistent and formal screening process — plus a response plan — will protect both the patient and the physician. Case Study: Reviewing Patient’s Full History Is Key A recent case illustrates how even if the

patient denies suicidal ideation when asked, the physician could be held liable for the suicide if there were other risk factors to consider. The case involved a 60-yearold woman with chronic back pain from an auto accident 10 years earlier, treated by her family practitioner over several years for pain, depression, and hypertension. Prior to her death, the woman had three appointments with the doctor over nine months for insomnia, pain medication adjustment, antidepressant medication monitoring, and blood pressure checks. The notes from the last encounter state: “No energy; insomnia; denied suicidal thoughts and denied feeling depressed.” Six days later, the patient overdosed on a combination of sleeping medication and anti-anxiolytics. Notes in the medical record from the next-to-last appointment said the patient “complained of insomnia; increased depression and increased anxiety; referral to psychologist.” However, she did not see the psychologist, and the family practitioner’s office did not follow up. The defense experts said that the doctor should have considered the entire history instead of just the last visit and concluded the patient was at risk of suicide. How to Help Prevent Tragedies These are some key strategies for ensuring that a physician practice or hospital is sufficiently addressing suicide risk in patients: • Establish a formal policy on screening and responding to suicide risk. Establish a policy that stipulates what screening will be done and how to respond to suspected risk. All employees should be trained. The policy should include front desk staff and other nonclinicians, who may pick up on signs that the patient could be suicidal. • Implement an effective screening process. The questions typically asked on intake can be more of a formality than a true screening. Ask specific questions that can reveal situations that might put the patient at risk for depression and suicide. Examples include asking whether the patient has recently experienced the loss of a family member, a change in marital status, a change in jobs, sleeping difficulty, or loss of appetite. • Connect with the patient. If in the screening process the patient demonstrates suicidal tendencies or it’s suspected that the patient may be suicidal, refer the patient immediately to a mental health professional or ask

the patient’s permission to contact family members or outpatient treatment providers. • Do not be deterred by HIPAA. The patient privacy law can leave clinicians thinking that they may not discuss their concerns about suicide with the patient’s family. The patient can give permission for the physician to talk to others about his or her healthcare, and refusal to grant that permission might be considered another sign of suicidal risk. • Establish a relationship with mental health professionals for referral. In a hospital setting, the physician should always know who is on call for patients with psychiatric risks. In other settings, the physician should establish a referral relationship with at least one or two professionals who can be called as needed. Be sure to document when and how the contact was made and any follow-up. Remember that simply advising the patient to seek help is insufficient. Contact the mental health professional directly and ar-

range for the patient to be seen quickly. Be sure to follow up to confirm that the patient has seen the mental health professional. • Establish safety procedures for the patient who may be suicidal. Once this risk is established, the clinician is responsible for protecting the patient from self-harm. That means keeping the patient away from sharp objects, medications, and bed sheets. Having the patient wait in a typical exam room may not be safe because the patient would have access to scissors, scalpels, needles, and other such items. When appropriate, ask the patient to put on a hospital gown and remove from the room the patient’s shoelaces, belt, and any other items that could be used for harm. • Monitor the patient closely. If feasible, have staff or the patient’s family monitor the patient continuously — in person or on video — until the next step of care. If continuous monitoring is not possible, check on the

patient frequently. Carefully document the monitoring procedure, including frequency and type as well as observed patient behaviors. • Call for help if needed. Call for additional help if the facility has no ability to isolate the patient from dangerous items or provide adequate monitoring, and also if the patient has already left against medical advice. State laws vary regarding how and when a patient may be held against their will. Ms. Diamond is senior vice president of patient safety and risk management for SDCMS-endorsed The Doctors Company. For more patient safety articles and practice tips, visit www.thedoctors.com/ patientsafety. Reference: 1. Detecting and treating suicide ideation in all settings. The Joint Commission. www.jointcommission.org/assets/1/18/ SEA_56_Suicide.pdf. Accessed Nov. 14, 2016.

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AC C ESS TO C A RE

Telemedicine for Everyone by Christopher P. Schmidt, MD

Note: This article was originally published in the November/December 2016 issue of The Bulletin, the Santa Clara County Medical Associationâ&#x20AC;&#x2122;s bimonthly magazine. As a dermatologist, the possibilities of telemedicine were evident early in my career. You did not need a patient to make a diagnosis. You just needed a good picture. Telemedicine was initially promoted as a benefit to patients. It would increase their access to specialty care and surmount geographic barriers. Unfortunately, the only reimbursed format at the time was live interactive video, which was too impractical for widespread use. Patients

January 2017

also had limited access to the technology. Telemedicine languished. During this dark time, I was involved with a few unsuccessful startup telemedicine platforms that focused on direct patient access to specialists. There was a lot learned from the experience, but there were no compelling reasons for physicians to adopt the practice. That changed in 2012, when Californiaâ&#x20AC;&#x2122;s own telehealth law (AB 415) went into effect. Now physicians of all specialties would be the primary beneficiaries of telemedicine. The new law authorized physicians to collect for all forms of electronic interaction. This means you could now be

reimbursed for all the free care that you normally give out via the phone or email by using store-and-forward telemedicine. The largest benefit, however, is the savings that will occur when physicians no longer have to shoulder the burden of rent, staff, and other expenses when providing care that can be done outside the boundaries of an office. As a result, physicians should explore what aspects of patient care can be responsibly provided online and then try to move patients in that direction. Any progress that physicians make in moving portions of their practice online will be protected by the parity clause in this law. It requires that online visits be re-

imbursed at the same full level as an office visit. Telemedicine is now very practical. Physicians should be wary of many of the telemedicine sites that are out there. Most of the ones you read about in the headlines do not meet CMA’s Principles of Telemedicine. These are the anonymous doctor banks, prescription mills, and sites that use physicians in foreign countries. Fortunately, there are telemedicine sites that closely adhere to the CMA’s telemedicine standards. Store-and-forward platforms like HealthLens (I am a founder), Azova, and SkyMD enable physicians to practice online in a medically sound and ethical manner. The primary standard is allowing patients to receive online care from their established physician. This enables followup with that particular physician and a physical location if an office visit is necessary. CMA-adherent platforms also provide secure messaging between patient and physician so the visits can be interactive. Some sites even facilitate the use of the patient’s medical insurance to cover the visit.

Most commercial insurance companies, including Blue Cross, Blue Shield, Cigna, UnitedHealthcare, and Aetna, cover storeand-forward telemedicine. Medicare only covers it in Alaska and Hawaii, but there is legislation in progress to expand to all 50 states. To get reimbursed for store-and-forward telemedicine visits, just attach the GQ modifier to your CPT code, e.g., 99203 GQ. In my practice, I see about 60 patients online per month. Acne, eczema, and seborrheic keratoses make up the majority of the conditions I diagnose online. Time-sensitive conditions, like shingles, are not uncommon online diagnoses, and it is much easier to get patients on antivirals within that 72-hour window of opportunity when they don’t have to wait for an office visit. I even see new patients on the internet. According to the Medical Board of California, you can evaluate a new patient online and establish a physician-patient relationship as long as the photo(s) submitted by the patient allow(s) the physician to perform an adequate physical examination to

reasonably make a diagnosis. Established patients, who make up the majority of my online visits, can be evaluated and treated without a photograph. This works out well for prescription renewals. Medical research will also benefit from the shift to online care because of the data that telemedicine provides. In the short time HealthLens has been in operation, we have amassed a large library of clinical images, corresponding diagnoses, treatments, and, most importantly, outcomes. The granularity of the data will allow for unprecedented levels of analysis. Veering from long practiced-norms is a troubling process for the medical community. However, the opportunity to eliminate so much of the expense involved in patient care cannot be ignored. Physicians should be leading the charge in shifting patient care online. We will be the primary beneficiaries. Dr. Schmidt is a dermatologist and member of the Santa Clara County Medical Association.

SAN DIEGO PHYSICIAN.org

LE G ISL ATI V E A DVO C AC Y

CMAâ&#x20AC;&#x2122;s Unseen Legislative Battles AB 533 vs. AB 72 by Peter Bretan, MD, FACS

January 2017

Note: This article was originally published in the Fall/Winter 2016â&#x20AC;&#x201C;17 issue of Marin Medicine and is republished here with the gracious consent of Dr. Bretan. One of the great difficulties in maintaining membership for the Marin Medical Society (MMS) and the California Medical Association (CMA) is trying to be all things to all members. This can be extremely difficult, since we have such a diverse membership and modes of practice. One of the toughest challenges we face is to show members the work we do all-but-invisibly on a daily basis. Our Small and Solo Group Practice Forum (SSGPF) used to represent the dominant mode of practice, making up over 75% of our membership for more than 20 years. Economic forces and an ever-evolving medical practice landscape have changed that significantly, so that many solo practices have joined multi-specialty groups or larger practices. The SSGPF now accounts for only about a third of our membership. Unfortunately, it is the SSGPF that is disproportionately hurt by much recent legislation. It is the goal of the Marin Medical Society and the California Medical

Most importantly, the bill now allows state health insurance regulators to better determine whether plans’ and insurers’ networks are adequate, and to take action if they are not. Association to battle and overcome some of these bills, which would not merely hurt solo/small practices but threaten their very survival. Many of CMA’s struggles are invisible to the membership, and sometimes certain bills’ passage appears to occur because of neglect by CMA. Nothing could be further from the truth. Often, when a controversial bill passes, it is the lesser of two evils. This is what happened in the passage of AB 72 over its more sinister twin, AB 533. Both bills were introduced by Assemblyman Robert Bonta of Alameda, and both were labeled as “Surprise Billing” legislation. They were introduced because out-ofnetwork billing prompted many patients to complain to the Legislature. These bills are a byproduct of insurance companies’ narrow and inadequate physician networks, which almost guarantee that out-of-network physicians are often dragged in to care for patients insured by these companies. These patients get procedures from anesthesiologists, surgeons, radiologists, and other non-contracted, hospital-based doctors who are thus “out of network” when they are on call at an in-network hospital. The patient then gets slammed with a “surprise billing.” Obviously this is the fault not of the provider but of an inadequate insurer network. Unfortunately, insurers have been using this loophole to avoid paying providers adequately. Also unfortunately, AB 72 eliminates “surprise billing” by transferring this cost to the non-contracted, outof-network providers. Many solo practitioners perceive this as a slippery slope, a ramp-up to unregulated capitated care as a consequence of insurers’ narrow networks, which angers many struggling providers. The most damaging accusation is that CMA did not fight to prevent this. On the contrary, CMA did everything possible. Let me outline here just what it did. AB 533 was the first of these bills to be introduced. It would have required non-contracted physicians to sign a written consent

form 72 hours before providing a service. It also called for reimbursement at 125% of the Medicare rate. CMA consistently opposed AB 533 and proposed a solution similar to legislation passed in New York using the interim payment metric of the 80th percentile of the Fair Health database. However, the Legislature didn’t agree. Supporters of AB 533 included all major labor unions, health plans, consumer groups, and the California Chamber of Commerce. CMA was able to defeat AB 533 by keeping it short of the 41 votes necessary for passage at the end of 2015. Unfortunately, the bill could still be brought up for reconsideration at any time after that. AB 72 was offered as an alternative to 533. When it was being vetted by CMA, it received input from a broad representation of physicians from every mode of practice. CMA’s various forums had spokespeople at each CMA Board of Trustees meeting. By ensuring stakeholder participation in the AB 72 development process, CMA was able to secure improvements in AB 72 that made it better than AB 533. CMA was able to get the Legislature’s support for these changes in the bill by switching its position from “opposed” to “neutral.” This was CMA’s only option: to seek the support of allies in pushing for AB 72 over AB 533. Despite the ongoing effort to make AB 72 more palatable than AB 533, our SSGPF asked CMA to send a letter to the governor urging him to veto AB 72 just at the time that CMA was in the midst of actively working to amend — to improve — AB 72 so as to destroy AB 533. Obviously, sending such a letter would have killed CMA’s credibility in the effort to make AB 72 as palatable as possible — and perhaps the credibility of future CMA efforts as well. What some physicians fail to realize is that there is truly no support in the Legislature for holding patients responsible for services they never agreed to. CMA’s stance has been that the insurers are responsible for these costs, since they are the direct result of the insurers’ narrow

networks, which are in turn the result of inadequate reimbursements to providers. Nevertheless, that is irrelevant to the negotiation process in the Legislature, especially since we needed the insurers’ support for AB 72 over AB 533. The CMA Board of Trustees directed CMA Government Relations staff to negotiate the best deal possible for AB 72 as a replacement for the more damaging AB 533. CMA leadership understood that this was the right thing to do despite the protest from unengaged members of the SSGPF. In its final form, AB 72 includes these provisions: • Health plans and insurers must pay physicians the greater of the average contracted rate or 125% of the Medicare reimbursement for that service. • A non-contracting physician must get written consent with an estimate of the patient’s total out-of-pocket cost for the use of out-of-network benefits more than 24 hours ahead of the scheduled service. • The continuity-of-care provision in existing law will remain in effect. Thus in certain instances a patient may still have a right to get covered services from a non-contracted physician. • Most importantly, the bill now allows state health insurance regulators to better determine whether plans’ and insurers’ networks are adequate, and to take action if they are not. The battles fought by MMS and CMA at the state Legislature and the AMA in Congress are part of an ongoing saga. We may not always get what we want, but we fight for what we need. I hope we can all understand that CMA/MMS look at the whole practice of medicine and the effect on our patients. I hope you stay involved and always question what insurers and government are going to do to your practice, but understand that the negotiating effort requires credibility, patience, and attention to detail. Rest assured that we are doing everything in our power for your practices, and that your membership enables us to fight day in and day out. Dr. Bretan, a urologist and transplant surgeon in Marin, Sonoma and Mendocino counties, is president of the Marin Medical Society, a member of CMA and AMA delegations, and a former CMA trustee. SAN DIEGO PHYSICIAN.org

LEGISLATIVE ADVOCACY

Congressional Plan to Repeal and Replace the ACA Is Not Clear

by Elizabeth McNeil, Vice President, CMA Center for Federal Government Relations

ongress has passed a budget resolution establishing procedural instructions to set up the repeal of the Affordable Care Act (ACA), setting in motion the GOP’s promise to repeal the ACA as its first legislative act. The repeal process, however, could take months, while developing a replacement plan could take years. Senate Republicans have agreed to use a budget resolution, allowing them to repeal ACA funding without any Democratic votes. Budget resolutions require a simple majority to pass in the Senate, instead of the 60 votes required to clear procedural

January 2017

hurdles. There are 52 Republicans in the 100-seat chamber. While the Senate budget resolution is a statement of priorities and lays the groundwork for the repeal of the ACA, it does not have the force of law. To repeal the law, the House Energy & Commerce and Ways & Means committees and the Senate Finance Committee need to meet to develop replacement legislation. The Senate plan introduced on Jan. 3 includes a “repeal and replace” strategy that would require passage of two separate bills. Looming over the whole process of repealing the ACA are the actions of the

healthcare marketplace. Congressional plans to repeal the ACA without a replacement plan in place could result in more uncertainty in an already fragile marketplace, prompting insurers to leave the individual market and creating chaos for the 20 million Americans insured through the ACA. In addition to working on a replacement plan, Congress must also act on a handful of healthcare programs before they expire, including the Children’s Health Insurance Program; Prescription Drug User Fee Act; Medical Device User Fee and Modernization Act; and the Veterans’ Access, Choice and Accountability Act. CMA is closely following these issues as they play out in Congress and will be actively engaged in shaping the future of healthcare reform at the national level. CMA will work to ensure that any resulting legislation will benefit the patients and physicians in California and the nation as a whole. We will also work to keep you up to date on any breaking news from the nation’s capital. Following are the principles that will guide CMA’s advocacy on healthcare reform: • Ensure Californians do not lose coverage or access to care. • Protect the billions in current state and federal healthcare funding. • Ensure appropriate and broad-based financing. • Advocate for patient choice of physicians, health plans, and coverage through private contracting, health savings accounts, health plans, and state and federal government programs. • Continue tax policies and subsidies that help low-income patients afford coverage. • Maintain the insurance industry reforms that protect physicians and patients.

CALIFORNIA MEDICAL ASSOCIATION

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TROUBLE GETTING PAID? WE CAN HELP! CMA’s Center for Economic Services (CES) is staffed by a team of practice management experts with a combined experience of over 125 years in medical practice operations. Our goal is to empower physician practices by providing resources and guidance to improve the success of your practice.

Access to CMA experts is a FREE, members-only benefit. Call (800) 786-4262 or email memberservice@cmanet.org.

We are here to help the doctors and their staff who have dedicated their lives to helping us. With over 125 years of practice management experience in the CES team, we can help medical practices work smarter, not harder.” Mitzi Young, Physician Advocate, CMA Center for Economic Services (CES) TO OPT OUT OF FUTURE NOTICES, EMAIL MEMBERSERVICE@CMANET.ORG OR FAX (916) 551-2036. BE SURE TO INCLUDE THE FAX NUMBER YOU WANT REMOVED. SAN DIEGO PHYSICIAN.org

LEGISLATIVE ADVOCACY

New Health Laws for 2017 Significant New California Laws of Interest to Physicians

The California Legislature had an active 2016, passing many new laws affecting healthcare. In particular, there was a strong focus on healthcare coverage, drug prescribing, public health, and workers’ compensation issues. Below is a list of the most significant new health laws of interest to physicians; SDCMS-CMA members can access a document explaining each of these new laws on CMA’s website at cmanet.org — search for “Significant New California Laws of Interest to Physicians for 2017.” ADVERTISING • AB 2744 (Gordon) — Healing Arts: Referrals • SB 1130 (Wieckowski) — False Advertising: Substantiation of Claims ALLIED HEALTH PROFESSIONALS • AB 923 (Steinorth) — Respiratory Care Practitioners • AB 1808 (Wood) — Minors: Mental Health Treatment or Counseling Services • AB 2105 (Rodriguez) — Workforce Development: Allied Health Professions • AB 2317 (Mullin) — California State University: Doctor of Audiology Degrees ANCILLARY SERVICES • SB 1044 (Nguyen) — Barbering and Cosmetology CLINICAL TRIALS • AB 1823 (Bonilla) — California Cancer Clinical Trials Program

January 2017

CONFIDENTIAL INFORMATION • AB 691 (Calderon) — Revised Uniform Fiduciary Access to Digital Assets Act • AB 1671 (Gomez) — Confidential Communications: Disclosure • AB 2083 (Chu) — Interagency Child Death Review • AB 2119 (Chu) — Medical Information Disclosure: Medical Examiners and Forensic Pathologists • AB 2296 (Low) — Digital Signatures • AB 2828 (Chau) — Personal Information: Privacy: Breach • SB 514 (Anderson) — California Health Benefit Exchange • SB 1121 (Leno) — Privacy: Electronic Communications • SB 1137 (Hertzberg) — Computer Crimes: Ransomware • SB 1238 (Pan) — Inmates: Biomedical Data CORPORATE BAR • AB 2024 (Wood) — Critical Access Hospitals: Employment

DRUG PRESCRIBING AND DISPENSING • AB 1069 (Gordon) — Prescription Drugs: Collection and Distribution Program • AB 1386 (Low) — Emergency Medical Care: Epinephrine Autoinjectors • AB 1668 (Calderon) — Investigational Drugs, Biological Products, and Devices • AB 1748 (Mayes) — Pupils: Pupil Health: Opioid Antagonist • AB 2235 (Thurmond) — Board of Dentistry: Pediatric Anesthesia • SB 139 (Galgiani) — Controlled Substances: Synthetic Cannabinoids • SB 482 (Lara) — Controlled Substances: CURES Database • SB 1174 (McGuire) — MediCal: Foster Care Psychotropic Medications • SB 1229 (Jackson) — Homegenerated Pharmaceutical Waste: Secure Drug Take-back Bins • SJR 29 (Hernandez) — EpiPen: Pricing HEALTHCARE COVERAGE • AB 72 (Bonta) — Healthcare Coverage: Out-of-network Coverage • AB 565 (Cooley) — Group Life Insurance: Required Provisions • AB 796 (Nazarian) — Healthcare Coverage: Autism and Pervasive Developmental Disorders • AB 1703 (Santiago) — Inmates: Medical Treatment • AB 1795 (Atkins) — Healthcare Programs: Cancer • AB 2308 (Hernández, Roger) — Healthcare Coverage: Information to Students • AB 2366 (Dababneh) — Long-term Care Insurance • SB 10 (Lara) — Healthcare Coverage: Immigration Status • SB 908 (Hernandez) — Healthcare Coverage: Premium Rate Change Notice • SB 923 (Hernandez) — Healthcare Coverage: Cost-sharing Changes • SB 1091 (Liu) — Long-term Care Insurance • SB 1135 (Monning) — Healthcare Coverage: Notice of Timely Access to Care • SB 1384 (Liu) — California Partnership for Long-term Care Program • SB 1477 (Committee on Health) — Health

HEALTHCARE FACILITIES AND FINANCING • AB 54 (Olsen) — Disability Access: Construction-related Accessibility Claims • AB 1732 (Ting) — Single-user Restrooms • AB 1797 (Lackey) — In-home Supportive Services: Application • AB 2053 (Gonzalez) — Primary Care Clinics • AB 2093 (Steinorth) — Disability Access • AB 2231 (Calderon) — Care Facilities: Civil Penalties • AB 2491 (Nazarian) — Vehicles: Stopping, Standing, and Parking • AB 2568 (Atkins) — County Integrated Health and Human Services Program • AB 2737 (Bonta) — Nonprovider Healthcare Districts • AB 2750 (Gomez) — Tissue Banks • SB 269 (Roth) — Disability Access • SB 833 (Committee on Budget and Fiscal Review) — Health • SB 837 (Committee on Budget and Fiscal Review) — State Government • SB 867 (Roth) — Emergency Medical Services • SB 957 (Hueso) — Healthcare Districts: Design-build Process • SB 1076 (Hernandez) — General Acute Care Hospitals: Observation Services • SB 1159 (Hernandez) — California Healthcare Cost, Quality, and Equity Data Atlas • SB 1365 (Hernandez) — Hospitals MEDI-CAL • ABX2 1 (Thurmond) — Developmental Services: Medi-Cal: Funding • AB 168 (Maienschein) — Mental Health: Community-based Services • AB 635 (Atkins) — Medical Interpretation Services • AB 847 (Mullin) — Mental Health: Community-based Services • AB 1114 (Eggman) — Medi-Cal: Pharmacist Services • AB 1299 (Ridley-Thomas) — MediCal: Specialty Mental Health Services • AB 1568 (Bonta) — Medi-Cal: Demonstration Project • AB 1696 (Holden) — Medi-Cal: Tobacco Cessation Services • AB 1849 (Gipson) — Foster Youth: Transition to Independent Living • AB 1863 (Wood) — Medi-Cal: Federally Qualified Health Centers Rural Health Centers

• AB 2207 (Wood) — Medi-Cal: Dental Program • AB 2394 (Garcia, Eduardo) — MediCal: Nonmedical Transportation • SBX2 2 (Hernandez) — Medi-Cal: Managed Care Organization Tax • SB 586 (Hernandez) — Children’s Services • SB 815 (Hernandez) — Medi-Cal: Demonstration Project • SB 1291 (Beall) — Medi-Cal: Specialty Mental Health: Dependents MEDICAL MARIJUANA • AB 21 (Wood) — Medical Marijuana: Cultivation Licenses • AB 2516 (Wood) — Medical Cannabis: State Cultivator License Types • AB 2679 (Cooley) — Medical Marijuana: Regulation: Research • SB 1036 (Hernandez) — Controlled Substances: Synthetic Cannabinoids: Analogs MEDICAL PRACTICE AND ETHICS • AB 1709 (Gallagher) — Deaf or Hardof-hearing Individuals • AB 1744 (Cooper) — Sexual Assault Forensic Medical Evidence Kit • AB 2457 (Bloom) — Autopsy: Electronic Image Systems • AB 2499 (Maienschein) — Sexual Assault Evidence Kits • SB 1005 (Jackson) — Marriage • SB 1065 (Monning) — Arbitration: Elder and Dependent Adult Civil Protection Act • SB 1189 (Pan) — Postmortem Examinations or Autopsies: Forensic Pathologists MENTAL HEALTH • AB 38 (Eggman) — Mental Health Early Diagnosis & Preventive Treatment Program • AB 59 (Waldron) — Mental Health Services: Assisted Outpatient Treatment • AB 1836 (Maienschein) — Mental Health: Referral of Conservatees • AB 1962 (Dodd) — Criminal Proceedings: Mental Competence • AB 2246 (O’Donnell) — Pupil Suicide Prevention Policies • SB 955 (Beall) — State Hospital Commitment: Compassionate Release PROFESSIONAL LICENSING AND DISCIPLINE • AB 2745 (Holden) — Healing Arts: Licensing and Certification • AB 2859 (Low) — Professions and Vocations: Retired Category: Licenses

• SB 1139 (Lara) — Health Professionals: Undocumented Immigrants: Nonimmigrant Aliens: Scholarships, Loans, and Loan Repayment • SB 1177 (Galgiani) — Physician and Surgeon Health and Wellness Program • SB 1261 (Stone) — Physicians and Surgeons: Residency Fee Exemption • SB 1478 (Committee on Business, Professions and Economic Development) — Healing Arts PUBLIC HEALTH • AB 857 (Cooper) — Firearms: Identifying Information • AB 1135 (Levine) — Firearms: Assault Weapons • AB 1554 (Irwin) — Powdered Alcohol • AB 1639 (Maienschein) — Pupil Health: The Eric Paredes Sudden Cardiac Arrest Prevention Act • AB 1680 (Rodriguez) —Crimes: Emergency Personnel • AB 1695 (Bonta) — Firearms: False Reports of Stolen Firearms • AB 1719 (Rodriguez) — Pupil Instruction: Cardiopulmonary Resuscitation • AB 2439 (Nazarian) — HIV Testing • AB 2510 (Linder) — Firearms: License to Carry Concealed: Uniform License • AB 2640 (Gipson) — Public Health: HIV • AB 2696 (Gaines, Beth) — Diabetes Prevention and Management • SB 32 (Pavley) — California Global Warming Solutions Act of 2006 • SB 819 (Huff) — Powdered Alcohol • SB 880 (Hall) — Firearms: Assault Weapons • SB 1064 (Hancock) — Sexually Exploited Minors • SB 1095 (Pan) — Newborn Screening Program • SB 1235 (De León) — Ammunition • SB 1383 (Lara) — Short-lived Climate Pollutants • SB 1408 (Allen) — Tissue Donation • SB 1435 (Jackson) — School Curriculum: Health Framework: Healthy Relationships REPORTING REQUIREMENTS • AB 1001 (Maienschein) — Child Abuse Reporting: Foster Family Agencies • AB 2325 (Bonilla) — Ken Maddy California Cancer Registry • SB 877 (Pan) — Reporting and Tracking of Violent Deaths

SAN DIEGO PHYSICIAN.org

LEGISLATIVE ADVOCACY REPRODUCTIVE ISSUES • AB 1954 (Burke) — Healthcare Coverage: Reproductive Healthcare Services • AB 2349 (Chiu) — Assisted Reproduction Agreements for Gestational Carriers • SB 999 (Pavley) — Healthcare Coverage: Contraceptives: Annual Supply • SB 1433 (Mitchell) — Incarcerated Persons: Contraceptive Counseling and Services TOBACCO • ABX2 7 (Stone, Mark) — Smoking in the Workplace • ABX2 9 (Thurmond) — Tobacco Use Programs • ABX2 11 (Nazarian) — Cigarette and Tobacco Product Licensing: Fees and Funding • AB 1901 (Quirk) — Taxation: Cigarettes: Unaffixed Stamps • AB 2770 (Nazarian) — Cigarette and Tobacco Product Licensing: Fees and Funding

• SBX2 5 (Leno) — Electronic Cigarettes • SBX2 7 (Hernandez) — Tobacco Products: Minimum Legal Age • SB 977 (Pan) — Tobacco: Youth Sports Events WORKERS’ COMPENSATION • AB 1244 (Gray) — Workers’ Compensation • AB 2503 (Obernolte) — Workers’ Compensation: Utilization Review • AB 2883 (Committee on Insurance) — Workers’ Compensation: Employees • SB 914 (Mendoza) — Workers’ Compensation: Independent Medical Reviews • SB 1160 (Mendoza) — Workers’ Compensation • SB 1175 (Mendoza) — Workers’ Compensation: Requests for Payment WORKFORCE & OFFICE SAFETY ISSUES • AB 488 (Gonzalez) — Employment Discrimination

• AB 1676 (Campos) — Employers: Wage Discrimination • AB 1843 (Stone, Mark) — Applicants for Employment: Criminal History • AB 1847 (Stone, Mark) — California Earned Income Tax Credit • AB 1978 (Gonzalez) — Employment: Property Service Workers • AB 2048 (Gray) — National Health Service Corps State Loan Repayment Program • AB 2337 (Burke) — Employment Protections: Victims of Domestic Violence • AB 2535 (Ridley-Thomas) — Employment: Wages: Itemized Statements • SB 1001 (Mitchell) — Employment Practices: Unfair Practices • SB 1063 (Hall) — Conditions of Employment: Wage Differential: Race or Ethnicity • SB 1167 (Mendoza) — Employment Safety: Indoor Workers: Heat Regulations

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January 2017

2017 SDCMS Physician Networking Mixer and Vendor Fair

April 14, 2017 Handlery Hotel, Mission Valley

Come mix and mingle with your peers while you meet physician-centric companies. Complimentary beer, wine and light hors d’oeuvres will be served.

Put Your SDCMS-CMA Membership to Work! Contact SDCMS: Membership@SDCMS.org (858) 565-8888

Help identify and elect legislators that share SDCMS’s and CMA’s vision for medicine and healthcare.

Get Involved!

Contact CMA: MemberService@CMAnet.org (800) 786-4262

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Speak with highly trained economic advocates with expertise in physician reimbursement and medical business issues by calling CMA’s Member Help Line at (800) 786-4262.

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Attend free of charge SDCMS’s many physician networking opportunities and mixers held throughout the year.

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Join SDCMS-CMA Today at SDCMS.org SAN DIEGO PHYSICIAN.org

classifieds PRACTICE FOR SALE SOUTHERN CALIFORNIA’S LARGEST MEDICAL SPA OFFERED FOR SALE: Injectable and laser services offered throughout San Diego and southern Orange counties. Virtually inexhaustible supply of new patients. Owned by a single physician who wishes to retire. Ideal for single physician who wants to step into a growing and lucrative esthetics practice in one of the nicest locations in the United States or for a San Diego or Orange County surgical group looking for a steady stream of procedure referrals in addition to the already lucrative cosmetics practice. Physician seller works 30 hours per week to net approximately 32% of current $1.15M gross income. Call (619) 994-8701. [564] PHYSICIAN POSITIONS AVAILABLE

Seeking Dermatologist for La Jolla practice Well established dermatology practice in La Jolla with extremely loyal patient base in need of an excellent board certified general and procedural dermatologist to round out our team. Cosmetic expertise and familiarity with lasers a plus. Our support staff is highly trained and our facilities are state of the art. Familiarity with Modernizing Medicine or EMA helpful. Requirements: • BC/BE in Dermatology • CA license Competitive compensation and benefits Please contact Stephen at 858-362-8800 stephen@torreypinesderm.com

PSYCHIATRIST WANTED TO JOIN GROWING PSYCHIATRIC PRACTICE: I have billing, credentialing, and admin support in place, as well as telepsychiatry service and EHR (drchrono). My clinic takes most major insurances, but not Medicare/Medi-Cal. The clinic will likely move to a larger space in North San Diego County soon. I’m open to the person working as a contractor for a split of their revenue, or for a flat fee for a portion of the overhead. Clinic also provides IV ketamine infusions. Open to part-time and full-time. POC is Dr. Jake Hollingsworth: (858) 261-4622; doctorjake@kflpsychiatry.com; www.kflpsychiatry. com and www.ketamineforlife.com. [567] FAMILY MEDICINE / PEDIATRIC PHYSICIANS NEEDED: Family medicine and pediatric physician positions currently available. Vista Community Clinic is a private nonprofit outpatient clinic serving the communities of North San Diego County, Riverside County, and Orange County. We have openings for full-time and part-time physicians. Current CA and DEA licenses required.

Malpractice coverage provided. Full benefits packet. Email resume to hr@vistacommuntyclinic. org or fax to (760) 414 3702. Visit our website at www.vistacommuntyclinic.org. EEO Employer/ Vet/Disabled/AA [566] SEEKING HOSPITALISTS: UC San Diego, Dept. of Pediatrics, is seeking hospitalists to provide direct patient care in the Level I/III Newborn Intensive Care Unit, Division of Neonatology, at UCSD Hillcrest and UCSD Jacobs Medical Center, both in the San Diego area. Candidates must have California medical licensing/eligibility, board certification in pediatrics, and experience in pediatric hospital medicine, preferably, with experience in the care of patients in a NICU or completion of a hospital medicine fellowship, and certification in neonatal resuscitation. The Division of Neonatology has a strong commitment to clinical care, teaching and research. Interested persons should email Erika Fernandez, MD, at erfernandez@ucsd.edu. [565] LOOKING FOR PRIMARY CARE PHYSICIAN: Well-established primary care group in San Diego is looking for a full- or part-time primary care physician. Out-patient only, with no calls or weekends. Please submit your CV with letterhead to infoclinic1@yahoo.com. [562] OPPORTUNITY FOR INTERVENTIONAL PHYSIATRY / PHYSICAL MEDICINE SPECIALIST: Practice opportunity for part-time or full-time interventional physiatry / physical medicine specialist with well-established orthopaedic practice. Office located near Alvarado Hospital. Onsite digital X-ray and EMR. Interested parties, please email lisas@sdsm.net. [554] SEEKING OCCUPATIONAL MEDICINE PHYSICIAN: Full time, part time or independent contractor for busy workers’ compensation specialist practice. Located in San Diego. Competitive salary. Please email CV or direct any enquiries to Robynne McMurtrie, Manager, at rmcmurtrie@davidkupfermd.com or call (858) 560-0242, ext. 101. [553] FAMILY PRACTICE MD/DO AND PHYSICIAN ASSISTANT WANTED IN BEAUTIFUL LA COSTA: Various shifts available at urgent care / family practice office. Nights, weekends, and day hours available. Please fax or email CV to (760) 603-7719 or gcwakeman@sbcglobal.net. [551] PUBLIC HEALTH MEDICAL OFFICER, TUBERCULOSIS CONTROL & REFUGEE HEALTH: HHSA. Anticipated range $145,000– $155,000. Excellent benefits package. For details, go to www.sandiegocounty.gov/content/dam/sdc/ hr/jobs/HHSA_TB_Control.pdf. [548] SEEKING A FEW GOOD PSYCHIATRISTS AND PHYSICIANS: The California Department of Social Services is seeking a few good psychiatrists and physicians who are interested in working with outside treating sources and other state professionals that evaluate medical evidence to determine its adequacy for making disability decisions as defined by Social Security regulations. On-the-job training is provided. Interested applicants must have a current CA MD/ DO License. Full-time salary ranges can start at $9,152.00 – $13,547.00 per month, depending on experience and credentials. If you are interested, please contact Ruby Chin at (916) 285-7593 or at ruby.chin@ssa.gov. [546] GENERAL FAMILY MEDICINE / GERIATRICS / LONG-TERM CARE PHYSICIANS / NPs wanted to join our team of professionals in beautiful

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.

January 2017

North San Diego County. We are dedicated to making “housecalls” to serve chronically ill patients in their homes. No hospital call, M–F, 8–5 or part time available. Independent contractor position. We are a very relaxed, professional practice environment. We very much look forward to your call! No recruiters, please. Email your CV or résumé to mobiledoctor@sbcglobal.net. [545] SEEKING URGENT CARE CLINICIANS: UC San Diego, Department of Pediatrics (www-pediatrics. ucsd.edu), and Rady Children’s Hospital of San Diego (www.rchsd.org) is seeking clinicians for our urgent care clinics, Division of Emergency Medicine & Urgent Care. Clinicians should be BC/BE pediatricians, with experience in general pediatrics and urgent care. Our main campus EM has a census of over 85,000 visits per year; the division also has four community pediatric urgent care centers with a combined census of about 54,000 visits per year. Salary will be commensurate with experience. Interested persons should contact Dr. Katherine Konzen, Director of Pediatric Urgent Care, at kkonzen@rchsd.org. [531] SEEKING FAMILY MEDICINE PHYSICIANS: Sharp Rees-Stealy Medical Group is seeking full-time or half-time (job share) BC/BE family medicine physicians to join our staff. Openings available in La Mesa, Downtown San Diego, Otay Ranch, and Kearny Mesa. 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, or email lori.miller@sharp.com. [529] SEEKING INTERNAL MEDICINE PHYSICIANS: SHARP Rees-Stealy Medical Group is seeking full-time BC/BE Internal Medicine physicians to join our staff. Openings available in La Mesa, Otay Ranch, Downtown San Diego and Kearny Mesa. 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) 2334730, or email lori.miller@sharp.com. [528] SEEKING OCCUPATIONAL MEDICINE PHYSICIANS: SHARP Rees-Stealy Medical Group is seeking full-time BC/BE Occupational 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, or email lori.miller@sharp.com. [527] SEEKING OB/GYN NOCTURNIST PHYSICIANS: SHARP Rees-Stealy Medical Group is seeking fulltime and part-time BC/BE ob-gyn nocturnists to join our staff working at Sharp Mary Birch Hospital. 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, or email lori.miller@sharp.com. [526] DERMATOLOGIST NEEDED: Dermatologist, with California license, needed for a well established, well respected dermatology practice in Encinitas, CA. Part-time or full-time position available immediately. Competitive salary. Training in Mohs micrographic surgery a plus. Exceptional new graduates are considered for the position. Please email CV to dermmd10@gmail.com or call (760) 612-7171. [523] PRIMARY CARE JOB OPPORTUNITY: Home Physicians (www.thehousecalldocs.com) is a fast-growing group of house-call doctors. Great pay ($200–$250+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]

OFFICE SPACE AVAILABLE / REAL ESTATE SOUTH BAY OFFICE SPACE AVAILABLE: Looking to grow your practice? If you’re an orthopedic specialist, ENT, urologist, neurologist, or geriatrics, we have an opportunity to enter a turn-key office. Medicare patients and stable income. Location: South Bay. Please call (619) 980-5282. [570]

and internet lines. Price negotiable, but looking for $1,200–$1,500 based on number of days per month and schedule. There is parking right out front and bathroom in lobby area. First floor and parking under building for lessee. Please contact Dana at (858) 603-2068 or at dana@sdrheumatology.com. [556] MEDICAL OFFICE BUILDING FOR SALE: 1729 Palm Avenue is an approximately 2,433-square-foot, freestanding, professional medical office building conveniently located in San Diego. The property can be occupied by an individual owner or as a two-tenant building, which would offer new owner flexibility in occupancy while receiving additional rental income. The property offers excellent exposure and visibility along Palm Avenue with approximately 38,000 ADT (Costar) and is minutes away from Imperial Beach and the Pacific Ocean. Please contact Chris Baumgart with Cushman & Wakefield for more information at (760) 431-3847 or at chris.baumgart@cushwake.com. [558]

ADMINISTRATIVE ASSISTANT FOR BUSY WORKERS’ COMPENSATION MULTISPECIALTY PRACTICE: Must know work comp, multi-task, and be detail-orientated. Bi-lingual helpful. Full-time with great benefits. Please email rmcmurtrie@davidkupfermd.com with resume. [547] 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. Part-time, flexible days / hours. Competitive compensation. Call (619) 992-5330 or email drhunt@thehousecalldocs.com. Visit www.thehousecalldocs.com. [038] OFFICE FURNITURE / MEDICAL EQUIPMENT FOR SALE

CLASS A MEDICAL OFFICE CONDO FOR SALE OR LEASE Encinitas • 781 Garden View Court 2,809 SF (divisible to 1,000 SF)

Rare opportunity to purchase or lease a first-class 2,809 SF medical office condominium in the heart of North County near Scripps Memorial Hospital Encinitas. The space can be easily reconfigured for a variety of medical uses and sizes, and is currently OSHPD-3 certified. The building has excellent parking and is located just off of N. El Camino Real near the vast number of highly-frequented retail and restaurant attractions and other healthcare providers. For more information, please contact Chris Ross at (858) 410-6377 or chris.ross@am.jll.com. LA JOLLA (NEAR UTC) MEDICAL OFFICE FOR SUBLEASE OR SHARE: Genesee Plaza medical office building. 9339 Genesee Ave. Great location between I-5 and I-805. Up to four exam rooms and private or shared consult office available. 1,500-square-foot beautiful office. Additional 1,800 square feet available to build out. Reasonable rent. Please call (858) 6257979 and ask for Alicia. [568] SHARE OFFICE SPACE IN SAN DIEGO: Near Alvarado Hospital. Beautiful office with two exam rooms and one procedure room. Available up to three days per week. Reasonable monthly rent with no contract required. Email Pat at patbutina@sbcglobal.net. [563] OFFICE SPACE TO SUBLET ON CAMPUS OF SHARP CHULA VISTA MEDICAL CENTER HOSPITAL: Located at 752 Medical Center Court. Half days to share available. Completely furnished, turnkey operation, pleasant environment. For additional details, please email Connie Espinoza, Business Office Manager, at conniee4@gmail.com. [561] LOOKING FOR OFFICE SPACE IN THE ENCINITAS AREA? I am looking to sublease a 2–3 exam room medical office and lobby area 2–3 days per week. I only plan to be there 1–2 days per week, so you’d have access to the entire office and could store charts, etc., there if needed. Can use phone

LA JOLLA (NEAR UTC) MEDICAL OFFICE FOR SUBLEASE OR SHARE: Scripps Memorial medical office building. Great location, steps to main hospital entrance. 9834 Genesee Ave. between I-5 and I-805. Up to four exam rooms and private or shared consult office available. Please call (858) 622-9076 and ask for Jennifer. [530] 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] 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] BUILD TO SUIT: 950SF 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 six gated parking spaces, two entryways, restrooms, lighted tower sign space. Build-out allowance to $5,000 for 4–5 year lease, rent $1,800 per month net ($400 NNN). 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 MEDICAL BILLERS NEEDED: Medical billers with greater than two years of experience needed. Part-time or full-time available. Full-time available with full benefits. Please send resume to FootMD@FootMD.org. [569] ADMINISTRATIVE ASSISTANT NEEDED for busy family practice solo office in La Mesa. Knowledge of medical billing and coding a must. Front office experience a must! Full time with great benefits. Please email resume to p.fortuna@efpmg.com. [557]

NEARLY NEW OFFICE FURNITURE AVAILABLE BELOW MARKET PRICING: Conference room table (medium to light wood) with black leather high back chairs with arm rests, physician desks with matching hutch, waiting room chairs (navy blue leather with light wood), and exam room tables and chairs (black leather with light wood). Everything is in excellent condition and looks brand new. Please call Tracy at (619) 286-9480 for information. [549] SERVICES OFFERED PHYSICIAN OFFICES IN NEED OF ASSISTANCE FOR MEANINGFUL USE ATTESTATION of their electronic health records can avail themselves of technical assistance from Champions for Health, the sister organization to SDCMS. Practices attesting on the Medi-Cal Incentive Program with at least 30% of patients billed to Medi-Cal can receive free assistance thanks to a federal funding source. Medicare practices can receive the same great service at a very reasonable rate, and SDCMS-CMA members receive a discount. For more information, email Barbara.Mandel@ChampionsFH.org or call (858) 300-2780. [559]

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

FAMILY PRACTICE MD/DO AND PHYSICIAN ASSISTANT WANTED IN BEAUTIFUL LA COSTA: Various shifts available at urgent care / family practice office. Nights, weekends, and day hours available. Please fax or email CV to (760) 603-7719 or gcwakeman@sbcglobal.net. [551]

SAN DIEGO PHYSICIAN.org

P o e t r y and M e d i c i n e

Honey of Your Hive by Daniel J. Bressler, MD, FACP Honey of Your Hive

References to honey as food and medicine go back to the earliest stories in human history. Cave paintings in Spain from 17,000 years ago show one of our ancestors taking honey from a hive as bees buzz menacingly about. In today’s medicine, honey has emerged as a wound dressing par excellence. I use it in my office practice for burns and abrasions, and in my nursing home practice for decubitus ulcers. A recent review article in Burns in 2016 — “The Effects of Honey Compared to Silver Sulfadiazine for the Treatment of Burns” — suggests that honey may be superior to a standard topical antibiotic for sterilizing wounds and hastening healing time. The authors from a 2016 article in Journal of Functional Foods found that honey had potent antibacterial qualities and also increased fibroblast proliferation and, through activation of antioxidant signaling pathways, protected mitochondrial function. Bees use honey to store energy for the winter when the pollen that they eat during the blooming seasons is not available. Honey is a product of their activity and also a protector of their future. In the poem “Honey of Your Hive,” I riff off the bee’s relationship with honey, imagining that inside of each of us is something that is both the outcome of our lives and a resource that we can draw on when our own winter season comes. Dr. Bressler, internist and SDCMSCMA member since 1988, is chair of the Biomedical Ethics Committee at Scripps Mercy Hospital and a longtime contributing writer to San Diego Physician.

January 2017

When the cawing crows are gathering in circles overhead And you think you may not make it out alive Turn your thoughts away from what will happen once you’re dead And reach into the honey of your hive. When the rolling dice of circumstance have snake eyes for your fear And the faithful few just do the shuck and jive Turn your full attention to the person in the mirror Remembering the honey of your hive. When you’re feeling like a phony in public word and deed And your résumé seems padded and contrived Ask yourself explicitly for whom and what you’d bleed Emboldened by the honey of your hive. When you’re floundering on surfaces afraid to dive down deep Waiting for some message to arrive Find the hidden place you store those promises to keep It’s there within the honey of your hive. If you’re going through the motions of your day-to-day routine Though you know this show is coming to you live Call to mind the crucial contribution you have been Stored within the honey of your hive. Forget the critics’ arguments, forget the hateful claims Those aren’t the gifts to cherish and archive Remember in their place affection’s warmest flames Glowing in the honey of your hive. So never give up easily — no don’t give up at all. Use everything you’ve mastered to revive The specified elixir that will heal you when you fall Is safe within the honey of your hive.

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You give your all to helping others live full, healthy lives. You go the extra mile to seek out answers and cures, knowing that sometimes even your best efforts aren’t enough. You’re a physician, and that’s how you do your job. At CAP, we salute your dedication and support you in every way we can — with protection to reduce the worry of professional liability lawsuits, but also with a host of value-added services to help manage your practice so you can focus on the highest quality professional care. Ask for a no-obligation quote and more information on CAP membership.

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