November 2018 by San Diego Physician

NOVEMBER 2018 OFFICIAL PUBLICATION OF SDCMS

Proposition 56 CMAâ&#x20AC;&#x2122;s One-Time $1 Million Investment Reaps Billions a Year for Healthcare in California

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NOVEMBER

CONTENTS

VOLUME 105, NUMBER 11

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 SALES DIRECTOR: Dari Pebdani ART DIRECTOR: Lisa Williams COPY EDITOR: Adam Elder OFFICERS President: David E. J. Bazzo, MD President-elect: James H. Schultz, MD Secretary: Holly B. Yang, MD Treasurer: Sergio R. Flores, MD Immediate Past President: Mark W. Sornson, MD, PhD GEOGRAPHIC DIRECTORS East County #1: Venu Prabaker, MD East County #2: Rakesh R. Patel, MD East County #3: Jane A. Lyons, MD Hillcrest #1: Gregory M. Balourdas, MD Hillcrest #2: Thomas C. Lian, MD Kearny Mesa #1: Jamie M. Jordan, MD Kearny Mesa #2: Alexander K. Quick, MD La Jolla #1: Laura H. Goetz, MD La Jolla #2: Marc M. Sedwitz, MD, FACS North County #1: Patrick A. Tellez, MD North County #2: Christopher M. Bergeron, MD, FACS North County #3: Veena A. Prabhakar, DO South Bay #1: Irineo “Reno” D. Tiangco, MD South Bay #2: Maria T. Carriedo, MD GEOGRAPHIC ALTERNATE DIRECTORS East County: Heidi M. Meyer, MD Hillcrest: Kyle P. Edmonds, MD Kearny Mesa #1: Anthony E. Magit, MD Kearny Mesa #2: Eileen R. Quintela, MD La Jolla: Wayne C. Sun, MD North County: Franklin M. Martin, MD South Bay: Karrar H. Ali, DO

feature

Prop. 56: CMA’s One-Time $1 Million Investment Reaps Billions a Year for Healthcare in California

departments 4

CMS Proposes Site-Neutral Payments for Some Physician Services BY CMA STAFF

BY ADAMA DYONIZIAK

CMA Urges CMS to Simplify the Quality Payment Program

Human Trafficking: It’s Time to Take Action BY PRITI OJHA, MD

BY CMA STAFF

25 Have You Received Your Supplemental Medi-Cal Managed Care Payments?

BY HARRISON BOLTER

Physician Classified Marketplace

BY MIRANDA FELDE, MHA, CPHRM

NOVEMBER 2018

ADDITIONAL NON-VOTING MEMBERS Alternate Resident Physician Director: Zachary T. Berman, MD Alternate Retired Physician Director: Mitsuo Tomita, MD San Diego Physician Editor: James Santiago Grisolia, MD CMA Past President: James T. Hay, MD CMA Past President: Robert E. Hertzka, MD (Legislative Committee Chair) CMA Past President: Ralph R. Ocampo, MD, FACS CMA President: Theodore M. Mazer, MD CMA Trustee: William T-C Tseng, MD CMA Trustee: Robert E. Wailes, MD CMA Trustee: Sergio R. Flores, MD CMA TRUSTEES Robert E. Wailes, MD William T-C Tseng, MD, MPH Sergio R. Flores, MD AMA DELEGATES AND ALTERNATE DELEGATES: District 1 AMA Delegate: James T. Hay, MD District 1 AMA Alternate Delegate: Mihir Y. Parikh, MD At-large AMA Delegate: Albert Ray, MD At-large AMA Delegate: Theodore M. Mazer, MD At-large AMA Alternate Delegate: Robert E. Hertzka, MD At-large AMA Alternate Delegate: Holly B. Yang, MD

BY CMA STAFF

Developments in Adjuvanted Vaccines

Virtual Reality for Pain Management

Who Is the Person Behind the Mask?

AT-LARGE ALTERNATE DIRECTORS #1: Karl E. Steinberg, MD; #2: Steven L-W Chen, MD, FACS, MBA; #3: Susan Kaweski, MD; #4: Al Ray, MD; #5: Preeti Mehta, MD; #6: Vimal I. Nanavati, MD, FACC, FSCAI; #7: Peter O. Raudaskoski, MD; #8: Kosala Samarasinghe, MD ADDITIONAL VOTING DIRECTORS Communications Chair: William T-C Tseng, MD Finance Committee Chair: J. Steven Poceta, MD Resident Physician Director: Trisha Morshed, MD Retired Physician Director: David Priver, MD Medical Student Director: Margaret Meagher

BY CHARLES LAWLOR

Briefly Noted • Calendar • Payer Issues and Reimbursement • Drug Prescribing/Dispensing • Practice Management • MACRA

AT-LARGE DIRECTORS #1: Thomas J. Savides, MD; #2: Paul J. Manos, DO; #3: Alexandra E. Page, MD; #4: Nicholas J. Yphantides, MD (Board Representative to Executive Committee); #5: Stephen R. Hayden, MD (Delegation Chair); #6: Marcella (Marci) M. Wilson, MD; #7: Toluwalase (Lase) A. Ajayi, MD (Board Representative to Executive Committee); #8: Robert E. Peters, MD

Beating Our Biases BY HELANE FRONEK, MD, FACP, FACPh

Opinions expressed by authors are their own and not necessarily those of San Diego Physician or SDCMS. San Diego Physician reserves the right to edit all contributions for clarity and length as well as to reject any material submitted. Not responsible for unsolicited manuscripts. Advertising rates and information sent upon request. Acceptance of advertising in San Diego Physician in no way constitutes approval or endorsement by SDCMS of products or services advertised. San Diego Physician and SDCMS reserve the right to reject any advertising. Address all editorial communications to Editor@SDCMS.org. All advertising inquiries can be sent to DPebdani@SDCMS.org. San Diego Physician is published monthly on the first of the month. Subscription rates are $35.00 per year. For subscriptions, email Editor@SDCMS.org. [San Diego County Medical Society (SDCMS) Printed in the U.S.A.]

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/////////BRIEFLY /////////////////NOTED //////////////////////////////////////////////////////////////////////// PAYER ISSUES AND REIMBURSEMENT

CMA Pushes Back on CMS’s Proposed Medicare Payment Changes

CALENDAR

Nov. 2 Shriners Western Regional Burn Conference. Shriners Hospital in Sacramento. CME Credit Approved. Nov. 8–10 Cardiovascular, Allergy & Respiratory Summit (CARPS) at Wyndham San Diego Bayside. Optional workshops Nov. 7 Nov. 9 Women in Medicine 2018 Conference in Irvine Nov. 10 Champions for Health Annual 5K Solana Beach Walk/Run Nov. 16-17 Pain Care for Primary Care (PCPC) with Dr. Bazzo at Wyndham San Diego Bayside. Optional addiction workshop Nov. 15.

NOVEMBER 2018

THE CALIFORNIA MEDICAL Association (CMA) recently submitted comprehensive comments to the Centers for Medicare and Medicaid Services (CMS) on the proposed 2019 Medicare Physician Fee Schedule and MACRA Quality Payment Program rule. CMA is supporting CMS’s proposal to substantially reduce the Evaluation and Management (E/M) documentation requirements because it would reduce note bloat, improve workflow, and allow physicians to devote more time to their patients. However, CMA is strongly opposed to the proposal to restructure payment and coding for (E/M) office visits by collapsing the codes from five to two for both new and established patients. Even with the new proposed add-on codes for prolonged visits, primary care and certain specialties treating sicker patients, the proposal would result in significant payment cuts that would harm physicians in specialties that treat the sickest patients, as well as those who provide comprehensive primary care. Collapsing E/M codes as proposed would jeopardize access to care for the chronically ill and patients with complex conditions. CMA believes there are a number of unanswered questions and potential unintended consequences that would result from the coding policies in the proposed

rule. CMA strongly recommends that CMS work with CMA and the proposed American Medical Association task force to develop alternative solutions. CMA also strongly opposes the new multiple service payment reduction policy in the proposed rule, as the issue of multiple services on the same day of service was factored into prior valuations of the affected codes and is an important payment for physicians, as well as patient convenience. Provisions CMA supports: • year 3 of the CMA-sponsored California geographic payment updates and the transition to metropolitan statistical areas • new payments for technology-based and telehealth services • E/M documentation reduction • eliminating extra documentation requirements for home visits • eliminating the prohibition on billing for same-day visits by physicians in the same group or medical specialty Provisions CMA opposes: • new E/M payment structure • multiple procedure payment reduction • reimbursement reduction for new drugs administered in physician offices • reporting expansion for physician office labs

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TrusT A Common sense ApproACh To InformATIon TeChnology

DRUG PRESCRIBING/DISPENSING

Annual Medicare Preventive Exams Now Include Review of Opioid Use ON AUG. 28, the Centers for Medicare and Medicaid Services (CMS) published an update to the Initial Preventive Physician Examination and Annual Wellness Visit benefits, highlighting that a review of patient opioid use is now a component of medical and social history assessments. Per CMS, the review of opioid use during these annual preventive exams will help physicians identify patients using opioids, discuss alternative for non-opioid pain therapies, and assist in diagnosing and treatment for patients experiencing or at risk for opioid-use disorders. CMA Safe Prescribing Resources The California Medical Association (CMA) supports a well-balanced approach to opioid prescribing and treatment that considers the unique needs of individual patients. CMA’s safe prescribing resource page includes the most current information and resources on prescribing controlled substances safely and effectively to relieve pain, while simultaneously reducing the risk of prescription medication misuse, addiction, and overdose. There you will find: • resources on prescribing controlled substances safely and effectively to relieve pain, while simultaneously reducing the risk of prescription medication misuse, addiction, and overdose • CMA’s white papers on prescribing opioids • links to relevant documents in CMA’s health law library • continuing medical education courses and webinars • current information on the state’s prescription drug monitoring database.

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/////////BRIEFLY /////////////////NOTED //////////////////////////////////////////////////////////////////////// MACRA

CMS Identifies and Corrects Errors in MIPS Scoring Logic

PRACTICE MANAGEMENT

Noridian Announces Improvements to Medicare Portal Noridian, the Medicare Administrative Contractor for California, recently announced improvements to the Noridian Medicare Portal (NMP) that will make it easier for providers to identify reasons behind eligibility-related claim denials. When a claim is denied for eligibilityrelated reasons, providers can select the link under Claim Status in the â&#x20AC;&#x153;Related Inquiriesâ&#x20AC;? portion of the page to access details to assist with determining their next steps. Effective July 27, 2018, all NMP users can also send secure online messages to Noridian regarding medical reviews or to voice concerns to be addressed by the Noridian CERT liaison teams. With the ability to message Noridian, providers better understand claim review decisions and are better prepared to avoid future denials. Messages sent regarding non-medical review/CERT will be directed to the Provider/Supplier Contact Centers. Additional instructions can be found in the Noridian User Manual and self-paced tutorials. Noridian also announced that provider enrollment functionality will soon be added to the NMP, allowing physicians the ability to review notification letters, application status and submit correspondence as needed, which will be automatically attached to the application. Having previously enrolled in Medicare is a prerequisite for NMP. This feature will assist providers with ongoing file maintenance. Additional NMP enhancements include an updated inquiry function providing details for active, inactive, deductible and coinsurance period eligibility for Medicare Diabetes Prevention Program patients. 6

NOVEMBER 2018

THE CENTERS FOR MEDICARE and Medicaid Services (CMS) recently released 2017 Merit-based Incentive Payment System (MIPS) performance scores and payment adjustment information for the 2019 payment year. Physicians have been able to request targeted reviews if they believe an error was made in the calculation of their performance score. The requests CMS received through targeted review led them to take a closer look at a few prevailing concerns. Those concerns included the application of the 2017 Advancing Care Information and Extreme and Uncontrollable Circumstances hardship exceptions, the awarding of Improvement Activity credit for successful participation in the Improvement Activities Burden Reduction Study, and the addition of the All-Cause Readmission measure to the MIPS final score. Based on these requests, CMS reviewed the concerns, identified a few errors in the scoring logic, and implemented system-wide solutions. The 2019 MIPS payment adjustments have been corrected for clinicians impacted by the identified issues. Additionally, in order to ensure the budget neutrality that is required by law under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), some clinicians not directly impacted by the corrections will see slight changes in their payment adjustment as a result of the reapplication of budget neutrality. These revisions were made to the performance feedback on the Quality Payment Program (QPP) website on Sept. 13, 2018. Physicians, physician groups, and accountable care organizations (and their authorized representatives) can access their performance feedback by logging into qpp.cms.gov with the same EIDM credentials used to submit and view their data during the submission period. Physicians who need assistance can contact the QPP Service Center at (866) 288-8292 or QPP@ cms.hhs.gov. CMS has posted the 2017 Performance Feedback User Guide on CMS.gov to help eligible clinicians and groups understand their 2017 MIPS performance feedback.

////////////////////////////////////////////////////////////////////////////////////////////////// 10TH ANNUAL SDCMS “OUTSTANDING MEDICAL OFFICE MANAGER” CONTEST Now accepting nominations! SDCMS wants to recognize San Diego County’s most outstanding medical office manager/practice administrator, i.e., someone who goes above and beyond his or her job description, who anticipates problems before they arise, who works efficiently with the practice’s time and resources, and who strikes the right balance between exercising control and boosting morale when supervising staff. SDCMS Member physicians can nominate their office managers by explaining in writing (up to 600 words) why their office manager is the BEST in San Diego County. Nominations will be accepted through Friday, Nov. 30, 2018. The winner will receive a $200 gift card and recognition as San Diego County’s Outstanding Medical Office Manager for 2018! Contest results will also be published in the February 2019 issue of San Diego Physician magazine. Please email your nominations to Hanna.Basler@SDCMS.org. Remember, only submissions from physician members will be considered.

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

SAN DIEGO PHYSICIAN.ORG

C H A M P I O N S F O R H E A LT H

Who Is the Person Behind the Mask? By Adama Dyoniziak

A COVERT OPERATIVE with a secret mission? A skilled practitioner of the arts with an eye for technical detail? A superhero who saves lives? Maybe yes and yes. The mask covers the many faces of the anesthesiologists who comprise the largest physician-owned and -run anesthesia practice in San Diego — Anesthesia Service Medical Group (ASMG). “Every minute of every day, an ASMG anesthesiologist is providing a pro bono community service somewhere in San Diego County,” says Dr. Andrew Zimmerman, president of the board and CEO of ASMG. At Champions for Health, Project Access San Diego patients have been the beneficiaries of these nerve-numbing, sleep-like inducing services for the past 10 years. ASMG has been a good steward in the San Diego community since its inception in 1946, with Project Access being one group in a constellation of many other worthy recipients of goodwill. More than 714 Project Access patients and counting have been the recipients of successful procedures and operations where an ASMG anesthesiologist was ensuring excellent medical care was being provided. The CMO for ASMG, Dr. Peter Raudaskoski, says, “Patients are placing their life in our hands because they trust they will receive a safe and state-of-the-art outcome.” ASMG’s strength is in the level of consistent performance achieved regardless of which anesthesiologist is involved. According to Dr. Mark Ransom, vice president of ASMG, “Our vision was developed several years ago with a mission statement of well-thought-out guidelines and principles that has served as the North Star for ASMG to navigate and make decisions.” Maintaining the highest integrity in relationships with patients, professional

NOVEMBER 2018

associates, corporate personnel, family, and community is realized as anesthesiologists, being perioperative physicians who are involved from the pre-op consult through discharge, ensure high-quality, efficient, patient-centered care. ASMG physicians work together in concert for the good of the entire group. Each anesthesiologist goes into a procedure prepared to provide the best in medical care, unaware if the patient is receiving pro bono services. The physicians are paid for their work, and the group as a whole absorbs the pro bono community service costs, making for seamless service provision. When asked what drew him to the practice of anesthesiology, Dr. Zimmerman mused that he enjoyed the hands-on, direct effect of anesthesiology, with second-bysecond decision making and intense work. Anesthesiologists get to see the results of their work almost instantly, and it is very

Top: Dr. Kris Lukauskis. Left: Dr. Blythe Newlin. Bottom: Dr. Peter Radauskoski from ASMG.

gratifying. As the sun sets over the San Diego skyline, Project Access patients cheer on their anesthesiologists, as our superheroes walk, ride or fly into the sunset, cape floating … mask in hand … ready to take on their next challenge. If you, your practice, or your facility would like to become a member of the Project Access network of physicians, please contact Adama Dyoniziak at (858) 300-2780 or adama.dyoniziak@championsfh.org. Ms. Dyoniziak is executive director of Champions For Health.

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M E N TA L H E A LT H

Human Trafficking It’s Time to Take Action By Priti Ojha, MD

Forced to have sex with multiple strangers in a matter of hours. Never being able to get away. Threats on families. Being promised a better life, a home, love. Being beaten, manipulated. Modern-day slavery. In our own backyard.

NOVEMBER 2018

OF THE 27 MILLION people who are trafficked internationally, 18,000 of them are suspected to be in the United States. More specifically, the FBI has ranked San Diego as one of the top 13 cities for high intensity child prostitution. An estimate of 3,400– 8,100 individuals are sex-trafficked annually in San Diego County, with an average victim age of 16 years.1 The vast majority of exploited individuals are U.S.-born women, and survivors span all ethnic backgrounds and socioeconomic levels. This is likely an underestimate given the reluctance with which an individual may self-identify as being involved “in the life.” Shame and fear are byproducts of the manipulation they endure. A fear of retaliation, arrest, deportation, and shame of the position they are in may make it difficult for victims to disclose their situations. Particularly vulnerable populations include those in the foster care system or struggling with homelessness. In addition to online solicitation, traffickers recruit on middle and high school campuses in all quadrants of San Diego County. There is virtually nowhere in San Diego that is not

impacted by sex trafficking. “Victims have been identified either living or ‘working’ in every city in San Diego County, and in areas of each that are both wealthy and impoverished,”1 according to researchers Ami Carpenter and Jamie Gates. As one of the largest underground economies, second only to drug trafficking, sex trafficking generates an estimated $810 million annually, with more than 100 gangs in San Diego reporting profit from this industry.1 According to the Department of Homeland Security, “human trafficking is modern-day slavery and involves the use of force, fraud, or coercion to obtain some type of labor or commercial sex act.” Force is typically in the form of physical or sexual assault or confinement. Fraud is when wages, work, or living conditions are insincerely promised. Coercion is when manipulation, document confiscation, and threats of harm or deportation are employed. Force, fraud, and coercion are not required if minors are involved in commercial sex acts.2 To better understand the medical sequelae of trafficking, we must understand the coercion to which victims are subjected. According to a study conducted by University of San Diego and Point Loma Nazarene in which traffickers were interviewed, three primary types of coercion are utilized. In economic coercion (74%), earnings are confiscated by the trafficker. Some patients have recounted the need to pay exorbitant fees to their trafficker in order to maintain their housing and access to utilities. In

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M E N TA L H E A LT H

“As medical providers, it is likely that we, at some point in our careers, have encountered a potential victim of human trafficking. In fact, more than half — and in some reports, up to 88% — of victims interacted with a healthcare professional while being trafficked.”

psychological coercion (57%), victims are socially and emotionally isolated, subjected to “emotional exhaustion and degradation, including humiliation, denial of the victim’s power, and name-calling.”1 In chemical coercion (42%), victims are provided, often forcibly, drugs and alcohol. Over time, the manipulation lends itself to the development of bonding between the trafficker and the victim. Victims may return to the trafficker with a sense of loyalty and regard. One patient I recently saw was a young woman in her late teens who moved to San Diego shortly after high school graduation. Soon, she met a young man online who she described as a handsome, nurturing guy that understood her. When he invited her to live with him, she thought she was entering a monogamous relationship. She quickly

NOVEMBER 2018

learned otherwise. Within days, she was being “passed around,” forced to have sex with multiple men, being verbally degraded by other women who lived in the home. Her driver’s license and passport were with her “boyfriend,” who also collected any payments that were meant for her. Understandably, she developed an invariable sense of mistrust as her self-esteem began to shatter. After nearly two years, she has successfully left being “in the life.” She suffers from daily nightmares that are coupled with hypervigilance of her trafficker finding her. Despite the complex trauma she has endured, she continues to persevere. She is now working part-time and takes college classes with hopes to pursue a career in the sciences. As I reflect on my work with patients such as her, I am struck by the resiliency with which they present. Through UCSD’s Com-

munity Psychiatry Program, I have been fortunate to work with survivors of trafficking in San Diego County. Our work with this specific population serves as a prudent reminder of the role physicians can play as advocates for our patients. As medical providers, it is likely that we, at some point in our careers, have encountered a potential victim of human trafficking. In fact, more than half — and in some reports, up to 88% — of victims interacted with a healthcare professional while being trafficked.3 They present in a variety of medical settings with physical, reproductive, and mental health chief complaints. These can range from traumatic injuries such as fractures, cuts, and burns to headaches, poor oral health, and malnutrition. They may present to primary care or ob-gyn with vaginal, perineal, and rectal injuries, frequent sexually transmitted infections, and unwanted pregnancies or complications of unsafe, forced abortions. Due to the delay in which individuals are able to seek care, chronic medical problems often go untreated, leading to chronic pain syndromes, and kidney and liver dysfunction.4 In addition to an increased disease burden and poorer health outcomes than their peers, survivors struggle with significant mental health sequalae. Among survivors in the U.S., more than 40% have attempted suicide, more than 50% have PTSD, and nearly 90% have depression. Other common co-morbidities include sleep disorders and substance use disorders, which develop subsequent to force and coercion.3 Working in San Diego County, it is imperative that we have this on our radar. At UCSD, we have mobilized by creating an interdisciplinary taskforce comprising physicians, nurses, case managers/ social workers, researchers, and community partners including survivor advocates and representatives from the district attorney’s office. In addition to increasing awareness and education, we have developed a policy and protocol for the screening, assessment, and reporting of suspected human trafficking in the emergency room and inpatient hospital settings. The protocol guides clinicians, using a trauma-informed approach, through screening for physical signs and control indicators of trafficking in addition to providing a primer for a focused social work evaluation. Physical signs and symptoms may include bruises at various stages of healing, branding tattoos

(i.e., traffickers’ name/initials, a bar code). Control indicators may include a patient being accompanied by a controlling person who carries the patient’s identification and does not allow the patient to meet with the clinician independently. Patients may avoid eye contact and appear nervous. Providing trauma-informed care that emphasizes patient empowerment is at the cornerstone of the healthcare provider’s initial response. We aim to provide a quiet, safe place in which one can build a rapport with the patient in a transparent and collaborative manner. It is important to note that once a potential victim has been identified, the immediate goal is not to rescue the individual. Oftentimes getting out of a trafficking situation can be dangerous. Our goal is to create a safe space for them to seek assistance. As healthcare providers, we must join our community in this battle against slavery. No community is immune to human traffick-

ing: in rural, suburban, and big-city areas, this violation of human rights is happening everywhere. Let us educate ourselves about human trafficking and the impact it has on our patients’ health. We are well-positioned to intervene. For more information contact: National Human Trafficking Hotline https://humantraffickinghotline.org 1 (888) 373-7888 or TTY 711 (24/7) or textBeFree 233733 (12 p.m.–8 p.m. PST) San Diego Human Trafficking Task Force and Hotline https://oag.ca.gov/bi/httf (858) 495-3611 Carpenter, Ami, and Jamie Gates. “The nature and extent of gang involvement in sex trafficking in San Diego County.” San Diego, CA: University of San Diego and Point Loma Nazarene University (2016). 1

2 US Department of Health and Human Services. “Fact sheet: Human trafficking.” Office of Trafficking in Persons. https://www. acf.hhs.gov/sites/default/files/otip/fact_ sheet_human_trafficking_fy18.pdf (2017). 3 Lederer, Laura J., and Christopher A. Wetzel. “The health consequences of sex trafficking and their implications for identifying victims in healthcare facilities.” Annals Health L. 23 (2014): 61. 4 Borland, R., and C. Zimmerman. “Caring for trafficked persons: guidance for health providers.” Geneva: International Organization for Migration (2009).

Dr. Ojha is an assistant clinical professor at UC San Diego in the department of psychiatry, Community Psychiatry Program, and serves as co-chair for UCSD Health System’s Committee of Healthcare Response to Human Trafficking.

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INFEC TIOUS DISE ASES

Developments in Adjuvanted Vaccines By Harrison Bolter

ONE OF MANY RECENT developments in the field of immunization has been the use of new classes of adjuvants. Adjuvants have been used in vaccines for decades, but the past two years have seen the release of three new vaccines containing novel adjuvants: (1) FLUAD, an influenza vaccine for adults 65 years and older; 2) Heplisav-B, a two-dose hepatitis B vaccine for adults 18 years of age and older; and 3) Shingrix, a shingles vaccine recommended for ages 50 and older. An adjuvant is a substance that is formulated as part of a vaccine to enhance its abil-

NOVEMBER 2018

ity to induce protection against infection. The word “adjuvant” comes from the Latin adjuvare and means “to help.” Adjuvants help activate the immune system, allowing the antigens in vaccines to induce longterm protective immunity.1 An effective vaccine stimulates both innate immunity and adaptive immunity. The former occurs within hours, as immune cells recognize a pathogen, while the latter develops over several days and involves coordination and expansion of adaptive immune cells. This leads to immune memory,

when cells highly specific to the pathogen are retained for later use in case of reinfection. Adjuvants are important for activating the innate immune response, resulting in improved adaptive immunity with enhanced activation of T and B cells.1 The first human vaccines were based on attenuated or inactivated pathogens that cannot cause disease. These vaccines contain naturally occurring adjuvants and antigens from the incapacitated pathogen and can elicit strong protective immune responses. Many of these types of vaccines are still widely used. For example, the seasonal flu shot contains inactivated influenza virus and the nasal spray flu vaccine includes attenuated virus, which is unable to cause flu illness.1 Most vaccines developed today include only the antigens that best stimulate the immune system, such as surface proteins, rather than the entire virus or microbe. For example, the recombinant flu vaccine contains the influenza hemagglutinin protein that is produced in cell culture. This design makes vaccines safer and easier to produce,

Get the mortgage benefits you deserve with the Bank of America® Doctor Loan1 although adjuvants may be needed to elicit a stronger protective immune response when the antigens alone do not induce adequate immunity and long-term protection.1 Alum was the only vaccine adjuvant in use in the United States until 2009, when the Food and Drug Administration (FDA) approved Cervarix, an HPV vaccine that contains an adjuvant called AS04. This adjuvant is a combination of alum and monophosphoryl lipid A (MPL), an immunestimulating lipid. In 2013, FDA approved the inclusion of another combination adjuvant, AS03, in the pandemic H5N1 influenza vaccine. Currently, this vaccine is included in the U.S. vaccine stockpile, but is not commercially available. AS03 is an oil-inwater emulsion that is similar to MF59, an adjuvant that has been used for many years in licensed flu vaccines in more than 30 countries outside the United States. Novel antigen-adjuvant combinations continue to be developed.1 Novel Adjuvants FLUAD Poor immune response to flu vaccine in older adults, especially those 65 years and older, has been known for some time to be a problem. One approach to increasing vaccine effectiveness in this population has been to offer high-dose influenza vaccine (containing four times the standard amount of flu antigen).2 Another approach is to add an adjuvant to a standard-dose flu vaccine. FLUAD contains the adjuvant MF59, which is an in-water emulsion of squalene oil. Squalene is a natural substance that occurs in humans, animals, and plants.3 Studies that have tested FLUAD’s ability to generate an immune response against an influenza virus have found that antibody levels were comparable to levels induced by unadjuvanted trivalent seasonal flu vaccines (e.g., AGRIFLU). However, an observational study, conducted in Canada among adults 65 years of age and older during the 2011–2012 flu season, found that FLUAD was significantly more effective in preventing laboratory-confirmed influenza compared with an unadjuvanted standard-dose inactivated influenza vaccine.4,5 Heplisav-B (HepB-CpG) This vaccine is recommended as a two-dose series for prevention of infection and complications caused by hepatitis B virus (HBV) in adults 18 years of age and above. It contains a novel adjuvant called 1018 adjuvant, which

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An applicant must have, or open prior to closing, a checking or savings account with Bank of America. Applicants with an existing account with Merrill Edge®, Merrill Lynch® or U. S. Trust prior to application also satisfy this requirement. Eligible medical professionals include: (1) medical doctors who are actively practicing, (MD, DDS, DMD, OD, DPM, DO), (2) medical fellows and residents who are currently employed, in residency/fellowship, or (3) applicants who are medical students or doctors and are about to begin their new employment/residency or fellowship within 90 days of closing. Must be actively practicing in their field of expertise. Those employed in research or as professors are not eligible. For qualified borrowers with excellent credit. PITIA (Principal, Interest, Taxes, Insurance, Assessments) reserves of 4 – 6 months are required, depending on loan amount. 2 Minimum down payment requirements vary by property type and location; ask for details. 3 Additional documentation is required. Credit and collateral are subject to approval. Terms and conditions apply. This is not a commitment to lend. Programs, rates, terms and conditions are subject to change without notice. Bank of America, N.A., Member FDIC. Equal Housing Lender. ©2018 Bank of America Corporation. ARY89JD7 | AD-07-18-0108 | HL-112-AD | 02-2018 1

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INFEC TIOUS DISE ASES

stimulates a directed immune response to hepatitis B surface antigen (HBsAg).6 Seroprotective antibody to hepatitis B surface antigen (anti-HBs) levels were achieved in 90.0%–100.0% of subjects receiving just two doses of HepB-CpG, compared with 70.5%–90.2% of subjects receiving three doses Engerix-B. The benefits of protection with two doses administered over one month make HepB-CpG an important option for HBV prevention.6 The Advisory Committee on Immunization Practices (ACIP) recommends the following groups of adults receive hepatitis B vaccine: •• persons at risk for infection through sexual exposure o sex partners of hepatitis B surface antigen (HBsAg)–positive persons o sexually active persons not in a long-term, mutually monogamous relationship o persons seeking evaluation or treatment for a sexually transmitted infection o men who have sex with men •• persons with a history of current or recent injection drug use •• persons at risk for infection by percutaneous or mucosal exposure to blood o household contacts of HBsAgpositive persons o residents and staff of facilities for developmentally disabled persons o healthcare and public safety personnel with reasonably anticipated risk for exposure to blood or bloodcontaminated body fluids o hemodialysis patients and predialysis, peritoneal dialysis, and home dialysis patients o persons with diabetes mellitus aged <60 years and persons with diabetes mellitus aged ≥60 years at the discretion of the treating clinician o international travelers to countries with high or intermediate levels of endemic HBV infection (HBsAg prevalence ≥2%) •• persons with hepatitis C virus infection, persons with chronic liver disease (including, but not limited to, those with cirrhosis, fatty liver disease, alcoholic liver disease, autoimmune hepatitis, and an alanine aminotransferase [ALT] or aspartate aminotransferase [AST] level greater than twice the upper limit of normal) •• persons with human immunodeficiency virus infection

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“Adjuvanted vaccines sometimes have more side effects than non-adjuvanted ones, but their efficacy, which is often superior to nonadjuvanted vaccines, merits serious consideration for administration to the relevant patient populations.” •• incarcerated persons •• other persons seeking protection from hepatitis B virus infection (even without acknowledgment of a specific risk factor) 6 Shingrix Shingrix (recombinant zoster vaccine or RZV) is recommended as a two-dose series for prevention of herpes zoster (shingles) and related complications in immunocompetent adults 50 years of age and older. Shingrix contains a novel adjuvant called ASO1.7 Shingrix is preferred over the older zoster vaccine live (Zostavax; ZVL) for prevention of herpes zoster and related complications. In separate clinical trials, for all age categories, RZV estimates of efficacy against herpes zoster were higher than those for ZVL. Estimates of efficacy against postherpetic neuralgia are also higher for RZV than for ZVL. ZVL efficacy wanes substantially during the four years following receipt.

As a result of higher efficacy, particularly in individuals 70 years and above, RZV is estimated to prevent more herpes zoster and postherpetic neuralgia compared with ZVL. ACIP acknowledged that several aspects of RZV performance will be further elucidated postlicensure, including the possibility of a rare adverse event related to the vaccine, the long-term duration of protection, the adherence to the two-dose schedule, and the effectiveness and duration of protection of one dose of RZV.7 Overall, clinical trials have shown that Shingrix has an efficacy rate of greater than 90%.7 Because of its efficacy, the vaccine is recommended to be used in healthy persons 50 years and older, and also in special populations (aged 50 years and older), such as persons with a history of herpes zoster, persons with chronic medical conditions (such as renal failure, diabetes and pulmonary disease), immunocompromised persons, and those known not to have a history of varicella.7 Shingrix is also recommended for adults who have already received zoster vaccine live (Zostavax). Adverse events reported included pain, redness, and swelling at the injection site, as well as myalgia and fatigue, shivering, fever, stomach pain, or nausea. About 1 in 6 people receiving Shingrix experienced side effects which altered their daily activities for two to three days. 8 While adjuvanted vaccines often induce

better immune responses, they also tend to cause more local and systemic adverse events. As a result of the enhanced immune response, pain, redness, and swelling at the injection site is often greater with these new adjuvanted vaccines, compared to previous vaccines. Additionally, systemic reactions such as fever and malaise are also noted with increased frequency following adjuvanted vaccines. It is important to advise your patients that these local and systemic symptoms may follow their vaccination. Fortunately, these adverse reactions are usually short lived and resolve within 24–48 hours. In summary, adjuvanted vaccines sometimes have more side effects than nonadjuvanted ones, but their efficacy, which is often superior to non-adjuvanted vaccines, merits serious consideration for administration to the relevant patient populations. It is likely that additional new vaccines will be developed using these and other new adjuvants.

References: 1. https://www.niaid.nih.gov/research/ what-vaccine-adjuvant, What Is a Vaccine Adjuvant?, accessed 09/13/2018 2. https://www.cdc.gov/flu/professionals/ vaccination/effectivenessqa.htm, What is the evidence that influenza vaccines work?, Adults 65 years or older, accessed 08/14/2018. 3. https://www.cdc.gov/flu/protect/vaccine/adjuvant.htm, What is MF59?, accessed 08/14/2018. 4. https://www.cdc.gov/flu/protect/vaccine/adjuvant.htm, Are there increased benefits of FLUAD™ compared to unadjuvanted seasonal flu vaccines for this age group?, accessed 08/14/2018. 5. https://www.cdc.gov/flu/protect/ vaccine/adjuvant.htm, How safe is FLUAD™?, accessed 08/14/2018. 6. Schillie S, Harris A, Link-Gelles R, Romero J, Ward J, Nelson N. Recommendations of the Advisory Committee on Immunization Practices for Use of a Hepatitis B

Vaccine with a Novel Adjuvant. MMWR Morb Mortal Wkly Rep 2018;67:455–458. DOI: http://dx.doi.org/10.15585/mmwr. mm6715a5 7. Dooling KL, Guo A, Patel M, et al. Recommendations of the Advisory Committee on Immunization Practices for Use of Herpes Zoster Vaccines. MMWR Morb Mortal Wkly Rep 2018;67:103–108. DOI: http://dx.doi.org/10.15585/mmwr. mm6703a5. 8. https://www.cdc.gov/vaccines/vpd/ shingles/public/shingrix/index.html, Shingles Vaccination, accessed 8/24/18).

Mr. Bolter is a Health Information Specialist II, Epidemiology and Immunization Services Branch in Public Health Services for the County of San Diego Health and Human Services Agency.

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Virtual Reality for Pain Management By Miranda Felde, MHA, CPHRM

IN 2016, SCIENCE TEACHER Bob Jester fell off a roof, broke 19 bones, and underwent surgery for his badly broken back. Doctors prescribed Oxycodone, an opioid, during Jester’s extended recovery. Jester worried that he would become dependent on opioids, so he jumped at the chance to try Virtual Reality (VR) as an alternative to opioids when an acquaintance told him about a company that

was using VR for pain management. When he started using a mobile headset connected to a smartphone that plays VR apps, Jester found his pain lessened and the effect lasted for several hours each time. About a year after his accident, Jester was able to wean himself off opioids. Could other patients with severe acute and/ or chronic pain experience the same results?

The State of the Opioid Crisis The number of opioid prescriptions written annually in the U.S. roughly equals the number of adults in the country. And sometimes opioids, though intended to help patients, cause harm: The opioid epidemic claims the lives of 115 people every day. While the financial costs of the opioid epidemic can be tallied — in 2016, the opioid epidemic’s toll hit $95 billion, with healthcare costs concentrated in emergency room visits, hospital admissions, ambulance use, and Naloxone use — the personal costs to those who have lost loved ones are uncountable. The epidemic’s impact is far-reaching and has emotional, physical, and financial implications for our entire society. Exploring VR for Pain Management Many physicians are exploring VR technologies as an alternative to prescriptions. The Gate Control Theory of pain, proposed by Melzack and Wall, suggests that a person may interpret pain stimuli differently depending upon mental/emotional factors such as attention paid to the pain, emotions associated with the pain, and past experience of the pain. VR addresses both attention paid to pain and the patient’s emotional state: The immersive distraction of VR can help a patient mentally transport to another space, such as an underwater seascape, which may also positively affect the patient’s emotional state. In 1996, the Harborview Burn Center in Seattle successfully piloted the use of VR for burn patients with severe acute pain. Since then, more providers have found VR can provide relief for patients experiencing acute pain, such as the type Jester experienced following surgery. Recent studies have explored whether VR can relieve chronic pain. One small but promising study of patients with neuropathic pain found that patients experienced a 69% reduction in pain during each session and a 53% pain reduction immediately after each session. Getting Started with VR To explore VR as an alternative therapy, first consider the distinctions between two key terms: • Virtual Reality (VR): Provides an immersive experience via a computergenerated 3D environment for the user to explore. The user may be able to move objects or otherwise change the environment.

NOVEMBER 2018

• Augmented Reality (AR): Adds sounds, videos, and/or graphics to an existing environment, such as an outdoor planetarium where AR viewing glasses show constellations highlighted in the sky.

“Patients experienced a 69% reduction in pain during each session and a 53% pain reduction immediately after each session.” Then, evaluate VR interfaces that are relevant for patients managing pain, such as: • Head-mounted display (HMD): Like a heavy-duty pair of goggles plus headphones. Completely surrounds the user’s visual field for an immersive experience. • Treadmills and haptic gloves: Allow the user to physically move around in the virtual environment, and to physically move objects within that environment And weigh the value of interfaces that are more relevant for physician use, such as: • Smart glasses: May look more like regular eyeglasses or more like safety glasses. May display information or help the physician capture information for the electronic health record (EHR). • Desktop VR or Window on a World (WOW): Uses a desktop or laptop computer to run simulation programs, including those for training. Mitigating VR Patient Safety Risks While therapeutic VR for pain management shows promise, there are patient safety risks. They include: • Falls: Patients wearing a full-surround headset cannot see their real-world environment and may walk into or trip over objects. Even patients in bed can knock things over while waving their arms around. Create a safe physical environment for VR use. • Motion sickness: Many people experience some combination of eye strain, headaches, and/or nausea. Patients who are ordinarily prone to any of these symptoms may not be good VR candidates. • Psychological effects: The brain can

store VR experiences as memories in almost the same way it stores physical experiences. Young children may confuse VR experiences with real experiences, especially when remembering them later. “If you were to do this in the real world, how would it affect you? That’s the way to think about virtual reality,” says Jeremy Bailenson, director of Stanford’s Virtual Human Interaction Lab. • The unknown: VR technology is still in its infancy, and therefore, little is known about the long-term consequences of VR use. The Future of VR for Pain Management Some physicians imagine a future of tetherless headsets that allow patients in pain the freedom to escape reality and transport to another emotional space. To reap the potential benefits of VR while mitigating its risks, clinicians could start with a two-part approach: identifying patients with specific clinical indications that would benefit from the use of VR and assessing patients for potential risk factors. Successful implementation of VR for pain management depends on wisely deciding which patients are VR candidates — and which are not. Contributed by The Doctors Company. For more patient safety articles and practice tips, visit www.thedoctors.com/patientsafety. The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider in light of all circumstances prevailing in the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered. References 1. Schroeder K. After accident leaves him paralyzed, retired teacher Bob Jester battles his chronic pain with virtual reality. Riverhead Local. October 4, 2017. https:// riverheadlocal.com/2017/10/04/accident-leaves-paralyzed-retired-teacherbob-jester-battles-chronic-pain-virtualreality/. Accessed June 25, 2018. 2. Marcus H. Prescribing opioids safely. The Doctor’s Advocate 2017; 2nd quarter. https://www.thedoctors.com/thedoctors-advocate/second-quarter-2017/ prescribing-opioids-safely/. Accessed

June 25, 2018. 3. Understanding the epidemic. Centers for Disease Control and Prevention Website. https://www.cdc.gov/drugoverdose/ epidemic/index.html. Accessed June 25, 2018. 4. Castellucci M. Economic burden of opioid epidemic hit $95 billion in 2016. Modern Healthcare. http://www.modernhealthcare.com/article/20171116/ NEWS/171119908. Accessed June 25, 2018. 5. Barad J. New realities in medicine—exploring the virtual and augmented horizon. Panel presented at: A4M MMI World Congress. December 14-16, 2017; Las Vegas, NV. 6. Li A, Montaño Z, Chen VJ, Gold JI. Virtual reality and pain management: current trends and future directions. Pain Management. 2011 Mar; 1(2): 147-157. 7. Loguidice CT. Virtual reality for pain management: A weapon against the opioid epidemic? Clinical Pain Advisor, September 5, 2017. https://www.clinicalpainadvisor.com/painweek-2017/chronicpain-management-with-virtual-reality/ article/684461/. Accessed June 19, 2018. 8. Loguidice CT. Virtual reality for pain management: A weapon against the opioid epidemic? Clinical Pain Advisor, September 5, 2017. https://www.clinicalpainadvisor.com/painweek-2017/chronicpain-management-with-virtual-reality/ article/684461/. Accessed June 19, 2018. 9. Palladino T. National Geographic’s open-air planetarium displays augmented reality constellations through Aryzon viewers. Next Reality, June 21, 2018. https://next.reality.news/news/ national-geographics-open-air-planetarium-displays-augmented-realityconstellations-through-aryzon-viewers-0185390/. Accessed June 25, 2018. 10. LaMotte, S. The very real health dangers of virtual reality. CNN Website, December 13, 2017. https://www.cnn. com/2017/12/13/health/virtual-realityvr-dangers-safety/index.html. Accessed June 25, 2018. 11. LaMotte, S. The very real health dangers of virtual reality. CNN Website, December 13, 2017. https://www.cnn. com/2017/12/13/health/virtual-realityvr-dangers-safety/index.html. Accessed June 25, 2018. Ms. Felde is vice president, Patient Safety and Risk Management for The Doctors Company. SAN DIEGO PHYSICIAN.ORG

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CMS Proposes Site-Neutral Payments for Some Physician Services By California Medical Association Staff

THE CENTERS FOR MEDICARE and Medicaid Services (CMS) has proposed eliminating the Medicare site of service payment differential for physician services. Under the proposed policy, Medicare would pay the same amount for office visit services provided by physicians in “off-campus” hospital outpatient departments as it would for the same office visit service provided in a physician’s office. Currently, Medicare pays a “facility fee” that results in a much higher rate for the same service when performed in outpatient clinics owned by hospitals, rather than in a physician’s office. For example, cardiac

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imaging payments are more than triple when patients receive care at a hospital outpatient department instead of a physician’s office — roughly $2,100 vs. $655. This rule change would result in significant savings for Medicare and its beneficiaries, and foster greater competition in the healthcare market. Healthcare policy experts have demonstrated that this site of service payment differential has incentivized hospitals to acquire physician practices, with an 86 percent increase between 2012 and 2015 in number of physician practices owned by hospitals nationwide. This unprecedented trend in

hospital acquisition of physician practices has caused provider consolidation in the marketplace that has decreased competition, led to increased prices and premiums in the private sector, and increased Medicare costs. Medicare hospital spending has increased 60 percent since 2000. UC Berkeley researchers recently reported that 40 percent of California physicians now work for foundations owned by hospitals, up from 25 percent in 2010. Nationwide, nearly 33 percent of physicians were employed by hospitals in 2014 (the most recent data available), up from 29 percent in 2012. Most healthcare economists, policymakers, and clinicians are now supporting site neutral payments in Medicare to reverse the policies that have artificially driven hospitalphysician consolidation and increased costs. The California Medical Association (CMA) believes that two factors led to this hospitalphysician consolidation: The higher facility fees for hospital outpatient services and the low Medicare physician payment rates. Medicare physician payments have remained flat since 2001, and now lag at least 25 percent behind the costs to operate a medical practice. While payments have remained flat, the administrative and reporting burdens of running a practice have dramatically increased. Without the resources to invest in practice infrastructure, such as EHRs and quality improvement activities now required for participation in value-based payment programs, independent practices have been driven to seek resources and assistance from hospitals. To reverse the trend in hospitals acquiring physician practices and the consolidation in the market that has increased costs, CMA is recommending the following: • CMS should eliminate the site of service payment differential for ALL services (not just office visits) and ALL settings (off campus and on-campus outpatient departments, except emergency departments). • CMS should reinvest the savings achieved by site neutrality in a budget neutral way by reinvesting in physician payment so that independent practices have the resources to remain viable, protect access to care, and participate in value-based payment programs. • CMS should provide a six-month transition period for providers to make adjustments, transition their practices, and maintain continuity of care for their patients.

P U B L I C PAY E R S

CMA Urges CMS to Simplify the Quality Payment Program By California Medical Association Staff

THE CALIFORNIA Medical Association (CMA) has submitted comments to the Centers for Medicare and Medicaid Services (CMS) on the proposed changes to the Medicare Quality Payment Program for 2019. CMA is disappointed that CMS did not reduce the reporting burdens in the Merit-based Incentive Payment System (MIPS) program in a more meaningful way. We also oppose the confusing new scoring tiers (gold, silver and bronze) and have urged CMS to simplify and overhaul the complex MIPS

scoring system. CMA strongly urges CMS to maintain the 10 percent weight of the cost category, rather than increasing it to 15 percent as proposed. Vast methodology improvements should be made to the cost category before its weighting is increased. Otherwise, physicians will be disincentivized from treating the sickest and most vulnerable patients, thereby jeopardizing access to care. CMA has also requested a delay in the new attribution methods for the inpatient condition measures.

CMA continues to urge CMS to expand the number and types of innovative physician-led alternative payment models (APM) and to remove the current administrative and financial barriers to participation. California physicians have been innovators in healthcare delivery, and we cannot emphasize more strongly the need to move forward with more innovative, physician-led models. APMs can address the shortcomings of a fee-for-service system that fails to incentivize high-value services, such as chronic care case management or palliative care — services that reduce spending and improve care. CMA has also urged CMS to: • significantly reduce the number of quality measures; restore the toppedout quality measures to give physicians a sufficient number of measures to report; reduce the threshold on patients from 60 to 50%; and only require 90 days of reporting • eliminate the requirement for physicians to report all payer data • only require yes/no attestations in the electronic health record (EHR) Promoting Interoperability category and allow physicians to choose from a larger menu of measures applicable to their practice • enforce EHR vendor interoperability and accountability

• require vendors, not physicians, to report on certified EHR technology functionality and to bear the costs for interoperability updates. • reward high-performing physicians within 1–2 standard deviations of the national average • restore the Small Practice Bonus to the overall MIPS score, rather than restricting it to the Quality category • reduce the barriers to participation in virtual groups. CMA has heard from numerous physicians across the state, in all specialties, from solo practices to large, sophisticated medical groups, who made substantial investments in order to participate in the MIPS program. Most of these physicians received high to perfect performance scores for 2017, but have now been told by CMS that they will only receive a 0.2–0.3% bonus in 2019 — if they receive a bonus at all. Additionally, APMs are so limited that these physicians cannot participate in the APM track either. Physicians are left without sustainable payment options and few resources to improve the quality of care. While CMA understands that CMS is not responsible for the budget neutrality requirements of the Medicare Access and CHIP Reauthorization Act, the limited return on investment has discouraged many physicians to the point of withdrawing from MIPS and Medicare altogether. CMA and the American Medical Association have urged CMS to seriously consider these issues and work with physicians on improvements that will allow physicians to continue to participate in the program. SAN DIEGO PHYSICIAN.ORG

FEATURE

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6 5 . P O PR

ns o i l l i B s p t Rea n e m t s e v LAWLOR n S I E L R M A 1 H C $ ia BY n -Time r e o n f i l O a â&#x20AC;&#x2122;s C A CM are in c h t l a e H r a Year fo

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PROVIDER PAYMENTS

In 2016, and with a one-time, $1 million investment, the California Medical Association (CMA) led a coalition of healthcare advocates to take on Big Tobacco and drastically expand funding for existing health programs and research into cures for cancer and other illnesses caused by tobacco products. ¶ Under CMA’s leadership, California voters overwhelmingly approved Proposition 56, which imposed a $2 per pack tax hike on tobacco products that will generate more than $1 billion a year dedicated to increasing access to healthcare by improving provider payments and other crucial healthcare programs.

The largest portion of Proposition 56 funds — more than $500 million a year, with an additional $500 million federal match — is dedicated to increasing provider payments in the Medi-Cal program, which serves one-third of the state’s population and half of the state’s children, so that more Medi-Cal patients can access care when they need it most. The tobacco tax funds are being used to provide supplemental payments for a total of 23 CPT codes, through both the fee-for-service and managed care delivery systems. DHCS will be increasing the supplemental payment for the eligible CPT codes to 85–100% of Medicare. This will in many instances more than double the amount that physicians are paid for caring for Medi-Cal patients. While California’s base payment rates for Medi-Cal physicians are still among the nation’s lowest, these supplemental payments will help increase access for the nearly 14 million Californians, including half of the state’s children, currently covered by the program.

GRADUATE MEDICAL EDUCATION Thanks to Prop. 56, the California Legislature created a $40 million graduate medical education (GME) fund for the University of California (UC) to sustain, retain, and expand GME programs, with the goal of increasing the number of primary care and emergency physicians in California. This program will be administered by CMA’s foundation — Physicians for a Healthy California (PHC) — on behalf of the UC and in coordination with a five-member executive board and 15-member Advisory Council. PHC expects to release these funds to GME programs in the current fiscal year. This GME funding is critically important as California is facing a serious physician shortage. A robust and well-trained primary care workforce

is essential to meeting the healthcare demands of all Californians. There is overwhelming data that physicians who complete training in California are very likely to set down roots and practice in the communities in which they trained. This funding will allow California to train more physicians to address the serious physician shortages and resultant access to care challenges that are plaguing our state. CMA is committed to ensuring California is training enough physicians to meet current and future demand. Expanding funding for graduate medical education to ensure that there are enough residency slots to train physicians in regions where healthcare services are needed most is one of our top priorities.

PHYSICIAN LOAN REPAYMENT The Prop. 56 tobacco tax also provided $190 million in expanded loan repayment opportunities for physicians practicing in underserved areas. Nationally, for the class of 2017, 75% of medical school graduates had education debt, with a median medical education debt of $180,000. CMA’s modest investment in support of Proposition 56 and its leadership in anti-tobacco initiatives, which will generate billions in new healthcare dollars, are part of our greater effort to combat the critical physician workforce shortage in California, which limits access to healthcare for patients — particularly in rural communities. To learn more about how this money may apply to you as a physician or medical group, visit cmadocs.org/prop56. Physicians with questions can contact the Medi-Cal Telephone Service Center at (800) 541-5555, or CMA’s Reimbursement Helpline at (888) 4015911. Mr. Lawlor is the associate director of strategic communications for the California Medical Association.

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DHCS Receives Approval on Medi-Cal Supplemental Tobacco Tax Payments for FY 2018–2019 The California Department of Health Care Services (DHCS) recently received federal approval on its plan to increase Medi-Cal fee-for-service physician payments for the 2018–2019 fiscal year. The supplemental payments — made possible by the Proposition 56 tobacco tax funding — will raise payments for a total of 23 CPT codes, including 10 new preventive CPT codes. DHCS will be increasing the supplemental payment for the previously eligible CPT codes to 85% of Medicare (a 40 percent average increase in payments for these eligible codes compared with 2017–2018 payment levels). The 10 newly added preventive CPT codes will be paid at 100% of Medicare. According to DHCS, the prospective fee-for-service supplemental payments are anticipated to begin as soon as Sept. 24. The timeline for the retroactive payments

back to the beginning of the fiscal year (which began July 1, 2018) is still being worked out, but DHCS expects to distribute retroactive payments in early 2019. There is no additional action required by providers to receive the supplemental payments. Reimbursement on claims for eligible codes (see table below) will automatically include the supplemental payments. The supplemental payments would apply to both feefor-service and managed care delivery systems. However, approval for DHCS’s managed care proposal is still pending. In the interim, DHCS is continuing to distribute supplemental payments at the 2017–2018 amounts and eligible CPT codes to the Medi-Cal managed care plans with the expectation that those funds be paid to physicians within 90 days of receipt from DHCS. A full list of the eligible CPT codes is listed below.

Table: Medi-Cal Supplemental Payments

CPT Code

Description

*2016 FFS Base Rate

2018 Base Rate w/ Prop 56 Supp Funds

% Increase

99211

Level 1 Est. Pt Visit

$10.80

$20.80

93%

99212

Level 2 Est. Pt Visit

$16.29

$39.29

141%

99213

Level 3 Est. Pt Visit

$21.60

$65.60

204%

99214

Level 4 Est. Pt Visit

$33.75

$95.75

184%

99215

Level 5 Est. Pt Visit

$51.48

$127.48

148%

99201

Level 1 New Pt Visit

$20.61

$38.61

87%

99202

Level 2 New Pt Visit

$30.87

$65.87

113%

99203

Level 3 New Pt Visit

$51.48

$94.48

84%

99204

Level 4 New Pt Visit

$62.01

$145.01

134%

99205

Level 5 New Pt Visit

$94.43

$181.43

92%

90791

Psych diagnostic eval

$115.27

$150.27

30%

90792

Psych diagnostic eval w/ medical svcs

$92.93

$127.93

38%

90863

Other psych services — pharmacologic mgmt

$20.30

$25.60

26%

99381

Prev. Visit Est. Pt Ages < 1 year

$45.33

$122.33

170%

99382

Prev. Visit Est. Pt Ages 1–4 Years

$47.13

$127.13

170%

99383

Prev. Visit Est. Pt Ages 5–11 Years

$54.83

$131.83

140%

99384

Prev. Visit Est. Pt Ages 12–17 Years

$65.78

$148.78

126%

99385

Prev. Visit Est. Pt Ages 18–39 Years

$114.10

$144.10

26%

99391

Prev. Visit New Pt Ages < 1 Year

$34.69

$109.69

216%

99392

Prev. Visit New Pt Ages 1–4 Years

$37.39

$116.39

211%

99393

Prev. Visit New Pt Ages 5–11 Years

$43.85

$115.85

164%

99394

Prev. Visit New Pt Ages 12–17 Years

$54.83

$126.83

131%

99395

Prev. Visit New Pt Ages 18–39 Years

$102.90

$129.90

26%

NOVEMBER 2018

PAYER ISSUES AND

REIMBURSEMENT

Have You Received Your SUPPLEMENTAL MEDI-CAL MANAGED CARE PAYMENTS?

BY CALIFORNIA MEDICAL ASSOCIATION STAFF

THE CALIFORNIA HEALTH CARE, Research and Prevention Tobacco Tax Act of 2016 (Prop 56) created new revenues dedicated to the Medi-Cal program. Physicians receive supplemental payments in both fee-for-service and Medi-Cal managed care when providing Medi-Cal services under certain CPT codes. While the California Department of Health Care Services (DHCS) began disbursing FY 2017–2018 supplemental fee-for-service payments in January 2018, federal approval of the supplemental Medi-Cal managed care payments was delayed. This resulted in delayed payment for Medi-Cal managed care services. DHCS began dispersing the FY 2017–2018 funds to the plans as part of its capitated payments in May. This includes both the go-forward payments and the retroactive payment for clean claims or accepted encounter data with dates of service between July 1, 2017, and the date the plan received the Prop 56 funds. Plans were required to issue supplemental payments to qualifying physicians within 90 days. The 90-day window ended Aug. 31, and physicians should have already received their supplemental payments. Practices that believe they have not received their supplemental payments should contact the plan. Plans chose to pay physicians directly, pass all payment responsibility down to their delegated plan/groups, or split the payment responsibility between the plan and the delegated plan/group. CMA has created a comprehensive list of Medi-Cal Managed Care plans identifying who distributed the incentive. Physicians with questions can contact CMA’s Reimbursement Helpline at (888) 401-5911.

MEDI-CAL MANAGED CARE PLAN Aetna Anthem Blue Cross Cal Optima California Health & Wellness CalViva Health Care 1st (purchased by Blue Shield) CenCal Central California Alliance for Health Community Health Group Contra Costa Health Plan Gold Coast Health Plan Health Net Health Plan of San Joaquin Health Plan of San Mateo Inland Empire Health Plan Kern Family Health LA Care Molina Partnership Health Plan San Francisco Health Plan Santa Clara Family Health UnitedHealthCare

ENTITY PAYING (PLAN VS. DELEGATED GROUP) Plan Plan Both Plan Both Both Plan Plan (except behavioral health, which will be paid through delegated group) Both Plan Plan Both Plan Plan Plan Plan Delegated groups Both Plan Both Both Plan SAN DIEGO PHYSICIAN.ORG

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. [282] SHORT-TERM MEDICAL VOLUNTEERS NEEDED FOR HAITI: Global Health Teams is looking for physicians, mid-level providers and nurses for one-week, primarycare medical clinics in rural Haiti every February, June, and October. This is a rewarding and fun opportunity to work with the people of Haiti and provide care in a rural clinic in a medically under served area. GHT is an experienced U.S.-based nonprofit and has been operating these clinics since 1998. We coordinate all incountry travel and logistics. Please contact Bob Downey at (619) 905-7157 or at bob@globalhealthteam.org if you are interested in applying. Visit www.globalhealthteam. org to see what we do and learn about the clinics and volunteer experience. PHYSICIAN OPPORTUNITIES

SURGEONS NEEDED FOR EXPANDING NATIONWIDE SURGICAL PRACTICE FT/PT positions available. Competitive pay and flexible schedule with complete autonomy. Add revenue to your current practice. For more information, contact us: P: 1-877-878-3289 F: 1-877-817-3227 or email CV to: JOBS@ADVANTAGEWOUNDCARE.ORG www.AdvantageWoundCare.org CARDIOLOGIST POSITION AVAILABLE: Seeking a cardiologist to work part-time in an outpatient cardiology practice in North San Diego County. Practice opportunities from Mon.-Friday. Hours are from 8 to 5 p.m. There is no night calls, or holidays work days. The contracted cardiologist would decide from the days available which days to work. Please fax resume to 760.510.1811 or via e-mail at evelynochoa2013@yahoo.com. FAMILY PRACTICE MD/DO: Family Practice MD/ DO wanted for urgent care and family practice office

in Carlsbad, CA. Flexible weekday and weekend shifts available for family practice physician at busy, wellestablished office. FAX or email CV to (760) 603-7719 or gcwakeman@sbcglobal.net. PART-TIME/FULL-TIIME RADIOLOGIST POSITION OPEN - IMPERIAL RADIOLOGY: MEDICAL DIRECTOR, CALIFORNIA CHILDREN’S SERVICES: The Our company is an outpatient diagnostic radiology facility in search of a part-time/full time radiologist. All candidates must have an active California Medical License. Please contact us via e-mail at info@ carlsbadimaging.com with your resume if this position is of interest to you. Thank you. Job Type: Part-Time/Full Time. Pay: TBD. PRACTICE OPPORTUNITY: Internal Medicine and Family Practice. SharpCare Medical Group, a Sharp HealthCare-affiliated practice, is looking for physicians for our San Diego County practice sites. SharpCare is a primary care, foundation model (employed physicians) practice focused on local community referrals, the Patient Centered Medical Home model, and ease of access for patients. Competitive compensation and benefits package with quality incentives. Bilingual preferred but not required. Board certified or eligible requirement. For more info visit www.sharp.com/ sharpcare/ or email interest and CV to glenn.chong@ sharp.com PART-TIME MEDICAL DOCTOR WANTED - IMPERIAL RADIOLOGY: Our company is an outpatient diagnostic radiology facility in search of a part-time Medical Doctor to help cover contrast administration. All Candidates must have an active California Medical License. Please contact via email info@carlsbadimaging.com with your resume if this position is of interest to you. (Posted 8/16/2018) FAMILY PRACTICE/INTERNAL MEDICINE PHYSICIAN NEEDED: Primary care physician wanted for established private practice in San Diego. La Jolla Village Family Medical Group has been caring for patients of all ages for 29 years in the UTC/La Jolla area of San Diego. We provide comprehensive preventive medicine, illness management, travel medicine, sports medicine, evidence-based chiropractic care, weight management, and more. Call responsibilities minor, hours consistent with a healthy work/life balance. Our office is modern, clean, and well appointed. Our staff is supportive, cohesive, and friendly. This a real family practice. Board-certified, California licensed MD and DO physicians who are passionate about medicine and interested in this opportunity should send their CV and cover letter addressed to Tricia at officemanager@ ljvfmg.com. Let us grow your practice according to your unique specialty interests and style. Responsibilities include: Provide excellent care, become part of a cohesive team, light call, maintain accurate and detailed medical records using HER, comply with all laws applicable to family practice/internal medicine, including HIPAA, recommend lifestyle changes as appropriate to improve quality of life, Full-time, Part-time. (Posted 8/16/2018) MEDICAL DIRECTOR, CALIFORNIA CHILDREN’S SERVICES: The County of San Diego invites qualified individuals to apply for the position of MEDICAL DIRECTOR, CALIFORNIA CHILDREN’S SERVICES (Job Classification: Public Health Medical Officer). Under the direction of the Deputy Public Health Officer or designee, this unclassified management position will be responsible for the medical oversight of County of San Diego, Health & Human Services Agency, California Children’s Services Division. Residency in Pediatrics or Family Medicine is highly desirable. Please view the detailed brochure for information regarding the position, duties, and benefits. | Job Number 18412807CCSU | PHYSICIAN NEEDED: Family Practice MD. San Ysidro Health is looking for an MD for our Family Practice

center. The Family Practice MD manages and provides acute, chronic, preventive, curative and rehabilitative medical care to patients and determines appropriate regimen in specialized areas such as family practice, prenatal OB/GYN, pediatrics and internal medicine. Bilingual preferred but not required. Medical school graduate, CPR, CA MD and DEA License, board certified or eligible in primary care specialty. For more info on San Ysidro Health, visit: http://www.syhealth.org/ If interested, please email CV to Meagan.underwood@ syhealth.org. DERMATOLOGIST NEEDED: Premier dermatology practice in beautiful San Diego seeking a full-time/ part-time BC or BE eligible Dermatologist to join our team. Existing practice taking over another busy practice and looking for a lead physician. This is a significant opportunity for a motivated physician to take over a thriving patient base. Work with two 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, cosmetic and surgical dermatology (including MOHs) in a medical office with state of the art tools and instruments. Please call Practice Administrator at (858) 761-7362 or email jmaas12@hotmail.com for more information. PHYSICIANS NEEDED – URGENT CARE & PRIMARY CARE: Family Health Centers of San Diego, a private nonprofit community health center, has opportunities available for Family Medicine Physicians in both our Urgent Care and Primary Care clinics. We offer an excellent benefits package that includes a competitive base salary, NHSC Loan Repay eligibility, Continuing Medical Education, a variety of health insurance options, a retirement plan matching program, malpractice insurance, and much more. Current ACLS required for Urgent Care. Bilingual Spanish preferred. Full Time and Part Time available. To apply email your CV to:alexaw@ fhcsd.org or visit www.fhcsd.org/careers PRACTICE FOR SALE INTERNAL MEDICINE PRACTICE FOR SALE: Internal Medicine practice for sale near SDSU and College Area that has been in practice for thirty years. This practice has great street exposure and very accessible parking. For immediate consideration, forward your details including your contact phone, your specialty and current professional status to: chandrasmreddy@gmail.com. Only Doctors will be considered, no brokers. (Posted 6/27/2018) HIGHLY PROFITABLE MEDSPA NOW AVAILABLE TO LICENSED PHYSICIAN: Southern California | Asking Price: $1,050,000 | Cash Flow: $410,419 | This profitable and expandable company performs non-invasive cosmetic procedures, including dermal fillers, Botox, and laser treatments. Experienced staff plans to stay, and protects current physician/owner at 30 hours/week max. If you’re ready to see online financials, a studio-quality video of their story, an industry-leading assessment, and more – visit: https://goexio.com/med-spa-landing-sd for a summary. Interested? Click on “Private Access” to sign an instant nondisclosure and unlock the entire story. Full financials available on request. Prefer a personal touch? Contact Doug Miller: (208) 762-3451. doug.miller@ goexio.com. OB/GYN PRACTICE FOR SALE IN SAN DIEGO: Asking $480,000,00. FY 2017 Gross $1,445,688,00. Established practice for 38 years. Suburban district. Easy freeway access. Dedicated and experienced staff able to stay on board through sale. Situated within a modern, high-end building. The region’s fast-growing population assures for an expanding client base. Features 3200 sq ft of working space; 6 fully equipped patient rooms (5 exam & 1 surgery rooms with surgical lighting and fully adjustable treatment tables). Furnished waiting room and reception area; doctor’s private office, sterilization area, staff lounge and storage. ADA compliant. Contact: dixon@cwmc4women.com

TO SUBMIT A CLASSIFIED AD, email Editor@SDCMS.org. SDCMS members place classified ads free of charge (excepting “Services Offered” ads). Nonmembers pay $150 (100-word limit) per ad per month of insertion.

NOVEMBER 2018

PRACTICES WANTED PRIMARY OR URGENT CARE PRACTICE WANTED: Looking for independent primary or urgent care practices interested in joining or selling to a larger group. We could explore a purchase, partnership, and/or other business relationship with you. We have a track record in creating attractive lifestyle options for our medical providers and will do our best to tailor a situation that addresses your need. Please call (858) 832-2007. PRIMARY CARE PRACTICE WANTED: I am looking for a retiring physician in an established Family Medicine or Internal Medicine practice who wants to transfer the patient base. Please call (858) 257-7050. OFFICE SPACE / REAL ESTATE AVAILABLE

KEARNY MESA MEDICAL OFFICE - FOR LEASE 7910 Frost Street. Class A medical office building adjacent to Sharp Memorial and Rady Children’s hospitals. Suites ranging from 1,300-5,000 SF. For details, floor plans and photos contact David DeRoche (858) 966-8061 | dderoche@rchsd.org SHARED OFFICE SPACE: Office Space, beautifully decorated, to share in Solana Beach with reception desk and 2 rooms. Ideal for a subspecialist. Please call 619-606-3046. OFFICE SPACE/REAL ESTATE AVAILABLE: Scripps Encinitas Campus Office, 320 Santa Fe Drive, Suite LL4 It is a beautifully decorated, 1600 sq. ft. space with 2 consultations, 2 bathrooms, 5 exam rooms, minor surgery. Obgyn practice with ultrasound, but fine for other surgical specialties, family practice, internal medicine, aesthetics. Across the hall from imaging center: mammography, etc and also Scripps ambulatory surgery center. Across parking lot from Scripps Hospital with ER, OR’s, Labor and Delivery. It is located just off Interstate 5 at Santa Fe Drive, and ½ mile from Swami’s Beach. Contact Kristi or Myra 760-753-8413. View Space on Website:www.eisenhauerobgyn.com. Looking for compatible practice types. SHARED OFFICE SPACE AVAILABLE: Shared Office Space: Very attractive 1 or 2 exam rooms available, medical spa office ‘Exquisite Md Spa’ in Bankers Hill near Balboa Park. Available 5 days per week. Reasonable rates. Call Claudia at 619-501-4758. (Posted 8/16/2018) OFFICE SPACE AVAILABLE: La Jolla (Near UTC) office for sublease or to share: Scripps Memorial medical office building, 9834 Genesee Ave-great location by the front of the main entrance of the hospital between 1-5 and 1-805. Multidisciplinary group and available to any specialty. Note we are in great need of a psychiatrist. Excellent referral base in the office and on the hospital campus. Please call (858) 455-7535 or (858) 320-0525 and ask for Sofia or call Dr. Shurman, (858) 344-9024. (Posted 8/10/2018) OFFICE SPACE FOR RENT: Multiple exam rooms in newer, remodeled office near Alvarado Hospital and SDSU. Convenient freeway access and ample parking. Price based on useage. Contact Jo Turner (619) 7334068 or jo@siosd.com. OFFICE SPACE AVAILABLE IN MISSION VALLEY: Unique space for lease in Mission Valley. 1300 sq. ft office space in medical/surgical office building, single story, ample free parking. Is currently in use as physical therapy suite with reception area, small waiting room, private treatment room, separate office, bathroom in suite and hook ups for washer/dryer. Easy access to

all freeways. Available approximately August 1, 2018. Please contact Joan McComb, Executive Director, CA Orthopaedic Institute. (619) 291-8930 or cell (619) 840-0624. NORTH COUNTY MEDICAL SPACE AVAILABLE: North County Medical Space Available: 2023 W. Vista Way, Suite C, Vista, CA 92083. Newly renovated, large office space located in an upscale medical office with ample free parking. Furnishings, décor, and atmosphere are upscale and inviting. It is a great place to build your practice, network and clientele. Just a few blocks from Tri-City Medical Center and across from the urgent care. Includes: Digital X-ray suite, multiple exam rooms, access to a kitchenette/break room, two bathrooms, and spacious reception area all located on the property. Wi-Fi is NOT included. Contact Harish Hosalkar at hhorthomd@gmail.com or call/text (858) 243-6883. (Posted 6/11/2018) SHARED OFFICE SPACE AVAILABLE: Established orthopedic group seeks additional orthopedic surgeon for partnership or overhead sharing opportunity. Our office is centrally located in Kearny Mesa near Highway 163 and Balboa, easy access to freeways, affiliations with Sharp, Scripps. Extensive referral base, EMR/”paperlight” office, experienced MA/surgery scheduler/ referral coordinator. Please call Lisa Vaughn, practice administrator, at (858) 278-8300 or email lmvomg@ yahoo.com. (posted 5/7/2018) SCRIPPS ENCINITAS CAMPUS OFFICE: 320 Santa Fe Drive, Suite LL4 It is a beautifully decorated, 1600 sq. ft. space with 2 consultations, 2 bathrooms, 5 exam rooms, minor surgery. Obgyn practice with ultrasound, but fine for other surgical specialties, family practice, internal medicine, aesthetics. Across the hall from imaging center: mammography, etc and also Scripps ambulatory surgery center. Across parking lot from Scripps Hospital with ER, OR’s, Labor and Delivery. It is located just off Interstate 5 at Santa Fe Drive, and ½ mile from Swami’s Beach. Contact Kristi or Myra (760) 753-8413. View Space on Website: www.eisenhauerobgyn.com. Looking for compatible practice types. (Posted 4/4/2018)

MEDICAL EQUIPMENT / FURNITURE FOR SALE HIGH TECH FACIAL IMAGING FOR SALE: New Reveal® Imager for sale. Ideal for MedSpa or cosmetic practice. The Reveal® Imager clearly demonstrates sun damage, brown spots, red areas and more. Create a personalized printed treatment record for the patient. Contact info@restoresdplasticsurgery.com or 858-2242281 if interested. MEDICAL EQUIPMENT AVAILABLE FOR DONATION: Carlsbad Imaging has medical equipment available for donation. Afinion HbA1c-Used, Siemens clinitek status+-Used, FastPack-Used. Please contact info@ carlsbadimaging.com if interested. (Posted 8/16/2018) NON-PHYSICIAN POSITIONS AVAILABLE PLASTIC SURGERY AND FRONT DESK COORDINATOR: The ideal position for someone with a background in plastic surgery, dermatology, ophthalmology, or medical spa. Will consider those with a background in a high-end hospitality setting. The Coordinator is primarily responsible for the dayto-day creation of an office environment that fosters highly personalized customer service. Responsible for the front/back office daily operations including patient care, scheduling, and optimizing surgical closure rates and sale of skin care lines. Contact info@ restoresdplasticsurgery.com with resume. Salary commensurate with experience. (Posted 9/4/2018)

NON-PHYSICIAN POSITIONS WANTED MEDICAL OFFICE MANAGER/CONTRACTS/BILLING PERSON: MD specialist leaving group practice, looking to reestablish solo private practice. Need assistance reactivating payer contracts, including Medicare. If you have that skill, contact ljmedoffice@yahoo.com. I’m looking for a project bid. Be prepared to discuss prior experience, your hourly charge, estimated hours involved. May lead to additional work. PRODUCTS / SERVICES OFFERED

MEDICAL OR DENTAL SPACE AVAILABLE: For lease a medical or dental related practice or business in a small boutique office space located in the center of “Hillcrest/Bankers Hill”. Just renovated! The second story of this beautiful two story building is available for lease. A private gated entrance leads to a 1,139 square foot upstairs with 4 to 5 consultation rooms, waiting room with adjoining private deck and full bathroom. Additional security gate and mailbox. Separate address. Wood floors, refinished windows, natural light, quiet street, walkable to restaurants. On-site parking with up to 8 parking spaces available! Asking: $3,000/month. Terms are negotiable. This will rent fast so hurry! CLICK HERE for photos. Please contact: hillcrestofficerental@ gmail.com | (858) 775-5075 OFFICE SPACE FOR RENT: La Jolla -- LEASE - Medical or dental related practice or business in a small boutique office space located in the center of beautiful La Jolla, California. Perfect opportunity for Psychiatrist, Psychologist, Counselor, Dentist, Physician, Surgeon. Any dental or medical related occupation welcome. Located in medical/dental building. Come join these great practices. Classy second floor suite with elevator. Perfect for entrepreneur. Partially equipped for dental or surgical practice. Terrific Opportunity. 612 square fee. $4.90/sq ft per month. Triple net lease. Contact Kevin Gott: dynamold@aol.com OFFICE SPACE / REAL ESTATE WANTED MEDICAL OFFICE SPACE SUBLET DESIRED NEAR SCRIPPS MEMORIAL LA JOLLA: Specialist physician leaving group practice, reestablishing solo practice seeks office space Ximed building, Poole building, or nearby. Less than full-time. Need procedure room. Possible interest in using your existing billing, staff, equipment, or could be completely separate. If interested, please contact me at ljmedoffice@yahoo.com.

DATA MANAGEMENT, ANALYTICS AND REPORTING: Rudolphia Consulting has many years of experience working with clinicians in the Healthcare industry to develop and implement processes required to meet the demanding quality standards in one of the most complex and regulated industries. Services include: Data management using advanced software tools, Use of advanced analytical tools to measure quality and process-related outcomes and establish benchmarks, and the production of automated reporting. (619) 913-7568 | info@rudolphia.consulting | www.rudolphia. consulting A VALUABLE EDUCATIONAL RESOURCE: Extensive Medical Articles File for sale. Charts, illustrations, articles. Emphasis on Emergency Medicine and Internal Medicine. Collected since 1973. Fills a large filing cabinet. (Cabinet not included.) Would make a useful gift for a medical student or resident. Best offer takes. Will accept offers for 30 days after the publication of this newsletter. View in person at a North County location by appointment. (858) 451-6517. PHYSICIAN OFFICES IN NEED OF ASSISTANCE FOR MEANINGFUL USE ATTESTATION of their electronic health records can avail themselves of technical assistance from Champions for Health, the sister organization to SDCMS. Practices attesting on the MediCal Incentive Program with at least 30% of patients billed to Medi-Cal can receive free assistance thanks to a federal funding source. Medicare practices can receive the same great service at a very reasonable rate, and SDCMS-CMA members receive a discount. For more information, email Barbara.Mandel@ChampionsFH.org or call (858) 300-2780. [559]

SAN DIEGO PHYSICIAN.ORG

P E R S O N A L & P R O F E S S I O N A L D E V E LO P M E N T

Beating Our Biases By Helane Fronek, MD, FACP, FACPh

RECENTLY, A MUSICIAN shared his love of being on the road, a lifestyle I would find challenging. London is his favorite city, as interacting with diverse cultures nourishes his sense of tolerance. Seeing a person of Asian descent speaking German, he explained, opens his mind. I was struck by how that would challenge our stereotypes, encouraging us to see each person as an individual. Attention is being focused on the effect of unconscious bias within the practice of medicine, offering the potential to improve relationships with patients and the care we provide. When we encounter people of various socioeconomic backgrounds, ages,

NOVEMBER 2018

races, or genders, we all have automatic reactions and assumptions that cloud our ability to perceive the nuances and truth of the person in front of us. To deny this is naïve and deprives us of the potential to make truly conscious, informed decisions. Harvard offers a quick assessment (implicit. harvard.edu/implicit/takeatest.html) to gauge our degree of implicit bias in multiple categories. The results are revealing — and can be unsettling! After working hard to build a career as a woman in medicine, and mentoring and supporting many younger women in our profession, I was dismayed to find that I strongly associate women with family rather than with career. And even as

I age, I was surprised to find that I assume elderly people are less capable than they might be. Once confronted with my results, I began to recognize the judgments resulting from these biases and am better able to filter them out in making assessments and decisions. We all have biases — against people who are overweight or excessively thin, those with tattoos, with accents, or who don’t share our political views. They affect our ability to see the person in the fullness of who they are, possibly limiting the options we offer or dampening our enthusiasm for helping them. Similarly, our patients have biases toward us that can compromise our ability to help them. The face of one patient fell as I entered the room — she didn’t want a woman physician. Another patient left my practice once she asked about my political views. Given these frequently unseen forces, how can we best minimize the role they play in our patient encounters and the care we provide? The most important step is to discover what our biases are — to excavate the hidden beliefs that may surreptitiously influence our decisions and choices. The Harvard assessment is a good tool for this. We can also become mindful of our thoughts when meeting someone new. What do we immediately assume and what are we basing that on? Once we know what’s lurking underneath what we think we believe, we’re able to question our decisions and ensure our actions reflect our values, best practices and ethics, rather than unseen forces of bias. As we shine a light on our biases, we can better see our patients as unique people and search for the best approach to their issues. In this way, we can begin to beat the invisible effect of bias. Dr. Fronek, SDCMS-CMA member since 2010, is assistant clinical professor of medicine at UC San Diego School of Medicine and a certified physician development coach who works with physicians to gain more power in their lives and create lives of greater joy. Read her blog at helanefronekmd.com.

Are Your Patients Giving You FIVE STAR REVIEWS? CAP’s Free Guide Can Help You Optimize Patient Experience and Improve Your Ratings!

The Physician’s Action Guide to an Outstanding Patient Experience is about optimizing the fundamentals of your medical practice so patients: • Feel cared for • Are fully prepared to comply with your course of treatment • Feel confident of your expertise and the ability of your staff • Are happy to recommend you to friends and in online reviews As a leading California provider of superior medical malpractice coverage, the Cooperative of American Physicians (CAP) is pleased to offer California physicians this important guide free for the asking.

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