A Big Year for California’s Patients and Physicians
CMA and SDCMS
Score Major Policy and Political Victories
Editor: William T–C Tseng, MD, MPH
Editorial Board: James Santiago Grisolia, MD; David E.J. Bazzo, MD; William T-C Tseng, MD; Holly B. Yang, MD, MSHPEd, HMDC, FACP, FAAHPM
Marketing & Production Manager: Jennifer Rohr
Art Director: Lisa Williams
Copy Editor: Adam Elder
OFFICERS
President: Steve H. Koh, MD
President–Elect: Preeti S. Mehta, MD
Immediate Past President: Nicholas (dr. Nick) J. Yphantides, MD, MPH
Secretary: Maria T. Carriedo-Ceniceros, MD
Treasurer: Karrar H. Ali, DO, MPH
GEOGRAPHIC DIRECTORS
East County #1: Catherine A. Uchino, MD
East County #2: Rachel Van Hollebeke, MD Hillcrest #1: Kyle P. Edmonds, MD
Hillcrest #2: Stephen R. Hayden, MD (Delegation Chair)
Kearny Mesa #1: Anthony E. Magit, MD, MPH
Kearny Mesa #2: Dustin H. Wailes, MD
La Jolla #1: Toluwalase (Lase) A. Ajayi, MD
La Jolla #2: David E.J. Bazzo, MD, FAAFP
North County #1: Arlene J. Morales, MD (Board Representative to the Executive Committee)
North County #2: Christopher M. Bergeron, MD, FACS
North County #3: Nina Chaya, MD
South Bay #1: Paul J. Manos, DO
South Bay #2: Latisa S. Carson, MD
AT–LARGE DIRECTORS
#1: Rakesh R. Patel, MD, FAAFP, MBA (Board Representative to the Executive Committee) #2: Kelly C. Motadel, MD, MPH #3: Irineo (Reno) D. Tiangco, MD
#4: Miranda R. Sonneborn, MD
#5: Daniel D. Klaristenfeld, MD
#6: Alexander K. Quick, MD #7: Karl E. Steinberg, MD, FAAFP
#8: Alejandra Postlethwaite, MD
ADDITIONAL VOTING DIRECTORS
Young Physician: Emily A. Nagler, MD
Retired Physician: Mitsuo Tomita, MD
Medical Student: Kenya Ochoa
CMA OFFICERS AND TRUSTEES
Trustee: Holly B. Yang, MD, MSHPEd, HMDC, FACP, FAAHPM
Trustee: Sergio R. Flores, MD
Trustee: Timothy A. Murphy, MD
AMA DELEGATES AND ALTERNATE DELEGATES
District I: Mihir Y. Parikh, MD
District I Alternate: William T–C Tseng, MD, MPH
At–Large: Albert Ray, MD
At–Large: Robert E. Hertzka, MD
At–Large: Theodore M. Mazer, MD
At–Large: Kyle P. Edmonds, MD
At–Large: Holly B. Yang, MD, MSHPEd, HMDC, FACP, FAAHPM
At–Large: David E.J. Bazzo, MD, FAAFP
At–Large Alternate: Sergio R. Flores, MD
At–Large Alternate: Bing Pao, MD
CMA DELEGATES
District I: Steven L.W. Chen, MD, FACS, MBA
District I: Vikant Gulati, MD
District I: Eric L. Rafla-Yuan, MD
District I: Ran Regev, MD
District I: Quinn Lippmann, MD
District I: Kosala Samarasinghe, MD
District I: Mark W. Sornson, MD
District I: Wynnshang (Wayne) C. Sun, MD
District I: Patrick A. Tellez, MD, MHSA, MPH
District I: Randy J. Young, MD
Opinions expressed by authors are their own and not necessarily those of SanDiegoPhysician or SDCMS. SanDiegoPhysicianreserves 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 SanDiegoPhysicianin no way constitutes approval or endorsement by SDCMS of products or services advertised. SanDiegoPhysicianand 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. SanDiegoPhysicianis 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.]
VOLUME 111, NUMBER 10
FEATURES
4 A Big Year for California’s Patients and Physicians By Robert E. Hertzka, MD
6 Terminating Patient Relationships By Julie Brightwell, JD, RN and Richard F. Cahill, JD
DEPARTMENTS
2
Briefly Noted: Healthcare Heroes • Patient Care
10
How Often Do Doctors Use New Weight-Loss Drugs in Kids?
By Sophie Putka
12 California Dengue Cases Prompt Swift Response From Public Health Officials By Claudia Boyd-Barrett
14
New FDA Panel Weighs in on Regulating Generative AI in Healthcare By Michael DePeau-Wilson
16 As California Taps Pandemic Stockpile for Bird Flu, Officials Keep Close Eye on Spending By Don Thompson
18
California Sets 15% Target for Primary Care Spending Over Next Decade By Vanessa G. Sanchez
20
Do You Feel Lucky? By Adama Dyoniziak
21
Classifieds
Celebrating the Retirement of Dr. Roberto Gratianne, South Bay’s First Hispanic Private-Practice Neurologist
By Branko Huisa, MD
IT IS WITH A MIX OF gratitude and nostalgia that we announce the retirement of Dr. Roberto Gratianne, who will be stepping back from practice in December 2024 after nearly 40 years of dedicated service to the South Bay community.
Dr. Gratianne has been a trailblazer, joining Drs. James Grisolia and Guillermo Cantu-Reyna in their combined practice, but staying on as the first full-time, Hispanic neurologist in private practice in the region. His commitment to serving everyone — regardless of insurance status — has been unwavering. He has cared for patients and their families from diverse backgrounds with compassion, understanding their unique needs and often going beyond what was expected to provide truly personalized care.
Over the years, Dr. Gratianne has made countless contributions to the South Bay, serving as a cherished neurologist at Scripps Mercy and Sharp Chula Vista hospitals, and covering neurologic colleagues at Paradise Valley, Scripps Mercy San Diego, and other hospitals. His practice has covered a wide range of neurological conditions, including stroke, dementia, Parkinson’s
disease, neuromuscular disorders, multiple sclerosis, and migraines. A remarkable general neurologist, he exemplified an approach to medicine that prioritized depth of care over the constraints of modern, industrialized healthcare.
For Hispanic patients in particular, Dr. Gratianne has been a pillar of support, sometimes as the only Spanish-speaking neurologist in the region. He has built a legacy of care that resonates deeply with his patients, many of whom have relied on his compassionate, thoughtful approach to neurological health.
Dr. Gratianne wishes to extend his heartfelt thanks to his patients, colleagues, staff, and community leaders who have made these four decades so meaningful. His career has been richly fulfilling because of the trust and relationships he has built within the community.
As Dr. Gratianne passes the torch, he does so to the next generation of neurologists at the Neuron Clinic, a growing multispecialty group in the South Bay. The Neuron Clinic is committed to upholding the high standard of compassionate neurological care that Dr. Gratianne has exemplified, and we are honored to carry forward his legacy in service to our community.
Dr. Huisa is a neurologist and founder of The Neuron Clinic.
Did You Know? Physicians Can Assist Patients in Appealing Medical Necessity Denials
By California Medical Association Staff
IN CALIFORNIA, BOTH THE DEPARTMENT of Managed Health Care (DMHC) and the Department of Insurance (CDI) offer an independent medical review (IMR) process that allows patients to appeal health plan or insurer decisions that deny, modify, or delay treatments based on claims of lack of medical necessity or for being investigational/ experimental.
Under California law, patients enrolled in fully insured commercial health plans regulated by either the DMHC or CDI can request an IMR
for such denials. This process was established to ensure fair decisions around medical necessity and to bolster public trust in the managed care system.
According to the DMHC’s 2020 Annual Report, 68% of IMR requests resulted in patients receiving the requested service or treatment, while CDI reports that 53% of their IMR cases were resolved in favor of the patient.
The IMR process involves independent physicians who review the case and determine whether the denial was justified. If the denial
Further Thoughts on Roberto Gratianne Ortega
By James Grisolia, MD
AFTER ROBERTO GRATIANNE FINISHED HIS RESIDENCY IN Indiana, he intended to return to practice in Imperial Valley to be close to his extensive family in Mexicali. However, like any Hispanic doctor in those days, he came first to present himself to the godfather of Hispanic medicine, the neurosurgeon Manuel Barba. Manuel was the first Mexican-American neurosurgeon or neurologist in the region, and was revered by the Hispanic community on both sides of the border, with patients coming from as far away as Mexico City. It was natural to come to pay one’s respects when starting a practice, and in fact that was how I ended up sharing office space with Dr. Barba until his retirement.
So I can’t take credit for bringing Roberto back home from Indiana, but I did use his visit to convince him that San Diego was a better place to start his practice, and that he could visit his Mexicali relatives on weekends. Roberto joined Dr. Guillermo Cantu-Reyna and me in 1986, when we had offices in Hillcrest and in the 450 4th Avenue building in Chula Vista. Over the years, Roberto’s practice grew and grew in South Bay, while mine was growing in Hillcrest. Eventually, Roberto had the foresight to buy and remodel a small house on H Street, close to the hospital, and many passers-by remember his wooden sign in front of the office.
As our practices grew and split up into solo practices, Roberto and I remained friends and covered each other in the hospital for many years. We remained good enough friends that I asked him to be my best man at my wedding in 1990, and to this day when I meet one of Nino Roberto’s old patients, I usually tell them proudly that he was my padrino de la boda!
When Roberto wanted to begin cutting back, he sold his office building and moved to the excellent and growing practice of The Neuron Clinic, ironically overlapping with the same office space where he and I started back in the ’80s. Roberto has always been extremely kind with patients as well as colleagues, and his signal contributions will be very much missed! He and Gloria are planning on enjoying their retirement, and I’m among the many who are wishing them the very best!
Dr. Grisolia is a neurologist, former editor of San Diego Physician magazine, and chief of staff at Scripps Mercy Hospital.
is found to be inappropriate, the insurer must cover the treatment or service.
Patients must first submit a grievance to their plan or insurer before applying for an IMR. If you disagree with the plan’s decision or if it has been at least 30 days since the complaint was filed, patients may proceed with an IMR through their plan’s regulator (typically, DMHC regulates HMOs and certain PPOs, while CDI oversees other PPOs).
Physicians can actively support patients through the IMR process, either by helping file or by filing on the patient’s behalf. Patients who want their physician or another representative to file an IMR
for them or assist in the process need to complete either the DMHC Authorized Assistant Form or the CDI Designation of IMR Agent form, depending on the regulatory body.
IMR requests should be submitted within six months, though extensions may be granted for special circumstances. There is no cost to apply for an IMR.
For more details on how physicians can assist with IMRs, refer to California Medical Association health law library document #7155, “Independent External Medical Review.”
A BIG YEAR for California’s Patients and Physicians
CMA and SDCMS Score Major Policy and Political Victories
By Robert E. Hertzka, MD
THE YEAR 2024 HAS BEEN MOMENTOUS FOR California’s patients and physicians. The California Medical Association (CMA) and the San Diego County Medical Society (SDCMS) have achieved significant policy and political triumphs through ballot measures, our own physician candidates, and the passage of key legislation.
The most notable success was the approval of Proposition 35, which garnered 67% of the vote.
Proposition 35 emerged as a solution to the longstanding underfunding of Medi-Cal, which affects 15 million children, seniors, disabled individuals, and low-income families in California. The shortage of funds has led to, among other things, the closure of labor and delivery services in more than 40 hospitals. It has also led to overcrowded emergency rooms, delaying timely access to specialist physicians.
The proposition will start to address these issues by allocating $2.8 billion annually in 2025 and 2026, and $3.8 billion annually from 2027 onward, to increase physician payments. This funding is a significant step toward ensuring that vulnerable populations can secure timely physician appointments.
Proposition 35 will also increase funding for emergency rooms, clinics, family planning services, and public hospitals, and will establish new graduate medical education positions, thereby improving healthcare access for all Californians (see charts).
A significant feature of Proposition 35 is the strategic allocation of a healthcare revenue source that, in previous years, had been diverted to other purposes. Following a definitive public vote, this funding source has not only been expanded but also mandated for exclusive use in healthcare. Despite some unease from the Governor, it received bipartisan support from numerous state legislators
and both of the two major state political parties. The California Medical Association has spearheaded this initiative process for more than three years, leading a strong coalition that includes hospitals, community health centers, Planned Parenthood, and healthcare workers.
Proposition 35 marks a significant achievement, and it alone would justify CMA and SDCMS dues for a lifetime, but 2024 had many other achievements as well.
Dr. Nina Chaya
Dr. Akilah Weber
Few things are more important to creating good healthcare policy than to see some of our own physician leaders elected to office. The year 2024 marked considerable success in this area, with two local physicians, endorsed by the San Diego County Medical Society and its members, achieving landslide victories. Dr. Akilah Weber won a California State Senate seat with more than 63% of the vote, and Dr. Nina Chaya was reelected to the Tri-City Healthcare District Board of Directors, also with 63% of the vote.
Beyond electoral triumphs, the California Medical Association had an extraordinarily successful legislative year in Sacramento, championing the interests of California’s physicians and patients. The CMA supported several key pieces of legislation that were passed into law, including AB 977, AB 2164, and SB 1120.
Gov. Newsom signed Assembly Bill 977, authored by Assemblymember Freddie Rodriguez, a bill sponsored by CMA to protect healthcare workers while at work in emergency departments. Previously, assaults against healthcare workers inside an emergency department carried lesser penalties than assaults committed outside an emergency department. This bill will ensure that healthcare workers are not treated differently simply because they work in a hospital emergency department.
Newsom also signed Assembly Bill 2164 by Assemblymember Marc Berman, a CMA bill aimed at reducing mental health stigma for physicians. Previously, the Medical Board of California’s licensure application for physicians and surgeons, including postgraduate training licensees, may have inadvertently discouraged physicians from seeking mental health services and perpetuated stigma around mental health.
In August, the Medical Board of California revised its licensure application to make clear to physicians that seeking care is encouraged. AB 2164 will further promote physicians’ mental healthcare by forbidding the Medical Board and the Osteopathic Medical Board of California from asking invasive questions that stigmatize care on licensure applications.
The governor has also signed State Senator Josh Becker’s Senate Bill 1120, the “Physicians Make Decisions Act,” to ensure that human oversight and patient safety are fundamental elements in the application of artificial intelligence (AI) in healthcare settings. This comes in response to news reports that have highlighted instances and allegations of health plans using AI algorithms to wrongfully deny medically necessary care.
SB 1120 requires physician oversight of utilization review decisions made or assisted by a health plan’s AI decisionmaking tools or algorithms. The bill establishes a sensible balance by introducing protections for automated decisionmaking tools while still encouraging the adoption of this emerging technology.
Finally, this was a politically successful year for CMA and SDCMS as well. The elections for our California state legislature had 36 open seats out of 120, an unusually high number, but many of us went to work educating and supporting physicianfriendly candidates.
CMA had huge success around the state, and SDCMS played a role by educating, endorsing, and financially supporting two new State Assembly members: Darshana Patel (D), who will be replacing the term-limited longtime CMA/SDCMS friend Brian Maienschein (D) in AD-76, as well as LaShae Collins (D), who will be replacing Dr. Weber (D) in AD-79. Dr. Weber, as noted, moved up to the State Senate to replace another longtime CMA/SDCMS friend in Toni Atkins (D).
Overall, this was a record-setting year for political spending by CMA and its political action committee (CALPAC). We are grateful for your CALPAC contributions, which have enabled us to support outstanding new legislators as they run for office.
San Diego County was recognized as a winner of CALPAC’s Victory Bell for having the highest average contribution by our physician members to CALPAC.
Statewide, CALPAC also hit a historic total of 10 Diamond Level ($6,500) donors to begin its 2025 membership year, with our own Robert E. Wailes, MD among them.
We extend our thanks to all the physicians in San Diego and across our state, as well as the SDCMS and CMA staff, who have dedicated so much in time and resources to help achieve these important policy and political victories. It really is a team effort, and it is our team that fills me with optimism about a brighter future for California’s patients and physicians.
Dr. Hertzka is a past president of the SDCMS and the CMA, a two-term past chair of CALPAC, a past chair of AMPAC, and a past chair of the AMA’s Health Policy Council. Recently retired after 35 years of practicing anesthesiology, he continues to serve as the chair of the SDCMS Legislative Committee, a role that he has had since 1990.
Dr. Robert E. Wailes
Terminating Patient Relationships
By Julie Brightwell, JD, RN and Richard F. Cahill, JD
A REVIEW OF OUR CALL DATA SHOWS THAT
terminating patient relationships consistently appears as one of the top reasons members request assistance from our Department of Patient Safety and Risk Management. Our data demonstrate that, despite best efforts, it may become necessary to end patient relationships that are no longer therapeutic or appropriate based on patient behaviors or financial factors. It is critical, however, that the practitioner end the relationship in a manner that will not lead to claims of discrimination or abandonment, litigation for alleged professional negligence, or complaints to administrative agencies (for example, the state licensing board or the Office for Civil Rights).
PREVENTIVE STRATEGIES
Prior to terminating a patient relationship, consider addressing the underlying reasons for ending the relationship, including noncompliant/nonadherent conduct, mental competency, health literacy, language or cultural
barriers, or financial restraints. (For strategies to address these concerns, read our articles “Nonadherent and Noncompliant Patients: Overcoming Barriers” and “Patient Relations: Anticipate and Address Challenging Situations.”) One effective approach to enhancing patient compliance and decreasing the potential need to terminate the professional affiliation is to implement and enforce a Conditions of Treatment Agreement, which is signed by all individuals at the beginning of the relationship. The document should clearly detail the practitioner’s expectations and indicate that repeated incidents of nonadherence may result in discharge from the practice. Posting the conditions on the practice website helps to emphasize the importance of following the requirements. (For additional recommendations, see our article “Proactively Manage Patient Expectations With a Conditions of Treatment Agreement.”)
TERMINATION CRITERIA
If efforts to rehabilitate the relationship are not appropriate
or are unsuccessful, it is generally appropriate to end a relationship under the following circumstances:
Treatment nonadherence: The patient does not follow the treatment plan or the terms of a pain management contract or discontinues medication or therapy regimens before completion.
Follow-up noncompliance: The patient repeatedly cancels follow-up visits or fails to keep scheduled appointments with practitioners or consultants.
Office policy noncompliance: The patient fails to observe office policies, such as those implemented for prescription refills or appointment cancellations, or refuses to adhere to mandated infection-control precautions.
Verbal abuse or violence: The patient, a family member, or a third-party caregiver is rude, uses disparaging or demeaning language, or sexually harasses office personnel or other patients, visitors, or vendors; exhibits violent or irrational behavior; makes threats of physical harm; or uses anger to jeopardize the safety and wellbeing of anyone present in the office.
Display of firearms or weapons: The patient, a family member, or a third-party caregiver threatens practice operations by wielding a firearm or weapon on the premises. Office staff may need to contact law enforcement promptly for support to help ensure that the situation does not escalate. Inappropriate or criminal conduct: The patient exhibits inappropriate sexual behavior toward practitioners or staff or participates in drug diversion, theft, or other criminal conduct involving the practice.
Nonpayment: The patient owes a backlog of bills and has declined to work with the office to establish a payment plan or has discontinued making payments that had been agreed previously.
EXCEPTIONS AND SPECIAL CIRCUMSTANCES
A number of circumstances may require additional steps or a delay before ending the patient relationship. Examples include the following situations:
• If the patient is in an acute phase of treatment, delay ending the relationship until the acute phase has passed. For example, if the patient is in the immediate postoperative stage or is in the process of a diagnostic workup, it is not advisable to terminate the relationship.
• If the practitioner is the only source of medical or dental care within a reasonable driving distance, care may need to continue until other arrangements can be made.
• When the practitioner is the only source of specialized medical or dental care, treatment may need to continue until the patient can be safely transferred to another practitioner who is able to provide appropriate care and follow-up.
• If the patient is a member of a prepaid health plan, the practitioner must communicate with the thirdparty payer to request the patient’s transfer to another practitioner or otherwise comply with the specific terms of the payer-practitioner agreement.
• If a patient is pregnant. During the first trimester: End the relationship only if it is an uncomplicated pregnancy and the patient has time to find another practitioner. During the second trimester: only for uncomplicated pregnancies and only if the patient transfers to another practitioner prior to cessation of services. During the third trimester: only under extreme circumstances, such as illness of the practitioner. Effect a safe transition by working with the risk manager of the facility where delivery is scheduled. Provide timely and accurate documentation in the medical record of the situation. Certain situations prohibit patient dismissal:
• Patients may not be dismissed or discriminated against based on limited English proficiency or status within a protected category under federal or state legislation, including race, color, national origin, sex, disability, and age. Examples of laws prohibiting discrimination — which carry significant civil and administrative penalties for violations — include the Americans with Disabilities Act (ADA), the Civil Rights Act, and the Affordable Care Act. (The Department of Health and Human Services outlines requirements for practitioners regarding nondiscrimination policies and notices.)
• A patient’s disability cannot be the reason for terminating the relationship unless the patient requires care or treatment for the particular disability that is outside the expertise of the practitioner. Transferring care to a specialist who provides the particular care is a better and safer approach.
STEPS FOR WITHDRAWING CARE
Establish a written policy and procedure with a standardized process that addresses interventions prior to ending the relationship and the steps to take if it becomes necessary to dismiss the patient. Ensure that approvals for any patient dismissal go through practice leadership and the assigned practitioner. Medical or dental groups may consider dismissing a patient from the entire practice. This avoids an on-call situation that might require the practitioner who ended the relationship to treat the patient.
When the situation for dismissing the patient is appropriate, provide a formal written notice that states you are withdrawing care by a specific date and the patient must find another practitioner. Mail the written notice to the patient by both first-class and certified mail with a return receipt requested. (Both types of mailing are required in some states.) To promote optimal continuity of care, you may reassure the patient that you will be available to confer with the new provider.
Keep copies in the patient’s medical or dental record of all the materials: the letter, the original certified mail receipt (showing that the letter was sent), and the original certified mail return receipt (even if the patient refuses to sign for the certified letter). Keep and file in the patient record any unopened envelopes that have been returned by the postal or other delivery service.
ELEMENTS OF THE WRITTEN NOTICE
Include the following information in the written notice:
Reason: Although stating a specific reason for ending the relationship is not required, it is acceptable to use the catchall phrase “inability to achieve or maintain rapport necessary to promote the trust critical to support an effective clinical relationship,” state that “the therapeutic practitioner-patient relationship no longer exists,” or assert that “the trust necessary to support the relationship has eroded beyond repair.” If the reason for ending the relationship is patient noncompliance/nonadherence, you may state it briefly and succinctly as well, along with your attempts to obtain patient compliance.
Effective date: Specify the effective date for ending the relationship and provide the patient with a reasonable amount of time to establish a relationship with another practitioner. Although 30 days from the date of the written notice is usually considered adequate, follow your state regulations. The relationship may be ended immediately under the following circumstances:
• The patient has ended the relationship. (Acknowledge this in writing with a letter from the practice.)
• The patient or a family member has threatened the practitioner or staff with violence or has exhibited threatening behavior.
• The patient participates in drug diversion, theft, or other criminal activity involving the practice.
• The patient exhibits inappropriate behavior or sexual misconduct toward the practitioner or staff.
Interim care provisions: Offer interim emergency care prior to the effective date. For emergency situations that cannot be appropriately handled in the office, refer the patient to an emergency department or instruct the patient to call 911.
Continued care provisions: Offer referral suggestions for continued care through medical or dental societies, nearby hospital referral services, community resources, or the patient’s health plan network. Do not recommend another healthcare practitioner specifically by name.
Patient records: Offer to provide a copy of the office record to the new practitioner by enclosing a HIPAA-compliant authorization (to be returned to the office with the name and address of the new practitioner and the patient’s signature). One exception is a psychiatric record, which may be offered as a summary in many jurisdictions in lieu of a full copy of the medical record.
Transition of care: Indicate your willingness to speak with the patient’s new practitioner to help ensure a smooth transition and continuity of care.
Patient responsibility: Specify that the patient is personally responsible for all follow-up and for continued medical or dental care.
Medication refills: Explain that medications will be provided only up to the effective date that the relationship ends.
CASE EXAMPLES
The following scenarios illustrate some of the issues involved in terminating a patient relationship.
Case 1
A patient has been in your practice for about 10 years and has faithfully made regular visits but has not been compliant with your medical regime for taking hypertension medications. You have repeatedly explained the risks of nonadherence, and you have rescued the patient on many occasions with emergent medications, usually in the local emergency department over a weekend. You are convinced that the patient understands but stubbornly refuses to comply.
Should This Patient Relationship Be Terminated?
With any noncompliant patient, it is essential to document your recommendations, the patient’s continued noncompliance, your attempts to address the patient’s reasons for noncompliance, your efforts to help the patient understand the risks of noncompliance, and the patient’s persistent failure to follow the treatment plan and advice. Terminate the relationship if the patient and practitioner agree that the patient would achieve better conformity with another practitioner. The written notice terminating this relationship should be explicit in stating the reason you are no longer willing to provide care — that the patient’s
outcome is predestined to be unfavorable because of the willful noncompliance with recommended treatment plans. Suggest that the patient would benefit from a relationship with another practitioner, and state that continued care is an absolute requirement.
Case 2
A new patient has made an appointment with your office for a complete examination. Before the appointment, the patient experienced an unusually long wait in your office as a result of your need to address an urgent situation. Your office personnel explained the delay to those in the waiting room, and this new patient reacted by becoming loud and abusive, insulting the practice staff, and shouting that his time is as valuable as that of the practitioner.
Options for the Practitioner
In the privacy of an office or an examination area, address your concerns about his behavior by indicating that the practice maintains a zero-tolerance policy for loud, threatening, or abusive behavior, and state that this type of reaction will not be condoned in the future. After you have completed his examination, suggest that he seek care
elsewhere if he is reluctant to observe office decorum. If the patient indicates a refusal to comply, consider preparing and sending a letter terminating the relationship. If the patient fails to keep subsequent appointments or has notified your office that he will be seeking treatment with another practitioner, document the conversation and send the patient a letter confirming his decision to seek care elsewhere.
ASSISTANCE IS AVAILABLE
The final decision about ending a patient relationship belongs to the practitioner. The Doctors Company’s Department of Patient Safety and Risk Management is ready to assist you. We can discuss patient dismissal issues, send you sample correspondence, or help you develop special letters for an individual situation. Contact your patient safety risk manager at (800) 421-2368 or by email at patientsafety@thedoctors.com.
Julie Brightwell is director of Healthcare Systems Patient Safety and Richard F. Cahill is vice president and associate general counsel at The Doctors Company, Part of TDC Group.
How Often Do Doctors Use New Weight-Loss Drugs in Kids?
Analysis Finds Large Increases in Prescribing of GLP-1 Agonists
By Sophie Putka
WHEN FATIMA CODY STANFORD, MD, MPH, MPA, attended a holiday party thrown by two patients she was treating for obesity, she noticed something unusual about the way their 6-year-old daughter gave the house tour.
“She would take me to a room, and she’s like, ‘OK, the quickest way to the kitchen from here is this way,’” said Dr. Stanford, of Massachusetts General Hospital in Boston. “Her entire focal point ... was, ‘How’s the quickest way to the kitchen.’”
Dr. Stanford now treats the girl, who is around 13 years old, for obesity. “She’s just wired a different way,” Dr. Stanford told MedPage Today, noting part of the consideration for using new GLP-1 agonists in this patient.
The girl responded better than expected, first with liraglutide (Saxenda), then with semaglutide (Wegovy), losing 23% of her body weight. Dr. Stanford said she has been enjoying sports for the first time and carries a newfound confidence.
“It’s been interesting to watch her trend down the growth chart to being a kid without obesity,” she said.
As optimism for GLP-1 receptor agonists for weight loss has grown, so too has their use in children.
Currently, liraglutide and semaglutide are the only two GLP-1 drugs FDAapproved to treat obesity in kids ages 12 and up.
Total prescriptions for those two drugs written by pediatric and adolescent medicine specialists rose from 3,448 in October 2022 to 24,435 in September of 2024 — about a sevenfold increase in two years — according to a MedPage Today analysis of data from Symphony, a prescription drug database.
Total prescriptions for all GLP-1 drugs prescribed by pediatric and adolescent medicine specialists have more than doubled during that time, from 59,868 to 125,538. These numbers reflect 11 GLP1 drug brands, many of which are approved for type 2 diabetes, and do not include GLP-1 drugs prescribed to children by primary care physicians or family medicine practitioners, or at compounding pharmacies.
Many obesity specialists told MedPage Today they generally feel comfortable prescribing GLP-1 drugs to children if they have ruled out most other options, and if the family is involved in ongoing lifestyle interventions.
However, they acknowledged the uncertainties of putting kids on a drug regimen that may last a lifetime, and that lacks long-term data — especially on critical questions like effects on bone density. And other experts remain entirely uncomfortable with these rapid changes in obesity treatment.
Proceeding With Caution
Both liraglutide and semaglutide were shown in clinical trials to reduce body mass index (BMI) in kids ages 12 to 17 to a greater extent than placebo. Liraglutide won a pediatric obesity indication for kids 12 and up in December 2020, and semaglutide did so in December 2022.
In September, results from the SCALE Kids trial showed liraglutide cut BMI in kids ages 6 to 11 better than placebo, and Novo Nordisk is seeking to expand approval of the drug to kids in this age group. Novo Nordisk and Eli Lilly have ongoing trials of semaglutide and tirzepatide (Zepbound), respectively, in this age group underway.
Last year, the American Academy of Pediatrics (AAP) issued an updated Clinical Practice
Guideline for children and adolescents with obesity, recommending the use of pharmacotherapy for adolescents 12 and up, including GLP-1 agonists. In certain circumstances, they wrote, healthcare professionals may offer them to children 8 and up. Sarah Hampl, MD, of the
University of Missouri-Kansas City School of Medicine, and lead author of the AAP guidelines, emphasized the role of other interventions that accompany medication.
“It was recommended, not in isolation or not as a monotherapy, but as adjunct or addition to intensive health behavior and lifestyle treatment,” Dr. Hampl said.
She said AAP “needed to comment on [pharmacotherapy], because it can be a very effective form of treatment — again, as an adjunct — and these kids, especially with severe obesity, they have some really serious and real comorbidities right here and now, in their childhood.”
Dr. Stanford, for her part, does not prescribe GLP-1 agonists earlier than age 12, she said. If she had a younger patient with hyperphagia — a condition marked by extreme and persistent feelings of hunger — she said she would “still have some significant discomfort” prescribing GLP-1 agonists.
“I would still probably use my other drugs where we do have some data, like a topiramate or metformin, or if they have very severe obesity, I would wonder if they had something else,” such as proopiomelanocortin (POMC) deficiency or leptin receptor deficiency, she said.
A child visiting her center would work with dietitians and a psychology team so that “we’re doing all the behavioral things that are not really on the biology side,” she said.
Dr. Stanford monitors her adolescent patients on GLP-1 agonists carefully. In the absence of long-term data, bone quality in particular is something she keeps an eye on. Bariatric surgery, which brings on a similar degree of weight loss as GLP-1 agonists, can lead to cortical bone loss, and she wondered if similar effects will emerge with the GLP-1 drugs.
Family medicine doctors may take an even more cautious approach, using weight-loss drugs as a last resort.
Tochi Iroku-Malize, MD, MPH, MBA, former board chair of the American Academy of Family Physicians, told MedPage Today that the group’s position mostly aligns with that of the U.S. Preventive Services Task Force, which this year recommended comprehensive, intensive behavioral health intervention for children 6 and older with obesity instead of weight-loss medication.
“When we’re starting with children, they have a longer way to go than adults when it comes to using these medications,” Dr. Iroku-Malize told MedPage Today Children’s bodies are still growing and developing, “so we don’t yet know what the long-term effects of taking the weight-loss medications are, and whether the young patients would have to continue taking them indefinitely to maintain their weight,” she said.
Still, she said using medication to treat pediatric obesity is not out of the question. “On the other side of it is that for those children who have obesity, and to the point that they are at risk of developing some other condition that could increase their morbidity and mortality, and they’ve tried the other methods and it’s not working, and they’re still at risk, then this may be an option,” Dr. Iroku-Malize said. “But we have to pay attention to what’s going on and not use it lightly.”
Emphasizing Lifestyle Changes
Others stress a bigger focus on root issues, like physical activity and nutrition — including Dan Cooper, MD, a pediatrician at the University of California Irvine. Dr. Cooper and colleagues have published on the unintended consequences of GLP-1 medications in children, including possible long-term effects on growth and development, abuse among patients with eating disorders or in competitive sports, and insufficient or excessive prescription in populations with high rates of obesity and poor fitness.
Though he has not ruled out the use of GLP-1 drugs in kids, he said there’s an urgent need to engage with lifestyle and behavioral interventions more meaningfully.
Experts were careful in interviews to emphasize the role of diet and exercise for anyone who starts a GLP-1 drug. The trials that led to approval of semaglutide and liraglutide to treat obesity in adolescents provided regular nutrition and physical activity counseling, and in both trials, participants were “encouraged” to get 60 minutes of daily moderate- to high-intensity physical activity, they said.
But few children have access to lifestyle interventions like those used in the trials, and in real life, they often fall short, Dr. Cooper said.
He explained that even when a physician tells a pediatric patient to exercise, specific instructions are rarely given, and there’s not usually much follow-up. There are other barriers at play too, he said.
He noted that in his community in Santa Ana, Calif., there are very few parks. “Parents don’t want the kids to play because it’s unsafe on the streets,” he said. “The schools don’t have the budget for after-school programs.”
“Don’t get me wrong, I’m not blaming the pediatricians. I’m a pediatrician,” he said. “I mean, we’re the best doctors on the planet. But it’s very, very tough to do these things.”
Scott Bowman, a friend of Dr. Cooper’s, is a physical education specialist and the author of the state’s Content Standards for Physical Education. He agreed that GLP-1 agonists don’t get at the root of a complicated systemic problem: a tenuous relationship between kids and exercise.
Bowman has helped schools organize family “Olympics,” and thinks professional sports teams should channel their excess funds into more community fitness programs.
While he says it’s not an either-or decision, Bowman would rather have “lifelong physical activity than lifelong medication,” he said. “We just have to start thinking outside the box.”
Sophie Putka is a veteran journalist who is an enterprise and investigative writer for MedPage Today, where this article first appeared. This story is part of a series called “Ozempic: Weighing the Risks and Benefits.” It was produced in part through a grant from the NIHCM Foundation.
California Dengue Cases Prompt Swift Response From Public Health Officials
By Claudia Boyd-Barrett
JASON FARNED AND HIS TEAM AT THE SAN Gabriel Valley Mosquito and Vector Control District had spent years preparing for the likely arrival of dengue, a dangerous virus typically found in tropical climates outside the mainland United States.
They’d watched nervously as invasive Aedes mosquito species that can carry the virus appeared in Los Angeles about a decade ago and began to spread, likely introduced by international trade and enticed to stay by a warming climate that makes it easier for mosquitoes to thrive.
Then, in October 2023, an email came from the Pasadena Public Health Department: A person in the city had contracted California’s first-known case of dengue from a local mosquito.
“When it happens in real time, real life, you know, it is very different,” Farned said. “There’s no room for error here. We have to be quick and effective in identifying the most at-risk areas and responding.”
Across California, public health and pest control authorities
then biting a previously uninfected person.
Mosquito-borne viral illnesses, chiefly malaria, have long been a scourge in many tropical regions, and preventive measures focus mainly on controlling the mosquitoes. The Aedes mosquitoes, known for their aggressive, daytime biting, are now present in at least 24 California counties. They breed in water, in as little as a capful.
“When these locally acquired cases occur, … we want to act on them pretty quickly so that it does not become an endemic infection in our region,” said Aiman Halai, director of the Los Angeles County Department of Public Health’s Vector-Borne Disease Unit.
are facing a new reality as the Aedes mosquitoes bring the threat of dengue and potentially other tropical diseases, such as chikungunya, Zika, and yellow fever, that were once of concern only to international travelers. So far this year, authorities have identified at least 13 cases of locally acquired dengue, up from two in 2023, with 11 in Los Angeles County and two in the San Diego area. The Aedes mosquitoes spread the disease by biting an infected person and
California officials are hoping to beat back dengue by expanding mosquito surveillance, developing detailed response plans for mosquito outbreaks and human infections, and improving data sharing across agencies. They’re also going door to door in neighborhoods to remove standing water sources and apply pesticides.
Residents are advised to wear bug repellent and long-sleeved clothing, and control mosquitoes around their homes to prevent biting and infection.
Some vector control districts — local agencies charged with managing disease-bearing insects and other animals — are even growing their own sterile mosquitoes to release into the wild to reduce local Aedes populations.
Outside of California, locally acquired dengue cases have occurred in Arizona, Florida, Hawaii, and Texas. In March, Puerto Rico declared a public health emergency after a spike in cases there, where dengue is endemic. Meanwhile, worldwide dengue cases are on track to more than double this year, with 12.3 million documented through August, up from 6.5 million in 2023, according to the World Health Organization.
Most people who get dengue have no symptoms, but about 1 in 4 become ill. A mild case can feel like the flu and usually dissipates within a week, but about 5% of those infected with dengue become very sick, with symptoms that can include internal bleeding, shock, and organ failure, and the most severe cases can be fatal. People infected a second time are at especially high risk.
There is no specific medication to treat dengue. Japanese pharmaceutical company Takeda developed a vaccine that has won approval in Europe and elsewhere, though it withdrew an application to the FDA last year, saying it could not provide data requested by the agency. A vaccine developed in Brazil could soon be approved for use in that country. But the only FDA-approved vaccine is authorized only for children in narrow circumstances and will soon go out of production.
At the San Gabriel Valley Mosquito and Vector Control District, one of five agencies tasked with mosquito control across Los Angeles County, public health workers have put together an Aedes and dengue response plan based on updated guidance from the state.
When they discover a case, they identify all the properties and public spaces within 150 meters — roughly the distance an Aedes mosquito can fly — and then go door to door, removing standing water, where mosquitoes can breed; applying pesticides from backpacks or trucks; and educating residents about the risk of dengue and how to protect themselves. District officials also set traps to catch mosquitoes so they can figure out their prevalence and test them for dengue.
Since local dengue cases began to appear, the district has gotten more efficient in implementing its response plan, district manager Farned said. All full-time and seasonal staff members — about 40 people — have been trained in a variety of tasks, such as door-to-door education and coming in during off-hours to answer phones, Farned said.
While vector control teams respond to cases, separate teams from the Los Angeles County Public Health Department go door to door in the affected neighborhood when they determine that a dengue case was locally acquired, surveying residents and offering free dengue testing to try to identify others who may be infected.
Additionally, the department has been sending alerts to local health providers, advising them to be on the lookout for possible dengue cases and test for it when suspected, even among patients who haven’t traveled to a place where dengue is endemic. This advice follows a national alert put
out by the Centers for Disease Control and Prevention in June. Health authorities are also emphasizing that people who travel to locations with dengue should continue to wear mosquito repellent when they get home, to reduce the risk of spreading the disease to local mosquitoes.
As happened during the COVID-19 pandemic, mistrust of public health authorities can make outreach challenging for health and pest control teams in some neighborhoods, officials said.
Pest control officers can seek a warrant to enter and treat a property for mosquitoes if a homeowner refuses to give access, said Jeremy Wittie, a former president and the legislative committee chair for the Mosquito and Vector Control Association of California, which represents the more than 70 mosquito and vector control agencies in California. This is easier in districts such as his, the Coachella Valley Mosquito and Vector Control District, that have warrants giving officials standing permission to enter a property after 24 hours without needing to ask a judge.
In counties such as Santa Clara, where Aedes mosquitoes first appeared in 2022 but have yet to establish themselves, officials hope to suppress the threat with stepped-up surveillance, speedy eradication efforts, and more public outreach. Santa Clara County Vector Control District Manager Nayer Zahiri said the aim was to eliminate Aedes but acknowledged the climate conditions that encourage the mosquitoes’ spread are “totally out of our control.”
In some counties with pervasive mosquito problems, including San Diego, San Joaquin, and Stanislaus, officials have sprayed pesticides from planes or helicopters to address spikes in local mosquito populations, Wittie said. These sprayings typically aim to control the larvae of a different type of mosquito, Culex, that can spread West Nile virus and which — unlike the Aedes species, which thrive in urban habitats — are found in harder-to-reach rural environments, Wittie said.
Aerial spraying hasn’t been deployed to address the recent dengue outbreaks, which are in more urban environments where spraying from trucks is a better option, Wittie said. Drones are another option that some vector control authorities are exploring.
Some districts are experimenting with the decades-old sterile insect technique, commonly used for other pests such as fruit and screwworm flies, in which males are sterilized with radiation and then released to mate, resulting in eggs that don’t hatch. (Female mosquitoes are separated from the males before sterilization and not released. Only the females bite).
Ultimately, the public will have to take the mosquito threat more seriously and contribute to prevention efforts, Wittie said. “This mosquito is going to be here to stay, unfortunately. I hope it kind of wakes people up and pushes them to be part of that solution.”
Claudia Boyd-Barrett is a correspondent for KFF Health News, which produced this article.
New FDA Panel Weighs in on Regulating Generative AI in Healthcare
Meeting Focused on Evaluating and Monitoring Performance and Risk
By Michael DePeau-Wilson
A NEWLY ASSEMBLED FDA ADVISORY COMMITTEE
recommended several approaches to how the agency should handle regulation of generative artificial intelligence (AI)enabled medical devices during a recent two-day meeting.
The Digital Health Advisory Committee (DHAC) held its first meeting to offer guidance to the FDA on a slew of questions related to the development, evaluation, implementation, and continued monitoring of AI-enabled medical devices.
During the opening remarks, FDA Commissioner Robert Califf, MD, said the DHAC would provide important advice and recommendations on the benefits and risks associated with all digital health technologies, including generative AIenabled medical devices.
“We’ve established this committee because we see great potential for digital health technologies to help address critical healthcare issues that we face today, and we need these technologies to be developed, deployed, and used responsibly in the best interest of patients and consumers,” Dr. Califf said, adding that “artificial intelligence is changing how we think about health and healthcare, and it’s one of the most exciting and promising areas of science because it’s built to transcend boundaries.”
In the executive summary shared before the meeting, FDA staff asked the committee to consider planning and design, data collection and management, model building and tuning, verification and validation, model deployment, operation and monitoring, and real-world performance evaluation.
The discussion produced a substantial number of considerations and ideas for how the FDA should approach all of the phases of the development process, said committee chair Ami Bhatt, MD, the chief innovation officer at the American College of Cardiology.
“There are a lot of eyes, a lot of opinions, many companies, research labs, friends of ours, and — most importantly — patients who are hopeful for the promise of generative AI, and that’s why we consider our job here the development of an infrastructure for growth with guardrails,” she said. “This is not the end, but only the beginning of a process of continuous change.”
While the committee did not vote on specific
recommendations for the agency, Dr. Bhatt noted that they were able to create “an actionable framework” for how generative AI-enabled devices should be handled by the FDA moving forward. Following the FDA’s list of discussion questions for the meeting, the committee members offered a framework based on three distinct areas: premarket performance evaluation, risk management, and postmarket performance monitoring.
Among the premarket performance considerations, the committee members said the agency should develop custom, multi-dimensional frameworks to evaluate the overall correctness of AI models, the effectiveness of the intended generative AI outputs based on user inputs or prompts, and the ability to identify potential harms and risks introduced by generative AI-enabled devices.
Along those lines, the committee noted that the FDA should consider developing a small set of widely accepted metrics and methods to be used
in the evaluation of such devices.
They also said the agency should develop standard definitions of terms and concepts to discuss generative AI, especially for key limitations such as outof-distribution data, data drift, and hallucinations. Notably, the lack of consistent definitions for several terms related to generative AI presented challenges during the meeting on several occasions.
The committee also pointed to a lack of sufficient study designs to test these devices for clinical use, and urged the FDA to explore potential use of alternative study approaches, such as synthetic control trials, to improve evaluation of the comparative efficacy of these devices.
For postmarket performance evaluation, the committee said the agency should consider approaches for scaling evaluations after a device is widely adopted by clinicians or consumers. They also emphasized the need to automate those monitoring and evaluation
processes to avoid time-consuming and costly human review of these devices once they are used at larger scales.
In addition, they said the FDA should consider establishing new frameworks for understanding the impact of generative AI-enabled devices on society once they are on the market.
For this, the committee recommended that the agency consider establishing a centralized data repository and reporting mechanism that can be used to track errors and harms caused by these devices, and noted that these tools could also be used to continuously monitor device performance across various populations and settings.
The committee also emphasized that the agency must keep in mind the impact of these devices on health equity. They recommended that the FDA develop requirements for companies to implement and demonstrate how safeguards are protecting against built-in or learned biases over time.
Finally, the committee said that the agency should develop certification programs or other standards to ensure that the companies that develop these devices understand the risk for bias in their generative AI-enabled devices.
After two days of in-depth discussion about these
issues, the committee members noted that developing this regulatory infrastructure would be an ongoing process. Dr. Bhatt acknowledged that this process would be incremental, but that establishing clear guidelines for the implementation of generative AI in the healthcare setting could help improve healthcare delivery across the country in the near future.
“One challenge we face, because generative AI is oftentimes related to clinical guidelines or clinical decision support, is what the gold standard is,” Dr. Bhatt said. “When we think about whether or not we’re delivering goldstandard clinical guideline-derived treatment throughout the United States throughout all of the different specialties, the answer is generally no.”
This technology could help improve the overall quality of care that is offered to patients, she added, so the question we should be asking is “how close does generative AI bring us to the gold standard?”
Michael DePeau-Wilson is a reporter for MedPage Today, where this article first appeared, and he serves on the enterprise and investigative team.
Family Medicine/Internal Medicine Physician
Federally qualified health center located in San Diego County is seeking a family medicine/internal medicine physician. This position reports to the chief medical officer and provides the full scope of primary care services, including diagnosis, treatment, and coordination of care to its patients. The candidate can be board eligible and working toward certification in internal medicine.
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As California Taps Pandemic Stockpile for Bird Flu, Officials Keep Close Eye on Spending
By Don Thompson
CALIFORNIA PUBLIC HEALTH OFFICIALS ARE
dipping into state and federal stockpiles to equip up to 10,000 farmworkers with masks, gloves, goggles, and other safety gear as the state confirms at least 21 human cases of bird flu as of early November. It’s the latest reminder of the state’s struggle to remain prepared amid multibillion-dollar deficits.
Officials said they began distributing more than 2 million pieces of personal protective equipment in late May, four months before the first human case was confirmed in the state. They said they began ramping up coordination with local health officials in April after bird flu was first detected in cattle in the U.S. Bird flu has now been confirmed at more than 270 dairies in central California, and traces were
recently detected at a wastewater sampling site in Los Angeles County. Bird flu was also recently detected in a flock of commercial turkeys in Sacramento County.
California is putting a number of lessons from the COVID-19 pandemic to use, such as coordinating emergency response with local health officials and tracking infectious diseases through wastewater surveillance, as the state tries to limit the spread of bird flu to humans. It’s striving to maintain an adequate emergency stockpile to withstand the first wave of any new public health disaster without hemorrhaging the state budget.
“We are far better prepared to respond to a pandemic than we were in 2020,” said Amy Palmer, a spokesperson for the Governor’s Office of Emergency Services.
For instance, before the coronavirus struck in 2020, the state’s emergency supplies stockpile was barely big enough to crowd two basketball courts.
By the time California ramped up its pandemic response, it had enough personal protective equipment and other disaster supplies to fill 52 football fields. California spent $15.6 billion on direct pandemic response during the COVID crisis years, much of it provided by the federal government.
Today, the stockpile fits into about 12 and a half football fields, though it can seesaw from month to month.
According to the state, the current stockpile includes 101 million face masks, 26 million more than the 90-day supply recommended by the state’s pandemic preparedness guideline.
That includes 88 million N95 masks, more than the emergency services agency said was needed last year. The high-efficiency masks are considered crucial to protect against airborne viruses such as COVID-19.
Although the state is building up its stockpile, Palmer could not say if the additional masks are related to fears of bird flu, only that planners are always working “to keep pace with the current risk environment.”
The state’s goal, Palmer said, is to have “an initial supply during emergencies to allow us the time to secure resources,” whether through the federal government or by buying more.
There is no indication of spread between humans in the recent California bird flu cases, and health officials say public risk remains low. Human transmission of bird flu is among several worst-case scenarios for a new pandemic, alongside the possibility of a resurgent mutant coronavirus; wider international spread of mpox, Marburg virus, or Ebola; or an entirely new virus for which there initially is no immunity or vaccine.
Yet, health officials nationwide have struggled to track bird flu transmission. And California has a history of swinging back and forth on preparedness.
Republican Gov. Arnold Schwarzenegger ordered an increase in California’s pandemic preparedness in 2006 in response to an earlier threat from bird flu. That included three mobile hospitals that could immediately be deployed during disasters.
Gov. Jerry Brown, a Democrat, ended the program in 2011 as state finances went bust. By the time COVID struck, the state released 21 million N95 masks, some so old they were past their expiration date.
Now hospitals are required to maintain their own three-month supply of masks, gowns, and other personal protective equipment under a state law passed in 2020. California’s aerosol transmissible disease standard also uniquely requires hospitals and other high-risk workplaces to follow precautions such as using negative pressure isolation rooms and the highest level of protective
equipment until more is known about a new pathogen.
“It is difficult to overstate the level of unpreparedness exhibited by hospitals both in and outside of California in dealing with the 2020 outbreak of COVID-19,” according to a legislative analysis. “Harrowing images of nurses walking the corridors of hospitals in makeshift masks and garbage bags became commonplace.”
California Hospital Association spokesperson Jan Emerson-Shea said hospitals “continuously prepare to respond to all types of disasters, including outbreaks of transmissible viruses.”
In addition, Palmer said California has five mobile hospitals acquired from the federal government, though they got little use during the pandemic. She said they have to be maintained, such as making sure pulse oximeters have working batteries.
But, once again, the current deficit has the state trying to strike a balance.
While lawmakers rejected most of Democratic Gov. Gavin Newsom’s $300 million proposed cut to public health funding, the state slashed funding for its stockpile of personal protective equipment by one-third a year ago after it determined that no additional COVID-related purchases were necessary, according to the Department of Finance. California eliminated funding this year for eight 53-foot-long trailers that would have moved stockpiled items between warehouses. It’s also cutting nearly $40 million over the next four years from its $175 million disaster stockpile budget.
The state’s preparedness wasn’t good enough for Californians Against Pandemics, which gathered more than 1 million signatures to put a ballot measure before voters in November. The measure would have increased taxes on people with incomes over $5 million and used that money for pandemic prevention and response.
But that effort collapsed after one of its key financial supporters, former cryptocurrency executive Sam BankmanFried, was convicted of defrauding customers and investors. In exchange for initiative backers dropping the measure, state officials agreed to broaden the scope of the California Initiative to Advance Precision Medicine, which was created in 2015 to focus on developing new medicines and therapies, to include technologies for preventing another pandemic.
“By harnessing the power of precision medicine, California is moving to the forefront of pandemic preparedness and prevention,” Newsom said at the time.
Rodger Butler, a spokesperson for the state Health and Human Services Agency, said it’s unclear if the precision medicine initiative will receive additional funding.
Don Thompson is a correspondent for KFF Health News, where this article first appeared.
California Sets 15% Target for Primary Care Spending Over Next Decade
By Vanessa G. Sanchez
A CALIFORNIA AGENCY CHARGED WITH SLOWING
health costs has set a lofty goal for insurers to direct 15% of their spending to primary care by 2034, part of the state’s effort to expand the primary care workforce and give more people access to preventive care services.
In October, the board of the state Office of Health Care
Affordability set its benchmark well above the industry’s current 7% primary care spending rate, in hopes of improving Californians’ health and reducing the need for costlier care down the road.
“It’s ambitious but achievable,” said Elizabeth Landsberg, director of the state’s Department of Health Care Access and Information, which oversees the affordability agency. “Plans and health systems need time to build the infrastructure to really change the way they’re providing care.”
But California’s target comes just six months after the affordability board set an annual cap of 3.5% for overall growth in healthcare spending, potentially squeezing insurers from two sides.
“How these two policies will interact is unclear and we believe it is important to not lose sight of our overall goal of reducing the growth of healthcare costs,” Mary Ellen Grant, a spokesperson for the California Association of Health Plans, said in a statement.
The affordability agency argues health plans are best positioned to promote more spending on preventive care services, since insurers are the ones that negotiate payment with providers. Landsberg said health plans could dangle incentives, such as offering higher reimbursement rates for primary care providers or paying for comprehensive care instead of for individual visits.
If successful, the agency says, the spending target could expand the primary care workforce through the hiring of staff and lead to better health management, disease prevention, and early diagnosis and treatment for more patients across the state.
California faces a shortage of primary care providers, which has limited people’s access to preventive care.
Approximately 6 million Californians live in parts of the state where there aren’t enough doctors to meet people’s needs, according to a data analysis by KFF, a health information nonprofit that includes KFF Health News.
A 2021 report by the National Academies of Sciences, Engineering, and Medicine found that while more than 35% of healthcare visits in the U.S. are to primary care physicians, only about 5% of health spending is on primary care. That’s compared with about 13% for some other developed nations.
“People have high regard for primary care, understand how important it is,” said Kevin Grumbach, a professor of family and community medicine at the University of California-San Francisco, who helped develop the state’s primary care target. “They way overestimate how much of their tax dollars are actually going to support primary care.”
Beginning next year, the affordability agency will start collecting data on how much health plans spend annually on primary care, particularly in settings such as community-
based clinics, schools, and homeless shelters. Doctors, nurses, and pharmacists are among the providers whose services can be counted toward the goal. But the agency is excluding obstetricians, who sometimes serve as primary care providers for pregnant women, to focus on those offering “coordinated, comprehensive care” for patients.
Health plans will be expected to increase primary care spending from 0.5% to 1% of their total medical expenses each year until 15% is reached in 2034.
At least six states — Colorado, Connecticut, Delaware, Oregon, Rhode Island, and Washington — have already implemented primary care targets with some success. Rhode Island, which set a 10.7% goal, more than doubled its primary care spending from 2008 to 2018, while also reducing overall health spending.
The Biden administration has launched initiatives to improve primary care, but it has not set a primary care target for Medicare.
In California, the affordability agency collects healthcare spending data that captures nearly 33 million of the state’s 39 million residents. The agency said it will begin to collect primary care spending data in fall 2025, but that information may not be released for two more years.
The state agency lacks enforcement authority in primary care spending, so to get health plans to hit the target, the agency is dangling financial incentives. At a primary care summit at the University of California-Davis in October, Landsberg said the agency could allow insurers to exceed the 3.5% overall growth cap if they show their spending went to boost primary care.
Efrain Talamantes, chief operating officer for AltaMed Health Services, one of the state’s largest federally qualified community health centers, said these payments could help the health center expand services by training and hiring staff.
If health plans comply, the policy should lead to more primary care providers, timelier appointments, and better health outcomes, especially for disadvantaged communities that historically haven’t had good access to care, Talamantes said.
“We should see an improvement where people are able to access their primary care the same day,” he said.
As discussions continue, the state is working on targets to increase spending on behavioral health, another underinvested service. A vote on that measure could come next summer.
Vanessa G. Sanchez is a correspondent for KFF Health News, where this article first appeared. She reports on the health of Hispanic populations, issues at the intersection of health and immigration, and health policies of the California State Assembly.
Do You Feel Lucky?
By Adama Dyoniziak
LUCKY IN LOVE … LUCK OF THE DRAW … DOWN on your luck … depending on the day or situation, you may attribute the result to this ephemeral quality. Throughout history, people have clung to totems for good fortune. The ancient Egyptians wore scarabs. Who among us has not wished upon a falling star, searched for a four-leaf clover, knocked on wood, or tossed coins in a fountain hoping it would usher in a good fate? We make wishes every year when blowing out our birthday candles hoping for something better to occur in the ensuing year.
Champions for Health is lucky to work with our dedicated volunteer network of physicians, hospitals, surgery centers, and private and public partners to improve the health of San Diegans where they live, work, play, and pray. It is the skills, determination, resilience, and adaptability of our volunteers and staff that truly defines our journey. We have embraced
the power of preparation and hard work in order to seize opportunities when luck knocks.
The free preventive and specialty care services received by Champions for Health participants make a priceless impact! No more need to worry about ER visits; loss of work due to excruciating pain; deciding between paying for food or a desperately needed medical appointment; or paying for flu or childhood vaccinations.
Access to care for all is our mission. We are creating luck for our neighbors with our compassionate community partners. When I listen to the stories from our volunteers and how much working with patients means to them, I can see that their purpose is being fulfilled: to relieve pain and suffering, to put their multiple medical talents to work, to lift the burden of poverty by removing the barrier to needed consultations and surgery.
the health of our patients, and in turn, they can better navigate the uncertainties of life. Let us leverage the skills of our volunteers with the contributions of our donors to unlock the full potential of Champions for Health.
There are so many ways to our mutual success! Your tax-deductible contribution can be onetime opportunity or you can join our monthly giving program for ongoing support. The end of the year signals an excellent time to transfer gifts of stocks and securities to Champions for Health. Direct charitable distributions of IRA funds can be contributed up to $100,000. Thank you for taking hold of this opportunity to create luck for yourself and others by contributing to making San Diego the healthiest place to live. For more information, visit championsforhealth.org/ donate.
When you support Champions for Health, you contribute to the health and wellbeing of thousands of individuals in San Diego. The skills of our volunteers help improve Adama Dyoniziak is executive director of Champions for Health.
PRACTICE ANNOUNCEMENTS
VIRTUAL SPEECH THERAPY AVAILABLE: Accepting new pediatrics and adult patients. We accept FSA/HSA, Private pay, Medicare, Medi-Cal, and several commercial insurance plans pending credentialing. Visit virtualspeechtherapyllc.org or call 888-855-1309.
PSYCHIATRIST AVAILABLE: Accepting new patients for medication management, crisis visits, ADHD, cognitive testing, and psychotherapy. Out of network physician servicing La Jolla & San Diego. Visit hylermed.com or call 619-707-1554.
OPPORTUNITIES
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PART–TIME PRIMARY CARE PHYSICIAN: Primary Care Clinic in San Diego searching for part-time physician for 1 to 2 days a week, no afterhours calls. Please send CV to medclinic1@yahoo. com. [2872-0909]
OB/GYN POSITION AVAILABE | EL CENTRO: A successful Private OBGYN practice in El Centro, CA seeking a board eligible/ certified OB/GYN. Competitive salary and benefits package is available with a tract of partnership. J-1 Visa applicants are welcome. Send CV to feminacareo@gmail.com or call Katia M. at 760-352-4103 for more information. [2865-0809]
COUNTY OF SAN DIEGO DEPUTY CHIEF ADMINISTRATIVE OFFICER: Salary: $280,000-$300,000 Annually. The County of San Diego is thrilled to announce unique openings for Deputy Chief Administrative Officers (DCAOs) across our four County Groups: Finance and General Government Group (FGG), Health & Human Services Agency (HHSA), Land Use and Environment Group (LUEG), and the Public Safety Group (PSG). With a new Chief Administrative Officer (CAO) at the helm, the County is in an extraordinary period of transformation and opportunity. The DCAOs will direct, organize and oversee all activities within their designated Group. Additionally, the DCAOs aid the CAO in the coordination of county operations, program planning, development, and implementation. The DCAOs must demonstrate strong leadership and model our core values of integrity, belonging, equity, excellence, access, and sustainability. How To Apply: Take this opportunity to make a significant impact and drive positive change in our community. Apply now by submitting your application here: Deputy Chief Administrative Officer-24210407U.
COUNTY OF SAN DIEGO PROBATION DEPT. MEDICAL DIRECTOR: The County of San Diego is seeking dynamic physician leaders with a passion for building healthy communities. This is an exceptional opportunity for a California licensed, Boardcertified physician to help transform our continuum of care and lead essential medical initiatives within the County’s Probation Department. Anticipated Hiring Range: Depends on Qualifications Full Salary Range: $181,417.60 - $297,960.00 Annually COUNTY OF SAN DIEGO As part of the Probation Administrative team, the Medical Director is responsible for the clinical oversight and leadership of daily operations amongst Probation facilities’ correctional healthcare programs and services. As the Medical Director, you will have significant responsibilities for formulating and implementing medical policies, protocols, and procedures for the Probation Department.
PART–TIME CARDIOLOGIST POSITION AVAILABLE: Cardiology office in San Marcos seeking part–time cardiologist. Please send resume to Dr. Keith Brady at uabresearchdoc@ yahoo.com. [2873-0713]
INTERNAL MEDICINE PHYSICIAN: Federally Qualified Health Center located in San Diego County has an opening for an Internal Medicine Physician. This position reports to the chief medical officer and provides the full scope of primary care services, including diagnosis, treatment, and coordination of care to its patients. The candidate should be board eligible and working toward certification in Internal Medicine. Competitive base salary, CME education, Four weeks paid vacation, year one, 401K plan, No evenings and weekends, Monday through Friday 8:00am to 5:00pm. For more information or to apply, please contact Dr. Keith Brady at: uabresearchdoc@yahoo.com. [2874-0713]
FAMILY MEDICINE/INTERNAL MEDICINE PHYSICIAN: San Diego Family Care is seeking a Family Medicine/Internal Medicine Physician (MD/DO) at its Linda Vista location to provide outpatient care for acute and chronic conditions to a diverse adult population. San Diego Family Care is a federally qualified, culturally competent and affordable health center in San Diego, CA. Job duties include providing complete, high quality primary care and participating in supporting quality assurance programs. Benefits include flexible schedules, no call requirements, a robust benefits package, and competitive salary. If interested, please email CV to sdfcinfo@ sdfamilycare.org or call us at (858) 810-8700.
PHYSICIAN POSITIONS WANTED
PART-TIME CARDIOLOGIST AVAILABLE: Dr. Durgadas Narla, MD, FACC is a noninvasive cardiologist looking to work 1-2 days/
week or cover an office during vacation coverage in the metro San Diego area. He retired from private practice in Michigan in 2016 and has worked in a San Marcos cardiologist office for the last 5 years, through March 2023. Board certified in cardiology and internal medicine. Active CA license with DEA, ACLS, and BCLS certification. If interested, please call (586) 206-0988 or email dasnarla@gmail.com.
OFFICE SPACE / REAL ESTATE AVAILABLE
MEDICAL OFFICE FOR SUBLEASE OR SHARE: A newly remodeled and fully built-out medical clinic in Torrey Hills. The office is approximately 2,700 sq ft with 5 fully equipped exam rooms, 1 lab, 1 office, spacious and welcoming waiting room, spacious reception area, large breakroom, and ADA-accessible restroom. All the furniture and equipment are new and modern design. Ample parking. Perfect for primary care or any specialty clinic. Please get in touch with Charlie at (714) 271-0476 or cmescher1@gmail.com. Available immediately. [2871-0906]
LA JOLLA/XIMED OFFICE TO SUBLEASE: Modern upscale office on the campus of Scripps Hospital — part or full time. Can accommodate any specialty. Multiple days per week and full use of the office is available. If interested, please email kochariann@ yahoo.com or call (818) 319-5139. [2866-0904]
SUBLEASE AVAILABLE: Sublease available in modern, upscale Medical Office Building equidistant from Scripps and Sharp CV. Ample free parking. Class A+ office space/medical use with highend updates. A unique opportunity for Specialist to expand reach into the South Bay area without breaking the bank. Specialists can be accommodated in this first floor high-end turnkey office consisting of 1,670 sq ft. Located in South Bay near Interstate 805. Half day or full day/week available. South Bay is the fastest growing area of San Diego. Successful sublease candidates will qualify to participate in ongoing exclusive quarterly networking events in the area. Call Alicia, 619-585-0476.
OFFICE SPACE FOR SUBLEASE | SOUTHEAST SAN DIEGO:
3 patient exam rooms, nurse’s station, large reception area and waiting room. Large parking lot with valet on-site, and nearby bus stop. 286 Euclid Ave - Suite 205, San Diego, CA 92104. Please contact Dr. Kofi D. Sefa-Boakye’s office manager: Agnes Loonie at (619) 435-0041 or ams66000@aol.com. [2869-0801]
MEDICAL OFFICE FOR SALE OR SUBLEASE: A newly remodeled and fully built-out primary care clinic in a highly visible Medical Mall on Mira Mesa Blvd. at corner of Camino Ruiz. The office is approximately 1000 sq ft with 2 fully equipped exam rooms, 1 office, 1 nurse station, spacious and welcoming waiting room, spacious reception area, and ADA accessible restroom. All the furniture and equipment are new and modern design. Ample parking. Perfect for primary care or any specialty clinic. Please contact Nox at 619-776-5295 or noxwins@hotmail.com. Available immediately.
RENOVATED MEDICAL OFFICE AVAILABLE | EL CAJON:
Recently renovated, turn-key medical office in freestanding single-story unit available in El Cajon. Seven exam rooms, spacious waiting area with floor-to-ceiling windows, staff break room, doctor’s private office, multiple admin areas, manager’s office all in lovely, drought-resistant garden setting. Ample free patient parking with close access to freeways and Sharp Grossmont and Alvarado Hospitals. Safe and secure with roundthe-clock monitored property, patrol, and cameras. Available March 1st. Call 24/7 on-call property manager Michelle at the Avocado Professional Center (619) 916-8393 or email help@ avocadoprofessionalcenter.com.
OPERATING ROOM FOR RENT: State of the Art AAAASF Certified Operating Rooms for Rent at Outpatient Surgery of Sorrento. 5445 Oberlin Drive, San Diego 92121. Ideally located and newly built 5 star facility located with easy freeway access in the heart of San Diego in Sorrento Mesa. Facility includes two operating rooms and two recovery bays, waiting area, State of the Art UPC02 Laser, Endoscopic Equipment with easy parking. Ideal for cosmetic surgery. Competitive Rates. Call Cyndy for more information 858.658.0595 or email Cyndy@roydavidmd.com.
PRIME LOCATION | MEDICAL BUILDING LEASE OR OWN OPPORTUNITY IN LA MESA: Extraordinary opportunity to lease or lease-to-own a highly visible, freeway-oriented medical building in La Mesa, on Interstate 8 at the 70th Street on-ramp. Immaculate 2-story, 7.5k square foot property with elevator and ample free on-site parking (45 spaces). Already built out and equipped with MRI/CAT machine. Easy access to both Alvarado and Sharp Grossmont Hospitals, SDSU, restaurants, and walking distance to 70th St Trolley Station. Perfect for owner-user or investor. Please contact Tracy Giordano [Coldwell Banker West, DRE# 02052571] for more information at (619) 987-5498.
POWAY MEDICAL OFFICE SPACE FOR LEASE: Fully built out, turnkey 1257 sq ft ADA-compliant suite for lease. Great location in Pomerado Medical/Dental Building, next to Palomar Med Center Poway campus. Building restricted to medical/allied health/dental practices, currently houses ~26 suites. Ideal for small health practice as primary or satellite location. Lease includes front lobby, reception area, restrooms, large treatment area, private treatment/exam rooms. Located on second floor, elevator/stair access. Bright, natural lighting; unobstructed views of foothills. On-site parking; nearby bus service. Flexible lease terms available from 3-5 years at fair market rate. Contact Debbie Summers at debjsummers3@gmail.com or (858) 382-8127. [2856-1101]
KEARNY MESA OFFICE TO SUBLEASE/SHARE: 5643 Copley Dr., Suite 300, San Diego, CA 92111. Perfectly centrally situated within San Diego County. Equidistant to flagship hospitals of Sharp and Scripps healthcare systems. Ample free parking. Newly constructed Class A+ medical office space/medical use building. 12 exam rooms per half day available for use at fair market value rates. Basic communal medical supplies available for
use (including splint/cast materials). Injectable medications and durable medical equipment (DME) and all staff to be supplied by individual physicians’ practices. 1 large exam room doubles as a minor procedure room. Ample waiting room area. In-office x-ray with additional waiting area outside of the x-ray room. Orthopedic surgery centric office space. Includes access to a kitchenette/ indoor break room, exterior break room and private physician workspace. Open to other MSK physician specialties and subspecialties. Building occupancy includes specialty physicians, physical therapy/occupational therapy (2nd floor), urgent care, and 5 OR ambulatory surgery center (1st floor). For inquiries contact kdowning79@gmail.com and scurry@ortho1.com for more information. Available for immediate occupancy.
LA JOLLA/UTC OFFICE TO SUBLEASE OR SHARE: Modern upscale office near Scripps Memorial, UCSD hospital, and the UTC mall. One large exam/procedure room and one regular-sized exam room. Large physician office for consults as well. Ample waiting room area. Can accommodate any specialty or Internal Medicine. Multiple days per week and full use of the office is available. If interested please email drphilipw@gmail.com.
ENCINITAS MEDICAL SPACE AVAILABLE: Newly updated office space located in a medical office building. Two large exam rooms are available M-F and suitable for all types of practice, including subspecialties needing equipment space. Building consists of primary and specialist physicians, great for networking and referrals. Includes access to the break room, bathroom and reception. Large parking lot with free parking for patients. Possibility to share receptionist or bring your own. Please contact coastdocgroup@gmail.com for more information.
NORTH COUNTY MEDICAL SPACE AVAILABLE: 2023 W. Vista Way, Suite C, Vista CA 92082. Newly renovated, large office space located in an upscale medical office with ample free parking. Furnishings, decor, 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: 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. For inquiries contact hosalkarofficeassist@gmail.com or call/text (858)740-1928.
MEDICAL EQUIPMENT / FURNITURE FOR SALE
UROLOGY OFFICE CLOSING 6/2023 | EQUIPMENT
AVAILABLE: Six fully furnished exam rooms including tables (2 bench, 3 power chair/table, 1 knee stirrup), rolling stools, lights, step stools, patient chairs. Waiting room chairs, tables, magazine rack. Specialty items—Shimadzu ultrasound, SciCan sterilizer, Dyonics camera with Sharp monitor, Medtronic Duet urodynamics with T-DOC catheters, Bard prostate biopsy gun with needles, Cooper Surgical urodynamics, Elmed ESU cautery, AO 4 lens microscope. RICOH MP-3054 printer with low print count. For more information contact: r.pua@cox.net.
NON–PHYSICIAN POSITIONS AVAILABLE
NURSE PRACTITIONER | PHYSICIAN ASSISTANT: Open position for Nurse Practitioner/Physician Assistant for an outpatient adult medicine clinic in Chula Vista. Low volume of patients. No call or weekends. Please send resumes to medclinic1@yahoo.com. [2876-1121]
POSTDOCTORAL SCHOLARS: The Office of Research Affairs, at the University of California, San Diego, in support of the campus, multidisciplinary Organized Research Units (ORUs) https://research.ucsd.edu/ORU/index.html is conducting an open search for Postdoctoral Scholars in various academic disciplines. View this position online: https://apol-recruit.ucsd.edu/JPF03803. The postdoctoral experience emphasizes scholarship and continued research training. UC’s postdoctoral scholars bring expertise and creativity that enrich the research environment for all members of the UC community, including graduate and undergraduate students. Postdocs are often expected to complete research objectives, publishing results, and may support and/or contribute expertise to writing grant applications https://apol-recruit.ucsd.edu/JPF03803/apply. [2864-0808]
RESEARCH SCIENTISTS (NON–TENURED, ASSISTANT, ASSOCIATE OR FULL LEVEL): The University of California, San Diego campus multidisciplinary Organized Research Units (ORUs) https://research.ucsd.edu/ORU/index.html is conducting an open search for Research Scientists (non–tenured, assistant, associate or full level). Research Scientists are extramurally funded, academic researchers who develop and lead independent research and creative programs similar to Ladder Rank Professors. They are expected to serve as Principal Investigators on extramural grants, generate high caliber publications and research products, engage in university and public service, continuously demonstrate independent, high quality, significant research activity and scholarly reputation. Appointments and duration vary depending on the length of the research project and availability of funding. Apply now at https://apol-recruit.ucsd.edu/ JPF03711. [2867-0904]
PROJECT SCIENTISTS: Project Scientists (non-tenured, Assistant, Associate or Full level): The University of California, San Diego, Office of Research and Innovation https://research. ucsd.edu/, in support of the Campus multidisciplinary Organized Research Units (ORUs) https://research.ucsd.edu/ORU/index. html is conducting an open search. Project Scientists are academic researchers who are expected to make significant and creative contributions to a research team, are not required to carry out independent research but will publish and carry out research or creative programs with supervision. Appointments and duration vary depending on the length of the research project and availability of funding: https://apol-recruit.ucsd.edu/JPF03712/ apply. [2868-0904]
