April 2013 by San Diego Physician

ANNOUNCING

LOWER RATES FOR SOUTHERN CALiFORNiA PHySiCiANS

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* We’ve lowered our rates in Imperial, Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Luis Obispo, Santa Barbara, and Ventura counties. Premium impact varies by factors such as medical specialty and practice location.

S A N D I E G O P HY S I CI A N .OrG O c tO ber 2011

Special mortgage financing for physicians Our special home financing program is designed specifically to meet your needs as a busy physician for the purchase of your primary residence. • Financing available with low down payment up to $1,750,000; refinances with high loan-to-values also available • Private mortgage insurance is not required • Single family homes are eligible

For details contact or visit: Daniel Schroeder Mortgage Banking Officer NMLS# 633034 Daniel Schroeder (858) 356-2601 Daniel.Schroeder@bbvacompass.com

All loans subject to approval, including credit approval. Eligible properties must be located in Alabama, Arizona, California, Colorado, Central Florida, North Florida, New Mexico or Texas where BBVA Compass has a market presence. BBVA Compass is a trade name of Compass Bank, Member FDIC.

Contents April

Volume 100, Number 4

MANAGING EDItOr: Kyle Lewis EDItOrIAl BOArD: Van L. Cheng, MD, Theodore M. Mazer, MD, Robert E. Peters, PhD, MD, David M. Priver, MD, Roderick C. Rapier, MD MArkEtING & PrODuCtION MANAGEr: Jennifer Rohr SAlES DIrECtOr: Dari Pebdani Art DIrECtOr: Lisa Williams COPY EDItOr: Adam Elder

features

SDCMS BoarD of DireCtorS

PRESCRIPTION DRUG ABUSE

offiCerS PrESIDENt: Sherry L. Franklin, MD (CMA TRUSTEE) PrESIDENt-ElECt: Robert E. Peters, PhD, MD

trEASurEr: J. Steven Poceta, MD SECrEtArY: William T-C Tseng, MD, MPH

Prescription Drug Abuse: A Call to Action for All San Diego Healthcare Prescribers

IMMEDIAtE PASt PrESIDENt: Robert E. Wailes, MD (CMA TRUSTEE)

geographiC anD geographiC alternate DireCtorS EASt COuNtY: Alexandra E. Page, MD, Venu Prabaker, MD HIllCrESt: Theodore S. Thomas, MD (A: Gregory M. Balourdas, MD)

BY RONEET LEV, MD

Prescription Drug Abuse Stats

departments

An Interview With Thomas P. Lenox, Supervisory Special Agent, DEA: Part 1

BY RONEET LEV, MD

Are Your Prescribing Practices Secure?

Briefly Noted: Calendar • Featured Members • Preceptors Needed • And More …

BY THE DOCTORS COMPANY

SDCMS Board of Directors Candidate Statements

Center

SDCMS 2012 Annual Report

HIPAA Privacy and Security: Major Changes Ahead

BY DAVID GINSBERG

What You Do Becomes You

BY DANIEL J. BRESSLER, MD

Claiming All the Learning and Joy of Change: The CLAIMS Model

BY HELANE FRONEK, MD, FACP, FACPH

Physician Marketplace: Classifieds

San Diego Physician Celebrates 100 Years: April 1967 2 apri l 2013

kEArNY MESA: John G. Lane, MD, Jason P. Lujan, MD (A: Sergio R. Flores, MD) lA JOllA: Geva E. Mannor, MD, Wynnshang “Wayne” Sun, MD (A: Matt H. Hom, MD) NOrtH COuNtY: Niren Angle, MD, Douglas Fenton, MD, James H. Schultz, MD (A: Anthony H. Sacks, MD) SOutH BAY: Vimal I. Nanavati, MD, Michael H. Verdolin, MD (A: Andres Smith, MD)

at-large DireCtorS Karrar H. Ali, MD, David E.J. Bazzo, MD, Jeffrey O. Leach, MD (DELEGATION CHAIR), Mihir Y. Parikh, MD (EXECUTIVE COMMITTEE BOARD REP), Peter O. Raudaskoski, MD, Kosala Samarasinghe, MD, Suman Sinha, MD, Mark W. Sornson, MD (EXECUTIVE COMMITTEE BOARD REP) at-large alternate DireCtorS James E. Bush, MD, Theresa L. Currier, MD, Thomas V. McAfee, MD, Carl A. Powell, DO, Elaine J. Watkins, DO, Samuel H. Wood, MD, Holly Beke Yang, MD, Carol L. Young, MD other voting MeMBerS COMMuNICAtIONS CHAIr: Theodore M. Mazer, MD (CMA SPEAKER) YOuNG PHYSICIAN DIrECtOr: Van L. Cheng, MD rEtIrED PHYSICIAN DIrECtOr: Rosemarie M. Johnson, MD MEDICAl StuDENt DIrECtOr: Suraj Kedarisetty

other nonvoting MeMBerS YOuNG PHYSICIAN AltErNAtE DIrECtOr: Renjit A. Sundharadas, MD rEtIrED PHYSICIAN AltErNAtE DIrECtOr: Mitsuo Tomita, MD SDCMS FOuNDAtION PrESIDENt: Stuart A. Cohen, MD, MPH CMA PASt PrESIDENtS: James T. Hay, MD (AMA DELEGATE), Robert E. Hertzka, MD (LEGISLATIVE COMMITTEE CHAIR, AMA DELEGATE), Ralph R. Ocampo, MD CMA truStEE: Albert Ray, MD (AMA ALTERNATE DELEGATE) CMA truStEE (OtHEr): Catherine D. Moore, MD CMA SSGPF DElEGAtES: James W. Ochi, MD, Marc M. Sedwitz, MD CMA SSGPF AltErNAtE DElEGAtES: Dan I. Giurgiu MD, Ritvik Prakash Mehta, MD AMA AltErNAtE DElEGAtE: Lisa S. Miller, MD

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

/////////brieFly ///////////////////noted ////////////////////////////////////////////////////////////////////// Calendar SDCMS Seminars, Webinars & Events SDCMS.org/event

For further information or to register for any of the following SDCmS seminars, webinars, workshops, and courses, email Seminars@SDCmS.org.

Unscrambling Your Contracting Future (seminar/webinar) Apr 25 • 11:30am–1:00pm Media Training (workshop) Apr 27 • 8:00am–12:00pm

CMa Webinars CMAnet.org/events California’s Health Benefit Exchange: How It Will Impact Your Practice and Change Commercial Insurance Apr 24 • 12:15pm–1:45pm The Power of the Pen: The Physician’s Responsibility in Prescribing and Referring for Medi-Cal Patients mAY 1 • 12:15pm–1:15pm Time Management: How to Quickly Make Decisions on What Matters Most mAY 8 • 12:15pm–1:15pm Enforcement Provisions of the Medical Practice Act mAY 15 • 12:15pm–1:15pm Essentials for ICD-10-CM: Part 1 mAY 16 • 12:15pm–1:15pm Documentation and Coding Auditing: Lessons Learned mAY 22: 12:15pm–1:15pm Essentials for ICD-10-CM: Part 2 mAY 23 • 12:15pm–1:15pm Estate Planning After the Fiscal Cliff mAY 29 • 12:15pm–1:15pm

“

SdCMS Featured MeMberS! Essentials for ICD-10-CM: Part 3 mAY 30 • 12:15pm–1:15pm

Community Healthcare Calendar

To submit a community healthcare event for possible publication, email Klewis@ SDCmS.org. events should be physician-focused and should take place in or near San Diego County. Mindfulness in Clinical Practice: Our Patients Ourselves mAY 11 • All-day Cme (6.75hrs) Workshop • presented by the uCSD Center for mindfulness • cme. ucsd.edu/mindfulness/mcp_ workshop_051113_home.html CMA’s 16 Annual California Healthcare Leadership Academy mAY 31–JuN 2 • planet Hollywood, las Vegas • www. caleadershipacademy.com th

DSM 5: What You Need to Know JuN 8–9 • 8:00am–5:50pm on Saturday, 8:00am– 12:30pm on Sunday • Hyatt regency la Jolla • www. dsm5sandiego.org Create Your Own Wave: Surviving the Riptide of SB 863 JuN 20–23 • Newport beach, Calif. • (800) 692-4199 • https://csims.org SDAFP Symposium, Family Medicine Update: 2013 JuN 28–30 • paradise point Hotel, mission bay • www. sandiegoafp.org RCMA’s “Cruisin’ Thru CME” — French Waterways: Highlights of Burgundy & Provence Jul 1–13 • Call rCmA at (800) 472-6204

Congratulations to Dr. Lewis L. Judd, SDCMSCMA member since 2002, for receiving the Award for Research in Mood Disorders by the American College of Psychiatrists.

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Congratulations to Dr. Arno J. Mundt, SDCMS-CMA member since 2007, for being inaugurated as the president of the American College of Radiation Oncology.

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Congratulations to Dr. Deena Tajran, SDCMS-CMA member since 2010, for having been named “2013 Woman of the Year” by the National Association of Professional Women.

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Congratulations to Dr. Robert N. Weinreb, SDCMS-CMA member since 2005, for receiving the American Glaucoma Society Innovator Award at the American Glaucoma Society’s annual meeting on March 1, 2013.

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preCeptorS needed

University of San Diego Needs NP Student Preceptors By Rekarda Devere MEd, BSN, RN

Nurse practitioner student enrollment at USD is increasing — and with it the need for additional physicians and nurse practitioners willing to mentor them. It is only because of the healthcare providers who educate students that USD is able to prepare competent and caring future nurse practitioners. Preceptors are vital to the programs. NP students need experience in pediatrics, family practice, women’s health, internal medicine, and also may do specialty rotations like cardiology, dermatology, endocrinology, orthopedics, etc. The student completes 54–162 hours per semester (fall, spring, or summer). We are currently securing preceptors for summer semester (June 3–Aug. 23). If you would like more information about educating an NP student or would like to volunteer, please contact me at rdevere@sandiego.edu or at (619) 2604718. Thank you for your time and consideration.

”

I hate flowers — I paint them because they’re cheaper than models and they don’t move!

4 apri l 2013

— Georgia O’Keeffe (1887–1986)

/////////////////////////////////////////////////////////////////////////////////////////////////// CoMMerCial real eState tipS & trendS By Chris Ross

Lease Negotiations: Personal Guarantees One lease provision that is often taken for granted is the personal guarantee. If you are among the ± 95% of medical tenants who have personal guarantees in their leases, one thing you can do the next time you renew or relocate is negotiate a cap in the financial exposure associated with the guarantee. Even more ideal (although very difficult to negotiate) is to have the guarantee dissolve altogether after a certain period of time. This is essentially impossible with any new lease, but once you have a good track record and the landlord has made back most or all of their expenses in tenant improvements, commissions, etc. (e.g., after your initial lease term), you might give it a try. If you are relocating or opening a new location, an unconditional guarantee is going to be inevitable since medical corporations associated with private practices tend to have minimal assets. That said, if you are one of those individuals who is simply not comfortable with a personal guarantee and you do not have any luck with negotiating a cap or fixed timeframe, a letter of credit is typically a good solution. LOCs can especially be a good

way to go if you are signing the lease as part of a larger medical group, since each doctor can contribute toward the total obligation, preventing multiple physicians from having to sign unconditional guarantees. Submarket Snapshot: North County Coastal Overview The North County Coastal submarket, defined herein as Carmel Valley up to Carlsbad, comprises 1,070,000 square feet in 44 buildings, half of which were completed in the past 15 years. Of the various coastal communities, Encinitas contains the majority of the submarket’s medical buildings as it is home to Scripps Memorial Hospital, the only hospital between La Jolla and Oceanside. There is all-but-zero space

available among the MOBs of Carmel Valley, Del Mar, and Solana Beach, and very little in Carlsbad as well. There was a limited amount of leasing activity in 2012, but on the flip side we saw only a very small handful of tenants vacate space. As of Q4 2012, North County Coastal as a whole maintains the county’s lowest vacancy rate at 6.1%. This is a particularly impressive number given the fact that more than 50% of the vacant space lies between two buildings: Tri-City Health’s sublease space in Carlsbad and Garden View Professional Center in Encinitas (AutoClub building), a mixed office/medical building with parking constraints. Vacancy did tick up slightly from 5.9% in Q3, attributed to negative absorption of 2,907 square feet for the quarter. Overall, net absorption of around +2,300 square feet on the year brought vacancy down from 6.3% in Q4 2011. The average asking rate dipped slightly over the past four quarters and currently stands at $3.21 per square foot on a full-service basis (inclusive of utilities) — still the highest rate in the county. Over the past three and a half years, average rental rates have dropped by 8%. This decline is very modest compared to other submarkets, and especially considering what average rates have done in other areas of commercial real estate, such as office and industrial. Most of the reduced asking rates

have occurred among the less dynamic medical buildings. Better located Class A and B medical office space is still leasing for $3.40–4.00 per square foot. Forecast Demand in this extremely stable submarket has been consistently positive for the past eight years, with 2003 being the last recorded year to post negative net absorption. Even throughout the recession, demand was steady, although leasing activity has been limited at times due to a shortage of quality space on the market (which tends to limit activity, since physicians do not typically make “lateral moves”). Steady demand can be expected throughout 2013 and beyond as entrepreneurial and cash-based practices are returning to the market and looking to take advantage of the area’s strong demographics and continued growth. Vacancy should continue its downward trend and approach 5% over the next 12–24 months. The average rental rate will likely rebound this year and begin a steady incline by Q4. Mr. Ross is vice president of healthcare real estate services at Colliers International. He is a commercial real estate broker, specializing exclusively in medical office and healthcare facilities in San Diego County. He can be reached at (858) 677-5329 or chris.ross@colliers.com.

Construction Spotlight The 40,000-square-foot 4S Health Center in 4S Ranch (West Rancho Bernardo, just east of Carmel Valley) was completed in November of last year. It is located on the corner of Dove Canyon Road and Camino del Norte next to the 265,000-square-foot 4S Commons Town Center. The building is home to California Cancer Associates for Research and Excellence (cCARE, formerly Pacific Oncology & Hematology), Arch Health Partners, Children’s Primary Care Medical Group, Valley Radiology Women’s Imaging, and a number of dentists and dental specialists. The “green” medical building (pending LEED certification) contains environmentally conscious features such as a white roof, dual-paned reflective glass, motion-sensor lighting, and high efficiency HVAC. The new development is now 92% leased.

SaN Di EGO pHYSiCiaN.OrG 5

/////////brieFly ///////////////////noted ////////////////////////////////////////////////////////////////////// WelCoMe neW and rejoining SdCMS-CMa MeMberS! NEW MEMBERS richard Abello, mD mahlet Alula, mD maryann beko, mD Christopher bergeron, mD John bestoso, mD Kelly bethel, mD Julie bevan, mD Adam burdick, mD Jacqueline Chang, mD Shannon Chavez, mD Catherine Chen, mD Abraham Chyung, mD Walter Coyle, mD Amy Day, mD emma Du, mD Jonathan Dunn, mD Darlene elias, mD Jonathan Fisher, mD David Frankel, mD William Fuller, mD Siu Geary, mD Douglas Gibson, mD ryan Grover, mD Kristen Haring, mD Kelly Harkey, mD maryam Hekmat, mD raneth Heng, mD James Heywood, mD Todd Hitchcock, mD marian Holland, mD Harish Hosalkar, mD melissa Houser, mD phong Hu, mD Arash izadpanah, mD rachna Jafri, mD Shazia Jamil, mD Anila Jonnala, mD bruce Kahn, mD Shipra Khushu, mD Tess Klaristenfeld, mD Scott Krishel, mD Annie Kupelian, mD Jill lane, mD David leopold, mD matthew levine, mD Hai-yan li, mD James lin, mD ray lin, mD John lyons, mD Christopher marsh, mD megan mcGarvey, mD Dale mitchell, mD James modir, mD Gaston molina, mD Christine morton, mD renee Nelson, mD laura Nicholson, mD Stacy ostrow, mD 6 apri l 2013

perminder parmar, mD malhar patel, mD Nikunj patel, mD Caroline piggott, mD mauricio pons, mD matthew price, mD Joyce Qaqundah, mD matilda remba, mD John rogers, mD edward ross, mD Carl rossi, mD robert russo, mD John Saad, mD Christopher Saucedo, mD lynne Scannell, mD randolph Schaffer, mD biraj Shah, mD mark Shalauta, mD laurence Shapiro, mD Anshuman Singh, mD Ayham Skaf, mD Herman Skorobogaty, mD maida Soghikian, mD Julie Steele, mD Curtiss Stinis, mD Christopher Suhar, mD mark Takata, mD michael Tran, mD Angela Wang, mD enoch Wang, mD Kimberly Washkowiak, mD David Wetherhold, mD Adam Whitman, mD Katharine Woessner, mD mark Wuchner, mD Arnold Yashar, mD Christopher Yokoyama, mD Jeffrey Zeitung, mD REJOINING MEMBERS Joseph Andrews, mD brian barmettler, mD Faith barnett, mD Douglas bates, mD michael beaumont, mD Andrew beros, mD prakash bhatia, mD pamela boswell, Do marilyn Carlin, mD ross Christensen, mD Carrie Chun, mD Caroline Diamant, mD Stephen Dimarzo, mD emily engel, mD John Fellow, mD Catherine Frenette, mD Jan Fronek, mD edwin Fuller, mD brendan Gaylis, mD

Huan Giap, mD robert Gordon, mD David Heller, mD Allen Johnson, mD robert Kakehashi, mD michael Kan, mD Sally Kim, mD Andrew King, mD Joan Kroener, mD Kirstin lee, mD Charles liu, mD Joseph luna, mD James mcCallum, mD Jennifer Namazy, mD Shirley otis, mD Athena philis-Tsimikas, mD Jerome pierce, mD Harold pimenta, mD robert reiss, mD Xing-Jian ren, mD David rubenson, mD

ross rudolph, mD Tracy ruymann, mD robert Sablove, mD ronald Salzetti, mD mayra Sanchez, mD lawrence Schlitt, mD Farhad Shadan, mD Sanjeev Shah, mD Allan Silver, mD Hyman Silverman, mD ronald Simon, mD ben Spiegel, mD Jo Ann Stewart, mD V. Tartar, mD eric Topol, mD Christopher uchiyama, mD John Verkleeren, mD Amy Witman, mD Amy Wu, mD Karim Zablit, mD Daniel Zelac, mD

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For more information, call (855) 222-8262 or visit TRICITYMED.ORG/ORTHO SaN Di EGO pHYSiCiaN.OrG 7

SDCmS boArD oF DireCTorS eleCTioNS

Candidate Statements

2013–14 SDCmS board of Directors Notes: Asterisk (*) After Name = Incumbent Number in Parentheses (#) After Name = Term Length in Years Candidate for President-elect: J. Steven Poceta, MD (1) I plan to move from treasurer to president-elect of the San Diego County Medical Society for the upcoming year. I have been a member of SDCMS since I came to San Diego in 1987; I have served on the Board of Directors and, for the past four years, on SDCMS’ Executive Committee. I am dedicated to the pursuit of medicine, and I believe in a pluralistic approach to the practice. All physicians have a role to play in the optimal delivery of healthcare to our fellow community members. The respect that we receive from our patients is great, and not only serves to enrich our lives, but to indicate our value to the community. No specific healthcare delivery system is better than another, considering the changes that have occurred since our profession was founded. That is, the practice of medicine has survived since long before the U.S. depression of the 1930s, the creation of Medicare, the HMO, and the current trend toward consolidation. All doctors are needed — from those in academics to those in solo practice — and I support them all. The backbone of the system remains the same: doctors who study, train, and work hard to take care of people who are sick and to understand the causes of disease. We need a system that fosters the most capable young people to go into our profession, rewards them appropriately, and provides career and personal satisfaction. I believe that we can meet these goals under the changing system.

to our Medical Society. As your candidate, I am committed to addressing physicians’ concerns affected by challenges facing our local and national healthcare policy. With constant political uncertainties and government overregulation threatening the welfare of physicians’ autonomy over medical practices, it is critical for all area physicians to have a strong focus and a strong voice. Without a doubt, organizing and uniting physicians is a necessity in preserving our authority, our autonomy, and our interest concerning our practice of medicine. As your candidate, I intend to focus my priorities on protecting physician independence and preventing further waning of our professional sovereignty. Through community, professional, and political involvement, I hope to assist SDCMS in becoming an even more influential organization. More so now than ever before, we need to deliberate on increasing regulatory complexities, partake in discussions shaping social and political mandates, and curtail external constraints that continue to “deprofessionalize” a physician’s influence over the medical decision-making process. Through SDCMS, we can take the helm in determining the future of our practices — how we care for patients, how we code (prescribe treatment), and how we are reimbursed. I believe that through SDCMS we can join our services in the best interest of all physicians, regardless of their modes of practice. Thank you for supporting my candidacy for SDCMS treasurer. Together, we will navigate through these difficult economic and political tides.

Candidate for Treasurer: William T-C Tseng, MD (1) My name is William Tseng, and I am honored to be your candidate for SDCMS’s treasurer. I appreciate this opportunity to share with you my thoughts on what I strongly believe in and what I would like to contribute

Candidate for Secretary: Mihir Y. Parikh, MD (1) I ask for your support as I run for secretary of SDCMS. It is an honor and privilege to have served over the past seven years as a young physician director on the Board of Directors and as an at-large member of the

8 apri l 2013

Executive Committee. We have an amazing team of physicians and staff in place that is absolutely committed to protecting the interests of our patients and our medical practices in this profoundly uncertain time. Our best line of defense is through organized medicine. We need all physicians in all modes of practice to become members of SDCMS. With a united voice we can sway public opinion, provide quality patient care, and maintain the integrity of the medical profession. As secretary I pledge to work with other directors to advocate for the doctors of San Diego County, educate fellow colleagues about pending legislative changes, and expand our physician membership. Thank you for supporting my candidacy for SDCMS secretary.

Candidate for East County Geographic Director #1: Venu Prabaker, MD* (3) As a primary care physician practicing in East San Diego County for more than 25 years, I have experienced a dramatic paradigm shift from a fee-for-service model to a managed care model. At this juncture, we are entering the uncharted territory of healthcare reform, accountable care organizations, and patient-centered medical homes, where the interests of PCPs and the patients we care for are being undermined by economic and political forces. Now more than ever, we need strong leadership to represent us and our patients. In this regard, I have recently founded San Diego Independent ACO, the only physician-based (out of three) ACO in San Diego County. Although a great challenge, I am excited to help pave the way for my fellow physicians during this time of instability in the healthcare arena. I am confident that, with the help of the dynamic leaders that I have the pleasure of working with on the SDCMS Board, we can convert the challenge into a great opportunity. I believe that my past leadership experiences and my dedication to our community make me the ideal candidate for East County geographic director. Prior to moving to San Diego, I served as an assistant director of the internal medicine residency program at Cleveland. I have served as voluntary clinical faculty in multiple educational institutions, including UCSD, USD, Western, Stanford, etc. I have attended three mini-MBA courses (two from UCI and one from UCSD), which have taught me how to effectively assume leadership roles. I was a past president (twice) of, and actively participate in leadership roles since the inception of, the San Diego Association of Physicians of Indian Origin (SAPI), where I coordinated educational, charitable, and collaborative programs for its members. I am serving as a co-chair of the technology committee of a national organization AAPI (American Association of Physicians of Indian Origin). Currently, I am participating in

Sharp’s Physician Leadership Academy. During the past few years as alternate East County geographic director, I witnessed the amazing talents, leadership, and dedication of my colleagues, who work tirelessly on behalf of fellow San Diego County physicians. It would be my proud privilege to join this vibrant group for another term. Never before was there a critical need for us to stand steadfast, to speak in one voice, and to safeguard the interests of our patients as well as our colleagues. Organized medicine is the only armor we have to shield ourselves from the political and economic onslaught ahead. I consider the opportunity to serve our esteemed organization, SDCMS, a great honor, and I pledge to be the voice of East County physicians as their geographic director.

Candidate for Hillcrest Geographic Director #1: Gregory M. Balourdas, MD (3) It has been a distinct pleasure to serve on the Board of the San Diego County Medical Society as an alternate director over the past two years. I look forward to the transition from alternate to voting member this year. I have been a member of the Medical Society since completion of my hand and microvascular fellowship at UCSD. During those 23 years, I have had the privilege to practice hand and upper extremity orthopedics in a traditional solo practice in the Hillcrest and Mission Hills area. In the past two years, I have received a valuable postgraduate education by participating in the CMA House of Delegates and a legislative trip to Sacramento. Despite disturbing trends in the practice of medicine, I believe our best chance to effect positive change for our profession is to unite on common ground and to advocate through these available avenues. I will endeavor to effectively represent all the physicians in my geographic community as well as the perspective of solo and small-group practitioners and my orthopedic colleagues. Thank you for this opportunity.

Candidate for Hillcrest Geographic Director #2: Thomas C. Lian, MD* (3)

Candidate for North County Geographic Director #2: Eileen S. Natuzzi, MD, MS, FACS (3) Eileen Natuzzi, MD, MS, FACS, is a private practice surgeon who is currently pursuing a masters in public health and health policy. She has been practicing in North County since 1997 as a member of the Coastal Surgeons Group. In addition to her practice in North County, Dr. Natuzzi has

provided surgical care for uninsured and disenfranchised members of our San Diego community through Project Access and the UCSD Student Run Free Clinic. Her goal in merging public health education with surgery is to forge mechanisms allowing San Diegans access to timely specialty care while encouraging all of San Diego’s physicians, including surgeons, to actively participate in preventive care measures in order to reduce preventable diseases. Changes in access to healthcare as well as reimbursement have been dramatic over the past two years, and, with even more shifts on the horizon, the need to be vigilant and keep physicians informed while representing them will be increasingly important. This is especially true for private practice physicians. Dr. Natuzzi also oversees an international continuing medical education program that provides in-country skills transfer training to nurses, doctors, and surgeons working on Guadalcanal in the Solomon Islands. While she has experience in working with many federal and international agencies on the development of sustainable health delivery programs in developing countries, she admits she has less experience with local healthcare politics. “The lessons I have learned working in resource-limited countries can be applied to our own community, with the greatest being the creation of a happy and productive workforce. Protecting the stability of physician practices while striving to provide access to quality, affordable care for all San Diegans has never been more important. Reducing redundancy in our local healthcare system, incentivizing care for our underinsured, and creating a medical community that possesses common goals will go a long way in protecting our own healthcare resources.”

for the quality of care and the safety of our patients.

Candidate for North County Geographic Director #2: Michael A. Lobatz, MD (3) I have been in the private practice of neurology for the past 32 years in North San Diego County. As such, I have had the opportunity and privilege of working with many outstanding physicians at multiple hospitals. Working in an environment of both private practice and managed care as well as in medical staff and hospital leadership positions, I have gained a deep and operational understanding of the critical issues facing physicians and hospitals today. Our sacred desire to provide excellent patient care alongside the challenges presented by healthcare reform define our current time. These challenges represent a sea change in the practice of medicine as we know it and present risks and opportunities for our profession. If elected, I will serve with drive and determination, and bring to bear all of my experience to represent physicians and advocate

Candidate for At-large Director #3: Kosala Samarasinghe, MD* (3)

Candidate for South Bay Geographic Director #1: Irineo D. Tiangco, MD (3)

Candidate for Hillcrest Geographic Alternate Director: Sunny R. Richley, MD (2)

Candidate for Kearny Mesa Geographic Alternate Director: Anthony E. Magit, MD* (3) I appreciate the opportunity to continue my service on the SDCMS Board of Directors. Maintaining access to healthcare for our region’s children is a primary focus of my practice and advocacy activities. My appreciation for the challenges facing medicine locally and nationally comes from practicing pediatric otolaryngology for more than 20 years in San Diego and interacting with all of the health systems in our region, as well as participating in the development of clinical guidelines through national pediatric and specialty organizations. The leadership provided by SDCMS is central to medical practice continuing to thrive in San Diego.

Candidate for La Jolla Geographic Alternate Director: Lawrence Goldberg, MD (1)

Candidate for At-large Director #5: Mark W. Sornson, MD* (3) It has been my privilege to serve as at-large director for the past three years, one year as a representative on the Executive Committee, and five times as a CMA delegate or alternate delegate representing San Diego. Previously, I chaired the CMA Young Physicians Section and authored a successful resolution. Taking part in the Board, Executive Committee, and Legislative Committee has reinforced my conviction that when a medical society speaks with a unified voice and builds relationships, we can make a difference. With healthcare reform on the national and state agendas, decisions made today on our key issues will greatly affect our futures. As a Board SaN Di EGO pHYSiCiaN.OrG 9

member, I will continue to be a voice for reasoned discussion, representing all physicians. I’ve greatly enjoyed my service on behalf of SDCMS and CMA, and I am honored to ask for your vote to continue my service as a member of the Board.

Candidate for At-large Director #7: Vimal I. Nanavati, MD, FACC, FSCAI (2) My name is Vimal I. Nanavati, MD. I work in the South Bay as an interventional cardiologist. I’ve been honored to represent the South Bay for the past six years as the South Bay director of SDCMS. I’m now running for the at-large director for SDCMS. In my six-year tenure at SDCMS, I’ve had the privilege to author and pass several resolutions to advocate for patients. In 2009, I authored a resolution to mandate HMOs to allow patients to complete critical work-ups and procedures already planned prior to their switch so as to allow for continuity of care and prevent fatal cardiac events. In 2012, I authored a resolution mandating mobile imaging companies to contact the primary MD of any and all abnormalities found on imaging tests so as to prevent any delay in treatment based on the abnormalities. Both of these resolutions passed the general California Medical Association House of Delegates and are being considered for legislation at the state level. The medical environment, now more than ever, presents direct challenges to the doctor-patient relationship. It is therefore imperative for physicians to be even more vigilant to protect their patients and their fellow physicians. When a patient requires medical attention, it is often lost to the public that of all the healthcare personnel he/she may encounter during the course of treatment, only the physician answers only to the patient. It is the physician who, by the Hippocratic oath, is required to look after the welfare of the patient and nothing else. With all the new regulations being imposed upon physicians from the Affordable Care Act, EMR mandates, threats to the corporate bar to the practice of medicine, and the ever-present threats to MICRA, we are at a critical crossroads. In these very turbulent times in medical environment, it becomes imperative for us to be even more vigilant and stand together boldly for the patients’ interests and the interests of the only real advocates of patients without a potential conflict: physicians. In this mission, I ask you to join me in this fight. I ask for your support. Thank you for your attention.

Candidate for At-large Alternate Director #1: Karl E. Steinberg, MD (3) I’m a family physician, geriatrician, and hospice physician who has worked for Scripps 10 apri l 2013

Coastal and its corporate predecessors in North County continuously since 1992. My passions are providing compassionate care to the frail elderly and others with serious or chronic illnesses, and helping to educate patients and healthcare providers about palliative care. In addition to patient care, I am editor-in-chief of a periodical called Caring for the Ages, published by Elsevier and AMDA (the American Medical Directors Association), and vice chair of AMDA’s public policy committee. I am vice president of the Compassionate Care Coalition of California (the people who brought you POLST), and a past president of CALTCM (the California Association of Long Term Care Medicine); I also currently serve on the government relations committee of CAHF (the California Association of Health Facilities). I provide long-term care consulting and medico-legal services, and I’m medical director of two North County skilled nursing facilities (Life Care Center of Vista and Kindred Village Square). I’ve been affiliated with Hospice by the Sea since 1995 and CareMinders Home Health since 2012. I am volunteer faculty for UCSD and Camp Pendleton’s family medicine residency programs, and serve as adjunct faculty for Case Western Reserve University’s Graduate School of Biomedical Engineering. At SDCMS, I’ve been on the Bioethics Commission for the past four years, and have been active on the POLST Coalition and TDC’s Physician Advisory Board. In my spare time, I take my dogs to the nursing homes with me, and play tennis and guitar marginally. My experience has given me a broad exposure to multiple sectors within the healthcare arena, not just locally but statewide and nationally as well. I believe we have a long way to go in getting incentives aligned to optimize care (for example, taking care of ill nursing home residents in the nursing home instead of shipping them to the hospital), increasing awareness of palliative care and advance care planning, and helping our patients get the care they want (and not get the care they don’t want). By participating in the political process, I hope I can help move things along — with the assistance of many other committed individuals within SDCMS and other involved organizations. Thanks for considering allowing me to participate in this arena.

Candidate for At-large Alternate Director #2: Perry N. Willette, MD (3) Remember those first few days of medical school, when one of the venerable and wise senior physicians stood at the front of the great lecture hall and, with a stern face, told us that 50% of what we were about to learn was right and 50% was wrong? We just didn’t know which half was right. Why didn’t they tell us about all the changes we would be

facing with the business and legal aspects of medicine? Maybe they didn’t know! I love that medicine is a science and an art, and that we “practice” this honorable profession through continuous learning and continuous improvement. But why do we have to struggle through the morass of frequent changes to the healthcare system? HMOs … PPOs … ACOs … PPACA … MICRA … CMS … MU … EMRs. So many acronyms … OMG! After spending 28 years in the Navy (where we have tons of acronyms), and now nearly five years as a “plain ole family doc,” I believe it is time for me to get involved in the important business of our profession. I have many concerns that I personally want to pursue with SDCMS, including proper implementation and support of electronic medical records, improved understanding and implementation of meaningful use, fostering and standardizing health information exchange, and promoting proper reimbursement for all the work we perform in the context of the new Affordable Care Act. But I also know that as a candidate for the alternate at-large director position, it is important to recognize that I will represent your concerns, voice your apprehensions, advocate for your causes and for your best interest. It would be a great honor and a privilege for me to fill this very important position. I would greatly appreciate your vote, and the chance to make a difference.

Candidate for At-large Alternate Director #4: Piyush (Phil) Kumar, MD (3) It is no secret that over the years, politics has and continues to become a bigger part of medicine than perhaps medicine itself. There are many reasons for this, not the least being a financially strapped and large government trying to pay for an increasing and older population — this too, in the setting of rising technology costs and often bureaucratic burden in healthcare. It is therefore important that we as physicians think and proactively come up with solutions for providing the optimal healthcare to our population with the goal being to attain the best health for each person. We need to work collectively as a single voice and interact as a single voice with policymakers to effect positive change. The greater the involvement by physicians, the higher the likelihood of our meeting our goals. Having been in the practice of medicine, and specifically GI, for more than 22 years, I find myself drawn to effect some change by means other than by only affecting patient lives, one at a time.

Election Opens april 10 and Closes May 7

Candidate for At-large Alternate Director #6: Elaine J. Watkins, DO, MSPH* (3) I am a board-certified internist (ABIM), and I also hold a master’s degree in public health and nutrition. I went to medical school at the Philadelphia College of Osteopathic Medicine and did my internship at Presbyterian Hospital of the University of Pennsylvania. I completed my residency at Lankenau Hospital, an affiliate of Thomas Jefferson University. My master’s degree was obtained at Columbia University. I am currently associate medical director for Profil Institute for Clinical Research. I would be honored to continue my second term on the Board of Directors. As a board-certified internist for 20 years, I have a multitude of experiences, and I have seen many changes in medicine over the years. We are all committed to practicing good medicine no matter what the environment; however, the evolution of healthcare needs organizations such as the San Diego County Medical Society to advocate for the protection of the practice of medicine and the delivery of that care to patients. These are challenging times in medicine, and I am proud to be part of such an important organization as the San Diego County Medical Society. I would consider it a privilege to continue as one of its leaders on the Board of Directors.

Candidate for Young Physician: Edwin S. Chen, MD (1) Healthy and happy physicians take better care of healthy and happy patients. In the dramatically changing healthcare landscape, SDCMS provides a meeting place and a launching platform from which we can advocate for ourselves and our patients. New physicians often find themselves immersed in a healthcare world they never imagined. As a young physician who recently started a solo practice, I look forward to collaborating with

my fellow physicians in sharing our knowledge and experience so that we can better advocate for the medical community and the patients whom we serve.

Candidate for Young Physician Alternate: Renjit A. Sundharadas, MD* (1)

Candidate for Resident Physician: Jane Bugea, MD* (1) As a USCD pediatric resident, I am the current SDCMS resident director and am running for reelection. I have been involved with SDCMS for over four years since I attended UCSD’s School of Medicine and became involved in politics my first year there. I was introduced to SDCMS through a medical politics course and became the SDCMS medical student director. During this time, I have had the opportunity to learn about and advocate for many issues facing San Diego patients and physicians. I brought many speakers and a regional AMA meeting to the medical school to further awareness of these issues with my fellow students. I hope to continue working with SDCMS in its efforts to protect physicians and patients, as well as continuing to learn more about medical politics and ways I can contribute to San Diego’s and California’s healthcare system. I also plan to expand SDCMS’ presence within the resident community, and residents’ knowledge of medical politics issues. Being a part of SDCMS has been an amazing opportunity, and I ask for your vote to continue as the SDCMS resident director.

Candidate for Resident Physician Alternate: Erin Whitaker, MD* (1) It has been a pleasure to be a part of SDCMS this past year, and to serve as a resident on the county Board of Directors. Involvement in organized medicine has been, for me, the most important way to ensure that we as physicians can continue to provide the best care for our patients. As a medical student, I was privileged to serve as a delegate to AMA for two years, and, during my senior year, to sit on the AMA Council on Medical Service. In that capacity I was able to be a part of a group that was developing and implementing new and innovative strategies to allow physicians to be ahead of the wave. The next decade will reveal a new landscape in the medical field. While there are many challenges in the implementation of the Affordable Care Act, I feel very strongly that there is room for optimism for the practice of medicine. It would be a privilege to serve on the Board of Directors at this exciting and important time.

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hipaa privacy and Security major Changes Ahead by David Ginsberg SdCMS phySiCianS should be aware of major changes to HIPAA Privacy and Security compliance that have been finalized and released in a rule published on Jan. 25, 2013. These changes formally go into effect on March 26, 2013, with compliance required by Sept. 23, 2013. Many of the changes are a result of the 2009 American Reinvestment and Recovery Act/HITECH Act, which provided for increased use of electronic health records and exchange of patient data to improve patient safety, healthcare quality, and access, and to reduce inefficiencies. Most physicians are aware of the incentive payments under the HITECH Act for achieving meaningful use. Recognizing that increased adoption of EHRs also increases threats to the privacy and security of patient information, HITECH also included additional compliance requirements under HIPAA. A few (and only a few) of the major changes that affect HIPAA compliance include: • Breach Notification Requirements: The obligation to notify patients if there is a breach of their PHI is expanded and clarified under the new rules. Breaches are now presumed reportable unless, after completing a risk analysis applying the following four factors, it is determined that there is a “low probability of PHI compromise.” The four factors to be considered include: 1. The nature and extent of the PHI involved. Issues to be considered include the sensitivity of the information from a financial or clinical perspective and the likelihood the information can be re-identified. 12 apri l 2013

2. The person who obtained the unauthorized access and whether that person has an independent obligation to protect the confidentiality of the information. 3. Whether the PHI was actually acquired or accessed, determined after conducting a forensic analysis. 4. The extent to which the risk has been mitigated, such as by obtaining a signed confidentiality agreement from the recipient. The four factors replace the previous determination of “significant risk of financial, reputational, or other harm” analysis for establishing a breach. The new rules do not modify the actual reporting and timeframe requirements for breach notification, i.e., covered entities must still adhere to requirements for individual notification, HHS notification, and, where applicable, media posting of the breach. We encourage all physician practices to update their breach notification procedures, since we often find these lacking during our HIPAA reviews! • Disclosures to Health Plans: At the patient’s request, physicians may not disclose information about care the patient has paid for out-of-pocket to

health plans, unless for treatment purposes or in the rare event the disclosure is required by law. Previously, physicians could refuse a request for restrictions on use and disclosure of PHI. The new law requires restrictions when the patient has paid out-of-pocket and requests the restriction (to a health plan). This change is likely to have the greatest impact on your practice workflow in terms of documentation, follow-up to ensure the restriction is adhered to, and how you will handle the payment. • Childhood Immunizations: Under the new rules, physicians may disclose immunizations to schools required to obtain proof of immunization prior to admitting the student so long as the physicians have and document the patient’s or patient’s legal representative’s “informal agreement” to the disclosure. • Decedents: The new rules allow physicians to make disclosures to the deceased’s family and friends under essentially the same circumstances such disclosures were permitted when the patient was alive — for example, when these individuals were involved in providing care or payment for care and the physician is unaware of any expressed preference to the contrary. The new rule also eliminates any HIPAA protection for PHI 50 years after a patient’s death. • Copies of ePHI: Physicians will now have only 30 days to respond to a patient’s written request for his or her PHI with one 30-day extension (compared to the current allowance under HIPAA of one 60-day extension), regardless of where the records are kept. They must provide access to EHR records in the electronic form and format requested by the individual if the records are “readily reproducible” in that format. Otherwise, they must provide the records in another mutually agreeable electronic format. Hard copies are permitted only when the individual rejects all readily reproducible electronic formats. Physicians must also consider transmission security, and may send PHI in unencrypted emails only if the requesting individual is advised of

SdCMS Members: Watch SDCMS’ “HIPAA Omnibus Rule” webinar, recorded on April 17 — visit www.SDCMS.org/webinars.

the risk and still requests that form of transmission. This only applies to a copy request, and not general communication and correspondence with a patient. Physicians are cautioned to continue to prohibit emailing PHI for other purposes unless a secure email system is used, or a patient portal! • Charging for Copies of ePHI or PHI: The new rule limits the costs that may be charged to the individual for copy requests to labor costs and supply costs if the patient requests a paper copy, or, if electronic, the cost of any portable media (such as a USB memory stick or a CD). • Notice of Privacy Practices (NPP): Physicians will need to amend their NPPs to reflect many of the changes. Most physicians have not amended their NPP since the initiation of the Privacy Rule, so this is an excellent time to update the NPP. SDCMS members who use the CMA/PrivaPlan HIPAA Compliance Toolkit will receive an updated NPP template in English and Spanish over the next month or so. • Business Associates (BAs): The new rules expand the universe of individuals and companies that must be treated as business associates, such as health information organizations, e-prescribing gateways or health information exchanges that transmit and maintain PHI, and personal health record vendors physicians sponsor for their patients (such as those offered through an EHR). Thus, physicians must review their relationships and determine if they must enter new BA agreements with these entities or others that create, receive, store, maintain, or transmit PHI on their behalf. These rules also modify the requirements for BA agreements, including: > Physicians no longer must report failures of their BAs to the government when termination of the agreement is not feasible, as HHS has concluded that the BA’s direct liability for these violations is sufficient. > BAs are now responsible for their subcontractors. > BAs must comply with the Security and Breach Notification Rules. > Physicians are liable for the actions of their BAs who are agents, but not for the actions of those BAs that are independent contractors. Mr. Ginsberg is president of PrivaPlan Associates, Inc., and long-term HIPAA adviser to SDCMS. Many SDCMS members use the CMA/PrivaPlan HIPAA Toolkit for their HIPAA compliance.

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poeTrY AND meDiCiNe

What you do becomes you introduction

by Daniel J. Bressler, MD the doWnloading of a brain onto silicon is a popular theme in writings about the future. When thinking about this Frankensteinian possibility, I often return to the writings of neurologist Antonio Damasio. In a number of books, starting with Descartes’ Error, Damasio dismisses the concept that a brain can be recapitulated by a sufficiently powerful computer. His perspective, as I understand it, is that a brain (and so too a mind) emerges from a continuous stream of unrepeatable experiences of a lived life that takes place in a physical body. These sensory and visceral experiences then weave into an inherited neural template a set of layer-by-layer, synapse-by-synapse changes that result in a unique entity that he calls the “embodied brain.” In ordinary non-neuroanatomic experience, we would simply know it as the emerging self-conscious self. Embryology and prenatal medicine teach us that there are periods when the fetus is particularly vulnerable to infections, toxins, and maternal stressors. So, too, childhood is not a flat track marked by bland chronologic milestones, but full of rises and falls, times of rapid and slow growth, of hardiness and weakness, of profound and lasting influences, and obviously variable outcomes. We typically think of adulthood as a time of volition, of choice, of decision. Choice is a crucial feature of the modern doctorpatient relationship; we don’t actually give patients orders, but rather advise them about tests and therapies. They choose. Volition is at the core of the bioethical principle of autonomy. It is the underlying legal assumption that calls for informed consent before a medical procedure. An adult human life, as lived, consists of a countless number of choices. Whether we call these choices “free” is a philosophical and neuroscientific conundrum. That 14 apri l 2013

we “make” choices, however, seems to be obvious. We are all at a particular place in life substantially due to the choices we have made throughout adulthood. To use a very practiced metaphor, we take the dealt cards of genetics, embryology, childhood circumstances, and random events, and use our lives to play those cards. Yes, there’s the luck of the draw. Yes, there’s the load of the deck. And yes, yes, there’s our play. Someday there may be a technology to determine which aspects of human behavior are freely chosen and which are determined. Such a technology will have great importance for social policy, particularly in education and the judicial system. But, for an individual considering his own lived life, it seems most empowering and catalytic to focus attention on the personal behaviors that feel free. I believe that this is where we are most ourselves, where we are most fully human. I have tried to celebrate this type of freedom in the poem at right, emphasizing that our whole lives, like Damasio’s brains, are emergent and cumulative: moment by moment, day by day, action by action, choice by choice. The double meaning of the word “becomes” (suits and also develops into) is intentional. I hope the poem speaks to you. Dr. Bressler, SDCMS-CMA member since 1988, is chair of the Biomedical Ethics Committee at Scripps Mercy Hospital and longtime contributing writer to San Diego Physician.

What you do becomes you It starts with how you take a breath Do you let life rouse or numb you? It ends with how you face your death What you do becomes you. A verdant forest burned to black. Does the headline’s bleakness bum you? You search for signs when off the track What you do becomes you. Can you keep a steady pace When what you love is taken from you? You wear your life upon your face What you do becomes you. The road bends, do you turn the wheel? The broken tarmac jolts and thrums you With every mile and every meal What you do becomes you. Change arrives in fits and starts Can you dance with the soundtrack’s hum? You Grow your day from bits and parts What you do becomes you. Parent, teacher, lover, friend Tries to know, assess, and sum you Is your heart concealed until the end? What you do becomes you. When all is lost and all is won When the day of judgment comes, you Look back on the race you’ve run What you’ve done’s become you.

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Claiming all the learning and joy of Change The ClAimS model

by Helane Fronek, MD, FACP, FACPh

phySiCianS are achievement-oriented. We strive, we accomplish, and then we strive for something else. In fact, between the striving and the accomplishing, there is much for us to investigate, acknowledge, and appreciate. The CLAIMS model of change, developed by Virginia Kellogg, MCC, describes several phases involved in change and provides a structure for us to benefit from the process as we pass through it. Completion: As we or our circumstances change, we may notice we’re not as happy with some aspect of our life, and may feel that our life no longer fits us. There is a need for change, yet we often hold on to “the way things are.” Admitting that a change is needed takes tremendous courage and self-compassion. By acknowledging the good of what we are completing and accepting why it no longer fits us, we can let go and make room for what is new and needed to enter. 16 apri l 2013

Listening and Longing: What are we now longing for? As experts at delayed gratification, many of us learned to turn down the volume on our wanting. We may set our sights low or simply accept what life brings so we don’t become disappointed. As we begin to contemplate change, we can listen to our deeper voice telling us what we actually long for. For example, if you are considering a new practice situation, what is your longing for? Recognition? Leadership? Camaraderie? Flexibility? What more are you wanting? Answering the Call: When you give in to that longing and begin to move toward your new project/phase/life, you are answering the call. You may not know exactly what you are moving toward yet, but you are following your instinct to change. Incubation and Investigation: Knowing what you are longing for, you begin to delve into the possibilities. What will

satisfy my longing? What more is possible? It can be difficult to remain here, as our habit is to dive into action. But give yourself more time — it is in this phase that our original impulse is often expanded, refined, and transformed into something even more thrilling. Movement: Now you throw yourself into action, creating the new project or pursuing the new venture. This is the stage that most of us are familiar with, during which we are “accomplishing.” The speed at which movement occurs often seems magical — can change really happen this quickly? Can we really have something that big? Satisfaction and Savoring: We now take time to really appreciate what we have accomplished or become. We recognize the effort and authenticity that we brought to the process. If we fell short of our goal, we notice what we learned. It is a place where we truly feel our impact in the world. We experience the satisfaction of honoring whatever value inspired us to make this change, and we savor both the accomplishment and the more fulfilling life we are consciously living. Dr. Fronek, SDCMS-CMA member since 2010, is a certified physician development coach, certified professional co-active coach, and assistant clinical professor of medicine at the UC San Diego School of Medicine. You can read her blog at helanefronekmd.wordpress.com.

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Prescription

DRUG RUG ABUSE A Call to Action for All San Diego Healthcare Prescribers By Roneet Lev, MD

PRESCRIPTION DRUG ABUSE has been declared a national epidemic by the Centers for Disease Control and Prevention, and we in San Diego are making a stand to bring solutions to our community. As youâ&#x20AC;&#x2122;ve probably read, prescriptiondrug-related overdose deaths have outpaced motor vehicle crashes, suicides, and homicides as the leading cause of unintentional death. In San Diego County in 2011, there were nearly 500 unintentional deaths involving alcohol, street drugs, and prescription medications, up 80% since 2000. More than 56% of those nearly 500 deaths were from prescriptions drugs. San Diego established a Prescription Drug Abuse Task Force (PDA TF) in 2008 with support from the County Board of Supervisors and a collaboration of law en-

forcement, education, addiction treatment, and public health. The PDA TF publishes a Prescription Drug Abuse Report Card and organizes take-back of unused controlled medications. This year the Task Force added the medical community as an important link in fighting prescription drug abuse and addiction. What does this mean for doctors? We are often caught between the requirement to treat pain, the responsibility to avoid addiction, and the risks of accidental death and morbidity. Chronic pain patients can be a difficult population, and physicians need the tools and education to appropriately balance the risks and benefits of prescribing pain medications. Under the umbrella of the San Diego County Medical Society, a new PrescripContinued on page 19

18 apri l 2013

san diego county medical society

2012 AnnuAl RepoRt official publication of the san diego county medical society January 2012

Reaching

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Politics

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16 SDCMS’ Bioethics Commission 18 The Surrogate Who Demands ‘Everything Be Done’ 22 Informed Consent and Patient Autonomy 24 A Test of Autonomy 26 Global Health Ethics 30 The Integration Model Trifecta

celebrates physician volunteerism.

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Our Obesity epidemic

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• Who Is GerM? • antimicrobial resistance • adult Immunization • Infection Prevention / Legislation / regulation • antimicrobial stewardship • Hantavirus Pulmonary syndrome

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stopping medi-cal cuts A CMA-led coalition, spending more than $1 million in legal fees, convinced a federal judge to block the 10% Medi-Cal reimbursement rate reduction in early 2012. When overturned, CMA requested a rehearing before the full Ninth Circuit Court of Appeals.

david Knetzer SDCMS celebrated the life of David Knetzer — SDCMS executive director from 1979 to 2001 — in our January 2013 magazine. David passed away in May of 2012.

stopping medicare cuts Due in no small part to CMA’s continued advocacy in Washington, DC, physicians providing care to Medicare patients avoided, once again, a 27.4% cut to reimbursement rates at the beginning of 2012. Fighting to Fix the unfair designation of san diego as a Rural county Legislative advocacy twice got us to within hours of repealing GPCI in 2012: once in February and again in December. The 2007 class-action lawsuit for $3.2 billion in retroactive compensation and prospective GPCI relief brought by three physicians — including one SDCMS physician — and seven California counties — including San Diego — against the Department of Health and Human Services continues to make its way through the courts.

SDCMS-CMA advocacy assured CMS would reject California’s request to impose mandatory copayments for Medi-Cal patients — copayments physicians would never have collected! In Douglas v. Independent Living Center of Southern California, CMA established a physician’s right to use the courts to enforce federal laws, thereby protecting safetynet providers from arbitrary cuts and potential retroactive recoupments. This precedent will now come into play in other actions regarding state and federal payment rules and access-to-care issues.

After DHCS repeatedly denied CMA’s requests for information on proposed MediCal cuts, CMA filed a lawsuit and the judge ruled that DHCS violated the California Public Records Act. mitigating the negative impact of the dualeligibles transition SDCMS and CMA limited the negative impact of the dualeligible demonstration project in San Diego by informing and educating physicians as to how to protect themselves and their patients in the transition.

scope of Practice CMA stopped physical therapists from treating patients directly without first seeing a physician by killing SB 924.

Fighting for Healthy Families CMA fought to prevent the elimination of Healthy Families, and, when further efforts failed, CMA came to within hours of getting the monies restored at the end of the legislative session.

continuing to Protect micRa In the last days of the legislative session, a move by trial lawyers to undermine MICRA was crushed by SDCMS’s and CMA’s shortterm advocacy and long-term pro-MICRA relationships with legislators. CMA killed AB 1062 and SB 558 and thereby stopped the elder abuse law from being used to get around the MICRA cap and plaintiff attorney fee limits. CMA ensured economic damage awards did not dramatically increase in all personal injury cases by killing SB 1528, a back-door attack on MICRA. In July, CMA and others filed an amicus curiae brief to support the constitutionality of the MICRA cap on noneconomic damages in Hughes v. Pham. CMA successfully litigated a MICRA case, resulting in a published decision upholding the constitutionality of MICRA’s $250,000 noneconomic damages cap and a rejection of the argument that MICRA infringes on the right to a jury trial because the noneconomic damages cap is not indexed for inflation.

CMA ensured penalties for illegally owning and operating a medical spa were increased by supporting AB 1548. CMA established that a physician could include a six-month — or longer — supervised experience requirement in the standardized protocol between physicians and advanced practice registered nurses.

Workers’ compensation Eleventh-hour intervention by CMA kept what was a “done deal” between labor and business from being harmful to the large majority of doctors who do work-comp. maintaining the Bar to the corporate Practice of medicine CMA stopped rural hospitals from employing physicians by killing AB 824. Protecting Hospital medical staff independence CMA assured medical staff independence and selfgovernance in El-Attar v. Hollywood Presbyterian Medical Center. CMA supported a Modesto nephrologist’s whistleblower suit. CMA released its new Model Medical Staff Bylaws in March.

cultivating strong state and Federal legislator Relations SDCMS physician leaders, medical students, and staff traveled to Sacramento and Washington, DC, on multiple occasions in 2012 to build and maintain strong, personal relationships with our state and federal legislators. Physician Wellbeing SDCMS and the SDCMS Foundation helped wellbeing committees learn from each other by hosting the first California Public Protection and Physician Health (CPPPH) regional networking meeting. CMA joined a large coalition of healthcare providers to create a physician health program through SB 1483. Gov. Brown signed a bill to allow reasonable peer review sharing agreements between peer review bodies, while maintaining confidentiality and protecting the public health. monitoring san diego’s Physician Workforce SDCMS published the fifth of its biannual workforce and compensation studies, documenting trends for San Diego physicians. With AB 589, CMA established a program to provide scholarships to medical students who agree to practice in one of California’s medically underserved areas upon completion of residency. CMA’s AB 1533 to increase the number of licensed physicians who can practice in the state was signed into law.

Healthcare Reform: informing Physicians SDCMS helped physicians explain to their patients the changes that will be brought about by the implementation of the Affordable Care Act (ACA). SDCMS physicians participated in a debate titled “Obamacare (PPACA) Is Harmful to Physicians and Patients,” with KPBS anchor Tom Fudge as moderator. SDCMS conducted an informational webinar to keep member physicians abreast of the impact of the June Supreme Court ruling. Healthcare Reform: influencing implementation On June 28, The San Diego Union-Tribune published an op-ed by James T. Hay, MD, CMA president and SDCMS past president, titled “Health care ruling: Requiring insurance coverage won’t fix everything.”

SDCMS Physician Workforce and Compensation Survey

2011 BY TOM GEHRING, CEO, SDCMS

20 SAN DI EGO PHYSICIAN .ORG J U LY 2012

Most San Diego media outlets turned to SDCMS for comment on the Supreme Court’s ACA decision: • The San Diego Union-Tribune • The North County Times • KUSI Channel 9/51 • KPBS Radio • KFMB-TV Channel 8 • Univision • KGTV Channel 10 • Fox 5 CMA demanded CMS’ proposed ACA rule requiring physicians to report and return Medicare and Medicaid overpayments be consistent with its other overpayment initiatives that provide for a three-year look-back period. With AB 1453 and SB 951, CMA prompted the establishment of a set of essential health benefits that insurers and health plans in California’s Health Benefit Exchange will be required to cover. CMA secured the prohibition of deceptive marketing by outlawing “copycats” from representing themselves as part of the California Health Benefit Exchange with AB 1761. CMA and SDCMS are deeply involved in molding the California Health Insurance Exchange so that, in 2014, it does not become the monopoly that depresses all reimbursements to Medi-Cal rates for all.

sdcms and cma Physician leaders

SDCMS member and past president James T. Hay, MD, served as president of CMA in 2012 (January UnionTribune: “Encinitas Doctor Heads California Medical Association”).

 SDCMS member Theodore M. Mazer, MD, was elected vice speaker of CMA’s House of Delegates. CMA member Richard Pan, MD, was named chair of the California Assembly Health Committee. CMA member Sharon Levine, MD, was elected president of the Medical Board of California. The vast majority of candidates backed by CMA’s political action committee, CALPAC, emerged victorious from their contests in November 2012. CALPAC-backed CMA members Raul Ruiz, MD, and Ami Bera, MD, were elected to the U.S. House of Representatives, unseating powerful and well-financed incumbents. SDCMS member Lawrence Friedman, MD, was named to California’s Telemedicine Board.

2012 2012 AnnuAl RepoRt

supporting Public Health initiatives With AB 2109, CMA ensured that any parent or guardian seeking a personal belief exemption for their child would need to obtain a licensed healthcare practitioner’s signature. With AB 1967, CMA guaranteed information on organ and tissue donation will be taught in school health and science classes statewide. SDCMS’s Emergency Medicine Oversight Commission (EMOC) is reducing prescription pain abuse in the ER.

CMA and its foundation supported myriad public health campaigns — cervical cancer, obesity, chronic obstructive pulmonary disorder, and more — fostering a healthier California. CMA endorsed Proposition 29 to dedicate new funds to cancer research and smoking cessation efforts. SDCMS worked with the County of San Diego to promote Live Well, San Diego! • influenza vaccine for healthcare personnel • influenza surveillance • pertussis epidemic survey • Hepatitis Free San Diego Project • and more. SDCMS educated physicians on emergent health issues throughout the year: MRSA • whooping cough • fake cancer drugs • salmonella outbreak • influenza A H3N2v • atypical hand, foot, and mouth disease • hepatitis A • flesh-eating bacteria • fungal meningitis • prescription drug abuse • thrombotic thrombocytopenic purpura • meningococcal disease. SDCMS was heavily involved in San Diego County obesity initiatives in 2012, making a difference in the health of our communities.

Policing the Health Plans CMA stopped physicians from having to inform enrollees in writing prior to providing out-of-network services by killing SB 1373!

Bringing the next generation into organized medicine Our excellent relations with UCSD resulted in almost 800 residents’ becoming SDCMS members! SDCMS held its annual “Preparing to Practice” workshop in April.

We signed up 100+ new UC San Diego medical students as members. SDCMS President-elect Robert Peters, MD, PhD, led UC San Diego’s Commencement Ceremony. SDCMS President Sherry Franklin, MD, led the procession of UC San Diego’s White Coat Ceremony. SDCMS sent medical students to Sacramento twice in 2012 to meet with our San Diego County legislators.

CMA halted insurance companies from further squeezing dollars out of healthcare delivery by killing AB 52.

CMA sued Aetna over its practice of terminating doctors the company claimed had breached contract.

CMA published a guide for physicians terminated by Aetna for out-of-network referrals. CMA obliged Aetna to eliminate its dual certification requirement for dermatologists and dermatopathologists. SDCMS assisted members when Aetna issued inappropriate refund requests to approximately 1,000 local physicians. CMA compelled Anthem Blue Cross to “cease-and-desist” for violating California’s unfair payment practices law. CMA forced Anthem Blue Cross to pay doctors money owed to them, with interest, for services provided to 2007. CMA fought a legislative struggle with Blue Cross and Blue Shield over criteria to consider before signing a payer contract. CMA addressed physician complaints regarding Blue Cross and Blue Shield’s refusal to honor assignment of benefits by sponsoring AB 1742. SDCMS-CMA helped physicians evaluate and negotiate complex managed care contracts. SDCMS-CMA assisted several physician practices that received refund requests from Blue Cross. CMA provided an objective analysis of the Blue Shield of California Independent Physician and Provider Agreement.

monitoring and affecting Regulations CMA killed a state regulation that would have legitimized “discount health plan” referral services. CMA published a complete summary of the Medicare / Medicaid EHR Incentive Program Stage 2 Rule. CMA’s input guided changes in the Physician Quality Reporting System, the valuebased payment modifier, the Physician Compare program, the Physician Feedback program, electronic prescribing, and the new care coordination fees. CMA strongly opposed the proposal to reimburse certified registered nurse anesthetists for chronic pain management. CMA urged the EPA to adopt the stronger “National Ambient Air Quality Standards for Particulate Matter” standards.

addressing growing audit Burdens SDCMS and CMA acted to relieve the burden of locating, copying, and mailing patient records imposed by CMS and other auditors. Physician Professional development • “Um Is Not a Word” Media Training • “The (Physician) Leader’s Toolkit” Workshops • “How to Be a Better Lobbyist” Advocacy Training • “Financial and Legal Skills for Docs” Workshop • “Taming Outlook” Workshop eHR & technology education • CMA published a guide to EHR Meaningful Use, Stage 2. • SDCMS conducted a members-only webinar to explain changes to Meaningful Use rules. eHR & technology assistance • The SDCMS Foundation offered free EHR implementation assistance to primary care practices and conducted EHR vendor demos in July and August. • SDCMS helped physicians meet the e-prescribing exemption deadline. eHR & technology implementation • CMA expressed its concerns that the proposed objectives and measures for Stage 2 were too aggressive given the capacity in the marketplace. • SDCMS is intimately involved in the establishment of a selfsustaining, San Diego-wide Health Information Exchange. • SDCMS surveyed where San Diego County’s physicians stand with respect to the EHR implementation process.

our seminars, Webinars, courses, and Workshops SDCMS and CMA conducted more than 70 seminars in 2012 with upwards of 800 physicians and office staff attending SDCMS’s seminars alone! A broad range of topics were covered, including: • Buying, Selling, Leasing Office Space • Dual Eligibles • HIPAA and Meaningful Use • ICD-10-CM • Lowering Practice Costs • Managing Challenging Patients • Medicare and Medi-Cal Topics • Payer Abuse • Social Media Basics • Workers’ Compensation (fourpart series) SDCMS conducted nine workshops in 2012. SDCMS partnered with PMI to conduct two courses in 2012: • Certified Medical Coder • Certified Medical Office Manager

events SDCMS’s White Coat Gala attracted more than 300 attendees, including six legislators. The 2012 Top Doctors Gala saw nearly 500 individuals in attendance.

office manager of the year! SDCMS held its fourth annual “Outstanding Medical Office Manager” in 2012, with Carol Carney winning — Carol was nominated by E.L. Sakas, MD, SDCMS-CMA member since 2005.

your sdcms Physician advocate at Work! In 2012, your physician advocate, Marisol Gonzalez, solved more than 500 member problems, including: • Working with Palmetto to get an internal medicine group paid the $30,000 owed it. • Helping an office manager with a DEA inspection. • Communicating to a small practice that installing security cameras in its hallway and waiting room was not a HIPAA violation. • Recovering $20,000 plus interest for a member surgeon who had problems with health plan denials. • Ensuring a member surgeon’s Medicare opt-out affidavit was retroactively approved. • Getting a $700 surgery procedure claim released for a member otolaryngologist. • Assisting members who needed help filing their e-prescribing exemptions.

2012 2012 AnnuAl RepoRt

communications and marketing San Diego Magazine again listed SDCMS (and only SDCMS) physicians in its April “Health Annex” and online in its “Find a Doctor” tool. We sent out 25 commercialfree e-newsletters, “News You Can Use.”

tangible member Benefits • More than 850 SDCMS physicians saved nearly $460,000 with The Doctors Company, SDCMS’ endorsed professional liability carrier, which offers a 5% membersonly discount on professional liability insurance. • More than 100 members used the results of SDCMS’s 2012 Medical Office Salary Survey. • SDCMS-CMA were able to recover roughly $700,000 in contested claims from payers. • We provided resources to help physicians transition to the new HIPAA 5010 Transaction Standards. • DocBookMD provides the entire San Diego physician database to members with iPads, iPod Touches, iPhones, or Android-based devices, with HIPAA-compliant bidirectional communication — with photos — for free! • SDCMS members enjoy: discounted disability insurance • a free annual physician mailing list • car insurance discounts • free classified ads • a free California Emergency Driving Emblem • significant savings on accounting services, security prescription pads, billing solutions, IT support, computer hardware, contract negotiations services, practice management consulting, banking, and legal services. • SDCMS created a private e-forum for the office managers and practice administrators of SDCMS member physicians.

We tweeted daily healthcare news and updates via our Twitter feed.

We published seven video updates to physicians on critical federal, state, and local issues. We published the 2012 edition of our Pictorial Membership Directory in January. We published 12 issues of San Diego Physician on varied topics, including “Our Obesity Epidemic,” physician volunteerism, technology, bioethics, San Diego County’s physician workforce and compensation, and more!

Keeping our members up to date on critical deadlines and issues! SDCMS kept you up to date on important practice management deadlines and changes: new healthcare laws • ICD-10 compliance date • HIPAA 5010 enforcement • Medicare e-prescribing hardship exemption • MediCal enrollment requirements • California employment law changes • Medicare participation deadline • and more.

sdcms membership continues to increase! SDCMS is now tied for first in California in total membership. We created the position of director of membership recruitment and retention to build relationships with new and current members.

SDCMS Membership in 2012: • Practicing Physicians: 2,683 • Resident Physicians: 918 • Medical Students: 355 • Total: 3,956

sdcms Financials

exPenses

Physician Engagement

Physician Database

Rent: 11% Copier: 1% Credit Card / Bank Charges: 2% Insurance: 1% Miscellaneous Expenses: 3% Telephone: 1% Staff Time G&A: 12%

13%

Governance

31%

23%

Infrastructure

Communications

12% Benefits

Foundation

Specialty Societies

Advocacy

Foundation

Credit Card Commission

Specialty Societies

25%

Investments

15%

income

Advertising and Sales

54% Dues

2 0 1 2 2 0 1 2

A N N U A L A N N U A L

R E P O R T R E P O R T

A Life Saved: Collaboration and Coordination is the Essence of Project Access Joel did not know his life was in danger when he sought care at his community clinic for abdominal pain he had lived with for three years. Referred to Project Access, Joel, a father of two young children, participated in the March 2011 Saturday Surgery Day to diagnose his intestinal issues and bleeding. As part of the GI procedures offered at the semi-annual Kaiser Permanente Super Saturday Surgery Days, Daniel Anderson, MD, performed a colonoscopy; it revealed a rare form of familial colorectal cancer, diagnosed at Stage 4. Colon cancer is second only to lung cancer as as a cause of cancer deaths in Californians. And yet, is alsoofone of the mostinpreventable lateone 2008, themost diagnostic colonoscopies ait cause cancer deaths Californians.cancers. And yet,Since it is also of the preventable cancers. provided Kaiser have removed potentially-cancerous growths inhave 21 removed patients, Since lateby 2008, thegastroenterologists diagnostic colonoscopies provided by Kaiser gastroenterologists a life-saving measure.growths in 21 patients, a life-saving measure. potentially-cancerous Joel received imaging from Imaging Healthcare Specialists, oncologist Alberto Bessudo, MD, provided chemotherapy, and Eva Lean, MD, provided radiation therapy. Marco Tomassi, MD, and Huathin Khaw, MD, performed multiple surgeries to save Joel, and in addition, Kaiser Permanente provided genetic testing for Joelâ&#x20AC;&#x2122;s two children; his five-year-old son carries the marker, and will be followed for early detection and treatment. Joel is now back to work, knowing he will celebrate many more of his childrenâ&#x20AC;&#x2122;s special occasions. Project Access exists due to the dedication of our volunteer physicians, such as those helping Joel. We are here for patients like Joel so that we can improve health and change lives in our community.

Our Mission: Our Mission: Improving community health, Improving community health, access to care for all, and wellness access to care for all, and wellness for patients and physicians through for patients and physicians through engaged volunteerism. engaged volunteerism. Vision: Vision: Improving health, changing lives Improving health, changing lives

858.300.2777 858.300.2777 www.sdcmsf.org www.sdcmsf.org

HIGHLIGHTS OF OUR HIGHLIGHTS OF OUR ACCOMPLISHMENTS ACCOMPLISHMENTS DURING 20122012 DURING 628 Physicians Volunteer for PASD 628 Physicians Volunteer for PASD Stony Anderson, MD Stony Anderson, MD with KP colleagues with KP colleagues Sandra Freiwald, MD Sandra Freiwald, MD and Paul Bernstein, MD and Paul Bernstein, MD

PASD PASD Physician Volunteers Honored in Community Physician Volunteers Honored in Community

DanielDaniel “Stony”“Stony” Anderson, MD,KPKP PASD champion and and “Stony” Anderson, MD, gastroenterologist, PASD champion and long-time Anderson, MD,gastroenterologist, KP gastroenterologist, PASD champion long-time physician volunteer, was honored by the County of San Diego Health physician volunteer, was honored by the County of San Diego Health & long-time physician volunteer, was honored by the County of San DiegoHuman Health & Human Services Agency in April 2012 as their HealthHealth Champions Services Agency in April 2012 as in their Public Health Champions ThemeChampions Awardee, & Human Services Agency April 2012 asPublic their Public Theme Awardee, the honor, for hisAccess. work Project Access.Access. Robert the highest honor, for highest histhe work with Project Robert MD, urologist, Theme Awardee, highest honor, for hiswith work withEisenberg, Project Robert Eisenberg, MD, was honored by the Grossmont Healthcare District was honored byurologist, the Healthcare District a 2012 Healthcare Hero for Eisenberg, MD,Grossmont urologist, was honored by theasGrossmont Healthcare District as 2012 Healthcare Hero for his volunteer contributions to PASD. We are so hisavolunteer contributions to PASD. We are so honored that two extraordinary as a 2012 Healthcare Hero for his volunteer contributions to PASD. We are so honored that extraordinary volunteers are recognized for theirthe volunteers aretwo recognized for their commitment to recognized improving health of those honored that two extraordinary volunteers are forcommitment their commitment to improving the health of those most vulnerable. most vulnerable. to improving the health of those most vulnerable.

ProjectProject AccessAccess San Diego now counts 628 628 San Diego now counts specialty care physicians as volunteers, providing specialty care physicians as volunteers, providing specialty healthcare consultations and services specialty healthcare consultations and services to uninsured adult patients. PASD is recognized to uninsured adult patients. PASD is recognized throughout the county as theasorganized systemsystem throughout the county the organized for local volunteerism. ThanksThanks to our to our for healthcare local healthcare volunteerism. growinggrowing number of volunteers, we have been number of volunteers, we have able been able to improve access to caretoand status status for for to improve access carehealth and health our community’s most vulnerable. our community’s most vulnerable.

2012 2012 Project Access San Diego Highlights Project Access San Diego Highlights Number of uninsured patients Number of uninsured patients receiving specialty care services receiving specialty care services

604 604

Number of uninsured patients assisted Number of benefits uninsured patients assisted 135 to receive public 135 to receive public benefits

Retired Physicians Retired Physicians at UC San Diego at UC San Diego

Retired Physicians Society Relaunched Retired Physicians Society Relaunched

ThanksThanks the efforts efforts ofMitsuo Mitsuo Tomita,MD MDand and Rosemarie Johnson, MD, to Rosemarie M.M.Johnson, MD, thethe Retired to the to the of efforts of Tomita, Mitsuo Tomita, MD and Rosemarie M. Johnson, MD, the Retired Physicians Society toured the UC San Diego Telemedicine Center and Physicians Society toured the UC San Diego Telemedicine Center and robotic surgery Retired Physicians Society toured the UC San Diego Telemedicine Center and robotic surgery lab,Blood thelab, San Bank, and over the history lab, therobotic San Diego Bank, andBlood reminisced overreminisced the of Scripps Health at surgery theDiego San Diego Blood Bank, andhistory reminisced over the history of Scripps Health at a presentation and booksigning by Sarita Eastman, MD, a presentation and booksigning by Sarita Eastman, MD, retired physician and author. of Scripps Health at a presentation and booksigning by Sarita Eastman, MD, retired physician and author. These lunch-hour meetings continuing These retired lunch-hour meetings continuing education andprovide opportunites to spend physician andprovide author. These lunch-hour meetings provide continuing education and opportunites to spend time with former colleagues. The group time with former colleagues. The group meets three to four times a year, and includes education and opportunites to spend time with former colleagues. The group meets three to four times a year, and includes those who retired from practice inmovedin those who retired from practice in the community, as well as others who have meets three to four times a year, and includes those who retired from practice the community, as well aswell others who have to SantoDiego to San Diego after retirement. the community, as as others whomoved have moved San after Diegoretirement. after retirement.

Number of donated specialty Number of donated specialty healthcare appointments healthcare appointments

1,901 1,901

Number of donated surgeries Number of donated surgeries

168 168

Number of volunteer specialty Number of volunteer specialty care physicians care physicians

628 628

Patient Marisol de la Cruz thanks her surgeon, Patient Marisol de la Cruz thanks her surgeon, Robert Eisenberg, MD Robert Eisenberg, MD City Heights residents City Heights residents received free flu shots received free flu shots thanks to Walgreens thanks to Walgreens pharmacists. pharmacists.

PASD PASD Immunization Initiative Launched Immunization Initiative Launched

San Diego County Medical Society Foundation ledled a collaboration of other Diego County Medical Society Foundation a acollaboration ofofother San Diego County Medical Society Foundation led collaboration other community agencies to adult rates immunization agencies toincrease increase adultimmunization immunization ratesfor forfluflu at community agencies to increase adult immunization rates forimmunization flu immunization at end ofend 2012. The County of San Diego, the Black Nurses Association, thethe endat ofthe2012. The County of San Diego, the Black Nurses Association, the San of 2012. The County of San Diego, the Black Nurses Association, the Chapter National Latina NursesWalgreens, Association, Walgreens, DiegoSan Chapter Latina Nurses Association, International Rescue the Diego SanNational Diego Chapter National Latina Nurses Association, Walgreens, International Rescue Committee, US Healthcare, WeSupportYou, the Mexican Committee, US Healthcare, WeSupportYou, the Mexican Consulate, and San Ysidro International Rescue Committee, US Healthcare, WeSupportYou, the Mexican Consulate, andpartnered San Health Centerto partnered with to outreach HealthConsulate, Center SDCMSF outreach andSDCMSF provide free flutoshots for andYsidro Sanwith Ysidro Health Center partnered with SDCMSF outreach and provide free flu shots for community members nine to 75 years of age. community members nine to 75 years of age. Sanofi-Pasteur donated vaccine in and provide free flu shots for community members nine to 75 years of age. Sanofi-Pasteur donated vaccine in addition to supplies from the County. This addition to supplies from the County. This effort is part of our goals to address Sanofi-Pasteur donated vaccine in addition to supplies from the County. This effort iseffort partis ofpart our of goals address preventable diseases. preventable diseases. our to goals to address preventable diseases.

WhiteWhite Coat Gala in Green Coat Brings Gala Brings in Green

The San CountyCounty Medical Society’s annualannual TheDiego San Diego Medical Society’s inauguration dinner, the White Coat Gala, benefitted inauguration dinner, the White Coat Gala, benefitted ProjectProject AccessAccess in Mayin2012 of a live May with 2012proceeds with proceeds of a live auction. Physicians gathered to celebrate their their auction. Physicians gathered to celebrate colleagues, learnedlearned about about ProjectProject Access,Access, and and colleagues, heard heard from Marisol de la Cruz, a local artist who from Marisol de la Cruz, a local artist who creditscredits her renewed healthhealth to Project AccessAccess and and her renewed to Project her physician, Robert Eisenberg, MD. She donated her physician, Robert Eisenberg, MD. She donated a painting, enthusiastically purchased by Alexe a painting, enthusiastically purchased by Alexe Page, Page, MD, a MD, PASD volunteeer and KP orthopedic a PASD volunteeer and KP orthopedic surgeon, and presented another to Dr. Eisenberg. surgeon, and presented another to Dr. Eisenberg.

ForFor a copy our fullour 2012 Annual Report, go go to www.sdcmsf.org or email us us at foundation@sdcms.org For aofcopy of full 2012 Annual Report, go to www.sdcmsf.org or email us at foundation@sdcms.org a copy of our full 2012 Annual Report, to www.sdcmsf.org or email at foundation@sdcms.org

SanSan Diego County Medical Society Foundation 5575 Ruffin Rd.,Rd., Ste. 250, San Diego, CACA92123 San Diego County Medical Society Foundation 5575 Ruffin Rd., Ste. 250, San Diego, CA92123 92123 Diego County Medical Society Foundation 5575 Ruffin Ste. 250, San Diego,

Sign up for CURES and use it before prescribing controlled substances. It takes only a few seconds to look up potential life-saving information.

tion Drug Abuse Medical Task Force began last October with the goal of activating the medical community as a force to prevent prescription drug misuse, addiction, and death in San Diego County, and to ensure appropriate prescribing of controlled substances in the community. The Medical Task Force includes primary care physicians, pain specialists, emergency physicians, dentists, pharmacists, and psychiatrists. It has broad representation from our medical community and includes the County of San Diego Public Health Services, the Hospital Association of San Diego and Imperial Counties, Scripps Health, Sharp HealthCare, Kaiser Permanente, the UC San Diego Health System, Palomar Health, and the community clinics. The number of prescribed opioid pills

increased tenfold in the past decade. The increased number of pills directly correlated to the increased number of deaths. We want to see both these numbers go down. In January the Medical Task Force adopted two tools: (1) the “Safe Pain Medication Prescribing Guidelines,” and (2) the “Patient Pain Medication Agreement and Consent.” The guidelines recommend that any patient who requires long-acting opioids or more than three months of opioids sign a medication agreement. The guidelines also include recommendations for acute and chronic treatment, dosages, side-effects, drug combinations to avoid (including not mixing opioids and tranquilizers), drug testing, using CURES (the state prescription drug monitoring program), and working with the DEA. It also includes several educational references. The Patient Pain Medication Agreement and Consent includes the patient’s responsibilities and the risk in taking the medications. All controlled substances should be obtained from a single prescriber or clinic and filled at a single pharmacy. The two documents are guidelines, not an obligation, but we hope they become widely used throughout the county. With a uniform medication agreement, all healthcare providers and patients will be on the same page regarding prescribing and using controlled substances. The Emergency Medicine Oversight Commission (EMOC), under the umbrella of the San Diego County Medical Society, organized a historic meeting in February, bringing together leaders of every emergency department in San Diego and Imperial counties. In this meeting the emergency departments agreed upon the “Safe Opioid ED Guidelines of San Diego.” This guideline is based on the Washington State model of an “Oxy Free” emergency department. This means that patients with

chronic pain will not get refills for opioids from the emergency department. The EDs will not write for any long-acting opioids, such as fentanyl, dilaudid, morphine, or methadone. The ED will not give regular IM medication for chronic pain. A photo ID or photograph may be requested before writing for controlled prescriptions. The guidelines will be transparent to patients before they see a physician with the hope of having a uniform standard for all emergency prescribers and clear expectations from patients. The purpose of the guidelines is to promote safe prescribing. It is often difficult to say no to a patient begging for opioid medications and creating a scene in the middle of the department. It is much easier and faster to write for just a few pills. But it is not just a few pills. We have had more than one patient in San Diego leave an emergency department with only six methadone tablets or 20 Percocet and end up dead from these prescriptions. We want you to be a SAFE OPIOID PRESCRIBER. Explain to your patients that your office follows the San Diego recommended guidelines for safe opioid prescribing. Please read the Safe Pain Medication Prescribing Guidelines and start using the Patient Pain Medication Agreement and Consent. To access these documents along with additional informational and educational materials on prescription drug abuse, email Editor@ SDCMS.org with “Safe Opioid Prescriber” as the subject line. Dr. Lev, SDCMS-CMA member since 1996, is the current director of operations for the Scripps Mercy Hospital Emergency Department, current chair of the SDCMS Emergency Medicine Oversight Commission (EMOC), and past president of the California chapter of the American College of Emergency Physicians (CAL/ACEP). SaN Di EGO pHYSiCiaN.OrG 19

7.1 %

other Source Got From Drug Dealer or Stranger Took From Friend or relative Without Asking

4.4%

55%

4.8%

bought From Friend or relative

11.4

obtained Free From Friend or relative

people Who abuse prescription painkillers get drugs From a variety of Sources

17.3%

prescribed by one Doctor

Prescription

DRUG ABUSE Stats DRUG OVERDOSE DEATH RATES BY STATE, 2008: NEW MExICO

27 10.4 CALIFORNIA

drug overdoSe death rateS

(illicit, prescription, and over-thecounter) in the united States have more than tripled since 1990. 20 apri l 2013

DeATHS / 100,000 Highest

DeATHS / 100,000

NEBRASKA

5.5

DeATHS / 100,000 Lowest

2 in 2010

Million

people reported using prescription painkillers nonmedically for the first time within the last year â&#x20AC;&#x201D; nearly 5,500 a day.

FOR EVERY

DEATH, THERE ARE

California & San diego County drug-induced deaths 1999–2010

10 Times More

Pain Pills This Year Than

California Population: 37,253,956

10 Years Ago

Death Rate From Drugs: 11.4 / 100,000 San Diego County Population: 3,095,313

in California: 6.2 kilograms of pain killers per 10,000 people — enough to medicate every single American round the clock for a month. in Florida: 12.6 kilograms.

Death Rate From Drugs: 12.4 / 100,000

unintentional overdose deaths involving opioid analgesics parallel opioid Sales, 1997–2007 Opioid analgesics Distributed by Drug Companies

mg/ Person

1997

698

mg/ Person*

2007

Opioid Overdose Deaths

Treatment Admissions for Abuse

emergency Department Visits for misuse or Abuse

130 825 people Who Abuse or Are Dependent

Nonmedical users

2,901 11,499 1999

2007

*Enough for every American to take 5 mg Vicodin every four hours for three weeks

SaN Di EGO pHYSiCiaN.OrG 21

39%

emergency Departments

distribution of narcotic analgesics to patients by healthcare Setting

10%

13 %

30%

Top

10 Drug

DeAThS in SAn Diego CounTy

Surgical Specialty offices

medical Specialty offices

primary Care offices

2000â&#x20AC;&#x201C;2011

Hospital outpatient Departments

2011

methamphetamine 1 Alcohol 2 Heroin 3 morphine 4 Cocaine 5 Diazepam (Valium) 6 methadone 7 oxycodone (percocet) 8 Hydrocodone (Vicodin, Norco) 9 Diphenhydramine (benadryl) 10

Alcohol methamphetamine Heroin oxycodone (percocet, Norco) methadone Alprazolam (Xanax) Hydrocodone (Vicodin) Diazepam (Valium) morphine Diphenhydramine (benadryl)

San diego drug deathS, 2011 Prescription, Illicit, and OTC

illicit and Alcohol

20 22 apri l 2013

illicit

135 prescription and oTC

49 prescription, illicit, and Alcohol

oTC

prescription, Alcohol, and oTC

prescription and illicit

prescription and Alcohol

prescription

158

Alcohol

55 ToTAl: 479

56% rx!

ranking of Substance by age group, 2011 *Five or Fewer Cases 10-19

20-29

30-39

40-49

50-59

60-69

Heroin (3)*

Heroin (10)

Heroin (20)

Methamphetamine (40)

Methamphetamine (46)

Methamphetamine (15)

alprazolam (2)*

alprazolam (20)

Methamphetamine (16)

oxycodone (23)

Hydrocodone (23)

Methadone (8)

Methadone (1)* Methamphetamine* (1) Methylone (1)*

Methadone (5)* diazepam (5)* Clonazepam (5)* Hydrocodone (5)*

alprazolam (12) oxycodone (12)

alprazolam (13)

oxycodone (21)

Morphine (6)

Methamphetamine*(4) Cocaine (4)* oxycodone (4)*

Methadone (9)

Heroin (12) Hydrocodone (12)

Heroin (20)

oxycodone (5)* Heroin (5)* Hydrocodone (5)*

diazepam (7) Cocaine (7)

Methadone (11)

Hydrocodone (6)

diphenhydramine (10)

Methadone (17) diazepam (17)

alprazolam (15) Morphine (15)

Project4:Layout 1

9/22/08

11:22 AM

Page 1

Tracy Zweig Associates A

REGISTRY

PLACEMENT

FIRM

Physicians

Nurse Practitioners Physician Assistants

Locum Tenens Permanent Placement V oi c e : 8 0 0 - 9 1 9 - 9 1 4 1 o r 8 0 5 - 6 4 1 - 9 1 4 1 FA X : 8 0 5 - 6 4 1 - 9 1 4 3

t z we i g @ t r a c y z we i g . c o m www. t r a c y z we i g . c o m

SaN Di EGO pHYSiCiaN.OrG 23

An Interview With

Thomas P.

Lenox

Supervisory Special Agent, Drug Enforcement Administration Interview by Roneet Lev, MD

24 apri l 2013

D Part 1

Dr. Lev: First of all, thank you for agreeing to be in San Diego Physician magazine and helping out the medical community. Why don’t you first tell us a little bit about yourself? Mr. Lenox: I’m a supervisory special agent with the Drug Enforcement Administration. I’ve been with them almost 27 years, and I’ve worked in San Diego for almost 19 years now. I’ve had prior assignments in El Paso, Texas, and in Mexico. For the last five years I’ve been working as part of a pharmaceutical task force — the first year working investigations and the last four years as the supervisor of that unit. We focus on cases that involve controlled substances only. They can range from people selling pills on the street to employees that are stealing them from a pharmacy or a doctor’s office, to patients who are doctor-shopping. We will also do cases on physicians who are abusing their registration numbers, and we’ve had several doctors who were abusing controlled substances themselves. My unit is a criminal investigation unit, which is very broad and comprehensive. We also have a regulatory and compliance unit that we work very closely with. If we look into a case targeting somebody who has a DEA registration, there may not be criminal violations, but there may be administrative issues. That ranges from a letter of admonition — which is sort of like a letter of reprimand telling you that you’re doing something wrong, what the violations are, that you need to fix them, and you need to notify us how you fixed them. In more egregious cases, a physician can potentially lose their registration, and we’ll request a hearing before an administrative law judge to revoke a registration. If we do a criminal case on a registrant, we’ll typically try and immediately suspend their registration so they can’t prescribe. One of the things that we’re trying to do here in San Diego and in our office is to really work with the physicians in advance so that if we come out and see you, it’s not going to be something that’s in a negative light. We’re going to be working with you to resolve the problems and to solve the issues in advance. We may recommend training or provide you with the necessary information so you don’t get caught up in a situation where your registration is at risk. SAN DI EGO PHYSICIAN.OrG 25

REPORT SUSPECTED DOCTOR-SHOPPING Call DeA Diversion at (858) 616-4100 or email deatips-sandiego@usdoj.gov. Give the name of the patient, his or her date of birth, the location of the occurrence, and describe the suspicion.

DR. LEv: But since I met you, my interactions with the DEA have all been positive. You’ve been involved in the Prescription Drug Abuse Task Force. You’ve been active in the Medical Task Force. And you’ve educated physicians that when they get a call from DEA, chances are they’re being called as a victim, and not necessarily as the bad guy.

“Typically, if we’re calling a doctor, they’re not in trouble. When we do a case against a doctor, we do not call — that would be undercover work.”

26 apri l 2013

DR. LEv: Your involvement in the medical community — is it all going after doctors, or do you have positive interactions with physicians and defend them? MR. LENOx: We’re very lucky in San Diego because we don’t have the situations that a number of other DEA officers are seeing around the country with pill mills. I think San Diego has a very conscientious, compassionate, and passionate medical community. But there’s a handful that we come across who, for a variety of reasons, take the wrong path. So we do a very small percentage of cases against physicians — one or two criminal cases a year. The majority of what we do is administrative action, typically a letter of admonition notifying a doctor that they’ve done something wrong and they need to fix it, and bring their prescribing practice into compliance with DEA regulations.

MR. LENOx: One of the things that we’re trying to do is work more with the medical community. Outside my role as a supervisor of the DEA, I also participate in the Prescription Drug Abuse Task Force and now the Prescription Drug Abuse Medical Task Force. In those roles we can partner with the medical community and let them know what the problems are that we’re seeing in law enforcement with prescription drugs, and how, if we work together, we can hopefully greatly diminish the abuse and addiction of prescription drugs by people in San Diego County. The reception I’ve received from the medical community in San Diego has been great. They’ve been very open and interested in learning what the current trends are, and what’s happening in our community. There are a few instances where some physicians are a little defensive when we’re going out trying to explain to them that their DEA registration number is being abused or that somebody may have stolen some of their pads — they didn’t realize they were stolen, and they get very nervous. There are some physicians or medical groups that believe that because of HIPAA they can’t discuss things with us. However, when we go out to the community, we’re doing criminal cases, and we’re looking at the physician as the victim — the questions that we’re asking really have no relationship to HIPAA issues. DR. LEv: So let’s divide this discussion: What happens when DEA calls, and what about HIPAA? If you get a call from a DEA

agent as a physician, what should you expect? Should you be thinking, “Oh my gosh, I’m in trouble. What does this guy want from me?” MR. LENOx: No. Typically, if we’re calling a doctor, they’re not in trouble. When we do a case against a doctor, we do not call — that would be undercover work. So if we’re calling you, 99% of the time we’re calling you because there is a patient who has come in to see the doctor and is committing fraud, such as lying to the doctor to get prescriptions. They’re abusing the doctor’s DEA registration number, and that’s what we’re trying to find out. We want to be able to talk to the doctor and let them understand that there’s a DEA issue with one of their patients, and figure out the best way to resolve it. DR. LEv: I’ve actually had that experience. I received a call from a DEA agent asking to meet me, and it was kind of scary. Why is a DEA agent coming to see me in the middle of my shift? Did I do something wrong? However, the agent was very professional, and it took less than five minutes. One time I was shown mug shots and asked if I recognized anyone. Sure enough, I identified a patient I recently saw and prescribed Vicodin. Another time I was asked if I had known my patient had already received prescriptions from five other providers, would I still have written another pain prescription. I simply answered. MR. LENOx: Yeah, it’s a very simple process. Unfortunately, because of our schedules and the physicians’ schedules, it’s not something where we can always make an appointment in advance, so a lot of times they’re random visits by the agents. Some of the agents will try to call in advance because they know that the physicians are very busy. We typically will not tell anyone other than the physician why we’re calling. We’re not trying to be disrespectful of the office staff; we’re trying to protect the patient’s privacy. Sometimes we’re referred to a receptionist, a clinic director, or a compliance officer, and we don’t tell them why we’re calling. We’re conducting an investigation and aren’t sure how it’s all going to pan out. So really, other than the investigator and the doctor, there’s no need for us to give information on a patient to

"I really encourage all physicians to get access to CURES. It’s a very important tool for the physicians because it gives a history of the controlled substances that a patient has been taking." anybody else. We may never arrest or file charges, and simply close the case. So we don’t want that patient to have a stigma with other people in the office. The patient should still be able to come into their doctor’s office without everybody standing around whispering, “Oh, that’s the one the DEA’s looking at.” We want to have that respect to both the patient and the physician. But again, we’ll come in, talk to the doctor, ask a half-dozen questions, and then we’re gone. So, five to 10 minutes and that’s about all it takes.

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DR. LEv: I would encourage physicians that if they get a phone call from the DEA, don’t be alarmed, just talk to them. It’s a very simple process, and, if anything, it’s interesting to see what is being investigated. So what should a physician do if called by the DEA about potential prescription drug abuse?

San Diego orange LoS angeLeS PaLo aLTo

MR. LENOx: DEA agents have the legal right to ask for any information about a prescription and the narcotic being prescribed. A typical initial encounter with a DEA agent is to verify a CURES report — essentially, the agent will work with the physician to validate the prescription. Typical questions include: “Was your DEA registration used?” “Did you write this prescription?” “Was the prescription for this amount?” “Was the prescription for this patient?” “Did you use CURES?” It would be as though the DEA agent handed

SacramenTo

SaN Di EGO pHYSiCiaN.OrG 27 CAP_1402.indd 1

2/5/13 11:13 AM

the doctor the CURES report and asked the physician to ensure it was correct. We do not require any HIPAA-related medical information for the CURES conversation. We don’t look through a patient’s chart. We’re just doing an interview of a doctor who’s the victim of fraud or theft. DR. LEv: If a physician suspects doctorshopping, if they run a CURES report and see that a patient is getting prescriptions at multiple different addresses and different physicians, do you encourage them to report to DEA? MR. LENOx: First of all, I really encourage all physicians to get access to CURES. It’s a very important tool for the physicians because it gives a history of the controlled substances that a patient has been taking. When physicians have access to CURES and find a pattern of doctor-shopping, there’s a couple of things they can do. I’m not opposed to physicians trying to work with the patients and getting them into programs to treat their addiction. Not all patients are ready to go into an addiction program, and some may go in and come out and relapse. We’ve found that in a number of instances the only way to have patients enter a treatment program is hav-

ing that hammer of the justice system over their head. So they’re sort of forced into a program by the justice system, and that’s where we step in. If a physician feels they can’t manage the addiction, they absolutely can refer the patient to us. Let us know the situation. It’s your patient; you ran CURES; they lied to you; they’re not willing to work with you. We will open up a case, and typically what happens is they’ll get into the judicial system and end up with court-mandated treatment. DR. LEv: Is it a HIPAA violation or breaking patient-doctor confidentiality to report a potential prescription drug abuse situation to you? MR. LENOx: No. All the doctor is saying is, I ran a CURES on this person, here’s who the patient is, here’s their name and date of birth, and I suspect them to be involved in doctor-shopping, which is criminal activity. It would be as though you saw somebody across the street breaking into a house; you would call the police and say, “I just saw this person, and they look like they were wandering around the house, and they were breaking in.” It’s suspicious activity, and that’s what they’re reporting:

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28 apri l 2013

suspicious activity to us. There’s no HIPAA violation if the only thing being reported is suspicious criminal activity. DR. LEv: When do HIPAA considerations arise? MR. LENOx: The operational reality is that if the DEA agent wants additional information from a patient chart, above and beyond the CURES report, they will bring a subpoena or a search warrant — in which case the doctor is compelled to provide the information legally requested without a requirement for a record/account of personal health information (PHI) disclosure. However, if the doctor voluntarily provides information above and beyond the CURES report, then, as in all PHI disclosures, the doctor is required to maintain a record/account of the disclosure. The patient does not have to be notified, but, if requested by the patient, the doctor must provide the patient with an accounting of all PHI disclosures. DR. LEv: Is it a crime if a patient lies to their physician about opiate use? For example, if they say they haven’t received a prescription for Vicodin in the past month, but they have?

MR. LENOx: Yes. It’s fraud if people lie for the specific purpose of getting drugs that they’re addicted to. They’re not seeing you to be treated for an injury. They’re at the doctor’s office to get drugs for addiction, abuse, or diversion. Their purpose for being at the doctor’s office isn’t true healthcare. DR. LEv: What should physicians document in their medical records to make such investigations easier? For example, one of the things that I’ve learned from you is that part of my medication history is to document who gave the patient the medication and when they last received it. MR. LENOx: Yes, and that helps down the line. The immediate crime is when a patient comes in and you ask them, “Are you taking any pain medication?” and they say no. The personal history is very important for the physician to get. Have you ever been prescribed opiates in the past? Are you seeing any other doctors? We will not ask for a copy of your records, but if a patient is going to commit fraud, and they’re going to lie to you, the more detailed their medical history is, the more likely they’re going to be lying to you. That’s why that’s important. The crime we investigate

is prescription fraud — in other words, obtaining drugs from the physician not for the purpose of an injury, but for the purpose of addiction or abuse. DR. LEv: Is it a crime for someone to take someone else’s Vicodin not prescribed to them? Patients often admit, yeah, I’ve taken a Vicodin, it was my husband’s. MR. LENOx: Yes, they would be illegally in possession of the drug because that person has no right to actually have the drug or to take that drug. This is where it gets a little interesting because if your husband has a pill bottle in the house, it’s his pill bottle, and they’re in the house. You have access to them, but you’re not taking them — they belong to your husband. That is legal. If you now open your husband’s pill bottle and start to take them, you are illegally in possession of those pills. They’re not yours. You have no right to them, and once you take them, you are illegally in possession of a controlled substance. DR. LEv: Even if your husband gave them to you? MR. LENOx: Yes. Well, now you have another problem because the husband is now

distributing drugs illegally. The medication was for his use, and if he gives them to you, then he’s committing a crime by giving you drugs, and you’re committing a crime for illegal possession. The husband’s crime is a bit more serious because distributing drugs is a greater offense than possession of drugs. DR. LEv: I don’t think the public realizes that sharing medications is not just medically unwise, but also a crime. MR. LENOx: For DEA’s purposes we’re just looking at the controlled substances, the schedule II through Vs. The truly abused drugs are the IIs and IIIs, a couple of IVs and Vs, but the majority fall within schedule II and III. Be sure to read Part 2 of this interview in the May issue of San Diego Physician. Dr. Lev, SDCMS-CMA member since 1996, is the current director of operations for the Scripps Mercy Hospital Emergency Department, current chair of the SDCMS Emergency Medicine Oversight Commission (EMOC), and past president of the California chapter of the American College of Emergency Physicians (CAL/ACEP).

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Are Your

PRESCRIBING PRACTICES Secure? By SDCMS-endorsed The Doctors Company (For more safety articles, practice tips, and interactive guides/site surveys, visit www.thedoctors.com/patientsafety.)

Prescription theft and abuse is a real and growing problem, making it imperative for physicians to protect themselves and their practices. In addition, a recent court ruling spotlights potential obligations to third parties when prescribing medications to patients. Together, these developments signal the need for vigilance and security in your prescribing practices.

30 apri l 2013

— two objectives of the HITECH Act. It eliminates the time-intensive process involved with tracking paper prescriptions, voids opportunity for alterations, and provides a direct connection to pharmacists to ensure accurate prescriptions. Physicians who continue to use paper prescriptions should implement protocols with local pharmacies to manage prescription theft, forgery, and alteration. Consider these risk management tips: • Request notifications from local pharmacies before prescriptions for controlled substances are dispensed. • Use the control batch number on each script to track the order of prescriptions. • Require patients to visit the office to obtain prescriptions for controlled medications. • Note actual amounts prescribed, and give matching numerals to discourage prescription alterations (e.g., thirty/#30). Physicians may also consider terminating the physician-patient relationship with a patient who is involved in prescription abuse, theft, or diversion. If prescription fraud occurs, physicians should investigate and notify local law enforcement, the local DEA office, and the necessary state licensing and medical boards. Physicians should also contact their malpractice insurer to discuss other reporting requirements and further safeguards for preventing diversion.

The Prescription Regulatory Environment The Drug Enforcement Administration (DEA) has developed federal and state regulations to safeguard prescribing practices. The Centers for Medicare and Medicaid Services (CMS) also requires that prescription pads have security features to prevent copying, modifying, and counterfeiting. Currently, 49 states have passed legislation to implement operational Prescription Monitoring Programs

(PMPs), which seek to curtail prescription drug abuse and diversion through highly effective tools and strategies developed for use by government officials. Tips to Avoid Prescription Fraud and Abuse Physicians can incorporate electronic prescribing, or e-prescriptions, into their practice to protect themselves against diversion. Electronic prescribing promotes efficiency and reduces medical liability

Court Rules Physicians Liable for Patient’s Actions In February, the Utah Supreme Court ruled that third parties may sue doctors for injuries caused by a patient whose actions are associated with alleged medication mismanagement. The ruling allowed relatives to sue a physician and his staff after a patient killed his wife. According to the American Medical Association, “The court ruled that when potential risks might outweigh potential benefits for a given activity, doctors must consider the potential effects their actions could have on third parties.” While state laws differ, courts in several other states have issued similar rulings. As a result, health professionals in Utah and other jurisdictions may be found to have a legal responsibility to third parties when prescribing medicine to patients, which will likely impact the way medicine is practiced. SaN Di EGO pHYSiCiaN.OrG 31

YOU ARE OUR HERO thank you for giving access to healthcare for those without!

San Diego County Medical Society Foundation’s Mission Is To Improve Health, Access To Care, And Wellness For Patients And Physicians Through Engaged Volunteerism.

You are the Heart & Soul of Project Access San Diego Through your support of our flagship program, Project Access San Diego, we have been able to assist over 1,850 uninsured adults in our community to improve their health through access to specialty healthcare services. You have provided over $6.3 million in contributed healthcare services to community members since our program’s beginnings in December 2008! Thanks to more than 625 volunteer physicians providing specialty healthcare services to those who most need our help, we are getting people back to work, and able to care for their families. Without the generous support and dedication of all of our physician volunteers, hospitals and outpatient surgery centers, imaging, labs, physical therapy, and other ancillary health providers, hundreds of hard-working but uninsured adults would go without care every year. Thank you for being a hero to our community!

Get Involved San Diego County Medical Society Foundation needs you! Join us to volunteer for Project Access, or provide specialty consultations to primary care physician colleagues through eConsultSD, our HIPAA-compliant, web-based system from the comfort of your home or office. Attend an event, assist us to recruit fellow physicians, or provide educational opportunities for primary care physicians or medical students. Our first annual Golf Tournament on Thursday, February 28, 2013 at Del Mar Country Club was a huge success; we hope you can join us next year! Watch for news on our Fall Heroes de la Salud event. And please consider making a contribution to SDCMS Foundation to support our efforts at www.sdcmsf.org, or call us at 858.300.2777.

5575 Ruffin Road, Suite 250, San Diego, California 92123 p: 858.300.2777 f: 858.569.1334 n

32 marCH apri l 2013 2013

Daniel “Stony” Anderson, MD Sandra Freiwald, MD Paul Bernstein, MD And the Kaiser Permanente Saturday Surgery Day Team Spirit of Volunteering Drs. Anderson, Freiwald and Bernstein have championed Saturday Surgery Days at Kaiser Permanente since Project Access’ beginnings; October 2012 marked our 10th Surgery Day at KP. More than 150 physicians, nurses, physician assistants, and medical staff assure that patients regain their health through surgeries and GI procedures. The KP team is recognized as our heroes thanks to their dedication to Project Access patients; 342 patients have benefited from their care. The majority of PASD patients require just office consultations and procedures. 30% of patients require surgery or GI procedures, which occur during a Carlsbad or Kaiser Permanente Surgery Day, or are accommodated at our partnering hospitals and outpatient surgery centers throughout the year. Thank you to all of our physician volunteers-- you are all our heroes!!

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at 858-231-1231 or DPebdani@SDCMS.org SaN Di EGO pHYSiCiaN.OrG 33

classifieds physiCian pOsitiOns aVailaBle FaMily MeDiCine OppOrtunity in nOrth COastal san DiegO COunty (Vista): This is with a long-established group, which is physician owned and governed. Board-certified / board-eligible candidates only. Full time. If interested, please send CV to judy@cassidymg.com or call (760) 630-5487. [123] physiCian neeDeD iMMeDiately! Southern Indian Health Council is seeking a board-certified physician for family practice Mon–Fri, 8:00am–4:30pm. Must have CA medical license, DEA license, ACLS, BLS. We offer: competitive salary, health benefits, vacation pay, holiday pay, sick pay, CME and license reimburse, and paid malpractice coverage. No weekends. Contact: tdentice@sihc.org or HR phone (619) 445-1188, ext. 308 or ext. 307, or HR fax (619) 659-3145. Visit www. sihc.org. [120] lOOKing FOr a BOarD-CertiFieD FaMily physiCian Or nurse praCtitiOner: Family medicine, private practice, part- or full-time coverage, North County San Diego. Looking for a board-certified family physician or licensed nurse practitioner who would like to join our small practice and provide personable, high quality, patient-centered care. Great position for someone who wants to practice medicine and make a difference. Flexible hours. Online access to EMR. We have a great team and would like to work with someone who can contribute to that experience. Please email CV to familypracticeNC@gmail.com. [111a] seeKing DerMatOlOgist: Established dermatology and cosmetic surgery practice in Encinitas is seeking a part-time to possible full-time dermatologist. We are currently looking for a dermatologist who is interested in doing general dermatology, dermatologic surgery, and possibly cosmetic procedures. Need physician with excellent patient rapport and interpersonal skills. Confidence and excellent surgical skills are key for this position. Compensation competitive! Please respond to this ad with cover letter and CV to dana@ doctorlashgari.com. [109] peDiatriC physiCian — nOrth COunty health serViCes, OCeansiDe: Full-time lead pediatrician position in FQHC community health center. Please forward your CV to Araceli Mercado at araceli.mercado@ nchs-health.org or fax to (760) 736-8740. [105] ChieF, Maternal anD ChilD health: The County of San Diego Health and Human Services Agency is seeking a qualified medical doctor to fill the position of chief, Maternal, Child, and Family Health Services (MCFHS) branch. The chief is responsible for the management and administration of public health programs that improve the health of mothers, children, and their families. For more information on the position, including minimum requirements and how to apply, please visit www.sdcounty.ca.gov. [092] aDult psyChiatrist — part tiMe: The County of San Diego’s Health and Human Services Agency is seeking a psychiatrist for 10-hour weekdays, parttime shifts for adult outpatient clinic work. Our psychiatrists work with a dynamic team of medical and nursing professionals to provide outpatient treatment, telepsychiatry, inpatient and emergency services, and crisis intervention. More information about psychiatrist positions can be found at www.sdcounty.ca.gov/ hr. Interested candidates may contact Lita Santos at (619) 563-2782 or email a CV to lita.santos@sdcounty. ca.gov. [091] aDult psyChiatrists: County of San Diego’s Health & Human Services Agency seeks FT/PT psychiatrists for key components in the Behavioral Health Division’s continuum of care. Our psychiatrists work with a dynamic team of medical and nursing professionals to provide outpatient treatment, telepsychiatry, inpatient and emergency services, and crisis intervention. More information about psychiatrist positions can be

found at www.sdcounty.ca.gov/hr. Interested candidates can contact Gloria Brown at (858) 505-6525 or email CV and cover letter to gloria.brown@sdcounty. ca.gov, and Marshall Lewis, MD, Behavioral Health clinical director, at marshall.lewis@sdcounty.ca.gov. Please specify clinical area of interest. [090] seniOr physiCian: The County of San Diego, Health and Human Services Agency’s HIV/STD/Hepatitis clinic has an immediate opening for a licensed physician with at least three (3) years of recent post-internship training or experience in internal medicine or as a general practitioner to manage a team responsible for planning and directing clinic services. Must be available to work flexible schedules at multiple sites, including some evenings is expected. Please read more about the senior physician job description, benefits, and application process at www.sdcounty.ca.gov/hr. Please include a copy of your CV along with your online application. For questions, please contact Gloria Brown, human resources analyst, at (858) 505-6525 or at gloria.brown@sdcounty.ca.gov. [088] MeDiCal DireCtOr / physiCian / anD Other healthCare pOsitiOns: Southern Indian Health Council is seeking a FT, board-certified physician, M–F, 8:00am–4:30pm. Must have current CA medical license, DEA license, ACLS, BLS. We offer: a competitive salary, health benefits, vacation, holidays, sick, CME and license reimbursement, and malpractice coverage. Forward resume to tdentice@sihc.org or fax to (619) 659-3145 or website at www.sihc.org. Contact: tdentice@sihc.org or HR phone (619) 445-1188, ext. 308 or ext. 307 or HR fax (619) 659-3145. [048] OppOrtunity KnOCKs FOr BC/Be DerMatOlOgists: Live in one of the country’s most desirable locations and practice with a premier San Diego multispecialty medical group! Sharp Rees-Stealy Medical Group is looking for BC/BE dermatologists. Competitive first-year compensation guarantee, excellent benefits, and shareholder eligibility after two years. Unique opportunity for professional and personal fulfillment while living in a vacation destination. Please send CV to Physician Services, 2001 Fourth Avenue, San Diego, CA 92101. Fax: (619) 233-4730. Email: Lori. Miller@sharp.com. [084] priMary Care JOB OppOrtunity: Home Physicians (www.thehousecalldocs.com ) is a fast-growing group of house-call doctors. Great pay ($140–$220+K), flexible hours, choose your own days (full or part time). No ER call or inpatient duties required. Transportation and personal assistant provided. Call Chris Hunt, MD, at (858) 279-1212 or email CV to hpmg11@yahoo.com. [037] seeKing BOarD-CertiFieD peDiatriCian FOr perManent FOur-Days-per-WeeK pOsitiOn: Private practice in La Mesa seeks pediatrician four days per week on partnership track. Modern office setting with a reputation for outstanding patient satisfaction and retention for over 15 years. A dedicated triage and education nurse takes routine patient calls off your hands, and team of eight staff provides attentive support allowing you to focus on direct, quality patient care. Clinic is 24–28 patients per eight-hour day, 1-in-3 call is minimal, rounding on newborns, and occasional admission, NO delivery standby or rushing out in the night. Benefits include tail-covered liability insurance, paid holidays/vacation/sick time, professional dues, health and dental insurance, uniforms, CME, budgets, disability and life insurance. Please contact Venk at (619) 504-5830 or at venk@gpeds.sdcoxmail.com. Salary $ 102–108,000 annually (equal to $130–135,000 full-time). [778] praCtiCe WanteD We Buy urgent Care Or reaDy MeD-CliniC: We are interested in purchasing a preexisting urgent care or ready med-clinic anywhere in San Diego County. Please contact Lyda at (619) 417-9766. [008]

OFFiCe spaCe / real estate get 1 MOnth Free rent: A 1215 sq.ft. office space is available for rent in a well-maintained professional building. This space is ready for move in. It has three large offices, a break room, a common space, a private bathroom, and a big reception area. Excellent for accounting office, insurance, medical office, chiropractor, real estate, complementary/alternative medicine, physical therapy, chiropractic, acupuncture, massage/ body work, etc. Located close to Rancho Bernardo, Scripps Ranch, 4-S Ranch, Poway. Get one month of free rent in the form of two half-months of rent. $1,400 net is all you pay, no NNN added. Please call Heather for any questions at (858) 909-9033 or email olgald@ palomar-neurosurgery.com. [124] OFFiCe spaCe in enCinitas — 477 n. el CaMinO real: 1600sf beautiful office occupied by a dermatologist. One or two rooms available. May have the space to yourself for a full day and some half days. Prime location in a multi-specialty, four-building complex with an outpatient surgery center. Close to Scripps Encinitas Hospital. Available immediately and staff available if needed. Great for solo physician or a small group seeking a presence in North County. Please contact Dana at (760) 436-8700 or at dana@doctorlashgari.com [122] reCently renOVateD MeDiCal OFFiCe in Vista, CaliF. aVailaBle FOr suBlease: Available Wednesday, Thursday, and Friday for $500 per room. Staff can also be provided based on need. Near TriCity Hospital. Call or email for more details: (858) 7359879, drsameergupta@gmail.com. [119] sCripps-XiMeD MeDiCal OFFiCe spaCe FOr suBlease part-tiMe: Newly renovated office for sublet 0.5–1.5 days per week. Perfect for Scripps physician desiring on-campus presence. Full use of 1100sqft, including reception, business office, three exam rooms, consultation room, nurses station, and breakroom. Suitable for internist, internist specialty, surgeon, or psychiatrist. Receptionist help available if needed. Call (858) 354-1088. [118] spaCe FOr suBlease in alVaraDO hOspital area in san DiegO: Two rooms and the front desk area available for sublease in comprehensive neurology and epilepsy center. This is a newly remodeled nice and bright office. Includes some storage area, chart area, and doctor’s parking. Walking distance to Alvarado Hospital. Five-minute drive to Grossmont Hospital. Call (619) 582-2595 to schedule viewing and for questions. [117] prOFessiOnal spaCe FOr lease: La Jolla Office Space: Two private offices with shared reception, waiting area, and exam / consultation rooms in new office. Five exam rooms. On-site X-rays with tech available. Office is close to Scripps Memorial Hospital. In Golden Triangle between 805 and 5 freeways. Terms negotiable. Please contact Kathy Koppinger at (858) 678-0455. [113] luXuriOus / BeautiFully DeCOrateD DOCtOr’s OFFiCe neXt tO sharp hOspital FOr suB-lease Or Full lease: The office is conveniently located just at the opening of Highway 163 and Genesee Avenue. Lease price if very reasonable and appropriate for ENT, plastic surgeons, OB/GYN, psychologists, research laboratories, etc. Please contact Mia at (858) 279-8111 or at (619) 823-8111. Thank you. [836] nOrth COast OFFiCe spaCe tO suBlease: North Coast Health Center, 477 El Camino Real, Encinitas, office space to sublease. Newly remodeled and beautiful office space available at the 477/D Building. Occupied by seasoned vascular and general surgeons. Great window views and location with all new equipment and furniture. New hardwood floors and exam tables. Full ultrasound lab and tech on site for extra convenience. Will sublease partial suite for two exam rooms and office work area or

To submiT a classified ad, email Kyle lewis at Klewis@sdcms.org. sdcms members place classified ads free of charge (excepting “services offered” ads). Nonmembers pay $150 (100-word limit) per ad per month of insertion. 34 apri l 2013

will consider subleasing the entire suite, totally furnished, if there is a larger group. Plenty of free parking. For more information, call Irene at (619) 840-2400 or at (858) 4520306. [041] Full- anD part-tiMe OFFiCe spaCe in utC: in 8th floor suite with established neuropsychologists and psychiatrists in Class A office building. Features include private entrance, staff room with kitchen facilities, active professional collegiality and informal consultation, private restroom, spacious penthouse exercise gym, storage closet with private lock in each office, soundproofing, common waiting room and parking. Contact Christine Saroian, MD, at (619) 6826912. [862] sCripps enCinitas COnsultatiOn rOOM/eXaM rOOMs: Available consultation room with two examination rooms on the campus of Scripps Encinitas. Will be available a total of 10 half days per week. Located next to the Surgery Center. Receptionist help provided if needed. Contact Stephanie at (760) 753-8413. [703] neW — eXtreMely lOW rental rate inCentiVe — eastlaKe / ranChO Del rey: Two office/medical spaces for lease. From 1,004 to 1,381 SF available. (Adjacent to shared X-ray room.) This building’s rental rate is marketed at $1.70/SF + NNN; however, landlord now offering first-year incentive of $0.50/SF + NNN for qualified tenants and five-year term. $2.00/SF tenant improvement allowance available. Well parked and well kept garden courtyard professional building with lush landscaping. Desirable location near major thoroughfares and walkable retail amenities. Please contact listing agents Joshua Smith, ECP Commercial, at (619) 442-9200, ext. 102. [006] pOWay / ranChO BernarDO — OFFiCe FOr suBlease: Spacious, beautiful, newly renovated, 1,467 sq-ft furnished suite, on the ground floor, next to main entrance, in a busy class A medical building (Gateway),

next to Pomerado Hospital, with three exam rooms, fourth large doctor’s office. Ample parking. Lab and radiology onsite. Ideal sublease / satellite location, flexible days of the week. Contact Nerin at the office at (858) 521-0806 or at mzarei@cox.net. [873] share OFFiCe spaCe in la Mesa: Available immediately. 1,400 square feet available to an additional doctor on Grossmont Hospital Campus. Separate receptionist area, physician’s own private office, three exam rooms, and administrative area. Ideal for a practice compatible with OB/GYN. Call (619) 463-7775 or fax letter of interest to La Mesa OB/GYN at (619) 463-4181. [648] BuilD tO suit: Up to 1,900ft2 office space on University Avenue in vibrant La Mesa / East San Diego, across from the Joan Kroc Center. Next door to busy pediatrics practice, ideal for medical, dental, optometry, lab, radiology, or ancillary services. Comes with 12 assigned, gated parking spaces, dual restrooms, server room, lighted tower sign. Build-out allowance to $20,000 for 4–5 year lease. $3,700 per month gross (no extras), negotiable. Contact venk@cox.net or (619) 504-5830. [835] share OFFiCe spaCe in la Mesa Just OFF OF la Mesa BlVD: 2 exam rooms and one minor OR room with potential to share other exam rooms in building. Medicare certified ambulatory surgery center next door. Minutes from Sharp Grossmont Hospital. Very reasonable rent. Please email KLewis@SDCMS. org for more information. [867] nOnphysiCian pOsitiOns aVailaBle seeKing QualiFieD pa: Wellspring Health is a growing Integrative Endocrinology practice located on the Scripps Memorial Hospital campus, and we are seeking a qualified PA. This is an exceptional opportunity as we integrate both allopathic medicine with a holistic, Ayurvedic approach. Wellspring Health has been fea-

tured on the Dr. Oz show, highlighting the practice’s unique methodology. This is a full-time position. Compensation will be based off of collections, with the opportunity to become a partner in the practice. If you would like to set up an interview, please call (858) 646-0400 and speak with Laura, or email your CV to manager@mywellspringhealth.com. [125] lOOKing FOr a BOarD-CertiFieD FaMily physiCian Or nurse praCtitiOner: Family medicine, private practice, part- or full-time coverage, North County San Diego. Looking for a board-certified family physician or licensed nurse practitioner who would like to join our small practice and provide personable, high quality, patient-centered care. Great position for someone who wants to practice medicine and make a difference. Flexible hours. Online access to EMR. We have a great team and would like to work with someone who can contribute to that experience. Please email CV to familypracticeNC@gmail.com. [111b] nurse praCtitiOner Or physiCian’s assistant: Established, busy pain management practice in Mission Valley is looking for a nurse practitioner or physician’s assistant, preferably experienced in pain management or family practice. Knowledge of controlled substance prescriptions and regulations is required. Interpretation of diagnostic tests and the ability to apply skills involved in interdisciplinary pain management is necessary. We offer a competitive salary and benefit package that provides malpractice coverage, CME allowance, as well as an excellent professional growth potential. Please email your curriculum vitae/resume to paindoctorstaff@hotmail. com. [094] physiCian assistant Or nurse praCtitiOner: Needed for house-call physician in Coachella Valley (Palm Springs / Palm Desert). Part time, flexible days/hours. Competitive compensation. Call (619) 992-5330. [038]

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

SaN Di EGO pHYSiCiaN.OrG 35

San Diego PhySician Celebrates 100 Years!

The Bulletin of the San Diego County Medical Society April 1967

In celebration of 100 years of publication of San Diego Physician (formerly known as The Bulletin), we will be reprinting throughout the year excerpts from past issues, and we will devote our December 2013 issue to recognizing the achievements of the official “Bulletin” of the San Diego County Medical Society. If you would like to contribute in any way to our December issue, please email Editor@SDCMS.org. Thank you!

the bulletin

Through the Looking-Glass Reports on Current Developments BY JOH N M. RUMS EY

This is a series of articles featuring taped inter, views with your five representatives to the AMA delCMA Local the CMA and the Chairman of egation. It is intended to bring you their views on the facing s action itical some of the medical-pol physician of today. reQuesTIoN: With Governor Reagan’s statement five cently that MediCal will bankrupt the state within years is there a possibility that there may be a major rs? revision in either benefits or payments to the vendo the ANsweR: Governor Reagan’s comment about most the even that fear the s costs of MediCal expose enthusiastic supporters of extensive welfare and mediis, cal care programs are expressing privately. That us. r devou may which er monst a d create they have 19 MediCal is California’s Public Law 89–97, Title al medic Implementation. It is not possible to give good its t withou and hospital care to a vast number of people being expensive.

36 apri l 2013

Our law makers instead of assuming the “prudent to man” position of assaying first how much we have of t amoun this only for cting spend — and then contra desirwere s service what first d services; rather decide ted able, actually and politically, then hopefully predic limits. tant exorbi too not costs within However, the voice in the wilderness, that is the American Medical Association, predicted catastrophic g to levels of costs, which predictions are now provin is done be ally have been too modest. What will eventu to: have either will anyone’s guess. Obviously, they

a. Find the money to pay for it b. Restrict the services they provide c. Reduce the amounts paid for the services d. Find some other method of providing services. To be very realistic, I would call your attention to from the difficulty from a political standpoint of taking usly previo any one, or any group, something you have voter. given him — particularly when he is a

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