May 2022 by San Diego Physician

Official Publication of SDCMS MAY 2022

The Latest Bold Breakthrough in Primary Care By Daniel J. Bressler, MD, FACP

Become Part of the Opioid Solution Do you have patients with complicated pain management issues? We can help you with peer-to-peer conversations, tools, and strategies to work through these cases. Our team of experienced licensed providers, including physicians, pharmacists, and nurse practitioners, can provide free virtual sessions on opioid stewardship to meet your needs. Contact us today to schedule a free, 30-minute session. For scheduling and inquiries, please contact Katy Rogers katy.rogers@championsfh.org or call 619-508-4460.

Academic Detailing Topics

1 Alternative Pain Management 2 Buprenorphine and the X-Waiver 3 Opioid Tapering 4 Benzodiazepine Stewardship 5 Naloxone

Funded through the Overdose Data to Action Cooperative Agreement with the Centers for Disease Control and Prevention.

Contents MAY

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

VOLUME 109, NUMBER 5

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

Features

The Latest Bold Innovation in Primary Care By Daniel J. Bressler, MD, FACP

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: William T–C Tseng, MD, MPH 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: David E.J. Bazzo, MD, FAAFP At–Large: Sergio R. Flores, MD At–Large Alternate: Bing Pao, MD 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.]

California Handed Its Medicaid Drug Program to One Company. Then Came a Corporate Takeover. By Samantha Young

Departments

Briefly Noted: Outstanding Physicians • COVID-19 • Advocacy

Why Black and Hispanic Seniors Are Left With a Less Powerful Flu Vaccine By Arthur Allen

When Symptoms Linger for Weeks, Is It Long COVID? By Nina Feldman

CMA Applauds Federal Court’s No Surprises Act Ruling that Will Protect Patient Access to Physicians By California Medical Association Staff

MICRA Modernization 2022 By California Medical Association Staff

FDA OKs First Breath Test for COVID-19 By Ian Ingram

It’s All About Family By Adama Dyoniziak

Psych Disorders Tied to More Breakthrough COVID Cases By Zaina Hamza

Holding the Opposites By Helane Fronek, MD, FACP, FASVLM, FAMWA

Classifieds

SA NDIEGOPH YSICI A N.ORG

BRIEFLY NOTED 2

M AY 2022

OUTSTANDING PHYSICIANS

Nominate an Outstanding Colleague for 2022 CMA Service Awards By California Medical Association

Every year, the California Medical Association (CMA) honors inspirational physician members during its annual House of Delegates in October. CMA is now accepting nominations for the following awards for 2022: 2022 COMPASSIONATE SERVICE AWARD This award best illustrates the association’s commitment to community and charity care. Nomination eligibility: Active physicians or physician organizations who have demonstrated a history of providing charity or donated care to communities within the state of California. The selection process will focus heavily on services donated by physicians or organizations to the indigent or services rendered to charitable groups. Awardee receives $1,000 stipend and recognition plaque. 2022 DEV A. GNANADEV MEMBERSHIP AWARD This award demonstrates a special or unique effort toward membership recruitment resulting in membership growth in their area during the past year. Awardee receives $1,000 stipend and recognition plaque. 2022 GARY NYE, MD, AWARD This award honors significant contributions toward improving physician health and well-

ness. The CMA Physicians’ and Dentists’ Confidential Line Committee acts as the nominating committee to the House of Delegates. Awardee receives recognition plaque. 2022 FREDERICK K.M. PLESSNER MEMORIAL AWARD This award best exemplifies the practice and ethics of a rural practitioner. Nomination eligibility: Physicians currently in active practice or recently retired, i.e., retired from active practice for a period of no longer than three years. The selection process shall take into consideration services donated by the physician to the indigent or services rendered to charitable groups. Awardee receives $1,000 stipend and commemorative silver bowl. Requirements and Instructions All nominations must reflect active CMA membership from a physician residing and practicing in California. See award description for any additional requirements. Deadline Please email all nominations to nominations@ cmadocs.org by Friday, June 10, 2022. The Gary Nye, MD, Award also requires a completed nomination form.

COVID-19

HHS Extends COVID-19 Public Health Emergency Through July BECAUSE OF THE NEW HIKE IN OMICRON subvariant BA.2 cases, in April, U.S. Health and Human Services Secretary Xavier Becerra extended the COVID-19 public health emergency determination for an additional 90 days. This is the ninth such extension since the original declaration. This means that all waivers will continue through at least the end of July. Congress also recently extended the current COVID-19 pandemic telehealth waivers for five months beyond the end of the public health emergency.

ADVOCACY

12 Ways to Be a Physician Advocate

TRUST

CRITICAL ISSUES AFFECTING TODAY’S PHYSICIANS ARE BEING DECIDED in the legislative arena at a fast and furious pace. Healthcare reform, medical liability, and scope of practice are just a few of the vital issues being debated and voted on by elected officials in Sacramento. The California Medical Association (CMA) has some of the best lobbyists, lawyers, and other advocates in the Capitol, but the most powerful weapon in advancing the cause of physicians and their patients is you. Below are 12 ways that YOU can be a physician advocate.

1. Know Your Power Hearing from physicians with experience on the front lines of medicine in their community can make all the difference for a legislator contemplating a complicated healthcare issue.

5. Get to Know Your Elected Officials Meet with your elected officials while they are in their home districts, or attend town halls/community events to educate them on healthcare issues.

2. Sign Up for Callto-Action Alerts Download the membersonly “CMADocs” mobile app to receive push notifications.

6. Be a Resource for Legislators Advocate on behalf of the physician community and your patients by offering your expertise and experience.

3. Attend CMA’s Live and Virtual Events Join your colleagues in Sacramento for our annual Legislative Advocacy Day to educate legislative leaders as champions for patients and the practice of medicine, or get involved with organized medicine at the CMA House of Delegates. Sign up for events. 4. Follow CMA’s Legislative Hot List Follow to receive a summary and the status of CMA-sponsored bills, as well as significant healthcare legislation.

7. Become a Social Media Ambassador Join to receive training, advice, and content to help keep your colleagues and other medical professionals informed, connected, and engaged online. Sign up to become a Social Media Ambassador. 8. Share Your Story Receive media training, ghostwriting assistance, and other media resources to share your powerful experiences and expertise with the public. Sign up to become a Media Surrogate.

9. Contribute to CALPAC Support CMA’s political action committee to benefit state and federal candidates who share CMA’s philosophy and vision. Donate to CALPAC. 10. Host a Local Fundraiser for a CMAEndorsed Candidate Host a candidate fundraiser or volunteer your time to develop a personal relationship — an excellent opportunity to become a legislator’s valued constituent. 11. Run for Local Office CALPAC can help you run for office to shape state and local government healthcare policy. 12. Join CMA For more than 165 years, CMA and its county medical societies have represented California’s physicians as the recognized voice of the medical profession. Together, we are stronger. Join or renew today.

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PATIENT CARE

The Latest Bold Innovation in Primary Care BY DANIEL J. BRESSLER, MD, FACP

OU NEVER KNOW WHERE

you’re going to hear about the latest big innovation in the delivery of primary healthcare. For me, it was while seated at a routine quality assurance meeting at a skilled nursing facility (SNF) in early March of 2022. Dr. Pouya Afshar, seated next to me, was giving the group an overview of Presidium Health, a new primary care organization that he had co-founded. Among other new approaches, Presidi-

M AY 2022

um had made arrangements to be able to directly admit patients to the SNF as an alternative to hospitalization. He gave, as an example, the recent short stay of a patient with pancreatitis who was hemodynamically stable but who needed high-volume intravenous fluids for a day and then was safely returned home. Direct SNF admissions have long been highly restricted by Medicare rules. Presidium had negotiated an arrangement that allowed them to circumvent those rules if deemed medically safe.

Intrigued, I stayed after the meeting to hear more about what Presidium was up to. It turns out, it’s up to a lot. Dr. Afshar and his co-founder, Dr. Ashkan Hayatdavoudi, have created a refreshingly radical way to take care of people leveraging a number of overlapping technologies including detailed comprehensive clinical care protocols; simplified mobile-phone-based ordering systems; intensive home-based diagnostic services such as X-rays, EKGs, and lab tests; and a coordinating communication web so that a patient’s status including location, workup, therapy, and progress are both transparent and accessible to their entire healthcare group. This is a situation where the hackneyed term “healthcare team” is not figurative but literal. After their first tentative steps in this direction in a small Medicare population, in 2020 Drs. Afshar and Hayatdavoudi took the audacious step of

assuming the medical responsibility for a population that is notoriously difficult to care for: the highest resource users in the County’s Medi-Cal population. Partnering with Community Health Group (Dr. Afshar is quick to laud CHG for “taking a risk” on their proposal), Presidium now has completed a one-year demonstration project providing their homebased primary care services to the “sickest of the sick” in this population. They have demonstrated both clinical effectiveness and large cost savings, the latter achieved by reducing unnecessary ER visits and hospital admissions, and shifting the locus of care to the home. The cost per patient per year in this high-need population dropped by almost a third. They have achieved this while improving clinical outcomes and achieving high marks on both patient and provider satisfaction. One key to their initial success comes from an expansive approach to the so-

called “social determinants of health.” In mainstream medicine, “the social history” typically consists of a summary of alcohol, tobacco, and drug use, sometimes adding in marital and employment status and education. Presidium has built upon that foundational social history using a database that captures the details of the patient’s living circumstances, circles of affiliation, hobbies, dietary preferences, and pet peeves. This information has been crucial in looking for ways to ethically influence both health behavior and treatment compliance. If a patient is homeless, they use various connections that they’ve developed to find them shelter. If the patient will agree to take their Abilify if they are provided with art supplies, then the team will get them. They’ve dramatically expanded the repertoire of actions that can be taken to help a patient “do the right thing.” This way-outside-thebox partnership between the individual and the system is both unconventional and refreshing, moving from a problem to a solution along an atypical but effective, honest, and ethical route. The money they invest in such things as art supplies and improved housing is more than offset by the decrease in avoidable high-cost services. Another linchpin of their new approach has been the development over several years of a highly detailed and specific set of protocols for responding to both medical and social emergencies. If a patient falls and calls into their always-on care center, there will be specific questions that are asked by the team member, questions that have been developed by Dr. Afshar and his co-clinicians and refined in ongoing use with the goal of both safety and efficiency. Was there head trauma? Is the patient on blood thinners? Is there any loss of range of motion? These are questions that a good nurse or doctor would know to ask. They have been taken out of the heads of the seasoned clinicians and put into what is essentially an “expert system” or artificial intelligence that can be used by those without necessarily the same level of skill or training. The protocolized questions, and their answers, provide direction for the initial level of response of the team. Does 911

need to be dispatched? Should an X-ray be performed? Does a clinician need to do an emergency home visit? Per Dr. Afshar, all such decisions are reviewed by senior clinicians, but as the protocols are continuously refined, fewer non-protocol interventions are needed. He points out they have developed protocols not only for common clinical scenarios (fall, fever, vomiting, etc.) but for common social protocols as well: I lost my phone, I have to move out of my apartment because my ex-boyfriend is threatening me, my dog just died and I’m thinking about going back on the street. I’ve been practicing primary care internal medicine for almost 40 years and have been witness to a number of innovations in care delivery. The HMO innovation was an early attempt to address perverse incentives in healthcare. The hospitalist innovation was a response to the demand to reduce lengths of stay. The concierge medicine innovation answered the need for more personal care for a population who was willing and able to pay extra for it. The Presidium Health innovation addresses the challenge of providing medical care to a population with an extraordinary mixture of medical and social needs. The organization has smartly combined available technologies into a novel framework reminiscent of Uber and Airbnb. They have, in fact, created a version of concierge medicine but adapted to the poor and the socially bereft. In doing so, they have forged a new model that may have application far beyond their current target highest-need population. Why not an efficient outpatient protocol-driven high-tech/high touch program for patients who are homebound, or living in board-and-care facilities or skilled nursing facilities? If Presidium’s pilot program continues, as expected, to deliver both excellent care and reduced cost, then this latest bold innovation in healthcare delivery has the potential to increasingly change the face of primary care. Dr. Bressler, an SDCMS-CMA member since 1988, is a former chair of the Biomedical Ethics Committee at Scripps Mercy Hospital and a longtime contributing writer to San Diego Physician.

SA NDIEGOPH YSICI A N.ORG

MEDI-CAL PHARMACEUTICALS

California Handed Its Medicaid Drug Program to One Company. Then Came a Corporate Takeover. BY SAMANTHA YOUNG

RESCRIPTION DRUG

costs for California’s massive Medicaid program were draining the state budget, so in 2019 Gov. Gavin Newsom asked the private sector for help. The new Medicaid drug program debuted this January, with a private company in charge. But it was woefully unprepared, and thousands of lowincome Californians were left without critical medications for weeks, some waiting on hold for hours when they called to get help. What happened in the two years between the contract award and the start of the program is a case study in what can go wrong when government outsources core functions to the private sector. California awarded the Medi-Cal Rx program to a unit of Magellan Health, a company with expertise in pharmacy benefits and mental health. But Magellan was then gobbled up by industry 6

M AY 2022

giant Centene, worth roughly $50 billion, which was looking to expand its mental health portfolio. Centene was already a big player in state Medicaid drug programs — but one with a questionable record. The company was accused by six states of overbilling their Medicaid programs for prescription drugs and pharmacy services and settled to the tune of $264.4 million. Three other states made similar allegations and have settled with the company, but the amounts have not been disclosed. Centene, in resolving the civil actions, denied any wrongdoing. Kaiser Health News (KHN) has learned California health officials also are investigating Centene.

Handing Over Control In his 2019 inauguration speech, Newsom vowed to use California’s “market power and our moral power to demand fairer prices” from the “drug companies that

gouge Californians with sky-high prices.” Drug spending by the state for its Medicaid, prison, state hospital, and other programs had been climbing 20% a year since 2012, so the first-term Democrat issued an executive order requiring California to make its own generic drugs and forge partnerships with counties and other states to buy drugs in bulk. He also directed the state to buy prescription drugs for Californians enrolled in MediCal, the state’s Medicaid program, which covers roughly 14 million people. Newsom no longer wanted to allow the state’s two dozen Medi-Cal managedcare health plans to provide prescription drug coverage to their enrollees, arguing the state would get a better deal from drug companies by harnessing its purchasing power. That December, California awarded a competitive $302 million contract to Magellan Medicaid Administration, a subsidiary of Magellan Health, to make

sure Medi-Cal enrollees get the medications that California would buy in bulk. Magellan provides pharmacy services to public health plans in 28 states and the District of Columbia. Even though Magellan’s biggest money maker is mental health insurance, it met a key requirement of the state’s call for bids: It didn’t provide health insurance to any Medicaid enrollees in California. Magellan was supposed to take over the drug program in April 2021. But on Jan. 4 of that year, Centene — which was seeking a greater role in the lucrative behavioral health market — announced plans to buy Magellan. St. Louis-based Centene, however, is one of the largest Medi-Cal insurers in the state, a factor that would have disqualified it from bidding for the original contract. Centene provides health coverage for about 1.7 million low-income Californians in 26 counties through its subsidiaries Health Net and California Health & Wellness. It earned 11% of its revenue from California businesses in 2019, according to its 2021 annual report to the U.S. Securities and Exchange Commission. But the state bent over backward to make it work, delaying implementation of the program while Magellan set up firewalls, sectioned off its business operations from Centene, and paid for a third-party monitor. State regulators reviewed the merger in a 30-minute public hearing in October 2021. They didn’t mention Centene’s legal settlements with other states. The state Department of Managed Health Care approved the merger Dec. 30. Two days later, the state launched its new prescription drug program with Magellan at the controls.

Centene’s Legal Troubles In the past 10 months, Centene has settled with nine states over accusations that it and its pharmacy business, Envolve, overbilled their Medicaid programs for prescription drugs and services: It settled with Arkansas, Illinois, Kansas, Mississippi, New Hampshire, and Ohio, according to news releases from attorneys general in those states. The three other states have not been identified by Centene or the states themselves. The company has set aside $1.25 billion

for those settlements and future lawsuits, according to its 2021 report to the SEC. Centene, which has denied wrongdoing in public statements, did not respond to multiple requests by KHN for interviews, nor did it respond to emailed questions. Magellan also did not respond to interview requests. From the start, other California health insurers opposed the state takeover of the Medi-Cal drug program, partly because it took away a line of business. They were even more furious when the state allowed one of their biggest competitors to seize the reins — especially given its legal entanglements. The state Department of Health Care Services, which administers Medi-Cal, acknowledged to KHN in March that it’s investigating the company but declined to provide specifics. The state is investigating Centene’s role in providing pharmacy benefits before the state took the job from managed-care insurers. “DHCS takes all allegations of fraud, waste, and abuse seriously and investigates allegations when warranted,” department spokesperson Anthony Cava said in a statement.

A Sale in the Offing? When Medi-Cal Rx debuted Jan. 1, thousands of Californians couldn’t refill critical — sometimes lifesaving — medications for days or weeks. Doctors, pharmacists, and patients calling for help often languished on hold for as many as eight hours. Magellan blamed the problems on staff shortages during the COVID-19 omicron surge and missing patient data from insurance plans. State health officials went to great lengths to fix the problems and appeared before legislative committees to provide lawmakers with assurances that the contractor wouldn’t be paid in full. But Medi-Cal patients still face uncertainty. Not long after Magellan took over California’s Medi-Cal drug program, reports surfaced in Axios and other publications that Centene might sell Magellan’s pharmacy business. Centene officials have not confirmed a sale. But it would align with the company’s recent moves to restructure its pharmacy operations in the face of state

investigations — such as seeking an outside company to begin managing its drug spending. “Once you tell a PBM they actually have to behave, that’s when there’s no more money in it. It’s time to go,” said Antonio Ciaccia, president of drug-pricing watchdog 3 Axis Advisors, referring to businesses known as pharmacy benefit managers. Yet another ownership change in California’s drug program could bring more disruption to the state’s most vulnerable residents, some of whom are still having trouble getting their drugs and specialty medical supplies after Magellan’s rocky takeover. “I don’t know what kind of instability that creates internally when there’s a change of this magnitude,” said Linnea Koopmans, CEO of Local Health Plans of California, which represents the state’s publicly run Medicaid insurers that compete against Centene. “It’s just an open question.” Koopmans and other Centene critics acknowledge that California has long relied on private insurance plans to offer medical and prescription drug coverage to MediCal enrollees and that the state shouldn’t be surprised by ownership changes that come with consolidation in the healthcare industry. For example, Centene has a history of taking over California contracts after an acquisition — it did so when it purchased Health Net in 2016. But consumer advocates say the Centene fiasco makes it clear that the state must improve oversight of corporate mergers if it chooses to hand over responsibility for public programs. “In an ideal world, this is all backroom machinations that people don’t notice — until they do, until there is a problem,” said Anthony Wright, executive director of Health Access California, a consumer advocacy group. “It just increases the need to make sure that that oversight is there, that accountability is there.” Samantha Young, senior correspondent for Kaiser Health News, where this article first appeared, is an award-winning journalist with 25 years of experience who covers healthcare politics and policy in California, focusing on government accountability and industry influence.

SA NDIEGOPH YSICI A N.ORG

VACCINES RACIAL EQUITY

Why Black and Hispanic Seniors Are Left With a Less Powerful Flu Vaccine BY ARTHUR ALLEN

M AY 2022

T WHITMAN-WALKER

Health, Dr. David Fessler and his staff administer high-dose influenza vaccine to all HIVpositive and senior patients. Although the vaccine is roughly three times as expensive as standard flu vaccine, it seems to do a better job at protecting those with weakened immune systems — a major focus of the nonprofit’s Washington, DC, clinics. At the University of New Mexico Hospital in Albuquerque, meanwhile, Dr. Melissa Martinez runs a drive-thru clinic providing 10,000 influenza vaccines each year for a community made up largely of Black and Hispanic residents. It’s open to all comers, and they all get the standard vaccine. These different approaches to preventing influenza, a serious threat to the young and old even with COVID-19 on the scene, reflect the fact that federal health officials haven’t taken a clear position on whether the high-dose flu vaccine — on

the market since 2010 — is the best choice for the elderly. Another factor is cost. While Medicare reimburses both vaccines, the high-dose shot is three times as expensive, and carrying both vaccines for different populations requires additional staffing and logistics. “We’ve focused on giving the standarddose vaccine, trying to get as many people vaccinated as possible,” Dr. Martinez says. And they will keep doing so, she adds, until the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices decides whether to preferentially recommend the enhanced vaccines. The CDC historically has been reluctant to pick winners among manufacturers’ competing products to prevent or treat disease. It recommended all three licensed COVID vaccines after establishing that each met its disease-fighting goals. In a given year, most influenza vaccines are not very effective. Drug companies vying for market share aren’t generally motivated to compare them, since they might lose out. And federal officials generally don’t fund such studies, so they are left to rely on research offered by the companies. In the meantime, older minority patients, especially Black seniors, are getting the short end of the stick, say some advocates for eliminating racial disparities in healthcare. Blacks are about 20% less likely than whites to get flu shots, although they are at higher risk of severe flu. Even those who get the vaccine are about 30% less likely to get the high-dose version. “Since you have an increased risk of diabetes and heart disease in the African American community, it inherently disadvantages this population to give them the standard-dose vaccine,” says Dr. Keith Ferdinand, a cardiologist and professor of medicine at Tulane University. While the data on the high-dose vaccines is not ironclad, “any tool we have in our toolbox to reduce ethnic/racial disparities should be embraced,” he says. A CDC workgroup has been investigating the issue since before the pandemic, with plenty of COVID-caused delays. On Feb. 23, committee members heard evidence that the high-dose flu vaccine and two other “enhanced” vaccines — one containing an immune-boosting substance, the other a recombinant protein — were better than low-dose vaccine produced in

hens’ eggs, the standard product for the past 80 years. The committee may vote at its next meeting, probably in June, on the matter. At February’s meeting, one CDC official estimated that switching to those vaccines for seniors could reduce influenza-related hospitalizations by thousands a year. But even a June vote would be too late to affect vaccinations before the fall flu season. Pharmacies and health systems have already ordered next season’s vaccine, and drug companies are committing their facilities now to meet the demand, says Dr. Michael Greenberg, a Sanofi vice president. Sanofi stands to gain from expanded use of its more expensive high-dose vaccine (it also produces a standard-dose version). Germany, Canada, and other countries provide the vaccine free to residents of long-term care facilities, but not to all seniors. In the United States, an estimated 75% of elders who are vaccinated receive an enhanced shot. But the remainder, who get the standard vaccine, are disproportionately members of ethnic and racial minorities, according to a study of the 2015–16 flu season. The racial and ethnic gaps are wider in doctors’ offices than pharmacies, which are more likely to stock both high-dose and standard vaccines, says Dr. Salaheddin Mahmud, director of the Vaccine and Drug Evaluation Centre at the University of Manitoba and first author in the report, which was funded by Sanofi. In a more recent, as-yet-unpublished study that included data through 2018, Dr. Mahmud found that Southerners were less likely to get the high-dose vaccine than other Americans, and the high-dose vaccine appeared to be less available in communities where more than 20% of the population were minorities. A decision to give all seniors the enhanced shots isn’t as simple as it seems. For one thing, the CDC’s advisory committee, known as ACIP, hesitates to promote one vaccine over another, afraid that doing so could lead non-touted producers to exit the market and cause vaccine shortages. In 2017 the advisory committee recommended GlaxoSmithKline’s Shingrix shot over an older shingles vaccine, but even then the committee vote was only 8-7 despite clear evidence of Shingrix’s superi-

ority, notes Dr. Kelly Moore, a professor of health policy at Vanderbilt University who led the Tennessee Department of Health’s immunization program at the time. As committee members feared, Merck took the older vaccine, Zostavax, off the market in the U.S., and for years there were shortages of Shingrix. Each February, flu vaccine formulas are based on scientific modeling of which strains of the ever-mutating virus will be present the following fall and winter. A mismatch can render the best vaccines nearly powerless to prevent infection, although any vaccine protects somewhat against severe illness. This year’s flu vaccine did almost nothing to prevent infection. Amid all this uncertainty, many health systems and clinics don’t bother buying high-dose or other enhanced vaccines. It’s complicated to store and administer them separately, physicians say, and patients often get vaccinated at a pharmacy rather than by their doctor. While Medicare will reimburse vaccination with any formula, clinics that end up with leftovers usually have to throw them out — a costlier proposition when the vaccines were more expensive to begin with, says L.J. Tan, chief strategy officer for Immunize.org, a group that promotes vaccination. For this reason, financially strapped community clinics “try very hard not to waste vaccine doses” and may opt for the simpler, cheaper solution, says Dr. Julia Skapik, a clinician in Virginia who is also chief medical information officer at the National Association of Community Health Centers. The best comparative study indicates it’s necessary to vaccinate about 220 seniors with the high-dose rather than the standard vaccine to prevent a single case of flu. Since none of the vaccines have great efficacy in older people, the most important thing is to cocoon the vulnerable by “vaccinating the people around them,” says Dr. Martinez, a family doctor in Albuquerque. “At least until the ACIP decides,” she says, “that seems like a better use of our resources.” Arthur Allen, senior correspondent for Kaisher Health News, where this article first appeared, writes about the FDA and the pharmaceutical industry as well as COVID-related topics.

SA NDIEGOPH YSICI A N.ORG

COVID-19

When Symptoms Linger for Weeks, Is It Long COVID? BY NINA FELDMAN

ANY AMERICANS ARE

discovering that recovering from COVID-19 may take weeks or even months longer than expected, leaving them with lingering symptoms like intense fatigue or a racing pulse. But does that mean they have what’s known as long COVID? Though such cases may not always amount to debilitating long COVID, which can leave people bedridden or unable to perform daily functions, it is common to take weeks to fully recover. “There could be more to help people 10

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understand that it’s not always a quick bounce back right away after the initial infection,” says Dr. Ben Abramoff, director of the Post-COVID Assessment and Recovery Clinic at Penn Medicine in Philadelphia. “This is still a very significant viral infection, and sometimes it’s just a more gradual recovery process than people’s previous viral illnesses.“ Recent federal health guidelines — which recommend only five days of isolation for those who test positive and are symptom-free — may inadvertently suggest most recoveries are, if not just

five days long, pretty quick. That’s the message I got, at least. I’ve reported on the coronavirus pandemic since it started, and I thought I knew what an infection would be like for a young, otherwise healthy person like me. I knew even mild cases could develop into long COVID. I thought they were relatively rare. Like many Americans, I found myself slowed by a recovery that took more than a month — far longer than I had expected. I got COVID over Christmas. I was vaccinated and boosted, and my symptoms were mild: sore throat, sinus pressure and headache, extreme fatigue. I felt better after eight days, and I tested negative two days in a row on a rapid antigen test. Soon after ending isolation, I had dinner with a friend. One glass of wine left me feeling like I’d had a whole bottle. I was bone-achingly exhausted but couldn’t sleep. The insomnia continued for weeks. Activities that once energized me — walking in the cold, riding an exercise bike, taking a sauna — instead left me intensely tired. The waves of fatigue, which I started calling “crashes,” felt like coming down with an illness in real time: weakened muscles, aches, the feeling that all you can do is lie down. The crashes would last a couple of days, and the cycle would repeat when I accidentally pushed myself beyond my new, unfamiliar limit. My colleague Kenny Cooper is also young, healthy, vaccinated, and boosted. He was sick for almost two weeks before testing negative. His symptoms lingered a few more weeks. A persistent cough kept him from leaving the house. “I just felt like there were weights on my chest,” he says. “I couldn’t sleep properly. When I woke up, if I moved around too much, I would start coughing immediately.” Dr. Abramoff has seen about 1,100 patients since Penn’s post-COVID clinic opened in June 2020. There is no official threshold at which someone officially becomes a long-COVID patient, he says. The clinic takes a comprehensive approach to patients who have had symptoms for months, evaluating and referring them to specialists, like pulmonologists, or social workers who can assist with

medical leave and disability benefits. Those coming to the clinic with symptoms lasting six to eight weeks, Dr. Abramoff says, are generally sent home to rest. They will likely get better on their own. He advises patients with lingering symptoms to adopt a “watchful waiting” approach: Keep in contact with a primary care doctor, and take things slowly while recovering. “You have got to build based on your tolerance,” he says. “People were very sick, even if they weren’t in the hospital.” A National Institutes of Health-funded study on long COVID, called Recover, designates any case with symptoms lasting more than 30 days as long COVID. Dr. Stuart Katz, a New York University cardiologist who is the study’s principal investigator, said he estimates 25% to 30% of the nearly 60,000 COVID patients in the study will fit the long-COVID criteria. The 30-day mark is an arbitrary cutoff, Dr. Katz says. “There’s this whole spectrum of changing symptoms over time.”

A study published in Nature last year tracked more than 4,000 COVID patients from initial infection until symptoms subsided. Roughly 13% reported symptoms lasting more than 28 days. That dropped to 4.5% after eight weeks and 2.3% after 12 weeks, indicating most people with symptoms lasting more than a month will recover within another month or two. That leaves potentially millions of Americans suffering from a variety of COVID symptoms — some debilitating — and a lingering burden on the healthcare system and workforce. Recent research from the Brookings Institution estimated that lasting COVID symptoms could be responsible for up to 15% of the unfilled jobs in the U.S. labor market. It took me about six weeks to start feeling better. My crashes got better, slowly, as a result of diligent rest and almost nothing else. My colleague, Cooper, has also improved. His coughing fits have

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subsided, but he’s still dealing with brain fog. The way most studies to date describe long COVID would leave us out. But what I’ve come to think of as my “medium COVID” affected my life. I couldn’t socialize much, drink, or stay up past 9:30 p.m. It took me 10 weeks to go for my first run — I’d been too afraid to try, fearing another crash that would set me back again. Failing to treat COVID as a serious condition could prolong recovery. Patients should monitor and care for themselves attentively, no matter how mild the infection may seem, according to Dr. Abramoff. “It’s something that could kill somebody who’s in their 70s,” he says. “It’s not nothing.” Nina Feldman is a journalist for NPR-affiliate WHYY who’s been covering COVID-19 since the beginning of the pandemic. This story is part of a partnership that includes WHYY, NPR, and KHN.

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SURPRISE BILLING

CMA Applauds Federal Court’s No Surprises Act Ruling that Will Protect Patient Access to Physicians BY CALIFORNIA MEDICAL ASSOCIATION STAFF

N WEDNESDAY, U.S.

District Court for the Eastern District of Texas ruled in favor of a lawsuit filed by the Texas Medical Association (TMA) challenging the U.S. Department of Health and Human Services’ (HHS) approach to dispute resolution under the No Surprises Act (NSA). The ruling by a Texas judge applies nationwide and means that, barring a higher court’s intervention, the balanced dispute resolution process that Congress created by NSA is restored. Late last year, the California Medical Association (CMA), through the Physicians Advocacy Institute (PAI), filed an amicus brief that argued that HHS’s NSA regulations were contrary to the law Congress enacted, and that by blatantly

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favoring the insurance industry, patient access to in-network physicians would be harmed when an emergency strikes. “This is a major win for patients in California,” said CMA President Robert E. Wailes, M.D. “CMA worked closely with Congress for more than two years to develop a law that protects patients from surprise medical bills and allows physicians to fairly resolve disputes with insurers, and this decision restores the intent of Congress when they passed that law.” To resolve billing disputes, the statutory language of the NSA called for a process that considers several different criteria; however, the flawed HHS regulation heavily favored the median in-network payment rate as the appropriate payment rate to be paid for out-of-network services in the dispute resolution process.

The Texas judge agreed that the challenged portion of the regulation was procedurally and substantively flawed, as it “conflicts with the unambiguous terms of the Act.” He ordered HHS to immediately vacate the rebuttable presumption standard favoring the median in-network payment rate. When HHS unveiled the rule, Congressional leaders challenged it as inconsistent with their intent and the clear direction of the law. CMA feared that if the dispute resolution process was not balanced it would disincentivize insurers from contracting with physicians, dramatically reduce fair payments, threaten the sustainability of physician practices, and thus, diminish patient access to in-network medical care. “The judge clearly agreed with physician organizations that the median in-network payment rate was intended to be one factor in dispute resolution, not the only factor,” said CMA CEO and PAI President, Dustin Corcoran. “CMA applauds the court’s decision to follow clear direction from Congress giving physicians a chance to fairly resolve disputes and encourage insurers to contract with adequate networks of physicians to meet the medical needs of patients.”

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MICRA

MICRA Modernization 2022 Historic Agreement Brings New and Sustained Era of Stability Around Malpractice Liability BY CALIFORNIA MEDICAL ASSOCIATION STAFF

N A HISTORIC AGREEMENT, CALIFORNIANS ALLIED

for Patient Protection (CAPP) and the Consumer Attorneys of California have announced a consensus on legislation to modernize the Medical Injury Compensation Reform Act (MICRA). The modernized approach to MICRA — introduced as Assembly Bill 35 in the legislature and jointly authored by Assembly Majority Leader Eloise Reyes and Senator Tom Umberg — will extend the long-term predictability and affordability of medical liability insurance premiums, while keeping MICRA’s essential guardrails solidly in place for patients and providers alike. For decades, California’s landmark medical malpractice laws have successfully struck a balance between compensatory justice for injured patients and maintaining an overall healthcare system that is accessible and affordable for Californians. Over the years, California’s physician and provider communities have repeatedly defended MICRA through expensive battles at the ballot, in the courtroom, and in the legislature. This year, with the so-called Fairness for Injured Patients Act (FIPA) slated for the November 2022 ballot, we were again facing another costly initiative battle that could obliterate existing safeguards for out-of-control medical lawsuits and result in skyrocketing healthcare costs. “For the first time in a generation, we were met with an oppor-

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tunity to achieve a meaningful consensus between competing interests through a modernized MICRA framework that could protect both the rights of injured patients while keeping MICRA’s essential guardrails solidly in place for patients and providers alike,” says Robert E. Wailes, MD, president of the California Medical Association (CMA). “At times like these, we have an obligation to protect patient care and to seize a historic opportunity for a brighter future for California’s health delivery system.”

The Threat If approved by voters, the FIPA initiative would have effectively eliminated MICRA’s cap on non-economic damages by creating a new, broadly defined category of injuries not subject to the cap. This would have resulted in a significant increase in litigation with unpredictably high verdicts and no less than an immediate doubling of malpractice insurance premiums. The nonpartisan state legislative analyst predicted FIPA would have resulted in more than $11 billion a year in increased healthcare costs. This would have had a chilling effect on the entire healthcare system, with the trickle-down effect borne primarily by low-income patients, who would face higher costs and restricted access to care. The initiative also directly targeted physicians, putting personal assets at risk.

A Modernized Framework A new consensus has been reached between healthcare, legal, and consumer advocates on legislation to modernize MICRA. This agreement unifies stakeholders and puts the interests and wellbeing of Californians ahead of historic conflicts. The compromise reflected in this legislation will ensure that healthcare is accessible and affordable, while balancing compensation for Californians who have experienced healthcare-related injury or death. “This balanced proposal modernizes and updates MICRA while preserving its essential guardrails, strengthening provider protections, and providing for fair compensation for injured patients,” says Dustin Corcoran, CMA CEO and chair of the Campaign to Protect Access and Contain Costs. “This framework is essential to our shared goal of health access for all Californians. We look forward to working with the Legislature and the Newsom Administration to enact this historic proposal.” The modernized framework preserves MICRA’s protections while providing a fair and reasonable increase to MICRA’s established limit on non-economic damages for medical negligence starting on Jan. 1, 2023 — with gradual increases over the next 10 years and a 2.0% annual inflationary adjustment thereafter. Other important guardrails of MICRA will continue unchanged, including advance notice of a claim, the one-year statute of limitations to file a case, the option of binding arbitration, early offers of proof for making punitive damages allegations, and allowing other sources of compensation to be considered in award determinations. Critical MICRA guardrails that will remain in place with modest updates include the ability to pay awards of future damages over time and limits on plaintiff’s attorney’s contingency fees. “This compromise will help to ensure that community health centers across California that serve some of our state’s most vulnerable patients will have continued access to safe, affordable healthcare,” says Jodi Hicks, Planned Parenthood Affiliates of California president and CEO. “It was important for Planned Parenthood to have a voice in this process because the proposed initiative would have caused significant harm to California’s safety net. We’re pleased to see a solution that creates long-term stability and protects access to care for those who need it most.” CAPP reached the agreement with the initiative’s proponent, Nick Rowley, and the Consumer Attorneys of California, the state’s largest organization representing plaintiffs’ attorneys.

Changes to the MICRA Cap Current law limits recovery of non-economic damages to $250,000, regardless of the number of defendants. The modernized framework would increase the existing limit to $350,000 for non-death cases and $500,000 for wrongful death cases on the effective date of Jan. 1, 2023, followed by incremental increases over 10 years to $750,000 for non-death cases and $1,000,000 for wrongful death cases, after which a 2.0% annual inflationary adjustment will apply. The proposal will also create three separate categories of caps, which could apply depending on the facts of each case:

• One cap for healthcare providers (regardless of the number of providers or causes of action) • One cap for healthcare institutions (regardless of the number of providers or causes of action) • One cap for unaffiliated healthcare institutions or providers at that institution that commit a separate and independent negligent act A healthcare provider or healthcare institution can only be held liable for damages under one category, regardless of how the categories are applied or combined.

New Protections for Benevolent Gestures and Statements of Fault Often, a patient’s decision to file a medical malpractice lawsuit is triggered by a failure in communication, not negligence. The modernized framework establishes new evidentiary protection for all pre-litigation expressions of sympathy, regret, or benevolence, including statements of fault, by a healthcare provider. Allowing physicians and patients to have full and open conversations about adverse events and unexpected healthcare outcomes will foster greater trust and accountability, while facilitating improved patient safety.

Next Steps The proposal reflected in this legislation strikes a prudent and patient-focused balance between fair compensation to injured patients and the need for universal, high-quality and costeffective healthcare. More significantly, in the shadow of the most sweeping public health crisis in a century, it demonstrates a unifying willingness to put the interests of California patients ahead of divisive political positions. Our broad and diverse coalition of physicians, community health centers, dentists, hospitals, nurses, and hundreds of other organizations dedicated to affordable, accessible healthcare will be working closely with the Newsom Administration and the California Legislature to ensure this updated approach to medical negligence cases is enacted and signed into law. CMA and the provider community remain united and committed to the principle of high-quality healthcare that is accessible and affordable to all Californians.

Who Made the Agreement? Californians Allied for Patient Protection is the large and diverse coalition working to protect access to healthcare through the Medical Injury Compensation Reform Act. Its membership includes the California Medical Association, California Hospital Association, California Dental Association, CMA’s component medical societies, medical malpractice insurance carriers, community clinics, Planned Parenthood Affiliates of California, and many more. (You can see the full membership at micra.org.) CAPP and its members also made up the core of Californians to Protect Patients and Contain Health Care Costs, the campaign CMA has been leading to defeat this dangerous ballot measure. CAPP reached the agreement with the initiative’s proponent, Nick Rowley, and the Consumer Attorneys of California, the state’s largest organization representing plaintiffs’ attorneys.

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INFECTIOUS DISEASE COVID-19

FDA OKs First Breath Test for COVID-19 With High Sensitivity and Specificity, Results Returned in Under 3 Minutes BY IAN INGRAM

HE FDA GRANTED AN EMERGENCY USE

authorization (EUA) to the first COVID-19 test that can detect the virus in breath samples, the agency announced. Dubbed the InspectIR COVID-19 Breathalyzer, the test uses gas chromatography-mass spectrometry to rapidly detect volatile organic compounds associated with SARS-CoV-2. Patients breathe into a disposable straw on the device — which is about the size of a piece of carry-on luggage, according to the agency — and results are returned in less than three minutes. The test is intended for healthcare settings where samples can be collected and analyzed, such as mobile testing sites, doctor’s offices, and hospitals. “Today’s authorization is yet another example of the rapid innovation occurring with diagnostic tests for COVID-19,” said Jeff Shuren, MD, JD, director of the FDA’s Center for Devices and Radiological Health, in a statement. “The FDA continues to support the development of novel COVID-19 tests with the goal of advancing technologies that can help address the current pandemic and better position the U.S. for the next public health emergency.” In its news release, the FDA noted that positive test results with the breathalyzer should be considered presumptive and confirmed with a molecular test. 16

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“Negative results should be considered in the context of a patient’s recent exposures, history, and the presence of clinical signs and symptoms consistent with COVID-19, as they do not rule out SARS-CoV-2 infection and should not be used as the sole basis for treatment or patient management decisions, including infection control decisions,” the agency said. Primary support for the EUA came from a study of 2,409 individuals with and without symptoms, conducted in four U.S. states. The breathalyzer test was found to have a sensitivity of 91.2% (90% CI 85.4–94.8) and specificity of 99.3% (95% CI 98.8–99.5) when compared with a PCR test. This yielded a negative predictive value of 99.6%, the agency noted, “meaning that people who receive a negative test result are likely truly negative in areas of low disease prevalence.” A follow-up trial of 12 symptomatic individuals in Texas, conducted in February when omicron accounted for nearly all cases there, showed a similar sensitivity of 90.9% (90% CI 67.7–98.0). The company expects to produce 100 units each week, with each unit estimated to be able to analyze 160 samples each day, according to the FDA. Ian Ingram is managing editor of MedPage Today, where this article first appeared.

CHAMPIONS FOR HEALTH

It’s All About Family BY ADAMA DYONIZIAK

AIN — INTOLERABLE BACK

pain — for years. Martha remembers her pain management physician saying, “Your pain is not something that needs time … I can only offer you pain medication, which will not cure you. On the contrary, you can become addicted.” This overwhelming message led Martha to a conversation with her PCP, Dr. Miller at Neighborhood Healthcare, which started her on the path to surgery and recovery. The years of pain changed Martha’s day-to-day life. “I sometimes went to work but at the end of the day I was in so much pain I couldn’t stand, sit, anything.” She couldn’t clean her house or cook her family’s favorite homemadefrom-scratch meals. Her response would be, “I can’t. It’s too long to be standing in the kitchen.” The family liked to visit the Del Mar Fair and the San Diego Zoo, attend extended family celebrations and holidays — but they stopped doing all these things when Martha couldn’t go with them for fear of being in agonizing pain too far away from home. Life started changing after Dr. Miller referred Martha to Project Access San Diego, and Evelyn Penaloza, her care manager. Javier, Martha’s husband, worked 12-hour shifts at night to support the family and would sleep during the day, limiting his availability, although he did accompany Martha to medical appointments. Evelyn connected Martha to Dr. Kevin Yoo, a neurosurgeon at San Diego Neurosurgery. An MRI revealed three injured discs and surgery was recommended. When Martha and her husband met with Dr. Yoo, he reviewed potential risks and reminded them that there is no guarantee. Martha says she was so impressed by his willingness and honesty.

“Volunteering with Project Access is a jewel in my practice that I can enjoy,” Dr. Yoo says. “There are a lot of struggles and shortcomings in life. I have the satisfaction that I helped somebody.” His mentor in medical school was “such a stellar person, outstanding character, and technically gifted” that Dr. Yoo was inspired to go into neurosurgery. Dr. Yoo also volunteers on medical missions abroad in Peru and Korea to perform brain and spinal surgery. When asked who had positively impacted his life, Dr. Yoo replies, “my wife, Heather — by creating a family, a life with our kids. There is so much meaning in life because of my family.” The ultimate connection between physician and patient is at the most basic of levels: family gives life meaning. The spinal surgery was a success. “I feel like it has changed everything,” Martha says. “I can help my husband at work, I can do the housework, I can go out with my son and my husband and be a part of my family again.” Javier adds, “Now we dance

Top: Martha (center) with her husband, Javier, and her son, Christian. Above: Dr. Kevin Yoo

together and we are more relaxed. Each person was part of the team, each and every one contributed their grain of sand. Each was a seed that was planted in our hearts. Each one is important in our lives.” Since 2008, Project Access has facilitated $24 million in care for 7,500-plus uninsured patients just like Martha by providing free consultations and surgeries — all thanks to the dedication, time, and talent of our volunteer specialty physicians. Be a part of bringing families together again — volunteer your expertise by contacting us at adama.dyoniziak@championsfh.org or call (858) 300-2780. Adama Dyoniziak is executive director of Champions for Health.

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PSYCHIATRY

Psych Disorders Tied to More Breakthrough COVID Cases Association in Veterans Appeared Largely Driven by Those 65 and Up BY ZAINA HAMZA

ULLY VACCINATED individuals were more likely to have a breakthrough COVID-19 infection if they had a psychiatric disorder diagnosis, a retrospective study of Veterans Affairs data found. In a fully adjusted model, any psychiatric disorder was associated with a 3% higher risk for a breakthrough COVID infection (adjusted relative risk [aRR] 1.03, 95% CI 1.01–1.05, P<0.001) though certain diagnoses appeared to carry far higher risk, reported Aoife O’Donovan, PhD, of the University of California San Francisco, and colleagues. 18

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“Individual psychiatric disorders were associated with a 3% to 16% increased incidence of breakthrough infection in our sample, which is comparable to the 7% to 23% increased incidence of breakthrough infection that we observed for physical comorbidities (e.g., cancer, kidney disease, and cardiovascular disease),” the group wrote in JAMA Network Open. For those with any psychiatric disorder, those 65 years and older had a 5% increased risk for breakthrough infection (aRR 1.05, 95% CI 1.03–1.08), while no increased risk was seen among younger

individuals (aRR 1.00, 95% CI 0.97–1.03). “The effects of having a psychiatric disorder on breakthrough infection risk were strongest and most robust in older individuals,” O’Donovan told MedPage Today. “This was a very important finding because older individuals are also most likely to have adverse outcomes of COVID-19.” In the older group, nearly every condition was significantly linked with breakthrough infections, with the greatest risks seen with: • Substance use disorder: aRR 1.24 (95% CI 1.16–1.32)

• Psychotic disorder: aRR 1.23 (95% CI 1.15–1.33) • Bipolar disorder: aRR 1.16 (95% 1.07–1.25) But even in the younger group, anxiety disorder, adjustment disorder, and substance use disorder were each associated with an increased risk for breakthrough infection. “Mental and physical health are intricately intertwined,” said O’Donovan. “It behooves us to increase the resources available for mental health during the pandemic.” As of November 2021, nearly twothirds of veterans were fully vaccinated against COVID-19, but breakthrough infections have remained relatively common due to waning vaccine immunity and the circulation of newer variants with better immune escape, O’Donovan’s group noted. Studies before the wide availability of vaccines have found individuals with psychiatric disorders to be at greater risk for COVID infection and severe

outcomes. Impaired immune function, risky behaviors, and pre-existing medical conditions such as cardiovascular disease may place those with psychiatric disorders at greater risk for worse outcomes. For their study, O’Donovan and colleagues examined electronic health record data on 263,697 fully vaccinated veterans from Department of Veterans Affairs databases. They included individuals who were tested at least once for SARS-CoV-2 infection from February 2020 to November 2021, but who did not have a SARS-CoV-2 infection prior to becoming vaccinated. Overall, 15% developed a breakthrough infection during the study period. Psychiatric disorder diagnoses and covariate data came from ICD-9 and ICD-10 codes. The fully adjusted model accounted for sociodemographic factors, vaccine type, time from vaccination, and other potential confounders, including medical comorbidities, smoking, and obesity. Most (90.8%) of the veterans were men,

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and the mean age was 66 years, with 70% being white, 21% Black, and 8% Hispanic. Almost two-thirds were current or past smokers, and common comorbidities included diabetes (36.4%), cardiovascular disease (35.7%), and obstructive sleep apnea (31%). Half had at least one previously diagnosed psychiatric disorder, with the most common including major depressive disorder in 32%, post-traumatic stress disorder in 23%, anxiety disorder in 21%, and adjustment disorder in 11%. O’Donovan’s group acknowledged several limitations to the data, such as the reliance on administrative data and electronic health records, which can be prone to misclassification and residual confounding. Also, breakthrough infection severity was not assessed for the analysis and the findings may not be generalizable given the demographics of the study population. Zaim Hamza is a staff writer for MedPage Today, where this article first appeared.

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PERSONAL AND PROFESSIONAL DEVELOPMENT

Holding the Opposites BY HELANE FRONEK, MD, FACP, FASVLM, FAMWA

N HER THOUGHTFUL ARTICLE,

“The Abortion I Didn’t Have” (The New York Times Dec 2, 2021), Merritt Tierce describes becoming a mother at age 19, sharing a struggle we all face: the difficulty and importance of holding the truth and validity of two opposing realities. A gifted student anticipating an academic career, Tierce’s path is interrupted when she becomes pregnant and faces motherhood and marriage before feeling ready for either. This is not the usual telling of this story, in which love for her son transcends her sacrifices and she triumphantly states she would do it all over again. Instead, she chooses the more difficult and honest discussion. She bravely

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faces the grief of losing her dreams of career and identity; her sadness at not experiencing the excitement of welcoming a child, knowing she wasn’t ready; and her guilt at being unable to be the mother she would have wanted her son to have, due to the deep depression that followed — while also acknowledging her love for her son. What’s important about her discussion is that, in the simpler lens we often look through, we abandon our younger self, implying that her hopes and dreams were unimportant. With her courageous choice to hold these opposites, Tierce offers us a crucial pathway to greater mental health and resilience as we travel the challenging road of life. We might have had a traumatic child-

hood, emerging from pain and loneliness with skills of resourcefulness and resilience. We are held up as models of strength and encouraged to appreciate the difficulties for what they taught us. However, by doing that, we turn our back on our younger selves and trivialize the suffering we experienced. When we hold the opposites — that we should not have had to endure an abusive childhood and that we emerged with significant strengths as a result — we show compassion and respect to all aspects of ourselves and allow for greater integration of our whole being. The ability to hold these opposites is extremely important in medicine. While most physicians make the right diagnosis and offer appropriate treatment most of the time, each of us gets things wrong and encounters adverse outcomes. Medical culture’s emphasis on what we could do better, important for quality improvement and continuous learning, tends to highlight our failings. The focus on our mistakes and resulting fear contributes to burnout and stunted professional growth. A smart, conscientious former medical student called me after a minor complication during her surgical residency, wondering, “Will I ever be a competent surgeon?” Being able to hold these opposites — that she will do most things well and she will also make mistakes — allowed her to find space for both truths to exist. She is now a confident, compassionate, and thoughtful surgeon, excited to contribute to her patients and her field. While taught to look for the “unifying diagnosis,” this is one aspect of medical practice in which accepting a dichotomy is essential. Without understanding that we are both competent and flawed, we set ourselves up to trivialize our failings or ignore our abilities. Neither stance allows us to be the best physicians we can be. 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 ASSISTANT, ASSOCIATE OR FULL PROFESSOR (HS CLIN, CLIN X, ADJUNCT, IN-RESIDENCE) MED-GASTROENTEROLOGY: Faculty Position in Gastroenterology. The Department of Medicine at University of California, San Diego, Department of Medicine (http://med.ucsd.edu/) is committed to academic excellence and diversity within the faculty, staff, and student body and is actively recruiting faculty with an interest in academia in the Division of Gastroenterology. Clinical and teaching responsibilities will include general gastroenterology. The appropriate series and appointment at the Assistant, Associate or Full Professor level will be based on the candidate’s qualifications and experience. Salary is commensurate with qualifications and based on the University of California pay scales. In-Residence appointments may require candidates to be self-funded. For help contact: klsantos@ health.ucsd.edu. 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 is 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. TUBERCULOSIS CONTROL & REFUGEE HEALTH CHIEF AND MEDICAL DIRECTOR: recruitment is attached and linked here: https://www.governmentjobs.com/careers/ sdcounty/jobs/3223044/chief-tb-control-refugee-healthpublic-health-medical-officer-21412809uth PUBLIC HEALTH SERVICES MEDICAL CONSULTANT MD, DO: Medical Consultant-21416207 | Job Details tab | Career Pages (governmentjobs.com)<https://www.governmentjobs.

com/careers/sdcounty/jobs/3148610/m-d-d-o-medicalconsultant-21416207?keywords=medical%20consultant&pag etype=jobOpportunitiesJobs 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. 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 in 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) 200-2426 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 3,000 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 CHULA VISTA MEDICAL OFFICE: Ready with 8 patient rooms, 2,000 SF, excellent parking ratios, Lease $4,000/mo. No need to spend a penny. Call Dr. Vin, (619) 405-6307 or email vsnnk@yahoo.com. OFFICE SPACE AVAILABLE IN BANKERS HILL: Approximately 500-square-foot 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. 1,700 square feet. 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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“We want to make sure that California’s finest physicians are properly protected.” A Team Approach to Medical Malpractice Coverage is a Winning Approach for Physicians More than 12,500 physicians rely on the Cooperative of American Physicians (CAP) to protect their practices every day. Physician-founded and physician-governed, CAP provides superior medical malpractice coverage and solutions to help California physicians realize professional and personal success. Sarah E. Scher, JD Chief Executive Officer

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