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2008 MAGGIE AWARD WINNER

OFFICIAL PUBLICATION OF THE SAN DIEGO COUNTY MEDICAL SOCIETY

AUGUST 2008

SUPPLYING YOUR OFFICE MANAGER

WITH THE TOOLS TO DO THE JOB

OFFICE MANAGER ADVOCACY ISSUE THE

“ P H Y S I C I A N S U N I T E D F O R A H E A LT H Y S A N D I E G O ”


Richard E. Anderson, MD, FACP Chairman and CEO, The Doctors Company


We proudly announce SCPIE and The Doctors Company have united. Together, we set a higher standard. We aggressively defend your name. We protect good medicine. We reward doctors for their loyalty. We ensure members benefit from our combined strength. We are not just any insurer. We are now the largest insurer of physician and surgeon medical liability nationwide. On June 30, 2008, The Doctors Company and SCPIE officially joined forces. With the addition of SCPIE, we have grown in numbers, talent, and perspective—strengthening our ability to relentlessly defend, protect, and reward our 43,000 members nationwide. Endorsed by the San Diego County Medical Society since 2005, The Doctors Company remains committed to protecting your livelihood and reputation. To learn more about our professional liability program for SDCMS members, call (858) 452-2986, or visit us at www.thedoctors.com.


Contents

VOL. 95 | NO. 8

OFFICE MANAGER ADVOCACY ISSUE THE

[ F E A T U R E S ] THE TOOLS TO DO THE JOB

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The Top 10 Risk Management Issues • When Patients Complain • Revenue Cycle Management • The Balanced Scorecard • Making a Contract • Coder Do’s and Don’ts • Choosing the Right Electronic Medical Record • Creative Attraction and Retention

E X C L U S I V E S ]

Insurance-related Items to Review With Your Practice Manager • Find the Best EHR/EMR System for Your Practice • Increase Managed Care Revenue • Collections Success VISIT SANDIEGOPHYSICIAN.ORG FOR THESE ARTICLES AND MORE

[ D E P A R T M E N T S ]

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CONTRIBUTORS: This Issue’s Contributing Writers EDITOR’S COLUMN: Physicians Caught in a Reimbursement Squeeze SEMINARS: SDCMS’ 2008 Seminars and Events COMMUNITY HEALTHCARE CALENDAR ASK YOUR PHYSICIAN ADVOCATE BRIEFLY NOTED

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16 18 20 38 41 44

INTERVIEW WITH DR. PREM REDDY FROM SWITZERLAND TO SAN DIEGO TO HAWAII: A Measles Virus Journey JUNE 2008 AMA ANNUAL MEETING HIGHLIGHTS SDCMS FOUNDATION: “The Pulse” PHYSICIAN MARKETPLACE: Classifieds TACKLING “NON-BENEFICIAL TREATMENT”


Contributors RON ANDERSON

Mr. Anderson is the director of business development for CHMB Solutions.

LYNETTE CEDERQUIST, MD MAXINE INMAN COLLINS LOUISE COLLINS

Dr. Cederquist is co-chair of SDCMS’ San Diego Bioethics Commission.

Ms. Collins is a coding and billing instructor with Practice Management Institute (PMI).

Ms. Collins is a product manager for HealthMatics EHR, a product of Allscripts.

JEFFREY J. DENNING

Mr. Denning is a principal management consultant with Practice Performance Group.

MARISOL GONZALEZ Ms. Gonzalez is your SDCMS physician advocate. She can be reached at (858) 300-2783 or at MGonzalez@SDCMS.org with any questions you may have about your practice or your membership. PAULA GOODMAN-CREWS

Ms. Goodman-Crews is co-chair of SDCMS’ San Diego Bioethics Commission.

ANNE HASSIDIM

Ms. Hassidim is a public health nurse with varied experiences in health program management, health promotion, and patient care services.

JEANNE MILLER

Ms. Miller is regional managing director for Medical Resources Staffing Services.

RONALD A. MITCHELL ALBERT RAY, MD

Mr. Mitchell is a certified public accountant and principal of AKT LLP.

Dr. Ray is SDCMS’ immediate past president and an alternate delegate to AMA.

PREM REDDY, MD Dr. Reddy, a cardiologist, owns Prime Healthcare Services with five other family members. Prime Healthcare owns several hospitals in Southern California, including Paradise Valley Hospital, the largest employer in National City. JOSEPH E. SCHERGER, MD, MPH

Dr. Scherger is clinical professor of family medicine at UCSD. He is also medical director of AmeriChoice, which administers San Diego County Medical Services. Dr. Scherger, along with editing San Diego Physician, is chair of the SDCMS Communications Committee.

DEAN E. SIDELINGER, MD KATHLEEN STILLWELL

Ms. Stillwell is regional patient safety risk manager for The Doctors Company.

KAREN WATERS-MONTIJO W. MICHAEL YOUNG

Dr. Sidelinger, a pediatrician, is the Deputy Public Health Officer for the County of San Diego.

Ms. Waters-Montijo is the chief of the County of San Diego’s Immunization Branch.

Mr. Young is a partner with Ladd Young Attorneys at Law.

Send your letters to the editor to Editor@SDCMS.org

EAST COUNTY DIRECTOR HILLCREST DIRECTOR KEARNY MESA DIRECTOR EDITOR MANAGING EDITOR ASSISTANT EDITOR

Joseph Scherger, MD, MPH Kyle Lewis Ketty La Cruz

EDITORIAL BOARD

Adam Dorin, MD Robert Peters, MD David Priver, MD Roderick Rapier, MD Joseph Scherger, MD, MPH

LA JOLLA DIRECTOR NORTH COUNTY DIRECTOR

SOUTH BAY DIRECTOR AT-LARGE DIRECTOR

YOUNG PHYSICIAN DIRECTOR RESIDENT PHYSICIAN DIRECTOR RETIRED PHYSICIAN DIRECTOR MEDICAL STUDENT DIRECTOR

Published by

PRESIDENT PUBLISHER DIR., BUSINESS DEVELOP. & MARKETING MARKETING & PRODUCTION MNGR.

William Tseng, MD Woody Zeidman, MD Roneet Lev, MD Thomas McAfee, MD Adam Dorin, MD Sherry Franklin, MD Steven Poceta, MD Wayne Sun, MD James Schultz, MD Douglas Fenton, MD Tony Blain, MD Vimal Nanavati, MD Anna Seydel, MD Jeffrey Leach, MD, Robert Peters, MD David Priver, MD Wayne Iverson, MD Paul Kater, MD John Allen, MD Kevin Malone, MD Mihir Parikh, MD Kimberly Lovett, MD Glenn Kellogg, MD Geraldine Kang

Jim Fitzpatrick Maureen Sullivan Heather Back Jennifer Rohr

SDCMS EXECUTIVE COMMITTEE PRESIDENT PRESIDENT-ELECT PAST PRESIDENT SECRETARY TREASURER COMM. CHAIR DELEGATION CHAIR BOARD REP. BOARD REP. LEGISLATIVE CHAIR EXECUTIVE DIRECTOR

Stuart Cohen, MD, MPH Lisa Miller, MD Albert Ray, MD Robert Wailes, MD Susan Kaweski, MD Joseph Scherger, MD, MPH Jeffrey Leach, MD Sherry Franklin, MD Robert Peters, MD Robert Hertzka, MD Tom Gehring

SDCMS CMA TRUSTEES

Theodore Mazer, MD Albert Ray, MD Robert Wailes, MD

OTHER CMA TRUSTEES

Catherine Moore, MD Diana Shiba, MD

AMA DELEGATES ALTERNATE DELEGATE

ACCOUNT EXECUTIVE PROJECT DESIGNER ADVERTISING ART DIRECTOR COPY EDITOR

James Hay, MD Robert Hertzka, MD Albert Ray, MD Lisa Miller, MD

Dari Pebdani Jessica Hedberg Geneen Montgomery Adam Elder

1450 Front Street • San Diego, CA 92101 • 619-230-9292 • Fax: 619-230-0493 • 800-600-CITY (2489) • www.sandiegomagazine.com 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 cpinfo@sandiegomag.com . San Diego Physician is published monthly on the first of the month. Subscription rates are $35.00 per year. For subscriptions, email Editor@SDCMS.org. [SAN DIEGO COUNTY MEDICAL SOCIETY (SDCMS) PRINTED IN THE U.S.A.]

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“Dispelling Hospice Myths”

For many, the word “hospice” is difficult to hear. It conjures up feelings of hopelessness and abandonment… but the realities are so much more promising. To help ease these concerns, VITAS has prepared a DVD that clarifies the many mistaken notions about hospice care and opens the door for meaningful choices when curative treatments are no longer effective. VITAS resources continue with educational materials and admissions consultations that gently build a clear understanding and confidence to address end-of-life needs. Call for a free copy and watch this DVD. See how a simple message can be most welcome to those who are facing a limited prognosis. VITAS can help.

Serving the San Diego area since 1995 1.800.93.VITAS www.VITAS.com


Editor’s Column

San Diego County Physicians Caught in a Reimbursement Squeeze

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an Diego County physicians in private practice face increasingly difficult times financially. While the costs of medical practice rise inexorably, reimbursement for medical care is declining. The downturn in reimbursement is especially problematic for a combination of reasons. First, San Diego County has an abundance of physicians in many specialties. The desirability of living here attracts many physicians who compete for a limited base of patients. In other areas less desirable to live in, physicians make up for declining reimbursement rates by working harder and seeing more patients. In the competitive climate of San Diego County, that option is less available. Secondly, San Diego County still has a dominance of HMO-style managed care. While managed care, with its fixed reimbursement determined by the health insurance plan rather than the physician, receded in most of the country during this decade, this did not happen in San Diego County. Elsewhere, the limited number of physicians simply refused to participate in such plans, and the insurance industry had to capitulate. Here in San Diego County, due to the competition for a limited base of patients, if one group of physicians refuses to participate in a health plan with

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lower reimbursement, another group will of the writing of this editorial) is planning a in order to get the patients. 10 percent reduction in reimbursement with Adding insult to this injurious situation, more reductions planned due to a “sustainMedicare, the health insurance plan for senable growth rate” formula enacted by Coniors, pays physicians differently in various regress in 1997. This law was a clear example of gions of the country. This geographic fixing a problem at the time by borrowing difference in reimbursement is based on hisfrom the future. Now that this future is here, tory dating back to the 1970s and has not physicians are facing cuts from Medicare that been changed, despite cause them to lose many attempts by unmoney caring for derpaid counties. San the patients. BeDiego County physiMost believe that there is cause of this, many cians are paid by plenty of money in health- physicians have Medicare the same rates care in America — $2.3 stopped seeing new as rural counties in Caltrillion by the latest esti- Medicare patients ifornia, such as Imperial mate — but as much as 30 and more are planCounty. San Diego percent of that money ning to do so. County physicians are Finally, Medidoes not go to those who paid lower for the same Cal, the state proprovide the care. care compared with gram for the poor, physicians in Orange or will cut physician Los Angeles County. The incorrect algorithm reimbursement by 10 percent (as of the in Washington, DC, computes that the overwriting of this editorial) in order to address head of office space and employees’ wages are the state budget deficit. Most physicians allower here, which is of course not true. Atready lose money seeing Medi-Cal patients, tempts to fix this geographic disparity in the and this further cut will drive out those who legislature have failed given that legislative efdo so out of a willingness to meet social forts for new money fail, and giving more to needs. In the past, physicians could survive San Diego County physicians would mean in practice seeing Medi-Cal patients taking money away from others. through “cost shifting” from patients with On top of this geographic disadvantage for higher reimbursement. Such higher reimSan Diego County physicians, Medicare (as bursement has all but disappeared for the

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reasons stated above, so treating Medi-Cal patients, especially with a further cut in reimbursement, is simply not feasible to stay in business. Cutting Medi-Cal reimbursement to physicians is a counterproductive action by the state since this will drive more patients to emergency rooms where the care is more expensive. All of this combines to form a “perfect storm” of inadequate reimbursement to run a medical practice. Physicians in small private practice are leaving the area or joining large groups. Those hanging in there are unable to recruit new partners due to the miserable financial situation. Many physicians wonder if private practice in San Diego County will survive. Given this bleak economic climate, many physicians are resorting to direct payment from patients. Some specialties, like plastic surgery, have always relied on a base of direct payment by patients. These physicians may be doing relatively better, but with the downturn in the overall economy, they are suffering too. When people have less money to spend, they will forgo medical treatment they would otherwise get. It is hard to see solutions to the reimbursement problems facing physicians in San Diego County. The combination of factors prevents any single solution from taking care of the problem. There are likely to be more major changes in healthcare financing with a new administration in Washington, DC. Most believe that there is plenty of money in healthcare in America — $2.3 trillion by the latest estimate — but as much as 30 percent of that money does not go to those who provide the care. Health insurance companies, pharmaceutical companies, and other corporations that supply the healthcare have done well in recent decades. The small nature of private medical practice puts physicians at a disadvantage in competing in the healthcare marketplace. Do not be surprised if there is some type of action among physicians to demand reimbursement that allows them to have sustainable medical practices.

ABOUT THE AUTHOR: Dr. Scherger is clinical professor of family medicine at UCSD. He is also medical director of AmeriChoice, which administers San Diego County Medical Services. Dr. Scherger, along with editing San Diego Physician, is chair of the SDCMS Communications Committee.

ADVERTISE HERE To run display advertising in San Diego Physician, please contact Dari Pebdani for information and rates. 619-744-0528 or darip@sandiegomag.com

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Seminars 2008 San Diego County Medical Society Seminars and Events OCTOBER

AUGUST SDCMS NEW MEMBER SOCIAL

CERTIFIED MEDICAL OFFICE MANAGER COURSE

Aug. 8, 6:00 p.m. – 9:00 p.m.

SEPTEMBER YOUNG PHYSICIANS SOCIAL

Along with its many social events held throughout the year, the SAN DIEGO COUNTY MEDICAL SOCIETY (SDCMS) strives to build a robust schedule of free seminars for our physician members and their staffs (attendance rates for nonmember physicians and their staffs vary by seminar).

Sep. 13, 3:00 p.m. – 8:00 p.m.

NOVEMBER RISK MANAGEMENT WEBINARS

Four Fridays: Oct. 10, 17, 24, 31, 9:00 a.m. 4:00 p.m.

Nov. 12, 11:30 a.m. – 1:00 p.m., and 6:30 p.m. - 8:30 p.m.; Nov. 13, 11:30 p.m. – 1:00 p.m.

SEXUAL HARASSMENT

RESIDENT AND NEW PHYSICIAN SEM-

TRAINING — FOR PHYSICIANS

INAR “Preparing to Practice: What You Need to Know Before You Begin Your Practice,” Nov. 22, 8:30 a.m. – 3:30 p.m.

Oct. 15, 6:30 p.m. – 8:30 p.m. SEXUAL HARASSMENT TRAINING — OFFICE MANAGERS FORUM

Oct. 16, 11:30 a.m. – 1:30 p.m.

DECEMBER YOUNG PHYSICIANS SOCIAL

Dec. 5, 6:00 p.m. – 9:00 p.m

For further information about any of these seminars or events, watch your emails and faxes, visit SDCMS’ website at www.SDCMS.org, call SDCMS at (858) 565-8888, or email us at SDCMS@SDCMS.org. Details may change as seminars approach – contact SDCMS to confirm.

ERRATUM: In the July 2008 issue of San Diego Physician (page 23), San Diego syphilis cases for 2007 were incorrectly reported. MSM syphilis cases in 2007 should have been reported as 290 instead of 209, and total syphilis cases in 2007 should have been reported as 345 instead of 554. Our apologies for this mistake.

Thank you for your membership!

SDCMS

Get In Touch ADDRESS: 5575 Ruffin Rd., Ste. 250, San Diego, CA 92123 TELEPHONE: Dareen Nasser, office manager, at (858) 565-8888 or at DNasser@SDCMS.org FAX: (858) 569-1334 CEO/EXECUTIVE DIRECTOR: Tom Gehring at (858) 565-8597 or at Gehring@SDCMS.org COO/CFO: James Beaubeaux at (858) 300-2788 or at Beaubeaux@SDCMS.org DIRECTOR OF MEMBERSHIP AND MEMBER SERVICES: Janet Lockett at (858) 300-2778 or at JLockett@SDCMS.org PHYSICIAN ADVOCATE: Marisol Gonzalez at (858) 300-2783 or at MGonzalez@SDCMS.org OFFICE MANAGER ADVOCATE: Lauren Wendler at (858) 300-2782 or at LWendler@SDCMS.org

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DIRECTOR OF EVENTS AND LEADERSHIP SUPPORT: Jennipher Ohmstede at (858) 300-2781 or at JOhmstede@SDCMS.org SDCMS FOUNDATION EXECUTIVE DIRECTOR: Aron Fleck at (858) 300-2780 or at AFleck@SDCMS.org SDCMS FOUNDATION ASSISTANT EXECUTIVE DIRECTOR: Tana Lorah at (858) 300-2779 or at TLorah@SDCMS.org DIRECTOR OF COMMUNICATIONS AND MARKETING: Kyle Lewis at (858) 300-2784 or at KLewis@SDCMS.org ASSISTANT EDITOR AND WEBMISTRESS: Ketty La Cruz at (858) 565-7930 or at KLaCruz@SDCMS.org SPECIALTY SOCIETY ADVOCATE: Karen Dotson at (858) 300-2787 or at KDotson@SDCMS.org LETTERS TO THE EDITOR: Editor@SDCMS.org GENERAL SUGGESTIONS: SuggestionBox@SDCMS.org

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Community Healthcare Calendar

PRIMARY CARE SUMMER CONFERENCE: OFFICE URGENCIES EMERGENCIES WHAT: This three-day course will focus on those patient situations requiring your urgent attention: hypertension, gynecology, ENT, ophthalmology, and cardiovascular urgencies. WHEN: August 1–3 WHERE: San Diego Marriott Hotel and Marina COST: $395 CME: 12 credits INFORMATION: Call (858) 652-5486 or email med.edu@scrippshealth.org.

MEDICAL SPANISH COURSE PRESENTED BY MEDICAL STUDIES ABROAD WHAT: The goal of this conference is to teach basic to intermediate medical Spanish language skills in the classroom and to implement the usage of these skills with native Spanish speakers in an immersion setting. WHEN: August 16–23 WHERE: Catamaran Resort Hotel, San Diego COST: $795 physicians CME: 20 AMA INFORMATION: Visit www.medicalstudiesabroad.com.

NEW ADVANCES IN INFLAMMATORY BOWEL DISEASE WHAT: This conference is intended for physicians, nurses, social workers, and others involved in the care of patients with Crohn’s disease or ulcerative colitis. WHEN: September 13 WHERE: Sheraton La Jolla Hotel COST: $125 INFORMATION: Call (858) 652-5486 or email med.edu@scrippshealth.org.

FRESH START’S 2008 SURGERY WEEKENDS WHAT: More than 100 volunteers join together to provide free reconstructive surgery and related medical services to disadvantaged children with physical deformities caused by birth defects, accidents, abuse, or disease. Both medical and nonmedical volunteers are needed to make children’s transformations possible. WHEN: Sept. 13–14; Nov. 1–2 WHERE: The Center for Surgery of Encinitas INFORMATION: Call (760) 448-2021 or visit www.freshstart.org.

19TH ANNUAL CORONARY INTERVENTIONS WHAT: This conference features live case demonstrations, lectures, and panel discussions that will discuss the state-of-the-art concepts and techniques of interventional cardiology.

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WHEN: September 17–19 WHERE: Hilton La Jolla Torrey Pines INFORMATION: Call (858) 652-5486 or email med.edu@scrippshealth.org.

2008 UPDATE ON PARKINSON’S DISEASE WHAT: This educational event will highlight all the changes in Parkinson’s disease management and treatment. WHEN: September 20 WHERE: Hilton La Jolla Torrey Pines COST: FREE CME: Available INFORMATION: Call (858) 273-6763 or visit www.pdasd.org.

2008 HEALTH AND WELLNESS FORUM: DEVELOPMENTAL DISABILITIES WHAT: This year’s conference will include five sets of workshops focusing on autism, genetics, early intervention, risk management, and special populations, as well as keynote presentations and a poster session/reception. WHEN: September 24–26 WHERE: Catamaran Resort Hotel, San Diego INFORMATION: Call (858) 534-3940 or email ocme@ucsd.edu.

THE CALIFORNIA HEART RHYTHM SYMPOSIUM WHAT: This conference will highlight what is known about basic arrhythmia mechanisms, how our clinical therapeutic strategies are driven by science, and how observations from clinical therapeutics have created new avenues for research. WHEN: October 2 WHERE: Manchester Grand Hyatt, San Diego COST: $300 CME: 15.5 AMA INFORMATION: Call (858) 534-3940 or email at ocme@ucsd.edu.

DESTINATION HEALTH: RENEWING MIND, BODY, AND SOUL WHAT: Experience a luxury vacation combined with lectures, workshops, and activities designed to empower you on your personal journey toward health and education. WHEN: October 12–17 WHERE: Kauai Marriott Resort and Beach Club, Kauai, Hawaii COST: Reduced rates for attendees: Garden View: $195; Pool View: $220; Renovated Rooms: $245; Run of Ocean: $245

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INFORMATION: Call (858) 652-5486, email med.edu@scrippshealth.org, or visit www.scripps.org/conferenceservices or www.scrippsintegrativemedicine.org.

THE LEUKEMIA AND LYMPHOMA SOCIETY’S LIGHT THE NIGHT WALK WHAT: This is a nationwide, annual fund-raising walk to celebrate and commemorate people whose lives have been touched by cancer. WHEN: October 24 WHERE: Qualcomm Stadium INFORMATION: Call (858) 427-6651 or email danielle.litke@lls.org.

THIRD ANNUAL HEART FAILURE AND ARRHYTHMIAS: FROM PREVENTION TO CURE WHAT: This program will update the primary care provider and practicing cardiologist on the latest treatments for heart failure and atrial arrhythmias as well as new therapies being developed. WHEN: November 1 WHERE: Paradise Point Resort INFORMATION: Call (858) 652-5486 or email med.edu@scrippshealth.org.

THE SCIENCE AND CLINICAL APPLICATION OF INTEGRATIVE HOLISTIC MEDICINE WHAT: The event’s course format includes lectures followed by question-and-answer sessions, experiential morning programs, and evening study groups. WHEN: November 17–21 WHERE: Paradise Point Resort, San Diego COST: Reduced Rates for Attendees: Garden Room: $192; Bayside Room: $219; Studio Garden Suite: $229; Studio Bay Suite: $259; Garden Bungalow Suite: $259; Bayside Bungalow Suite: $279 INFORMATION: Call (858) 652-5486, email med.edu@scrippshealth.org, or visit www.scripps.org/conferenceservices or www.scrippsintegrativemedicine.org.

NATURAL SUPPLEMENTS: AN EVIDENCE-BASED UPDATE WHAT: This course provides practical information for healthcare professionals who make nutritional recommendations or manage dietary supplement use. WHEN: January 22–25, 2009 WHERE: Paradise Point Resort, San Diego CME: Credits available. INFORMATION: Call (858) 652-5486, email med.edu@scrippshealth.org, or visit www.scripps.org/naturalsupplementsCME.


Ask Your Physician Advocate! By Marisol Gonzalez

Family Trusts, Reporting Syphilis, and Hearing-impaired Patients

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UESTION: Will a family trust protect your personal assets if you are sued for more than your policy limits? ANSWER: A family trust will not protect personal assets. An irrevocable trust (not your typical family trust) could protect assets if done properly. Consult a tax attorney.

UESTION: A patient is coming to us for follow-up care from a hospital, and they are hearing impaired. The patient’s sign language interpreter called us and told us that we would have to pay for the interpreter’s services. Is this true? ANSWER: Yes, in certain circumstances. According to CMA ON-CALL document #0802, “Sign Language Interpreters,” the ADA (American Disabilities Act) does not require the provision of any auxiliary aid that would result in an undue burden or in a fundamental alteration in the nature of the goods or services provided by a public accommodation. The determination of whether providing an auxiliary aid such as an interpreter constitutes an “undue burden” must be decided on a case-by-case basis. Contrary to the suggestions that have been made by some groups,

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UESTION: How do I report a new case of syphilis? ANSWER: Contact the San Diego County Community Epidemiology Branch of Communicable Diseases at (619) 515-6620. Sexually transmitted disease reports must include the specific causative agent, syphilis-specific laboratory findings, and any complications of gonorrhea or chlamydia infections.

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the law does not mandate the provision of an ASL interpreter in all cases. This ON-CALL document provides some suggestions to effectively communicate with hearing-impaired patients without having to hire an interpreter. You can contact me, Marisol Gonzalez, your SDCMS physician advocate, to obtain this document at (858) 300-2783 or at MGonzalez@SDCMS.org.

ABOUT THE AUTHOR: Ms. Gonzalez is

your SDCMS physician advocate. She can be reached at (858) 3002783 or at MGonzalez@SDCMS.org with any questions you may have about your practice or your memberMARISOL GONZALEZ ship.


y l f e i Br

Noted

San Diego Childhood Obesity and Diabetes Prevention Resource Database in the Works sk and you shall receive: A comprehensive database of obesity and diabetes prevention programs and services in San Diego County will soon be a reality. The information will be accessible by physicians and the general public by early next year through 2-1-1 San Diego, both online and via phone. Physicians are welcome to visit 2-1-1 at www.211sandiego.org to search for childhood obesity and diabetes resources. If you would like to list a resource not found in the database, please contact the 211 Resource Center at (858) 300-1200. Look for further information on this and other 2-1-1 resources in future issues of San Diego Physician.

A

Announcing Allscripts as a Preferred Vendor of the San Diego County Medical Society Allscripts is pleased to announce that it will offer preferred pricing to SDCMS members on the award winning HealthMatics® Office Practice Management and Electronic Health Records solution. This integrated PM and EHR solution offers state of the art technology that includes: • • • •

Complete work flow management P4P, clinical and financial reporting Advanced Scheduling Comprehensive Claims management

• • • •

E-prescribing with formularies Electronic orders and results Automated Health Maintenance Online Patient Portal

For more information please contact Jamie Smolin at 619.955.6929 or at jamie.smolin@allscripts.com. Visit us online at www.allscripts.com/healthmatics.

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The AMA Foundation Honors San Diego Physician Outstanding Leader in Medicine

If your medical license or privileges are on the line…

Rosenberg, Shpall & Associates, APLC A P R O F E S S I O N A L L A W C O R P O R AT I O N

iana R. Shiba, MD, secondyear ophthalmology resident at the Shiley Eye Center at the University of California, San Diego, has been named a recipient of the American Medical Association (AMA) Foundation’s 2008 Leadership Award, which provides medical students, residents/fellows, early career physicians, and established physicians from around the country with special training to develop their skills as future leaders in organized medicine and community affairs. The AMA Foundation honored 56 individuals with the award at its annual Excellence in Medicine Awards ceremony on March 31, 2008, in Washington, DC. Presented in association with the Pfizer Medical Humanities Initiative, recipients of the award are recognized for demonstrating outstanding non-clinical leadership skills in advocacy, community service, and education.

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Testimonial

Members Of The Firm: David Rosenberg, J.D. Tomas A. Shpall, J.D. Annette Farnaes, J.D. Steven H. Zeigen, J.D. Corey Marco, M.D, J.D. Jason L. Nienberg, J.D. Amy C. Lea, J.D. Wells Fargo Bank Plaza 401 “B” Street, Suite 2209 San Diego, California 92101 Telephone: (619) 232-1826 Facsimile: (619) 232- 1859 Email: RSALAW@yahoo.com

• More than 50 years of combined experience in Medical License/Hospital Privilege Disputes • Medical Board accusations • Hospital privilege disputes • Wrongful termination • Civil actions/Independent counsel for medical malpractice claims • Provider Membership Disputes/Exclusion • Medical Corporations/Partnership Formation/Disputes

“One of the best investments I’ve made has been becoming a member of the San Diego County Medical Society.”

ADVERTISE HERE To run display advertising in San Diego County Medical Society Membership Directory, please contact Dari Pebdani for information and rates. 619-744-0528 or darip@sandiegomag.com

— Dr. Chrystal E. de Freitas

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Interview Dr. Prem Reddy, Cardiologist, Founder, Prime Healthcare Services, Owner, Paradise Valley Hospital

Prem Reddy, MD

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technicians, dedicated lab technicians, and a system where we have more nursing staff that take the patients when they need admission quickly. That has become our model — efficiency — therefore, we rarely go on bypass.

AN DIEGO PHYSICIAN: Could you talk about your philosophy?

DR. REDDY: Originally, we started this philosophy of keeping the emergency departments more open because we were catering to managed care; our own patients weren’t able to come into our emergency room because our emergency room was on saturation. So we staffed our emergency departments more than others. We have dedicated radiology

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SDP: What’s the difference between Paradise Valley Hospital and the other hospitals/systems in San Diego County? DR. REDDY:

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Sharp and Scripps, and they have, in addition to the synergies of being bigger and of having a market presence, substantially captured managed care. So we’re competing, from our perspective, against big systems here. In addition, Paradise Valley Hospital faces a somewhat different market compared to the other markets. We have more Medi-Cal, less managed care, either HMO or PPO. SDP: Has your patient mix changed since you took over? DR. REDDY: No, actually it’s the same as when Adventist owned the hospital. Now, even though we are a for-profit hospital, it’s only on paper — we do the same as not-forprofit hospitals.

Is your relationship with the community pretty much the same as what Adventist’s was?

SDP:


DR. REDDY: Exactly the same, no change. Except we probably see a little more uninsured than Adventist was seeing because we keep our emergency department open more than before. The market dynamics haven’t changed much, but the perception among some of the other hospitals that we don’t contract with managed care is not necessarily true because there aren’t any managed care players here. The only big managed care player is Community Health Group, with which we have a contract. We have a contract with the County and with Medi-Cal, and, of course, Medicare. Other than that, we get a few patients that belong to Sharp or Scripps. Of course they want a contract, but it doesn’t help us because we don’t get the volume other than through the emergency department.

Describe your personal experience with Paradise Valley Hospital since you’ve become the owner.

SDP:

When we took over this hospital, it was in very poor shape; it was losing about $1.5 million per month, and it needed a lot of infrastructure improvement. And then they were being reviewed by the Joint Commission and also by CMS — it was in a bad shape. We pulled all of our resources into this hospital and survived those two tests. Since then, we have put a lot of money into this hospital. We upgraded a lot of systems.

DR. REDDY:

SDP: Where was the million-plus per month

disappearing to? DR. REDDY: We cut down a lot of inefficiencies. We don’t have a big corporate overhead here now. We run a lean machine; that’s one. Second, when you have less efficient equipment, your costs go up. Sometimes you have to put the moneys up front to see the efficiencies. We put probably $15 million into this hospital in the first year. SDP: Are you seeing positive results then?

I cannot say that we are making profits yet, but I could say that the losses we sustain are minimal now.

DR. REDDY:

SDP: Describe your experiences with the medical staff when you first came on board. DR. REDDY: We faced tough challenges with

the medical staff here, which we did not in other places. For one, the medical staff opposed Prime Healthcare Services because they wanted to buy this facility in partnership with somebody else. They didn’t realize it’s a very difficult enterprise to raise that kind of money to operate this kind of hospital — [one] that is losing money. But you know with physicians they have a lot of emotional feelings; you know they want to keep this hospital alive, and, on top of that, they had heard a lot of negative things that are not true about Prime Healthcare Services. What we do with all our hospitals is we sell the property to a real estate investment trust called REIT; that’s one way of financing our assets. But they interpreted it as if somehow we didn’t have a commitment to run it as a hospital. On the contrary, it’s the opposite. We only run these facilities as hospitals. So what is your commitment to REIT?

SDP:

DR. REDDY: REIT owns the building and they

lease it to us on a long-term, 30-year lease, which we could keep on extending for as long as we pay REIT’s payments. It’s the same thing like going to the bank and borrowing. Then why REIT instead of a bank? It’s because of certain tax benefits the REITs have as opposed to banks, so the REIT’s financing I see as a better way of financing. SDP: Did you have a lot of physicians leave? DR. REDDY: You know, actually nobody really

left. There had been some rumors. They realize now we’re very pro-physician, and I

am, personally, being a physician. SDP: What does it mean for you to be prophysician? DR. REDDY: We try to work with the physicians to improve efficiencies, quality. For example, we put a lot of efforts behind the physicians in achieving the core measures. What it does is not only improve our quality, it helps the physician quality because when you supply all this data to Medicare, their quality measures go up. In other words, I’m trying to bring the hospital and physicians on the same side. SDP: If you were to communicate one para-

graph that you wanted every physician in the county to read, what would that be? DR. REDDY: My advice to physicians would be that they have to be independent. They should work more in the political arena. It’s easy to bash a physician because a physician drives a better car and lives in a better home — nobody realizes how long it took the doctor to get there in the first place. The physician now is under substantial economic pressure to seek these contracts that pay less than the cost or at least don’t pay properly for their services. Managed care guys come and say, “You know, we’ll give you more volume,” and everybody signs up. So who’s getting more volume? They somehow think our hospitals are not signing up with all managed care, and therefore I’m kind of destabilizing the healthcare, and I say, you know, if everybody’s like a Wal-Mart, why do you need a boutique? Everything could be WalMart. But right now we need to offer the best care we believe we can offer, without everybody jumping on the bandwagon of HMO. The Blue Crosses of the world keep driving our payments down, and everybody will be working for a Blue Cross or Aetna; it’s another form of socialized medicine, except we’re working for profiteers.

This interview is one of an ongoing series of interviews with San Diego County hospital leaders conducted by San Diego Physician magazine. Neither San Diego Physician magazine nor the San Diego County Medical Society (SDCMS) supports or opposes any views expressed by an individual interviewed for the purposes of publication in San Diego Physician Magazine.

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County Public Health

From Switzerland to San Diego to Hawaii A Measles Virus Journey

By DEAN E. SIDELINGER, MD, MSED, KAREN WATERS-MONTIJO, MPH, AND T. ANNE HASSIDIM, RN, PHN, MSN tional children, three under the age of one and thus ineligible to receive routine MMR vaccination, were infected when the parents of the index case sought care at his pediatrician’s office.

n February 2008, the County of San Diego Immunization Branch investigated a measles outbreak that infected twelve children. None of the children infected with measles had been vaccinated — three because they were less than a year old and nine because their parents had chosen not to vaccinate their children against measles. The cases in this outbreak were just a fraction of the 103 cases of measles reported in the United States in the first five months of 2008. In the San Diego outbreak, a seven-yearold boy who had not been immunized against measles traveled to Switzerland with his family. Switzerland is in the midst of a nationwide measles epidemic, with more than 2,000 cases since November 2006, due in part to immunization coverage dropping below 90 percent. The child was infected with measles, becoming symptomatic after his return to the United States. Before he was diagnosed, the measles spread to his two siblings and five fellow students at his school. Four addi-

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To contain the outbreak, the County of San Diego Public Health Services, with the Immunization Branch taking the lead, investigated all suspected cases, coordinated with medical providers, and provided education and updates to the San Diego community. There were 682 children and adults with known exposures who were followed up as part of the outbreak response: • Sixty percent had evidence of full immunity • Twenty-six percent had received a single dose of measles vaccine • Nine percent were under one year old (not eligible for vaccination), and • Five percent had parent-signed personal belief exemptions (PBEs).

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At the height of the outbreak, 71 people were placed on voluntary quarantine. Exposures to measles occurred at the index case’s school, a preschool, a child-care facility, a swim school, and a physician’s office. Additional potential exposures occurred in grocery stores, restaurants, after-school activities, and a circus performance. One child traveled to Hawaii while infectious, potentially exposing travelers at the airport and on the flight. None of these public exposures resulted in any susceptible person contracting measles. During the response to the outbreak, 16 individuals received post-exposure prophylaxis with IgG and 16 received postexposure MMR vaccination. PRACTICAL TIPS

The outbreak highlighted the need for increased focus on infection control policies in outpatient physicians’ offices, urgent care centers, and emergency departments. In response to the outbreak, the Immu-


nization Branch staff has compiled practical tips for disease containment. The recommended measures are as follows: Infection Control Measures

515-6620 in San Diego or online Morbidity Reporting Form at www.dhs.ca.gov/forms/pdf/pm110-807.pdf ]. Medical Work-up

• Triage should be instituted at the time • Do not send the patient to a lab facility of the office visit. for serology. Draw blood for testing and • If patient has a febrile rash illness and complete form for appropriate tests (call history of travel in the prior three weeks, the local Public Health Laboratory with measles should be suspected. questions about what tests to order). • If measles is suspected, the following • For suspected measles, order measles measures should be implemented : (rubeola) IgM and IgG tests and im- Use a separate entrance, mask the pamunize patient if vaccination status is tient (or use other practical means of not current at the time of visit. source control), and immediately place • To minimize delays in determining a dithe patient in the exam room (use a agnosis, submit blood or a split of blood negative pressure room if available). to the local public health lab [(619) - Schedule visit for end of day and just 692-8500 in San Diego] so it can be exuse one room. pedited to the state lab, if needed. Patient Advice - Do not have the • Instruct families to patient circulate protect themselves to other stations The outbreak highlighted the and community in the office. need for increased focus on members by main- Close the door taining home isolaof exam room tion until the and limit access. infection control policies in diagnosis is deter- Keep the room mined. Ascertain closed off for at outpatient physicians’ ofthe vaccine status of least two hours other household after the visit is fices, urgent care centers, members as well as completed. visitors or care • Have face masks and emergency departments. givers coming to available in waitthe home. ing rooms with • Advise parent/patient that a report will recommendations for their use. be made to the health department and • Have separate well and sick waiting to expect a follow-up phone call. [In rooms with their own entrances and San Diego, Urgent Communicable check-in areas (if feasible). Disease Reporting contact info is (619) • Post a sign outside the office: “If you or 515-6620 weekdays and (858) 565your child has a rash or skin condition 5255 after hours.] that you think might be contagious, Workforce Safety please stay outside and have someone • As part of the hiring practice for ofnotify the receptionist.” fice/clinical staff, check immunization Contact Investigation status or provide vaccines for measles, • Note time of visit so records can be exmumps, rubella, hepatitis B, varicella , amined for other individuals potentially Tdap, and annual influenza vaccine. exposed in common spaces, if needed. Refer to the Immunization Action CoaliMedical History tion (IAC) website (www.immunize.org/ • Consider vaccine-preventable diseases as catg.d/p2017.pdf) for current Healthcare a diagnosis when it is known that the paPersonnel Vaccination Recommendatient has traveled; check the patient’s imtions. munization record in the medical record or immunization registry (see sidebar). Reporting

LESSONS LEARNED

• Notify the Public Health Department of the suspect case as soon as possible. Do not wait for testing results [(619)

• The cooperation of the medical community was key in maintaining high immu-

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nization coverage rates and in identifying persons at risk during the measles outbreak. • Clear pathways for obtaining, collecting, and sending laboratory specimens to appropriate testing locations were essential for prompt diagnosis. Pathways should be identified and communicated quickly to contain the outbreak. • Use of the San Diego Immunization Registry helped to quickly determine immune status of persons exposed. For additional information, please contact the San Diego Immunization Branch at (619) 692-8661.

ABOUT THE AUTHORS: Dr. Sidelinger, a pediatrician, is the County of San Diego’s deputy public health officer. Ms. Waters-Montijo is the County of San Diego’s Immunization Branch chief. And Ms. Hassidim is a public health nurse with varied experiences in health program management, health promotion, and patient care services.

QUESTION: Which patients need a second dose of MMR? ANSWER: If your response is “I don’t know” or “Sounds like a lot of work to find out!” consider the services of the San Diego Regional Immunization Registry (SDIR). By having patients’ immunization records in SDIR, a physician can find out who is missing a vaccine dose in less time than it takes to order lunch. The SDIR is a Webbased system that can help keep track of patients’ immunizations as well as track vaccine inventory. The registry can be used to forecast needed immunizations regardless of the age of the patient or the number of doses given. Medical providers receive personal attention from SDIR staff to help clinic staff incorporate this Web-based tool into the practice. For more information, call the SDIR Manager at (619) 692-8403.

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AMA June 2008 AMA Annual Meeting: California Delegation Highlights By ALBERT RAY, MD, SDCMS IMMEDIATE PAST PRESIDENT AND AMA ALTERNATE DELEGATE, AND GINNIE YEE, CMA STAFF PERSON

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change in family planning, access, care, and treatment legislation, such that surgical sterilization not be a reason for exclusion. 5. PROMOTION OF BETTER PAIN CARE: Amended resolution adopted to 1) commit to better access and delivery of quality pain care; and 2) encourage relevant specialties to collaborate. 6. MODERN CHEMICALS POLICIES: Substitute resolution adopted to 1) implement a national policy; 2) support restructuring the Toxic Substances Control Act; 3) support the strategic approach to international chemicals; and 4) encourage the training of health professionals about toxic chemical exposures.

MA Elections: Robert Hertzka, MD, elected to the Council on Medical Service. Kathryn Berndt, MD, elected Resident and Fellow Section (RFS) representative to the Surgical Caucus Executive Committee. Diana Shiba, MD, elected RFS vice speaker. CALIFORNIA RESOLUTIONS 1. PHARMACEUTICAL GRANTS AND GIFTS TO PHYSICIANS: Resolution defeated to 1) support

mandatory disclosure of financial relationships between physicians and pharma; and 2) require pharma to report payments over $100.

7. RATING SYSTEM FOR PROCESSED FOODS:

Amended resolution adopted to support a simplified, uniform nutrition rating system. 8. AIR POLLUTION AND PUBLIC HEALTH: Amended resolution adopted to 1) support increased physician participation regarding air pollution; 2) promote education and support efforts leading to significant reduction in fuel emission; and 3) adopt effective air pollution control strategies. 9. “ABSTINENCE ONLY” EDUCATION: Resolution referred to urge all mandates of abstinenceonly approaches be stopped.

2. REMOVING BARRIERS TO CARE FOR TRANSGENDER PATIENTS: Amended resolution adopted

to support insurance coverage for treatment of gender identity disorder recommended by physicians. 3. BLOOD CENTERS AND MEDICAL LIABILITY:

Amended resolution adopted to advocate that blood centers be covered under healthcare liability reform. 4. SURGICAL STERILIZATION AND FAMILY PACT ELIGIBILITY: Resolution adopted supporting a

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10. INTERNET MARKETING TO CHILDREN ON HEALTH:

Amended resolution adopted to 1) use the Internet for educating children about healthy lifestyles; and 2) partner with other organizations to promote Internet marketing to children about healthy lifestyles. 11. RECLASSIFICATION OF “ALCOPOPS”: Resolution referred asking to support regulations that would reclassify alcopops as a distilled spirit so that it can be taxed at a higher rate and cannot be advertised or sold in certain locations. 12. MINORS AND SEXUALLY TRANSMITTED INFECTIONS: Reaffirmed existing policy to support

1) physicians to consult with parents when possible in providing treatments to minors; and 2) legislation allowing patients 12–17 years of age to obtain vaccines to prevent sexually transmitted infections without parental consent. 13. HEALTHCARE COSTS OF VIOLENCE AND ABUSE ACROSS THE LIFESPAN: Resolution adopted to

1) urge Congress to commission the Institute of Medicine to issue a report on the impact and healthcare costs of violence and abuse across the lifespan; 2) encourage the NIH, the Agency for Healthcare Research


and Quality, and the CDC to conduct research on the cost savings resulting from health interventions on violence and abuse, and implement strategies advocating for increased research funding; and 3) encourage agencies to increase research funding on the impact and healthcare costs of elder mistreatment. 14. ELIMINATION OF THE 48-HOUR SIGNATURE RULE:

Resolution adopted to 1) request from the government data supporting the mandate that verbal orders from a physician be signed within 48 hours; and 2) request, in the absence of supporting data, that this requirement be rescinded and publicized in the press, the request and rationale. 15. HIV AND PUBLIC HEALTH PREVENTION SERVICES: Substitute resolution adopted to

work with the CDC to develop comprehensive risk counseling and services to be offered to persons with HIV infections that are modeled after persons with STDs. 16. FDA DRUG SAFETY POLICIES: Substitute reso-

lution adopted to monitor and respond, as appropriate, to the implementation of the drug safety provisions of the FDA Amendments Act of 2007 so that the FDA can more effectively ensure the safety of drug products for patients. 17. INTERNET PRESCRIPTIONS: Substitute resolution adopted to advocate for its model legislation on Internet prescribing as the best means to effectively regulate the sale of prescription drugs, including controlled substances.

OTHER KEY ACTIONS: 1. INDUSTRY SUPPORT OF PROFESSIONAL EDUCATION IN MEDICINE: Report referred. 2. STUDY INCENTIVES FOR CADAVERIC ORGAN DONATION: Amended resolution adopted for

modification of the National Organ Transplantation Act to rescind prohibition of “valuable consideration” for cadaveric organ donation so that studies of financial incentives for donation can be carried out.

18. HEALTHCARE QUALITY IMPROVEMENT ACT AMENDMENTS: Reaffirmed existing policy to

3. CENTERS FOR MEDICARE AND MEDICAID SERVICES POLICY ON HOSPITAL-ACQUIRED CONDITIONS — PRESENT ON ADMISSION: Amended report

review the Health Care Quality Improvement Act of 1986 to 1) reduce the opportunity for a hospital governing body or its medical staff to subvert the peer review process into a retaliatory weapon against physicians who advocate for quality patient care, or for primary economic purposes; and 2) increase the likelihood a peer review hearing process will be structured to assure fairness and justice.

adopted to 1) continue opposition to nonpayment; 2) ask CMS to evaluate changes as a result of HAC-POA law; 3) educate physicians about the HAC-POA law; 4) continue its education of CMS, Congress, and the public; 5) oppose coverage decisions of governmental and commercial health insurers; 6) study increased documentation physician requirements; and 7) study the effect of HAC-POA penalties.

How Would You Like To… Increase Cash Flow? Reduce Expenses? Improve Billing Efficiency? Decrease Accounts Receivable? TSC Accounts Receivable Solutions, an innovative medical accounts receivable recovery company, has been providing our customers with personalized service since 1992. TSC offers: ■ Bad-Debt Collections ■ Self-Pay Clean-Up ■ Insurance Re-Billing & Clean-Up ■ Back-Logged Accounts Receivable Liquidation ■ System Conversion Clean-Up Endorsed by:

Contact us to see how you can benefit from the expertise of TSC Accounts Receivable Solutions. SDCMS Members qualify for reward incentives.

Catherine Sherman 888-687-4240, x14 csherman@tscarsolutions.com ■ www.tscarsolutions.com

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THE

OFFICE ADVOCACY MANAGER ISSUE

SDCMS’ OFFICE MANAGER ADVOCATE, LAUREN WENDLER, IS HERE TO HELP!

Supplying Our Members’ Office Managers With the Tools to Do Their Jobs

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e at the San Diego County Medical Society (SDCMS), in addition to doing everything in our power to support our member physicians, understand that their office managers need our support as well. That is why we have on staff, in addition to Marisol Gonzalez, our full-time physician advocate, Lauren Wendler, our full-time office manager advocate! Lauren Wendler (formerly “Woods” — Lauren just got married in July … Congratulations, Lauren!) is here to help office managers with any questions they may have as they work hard to support you, our member physicians. Please share this issue of San Diego Physician with your office manager, and tell him or her that Lauren is ready to help at (858) 300-2782 or at LWendler@SDCMS.org. Thank you for your membership in the San Diego County Medical Society and the California Medical Association. Let us know how we can help!

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The Top 10 Risk Management Issues for California Medical Office Practices 10 Tips for Making Lemonade From Lemons: When Patients Complain Revenue Cycle Management: Top 10 Tips The Balanced Scorecard: The Top 10 Things to Watch Out For Top 10 Considerations When Making a Contract Top 10 Medical Coder Do’s and Don’ts: Tips for Getting Paid Top 10 Things to Look for When Choosing the Right Electronic Medical Record (EMR) Creative Attraction and Retention: Engaging Top Healthcare Support in a Changing Economy

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RISK O MANAGEMENT P ISSUES

For California Medical Office Practices By KATHLEEN STILLWELL, MPA, HSA, RN

hat are the most frequent risks facing the medical office practice today? What strategies can minimize risks that might result in patient problems and professional liability claims? The following list identifies frequent risk management issues and suggests strategies for your medical office practice.

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SDCMS MEMBER BENEFIT: Most SDCMS members who use The Doctors Company for their professional liability insurance receive a 5 percent discount on their insurance.

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Patient Termination: The Medical Board of California advises that physicians must provide emergency care and prescriptions to a patient for at least 15 days before termination. Give notice of the termination in writing and include the termination date in the letter. Send the termination letter by certified mail, return receipt requested, and by regular mail. Be sure to keep the return receipt and a copy of the letter in the patient’s medical record. Do not refill the patient’s prescriptions beyond the termination date. [Reference: CMA ON-CALL document #0805, “Termination of the PhysicianPatient Relationship,” www.cmanet.org.]

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Test Results Follow-up: Ensure the practice has a system in place for tracking all tests ordered. Follow up on test results that do not come back to the office. The physician should review and initial all test results prior to filing them in the patient’s medical record. The physician should advise the patient of any abnormal test results.

Missed Appointments: The practice should have a formal missed appointment tracking system. Follow up with the patient by telephone to determine why the patient failed to arrive and to reschedule the appointment. Document missed appointments in the patient record. Send a letter to patients who repeatedly miss appointments, explaining the importance of follow-up care to their overall health. At the point established by your office policy, consider terminating the patient-physician relationship. Scope of Practice: Medical office

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staff includes a variety of healthcare professionals. Never allow medical office personnel to Listen to your patients, and act outside the scope of their job descripobtain their input to learn tions, licensures, or certificaabout potential opportunities tions. Do not refer to medical assistants as “nurses,” and do for improving your office not imply to patients that a practice. Review and evaluate member of your office staff is licensed or certified if he or all complaints with your staff. she is not. Do not allow personnel to manage technology or medical equipment unless they have received appropriate training and, if necessary, are certified to operate the equipment.

Medication Management: During each visit, review

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the medication list with the patient (including all overthe-counter medications) and update accordingly. Provide the patient with a written medication list that includes dosage, directions for use, and side effects. There are many drug-drug and food-drug incompatibilities. Review a drug’s side effects and interactions with the patient. If the office

The guidelines suggested in this article are not rules, and they do not ensure a successful outcome. They attempt to define principles of practice for providing appropriate care. The principles are not inclusive of all proper methods of care nor exclusive of other methods reasonably directed at obtaining the same results. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider in light of all circumstances prevailing in the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

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distributes medication samples, record the medication lot number in the medical record. In the event of a medication recall, the practice must have a system in place for identifying samples that have been distributed.

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Documentation: Documentation is your primary de-

fense in the event of a lawsuit — additionally, the medical record is the method for clinicians to communicate about the patient’s plan of care. Remember to document the medical record objectively. Never point fingers at other physicians or clinicians. Do not impeach the integrity of the medical record by altering the record. Be sure to use approved abbreviations and to write legibly. If you use an electronic medical record (EMR), ensure that the system has a reliable backup and an appropriate disaster recovery program.

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Dealing With a Disruptive Patient: Do not allow a disruptive patient to disturb your practice, to abuse office staff, or to threaten the safety of staff or other patients. Set boundaries and learn to say “no” to disruptive patients. If a patient becomes violent, call 911. Do not hesitate to terminate a disruptive patient from your practice.

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10 TIPS

FOR MAKING LEMONADE FROM LEMONS When Patients Complain By JEFFREY J. DENNING

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Communication: Health literacy is an increasing risk issue for providers and patients. A patient’s limited understanding of medical and prescription instructions results in increased risks for the provider and the patient. Ensure that the patient understands instructions. Document the name and relationship of anyone acting as a patient’s translator. Consider using the Ask Me 3 communication tool for your patients. Ask Me 3, a free educational program sponsored by the National Patient Safety Foundation, is available at www.askme3.org.

hen patients complain, it’s a good sign. It means that they care enough about your practice to help you improve by letting you know how you can. They want to come back, but they want the experience to be better. That’s why the best practices value patient feedback — even in the form of complaints — as a way of improving patient service. Physicians rarely hear patient complaints firsthand. But nurses, receptionists, and billers hear plenty of them. Here are 10 ideas to make the most of the opportunity.

Patient Satisfaction: Listen to your patients, and

Listen. Ask the patient to explain what went wrong. Don’t interrupt and, if they’re angry, let them vent until they’re finished. It’s a good idea to move patients to a private area if they’re angry. That way, if they make a scene they’ll later regret, they’re less likely to be embarrassed. Take notes. By being seen to write, you dignify the patient’s message and prove you’re listening. Get all the details. Cover the five journalist’s questions: Who? What? When? Where? Why? Then, feed back to the patient what you understand the problem to be.

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obtain their input to learn about potential opportunities for improving your office practice. Review and evaluate all complaints with your staff.

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Medical Record Retention: The California

Medical Association (CMA) has concluded that while a retention period of at least 10 years may be sufficient, it recommends that all medical records be retained indefinitely or, in the alternative, for 25 years after the last date of treatment. Destroy medical records appropriately, and maintain an inventory of all records destroyed. [Reference: CMA ON-CALL document #1160, “Retention of Medical Records,” www.cmanet.org.]

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SDCMS MEMBER BENEFIT: Practice Performance Group has signed an agreement to offer SDCMS members practice management consulting discounts (equal to 10% or $500, whichever is larger), free half-day seminars at SDCMS (watch your faxes and emails), and a free one-year subscription to their newsletter. Call (800) 452-1768 or visit www.PPGConsulting.com.

ABOUT THE AUTHOR: Ms. Stillwell is regional patient safety risk manager for The Doctors Company, which provides onsie patient safety/risk management assesment and support services and telephone assistance to all insured physicans; call (800) 4212368, extension 1243. 24

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OFFICE MANAGER TOOLKIT

Remember: The practice is dependent on patients, not the other way around.

Be Sincere. Tell patients you understand; it gives

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them encouragement to give you the information you need to solve their problem. And express regret: “I’m sorry.” “This shouldn’t have happened.” “This is not up to our standard.” “I’m sorry you are upset.” Apologizing for the problem, even when it isn’t your fault, will go a long way to let patients know you care about them. Lots of medical office employees are too defensive, too early in the process. Instead, the message to the patient should be that he or she was right to complain.

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Explain. Look the patient in the eye and do your

best to describe what caused the problem. If you don’t know, promise to find out. But don’t make excuses. The patient doesn’t want to hear that it’s not your fault. This is particularly true when it is, in fact, the patient’s fault. Blaming your patient for problems won’t get you far, even if you’re right. Of course, sometimes patients just want to go on and on with their complaints. For these people, try to get out of the past and into the future by focusing on what they want you to do: “I’m sorry this has happened. What can I do now to make it right?”

Don’t Take It Personally. Some patients can be

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rude, even abusive. When confronted by a bully or a hothead, a nurse or receptionist should quickly offer the patient someone in authority: “Mr. Crabbe, I can see I’m not going to be able to help you. Let me get our administrator.” This is the equivalent of calling a cop, and the break in the action allows everyone to calm down. This is also a good technique if the employee is beginning to get angry or lose control. All practice employees should be instructed, “Don’t get mad. Don’t get argumentative. Get help.”

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Compensate. Offer helpful alternatives to make up for the inconvenience the patient has experienced. Don’t make a list of all the things you can’t do for the patient. Just get to

what you can do: “I’m sorry, we don’t participate with that plan. But let me give you a blank claim form and pre-addressed envelope to make it easy for you to submit your own claim.”

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Keep Your Word. Promise to correct the problem and then do it as soon as possible. Find a place to start and be seen by the patient doing something now. Make a call. Write it down. Provide a substitute. Then, follow up. “Mr. Crabbe, I’m going to attend to this personally.”

Set a Deadline. Explain how long it will take to correct the problem. Be realistic; you don’t want to overpromise and then risk another disappointment.

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Fix the Problem. Don’t fight, make it right. Smart retailers know you can’t win arguments with customers. Take a lesson from their files and give patients what they want as often as you possibly can. Explain to your staff that making exceptions to your normal policy for complaining patients does not represent a defeat for the practice or for the individuals involved. Instead, it’s just smart business.

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Stay in Touch. Keep close contact with the patient while the problem is being corrected. Give them plenty of feedback. If you promised to call the hospital but were unable to make contact by the end of the day, call the patient and let them know that. Remember: The Practice Is Dependent on Patients, Not the Other Way Around. Patients have plenty of choices for their healthcare these days. Don’t give them an excuse to choose someone else if you can avoid it.

ABOUT THE AUTHOR: Mr. Denning is a principal management

consultant with Practice Performance Group. Since 1978, he has worked in a consulting capacity throughout the nation with hundreds of practices in 39 states and has conducted more than 500 workshops, seminars, and speaking engagements in the United States and Australia. He can be reached at (858) 459-7878 or via the Web at PPGConsulting.com.

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REVENUE CYCLE MANAGEMENT

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By RON ANDERSON

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he revenue cycle begins when the patient appointment is made and only truly ends when the services rendered during that appointment are paid for by the responsible parties. For many physicians and practice executives, managing the revenue cycle is a constant struggle of cost over return and making the most out of the resources available. Whether you have the best resources to draw upon or those less desirable, here are a few ways to improve your collections, increase staff efficiency, and, ultimately, enable physicians to keep an eye on this portion of the business side of their practice.

TIPS

FRONT OFFICE Gathering and Verifying Quality Data: The

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adage, “Good Information = Good Results,” is true, and without current patient demographic and insurance information, the ability to get paid correctly and on time is impossible.

Point of Service Collections: With increasing pa-

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tient co-payment amounts, medical savings accounts, and health savings accounts, it is imperative to ensure every practice has policies and procedures to collect patient-due amounts at the time of service. Not only will this decrease accounts receivable, but it ensures that your staff has the time necessary to collect the “hard-to-collect” dollars from insurance companies and patients.

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Capturing Billable Charges: One of the worst

possible things is not capturing and billing all possible charges. Three important aspects to this are: • Make sure your fee schedule is set appropriately so you can get reimbursed the maximum amount available through your contracts with all payors. • Review coding trends to make sure all CPT codes are selected and billed for all services rendered. It is well worth the cost to use a certified coding expert if you do not have such a resource internally. • Make sure you incorporate simple, easy-to-use audit trails and points of reconciliation so that you can make sure all charges are posted and billed. This might include reconciling: superbills to patient appointments; surgery logs from hospitals, ambulatory surgical centers, and nursing home or SNF visits.

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BACK OFFICE Measuring Productivity: Dif-

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“Righting your ship” doesn’t necessarily mean cleaning house, but it does mean that you should always be looking for ways to “clean up” your practice to give you the best possible chance to survive for you as physicians, your staff, and your patients as well.

ferent people have different strengths and weaknesses and, as such, billers and collectors may vary in quantities of work each employee accomplishes. Having said that, it is vital to ensure you have enough staff to do all the necessary tasks so that charges, payments, and follow-ups are done without creating backlog or undone tasks. Creating benchmarks or productivity standards allows you to make sure you have proper staffing for your practice volume and allows you to measure efficiency of existing staff. Quality standards are equally important, so monitoring or periodically auditing staff work is vital to analyzing revenue cycle management.

Analyzing Payer Contracts:

The best staff using the best technology can still only produce the best results based on your current contracts. Clearly this is a challenging point to improve upon because certain payors or contracts are non-negotiable. However, if you clearly understand your key (top 15–20) payors based on patient volume, charges, or payments (all three are best to know) and then compare reimbursements of the top 15–20 procedures, you should be able to intelligently identify those payors and procedures that affect your collections.

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Accounts Receivable Metrics: Using industry standard benchmarks or metrics allows you to understand your practice AR as well as identify problem Receive a 50 percent discount on startup fees and a $33 per physician areas for further review and to corper month services credit. Contact Ron Anderson (CHMB Solutions) rect problem areas before they get at (760) 520-1340 or at randerson@chmbsolutions.com. out of control. There are many metrics to use, and we recommend these at a minimum (you must exclude capitated services and payments from this analysis to accurately assess your data): • Average Days Charges in AR Use the Best Resources Available: Too often we • Average Months Charges in AR see practices emotionally or financially attached to ex• Percentage of AR over 90 days (aged based on date on billing or isting practice management systems and/or staff withresponsibility, not date of service) out regard to how much those resources are actually • Net Collections Percentage costing the practice. Clearly there should be an expectation to make Formulas for these and other metrics are widely available from SDCMS, best use of investments in systems and training staff, but at some CMA, MGMA, or other healthcare professional organizations. point by avoiding hard questions practices will lose staff moral and Monitoring Cash Flow: Creating a simple spreadpotentially thousands of dollars. “Righting your ship” doesn’t necessheet or table to track daily receipts or deposits allows sarily mean cleaning house, but it does mean that you should always you to know where you are at any time during the be looking for ways to “clean up” your practice to give you the best month. The benefit here is to be aware of and react to possible chance to survive for you as physicians, your staff, and your cash flow problems before the end of the month. Some patients as well. practices create separate columns for time of service, inUse the Best Resources Available: surance, and patient payments received in the mail. This one is so important it is worthy of reitDenials/Underpayments: By tracking types erating. of denials (eligibility, bundling/coding, non-covered services) as well as by provider, practices can use this information to identify and resolve probABOUT THE AUTHOR : Mr. Anderson is director of business delems in the revenue cycle. The key point is then velopment for CHMB Solutions, which delivers business, clinical taking that information and incorporating modifications into the and technology solutions to transform physician practices. Visit www. point in the revenue cycle to effect positive change. Doing nothing chmbsolutions.com with that information will have a corresponding effect.

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THE BALANCED

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SCORECARD T

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Things to Watch Out For

hat is a balanced scorecard? Most medical professionals focus only on the financial perspective of running a practice. Short-term financial decisions put many practices at risk in the future. A balanced scorecard evaluates three other perspectives besides financial. They include learning and growth, patient, and internal processes. The internal process perspective includes operations management, innovation, patient relationship management, and compliance management. Process management is often overlooked, and leadership does not always allocate the proper resources and is often unaware of

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By RONALD A. MITCHELL, CPA helpful, new advances in technology and new ways of processing information. Learning and growth involves training your staff and physicians to utilize the technology and processes to their full advantage. It’s great to have the tools, but if they are not being used or used incorrectly, the return on investment is minimal. Healthcare is a service-oriented business. Patients will evaluate the quality of the medical practice based on the quality of the customer service they receive. Most patients know little about clinical medicine, but they know a lot about how they like to be treated. If they are treated poorly during a visit, will they respond quickly and cooperate with payment? Below is the basic information that all physicians and administrators should be held accountable for in managing a medical practice. Visibility of this information to leadership is a key component of accountability. Without “public” disclosure of the results, those being managed will believe that the data is not being acted upon. This information should be benchmarked against budget, prior year, and peers (industry comparison). If possible, it should be summarized on not more than two pages with graphs. Not all of the data is financial and may reflect the practice’s investment in tomorrow rather than today.

Healthcare is a service-oriented business. Patients will evaluate the quality of the medical practice based on the quality of customer service they receive.

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with human resource issues. There are very inexpensive tools (SurveyMonkey) that can easily gather quality information.

Days in Accounts Receivable: Formula = Total

Accounts Receivable ÷ Gross Fee for Service Charges (1/365). The higher number of days indicates a collection problem and potential with billing and collection follow-up. This should also be calculated by payer, as the cash problems may be caused by one payer.

Total Support Staff per FTE (Full-time Equivalent) Physician: This is an indicator to

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RBRVS by Physician: Measures the complexity and value provided by the physician. Eliminates distortions caused by different types of contracting and managed care.

Income Available to Physicians: This calculation is the amount of income generated by a practice to fund physician compensation, benefits, and other discretionary physician expenses. Most practices commingle this information with practice expenses.

SDCMS MEMBER BENEFIT:

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AKT, LLP provides SDCMS members with a 15 percent discount on standard rates for professional services, with an unconditional satisfaction guarantee: disappointed clients pay only what they thought the work was worth. Contact Ron Mitchell at (760) 431-8440 or at rmitchell@aktcpa.com.

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Aged Accounts Payable: Total accounts payable ÷ operating expenses (1/365). Indicator of how current operating expenses are being paid. A higher number may indicate cash flow problems.

Physician Compensation to Collections Ratio: Measures the income available to physi-

Patient Satisfaction: Many physician groups do

cian owners based on collections generated from the individual physician services.

not measure patient satisfaction. Payers today are forcing “pay-for-performance” reimbursement formulas that will require physicians to survey their patients. Even without insurance pressure, it makes good business sense to know how your patients feel about your service. The patient “experience” usually is a key influencer in the perception of quality of medical services.

Information Technology Cost: Cost

New and Established Patient Total: This is a patient “growth” indicator. The practice should track where new patients are coming from (patient referrals, yellow pages, physician referrals) so a “marketing” focus can be developed to expand the practice.

ABOUT THE AUTHOR: Mr. Mitchell, cer-

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evaluate whether your practice is over or understaffed in relation to the number of physicians. There are excellent benchmarks to measure your practice against the Medical Group Management Association (MGMA).

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of practice-wide data processing, computer, telephone, and telecommunications services as a percentage of revenue and per fulltime equivalent staff.

tified public accountant and principal, AKT LLP, can be reached at (760) 4318440. Visit AKT at www.aktcpa.com.

Employee Satisfaction: This is another indicator that most practices ignore. Employee turnover is a significant cost that is usually lost in the numbers. Find out your employees’ opinion on compensation, work-life balance, technology, and their managers. Good surveys can help eliminate “antidotal” information in dealing

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10 T O P

CONSIDERATIONS WHEN MAKING A CONTRACT Ask the Right Questions — Get the Right Answers By W. MICHAEL YOUNG

SDCMS MEMBER BENEFIT: SDCMS members receive a free consultation and discounts on corporate legal services. Call Ladd Young Attorneys at Law at (619) 564-6696.

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ny business needs people to do things for it, whether it is answering the telephone, delivering supplies, renting an office, or paying for services rendered. Businesses get those needs filled through contracts. Below are 10 key considerations when making a new contract.

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Think First. Why do you

want to enter into a contract? What is your goal? What will you do in return for what you want the other party to do? What factors may have an effect on your agreement? What might go wrong? Thinking through your deal beforehand will save you time and result in a better agreement.

Thinking through your deal beforehand will save you time and result in a better agreement.

Get It in Writing. Oral contracts are valid but not

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Make It Clear. Are there vague words or ambiguous terms? Is the document unnecessarily wordy? Are any defined terms inconsistently used? If so, have the document rewritten. Also, make sure that any blanks are filled in with the correct information.

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recommended for a transaction of any importance. If something goes wrong with an oral agreement, the other side will almost certainly not recall the terms of the deal as you do. Also, with a written contract, do not leave any terms to an oral understanding or side agreement. Make sure all the terms are in one written document.

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Who Are the Parties? Make sure that the name of your business is accurately stated, and the name of any other party is as well. Use full names for individuals. If the other party is an entity, always check the name through the California Secretary of State’s office online at http://kepler.sos.ca.gov/list.html. (While there, also check to see if the entity is listed as “active,” which means not suspended as an entity.) If the entity is required to be licensed, check the license at www.dca.ca.gov.

Understand It. Read everything, including the fine print. Attachments must be attached and reviewed, and also read any external documents referenced in the proposed agreement. Make sure you


OFFICE MANAGER TOOLKIT

know what it all means, and how the contract is to work. Get an explanation of anything you do not understand, and consult someone with expertise if you need to, such as an attorney.

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Watch the Money. What, when, and how will you

pay or get paid? What are the additional fees and charges? Will you have to pay sales taxes or personal property taxes, such as on leased equipment? What conditions may permit price changes? Are any estimates included reasonable?

Make It Complete. Make sure that every point important to you is included in the document. Not everything can be simple and short; add the terms you need.

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How Long Will It Last? If the transac-

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tion will be ongoing, such as an equipment lease, be clear on when it ends. Must you give notice of renewal and, if so, how and when? Will it automatically renew unless cancelled? Is there an option to extend the term, or cancel early, and how?

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Default? In more complex transactions, the remedies for inadequate performance should be spelled out. The remedy may vary depending on the type of default. Also, make sure there is complete contact information for someone to contact in case of trouble. Ask for Changes. There is nothing wrong in asking for better terms, or in suggesting better language. Errors must always be fixed before signing. Pre-printed forms can be changed too by crossing out and handwriting new language (make sure the changes are initialed!), or by adding an addendum or rider to the end of the document.

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ABOUT THE AUTHOR: Ladd Young assists SDCMS member physicians in the areas of real estate purchase and sales, leasing, finance, management and operations, business acquisition and sale, corporation, limited liability company and partnership formation and operation. SDCMS member physicians receive a free initial consultation and a 20 percent discount against attorneys’ fees if the member pays by credit card. For more information, contact Jon K. Ladd or W. Michael Young at (619) 564-6696.

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10 T

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MEDICAL CODER DO’S AND DON’TS Tips for Getting Paid

By MAXINE INMAN COLLINS oday’s professional medical coder/billing specialist faces many challenges and complexities when dealing with insurance contracts and carriers. The following tips will help pinpoint important concepts that we must continually manage in our fight for proper reimbursement for services rendered.

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Review and Copy Patient’s Card at Every Visit. Verify

Embrace Your Coding Manuals. Even with today’s technology, we must review the basics to learn the coding guidelines and use them effectively. Make sure to link diagnosis code to the CPT

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Implement Policies and Procedures and Train Staff to Process Claims Consistently and Efficiently. Have

Even with today’s technology, we must review the basics to learn the coding guidelines and use them effectively.

eligibility, check demographics, and determine benefits and co-pay. One mistake in information can cost the practice precious time and money.

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code to show medical necessity for services performed. Continue to educate yourself, your staff, and physicians to be more specific in the diagnosis codes.

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short, weekly correct claim and collection meetings with doctors and staff to motivate and stop problems before they escalate into thousands of uncollected dollars.

Master the Proper Use of Modifiers, and Learn the Ones Accepted

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by Each Carrier. See billing guidelines on your carrier’s website. Also review modifier rules — inappropriate use of modifiers is a common area for claim denials.

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Create an “insurance catalog” with a summary of the main provisions and contact information for easy reference.

SDCMS MEMBER BENEFIT: SDCMS members and their office staff receive discounts on attendance at PMI seminars.

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Understand the “NCCI” Edits to Prevent Bundling Denials. You can assess the

carrier’s acceptable diagnosis codes per service just as you can Medicare’s LCDs and NCDs. On the website, look under clinical or billing guidelines for this valuable information.

Read the Managed Care Contracts, and Share the Pertinent Parts With the Staff That Are Working With the Information. Often, the front desk and/or billing

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line audit to assess billing efficiency. A well-developed and followed compliance plan could prevent penalties and interest should a governmental audit uncover billing errors. Recovery audit contractors (RACs) are companies contracted by CMS to audit physician charts and recoup funds for the Medicare system when they find they have paid claims in the past incorrectly. The contractors are paid a percentage of all funds recaptured for the Medicare trust fund. They typically go back four years in their audits.

tems allow practices to upload information on scheduled patients directly into the carrier’s database to provide eligibility, coverage, etc. You may even find that you could get paid faster by filing claims directly to the carrier. Spending needless time on the phone is costly.

Develop a “Denial Tracking System” That Categorizes Each Denial. This will

specialists do not have access to the contract provisions. In many instances, you could be wasting time appealing an item that is non-covered by contract. Create an “insurance catalog” with a summary of the main provisions and contact information for easy reference. Make sure you include a copy of the fee schedule for each plan in which you participate. Enter the individual allowable for each in your computer system, if possible. Don’t write off amounts that you could have collected had you known the contracted fees.

Set Up a Compliance Program As Suggested by the Federal Government. Have an objective base-

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Expedite Claims Processing by Using the Online Services Now Available. Some sys-

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pinpoint areas in the office that may need to be improved. You can project the amount of money uncollected because of incorrect patient demographics, posting errors, etc. Set up a system for timely review of aging reports. Unpaid claims and unapplied credits can get out of hand quickly. Setting up a timeline to monitor and review all accounts over 60 days will help keep your A/R under control.

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Begin Each Day With a Brief Meeting to Review Problems Detected the Day Before. Don’t permit problems to es-

calate. Become passionate about coding and collections. Make sure the practice is receiving the proper reimbursement of claims. This

will benefit the patient, the physician, and you and your staff.

ABOUT THE AUTHOR: Ms. Collins is a coding and billing instructor with Practice Management Institute (PMI). For more information about PMI, visit www.pmiMD.com.

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CHOOSING THE RIGHT ELECTRONIC MEDICAL RECORD (EMR)

10 T O P

Things to Look For

By LOUISE COLLINS, RN, BSN

SDCMS MEMBER BENEFIT: Allscripts provides special preferred early adopter pricing and discounts for SDCMS members on their HealthMatics EHR and practice management solutions. Contact Jamie Smolin at (310) 490-9711 or at Jamie.Smolin@Allscripts.com.

he right electronic medical record (EMR) will simplify the practice of medicine, making physicians more effective, efficient, and satisfied. Too often, though, physician practices make the mistake of thinking of an EMR as just another piece of equipment. Unlike an EKG machine, an EMR connects to multiple information systems both inside and outside the practice. Its implementation affects virtually every aspect of your business, from billing to claims management to patient workflows. It’s clear this is a decision requiring careful consideration. There are more than 150 EMR vendors plying their wares today. Only a handful have all the qualities you’ll need.

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Affordability: Affordability is the least important measure of quality, but it’s good to know there are ways to offset the cost of an EMR, including financing options, partnerships, and discounts provided by professional associations such as SDCMS. 34

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By automating time-intensive processes, many physician practices have reported up-front cost recovery in as little as five months. Also, the best EMRs meet DOQ-IT standards for pay-for-performance incentives, greatly increasing the ROI capabilities of your practice.

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Ease of Use: A good EMR makes your job eas-

ier, not more difficult. New users should be able to adapt to the system quickly and begin using the EMR in just a couple of days. The system should have built-in knowledge and be intuitive so that even your least “computer-savvy” physician will have very little trouble making the transition.

Clinical Decision Support: Many physicians feel more confident because of the clinical decision support that comes with electronic systems — something that is impossible to replicate in the paper

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OFFICE MANAGER TOOLKIT

world. The EMR can suggest treatments, medications, and follow-up based on new medical knowledge and best practices. More importantly, warning alerts will notify physicians when patients are at-risk.

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menting an EHR system without the support of seasoned and responsive professionals. Research each vendor’s reputation for fixing errors and fulfilling requests in a timely manner.

Crisis Prevention and Disaster Recovery: Implementation Expertise: While it’s im-

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Support is vital, but the best support is proactive. portant the EMR be Consider partnering customizable to suit with an EMR venyour specialty and dor who is continuously moniworkflow patterns, toring your system to prevent Maybe the most important criterion physicians need to focus on seeing errors. In the event of an emerin selecting an EMR vendor is their patients and don’t have time to be gency such as a virus infecting building and tweaking templates. your server or a hardware malcredibility, and the best measure of It’s important to purchase an EMR function that causes your system credibility is proven expertise. from a vendor who has a proven to run inefficiently, you’ll need a track record of developing and imsecure Web location that lets you plementing the tools you’ll need to temporarily access all data so pabe successful. Look for a vendor tient visits aren’t disrupted. who has successfully implemented thousands of physicians Innovation: As your practice grows, you’ll and who will provide not just a project manager during the want to be aligned with new technologies and implementation period, but a clinical expert with years of exnew opportunities. Look for an EMR vendor perience who will help you customize your system. that exhibits industry leadership and innovaPMS Interface: Your practice management tion. Be sure that the EMR you choose is on the cutting system and EHR edge of EMR functionality and contains applications for must be able to clinical trials, medication dispensing, and Web-based pashare data or you tient portals. will end up with Interoperability: More and more, healthdouble entry of data, such as care is connecting. Look for an EMR that’s patient demographics and diinteroperable with every major competitor, agnoses. Building and maindevice manufacturer, and other healthcare taining a software interface stakeholder (especially your practice manbetween the PMS and EMR agement system). You’ll want demonstrated interfaces to labs, requires the cooperation of both hospitals, and pharmacies that were deployed within the last the PMS and EHR companies. To determine whether an EMR 12 months. has created interfaces with your PMS, ask your PMS company.

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Staying Power: While it’s important that your

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EMR meets your current needs, it must also meet your future needs. In short, your EMR vendor needs to be around in five, 10, 20 years. The best EMRs are certified by the federally funded Certification Commission for Healthcare Information Technology (CCHIT). Those EMR vendors who lack sufficient development resources to keep pace with ongoing CCHIT requirements may not have real staying power in a highly competitive market. Look for vendors who are publicly traded, financially stable, with the resources to invest in future product development.

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Support: When you buy an EMR, you’re not just buying software; you’re entering into a relationship. There is little to be gained by imple-

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Credibility: Maybe the most important criterion in selecting an EMR vendor is their credibility, and the best measure of credibility is proven expertise. You don’t need to choose the EMR vendor with the most physicians, but the number of users is an important indicator of the EMR’s success. Vendors worth your while will have reference sites they can refer you to. In the end, it’s the word of other users that you’ll trust the most.

ABOUT ALLSCRIPTS: Ms. Collins is product manager for Allscripts’ HealthMatics EHR. Allscripts is a leading provider of clinical software, connectivity, and information solutions that physicians use to improve healthcare. Find out more at www.allscripts.com.

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CREATIVE ATTRACTION AND RETENTION Engaging Top Healthcare Support in a Changing Economy

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By JEANNE MILLER aced with a slowing economy and shrinking reimbursements, many healthcare practices are looking at where they can cut back; however, investing in your internal staff is crucial in these times to decrease turnover, increase retention, and stay on top while other providers scramble to find needed talent. That said, how does a San Diego County practice address the age-old issue of attraction and retention in today’s business climate? Let’s take a look at two in-demand clinical support staff positions to understand how wages and benefits factor.

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practices increased from $18.95 per hour in 2005 to $21.93 in 2007, a 16 percent boost. Although a healthy jump, this hourly wage is still significantly less than the $33.45 RNs were paid on average in 2007.

Clinics With Benefits

In the next few years, providing competitive wages is only going to be a fraction of what it takes for San Diego County practices to attract and retain qualified staff; to the highly sought-after candidate, competitive benefits are becoming essential. Salary and the City According to Medical Resources’ 2007 salary survey, 93 percent of San Diego County practices provided health insurance Medical assistants (MAs) and licensed vocational nurses (LVNs) benefits last year, but only 45 percent offered 401(k) plans. When are a critical component of the patient experience. From a local competing with larger healthcare organizations for talent, smaller medical staffing perspective, both positions are in high demand, practices may want to consider investing in a 401(k) program. and this trend is expected to continue. The Bureau of Labor StaNot only does it assist in retaining key employees, but also helps tistics (BLS) agrees, predicting an ensure their financial security — a increased demand for both LVNs win-win for both parties. and MAs. In fact, the BLS projects In actuality, employers can proMAs will be one of the fastestvide a 401(k) program at little to no Investing in your internal staff is crugrowing occupations, with a 35 cost, depending on how much of percent increase nationwide from the administrative expenses are abcial in these times to decrease 2006 to 2016. sorbed by employees. Although the turnover, increase retention, and The BLS also forecasts amplified ideal situation for staff is to have the competition between physician ofemployer bear at least 50 percent of come out on top while other providers fices and hospitals for LVNs, as the the costs and additionally offer scramble to find needed talent. advantages of cost containment and matching and vesting, simply pronew technology allow many proceviding the benefit can give your dures once performed only in hosclinic an edge. pitals to be completed in And don’t forget the personal ambulatory care settings. As a result, San Diego County practices touches that shape the distinct culture of a practice or office, makmust implement creative strategies to attract and retain clinical ing it a welcoming place to work. Thoughtful perks such as prosupport staff as they compete nationally and locally against large viding lunch or offering recognition for a job well done can go a medical clinics and other healthcare providers. long way in keeping your team engaged. From 2005 to 2007, MAs and LVNs both experienced an inAdditionally, investing in continuing education is a great recrease in average hourly wages, according to annual salary surveys tention strategy with a multiplier effect: employees are pleased conducted by Medical Resources Staffing Services. MAs showed and the practice reaps the benefits by providing the very best in an average 5 percent wage raise year over year — the minimum healthcare from a well-trained staff. increase any practice should offer to encourage employee retention. Competitive employers should also factor in the cost of livABOUT THE AUTHOR: Ms. Miller is regional managing diing in San Diego County; offering an additional 2 to 3 percent rector for Medical Rescources Staffing Services, which specialon top of the standard raise can make a big difference to someizes in connecting medical professionals and support staff with one on the lower end of the pay scale. top healthcare providers, laboratories and related organization. Trends show a popular alternative to registered nurses is the For more informations, call (619) 260-2188 or visit LVN, who can perform some of the same duties at a significantly www.medresourcesstaffing.com lower cost. The average wage paid to LVNs by San Diego County

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building a healthier San Diego by addressing unmet healthcare needs for all patients and physicians through education, innovation and service

The

Pulse

MESSAGE FROM THE PRESIDENT

Dear Foundation Friends: Happy belated Independence Day! Our country’s founding fathers’ vision in the Declaration of Independence — “Life, Liberty and the Pursuit of Happiness” — is just one of the great reasons that make being an American such a privilege. At the SDCMS Foundation, our mission to address the unmet healthcare needs for all patients and physicians in San Diego through education, innovation and service is just a small part of providing this opportunity for residents of our county! MAKING A DIFFERENCE EVERY DAY IN OUR PHYSICIANS’ AND PATIENTS’ LIVES. Our physi-

cian volunteers both at the Foundation and in the community are committed to protecting and enhancing lives with innovative programs like Project Access San Diego (PASD) and the Emergency Department Medical Home Project (EDMH). As a stakeholder in many of the healthcare issues that face our county, the Foundation is looking for ways to help secure the safety net in San Diego in a way that is meaningful and appropriate

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for patients and physicians. MAKING A DIFFERENCE IN OUR FUTURE PHYSICIANS’ LIVES. Assisting medical students

from the first year to their senior year is a longtime pursuit of the Foundation. The Foundation offers annual, competitive awards for graduating UCSD School of Medicine students and for first-year students intending to stay in San Diego. In addition to the scholarship programs, the Foundation has also been able to support students with medical school loans and unique training opportunities. Students have been invited to participate in legislative and policy trainings in Sacramento and to meet San Diego’s legislators face-to-face at the seat of government. MAKING A DIFFERENCE IN THE COMMUNITY. Our Retired Physicians Society hosts quarterly luncheons around San Diego County. These luncheons are open to the public for a nominal fee to attend. Dr. Ralph Ocampo, treasurer of the Foundation and retired general surgeon, has em-

barked on a project to document the history of medicine in San Diego. The project has generated multiple videographies of some of our great past and present practicing physicians as well as capturing the essence of the specialist, primary care, and surgical practices of our region. In partnership with the San Diego Historical Society, these histories will leave a long-lasting legacy on the history of medicine in San Diego. YOU MATTER! The Foundation has many lev-

els of participation for practicing and retired physicians living in San Diego. Please call Aron Fleck, executive director, at (858) 300-2780 or send him an email at AFleck@SDCMS.org to find out how to get involved in the community! Thank you for your continued commitment to the Foundation.

Sincerely, Carol L. Young, MD, President of the Board

Save RETIRED PHYSICIANS SOCIETY EVENTS Thursday, October 23, 2008, Sharp Chula Vista Thursday, January 22, 2009, San Diego Zoo Hospital

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We Want You for Project Access San Diego Project Access San Diego (PASD) needs your expertise! Can you see one or two patients per year on a pro-bono or discounted basis? If you, or someone you know, are interested in joining PASD to offer healthcare services for uninsured or underinsured patients in our community, contact Aron Fleck at (858) 300-2780. |

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We take care of case management services for your office and track the value contributed to our county. You can help as much or as convenient for your type of practice. We make it EASY to give back! Find out how you can join this special league of physicians. Call today at (858) 300-2780.


Showcasing a Foundation Inititative The Emergency Department Medical Home Project: Building Pathways for Patients to Access Care in San Diego

The SDCMS Foundation received funding in 2007 from the Blue Shield Foundation to facilitate finding health coverage and a medical home for uninsured patients seen in the emergency rooms of six participating hospitals. To date, the Emergency Department Medical Home (EDMH) project has processed nearly 3,000 patients through the project’s current scope of work. The innovative project has produced some valuable lessons in achieving medical homes for emergency room patients. Dr. Stephen H. Carson, chief medical officer at the SDCMS Foundation and project director of EDMH, will be identifying the key lessons learned in an upcoming article for San Diego Physician. The reasons to provide medical homes for emergency department patients are numerous. There are an estimated 38,576 patients who show up in the 19 emergency departments throughout the county without adequate health insurance coverage and without a source of primary care. Many of these patients use the ER as their only source of primary care for problems that are often better handled in an outpatient setting and many of these visits are preventable. The American Hospital Association reported that community hospitals’ uncompensated care costs across the United States rose 7.1 percent in 2005 to $28.8 billion, from $26.9 billion in 2004. It is estimated that the 19 emergency departments across San Diego County will collectively write off in excess of $30 million per year in charges to uninsured patients. Anecdotal data suggests that many of the uninsured patients visiting the emergency departments in San Diego County qualify for a variety of private and public assistance programs. Helping these patients apply and qualify for these resources will allow the local ERs to channel these patients to our safety net providers and significantly reduce the long waits and expenditures of limited resources. Access to care is a major initiative for the SDCMS Foundation. The Foundation is using the innovative EDMH platform to plan for and better facilitate a sustainable model for the community at large. To find out more about the EDMH Project or Project Access San Diego (PASD), contact Aron Fleck at (858) 300-2780 or AFleck@SDCMS.org.

In the Spotlight: Meet a Physician Volunteer MEET DR. RALPH OCAMPO Retired General and Vascular Surgeon (2003) Treasurer, SDCMS Foundation Past President of Both SDCMS and CMA SDCMSF: When did you begin practicing medicine? DR. OCAMPO: I began in San Diego in 1960 with my first-year surgical residency at San Diego County Hospital. As a U.S. Air Force reservist, I was called to active duty during the second Berlin Wall crisis (1961–1963). I finished my four-year surgical residency at San Diego County Hospital in 1966 and transitioned from the County Hospital Surgical Residency to UCSD that year as a clinical instructor in surgery. SDCMSF: Where did you practice? DR. OCAMPO: I remained a USAF reserve flight surgeon after active duty until a busy practice forced me to resign my commission (Major USAF) after 15 years. Brigadier General Marshall Persky, a good friend and El Cajon pediatrician, was my commanding officer. I practiced at Mercy Hospital and Medical Center; was chief of surgery at Coronado Hospital; and director of the Logan Heights Family Health Center. I served as a clinical associate professor at UCSD School of Medicine from 1966 to 2003. SDCMSF: What is your background of involvement in the community? DR. OCAMPO: I served as a delegate and trustee for the California Medical Association and was honored to serve as president of the San Diego County Medical Society in 1982 and the California Medical Association in 1994. I have stayed active in the community, serving over the years in various leadership positions at the Mexican and American Foundation; Children’s Home Society, the National Conference of Christians and Jews; American Cancer Society; Scripps Clinic and Research Foundation; San Diego Community Foundation; President’s Council at SDSU; Chancellor’s Associates at UCSD; The Mayor’s Crime Commission at the City of San Diego; and 20 years on the board of directors of Sempra Energy. SDCMSF: What is your level of involvement at the SDCMS Foundation? DR. OCAMPO: Currently, I am serving as the treasurer and a member of the board of directors for the Foundation. I am also an active member and past chairman of the Retired Physicians Society. In partnership with the San Diego Historical Society, I am working with retired San Diego physicians to bring our history to life in the form of videotaped oral histories on the progress of specialty practice following World War II. SDCMSF: Why should San Diego physicians get involved with the SDCMS Foundation? DR. OCAMPO: There are many ways to stay active in the community, but not all of them provide an opportunity to use your expertise! The San Diego County Medical Society Foundation offers practicing physicians opportunities to engage in volunteer work by participating in Project Access San Diego. Retired physicians have opportunities to participate in practice-related volunteer activities with Project Access or they can join the Retired Physicians Society. Ralph Ocampo, MD A U G U S T

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Prime Medical Office Space for Lease

3434 Midway Drive, San Diego, CA 92110 • 6,775 sq feet of ground floor medical space available. • Over $250k in medical build outs already in place. • Full office, reception area, three bathrooms, locker rooms and exam rooms.

Brian Baker Commercial Leasing La Jolla Development Group LLC (858)436-4318 - direct bbaker@lajolladevelopment.com

• Easy access to the 8 and 5 freeways. • Tons of available on site parking available. • Recently remodeled lobby with attractive glass enclosed elevator. • Fully accessible building with multiple entrances.

4488 Convoy Street, San Diego, CA 92111 • 5,521 sq feet of high traffic space available on the southwest corner of Convoy Street & Balboa Ave. • Ideal location for busy medical or dental practice. • Just one mile from the 163, 805 and 52 freeways.

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• Extremely busy intersection with over 57,000 cars passing daily. • Great area, just 8 miles from downtown and the airport. • Recent upgrades include new paint and parking lot.

Jason DiNofia Commercial Leasing La Jolla Development Group LLC (858)405-4308 - direct jdinofia@lajolladevelopment.com

• Specials offered including free rent and build outs.

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Classifieds DONATED ITEMS MEDICAL JOURNALS: Retired neurologist has several neurological medical journals that range from 1960 to present. Some are bound. Please contact Dr. Levine at (619) 5884929 if interested. [562] FREE CPAP MACHINE: This is an opportunity to obtain a used CPAP machine in excellent condition for a deserving patient or institution. Call Irv Sherman at (858) 487-6370. [548]

"DEAR EDITOR: I wanted to formally thank you for helping me find employment through your magazine, San Diego Physician. I will be joining a family medicine practice, and found the ad in the classifieds. I re-

OFFICE SPACE MISSION HILLS OFFICE FOR SALE: Rare opportunity to own prestigious North Mission Hills physician’s office. Beautifully restored house located in the West Lewis Planned District. Classic hardwood floors, stained glass, craftsmanship woodwork throughout, recessed lighting, complete exam rooms, two patient waiting areas, and four offices. Neighborhood atmosphere for patient care. Perfect for primary or specialty practice. Ample street parking. Mills Act designation with significant tax savings. Call Annamarie Clark at (619) 962-2095 for photos and appointment. [610]

LEASING, RENEWALS AND SALES: Call the Healthcare Real Estate Specialists at Colliers International for a complete inventory of all available medical office space for lease or for sale in San Diego County. Use our knowledge and expertise to help you negotiate a new lease, renewal, or purchase agreement to assure you obtain the best possible terms. There is no charge for our consulting services. Contact Chris Ross at (858) 6775329; e-mail chris.ross@colliers.com.

ally appreciate the services SDCMS provides, and I plan to be an even more active member in the organization as I begin my practice. Thanks!" - SDCMS Member Physician

suite with board-certified plastic surgeon. The building also houses a fully accredited surgical center and spa facility. Address: 11515 El Camino Real, Suite 150, San Diego, 92130. If interested, please contact Melanie (858) 720-1440. [602]

2,600ft2 of medical space for sublease in prominent Del Mar Heights building, fronting El Camino Real. Building is shared with fertility practice, surgery center, and plastic surgeon. If interested, contact Russ Sande at (858) 7945500 [612]

POMERADO PROFESSIONAL PLAZA: The “Blue Awing” building across from Pomerado Hospital. Fully built-out medical office space or customized turn-key improvements. Space is 1,000–5,000ft2 and has reserved carports. Contact CIC at (760) 743-3228. [615]

OFFICE SPACE IN DEL MAR: Space for lease, approximately 1,600ft2, in Del Mar available July 1. Space is located on Camino Del Mar and can be leased in sections. Contact Judy Gonya at (858) 793-5025 for more information. [609]

POWAY: Office space for rent part-time within a specialty practice located at Gateway Medical Center in Poway. Call (858) 361-7376 for more information. [608]

CLAIREMONT MESA BLVD.: Nicely decorated, 3,000ft2 medical office with adjoining treatment rooms, X-ray, and private offices. Ideal for a medical professional looking for ancillary site for physical or occupational therapy or need for an open area. Space has a separate entry, lobby, bathrooms, and small offices great for reception and billing. Ample free parking. Easy access to all freeways. Please contact Joan McComb at (619) 291-8930 for more information. [605] CARMEL VALLEY: Beautiful medical office space available to rent in a Class-A building centrally located in an affluent area off the I-5 and Highway 56 junction. Renter to share

$2.75/ft2 plus utilities and janitorial services. Ready to move in but tenant improvement allowable. Easy access to I5. Serving Del Mar through Encinitas. Call (760) 431-4238. [584]

SAN DIEGO: Space available from approximately 800ft2 to 1,200ft2. Professional, mixed-use building with medical as major tenant. Space located in Mission Valley with easy access to I-8 and I-15. Call (619) 398-1862 or (619) 723-0074. [599]

YUMA: Medical space from 1,000ft2 to 2,200ft2 available. Existing medical professional tenants, mixed. Will do tenant improvement to suit. Space located across from hospital. Call (619) 398-1862 or (619) 723-0074. [598]

EL CENTRO: Medical office space up to 5,000ft2 available. PREMIUM MEDICAL SPACE AVAILABLE: Approximately

SOLANA BEACH MEDICAL CENTER: 2,374ft2 for lease;

Will provide tenant improvement to suit. Existing medical tenant in building. Call (619) 398-1862 or (619) 723-0074. [597]

CARMEL VALLEY OFFICE SPACE: Office space to share or sublease in busy, solo OB/GYN office. Ideal for OB/GYN, internal medicine, osteopath, dermatology, or other sub-specialty. Excellent referral potential. Scripps medical office building. Call Liz at (858) 259-9900. [593]

OCEANSIDE OFFICE: Office with ocean view available in 1,000ft2 suite. Prefer full time, but part time is available. Share suite with psychologist. Includes furnished waiting room, lots of storage, locking file cabinets, and receptionist area. Currently furnished, but unfurnished is an option. Available immediately. Contact Michael Samko, PhD, at (760) 7211111 or michael@michaelsamko.com. [580] PRIME OFFICE SPACE TO SHARE: Office currently occupied by orthopedic surgeon situated in highly desirable location in a beautiful new building at 7910 Frost Street. The new hospital under construction for Sharp Memorial Hospital is directly across the street. Digital X-ray, MRI, fluoro, CT Scan, pharmacy, PT, and other in the building. Wired for and using EMR. Please call (858) 220-0700 or email dglosrsc@mac.com. [579] ACROSS FROM SHARP AND CHILDREN’S HOSPITAL: Beautifully furnished 2,000ft2 office, fully equipped, five exam rooms. Share with part-time physician. Please call (619) 823-8111 or (858) 279-8111. [385]

OFFICE SPACE FOR RENT: Convenient location, free parking, in Clairemont (Balboa/Genesee). 1,350ft2, three exam rooms, two bathrooms, lab, share with one other doctor. Office located next to lab/draw station, Internet access ready. Reasonable rent. Call (858) 277-9669 or email ykidsd@aol.com. [588]

CLAIREMONT MESA: Small, two-office space for rent in newly constructed medical office. Not a shared space! Approximately 400ft2, built to maximize space, light and airy! Great for therapist, research, small specialty practice, etc. Building is recently renovated, common-area bathrooms, break rooms, elevator, TI available, and free parking. Centrally located between highways 52, 805, 163, and 15 for easy hospital and facility access. Contact (858) 268-1111, ext. 311, for more details. [587] OFFICE SPACE FOR RENT IN ENCINITAS (92024): Convenient location five minutes from Scripps Encinitas Hospital. Close to 5 freeway. Features include two spacious exam rooms, private consultation/doctor’s office, lunch room, private bathroom, and a spacious waiting room shared with one other doctor. Share lab, ultrasound, and bone density equipment. Very affordable rent. Office located at the corner of Encinitas Blvd. and Manchester Ave. Call (858) 756-3021 or email ktagdiri@gmail.com for more information. [586]

SUBLEASE NEW MEDICAL OFFICE IN SAN MARCOS: Premium, Class-A medical office space in San Diego County’s fastest growing city! All or part of an approximately 1,950ft2 newly constructed suite in San Marcos’ city hall building. Spacious reception area, large procedure room with hardwood floors, four exam rooms, two restrooms, doctor’s office with large window, and reserved parking. Easy access to I-78. Ample patient parking. Contact Kristina at (760) 942-9028 or by email at Kristina@sdsleepclinic.com for more information. [520]

MEDICAL OFFICES FOR SALE FROM 1,500 SF: OWN FOR LESS THAN LEASING! 10—building medical campus. Suites from 1,500 -6,300 sq. ft. Strategically located between TriCity Medical Center & Scripps Encinitas. Purchase your office. Prices starting about $650,000. Outstanding signage available on Melrose Dr. and Sycamore Ave. For information call: Jon Walters, Colliers International at (760) 438-8950; John Hoffmann, Cushman Wakefield at (760) 929-2000. www.premiercrossing.com

TO SUBMIT A CLASSIFIED AD, email Ketty La Cruz at KLaCruz@SDCMS.org. SDCMS members place classified ads free of charge (excepting “Services Offered” ads). Nonmembers pay $100 for the first 75 words and $0.50 per word thereafter (limit 100 total words).

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Classifieds SUBLEASE OPPORTUNITY IN HIGH-END MEDICAL SPA IN CARMEL VALLEY: A portion of an upscale, 4,000ft2 medical spa available for sublease. Ideal for an ophthalmologist, plastic surgeon, ENT, and cosmetic dentist. Sublease includes a spacious reception and waiting area, six exam/procedure rooms, surgery suite, two dental chairs, three doctor offices, and consultation room. Easy access to I-5, 805, 56, and I-15. Located inside a medical and dental office building within a retail center. Contact Janice at (858) 481-7701 or janice@laser-clinique.com for more information. [561]

MEDICAL OFFICE AVAILABLE TO SHARE: Primary care office available to share. Store-front building with great visibility and recently updated interior. Current physician has been in practice for 10 years and wants to cut down on hours. Lots of opportunities for a starting physician or specialist. Office staff available to share if needed. Call (619) 575-4442 or fax letter of interest to (619) 575-1297. [518] OFFICE SPACE FOR LEASE (ESCONDIDO): Premier furnished medical office space for lease in Escondido. Excellent location near Palomar Medical Center. Please call (760) 743-1033. [501]

MEDICAL OFFICE SPACE (SCRIPPS ENCINITAS CAMPUS): OB/GYN-type consultation room and one to two exam rooms with staff, receptionist, etc. Equipment is available at extra cost. Surgical center next door. Free parking. Perfect for lowvolume hospital campus consultations one to five half-days per week. Email sbrooksreceptionist@yahoo.com or call (760) 753-8413. [557]

MEDICAL OFFICE SPACE: Approximately 1,289ft2; conveniently located about one mile east of Tri-City Hospital in a four-unit building. Three exam rooms (one leaded) and two baths. Nice layout and ample parking. Office is ideal for a solo practitioner. For further details, contact Wendy Shumate, MD, at (760) 630-4715 or Aruna Garg, MD, at (760) 724-8562. [478]

3998 VISTA WAY, SUITE 100, IN OCEANSIDE: Three medical office spaces (approximately 2,000ft2 each) available for lease. Close proximity to Tri-City Hospital with pedestrian walkway connected to parking lot, and ground floor access. Lease price: $2.40/ft2+NNN. Tenant improvement allowance. For further information, please contact Lucia Shamshoian at (760) 931-1134 or at shamshoian@coveycommercial.com. [556]

OFFICE SPACE AVAILABLE: Office space at the corner of 8th Avenue and Washington Street in Hillcrest. Surgical center in building. Ample parking and simple freeway access. Close proximity to Scripps Mercy Hospital. Call (619) 297-6100 or email rbraun@handsrus.com. [555] OFFICE TO SHARE: Office available in desirable building on Scripps Encinitas lot. Share elegant office that has just undergone complete interior design renovation. Includes doctor’s desk, your own exam room, front desk, common waiting area, staff bathroom (including shower), and kitchen. Contact us at San Diego Vein Institute at (760) 944-9263. [546] COSMETIC OFFICE AVAILABLE TO SHARE: East County location with accredited operating room. Ideal for facial or general plastic surgeon to use as satellite office. Central location with ample parking. For more information, please contact (619) 701-4786. [542]

OFFICE SPACE FOR SUBLEASE: Office available part time for Scripps doctor in desirable Scripps/Ximed building in La Jolla. Share elegant office; available full day Mondays and Friday afternoons. Includes consultation office, two exam rooms, front desk, common waiting area, staff bathroom, and kitchen. Use of operating suite or use on other days negotiable. Contact Cindi at (858) 452-6226. [535]

SHARE MEDICAL OFFICE SPACE IN POINT LOMA AREA (OFF MIDWAY): Share fully furnished, six-exam-room/two-office suite with internist. Ample free parking, great location. Contact Elaine Watkins at (858) 945-3813 or at ejwatkins@gmail.com. [527]

MEDICAL OFFICE SPACE AVAILABLE: Medical office space located in Hillcrest available. The space is approximately 4,500ft2 with several advantages for a group of one to four surgical specialists. There is ample parking, a full outpatient surgical center on first floor of the building, and a therapy area on the second floor. Ample medical records storage space and phone and computer wiring already installed. For more information, please contact (619) 299-0007. [462]

OFFICE SPACE TO SUBLET: Internal medicine practice in Escondido has office space available for one part-time physician/healthcare professional. Excellent location near Palomar Medical Center. Please contact office manager at (760) 4326644 or at EIM2006@sbcglobal.net. [459]

OFFICE SPACE TO SHARE (SOUTH COUNTY): Chula Vista-area family practice office to sublease at 340 4th Ave., Suite 10, just north of Scripps Mercy Chula Vista Hospital. Office includes three exam rooms and one treatment room, and is 1,700ft2. Support staff available. Contact Dr. Jenkin or Dr. Tetteh at (619) 804-7252. [521]

MEDICAL SPA AVAILABLE TO SHARE: Brand new, upscale medical spa in Eastlake available to sublet a portion of the facility to a specialist. Ideal for plastic surgeon or aesthetic physician performing minimally invasive procedures. Also open to acupuncturist or wellness/anti-aging physician, which complements the spa and noninvasive aesthetic services currently being offered. Call (619) 228-4483 for more information. [519]

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INTERVENTIONAL CARDIOLOGIST OPPORTUNITY: Income potential well above national average. Immediate opening to take over 20-year private practice in North County. Excellent referral basis, limited HMO care, new cath lab opening in July. One-in-three interventional call, mature hospitalist program for other call. Office diagnostic services include: nuclear, holtor, accredited ECHO lab. Fax CV to office manager at (760) 940-8153. [607]

PARTNERSHIP OPPORTUNITY: New surgery center in early planning stages located in Santee (will be adjacent to the new RiverView MD spa). Any surgeons or surgical groups interested in becoming junior partners — and getting involved in this project at the ground level — should call (858) 3444496. [606] CARDIOLOGIST NEEDED: Due to a recent accident resulting in disability, North County cardiologist seeks either an invasive or non-invasive cardiologist to work part time in an outpatient setting. No night call. No pager. Hours, days, and number of hours per week negotiable. Can start immediately. Fax CV to (760) 591-0924. Call (619) 806-1229 or email achavira@roadrunner.com for more information. [604] PER DIEM OPENING: BC/BE family practice physician, parttime, as needed. Office practice only. Variable days (Monday– Friday, 8:00 a.m.–4:00 p.m.), half- and full-day shifts depending on need. California license and unrestricted DEA license required. Please fax CV to (619) 445-0988, attn: Teresa Mogielnicki, MD, or email to teresam@sycuanmed.org. [601]

SPACE FOR LEASE (CORONADO): Brand new building in Coronado. Last space available: 1,105ft2, $2.75+NNN. Call (619) 742-5555 or email cpatricia@glenncookmd.com. [435]

NORTH COUNTY OFFICE SPACE TO SHARE (POWAY): In-house, accredited surgery office available. 3,000ft2 includes exam room, dexa scanner, and physical therapy. Ideal for a pain management or newly starting orthopedic physician. Call John at (619) 549-8870 for more details. [398]

MD OR DO WANTED: San Diego occupational/urgent care clinic has opening for a MD or DO to work part or full time. Previous experience in occupational, emergency, internal medicine, or general practice preferred. Current unrestricted license to practice medicine in California and DEA license required. Board certified or qualified preferred. Fax CV to (858) 5656932 or email to sheri.alley@ushworks.com. [600]

URGENT CARE: Busy practice established in 1982 seeks fullLARGE SUITE (CHULA VISTA): Beautiful suite, 4,550ft2, adjacent to Scripps Hospital, includes large reception and front office, audiology lab, private office space as well as three large area rooms, many built-in storage cabinets, and staff lounge. Previous tenant was Children’s Hospital. Contact Sammye at (619) 342-7207, ext. 8, or at baymedical@smiser.net. [389]

CHULA VISTA: Several suites available now at Bay Medical Plaza. We are conveniently located near Scripps Hospital, major freeways, and many restaurants and retailers. There’s an onsite pharmacy, a good parking ratio, and building is secure. This is a great opportunity to expand or relocate your medical practice in Chula Vista. For more information, contact Sammye at (619) 342-7207, ext. 8, or at baymedical@smiser.net. [387]

MEDICAL SPACE FOR LEASE: 2,350–11,761ft2 completed shell building on Highway 86 in Imperial County for $2.05ft2/month. Please contact Dr. Maghsoudy at (760) 7303536 or at afsaneh_maghsoudy@hotmail.com. [525]

our newest facilities in Oceanside. We also have morning, afternoon, and evening per diem shifts available. For more information on these opportunities, please contact Dave Horton, area operations administrator, at (760) 510-5745 or at david.h.horton@kp.org. [614]

BEAUTIFUL, NEWLY RENOVATED OFFICE SPACE TO SHARE: Located in Hillcrest/Uptown San Diego. Physician with large suite seeking physician/healthcare professional or other business professional to share offices and/or exam rooms and receptionist. Parking spaces available for rent (off street, covered). Call (858) 354-9833 for further information. [346]

PHYSICIAN POSITIONS AVAILABLE PHYSICIAN NEEDED: Part-time or full-time position for board-certified/eligible physician to help two physicians in Chula Vista. Cheerful work atmosphere, variety of options (office, hospital, or nursing homes). Very light calls mainly over the phone. We are very flexible in job details. Please call Suzi King at (619) 426-9731. [613]

time or part-time physician. Fax CV to (619) 442-2245. [595]

INTERNAL MEDICINE (SAN MARCOS): North County Health Services, a Joint Commission, federally qualified community health center, has opportunity for full-time BC/BE internal medicine physician to work Monday through Friday and one Saturday per month. Attractive compensation package includes bonus for call and incentive. Benefits package includes PTO, holidays, malpractice, and reimbursement for CMEs (expense and time) and licensure. Spanish language knowledge helpful. Please send CV to C. Bekdache at Cynthia.bekdache@nchs-health.org or fax to (760) 736-8740. [590]

FAMILY PRACTICE (OCEANSIDE): North County Health Services, a Joint Commission, federally qualified community health center, has opportunity for BC/BE family practice physician to work Monday through Friday and occasional Saturdays (shared with other clinicians). Attractive compensation package includes bonus for call and incentive. Benefits package include PTO, holidays, malpractice, and reimbursement for CMEs (expense and time) and licensure. Spanish language knowledge helpful. Please send CV to C. Bekdache at Cynthia.bekdache@nchs-health.org or fax to (760) 736-8740. [591] OB/GYN PHYSICIAN (ENCINITAS): North County Health Services, a Joint Commission, federally qualified community health center, has an opportunity for BC/BE OB/GYN. Hours and call shared with other clinicians and NMWs. Attractive compensation includes call and incentive pay. Benefit program includes PTO, holidays, malpractice, and reimbursement for CMEs (expense and time) and licensure. Spanish language knowledge helpful. Please send CV to C. Bekdache at Cynthia.bekdache@nchs-health.org or fax to (760) 736-8740. [592]

KAISER PERMANENTE IS HIRING FULL-TIME AND PER DIEM PHYSICIANS: We have daytime primary care staffing needs

EXCELLENT OPPORTUNITY FOR OB/GYN: Full service OB/GYN

at all of our North County medical offices, which include Carlsbad, Escondido, Rancho Bernardo, San Marcos, and

position available in North County. Willing to consider partand full-time positions. Advanced 3D/4D ultrasound, in-office

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Classifieds procedures (Essure, endometrial ablations), minimally invasive gynecology, urogynecology with urodynamics, infertility and obstetrics. Amazing future. Combine the best of technology with compassionate care. Email CV to robertbiter@gmail.com or fax to (760) 642-0802. [589]

WOMEN’S HEALTH NURSE PRACTITIONER OR PHYSICIAN ASSISTANT: Chula Vista office looking for a part-time NP or PA

UROLOGIST NEEDED: We have an immediate opening for a

MEDICAL BILLER: Experienced in imaging preferred. Hours

part-time or per-diem urologist to join our multi-specialty medical office located in La Mesa. We are a busy office with exceptional staff, and we need an exceptional individual to join our team. We offer flexibility, independence, and a great office environment. Please contact Sedrak at (310) 717-9121 or email your resume to Harmonymedicalgroup@yahoo.com. [585]

are Monday – Friday, 7:00 a.m. – 3:30 p.m. Friendly staff, good working conditions. Call (760) 730-3536 or email info@carlsbadimaging.com for salary range and more information. [596]

TEMPORARY PCP COVERAGE SOUGHT: BC/BE internist or family practice doctor sought to cover three-month maternity leave for private practice internist in Kearny Mesa area starting August 2008. Hours are M–F, 7:30 a.m. – 1:30 p.m. No hospital work or call. Please fax CV to (858) 277-0690 or call (858) 277-0696. [583]

MISSION HILLS OFFICE FOR SALE: Rare opportunity to own prestigious North Mission Hills physician’s office. Beautifully restored house located in the West Lewis Planned District. Classic hardwood floors, stained glass, craftsmanship woodwork throughout, recessed lighting, complete exam rooms, two patient waiting areas, and four offices. Neighborhood atmosphere for patient care. Perfect for primary or specialty practice. Ample street parking. Mills Act designation with significant tax savings. Call Annamarie Clark at (619) 9622095 for photos and appointment. [610]

with strong OB/GYN experience. Flexible schedule, EMR, Spanish speaker a plus. Fax resume to (619) 482-8072. [603]

MEDICAL EQUIPMENT

RN, NP, OR PA: Registered nurse, nurse practitioner, or physician assistant needed for Encinitas ENT, facial plastic surgery practice. Dermatology, laser, and filler experience preferred. Call Carol at (760) 944-4211. [594]

ULTRASOUND, STRESS, ECG: HP 2000 ultrasound — cardiac, vascular, abdominal, small parts, five transducers: $6,000. Quinton 4000 monitor with Q55 treadmill, recording paper, electrodes, crash cart, defibrillator: $2,500. HP ECG Pagewriter XLE, lots of recording paper and electrodes: $700. Call (619) 460-0083 or (619) 518-9542. [513]

REGISTERED NURSE: Family medicine office in Torrey Hills seeking a full-time experienced RN. Previous clinical experience required. Salary and benefits are negotiable. Please call (858) 350-8100 or email resume to admin@torreyhillsfamilymedicine.com. [577]

SPORTS MEDICINE/FAMILY PRACTICE POSITION: Seeking board-eligible/certified family practice physician with an interest in musculoskeletal and sports medicine for a busy multidisciplinary pain management practice located in Kearny Mesa across from Sharp Memorial Hospital. The office is state-of-the-art, complete with procedure room. Parttime or full-time opportunities are available. No after-hours calls. Fax CV to Hjordis Williams, office manager, at (858) 565-4146, email to hjordis.williams2@sharp.com, or call (858) 565-4117. [578]

Valley office looking for a part-time nurse practitioner with strong GYN experience including HRT. Fax resume to (619) 220-8567. [573]

PER DIEM/WEEKEND PHYSICIAN INDEPENDENT CONTRACTOR:

PHYSICAL THERAPIST: Part-time or full-time PT needed for

Temecula independent diagnostic testing facility seeks physician to monitor patient examinations requiring contrast. Position requires availability of at least two Saturdays a month, typically scheduled for nine-hour shifts. Candidates must have California license. Please contact Lynn at (619) 8196577 for more information, or fax your CV to (619) 241-7790 for immediate consideration. [572]

group orthopedic practice. Great opportunity, benefits. Please fax CV to (619) 229-3933. [565]

PARTNERSHIP OPPORTUNITY: ENT position available immediately in an existing La Jolla practice. Partnership may be quickly achievable. Please call (858) 458-1287 for details. [564] VOLUNTEER FP/IM PHYSICIANS NEEDED: Camp Pendleton family practice residency is looking for a few enthusiastic volunteer family practice or internal medicine physicians interested in teaching to help preceptor residents and medical students in our outpatient family practice clinic. Please contact CAPT John Holman at (760) 725-1398. [511]

PRIMARY CARE JOB OPPORTUNITY: Home Physicians is a fast growing group of doctors who make house calls. Great pay ($60–$100+/hour), flexible hours, choose your own days (full or part time). No weekends, no call, transportation and personal assistant provided. Contact Chris Hunt, MD, at (858) 279-1212. [458] FAMILY PRACTICE (CHULA VISTA): Seeking a family practice physician to cover solo physician practice one week every two months. Contact Ann at (619) 422-1324 or at doctorwp@pacbell.net. [451]

FAMILY PRACTICE DOCTORS NEEDED: Full time and part time; days, nights, and weekends available. Fax CV to La Costa Urgent Care at (760) 603-7719. [449]

NONPHYSICIAN POSITIONS AVAILABLE FAMILY MEDICINE PHYSICIAN: Sharp Rees-Stealy Medical Group, a 350+ physician multi-specialty group in San Diego, is seeking full-time or half-time job share BC/BE family medicine physicians to join our staff. We offer a first-year competitive compensation guarantee, excellent benefits package, and shareholder opportunity after two years. Please send CV to SRSMG, Physician Services, 2001 Fourth Avenue, San Diego, CA 92101; fax to (619) 233-4730; or email Lori.Miller@sharp.com. [611]

PART-TIME MEDICAL ASSISTANT/BACK OFFICE: Two years experience required including phlebotomy. Busy specialist office near Alvarado Hospital. Submit resumes via email to dlpotter22@hotmail.com. [576]

RETIRED SURGICAL PRACTICE OPERATING ROOM/SURGICAL EQUIPMENT: Perfect for plastic surgery/oral surgery. Endoscopy, cameras, loupes, tools. Waiting room furniture inventory list is available upon request. Email kwahl@san.rr.com. [506]

SERVICES OFFERED HOUSEKEEPER: Seeking weekly/bi-weekly housekeeping posi-

WOMEN’S HEALTH NURSE PRACTITIONER: Progressive Mission

MEDICAL BILLING CONNECTION (MBC): After your patients’ care, the most important aspect of your business is your billing. MBC provides full-practice management to ensure your billing and collections are optimal. With MBC, expect great services and great results! The difference is our service … let MBC make the difference for you. Call (800) 980-4808 x102. [575]

MEDICAL RECEPTIONIST/FRONT OFFICE: We are looking for a front office receptionist for a busy OB/GYN practice. Bilingual in Spanish and OB/GYN experience is a must! Resumes can be faxed to (858) 565-0033. [563]

NURSE PRACTITIONER: Four-physician internal medicine practice in Chula Vista seeks part-time/full-time nurse practitioner. Work with a quality group; reasonable hours. Previous experience is preferable; salary negotiable depending on experience. Call (619) 421-4470 or (619) 421-4000. [488]

PHYSICIAN POSITIONS WANTED MEDICAL OPHTHALMOLOGIST (PER DIEM): Board-certified medical ophthalmologist available two days per week for per diem or locums work in the San Diego or nearby areas. Highest ethical standards. Experienced and skilled in therapeutic and cosmetic Botox and dermal fillers. Also experienced in clinical trials. Email bshaw1@san.rr.com. [569] CARDIOLOGIST SEEKING EMPLOYMENT: Noninvasive cardiologist wants to join IM or cardiology practice (office based). Board eligible. Experienced in echo, stress test, nuclear, and CT. Call (858) 922-8354 (cell), (760) 633-3044, or email cvshah@aol.com. [558]

PRACTICE FOR SALE UROLOGY PRACTICE FOR SALE (SAN DIEGO): Practice opportunity in San Diego. Busy solo practitioner to retire in October 2008. Thriving practice; multiple contracts; turnkey operation with Spanish language and laparoscopy skills. Can’t miss. Interested applicants email rvsmith13@san.rr.com. [571] SUCCESSFUL MEDICAL SKIN CARE CLINIC FOR SALE: Small investment for 51 percent ownership. Looking for a new medical director. Contact Leonard Schulkind at (619) 807-5485. [539] DEL MAR-AREA GENERAL PRACTICE: Prime location, huge potential for practice expansion in fast growing Carmel Valley community. Established in 1990; terms available. Inquiries call (858) 755-0510. [185]

tion in San Diego County. Bilingual, 20 years experience. Honest! (619) 787-8257 Ask for Carmen. [581]

PRACTICE FINANCING FOR PHYSICIANS: Up to 100 percent financing available for physicians! Includes purchase of a practice, equipment, partner buyout, working capital, and real estate. Call Monica Coburn at CBN Financial: (702) 3107111 or mcoburn@communitybanknv.com. [522] BILLING, CONSULTING, OUTSOURCING: We are committed to maximizing your bottom line! Our billing service uses stateof-the-art technology to ensure charge capture, code validation, electronic submission and remittance, payment postings, patient statements, structured follow-up and appeals, electronic document storage and meaningful reporting. Supplemental services include online appointment scheduling, automated call reminders, scan systems, and other technological advances. Consulting services include accounts payable, auditing, business development, electronic medical record selection and implementation, credentialing, contracting (payor, physician, and staff), executive assistant, financial management, information systems, operational management, practice assessment, practice management, relocation management, and other technological advances. Contact us today for your free consult! Contact Kena Galvan (619) 326-0700 or kena.galvan@abs-sol.com. [452]

RMC VINYL REPAIR PLUS: Medical equipment upholsterer. Expert in repair and replacement of medical fixture upholstery, including exam room equipment and waiting room furniture. Free estimates and mobile service! Call (619) 443-4060. [400]

MISCELLANEOUS 2005 SEA RAY SUNDANCER 30-FOOT LOADED POWERBOAT (PRICE SLASHED $5,000 6/17/08): Excellent condition; 2K in recent/routine maintenance, new front eisenglass, 3.5 years remaining on full-warranty ($6,000 value), only a paltry100 hours for two pristine 220-hp engines, GPS, generator, TV/DVD/stereo/air/heat and much more. Exact boat with less features costs $150K; $98,000 (firm) to first buyer. (858) 254-0202. [454]

2003 BMW M3 CONVERTIBLE (RED, MANUAL) (PRICE SLASHED $4,000 6/17/08): Very good condition, low miles, and new

REAL ESTATE

tires: $33,750. (858) 254-0202. [453]

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Bioethics San Diego Bioethics Commission Tackling “Non-beneficial Treatment” By LYNETTE CEDERQUIST, MD, AND PAULA GOODMAN-CREWS, LCSW

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he San Diego Bioethics Commission, chaired by Lynette Cederquist, MD, (USCD) and Paula Goodman-Crews, LCSW (Kaiser Permanente), was developed within the San Diego County Medical Society (SDCMS) with a vision of bringing together San Diego County’s medical community to develop standards in bioethics practices. Very few communities have organized such an effort! At this point in time, there is only one other bioethics commission in California of which we are aware, the Southern California Bioethics Consortium, based in Los Angeles. So far, our commission has representation from UCSD, Kaiser Permanente, Sharp Grossmont, Sharp Coronado, the VHA (Veterans Health Administration), Rady Children’s Hospital, Sharp Grossmont, Sharp Mission Park, Edgemoor, Navy Medical Center, San Diego Hospice, Silverado Hospice, Scripps La Jolla, and Palomar Medical Center. The first issue the commission has tackled is “non-beneficial treatment,” also referred to as “medical futility.” This is an issue that every hospital and every ethics committee wrestles with on a regular basis. In a recent review of UCSD’s ethics consultations, close to 50 percent of consults were requested because of conflicts surrounding perceptions of medical futility or medically ineffective treatment. This has been identified by all of the commission’s participants as a major source of conflict, especially intractable cases that are not remediated by ethics facilitation. The nearly universal consensus has been that, when faced with cases where physicians have determined treatment is non-beneficial but the patient or surrogate

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continues to insist on treatment, most physicians continue treatment. Physicians tend to default to continuation of treatment even if their institution’s policies support withdrawal of non-beneficial treatment. We believe that by developing a community standard to guide policy, each individual institution’s policies and practices will be better enforced. When we reviewed the policies from the hospitals represented, we found significant variations. In an attempt to help develop a “model policy” that will be identified as San Diego County’s community standard, we have developed a work group to craft such a policy. We are drawing from current policies, as well as looking at policies from other institutions within California, and the Texas legislation, which offer legal immunity to physicians and institutions who withdraw treatment considered to be non-beneficial. Effective policies that address medical futility or non-beneficial treatment, in general, contain three major components: 1. A definition of medical futility/nonbeneficial treatment. The commission is still in the process of creating a definition. Of note, the inability of the medical community to achieve consensus on a proper definition has been a major barrier in the development of a standard. 2. A process for conflict resolution. This portion of the policy will outline the steps that should be followed when conflicts arise. The hope is that with careful deliberation by all parties involved, including the ethics consultation service, the majority of conflicts can be resolved using a model of mediation.

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The “bottom line”: What should be done in intractable cases when the conflict cannot be resolved? This is the component that varies the most widely. Some San Diego County policies explicitly state that the disputed treatment can be unilaterally discontinued and will not be offered at that institution. Other policies are silent on this issue, while others advise referring the case to hospital administration, or in one policy, to the courts. The nature and scope of the Bioethics Committee role and function also requires further scrutiny, as some hospitals consign moral agency and decisional authority to the committee, while others do not. This vital “bottom line” will be the most critical component. We believe we are making great headway but still have much work ahead of us. We are very excited about the enthusiastic participation by all of the members of the Bioethics Commission and workgroup. Each individual has volunteered his or her own time out of a sense of commitment to their institutions, an effort that is to be commended! In the coming months, we will be working to contact other hospital ethics committees that are not yet involved to solicit involvement and input into this vital process. If you have not heard from us and would like to be involved, please contact SDCMS at (858) 565-8888. 3.

ABOUT THE AUTHOR: Dr. Cederquist and Ms. Goodman-Crews are co-chairs of SDCMS’ San Diego Bioethics Commission.


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August 2008