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San Diego County Medical Society

2006 IN 2006, WITH MANY SAN DIEGO COUNTY PHYSICIAN PRACTICES NEARING COLLAPSE under the burden of a broken healthcare financing system, and with the number of uninsured and underinsured patients across the nation rising further still, the U.S. healthcare system continued its decade-long march back to the center of the political stage. In early 2007, Governor Schwarzenegger and other state legislators, both Democratic and Republican, put forth reform proposals to address these and other healthcare challenges. As the discussions around healthcare reform in California take shape in 2007, and as growing national attention is drawn to the issue with the 2008 presidential election, physicians in San Diego County, across California, and in every state in the nation must speak with a united voice to ensure the viability of our practices and the health of our patients. No one is better positioned to address the larger systemic problems facing healthcare today than physicians speaking as one while working closely with their elected representatives. The San Diego County Medical Society (SDCMS) and the California Medical Association (CMA) will continue to lead the discussion in California to ensure that physicians are well represented and that our interests and the interests of our patients are protected. SDCMS works hard on behalf of our member physicians and their office staffs by ADVOCATING for physicians locally, in Sacramento, and in Washington, DC, by offering to our members tangible member BENEFITS, by COMMUNICATING to our members what they need to know when they need to know it in order to save them time and money, and by ENGAGING our members in the issues so that they can be part of the solution! Working together, SDCMS physicians are “Physicians United for a Healthy San Diego.�


2006 Legislation Sponsored by CMA

CMA

What SDCMS Does for Our Physicians

sponsors many bills every year — in addition to tracking hundreds of bills annually — that cover measures affecting every aspect of healthcare in California.

Advocacy

5% MEDI-CAL PROVIDER RATE CUT ELIMINATED SDCMS and CMA worked closely with Senator Denise Ducheny to eliminate this devastating cut by enacting SB 921. SDCMS leadership travelled to Sacramento to personally lobby every San Diego County legislator to support this bill. SDCMS also worked with The San Diego Union-Tribune to publish a front-page article and an op-ed in opposition to this egregious attack on access to care for our most vulnerable patients.

Benefits

CALIFORNIA DEPARTMENT OF PUBLIC HEALTH CREATED The enactment of SB 162 was a huge win for CMA, which has long sought to rescue public health from the massive California Department of Health Services.

Communications

PROHIBITION OF PHYSICIAN PARTICIPATION IN EXECUTIONS BILL PUSHED AB 1954, which would have prohibited the Department of Corrections from utilizing physicians in executions, died in committee. CMA will continue to push for passage of similar legislation. REDUCTION IN MEDI-CAL PROVIDER APPLICATION BACKLOG FOUGHT FOR SB 1353 would have expedited the Medi-Cal provider enrollment process. Unfortunately, the governor vetoed the bill, saying it could create opportunities for fraud. Until SDCMS-CMA ensures applications are approved in a timely manner, member physicians can get their applications expedited by calling SDCMS at (858) 565-8888.

Engagement Foundation

$5 Million in Your Pockets

CMA’S RICO

class action lawsuit, challenging the rapacious tactics of the forprofit managed care industry, saw settlements by Health Net, Anthem/WellPoint, and Humana in 2006, with United and Coventry the only remaining defendants. The Anthem/WellPoint settlement alone brought $465,891 to UCSD, $449,513 to Scripps Clinic Medical Group, $427,037 to Sharp Rees-Stealy Medical Group, $287,479 to Emergency and Acute Care Medical Corporation, $274,238 to Anesthesia Services Medical Group, $153,322 to Children’s Specialists of San Diego, and $109,416 to Sharp Mission Park Medical Group. In total, San Diego physicians received $3,911,406 from the Anthem/WellPoint settlement in 2006. The Health Net settlement brought $189,887 to Scripps Medical Group, $145,327 to Sharp ReesStealy Medical Group, and $103,933 to Anesthesia Services Medical Group. In total, San Diego physicians received $1,148,496 from the Health Net settlement. As of the end of 2006, CMA’s RICO lawsuits against Aetna, Cigna, Health Net, Prudential, Anthem/WellPoint, and Humana have returned $384,000,000 to physicians and more than $1,000,000,000 in prospective relief — your SDCMS-CMA dues dollars hard at work!

Delivering Your Message!

MORE THAN 50 SDCMS

member physicians delivered compelling testimony at a Department of Managed Health Care (DMHC) public hearing on September 25, 2006 — held in San Diego at SDCMS’ urging — in response to proposed regulations by Governor Schwarzenegger in the summer of 2006 that would have prohibited billing patients for emergency services provided by non-contracting physicians. Supporting the testimony of hundreds of physicians from organized medicine delivered across the state, CMA sent DMHC extensive written comments, calling the proposals “flatly illegal” and a threat to the quality and availability of emergency care throughout the state. SDCMS-CMA strongly oppose (and continue to fight against) any DMHC proposal that would place the interests of Wall Street-driven insurers before those of physicians, irreparably harming access to care by denying physicians the right to bill for services rendered.

25% Workers’ Compensation Increase

RESULTING DIRECTLY

from CMA lobbying, physicians who perform medical-legal evaluations for injured workers received a 25% reimbursement increase effective July 1, 2006.

L E G E N D

Financials Your Health Plan Victories • CMA Lobbied DMHC to Force PacifiCare/United Healthcare to Make Its Contract Consistent With the Knox-Keene Act • CMA Forced Aetna to Pay for Multiple E&M Services With Modifier 57 • CMA Forced Aetna to Pay for CAD Mammography and Myocardial Perfusion Testing • CMA Forced Aetna to Pay for EKGs Billed With E&M Codes Without Modifier 25 • CMA Fought to Have Blue Cross Spend 85% of Every Premium Dollar on Medical Care, Instead of the 78.9% It Does Spend — CMA Continues This Fight • CMA Forced Blue Cross to Withdraw Its Controversial Endoscopy Payment Policy • CMA Lobbied DMHC to Expand Its Jurisdiction Over “Discount Health Plans”

Your Patients Receive Emergency Funding

AFTER HEAVY LOBBYING including a widely publicized South Bay rally organized by SDCMS working with South Bay physicians, the governor implemented emergency funding on January 12, 2006, to have the state as a stopgap measure continue to pay for Medicare Part D drugs for Medi-Medi patients for 15 days, saving thousands of lives and unnecessary hospital admissions.

by CMA, coupled with protests across the state,


SDCMS Membership Grows 9% in 2006

INCREASING

our membership numbers in each of the past five years, the San Diego County Medical Society has outperformed every

other county medical society in California! 2,400

SDCMS Member Physicians: 2006: 2390 2005: 2195 2004: 2163 2003: 2056 2002: 2029

2390

2,350 2,300

2,200

our portfolio of member benefits in 2006, SDCMS continues to search for ways to increase the value of membership with the goal of returning to each member his or her dues in tangible member benefits. FULL-TIME SDCMS PHYSICIAN ADVOCATE & OFFICE MANAGER ADVOCATE SDCMS has a full-time physician advocate and a full-time office manager advocate on staff to help you and your office staff at any time with any question or need you may have!

BILLING SOLUTIONS DISCOUNT SDCMS member physicians receive a 50% discount on startup fees (a $500 savings) and a $33 per month services credit ($396 savings per year per physician) with CHMB Solutions, SDCMS’ endorsed billing services company.

2195

2,150

2163

2,050

2056 2029

2 0 0 2

2 0 0 3

2 0 0 4

2 0 0 5

2 0 0 6

SDCMS Income 2006-2007 Sponsorships: 6%

EXPANDING

PROFESSIONAL LIABILITY INSURANCE DISCOUNT Eligible SDCMS member physicians receive a 5% discount from The Doctors Company on their professional liability insurance, saving current TDC insureds hundreds, if not thousands, of dollars.

2,250

2,000

Your Expanded Member Benefits

AMA/CMA Commissions: 2% Investments: 25%

Advertising & Sales: 10% Dues: 57%

FREE CMA ON-CALL DOCUMENTS SDCMS-CMA members can access CMA’s online medical-legal library of over 300 up-to-date documents with specific legal and practice management information on nearly every aspect of medical practice, along with hundreds of sample letters, free of charge. WORKERS’ COMPENSATION INSURANCE DISCOUNT SDCMS members save potentially thousands of dollars on annual premiums through Zenith — with the average savings at 15%! AUTOMOBILE INSURANCE DISCOUNT SDCMS-CMA members receive discounts from both the Automobile Club of Southern California (AAA) and Mercury Insurance Group, potentially saving you hundreds of dollars a year. FREE SDCMS 2005 COMPENSATION SURVEY In 2006, SDCMS released the results of our 2005 “San Diego Physician Compensation Survey” to our member physicians, free of charge. EPOCRATES CLINICAL REFERENCE GUIDES DISCOUNT SDCMS-CMA members receive 30% off of one-year subscriptions and 35% off of two-year subscriptions to Epocrates’ clinical reference guides, with students and residents receiving a 50% discount. FREE HOTLINE ASSISTANCE SDCMS-CMA offer our members free access to a Reimbursement Hotline [(888) 401-5911], a Legal Information Hotline [(415) 882-5144], a Legislative Hotline [(866) 462-2819], and a Confidential Hotline [(213) 383-2691].

SDCMS Expenses 2006-2007 Website & Database: 4% Strategic Planning: 8%

General & Administration: 28%

Membership Recruitment & Retention: 6%

Advocacy: 18% Communications: 18%

Growing San Diego Physician & “News You Can Use”

8,000 PHYSICIANS

in San Diego County now receive San Diego Physician magazine every month as a result of negotiations that spanned much of 2006. Along with “News You Can Use” — SDCMS’ enewsletter, which regularly goes out to nearly 3,000 San Diego County physicians and healthcare stakeholders — and CMA’s many email newsletters, SDCMS brings to our members exactly the information they need to know when they need to know it so that they can save precious time and money, all the while keeping themselves abreast of the latest medical, local, state, and federal news important to them! To sign up to receive “News You Can Use,” send Tom Gehring, SDCMS CEO, an email at Gehring@SDCMS.org.

Your New Website: www.SDCMS.org

LAUNCHING

our new website in 2006, SDCMS brings to its members and their patients the convenience of searching for the information they need when they need it, as well as helpful resources, such as online classifieds, seminar webcasts, calendar listings, a physician bulletin board, legislative advocacy resources, and much more.

Your Voice Is Being Heard ... and Sought!

SOLIDIFYING

our relationships with local media in 2006, SDCMS has become known as the go-to resource on healthcare matters in San Diego County. SDCMS physician leaders are contacted almost daily by local print and broadcast journalists and producers to deliver original editorial content and to comment on myriad healthcare topics. SDCMS is frequently cited in The San Diego Union-Tribune, The San Diego Business Journal, and The North County Times, as well as on KPBS television and radio, KGTV Channel 10 (ABC), KNSD TV (NBC 7/39), XETV (Fox 6), and KFMB Channel 8 (CBS). Your voice is being heard! Some of the stories covered in 2006 relying heavily on SDCMS assistance: Paradise Valley Hospital Sale • The San Diego County Safety Net Crisis • Healthcare Access and Quality Issues • Walk-in Medical Clinics • Alvarado Hospital Sale • Patient Access to Care • San Diego County’s 2006 Top Doctors • The “Balance Billing” (Billing for Services Rendered) Crisis of Late Summer, Early Fall • Molina HealthCare and Medi-Cal Patients • Health Information Technology Mandates • Electronic Health Records • Tobacco Tax (Prop. 86) • Cross-Border Health Crisis • A Daily Transcript Healthcare Roundtable With Eleven SDCMS Physicians • The Looming Physician Shortage • Medicare Part D • Health Savings Accounts • The Looming Crisis in Healthcare Financing.


2006 Legislation Killed by CMA

CMA FIGHTS

to defeat many bills every year that would have serious, negative repercussions on the practice of medicine.

Medicare Reimbursement Cuts Stopped!

TWICE IN 2006,

INFORMED CONSENT FOR PRESCRIPTION MEDICATION OFF-LABEL USE BILL KILLED! AB 2856 would have required a physician to obtain informed consent from a patient before prescribing a prescription medication for off-label use. After staunch opposition from CMA, working closely with legislators, AB 2856 was withdrawn by its author.

physicians had to lobby their legislators to reverse Medicare reimbursement cuts, first after a January 1, 2006, 4.4% cut took effect, and then again at the end of the year when a 2007 5.1% cut loomed. In large measure due to pressure put on it from the physicians of organized medicine, Congress reversed the 2005 cut in February 2006 and stopped the proposed 2007 cut at the last minute in 2006. SDCMS, along with San Diego County’s congressional representatives, understands that this cycle of Medicare cut threats and retractions cannot continue. SDCMS-CMA continue to fight to eliminate the Sustainable Growth Rate (SGR) formula and replace it with the Medical Economic Index (MEI), which is used to calculate reimbursements for health plans, hospitals, and nursing homes, and which would have increased physician payments 2.8% in 2007. In the interim, SDCMS-CMA will fight in 2007 to stop the scheduled January 1, 2008, 10% Medicare physician reimbursement cut.

PRESCRIPTION DRUG LABELING REQUIREMENT BILL KILLED! AB 657 would have required physicians to ask patients if they wanted the intended purpose of the drug to be placed on the label. After rigorous opposition from CMA against continued physician mandates, AB 657 failed in committee.

Help With Your Medicare Participation Decisions

ACUPUNCTURE PRACTICE BY HEALTHCARE PROFESSIONALS BILL KILLED! AB 2152, a mode-of-practice infringement bill, would have required physicians who wished to incorporate acupuncture into their practices to be separately licensed by the Acupuncture Board. With CMA strongly opposed, AB 2152 failed in committee!

MOTORCYCLE HELMETS LAW GUTTING BILL KILLED! AB 2427 would have gutted the motorcycle helmet law. With strong opposition by CMA, AB 2427 failed in committee. DISCOUNT HEALTH CARDS AND PROGRAMS BILL KILLED! AB 2855 would have legalized “discount health programs” that sell lists of physicians to uninsured individuals. After vigorous opposition from CMA, AB 2855 was withdrawn by its author. MANDATORY DEPRESSION CME BILL KILLED! SB 524, which would have added mandatory CME on depression, was defeated on the Assembly floor and later amended to a subject of no interest to CMA. PHYSICAL THERAPISTS BILL SIGNED Among its few disappointments in 2006, CMA, though it fought hard against it, saw the governor sign AB 2868, which authorizes physical therapists with doctorates to use the term “doctor” in written and verbal communications, but only as long as it is clarified that their doctorate is in physical therapy or in a related health science. ORAL AND MAXILLOFACIAL SURGERY BILL SIGNED Notwithstanding fierce opposition from CMA, and even though CMA killed a similar bill in 2005, the governor signed SB 438 in 2006, allowing oral and maxillofacial surgeons to perform certain cosmetic procedures.

PHYSICIANS NEED HELP

assessing the economic impact of continued Medicare cuts on their practices. SDCMS-CMA in 2006 worked hard to supply its member physicians with the data they need to decide whether or not to participate in Medicare. • On December 6 and 7, 2006, SDCMS offered to its members a “What Are My Medicare Contractual Options?” seminar, and will offer the same in 2007. • SDCMS-CMA helped its physicians review their private payor contracts that tie their payment rates to Medicare (an especially large problem in San Diego County). • In 2007, SDCMS-CMA will embark on an aggressive campaign to overhaul the entire physician payment system with a long-term solution. A fair, long-term solution is long overdue. It is time for CMA to take the national lead to ensure that the Medicare program fulfills its mission of protecting access to quality care for the nation’s seniors.

SDCMS Sponsors Pain Management CME Program

PARTNERING

with San Diego Hospice and UCSD, SDCMS sponsored a heavily discounted CME program for SDCMS members, with dates offered throughout the year, for physicians to complete their required 12 credit hours in pain management and the treatment of terminally ill and dying patients before the December 31, 2006, deadline.

GPCI Inequity Approaching Resolution

SDCMS IS TAKING THE FEDS

to court! Ted Mazer, MD, SDCMS president, has fought long and hard to address the current Geographic Practice Cost Index (GPCI) inequity that results in San Diego County’s physicians receiving 5.5% less in Medicare reimbursements that what they would be entitled to if San Diego County were a stand-alone county, annually shortchanging San Diego County’s physicians approximately $24 million. SDCMS fought hard in 2006 for a congressional fix, continuing to drive the GPCI problem locally by obtaining signatures from all of our congressional representatives on a document to the Speaker of the House of Representatives, asking for a resolution to the problem. In 2007, with the discrepancy increasing to negative 7%, SDCMS, working with a coalition of underpaid California counties, has begun the process of taking the federal government to court to get this egregious attack on San Diego County’s physicians resolved once and for all.

SDCMS Participates in Safety Net Study

SDCMS PARTNERED

with other healthcare stakeholders in 2006 and worked with the Abaris Group consultants to produce the San Diego County Healthcare Safety Net Study. SDCMS plans to continue to play a central role in studying the healthcare safety net of our community with the potential to rethink the delivery of safety net services within San Diego County.

Medicare Advantage Plans Told to Increase Fees

SDCMS-CMA ADVOCACY

pushed the Centers for Medicare and Medicaid Services to have fee-for-service Medicare Advantage (MA) plans “pay the same as Medicare using the same rules, including the Deficit Reduction Act fee increase.” Although the federal budget package reversed the 4.4% Medicare physician cut that took effect January 1, 2006, many MA plans have not yet adjusted their payments.

SDCMS Physician Becomes CMA Speaker

JAMES T. HAY, MD,

SDCMS’ 2001 president, became speaker of the CMA House of Delegates in 2006. SDCMS as well, with its unparalleled growth in membership, is set to take on a third CMA trustee in 2007.

“Status Quo No More!”

JOE DUNN, ESQ.,

a termed-out state senator from Orange County, was named the new chief executive officer of CMA in 2006. Dunn, an attorney first elected to the California Senate in 1998 and re-elected in 2002, has promised a new start for CMA: “Status quo no more!”


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“Physicians United for a Healthy San Diego”

PRSRT STD U.S. POSTAGE PAID San Diego, CA Permit #99

5575 Ruffin Road, Suite 250 San Diego, CA 92123

San Diego County Medical Society SDCMS Expands Its Robust Schedule of Seminars & Involvement Opportunities in 2006

EXPANDING

our 2006 seminar offerings, SDCMS looked to our members and their staffs for topic ideas and times/locations most convenient to them. All SDCMS seminars are FREE TO SDCMS MEMBERS AND THEIR STAFFS as a benefit of membership! • • • • • • • • • • •

Medical Reserve Corps Volunteer Training — March 16, 18 Office Managers Forum: Employment Law Update — March 17 Disaster and Shelter Medicine Following Hurricanes Katrina and Rita — March 28 Joint Conference on Pain Management and Palliative Care — April 8-9 Preparing to Practice: What Residents & Young Physicians Need to Know Before They Begin Their San Diego Practice — April 22 Medical Reserve Corps Volunteer Training — June 1, 3 Office Managers Forum: Regulatory Compliance and Your Office — June 7, 8 Taking Charge: Contract Analysis and Preparing for Negotiations — July 19 Medical Reserve Corps Volunteer Training — July 20, 22, August 23, 26 Media Training for Physicians — September 16 Medical Reserve Corps Volunteer Training — September 21, 23

A capacity crowd attended one of SDCMS’ many Office Managers Forums, held throughout the year at SDCMS’ office — free to SDCMS members and their staffs.

• Joint Conference on Pain Management and Palliative Care — September 23-24 • Closing the Loop: Essential Tips for Appropriate Patient Handoffs, Follow-up, and Follow-through — October 4, 5 • Office Managers Forum: Tap Dancing With Toxic Patients — October 12 • Joint Conference on Pain Management and Palliative Care — October 21-22 • Disaster Preparedness for San Diego Surgeons: Hurricane Katrina Lessons Learned — October 24 • Medical Reserve Corps Volunteer Training — October 25, 28 • Preparing to Practice: What Residents and Young Physicians Need to Know Before They Begin Their San Diego Practice — November 4 • What Are My Medicare Contractual Options? — December 6, 7 • Joint Conference on Pain Management and Palliative Care — December 8-10 SOCIAL GATHERINGS • SDCMS Open House — April 28 • Residents and Young Physicians End of Summer Pool Party — September 9 • 2006 “Top Docs” Gala — October 21

Dr. Carol Young, (standing left, facing camera) 2005 SDCMS president, joined her young physician colleagues at Dr. Mazer’s house for a young physicians social.

San Diego County Medical Society 5575 Ruffin Road, Suite 250, San Diego, CA 92123 Telephone: (858) 565-8888 Fax: (858) 569-1334 Email: SDCMS@SDCMS.org Website: www.SDCMS.org


Your SDCMS Foundation 2006 Annual Report OUR MISSION: “addressing unmet San Diego health care needs for all patients and physicians through innovation, education and service”

ACCOMPLISHMENTS • A $313,400 grant was received from the Blue Shield Foundation for our Emergency Department Medical Home Project (EDMH). In February 2007, the SDCMS Foundation began working with local emergency departments to lower non-emergency visits by diverting patients who qualify to community health centers for their primary care. • $33,000 was received from Sanofi-Aventis for website hosting of the consumer health education materials. • Project Access (PA) is almost ready to go public. PA is an innovative physician volunteer initiative designed to expand access to comprehensive medical care for uninsured and underinsured people who live in San Diego County. The case statement is almost ready for funding solicitation. • $30,000 was added to the Simon-Hertzka Fund for Medical Student Advocacy Training from Martin & Pam Wygod and the WebMD Foundation. There is now over $80,000 in that fund. • SDCMS Foundation will partner with San Diego Magazine for next year’s online and silent auction. • Working with UCSD to establish five scholarships to continue to attract the best and brightest medical students to San Diego.

UCSD medical students join Sen. Christine Kehoe, Dr. James Hay, Dr. Robert Hertzka, and Aron Fleck in Senate chambers during a legislative advocacy training trip to Sacramento. Left to right: Daniel Ghalchi, Chester Yarborough, Amanda Lamand, Robert Basseri, Shirin Alonzo, Dr. Robert Hertzka, Yalda Azarmehr, Senator Christine Kehoe, Lindsay Frost, Dr. James Hay, Albert Kashanian, Veronica Fair, Kamyar Shahedi, Chris Moriates, and Aron Fleck.

FOCUS ON PATIENTS & PHYSICIANS Through a series of stakeholder interviews, along with an assessment of healthcare in San Diego County, the SDCMS Foundation established the following six initiatives: 1) Improving Access to Care: Ensuring San Diego County residents have access to the quality healthcare they need regardless of their socio-economic status. 2) Physician Service to the Community: Connecting our talented retired and practicing physicians to organizations in the community that desperately need their volunteer services. 3) Providing Practical Consumer Health Education: Providing online patient education materials translated into all threshold languages in San Diego County, at a fourth-grade reading level. 4) Improving Medical Technology: Increasing access to critical patient information at the point of care in order to enhance patient safety throughout the region. 5) Supporting Medical Students: Low-interest student loans, scholarships, and grants to qualifying San Diego County resident medical students, as well as public policy education that instructs medical students about the impact of legislation on their ability to serve patients. 6) Endowing our Programs and Initiatives: Securing San Diego’s healthcare future.

YOUR VISION REALIZED In May of 1968, SDCMS formed the Association for Medical and Paramedical Education and Research (AMPER) to support San Diego County students who were pursuing careers in medicine and paramedical services by giving them lowinterest loans. Since 1992, AMPER has supported 31 students with loans totaling more than $250,000 (1). In June of 2003, the unrestricted proceeds from AMPER enabled SDCMS to broaden AMPER’s scope by creating the San Diego County Medical Society Foundation (SDCMS Foundation). Approximately 50 percent ($250,000) continues to be designated for the Medical Student Support Program and 50 percent to the greater good of the San Diego community. (1) These figures understate the total number of students assisted and dollars loaned as they reflect only 14 years of available data verses 38 years of service. As well, it was the practice at the time to delete records once students fulfilled their loan commitments.

SDCMS FOUNDATION ASSETS ( $622,713 ) 10%

28%

11% 13%

1% 37%

37% . . . . . Unrestricted, Medical Student Loans ($234,584) 28% . . . . . Unrestricted, General ($173,130) 13% . . . . . Endowment, Simon-Hertzka Fund for Medical Student Advocacy Training ($80,559) 11% . . . . . Restricted, Project Grant Income ($66,769) 10% . . . . . Unrestricted, Student Loans Outstanding ($64,094) 01% . . . . . Restricted, Simon-Hertzka Fund for Medical Student Advocacy Training ($3,577)

REVENUES 12%

6%

EXPENSES 14%

35%

43% 18%

15%

32% 35% . . . . . 32% . . . . . 15% . . . . . 12% . . . . . 06% . . . . .

Grants Special Events Contributions Interest and Investment Income Other

25%

43% . . . . . 25% . . . . . 18% . . . . . 14% . . . . .

Program Services Special Events Fund Development Administrative


2006