March 2022 by San Diego Physician

Official Publication of SDCMS MARCH 2022

MICRA AT RISK!

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Editor: James Santiago Grisolia, MD Editorial Board: James Santiago Grisolia, MD; David E.J. Bazzo, MD; Robert E. Peters, MD, PhD; William T-C Tseng, MD Marketing & Production Manager: Jennifer Rohr Art Director: Lisa Williams Copy Editor: Adam Elder OFFICERS President: Sergio R. Flores, MD President–Elect: Toluwalase (Lase) A. Ajayi, MD Secretary: Nicholas (Dr. Nick) J. Yphantides, MD, MPH Immediate Past President: Holly B. Yang, MD, MSHPEd, HMDC, FACP, FAAHPM GEOGRAPHIC DIRECTORS East County #1: Catherine A. Uchino, MD East County #2: Rakesh R. Patel, MD Hillcrest #1: Kyle P. Edmonds, MD Hillcrest #2: Steve H. Koh, MD (Board Representative to the Executive Committee) Kearny Mesa #1: Anthony E. Magit, MD, MPH Kearny Mesa #2: Alexander K. Quick, MD La Jolla #1: Preeti S. Mehta, MD (Board Representative to the Executive Committee) La Jolla #2: David E.J. Bazzo, MD, FAAFP La Jolla #3: Sonia L. Ramamoorthy, MD, FACS, FASCRS North County #1: Arlene J. Morales, MD North County #2: Christopher M. Bergeron, MD, FACS North County #3: Nina Chaya, MD South Bay #1: Paul J. Manos, DO South Bay #2: Maria T. Carriedo-Ceniceros, MD AT–LARGE DIRECTORS #1: Thomas J. Savides, MD #2: Kelly C. Motadel, MD, MPH #3: Irineo (Reno) D. Tiangco, MD #4: Miranda R. Sonneborn, MD #5: Stephen R. Hayden, MD (Delegation Chair) #6: Marcella (Marci) M. Wilson, MD #7: Karl E. Steinberg, MD, FAAFP #8: Alejandra Postlethwaite, MD ADDITIONAL VOTING DIRECTORS Medical Student: Jimmy Yu Resident: Nicole L. Herrick, MD Young Physician: Brian J. Rebolledo, MD Retired Physician: Mitsuo Tomita, MD CMA OFFICERS AND TRUSTEES Robert E. Wailes, MD William T–C Tseng, MD, MPH Sergio R. Flores, MD Timothy Murphy, MD AMA DELEGATES AND ALTERNATE DELEGATES District I: Mihir Y. Parikh, MD District I Alternate: Sergio R. Flores At-Large: Albert Ray, MD At-Large: Robert E. Hertzka, MD At-Large: Theodore M. Mazer, MD At-Large: Kyle P. Edmonds, MD At-Large: Holly B. Yang, MD, MSHPEd, HMDC, FACP, FAAHPM At-Large Alternate: David E.J. Bazzo, MD, FAAFP CMA DELEGATES District I: Karrar H. Ali, DO, MPH District I: Steven L.W. Chen, MD, FACS, MBA District I: Franklin M. Martin, MD, FACS District I: Vimal I. Nanavati, MD, FACC, FSCAI District I: Peter O. Raudaskoski, MD District I: Kosala Samarasinghe, MD District I: James H. Schultz, MD, MBA, FAAFP, FAWM, DiMM District I: Mark W. Sornson, MD District I: Wynnshang (Wayne) C. Sun, MD District I: Patrick A. Tellez, MD, MHSA, MPH RFS: Rachel Buehler Van Hollebeke, MD

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.]

Contents MARCH

VOLUME 109, NUMBER 3

Features

Protect Access to Quality Healthcare — Oppose the Costly MICRA Measure By Paul Hegyi, MBA

Protect MICRA! An Important Message from SDCMS’ President By Sergio R. Flores, MD

Polio, Chickenpox, Measles, Now COVID. It’s Time to Consult History on School Vaccine Mandates By Elisabeth Rosenthal

Op Ed: Medical Malpractice Ballot Measure Would Benefit Lawyers By Kerry Hydash, MPA

Is There a Role for Maintenance PARP Inhibition in Metastatic Urothelial Cancer? By Mike Bassett

Departments

Briefly Noted: Medical Organizations • Pandemic Preparation • Practice Management

A Reflection on Pharmacotherapy for Alzheimer’s Disease By Ian Curtis Neel, MD

Telehealth As Disruptive Innovation By James Grisolía, MD

What are Taxpayers Spending for Those ‘Free’ COVID Tests? The Government Won’t Say By Christine Spolar

Then Life Changes By Adama Dyoniziak

Social Media’s Role in Youth Suicide Gets Spotlight at House Hearing By Shannon Firth

As Corporate Entities Enter Healthcare, Practices Can Respond Via Patient-Centered Care By Richard E. Anderson, MD, FACP

Which Version of Hard Will You Choose? By Helane Fronek, MD, FACP, FACPh

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BRIEFLY NOTED 2

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MEDICAL ORGANIZATIONS

CMA Legal Counsel to Lead Primary Care Association As New President and CEO THE CALIFORNIA MEDICAL ASSOCIATION (CMA) announced with pleasure that legal counsel Francisco J. Silva, Esq., will become the California Primary Care Association’s (CPCA) new president and CEO, starting March 28, 2022. CPCA represents 1,370 not-for-profit community health centers and regional clinic associations across the state that provide care to more than 7.2 million patients each year. Community health centers are committed to providing comprehensive, high-quality healthcare in a compassionate and culturally sensitive manner. “On behalf of the entire organization, we thank Francisco for his tireless service, passion, and dedication to California’s physicians,” said CMA CEO Dustin Corcoran. “We know that he will continue to be a tremendous leader in healthcare and CPCA is fortunate to have him. The entire team at CMA celebrates this incredible opportunity and honor for Francisco.” Silva’s tenure at CMA spanned 17 years. He most recently served as general counsel and senior vice president of legal affairs, economic services, and health policy.

In this role, he provided strategic counsel to the executive team, Board of Trustees, and affiliated companies, as well as spearheaded CMA’s litigation, legal, and regulatory advocacy efforts. He was instrumental in helping CMA navigate the politics and policy of complex healthcare issues before federal and state regulators to drive the public interest mission of the association and its physician members. He also helped establish and directed the organization’s first Justice, Equity, Diversity, and Inclusion initiative. Silva is a graduate of Santa Clara University, UCLA School of Law, and USC Marshall School of Business, and holds both a JD (Juris Doctor in Law) and an MBA (Master’s in Business Administration). Prior to joining CMA, Silva served as the vice president and counsel for government affairs for the California Apartment Association and was a litigation attorney at Heller Ehrman, LLP, in San Francisco and at the office of Downey Brand, LLP, in Sacramento.

PANDEMIC PREPARATION

CMA Issues Statement of Support for California Pandemic Early Detection and Prevention Initiative CMA PRESIDENT ROBERT E. WAILES, MD, issued the following statement in support of the California Pandemic Early Detection and Prevention Initiative: “The COVID-19 pandemic is a stark reminder of the cost of not having a robust public health system in place. The United States was unprepared for COVID-19 because our public health and disease prevention systems have been chronically underfunded and neglected. We were left vulnerable to the pandemic, which has led to a dramatic loss of human life, severely strained

our hospitals and healthcare workers, and caused widespread economic destruction while disproportionally harming low-income and underserved communities. The California Medical Association is in strong support of the California Pandemic Early Detection and Prevention Initiative because everyone deserves to live a long and healthy life. This initiative will modernize local public health departments across our state and invest in science and technology to detect, prevent, and defeat diseases before they can cause a deadly and devastating pandemic.”

PRACTICE MANAGEMENT

CMA Tells Congress More COVID-19 Relief Is Needed to Sustain Physician Practices

TRUST

WITH MORE THAN 70% OF PHYSICIANS STILL CONCERNED ABOUT THE

financial health of their practices, the California Medical Association (CMA) is urging Congress to continue to support physicians and their staff during this unrelenting pandemic. The second year of the pandemic truly tested physician stamina. Frontline physicians fought burnout and massive health staffing shortages, all physicians worked to sustain the viability of their practices, and physicians began to address the secondary impacts of the pandemic: worsening health conditions caused by delays in care, as well as a tsunami of mental health and substance-abuse issues. CMA warned Congress that the long-term fallout from the pandemic would be felt by patients for years to come and fundamentally alter the long-term stability of physician practices threatening access to care throughout California. CMA is urging Congress to help physicians continue to respond to the pandemic by distributing the remaining Provider Relief Fund funds immediately and to replenish the fund to ensure the long-term stability of the healthcare system. CMA is also urging Congress to extend the Medicare sequestration waiver and stop the cuts until the end of the public health emergency. Since the beginning of the pandemic, Congress has waived the 2% sequestration cut in Medicare payments to providers, but the most recent legislation only blocks the cut until April 1, 2022. At the beginning of the pandemic, Congress also provided advance payments through the Medicare program, similar to short-term loans. The repayments are due soon and CMA is urging Congress to push back the repayment schedule to allow physicians additional time to repay these loans. Two years of sustained financial and staffing pressures have pushed almost one in three physicians to consider consolidation, either in the form of becoming employed by or being acquired by a health system, hospital, or other entity, in favor of financial stability, decreased administrative hassle, and better access to reliable staffing. Additionally, some physicians note they are now preparing for an early retirement due to the physical, mental, and financial stress of the pandemic or have already had to close their practices. CMA’s alarming survey findings underscore the need to address these pressures so that physicians are able to continue serving their patients during the pandemic and beyond.

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Protect Access to Quality Healthcare — Oppose the Costly MICRA Measure BY PAUL HEGYI, MBA

HIS FALL, CALIFORNIA VOTERS WILL BE ASKED

to vote on a new ballot measure that would drive up healthcare costs, restrict access to care for low-income patients, and decimate the protections afforded to patients across California as part of the Medical Injury Compensation Reform Act (MICRA). This initiative, bankrolled with millions of dollars from an Iowa-based trial attorney, would effectively eliminate the cap on non-medical damage awards in malpractice cases, substantially raising healthcare costs for all Californians while allowing attorneys to collect unlimited fees from medical malpractice awards. In short, this measure would provide new incentives for lawyers to file frivolous medical malpractice suits, creating a chilling effect on the practice of medicine and clearing the way for new financial windfalls for California’s trial lawyers at taxpayer expense. While current California law allows patients to recoup unlimited damages for medical expenses, lost wages, and in cases of gross medical negligence, the law also caps noneconomic damages in malpractice cases. The law was put in place to ensure injured patients receive fair compensation while also protecting doctors, hospitals, and other healthcare providers from frivolous, punitive lawsuits that drive up healthcare costs. This initiative would erase those protections and send taxpayers the bill. According to California’s independent Legislative Analyst’s Office, this measure would lead to “annual government costs likely ranging from the low tens of millions of dollars to the high hundreds of millions of dollars,” and will reduce access for those who need it most, including those who use Medi-Cal, county programs, safety net providers, and school-based health centers. County and state hospitals have to pay medical malpractice awards out of the budgets they receive from taxpayers. This means that if medical malpractice awards increase, government costs will increase too. Somebody has to pay, and that will be taxpayers through higher taxes and California citizens

through higher healthcare premiums. According to one economic analysis, this measure would increase the average annual cost of healthcare for a family of four by $1,100. This push to eliminate MICRA is led by Nicholas Rowley, a rich trial attorney from Iowa, who has publicly said that he is willing to spend at least $20 million of his own money in support of the initiative. For Rowley, the investment makes sense. If he is successful, he and his law firm will be unshackled from current limits on attorneys’ fees, and stand to make millions while sending California taxpayers the bill. Physicians take an oath to protect patients — and this dangerous proposal would put patients at risk of losing access to quality medical care. In 2014, voters were clear when they rejected Prop. 46 and changes to MICRA that would have quadrupled the cap on non-economic damages because of the negative effects that it would have on their quality of care and pocketbooks at large. This measure goes well beyond what Prop. 46 would have done, and the cost to taxpayers would be far greater. The California Medical Association has joined Californians to Protect Patients and Contain Health Care Costs, a broad coalition of physicians, dentists, nurses, hospitals, safety net clinics, and other healthcare providers, to oppose this initiative. Together, we are vigorously fighting this initiative in order to protect access to quality healthcare for Californians across the state. To join the campaign, please visit cmadocs.org/micra. Paul Hegyi is CEO of the San Diego County Medical Society.

MICRA A

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Protect MICRA! An Important Message from SDCMS’ President BY SERGIO R. FLORES, MD

S A PHYSICIAN, MY PRIMARY GOAL IS TO

protect my patients and provide quality medical care to those who need it most. Unfortunately, a measure heading to California’s November 2022 ballot could put patient access to care at risk and make it even more burdensome for physicians like you and me to treat and care for the patients we aim to serve. The California Medical Association (CMA) and the San Diego County Medical Society have joined with a broad coalition of community clinics, hospitals, nurses, public safety, business, and labor groups to oppose a dangerous measure that will appear on the ballot this fall. This costly ballot measure, bankrolled and written by an out-of-state trial lawyer, is an effort to eliminate the cap on non-economic damages in medical malpractice cases and erase the current cap on fees lawyers can take in victim damage award cases. This dangerous proposal would pave the way for new rounds of frivolous lawsuits and send

the price of healthcare soaring by hundreds of millions of dollars, according to the state’s nonpartisan Legislative Analyst’s Office. These costs would be borne directly by patients and taxpayers and have a devastating effect on access to care for patients everywhere. It would hit particularly hard for patients in rural and other medically underserved communities. At a time when our state is in the midst of an affordability crisis, now is the worst possible time to drive up healthcare costs and reduce access to care for those who need it most. That’s why I am asking you to join me, CMA, and SDCMS in the campaign to defeat this measure in November. The initiative, which does not yet have a ballot number, is bad for patients, taxpayers, and the entire healthcare system. There has never been a greater need for physicians to band together and use our collective voice to fight for our patients. This measure was written by one out-of-state trial lawyer trying to change state law so he and his law firm can profit. While proponents will talk a lot about how they are trying to protect patients, make no mistake — this measure is about padding their profits at the expense of patients and taxpayers. Our health laws should protect access to care and control costs for everyone, not be manipulated by a single attorney for his own profit. Over the next several months, you’ll hear a lot of rhetoric from the proponents of the measure. Don’t be fooled. This is just the latest example of an out-of-state trial lawyer trying to fool the voters into thinking this is about something it’s not. We need your help to educate yourselves, your patients, and your communities about the risk this measure poses for all of California. Please join me, CMA, and SDCMS in this opportunity to rally together to protect the medical profession against forces that are simply trying to enrich themselves, regardless of who may be hurt by this regressive policy proposal. For more information about how to get involved, please visit cmadocs.org/micra. Thank you for your support! Dr. Flores is president of the San Diego County Medical Society, vice chair of the California Medical Association Board of Trustees, and is a gastroenterologist.

AT RISK

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MICRA BALLOT MEASURES

Op Ed: Medical Malpractice Ballot Measure Would Benefit Lawyers BY KERRY HYDASH, MPA

ERHAPS MORE THAN ANY

state in America, California continues to make progress toward the historic promise of health access for all. Vital to that prognosis has been our state’s community health centers, located in medically underserved communities and providing diverse, vulnerable populations with primary and reproductive care. Pandemic-related stresses on our overall health system, including the most recent hospitalization surge, has underscored the safety-net imperative of a strong and financially solvent system of community clinics. It would be hard to imagine a worse possible time to pass a ballot measure that would disrupt the financing of California’s community health centers and access to the physicians and other clinicians providing essential care to Californians in need while increasing health costs for every Californian. But that’s what the proponents of the misleadingly self-proclaimed Fairness for Injured Patients Act, or Changes to Medical Malpractice Lawsuits Cap Initiative, appearing on the statewide ballot in November are trying to do. This measure would dramatically impact the cost and delivery of healthcare in California — but it’s not written 6

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by health experts or real-life medical practitioners. Instead it was drafted to allow a few to make millions more from filing personal injury lawsuits. What’s worse is that supporters are not saying what this measure would truly do. For many years, California’s medical liability system has been protected by a bipartisan series of laws called MICRA, the Medical Injury Compensation Reform Act, which has balanced the rights of injured patients while keeping healthcare more accessible and affordable for all patients. While injured patients can receive unlimited payments for economic losses and medical expenses, there is a “cap” on non-economic damages. Despite what proponents are saying, the Fairness for Injured Patients Act would dramatically overhaul our health system far beyond a simple increase in the MICRA cap. In fact, the Fairness for Injured Patients Act brazenly creates a new category of injury with no cap whatsoever — which is broadly defined and can include outcomes as innocuous as unwanted scarring. This is the loophole that would effectively obliterate the MICRA cap and start a mad dash by enterprising attorneys filing countless new lawsuits in already overcrowded courts. To no one’s surprise, the Fairness for

Injured Patients Act’s fine print stealthily removes all existing caps on attorney’s fees, resulting in huge financial windfalls for trial lawyers who sue doctors, nurses, clinicians, and other health providers for a living. It also creates a new process that prohibits judges from independently verifying the truthfulness of statements made by trial attorneys in the initial court filings — another incentive for more frivolous lawsuits. And who pays for this onslaught of new lawsuits and attorney payouts? The rest of us. The initiative would place an unmanageable burden on our healthcare delivery system at a time when many of our community health centers are already operating on razor-thin margins and are faced with staffing shortages. Taxpayers are on the hook as well. The state’s nonpartisan Legislative Analyst’s Office said the Fairness for Injured Patients Act “would likely have a wide variety of fiscal effects on state and local governments,” including “annual government costs likely ranging from the low tens of millions of dollars to the high hundreds of millions of dollars.” The trickle-down effect of this measure would result in community clinics closing their doors, essential health services being slashed, and healthcare providers having to limit new patients. The hardest impact will be felt by women, communities of color, and individuals with special needs — all when we should be reducing health inequities and expanding access to healthcare for those who need it most. That’s why hundreds of organizations have already signed up to oppose the Fairness for Injured Patients Act in November. Clinicians, physicians, nurses, dentists, community clinics, health centers, hospitals, public safety organizations, and other frontline healthcare workers across the state are urging voters to say “No” to this dangerous, costly measure. Kerry Hydash is president and chief executive officer of Family Healthcare Network. For more than 40 years, Family HealthCare Network has advanced the development of community-based primary healthcare delivery systems to address the healthcare needs of underserved and vulnerable populations. This op-ed originally appeared on CalMatters.org.

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DEMENTIA

A Reflection on Pharmacotherapy for Alzheimer’s Disease BY IAN CURTIS NEEL, MD

WAS ASKED TO EVALUATE JUDY, an 85-year-old who had a diagnosis of Alzheimer’s disease and had developed behavioral agitation. She first developed symptoms 10 years prior to my evaluation and had gradual progression of memory decline since that time. In 2015 she had scored in the moderately impaired range on cognitive testing and was started on an acetylcholinesterase inhibitor, donepezil. She was unable to tolerate donepezil due to severe nausea and migraine headaches, and as a result was changed to the NMDAreceptor antagonist, memantine. She remained on memantine for three years without notable benefit with the medication stopped due to increasing agitation. She was then started on transdermal rivastigmine but could not tolerate it due to nausea on high dose and migraines on the lower dose. Despite this, she was continued on the rivastigmine patch for four more years with worsening of her memory symptoms, which had progressed to the point of an inability to perform any activities of daily living (ADLs), ambulate safely, or speak. Several months prior to my seeing her, she was started on galantamine, another acetylcholinesterase inhibitor, while also continued on the low-dose rivastigmine patch. She had worsening aggression after initiation of galantamine and had been losing weight due to food refusal. Among other polypharmacy reductions, upon seeing her I discontinued both her rivastigmine and galantamine to lessen her behavioral agitation. Judy’s case has stuck in my mind as a recent salient example of how we can often forget the patient when prescribing for dementia, focusing on the disease

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rather than what the treatment may or may not be doing to the patient. A standard principle of prescribing in geriatric medicine is to always weigh the risks of a prescribed medication against the potential benefits — and reconsider the approach if the adverse effects outweigh any observed improvement. This question is one I weigh in treating patients with dementia on a daily basis and is best answered with a review of the evidence behind the benefits of the available pharmacotherapy. The first class of medications available for the treatment of Alzheimer’s dementia are the acetylcholinesterase inhibitors. Several landmark papers such as the AD2000 trial and a 2018 metaanalysis reviewing 142 different trials of acetylcholinesterase inhibitors, as well as the non-competitive NMDA receptor antagonist memantine, have shown minimal statistical but not clinical benefit for the available treatments for dementia. When prescribing them one must constantly evaluate if a clinically relevant benefit is observed via serial cognitive test evaluations, as well as routinely monitor for adverse effects. The side-effect profile is large, with 23% of patients started on donepezil experiencing some degree of GI adverse effect, which can range from nausea to refusal of food and resultant weight loss. A rarer side effect is that of symptomatic bradycardia, which can be fatal. I have unfortunately seen a significant number of patients who developed third-degree AV block shortly after being started on acetylcholinesterase inhibitors, leading to pacemaker placement in whom the treating physicians did not attempt to stop the precipitating drug due to lack of

recognition of the risk. Memantine has a smaller side-effect profile than the acetylcholinesterase inhibitors, but the side effects of the agent can be deleterious to those with laterstage dementia for whom it is approved to treat. These side effects are largely neuropsychiatric and can range from mood lability and vivid dreams to frank psychosis. As with acetylcholinesterase inhibitors, it is recommended to stop the medication if side effects develop due to the unfavorable risk-to-benefit ratio. These questions of risk versus benefit weigh even heavier when considering the recent FDA approval of a monoclonal antibody, which to date hasn’t shown a clear clinically relevant benefit but has a 41% risk of developing amyloid-related imaging abnormalities (ARIA) consisting of cerebral hemorrhage or edema. In a disease such as Alzheimer’s, where there is no clearly effective pharmacotherapy, we often prescribe what medications exist to give hope in the face of a frightening syndrome. The risk, as in cases such as Judy’s, is we often can continue these medications well beyond their point of benefit, causing patients to suffer potentially significant side effects, such as Judy’s constant struggle with migraines following initiation of rivastigmine. As healthcare providers, we provide hope to patients but must be careful to avoid providing false hope. By understanding the evidence behind the pharmacotherapy approved for the management of Alzheimer’s dementia, we can better equip ourselves to discuss the risks and benefits of these agents with patients for shared decision making on their use. Dr. Neel is a board-certified geriatrician affiliated with UC San Diego Health, where he specializes in the treatment of memory disorders. He is also an active member of the San Diego Alzheimer’s Project. The Alzheimer’s Clinical Guidelines and more information and resources on pharmacotherapy can be found at ChampionsforHealth.org/alzheimers.

TELEHEALTH

Telehealth As Disruptive Innovation BY JAMES S. GRISOLÍA, MD

ELEHEALTH EXPANDED

radically with Medicare authorization during the pandemic, growing from some 840,000 visits in 2019 to 52.7 million visits in 2020. Aside from helping patients and providers avoid contagion, frail and immobile patients and their families continue to benefit hugely, transforming healthcare in truly unexpected ways. Disruptive innovation became a cliché concept in the ’90s but actually disrupting healthcare has proven more difficult. Telehealth will do it. Potentially, our unsustainable healthcare system could improve, yet without a doubt it will change. But with how much discomfort for physicians and others invested in the current system? To great fanfare, Amazon, JP Morgan, and Berkshire Hathaway started Haven, a joint venture to transform healthcare in 2018, but slunk offstage in late 2020, saying “Healthcare was too big a problem.” Meanwhile, Amazon developed

Amazon Care for its employees in Seattle, and now is expanding to cities across the country, including LA and soon San Francisco. Amazon Care potentially disrupts healthcare by providing online, appbased 24/7 access to telehealth services, with options for in-person home follow-up by nurses or even physicians to provide exams, vaccination, lab draws, etc., plus home delivery of meds from Amazon’s pharmacy. In Seattle, Amazon formed a relationship with Oasis Medical Group, apparently independently owned, but now rebranded as Care Medical and expanding with Amazon Care into states across the nation. Amazon Care intends to offer continuous, on-demand urgent care/primary care online. For most patients, fees are charged directly to a credit card or HSA/ FSA (healthcare savings account/flexible savings account) and the patient must then submit to insurance for any reimbursement, but some employers already

find the usage-based fee structure more attractive than current per member/ per month charges. Apparently, Amazon Care does not have contracted relationships for surgical or other specialty services — yet. It does not provide emergency or any hospital-based services. However, if it can successfully market as a value-added service to employers, with time, it could take a larger chunk of the employer-based insurance market. While Amazon Care provides a more elaborate model, the underlying disruption relies on telehealth and its dramatic acceptance during the pandemic. Haven imploded because it tried to do too much, taking on the entire healthcare system at once, but telehealth and virtual care are low-hanging fruit. Other companies are also moving in, such as Doctor on Demand, which now combines telehealth with care navigation and second opinion services. All physicians, indeed all of healthcare, will have to think about how to meet this challenge. Of course, regulation and quality oversight will have to evolve, but how does conventional medical practice evolve under this pressure? Increasingly, we live in a world of on-demand services, instant access, and quick answers to simple questions. How can we articulate the difference between a five-minute consultation about a simple rash versus a complex, wisdombased assessment of multiple chronic conditions? As healthcare systems, how can we offer surgical procedures and complex consultations in a more timely, cheaper format? As healthcare costs continue to climb, each of us should reflect on disrupting our current system: both the benefits and the potential costs. Dr. Grisolía is chief of staff-elect at Scripps Mercy Hospital in San Diego and a clinical neurologist. He is also an SDCMS member and editor of San Diego Physician.

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COVID TESTING

What Are Taxpayers Spending for Those ‘Free’ COVID Tests? The Government Won’t Say BY CHRISTINE SPOLAR

HE FOUR FREE COVID-19

rapid tests President Joe Biden promised in December for every American household have begun arriving in mailboxes and on doorsteps. A surge of COVID infections spurred wide demand for over-the-counter antigen tests during the holidays: Clinics were overwhelmed with people seeking tests and the few off-the-shelf brands were nearly impossible to find at pharmacies or even online via Amazon. Prices for some test kits cracked the hundred-dollar mark. And the government vowed that its purchase could provide the tests faster and cheaper so people, by simply swabbing at home, could quell the spread of COVID. The Defense Department organized the bidding and announced in mid-January, after a limited competitive process, that three companies were awarded contracts totaling nearly $2 billion for 380 million over-the-counter antigen tests, all to be delivered by March 14. The much-touted purchase was the latest tranche in trillions of dollars in public spending in response to the pandemic. How much is the government paying for each test? And what were the terms of the agreements? The government won’t yet say, even though, by law, this information should be available. The cost — and, more importantly, the rate per test — would help demonstrate who is getting the best deal for protection in these COVID times: the consumer or the corporation. The reluctance to share pricing details flies against basic notions of cost control and accountability — and that’s just quoting from a long-held position by the Justice Department. “The prices in government contracts should not be secret,” according to its website. “Government contracts are ‘public contracts,’ and the taxpayers have a right to know — with very

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few exceptions —what the government has agreed to buy and at what prices.” Americans often pay far more than people in other developed countries for tests, drugs, and medical devices, and the pandemic has accentuated those differences. Governments abroad had been buying rapid tests in bulk for over a year, and many national health services distributed free or low-cost tests, for less than $1, to their residents. In the U.S., retailers, companies, schools, hospitals, and everyday shoppers were competing months later to buy swabs in hopes of returning to normalcy. The retail price climbed as high as $25 for a single test in some pharmacies; tales abounded of corporate and wealthy customers hoarding tests for work or holiday use. U.S. contracts valued at $10,000 or more are required to be routinely posted to sam.gov or the Federal Procurement Data System, known as fpds.gov. But none of the three new rapid-test contracts — awarded to iHealth Labs of California, Roche Diagnostics Corp. of Indiana, and Abbott Rapid Dx North America of Florida — could be found in the online databases. “We don’t know why that data isn’t showing up in the FPDS database, as it should be visible and searchable. Army Contracting Command is looking into the issue and working to remedy it as quickly as possible,” spokesperson Jessica R. Maxwell said in an email in January. This month, she declined to provide more information about the contracts and referred all questions about the pricing to the Department of Health and Human Services. Only vague information is available in DOD press releases, dated Jan. 13 and Jan. 14, that note the overall awards in the fixed-price contracts: iHealth Labs for $1.275 billion, Roche Diagnostics for $340 million, and Abbott Rapid Dx North

America for $306 million. There were no specifics regarding contract standards or terms of completion — including how many test kits would be provided by each company. Without knowing the price or how many tests each company agreed to supply, it is impossible to determine whether the U.S. government overpaid or to calculate if more tests could have been provided faster. As variants of the deadly virus continue to emerge, it is unclear if the government will re-up these contracts and under what terms. To put forth a bid to fill an “urgent” national need, companies had to provide answers to the Defense Department by Dec. 24 about their capacity to scale up manufacturing to produce 500,000 or more tests a week in three months. Among the questions: Had a company already been granted “emergency use authorization” for the test kits, and did a company have “fully manufactured unallocated stock on hand to ship within two weeks of a contract award?” Based on responses from about 60 companies, the Defense Department said it sent “requests for proposals” directly to the manufacturers. Twenty companies bid. Defense would not release the names of interested companies. Emails to the three chosen companies to query the terms of the contracts went unanswered by iHealth and Abbott. Roche spokesperson Michelle A. Johnson responded in an email that she was “unable to provide that information to you. We do not share customer contract information.” The customers — listed as the Defense Department and the Army command — did not provide answers about the contract terms. The Army’s Contracting Command, based in Alabama, initially could not be reached to answer questions. An email address on the command’s website for media bounced back as out-of-date. Six phone numbers listed on the command’s website for public information were unmanned in late January. At the command’s protocol office, the person who answered a phone in late January referred all queries to the Aberdeen Proving Ground offices in Maryland. “Unfortunately, there is an issue with voicemail,” said Ralph Williams, a representative of the protocol office. “Voicemail is down. I mean, voicemail has been

down for months.” Asked about the bounced email traffic, Williams said he was surprised the address — acc.pao@us.army.mil — was listed on the ACC website. “I’m not sure when that email was last used,” he said. “The army stopped using the email address about eight years ago.” Williams provided a direct phone number for Aberdeen and apologized for the confusion. “People should have their phone forwarded,” he said. “But I can only do what I can do.” Joyce Cobb, an Army Contracting Command-Aberdeen Proving Ground spokesperson, reached via phone and email, referred all questions to Defense personnel. Maxwell referred more detailed questions about the contracts to HHS, and emails to HHS went unanswered. Both the Defense and Army spokespeople, after several emails, said the contracts would have to be reviewed, citing the Freedom of Information Act that protects privacy, before release. Neither explained how knowing the price per test

could be a privacy or proprietary concern. A Defense spokesperson added that the contracts had been fast-tracked “due to the urgent and compelling need” for antigen tests. Defense obtained “approval from the Assistant Secretary of the Army for Acquisition, Logistics, & Technology to contract without providing for full and open competition.” KHN separately searched for the contracts on the sam.gov website during a phone call with a government representative who assisted with the search. During an extended phone session, the representative called in a supervisor. Neither could locate the contracts, which are updated twice a week. The representative wondered whether the numbers listed in the Defense press release were wrong and offered: “You might want to double-check that.” On Jan. 25, Defense spokesperson Maxwell, in an email, said that the Army Contracting Command “is working to prepare these contracts for public release and part of that includes proactively

Tracy Zweig Associates A

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Physicians

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readying the contracts for the FOIA redaction.” Three days later, she sent an email stating that “under the limited competition authority … DOD was not required to make the Request for Proposal (RFP) available to the public.” Maxwell did not respond when KHN pointed out that the contracting provision she cited does not prohibit the release of such information. In a Feb. 2 email, Maxwell said “we have nothing further to provide at this time.” On sam.gov, the COVID spreadsheets include a disclaimer that “due to the tempo of operations” in the pandemic response, the database shows only “a portion of the work that has been awarded to date.” In other words, it could not vouch for the timeliness or accuracy of its own database. Christine Spolar is an experienced investigative reporter who is a former executive editor of Kaiser Health News, where this article first appeared. It also appeared in USA Today.

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COVID VACCINE MANDATES

Polio, Chickenpox, Measles, Now COVID. It’s Time to Consult History on School Vaccine Mandates BY ELISABETH ROSENTHAL

HE RAPID SPREAD OF

omicron across the nation — and the finding that vaccines continue to provide strong protection against severe disease — brings COVID-19 one step closer, perhaps, to truly earning its place on the list of diseases that have been tamed by vaccines. These include polio, measles, mumps, rubella, and chickenpox — all of which most kids must generally be vaccinated against before they enter school or day care. Some states have announced COVID vaccine requirements for certain students. But not everyone agrees that vaccine mandates for children are the way forward. Sen. Rand Paul, who has opposed vaccine mandates, called omicron “nature’s vaccine.” Seventeen mostly Republican-led states have proactively banned, in some form, COVID vaccine requirements for students. Resistance to adopt mandates has profound repercussions, especially as vaccination rates among kids ages 5 to 11 remain alarmingly low — under 15% in some states — even though children 5 and over have been eligible for shots since last fall. History holds lessons for why low vaccination rates for children are so risky and why officials should strongly consider school mandates for the COVID vaccine. In the United States, children generally must get a number of vaccines 12

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before they enter school. Such requirements help ensure an entire generation gets their shots against diseases that were feared for decades — sometimes centuries — before vaccines did their work. Such diseases proved even more terrifying in places that were immunologically “naïve,” showing up in bodies that hadn’t seen them before. That’s the devastating place we were with COVID-19 in early 2020. When explorers brought diseases like measles, which had long circulated on the European continent, to native populations of the New World, they killed up to an estimated 80% to 95% of the Indigenous population in repeated outbreaks over the ensuing 100 to 150 years. When global travel become more available, the king and queen of Hawaii arrived in England in 1824 and both died there of measles. The virus came back to Hawaii in 1848 and started an epidemic that killed one-quarter of the native population, by one estimate, then flared to create additional waves that killed more people in the following decades. Even after vaccines were invented and diseases like measles and chickenpox were no longer common (and not medically dangerous for the average child), the United States continued to mandate school vaccination for different but important reasons. We vaccinate against chickenpox and measles in part because those diseases

can be more deadly for adults, for the immunocompromised, and for babies, whose immune systems are still developing. Like COVID. We vaccinate against mumps, in itself usually a mild disease, because some who get it will suffer serious lasting effects, such as hearing loss or infertility in males who’ve passed puberty. You can draw parallels here with “long COVID,” and we still don’t know about the longterm effects of the coronavirus, which can inflame organs. Also, kids with chickenpox must endure a prolonged, miserable isolation at home. And we vaccinate against the chickenpox virus — and measles — because an outbreak at a school can cause significant disruption if vaccination rates are low, triggering actions like contact tracing and other public health measures. Just as with the coronavirus today. We could get lucky and achieve more widespread immunity for COVID relatively quickly, after new waves become less and less overwhelming. But even if that happens, many unvaccinated people

will die or get seriously ill and some kids will miss school when they didn’t need to. New, potentially more dangerous strains have a better chance to emerge. Do we really want to roll the dice and not take full advantage of this very effective tool at our disposal? Which path do we want to take to put the pandemic behind us: the quicker, more certain one of mandatory vaccination or a stuttering, drawn-out affair? Unfortunately, the COVID vaccines landed at a time of deep national divides, when science had become politicized and mistrust of government was high. Even parents who get their children the school-required shots have balked at COVID vaccines. States and school districts that have announced plans for school vaccination requirements already face backlash. This is a far cry from the way the public reacted to the introduction of childhood vaccines in the 20th century. People reacted enthusiastically to the availability in 1955 of the vaccine against polio, a disease that could have disas-

trous health consequences, but — like COVID — was asymptomatic or mild in most people who were infected, particularly children. The hesitancy that existed then was not driven by intense partisanship or political division. One explanation for that era’s enthusiasm for a new shot was that Americans’ memories were long, having lived through fearsome polio outbreaks and the attendant quarantines through much of the mid-20th century. By 1955, many Americans knew someone who had perished from polio or was left partly paralyzed. People have lived with COVID for a relatively short amount of time. Resistance to the COVID vaccine will perhaps dissipate once the FDA moves the shot for children from emergency use authorization to full approval and as waves of COVID affect more Americans. Here’s how my thinking about another vaccine was affected a generation ago: My older child got chickenpox before the shot was available and spent hours in oatmeal baths covered with hundreds of itchy blisters. She couldn’t return to

preschool (nor I to work) for 10 days, until her blisters scabbed over; some scars took years to fade. So when the chickenpox vaccine came to market in 1995, I raced to get my 2-yearold the shot. He still got chickenpox, but a mild case, just like most breakthrough COVID cases: One evening while he was playing, I noticed two telltale blisters on his upper arm that disappeared within 24 hours. He didn’t miss a single play date. Like many childhood vaccines, that shot protected him, our family, my work, our caregiver, his toddler classes, his grandmother, and all the vulnerable people we had come in contact with at the market or on the subway. If we want to bring this pandemic to a rapid denouement, vaccinating schoolchildren can have the same ripple effect and may well be the best way to go. Elisabeth Rosenthal is editor-in-chief of Kaiser Health News, where this column first appeared, and a former reporter for The New York Times, where this article also appeared.

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CANCER TREATMENT

Is There a Role for Maintenance PARP Inhibition in Metastatic Urothelial Cancer? Treatment with Rucaparib Extends PFS in Molecularly Selected Patients BY MIKE BASSETT

N THE ATLANTIS TRIAL, TREATMENT

with rucaparib (Rubraca) led to a median PFS of 35.3 weeks (80% CI 11.7–35.6) versus 15.1 weeks (80% CI 11.9–22.6) with placebo (hazard ratio 0.53, 80% CI 0.30–0.92, P=0.07), according to Simon J. Crabb, PhD, MBBS, of Southampton Experimental Cancer Medicine Centre in Southampton, England. “Further investigation of PARP inhibition is warranted in urothelial carcinoma within a molecularly selected group of patients,” Crabb said at the Genitourinary Cancers Symposium (GuCS). The ATLANTIS trial is a multi-center, umbrella trial in the U.K. in which patients with advanced urothelial carcinoma underwent biomarker pre-screening while receiving first-line chemotherapy. Depending on biomarker allocation, patients were eligible to participate in multiple phase II studies evaluating targeted agents in biomarker-defined subgroups. Patients in the ATLANTIS rucaparib arm (median age 69.5; majority male; most with pure transitional cell carcinoma) were all positive for a biomarker 14

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for DRD that was defined as 10% or greater genome-wide loss of heterozygosity (LOH); alteration in a list of 15 different genes relevant for DNA repair; or known to have germline BRCA1 or BRCA2 alteration. Patients were randomized 1:1 to receive treatment within 10 weeks of completion of chemotherapy with either rucaparib 600 mg twice daily or placebo until disease progression. “We discontinued recruitment after 40 patients had been randomized,” Crabb noted. “There were two reasons for this. Firstly, a shutdown of recruitment to clinical trials in the U.K. in March 2020 as a result of the emerging pandemic, and then data presented just a few months after [in the JAVELIN Bladder 100 trial] that showed there was a survival advantage for the use of avelumab [Bavencio] immunotherapy in this treatment setting.” GuCS session moderator Andrea B. Apolo, MD, of the National Cancer Institute in Bethesda, Maryland, asked whether there were efficacy signals from particular gene alterations. Crabb replied his group is looking at the PFS in those patients that had a gene alteration compared to those who had high LOH alone. “This was an exploratory analysis, and this was post-hoc, and the numbers start to get a bit small, but it does look as though the PFS benefit may be in those patients who had a gene alteration rather than those who had high LOH alone,” he said. “It starts to make you think that in a gene-selected group of patients, potentially there is a way forward here.” For the secondary endpoint of overall survival (OS), the median OS was not reached in the rucaparib arm versus 72.3

weeks (80% CI 51.6–85.4) in the placebo arm (HR 1.22, 80% CI 0.62–2.38, P=0.35). Median duration of treatment was 10 cycles in the rucaparib arm, and six in the placebo arm. There was one confirmed partial response in a patient receiving rucaparib. “So the difference in progression-free survival between the two arms in this trial appears to have been primarily because of maintenance of a preexisting response to prior chemotherapy, rather than we were inducing new objective responses during maintenance treatment,” Crabb said. The safety profile of the drug was consistent with prior experience of this drug with other cancers, Crabb reported. Rucaparib is currently FDA approved in previously treated patients with deleterious BRCA mutation-associated metastatic castration-resistant prostate cancer; for maintenance treatment of recurrent epithelial ovarian, fallopian tube, or primary peritoneal cancer that is in complete or partial response to platinum-based chemotherapy; and in patients with pre-treated deleterious BRCA mutation-associated advanced ovarian cancer. For all grades of treatment-related adverse events (TRAEs) in ATLANTIS patients, the most frequent TRAEs were fatigue (63.2% with rucaparib vs 30.0% with placebo), nausea (36.9% vs 5.0%), and rash (21.1% vs 0%). More patients in the rucaparib arm experienced anemia, lymphopenia, and low phosphate. No TR deaths occurred. Crabb was asked about the role PARP inhibition might play in the context of the JAVELIN 100 study, and responded that he is “fairly convinced” that PARP inhibition should be developed in molecularly selected patients. “So it is going to be a subgroup of maintenance therapy, if that’s where the development is going to be,” he said. “Should that be in combination with avelumab or in competition with it? I think you could answer that either way. If that’s where the setting is, it is probably going to be in combination, realistically, but molecularly selected.” Mike Bassett is a staff writer for MedPage Today, where this article first appeared.

CHAMPIONS FOR HEALTH

Then Life Changes BY ADAMA DYONIZIAK

MAGINE NINE YEARS OF

abdominal pain and hemorrhaging so severe that your loved one is in the emergency room every two weeks. Your wife or sister or mother needs surgery, but is told time and again that emergency MediCal does not cover the expensive procedure that your family can’t afford. She uses over-the-counter pain medication and hot water bottles, but the pain, hemorrhaging, and severe blood loss persists from an ever-growing cyst. This is Gloria’s story. Constant discomfort, pain, and then agony — this was Juan’s existence for five years when a bean-sized lump in his groin area turned into a lemon-sized protrusion. Working in construction required heavy lifting, going up and down ladders, and frequent physical exertion, which caused the lump to pop out and resulted in great discomfort. Juan was exhausted from work, unable to move or bend over, in need of rest, and unable to eat. His family noticed his weight loss and decreased activity, especially going to the park with his kids. “One doesn’t think things are going to happen, and then life changes,” says Carmen, Juan’s wife. When Juan went to see his physician, he was referred to Project Access and quickly approved and scheduled for the surgery he would need. Setbacks arose, resulting in surgery rescheduling. Then the COVID pandemic hit. The constant uncertainty of the new reality was stressful. While he had the support of his supervisors at work, as the primary breadwinner for his family he had to keep working, even though the pain had now become unbearable. Juan felt like he had angels around him who were working extra hard. Juan and his entire extended family were diag-

nosed with COVID-19, but his father was the only one hospitalized. As his father struggled in the hospital in a coma, Juan was scheduled with another surgeon for his hernia: Dr. Sunil Bhoyrul, the chief of surgery at Olde Del Mar Surgical. Juan recalls meeting Dr. Bhoyrul, who was happy, smiling, and excited to be able to help. Dr. Bhoyrul said to Juan, “There are people who need medical support, and there are physicians and others who have the means to help people. I am happy to be of service in your time of need.” Right before Juan was sedated for surgery he recalls one of the nurses saying, “Think about God and think about your family. Everything will be OK.” It was exactly what he needed to hear. Juan’s surgery and recuperation went very well, and his family welcomed his father home two weeks after Juan’s surgery. Juan emphatically repeated, “I received an unexpected gift from not just one person but a group of people — only God knows why he put them in my path. I am grateful for the system that put this together: Project Access, Dr. Bhoyrul, the nurses, everyone without exception. I don’t have the words for appreciation for all you’ve done.”

Top: Project Access patient Juan Martinez and family. Above: Sunil Bhoyrul, MD.

Dr. Bhoyrul adds, “I am here for my patients, so that I can provide my expertise and excellence in service to each person.” Dr. Bhoyrul will be receiving the Physician of the Year award at the third annual Champions Soiree on March 19 for his volunteer work and dedication to Project Access patients. Since 2008, we thank our volunteer physicians with Project Access for their dedication, time, and talent in providing free consultations and surgeries to patients just like Juan. Join us by volunteering your expertise at www.championsforhealth.org. Adama Dyoniziak is executive director of Champions for Health.

SA NDIEGOPH YSICI A N.ORG

YOUTH MENTAL HEALTH

Social Media’s Role in Youth Suicide Gets Spotlight at House Hearing Some Republican lawmakers blame school closures, masks for rise in mental health issues in kids BY SHANNON FIRTH 16

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I “

F PEOPLE DON’T KNOW when

someone needs help, how can they get them help?” That was the question Christopher Thomas, co-founder of The Defensive Line, a nonprofit that aims to end youth suicide, particularly for young people of color, put to House lawmakers in February. During a subcommittee hearing of the House Committee on Energy & Commerce that focused on the rising toll of youth mental health challenges during the pandemic, Thomas shared the story of his daughter, Ella Elizabeth, who died by suicide at the age of 24 in 2018. About a week before she took her life, Ella asked her father to take care of her dog, Mickey. What Thomas didn’t know then was that giving away prized possessions is a warning sign among people planning to take their lives. An estimated 125 million Americans struggle with mental health issues, noted

Diana DeGette (D-Colo.), chairwoman of the Subcommittee on Oversight and Investigations. And in 2020, mental-healthrelated emergency department visits for children rose by 24% for children ages 5 to 11 and by 31% for those ages 12 to 17, according to the CDC.

Awareness and Connection Every week, 119 young people die by suicide, which is about the number of people in one Boeing 737, according to Thomas. “I have to believe if a plane went down every week in America, Congress would ... work together and create immediate solutions to address the issue. Let’s do that for suicide prevention,” he said. Recognizing the warning signs and knowing how to have “hard conversations” can prevent suicides and save lives, he added. Thomas created The Defensive Line along with his wife, Martha, and his son, Solomon, a football player for the Las Vegas Raiders. One solution Thomas believes strongly in is establishing a mandated, standardized, and funded K-12 suicide prevention curriculum in schools — one that would require annual certification for educators. The organization is already helping to train teachers and coaches in Dallas and Las Vegas, and plans are underway to launch a third training program in Nashville, he said. Rep. Scott Peters (D-Calif.) shared that he and Rep. Gus Bilirakis (R-Fla.) introduced the “STANDUP Act,” with the goal of “encourag[ing] schools to implement suicide prevention training for students.” The bill was passed by the House in May 2021, but has yet to be approved by the Senate. Dark Patterns and Suicide Websites Another significant theme of the hearing was social media’s influence on young people’s mental health. Rep. Kim Schrier, MD, (D-Wash.) noted that while social media can help curb feelings of isolation, algorithms on platforms like Facebook can lead children and teenagers down a “rabbit hole” of dangerous content. For example, a girl interested in eating healthy might find herself exposed to harmful content focused on eating disorders, Schrier noted. And “children feeling sad, as we heard, might find themselves channeled to discussions that glorify suicide or self-harm.” Rep. Lisa Blunt Rochester (D-Del.)

pointed out that her bill, “The DETOUR Act,“ may be one way of addressing these problems by banning “dark patterns,” which she defined as “design practices that manipulate people, often children, to use social media platforms compulsively.” “Social media alone does not cause mental illness in teens,” said Jacqueline Nesi, PhD, a psychiatrist at Brown University in Providence, Rhode Island, and a witness at the hearing. Social media has benefits but also risks, she said. “More research is urgently needed to determine exactly how, when, and for whom social media is more harmful than helpful.” Nesi also suggested that parents can help by setting limits on the times of day or the location where kids can use their phones, or by reducing access to certain content or activities — all with the goal of reducing the risk of exposure to harmful content. Rep. Lori Trahan (D-Mass.) zeroed in on one particular danger: “online suicide instruction forums.” She mentioned the story of Demetrios James Viglis, who first attempted suicide at the age of 14. Mary-Ellen Viglis, his mother, shared Demetrios’s story with Trahan. After the pandemic hit, Demetrios, then 19, lost his job, and his support group meetings were canceled, according to Trahan. “The isolation became too much,” Trahan said. “He discovered a website that encouraged suicide, and provided information and access to methods. There, he learned about a poison, popularized by the website, and where he could buy it, which he did with ease on Amazon. Not long after the package arrived, he died by suicide.” Trahan said she and Rep. David McKinley (R-W.Va.) are conducting an investigation into these forums, and she encouraged her colleagues to join their efforts.

Masks and Mental Health Some Republican lawmakers at the hearing blamed the government’s response to COVID-19 for the increase in young people’s mental health problems. “School closures and lockdowns, in particular, have been associated with adverse mental health symptoms,” said the subcommittee’s ranking member, Morgan Griffith (R-Va.). “While it may have been wise to implement certain policies at the outset of COVID-19, many of them have been unnecessarily prolonged.”

Cathy McMorris Rodgers (R-Wash.), the ranking member for the full committee, took aim at masking. Coronavirus “poses very little risk to children,” but “forced masking is undermining the benefits of being in the classroom [and] cannot be a condition for in-person learning anymore,” she argued. (Many experts would disagree with the characterization of COVID-19’s risks in children.) Europe’s own CDC and the World Health Organization do not recommend young kids mask in school, but the CDC here continues to call for universal masking in schools, McMorris Rodgers said. She said that when CDC Director Rochelle Walensky, MD, MPH, was asked about mask-wearing in schools, she cited a “flawed Arizona study three times,” McMorris said, suggesting that the director’s commitment to masks may have been influenced by her “corrupted relationship with Randi Weingarten and teachers unions.” Weingarten is the president of the American Federation of Teachers. Elinore McCance-Katz, MD, PhD, a psychiatrist and the former assistant secretary for mental health and substance use during the Trump administration, agreed that the Arizona study has “a couple of major problems methodologically,” including a mismatch in observation periods between the schools and a lack of consideration for vaccination rates among students and staff. She added that “it’s concerning” that the CDC “touts this study” when another study of 90,000 children in Georgia found that “masks were not a significant factor in COVID outbreaks in those schools.” Other witnesses, however, stressed that no single factor is responsible for the rise in children’s mental health issues. And while no one enjoyed being isolated, said Lisa Fortuna, MD, MPH, vice-chair of psychiatry at the University of California San Francisco, “there were so many other things ... loss, people really sort of grappling with already preexisting mental health needs, economic devastation in disenfranchised communities.” “It just is very multifactorial,” Dr. Fortuna said. “We have to look at it comprehensively.” Shannon Firth is the Washington correspondent for MedPage Today, where this article first appeared.

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HEALTHCARE SYSTEMS

As Corporate Entities Enter Healthcare, Practices Can Respond via PatientCentered Care BY RICHARD E. ANDERSON, MD, FACP

ETAIL MEDICINE AND

private equity are important drivers of primary care delivery in the U.S., and they are poised to become even more so. Corporate entities have always been involved in healthcare, but now mega corporations — from outside the medical space — are entering the field. The involvement of these large, non-legacy corporate entities in healthcare is growing and is challenging — and while this trend brings some benefits, it will also impact how all clinicians provide healthcare. In a single quarter of 2021, private equity firms acquired $126 billion in medical practices. And these private equity firms, formerly mostly interested in specialty practices, have now set their sights on primary care. Similarly, the expansion of retail medicine into traditional areas of physician practice has been massive. For context, here’s a quick snapshot of the retail medicine landscape: • Walgreens is the first national pharmacy chain to offer full-service provider offices co-located at its stores on a large scale. • CVS now has around 1,000 HealthHUBs associated with its pharmacies. These will play an important role in managing patients’ chronic diseases between primary care visits. • Amazon is on a path to offer healthcare across a broad swath of the healthcare spectrum.

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• Apple recently announced a new data-sharing feature for Apple Health Records that allows users to choose a participating organization and select health metrics to share with their doctor, and the Apple Health app is being widely adopted in healthcare facilities nationwide. • Microsoft is moving aggressively into healthcare with several partnerships with large healthcare systems. Its key initiatives are to help healthcare move into the Microsoft Azure cloud and to thoughtfully apply AI to medical data. • Urgent care clinics now number more than 10,000 in the U.S. Let’s focus on several of these. Amazon Brings Credibility to Claims of Service As Amazon continues its push into healthcare, it has several advantages. One is the company’s remarkable reputation for customer service. As it moves into healthcare, it will have significant credibility in claims about providing better service, better access, better prices, and better convenience. Traditional healthcare will struggle to match this. We clinicians are aware of the distinction between medicine’s definition of “patient-centered care” and retail’s perspective on “customer service.” Yet despite the profession’s emphasis on patient-centered care for several decades,

we haven’t fully achieved it. That’s one reason that these new healthcare entities will exert broad downward economic pressure on primary care practices. But Amazon’s expanding influence goes beyond drawing patients away from individual small practices. Nobody has more data than Amazon — between Whole Foods, Alexa, and Prime members — and this data can be used to shape healthcare delivery. Moreover, Amazon is in the process of developing nationwide pharmacy availability, a hospital-at-home partnership with leading healthcare providers, and an accelerator for healthcare startups. Clearly, Amazon plans to develop into a major player in healthcare delivery. Walmart Brings Experience As an Insurer — Plus Affordable Prescriptions Walmart seems to be one company that is able to compete, at least along some metrics, head to head with Amazon. Though Walmart once had a terrible reputation for not providing healthcare insurance for its own employees, it now provides substantial coverage. And it already has more than a million people in its own insurance plan. It may not be long before Walmart starts providing a health insurance plan for non-employees.

In addition, Walmart has done some very commendable things in the realm of pharmaceutical pricing. Walmart provides most of the most common generic drugs for a flat $4 per prescription, which is a true blessing for many people. In addition, while the cost of some proprietary insulins runs to thousands of dollars a month, Walmart has its own privatelabel version of analog insulin, which it makes available at very nominal cost. That’s not only an important service, but a visionary one. We’ll see how the healthcare competition between Walmart and Amazon shapes up over time, but the outcome is likely to have a major impact on pricing and service in many areas of clinical practice. Health Insurers Bring Their Ambition to Become Healthcare Providers — at Scale Health insurers are not just financing care. They’re providing care. Optum, working under its parent company, UnitedHealth Group, purchased its first medical practice 15 years ago. Today, it owns the practices of 56,000 physicians in 1,600 clinics, representing $40 billion a year of revenue. By 2028, its expressed goal is to reach $100 billion in revenue.

Optum is far from the only player in this space, but it is the biggest. This is a different model of healthcare delivery, with a real potential for conflicts of interest. As this trend accelerates, it is conceivable that health insurance will come to cover an increasingly limited range of clinical options. Private Equity Brings Ongoing Disruption The model of private equity — invest, disrupt, exit — wouldn’t seem to fit healthcare. Nonetheless, as the first wave of private equity investments matures, we’ll see what those exits look like. Who will buy these companies and practices? They will be sold, presumably, at much higher valuations than before. This means that revenue and operational efficiencies will become more important than ever, and the management agreements that may have been attractive in the initial partnership may or may not be continued into the new partnership. Regardless, when we see that private equity firms acquired $126 billion in medical practices in a single quarter of 2021, we must expect that pressure will increase on physician-owned practices to compete with the challenges presented by private equity investment.

Can Medicine Compete Through Patient-Centered Care? If we want to continue to be the driving force in our healthcare system, when medical professionals say “patientcentered care,” we’re really going to have to mean it. We’re going to have to mean it in the customer-service-forward way practiced by corporations like Amazon or Nordstrom or FedEx. After a decade of talking about “patient-centered care,” although we know what it should mean, it isn’t what we typically offer. We need to stop requiring outpatients to see multiple doctors, labs, and imaging centers in different locations at different times, and then to hope that someone thoughtfully acts on the results. That isn’t how we access services anywhere else in the economy. Retail medicine is making significant inroads into primary care by providing rapid access at convenient locations at lower cost. We should recognize that some of the disruption in healthcare today is actually healthy, because it is based on the pressing need for improved healthcare access, healthcare equity, and healthcare literacy. That said, as these new forces in healthcare compete to recruit new medical school graduates, they will also disrupt the day-to-day operations of many existing physician practices. Instead of reacting in surprise when these forces reach the door of our practice or our healthcare system — if they haven’t already — we would be wise to think now about how we should respond. We would like to know what steps your practice or medical system has already taken in response to large, non-legacy corporate entities delivering healthcare. Please answer our poll, and we will provide an update with your responses. To discover more about upcoming changes, read our whitepaper, “What U.S. Healthcare Will Look Like in 2032.” Dr. Anderson is chairman and chief executive officer of The Doctors Company and TDC Group.

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PERSONAL AND PROFESSIONAL DEVELOPMENT

Which Version of Hard Will You Choose? BY HELANE FRONEK, MD, FACP, FACPH

OO OFTEN, WE FORGO

things we want to do because choosing them seems “hard.” I’ve heard people lament that they wanted to be a leader, participate in sports, pursue additional training or various other desires, but didn’t follow these dreams. Conflicts with other responsibilities, lack of time, self-doubt, or a belief that they didn’t deserve to take this time for themselves held them back. As these people recalled their decisions, they felt regret for what they didn’t do. In fact, interviews with people near the end of their lives reveal that most regrets related to what they didn’t do, not to things they did. In spite of their regrets, people often continue to excuse the choice to miss this experience because it felt “too hard.” In fact, each choice we make has consequences. We need to better examine what it is we are actually choosing, as something equally or even more difficult may lie on the other side of our “easier” choice. We see this more clearly in other

M A RCH 2022

people. A patient with a long smoking history ignores our recommendations to stop smoking. No one would argue that to quit smoking is a hard thing to do. Yet, what is harder? Quitting, or living the final years of our life with shortness of breath and repeated infections, struggling to perform our activities of daily living? Framing the choice as “which version of hard do I want?” makes the decision easier. A lifelong swimmer, I began swimming distances in medical school, when I had a free hour at lunch and access to an indoor pool. I vividly recall sitting on the side of the pool, dreading getting into the cold water and knowing I would leave with wet hair in order to get to class on time. Not bad during the heat of the summer, but less enticing during Chicago’s cold winters. Propelling myself into the water felt hard and sometimes I would sit on the edge of the pool for nearly a minute, talking myself into taking action. What eventually got me to move was the recognition that I always felt great when

I got out of the pool. Whatever worries I had would evaporate by the time I finished my mile. Forty minutes in the pool would allow me to enjoy eating my favorite foods while staying healthy and fit. I had decided which version of hard I preferred. To further refine this, we can assess whether we, or our patients, respond best to what we will gain, or what we will avoid. Is it more motivating to consider the fact that, with healthier lungs, we will have greater ability to hike the Grand Canyon or play with our grandchildren, or to imagine the bleak reality of debilitating pulmonary symptoms? It is true that some things in life are hard. It’s just as true that, by deciding to avoid that version of hard, we may be sentencing ourselves to something even harder. Dr. Fronek is an assistant clinical professor of medicine at UC San Diego School of Medicine and a Certified Physician Development Coach.

CLASSIFIEDS VOLUNTEER OPPORTUNITIES

PHYSICIANS: HELP US HELP IMPROVE THE HEALTH LITERACY OF OUR SAN DIEGO COUNTY COMMUNITIES by giving a brief presentation (30–45 minutes) to area children, adults, seniors, or employees on a topic that impassions you. Be a part of Champions for Health’s Live Well San Diego Speakers Bureau and help improve the health literacy of those with limited access to care. For further details on how you can get involved, please email Andrew.Gonzalez@ChampionsFH.org. CHAMPIONS FOR HEALTH PROJECT ACCESS: Volunteer physicians are needed for the following specialties: endocrinology, ENT or head and neck, general surgery, GI, gynecology, neurology, ophthalmology, orthopedics, pulmonology, rheumatology, and urology. We are seeking these specialists throughout all regions of San Diego to support those that are uninsured and not eligible for Medi-Cal receive short-term specialty care. Commitment can vary by practice. The mission of the Champions for Health’s Project Access is to improve community health, access to care for all, and wellness for patients and physicians through engaged volunteerism. Will you be a health CHAMPION today? For more information, contact Andrew Gonzalez at (858) 300-2787 or at Andrew.Gonzalez@ChampionsFH.org, or visit www.ChampionsforHealth.org.

PHYSICIAN OPPORTUNITIES CARDIOLOGIST POSITION AVAILABLE: Cardiology office in San Marcos seeking part-time cardiologist please send resume to albertochaviramd@yahoo.com DERMATOLOGIST NEEDED: Premier dermatology practice in La Jolla seeking a part-time BC or BE dermatologist to join our team. Busy practice with significant opportunity for a motivated, entrepreneurial physician. Work with three energetic dermatologists and a highly trained staff in a positive work environment. We care about our patients and treat our staff like family. Opportunity to do medical/surgical and cosmetic dermatology in an updated medical office with state-of-the art tools and instruments. Incentive plan will be a percentage based on production. If you are interested in finding out more information, please forward your C.V. to jmaas12@hotmail.com RADY CHILDREN’S HOSPITAL - PEDIATRICIAN POSITIONS: Rady Children’s Hospital of San Diego seeking board-certified/eligible pediatricians or family practice physicians to join the Division of Emergency Medicine in the Department of Urgent Care (UC). Candidate will work at any of our six UC sites in San Diego and Riverside Counties. The position can be any amount of FTE (full-time equivalent) equal to or above 0.51 FTE. Must have an MD/DO or equivalent and must be board certified/eligible, have a California medical license or equivalent, PALS certification, and have a current DEA license. Contact Dr. Langley glangley@ rchsd.org and Dr. Mishra smishra@rchsd.org. PER DIEM OBGYN LABORIST POSITION AVAILABLE: IGO Medical Group is seeking a per diem laborist to cover Labor and Delivery and emergency calls at Scripps Memorial Hospital in La Jolla. 70 deliveries/month. 24-hour shifts preferred but negotiable. Please send inquiries by email to IGO@IGOMED.com. MEDICAL CONSULTANT – SAN DIEGO COUNTY: The County of San Diego, Health and Human Services Agency’s Public Health Services is looking for a Board Certified Family Practice or Internal Medicine physician for the Epidemiology and Communicable Disease Division. Under general direction, incumbents perform a variety of duties necessary for the identification, diagnosis, and control of communicable diseases within the population. This position works closely with

the medical and laboratory community, institutional settings, or hospital control practitioners. Learn more here: https://www.governmentjobs.com/careers/ sdcounty?keywords=21416207

KAISER PERMANENTE SAN DIEGO - PER DIEM PHYSIATRIST: Southern California Permanente Medical Group is an organization with strong values, which provides our physicians with the resources and support systems to ensure they can focus on practicing medicine, connecting with one another, and providing the best possible care to their patients. For consideration or to apply, visit https://scpmgphysiciancareers.com/ specialty/physical-medicine-rehabilitation. For questions or additional information, please contact Michelle Johnson at 866-503-1860 or Michelle.S1.Johnson@ kp.org. We are an AAP/EEO employer. PRIMARY CARE PHYSICIAN POSITION: San Diego Family Care is seeking a Primary Care Physician (MD/ DO) at its Linda Vista location to provide direct outpatient care for acute and chronic conditions to a diverse adult population. San Diego Family Care is a federally qualified, culturally competent and affordable health center in San Diego, CA. Job duties include providing complete, high quality primary care, and participation in supporting quality assurance programs. Benefits include flexible schedules, no call requirements, a robust benefits package, and competitive salary. If interested, please email CV to sdfcinfo@sdfamilycare.org or call us at (858) 810- 8700. FAMILY MEDICINE OR INTERNAL MEDICINE PHYSICIAN: TrueCare is more than just a place to work; it feels like home. Sound like a fit? We’d love to hear from you! Visit our website at www.truecare.org. Under the direction of the Chief Medical Officer and the Lead Physician, ensure the provision of effective quality medical service to the patients of the Health center. The physician is responsible for assuring clinical procedures are continually and systematically followed, patient flow is enhanced, and customer service is extended to all patients at all times. PUBLIC HEALTH LABORATORY DIRECTOR: The County of San Diego is seeking a dynamic leader with a passion for building healthy communities. This is a unique opportunity for a qualified individual to work for a Level 3 Public Health Laboratory. The Public Health Services department, part of the County’s Health and Human Services Agency, is a local health department nationally accredited by the Public Health Accreditation Board and first of the urban health departments to be accredited. Public Health Laboratory Director-21226701UPH NEIGHBORHOOD HEALTHCARE MD, FAMILY PRACTICE AND INTERNISTS/HOSPITALISTS: Physicians wanted, beautiful Riverside County and San Diego County- High Quality Family Practice for a private-nonprofit outpatient clinic serving the communities of Riverside County and San Diego County. Work Full time schedule and receive paid family medical benefits. Malpractice coverage provided. Be part of a dynamic team voted ‘San Diego Top Docs’ by their peers. Please click the link to be directed to our website to learn more about our organization and view our careers page at www.Nhcare.org. PHYSICIAN WANTED: Samahan Health Centers is seeking a physician for their federally qualified community health centers that emerged over forty years ago. The agency serves low-income families and individuals in the County of San Diego in two (2) strategic areas with a high density population of Filipinos/Asian and other low-income, uninsured individuals — National City (Southern San Diego County) and Mira Mesa (North Central San Diego). The physician will report to the Medical Director and provide the full scope of primary

care services, including but not limited to diagnosis, treatment, coordination of care, preventive care and health maintenance to patients. For more information and to apply, please contact Clara Rubio at (844) 2002426 EXT 1046 or at crubio@samahanhealth.org.

PRACTICE FOR SALE OTOLARYNGOLOGY HEAD & NECK SURGERY SOLO PRACTICE FOR SALE: Otolaryngology Head & Neck Surgery solo practice located in the Ximed building on the Scripps Memorial Hospital La Jolla campus is for sale. The office is approximately 3000 SF with 1 or 2 Physician Offices. It has 4 fully equipped exam rooms, an audio room, one procedure room, one conference room, one office manager room as well as in house billing section, staff room and a bathroom. There is ample parking for staff and patients with close access to radiology and laboratory facilities. For further information please contact Christine Van Such at (858) 354-1895 or email: mahdavim3@gmail.com

OFFICE SPACE / REAL ESTATE AVAILABLE OFFICE SPACE AVAILABLE – BANKERS HILL: Approximately 500sq feet suite available to lease, includes private bathroom. Located at beautiful Bankers Hill. For more details, please call Claudia at (619) 501-4758. OFFICE AVAILABLE IN MISSION HILLS, UPTOWN SAN DIEGO: Close to Scripps Mercy and UCSD Hillcrest. Comfortable Arts and Crafts style home in upscale Mission Hills neighborhood. Converted and in use as medical/surgical office. Good for 1-2 practitioners with large waiting and reception area. 3 examination rooms, 2 physician offices and a small kitchen area. 1700 sq. ft. Available for full occupancy in March 2022. Contact by Dr. Balourdas at greg@thehanddoctor.com. OFFICE SPACE IN EL CENTRO, CA TO SHARE: Office in El Centro in excellent location, close to El Centro Regional Medical Centre Hospital is seeking Doctors of any specialty to share the office space. The office is fully furnished. It consists of 8 exam rooms, nurse station, Dr. office, conference room, kitchenette and beautiful reception. If you are interested or need more information please contact Katia at (760) 4273328 or email at Feminacareo@gmail.com

OFFICE SPACE / REAL ESTATE WANTED MEDICAL OFFICE SUBLET DESIRED: Solo endocrinologist looking for updated bright office space in Encinitas or Carlsbad to share with another solo practitioner. Primary care, ENT, ob/gyn would be compatible fields. I would ideally have one consultation room and one small exam room but I am flexible. If the consultation room was large enough I could have an exam table in the same room and forgo the separate exam room. I have two staff members that will need a small space to answer phones and complete tasks. Please contact (858) 633-6959.

NON-PHYSICIAN POSITIONS AVAILABLE ASSISTANT PUBLIC HEALTH LAB DIRECTOR: The County of San Diego is currently accepting applications for Assistant Public Health Lab Director. The future incumbent for Assistant Public Health Lab Director will assist in managing public health laboratory personnel who perform laboratory activities for the purpose of identifying, controlling, and preventing disease in the community, as well as assist with the development and implementation of policy and procedures relating to the control and prevention of disease and other health threats. Please visit the County of San Diego website for more information and to apply online.

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