May 2009

official publication of the san diego county medical society • MAY 2009

Update on the Future of Healthcare

New Associates: No More Double Dipping P.16 Removing Shackles, Moving Boundaries: May is Mental Health Month P.18 Science of Addiction: A Brain Disease P.24 “ 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 ”

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Contents VOL. 96 | NO. 5

28

Update on the Future of Healthcare

• How Obama Could Slash Healthcare Costs • The Fight to Undo Deeply Flawed Medicare Formulas • Federal Issues Update • Revisiting the Medical Home

[Departments]

4 6 8 10 12 16

Contributors

This Issue’s Contributing Writers

Editor’s Column

How Obama Could Slash Healthcare Costs

SDCMS’ 2009 Seminars and Events Community Healthcare Calendar Ask Your Physician Advocate Practice Management

New Associates: No More Double Dipping

18 22 24 41 42 44

Mental Health

Removing Shackles, Moving Boundaries

Public Health

Every Child, Every Time, Every Place

Public Health

Science of Addiction: A Brain Disease

Volunteer

With SDCMSF’s Project Access San Diego

Physician Marketplace Classifieds

Healthcare financing A Global Overview

[ w e b e x clu s i v e ] “The Anesthesia EMR: Vision of the Future or Technological Holdout?” by Adam F. Dorin, MD, MBA

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TORREYPINESBANK.COM

Contributors KITTY BAILEY Ms. Bailey is the executive director of the San Diego County Medical Society Foundation.

ELIZABETH MCNEIL Ms. McNeil is vice president of federal government relations for the California Medical Association.

STUART A. COHEN, MD, MPH Dr. Cohen, pediatrician and SDCMS and CMA member since 1988, is current president of SDCMS.

Joseph E. Scherger, MD, MPH Dr. Scherger, SDCMS and CMA member since 2003, is clinical professor of family medicine at UCSD. He is also vice president for primary care at Eisenhower Medical Center in Rancho Mirage, Calif. Dr. Scherger, along with editing San Diego Physician, is chair of the SDCMS Communications Committee.

Jeffrey J. Denning Mr. Denning is a management consultant with SDCMS-endorsed partner Practice Performance Group (PPG). PPG provides high-performance medical practice management services for physicians, including consulting, expert witness, workshops, speaking, and a monthly newsletter. SDCMS members receive discounted management consulting on productivity and patient flow, personnel, governance and management, market strategy and tactics, practice acquisitions, sales and mergers, and a free, one-year subscription to UnCommon Sense. PPG also conducts free half-day seminars for SDCMS members and their staffs at SDCMS’ offices.

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.

Dean E. Sidelinger, MD, MSEd Dr. Sidelinger, pediatrician and SDCMS and CMA member since 2008, is the deputy public health officer for the County of San Diego. He also serves as the chief of the Maternal, Child, and Family Health Services Branch for Public Health Services. Dr. Sidelinger is vice president of the local chapter of the American Academy of Pediatrics (AAP) and active on the national level of the AAP. FRANCISCO J. SILVA Mr. Silva is vice president and general counsel for the California Medical Association.

Nora Volkow, MD Dr. Volkow is director of the National Institute on Drug Abuse (NIDA), National Institutes of Health.

Marshall E. Lewis, MD Dr. Lewis, SDCMS and CMA member since 2009, is clinical director of the County of San Diego Health and Human Services Agency Behavioral Health Division.

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

East County Director Hillcrest Director Kearny Mesa Director EDITOR MANAGING EDITOR

Joseph Scherger, MD, MPH Kyle Lewis

La Jolla Director North County Director

editorial board

MARKETING & PRODUCTION manager Sales Director PROJECT DESIGNER COPY EDITOR

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

Jennifer Rohr Dari Pebdani Lisa Williams Adam Elder

South Bay Director At-large Director

Young Physician Director Resident physician director Retired Physician director MEDICAL Student Director

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 Arthur Blain, MD Vimal Nanavati, MD Anna Seydel, MD Jeffrey Leach, MD Robert Peters, PhD, 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

SDCMS EXECUTIVE COMMITTEE PRESIDENT president-elect past president secretary treasurer COMM. CHAIR DELEGATION CHAIR Board REP. Board REP. LEGIslative chair executive director 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

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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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, PhD, MD Robert Hertzka, MD Tom Gehring

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

M AY

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Editor’s Column

By Joseph E. Scherger, MD, MPH

I

t looks as if major healthcare reform is going to happen this time. The March 11, 2009, USA Today proclaimed that healthcare costs are the biggest problem facing the United States. In the worst economic crisis since the Great Depression, the United States can no longer afford to spend more than $8,000 a year per person on healthcare.

The pressure to make major changes is mounting, and we have a charismatic and practical president and a Congress of the same party, both determined to act this year.

When you ask the leaders just what the future U.S. healthcare system will look like, their eyes seem to glaze over. They look like a deer in headlights. The singlepayer advocates know what they want, but the majority in the United States is not inclined to have the government run the

How Obama Could Slash Healthcare Costs Without Changing the System

whole system. Most agree that healthcare in the United States should be a partnership between public agencies and private enterprise. We have that now in a patchwork non-system of care that leaves out 15 percent (and growing) of the population.

We must do something to reform healthcare in the United States, but what? Many books out there offer different solutions, and none seems palatable to a majority of stakeholders.

I’d like to offer five things that President Obama could do right now that would slash healthcare costs with our system of public and private health plans covering care delivered by largely private providers.

By reducing costs and expanding coverage, everyone would have access to care, not just in the emergency room but also in a medical home.

1) Stop Unnecessary Care Many analysts tell us that 30–35 percent of care currently being delivered is of no benefit to the patient. As a primary care physician, I see it every day. MRIs hum day and night imaging degenerative disease of the spine with no neurologic deficit to justify the expense. Fibromyalgia patients bounce among specialists getting big workups for no benefit. As I watch medical students and residents order what they do, I get the impression that we train physicians to waste money.

We need a “green movement” in healthcare. We need to look at healthcare spending like a precious resource not to be wasted. I have this fantasy of being a healthcare czar and proclaiming that everyone please stop wasting money. We all know the waste around us. There would be an immediate 10 percent reduction in cost.

Penalize rather than reward those regions of the country that are notorious for wasteful healthcare spending.

2) Provide Liability Protection for Appropriate Care Defensive medicine, especially in emergency departments, is wasteful yet done to avoid liability exposure just in case there is a bad outcome. The public needs to be reminded that we all will die, and we all will die of something. Bad things happen with disease, despite our best efforts. Whenever there is a question of liability, an impartial review panel should look to see if the care

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was appropriate, and, if so, there would be no litigation. When current clinical guidelines are followed, there is immunity from litigation. All of the United States should have the tort reform of California’s MICRA. Obama was a community organizer, not a trial attorney, and we can no longer afford the wasteful spending that comes from liability risk.

3) Reduce Administrative Waste We spend an enormous amount of healthcare dollars for work that has nothing to do with clinical care. Just like how the Obama administration is going line by line in the federal budget to eliminate programs that are not working, there should be a line-byline review of all administrative spending in healthcare. A massive simplification effort could save many billions of dollars.

Today we can buy a ticket on the Internet and fly across the country for less money than ever before in commercial aviation. Part of that is because we never have to interact with anyone from the airline company until we arrive at the gate to board the plane. Personal banking is now done for pennies compared with the high cost of teller transactions. How many automated applications in healthcare are out there ready to be discovered if we had the cost-reduction imperative to simplify the process of care?

4) Use Patient Visits Only When Necessary • Use Other Methods for Communication and Care Our visit-based system of care is highly wasteful when less-expensive methods of communication and care are available.

Redesigned practices such as Greenfield Health in Portland, Oregon, show that 40–60 percent of healthcare can be delivered well online or with planned telephone encounters. The new medical home projects are paying physicians for care coordination separate from visits. When the impact of the Internet is fully appreciated in healthcare, most Americans will have a web-based personal medical home and be able to coordinate much of their own care with their chosen providers. Modernize the process of healthcare delivery like other service industries have, and many billions of dollars are to be saved. That is the type of reimbursement reform and practice transformation that Obama should support, and not simply throw money at HIT in practices that continue the wasteful dependence on visits as the only means of care.

5) Lower the Cost of Brand-name Drugs Drug pricing in the United States is a scandal that we can no longer afford. There is no market competition when the person getting the drug is not paying the true price and the person ordering the drug has no stake in the costs. For complex reasons, U.S. drug companies charge what the market will bear for drugs in the United States while other countries regulate prices.

I am all for the continued development of new drugs, and that is expensive, but it is time to reckon with wasteful spending by drug companies in marketing and pricing medications. Coca Cola and Pepsi have suppressed the generic sodas by pricing their products competitively and being affordable to everyone. Today’s drug companies price their brand products such that most of the people who need them cannot afford the cost. Obama should ask for cost reductions in exchange for support in developing promising new drugs. He could just mention price controls and send shivers down the spine of drug companies. If these companies are good corporate citizens, they will become part of the solution and not part of the problem in healthcare costs.

While we wait and wait for some new model to emerge (which may never happen), we can act to drastically reduce our healthcare spending without changing the system. We can offer affordable healthcare coverage through employer programs, individual purchasing, and government programs for those who need them. To get everyone under the health coverage tent, we will need legislation, but it should not be into a wasteful system of care. The solutions offered here are oversimplified because space only allows a short mention of what are certainly complex problems.

In this time of economic crisis, wasteful healthcare spending is especially egregious. The time is now for the Obama administration to get smart in waste reduction, and the good news is that we do not have to radically change the public-private structure of healthcare in America.

Dr. Scherger is clinical professor of family medicine at UCSD. He is also vice president for primary care at Eisenhower Medical Center in Rancho Mirage, Calif. Dr. Scherger, along with editing San Diego Physician, is chair of the SDCMS Communications Committee.

A b ou t

the

Au t ho r :

M AY

Letter to

the Editor

RE: Volunteer Opportunities (see March 2009 San Diego Physician)

March 17, 2009 Dear Editor, I have been a family medicine physician in Oceanside for 28 years and would like to inform you about a volunteer experience that I will be going on for the fourth time in May 2009. I go to Guatemala with a 90-person team (17 physicians) entitled “HELPS.” The organization is out of Texas and has seven teams from different states. Each team goes on a 12day trip, of which seven are in a small village in the northern highlands of Guatemala. We usually use an old “hospital” where we provide free services in general medicine, ophthalmologic surgery (cataracts), general surgery, ENT surgery, gynecologic surgery (last year on the first night an emergency C-section), and plastic surgery. The highlands of Guatemala are populated mostly by the Mayan descendents living in the beautiful mountains, 5,000–8,000 feet altitude. They basically have no medical care and are very gracious for our help.

The organization provides the complete infrastructure for providing the primary and specialty care. The HELPS organization is very professional. There are needs for generalists and specialists (including anesthesiology). It is a 12-day experience you will never forget, and what I have always called “the best week of my year.”

Eliot Miller, MD ekmiller@cox.net

Do You Know of Any Physician Volunteer Opportunities?

If you know of any volunteer opportunities for physicians in San Diego County, California, across the United States, or anywhere else in the world, please email the information to Editor@SDCMS.org. SDCMS will publish all physician volunteer opportunities free of charge on our website at SDCMS.org.

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SDCMS Members-only Benefits

2009

Seminars and Events

May

August

7 Thursday 11:30AM–1:00PM Billing Seminar/Webinar (Office Managers Forum)

12 Wednesday 11:30AM–1:00PM OSHA Updates Seminar/Webinar (Office Managers Forum)

21 Thursday 11:00AM–7:00PM EMR Trunk Show

October

June 18 Thursday 11:30AM–1:00PM Legal Seminar/Webinar (Office Managers Forum) 24 Wednesday 2:00PM–6:00PM CMA Contracting Seminar/Webinar: “Taking Charge: Steps to Evaluating Relationships and Preparing for Negotiations — A Focus on Payor Contracting” 25 Thursday 9:00AM–2:00PM CMA Reimbursement Seminar/ Webinar (Office Managers Forum): “Back to Basics: A Step-by-Step Guide to Maximizing Your Cash Flow”

July 22 Wednesday 6:30PM–7:30PM Risk Management Webinar: “Who Can Be Told What? (Communicating in a HIPAA World)”

15 Thursday 11:30AM–1:00PM Financial Issues Seminar/Webinar: "Controlling Practice Finances" (Office Managers Forum) 23, 30, Five Fridays 8:00AM–4:00PM Certified Medical Coder (CMC) Course Nov. 6, 13, 20

SDCMS strives to build a robust schedule of free seminars and events for our member physicians and their office staff. All SDCMS member physicians and their office staff attend SDCMS seminars free of charge (excepting our Certified Medical Coding course, which is discounted for members and staff).

Our seminars cover a broad range of practice management topics, including legal issues, HIPAA, risk management issues, contract negotiations, and more.

For further information about any of these seminars and events, watch your emails and faxes, visit SDCMS’ website at www.SDCMS.org, or contact Lauren Wendler at (858) 300-2782 or at LWendler@SDCMS.org.

November 14 Saturday 8:30AM–3:30PM Resident and New Physician Seminar: “Preparing to Practice: What You Need to Know BEFORE You Begin Your Practice” 18 Wednesday 6:30PM–7:30PM Risk Management Webinar: “Electronic Health Records — Are You Ready?”

19 Thursday 11:30AM–12:30PM Risk Management Webinar: “Electronic Health Records — Are You Ready?”

23 Thursday 11:30AM–12:30PM Risk Management Webinar: “Who Can Be Told What? (Communicating in a HIPAA World)”

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Free to Member Physicians and Their Office Staff!

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Watch Previous SDCMS Seminars Online Now! Available to Members at SDCMS.org

SDCMS Member Physicians and Staff: Don’t forget that you can view all previous SDCMS seminars online whenever you like. To locate a previously held seminar for viewing, simply go to SDCMS.org and do a search in the search field on the homepage. For assistance in locating a seminar or in logging into SDCMS’ website, please contact Kyle Lewis at (858) 300-2784 or at KLewis@SDCMS.org. Most SDCMS seminars are made available for viewing online within 24 hours of their date of occurrence. Thank you for your membership!

More than a healthcare professional, you are a trusted partner in your patients’ health. So are we.

Beyond providing outpatient diagnostic imaging services, we’re here to help you improve the health of your community. How? By becoming, like you, a true and trusted partner in patient care.

And as your partner, we’ll work to improve your patient outcomes as well as satisfaction. That means helping you diagnose diseases and disorders safely, quickly and accurately, so that you can begin treatment sooner. We also understand that no two patients are alike. We’ll help you treat the individual needs of unique patient populations, including athletes and the physically disabled. Along with prompt, patient-friendly customer service, we also provide convenience—with 15 San Diego area locations and contracts with most insurance companies. Making it easier for your patients to get the care they need.

From the professionals they trust.

So here’s to your patients’ health. And to the start of a long and healthy partnership.

Contact Imaging Healthcare Specialists today.

M AY

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Community Healthcare Calendar To submit a community healthcare event for possible magazine and website publication, email KLewis@SDCMS.org.

All events should be physician-focused and should take place in San Diego County.

Essential Topics in Pediatrics 2009 May 14–15 at the Catamaran Resort Hotel. Visit http://cme.ucsd.edu/events.cfm.

26th Annual Primary Care Summer Conference

UCSD Tele-medicine Full-day Training

August 7–9 at Paradise Point Resort, San Diego. Visit www.scripps.org/conferenceservices.

May 15 at the Southern California Telemedicine Learning Center, UCSD Campus. Visit www.telemedicine.ucsd.edu.

New Advances in Inflammatory Bowel Disease

2009 American Thoracic Society International Conference

September 12 at the Hilton San Diego Resort, San Diego. Visit www.scripps. org/conferenceservices.

Educational program for clinicians and researchers in adult and pediatric pulmonary, critical care, and sleep medicine. Sample a broad spectrum of topics or concentrate on critical care, sleep, allergy/immunology or other specialty related to respiratory medicine. May 15–20. Visit www.thoracic.org.

Alzheimer’s Disease: Update on Research, Treatment, and Care

4th Annual Clinical Update on Heart Failures and Arrhythmias: From Prevention to Cure October 17–18 at the Hilton La Jolla Torrey Pines. Visit www.scripps.org/ conferenceservices.

9th Annual Destination Health: Renewing Mind, Body, and Soul

May 21–22 at the Omni San Diego Hotel.

Visit http://cme.ucsd.edu/events.cfm.

October 18–23 at the Marriott Kauai Resort, Kauai, Hawaii. Visit www.scripps. org/conferenceservices.

Fresh Start’s Surgery Weekend

20th Annual Coronary Interventions

A team of dedicated medical volunteers donates their time and expertise to provide disadvantaged children with the highest quality medical services and ongoing care. June 13–14, July 25–26, September 12–13, and November 7–8 at the Center for Surgery of Encinitas.

Contact (760) 448-2021 or mimi@freshstart.org, or visit www.freshstart.org.

San Diego Academy of Family Physicians 52nd Annual Postgraduate Symposium June 26-28 at the Hilton Resort San Diego.

Visit www.sandiegoafp. org.

Riverside County Medical Association’s 5th Annual “Cruisin’ Thru CME” (Eastern Mediterranean) July 6–17. Call (800) 745-7545.

October 28–30 at the Hilton La Jolla Torrey Pines. Visit www.scripps.org/ health-education.

2009 San Diego Day of Trauma October 30 at the Joan B. Kroc Institute for Peace and Justice, University of San Diego. Visit www.scripps.org/conferenceservices.

XVII World Congress of Psychiatric Genetics Offers a forum for exchange of the latest scientific data and education for the interested clinician. November 4–8 at the Manchester Grand Hyatt, San Diego.

Contact (858) 534-3940 or ocme@ ucsd.edu.

Melanoma 2010: 20th Annual Cutaneous Malignancy Update January 16–17, 2010, at the Hilton San Diego Resort, San Diego. Visit www. scripps.org/conferenceservices.

7th Annual Natural Supplements: An Evidence-based Update January 21–24, 2010, at the Paradise Point Resort, San Diego. Visit www. scripps.org/conferenceservices.

Scripps Cancer Center’s 30th Annual Conference: Clinical Hematology and Oncology February 13–16, 2010, at the Omni San Diego Hotel. Visit www.scripps.org/conferenceservices.

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Noted

the other groups in which this plan has reciprocity. When physicians see this type of wording in their payer contracts, they should ask the plan who they have reciprocity with. You can decide to either negotiate this type of provision with the plan, or you can ask them to completely remove it from the contract.

Q

UESTION: Recently, I overheard a conversation about United Healthcare’s losing a battle over a progressive fee schedule.

Could you give me the details on that?

Ask Your

Physician Advocate

By Marisol Gonzalez

Reciprocity • United Healthcare • CME Tracking and Reporting

Q

UESTION: I received a contract from a medical group that contains a provision about “reciprocity” that concerns me.

I believe this medical group may function as a silent PPO. Can someone take a look at the clause and double-check my suspicion?

Your SDCMS Physician Advocate Has the Answers!

12

ANSWER: CMA’s Center for Economic Services reviewed this section and agreed that it does raise a red flag. The reason for the concern is that if you do contract with a group that has a provision in the contract such as this one, and you negotiate a certain rate, this will be the same rate for

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ANSWER: In response to CMA advocacy, United Healthcare has agreed to stop using its “progressive fee schedule” methodology, which CMA believes to be a violation of state fair payment laws. Currently, United makes significant changes to its fee schedules under the guise of “routine maintenance” without notifying physicians or giving them the opportunity to cancel their contracts. Last year, CMA asked the Department of Insurance to force United to comply with state law, which requires insurance companies to give contracted physicians 45 days’ notice of any material changes to their contracts.

CMA reminds physicians that before signing a health plan contract or contract amendment, it is important to know what value it will bring to your practice. Physicians do not have to accept bad contracts or contracts that are not mutually beneficial.

United’s progressive fee schedules are developed using third-party data (such as Medicare’s relative value units). According to United, “routine maintenance” occurs when it “mechanically incorporates revised information created by a third party that is the source for a portion of the fee schedule.” Physicians have reported to CMA that payments for some CPT codes have been reduced by as much as 10 percent during such “routine maintenance.”

These fluctuations make it difficult for physicians to predict the exact amount they will be paid.

More than 50 percent of physicians con-

tracted with United Healthcare in California — approximately 25,000 physicians — are on these so-called progressive fee schedules. Affected physicians were recently notified by certified mail of United’s decision to eliminate the progressive fee schedule. Effective April 1, 2009, the fee schedule is fixed to 2008 CMS RBRVS. (Physicians will see no difference in their current reimbursement.) Included with the notice was a sample fee schedule.

CMA reminds physicians that before signing a health plan contract or contract amendment, it is important to know what value it will bring to your practice. Physicians do not have to accept bad contracts or contracts that are not mutually beneficial.

SuperSmart Health.com

Q

UESTION: Is there a change in the way the Medical Board of California will be requiring physicians to track and report their CME credits as of 2009?

ANSWER: Yes. As of 2009, physicians will now be required to complete 50 CME hours during every two-year licensure period. Previously, physicians were required to complete 100 hours every four years.

CMEs will also be calculated based on the physician’s personal license renewal date (the last day of the month of your birthday) and not the calendar year.

Website Snapshot

The word “health” is derived from the word “wholeness” (old English hāl). We seek knowledge, support, and inspiration to cultivate health in mind, body, and spirit. However, this can be challenging for healthcare providers and patients alike. We are overwhelmed with information, the complexities of the healthcare system, and underlying stress and uncertainty that can fragment our mental, physical, and spiritual well-being.

SuperSmartHealth incorporates evidence-based medicine and integrative holistic medicine into a new vision of health. We provide a framework and resources for health professionals and patients to navigate scientific information, the healthcare system, and stress and uncertainty to empower a partnership to better health.

Note: Text Taken From SuperSmartHealth.com

4%

Other $5.5 Billion

A b ou t t h e Au t ho r : Ms. Gon-

zalez 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.

7%

2%

Other Medicaid $3.2 Billion

National Institutes of Health $10.0 Billion

Total: $149.2 Billion Does Your Office Manager Have a Question Too? Lauren Wendler, your SDCMS office manager advocate, is on staff and ready to help your office manager with any questions he or she may have.

Feel free to contact Lauren at (858) 300-2782 or at LWendler@SDCMS.org for help.

13%

Distribution of Health Funding in the American Recovery and Reinvestment Act (ARRA) M AY

Health Information Technology $19.2 Billion

17%

57%

Federal Medical Assistance Percentage Increase $86.6 Billion

COBRA $24.7 Billion

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Noted icer f f O l a c i d e M s Chief e s o o h C n o i t da SDCMS FoaulnCommunity Liaison and Medic ation

Found ical Society ed M y nt u o Diego C — as our ince 2006 at the San s th er b w o em kn m l Johnson, let you d CMA ie Marshal SDCMS an pleased to ar — ry em D ve s o M R , am r. d I an aison. chultz J ical officer mmunity li ames H. S ) chief med medical co D D S S A has hired J A (P P r go u ie as o cess San D 26 years — Project Ac ember for m A icine M C d MS an cticing med MD — SDC as been pra h cer e, in ic o ed medical ffi mily m tified in fa y the chief er tl c en d rr ar 80 o u r b c , ove e is z, who is with 11 sites 20 years. H Dr. Schult nt lth center r the past ea fo h y the inpatie ed nt in u ifi o al ly C clinical rally qu de ve ti fe ac a in San Diego e, er ns ar ai artn rem lthc he was a p rhood Hea atients. He at Neighbo Healthcare, y indigent p d tl o s o o medical m rh e o 0 b th 0 d 65,0 at Neigh erving as ng s vi ng er s di lu to c providers, an , in has s. Prior for 13 years r. Schultz ient setting e he worked agement. D er an and outpat h M w y , ntracting it p o u al c t and Qu lth plan edical Gro en ea M h em l , il ag es yb an te ra M it in G al omm Utilization ciate clinic operating c d chair of nteer asso pital joint s lu o h vo , San a director an ds is ar th bo ds. He its on e ultiple IPA profit boar CSD. He s U nno at e ty in ni served on m ic u il comm ive Med the Counc units, and and Prevent member of of Family a and quality t is en d tm an ar rs in the Dep d of directo e. professor ciety’s boar o S g Committe al in ic er ed te yM ouncil S C n ia Diego Count ic ys Ph vice Medical nity Clinic’s sthesia Ser ne A h it of Commu w for many logist thesiology anesthesio es ed an fi ti f o er c r o fess a boardprestigious sociate pro n has been f SDCMS’ CSD as as o U Dr. Johnso nt at ie d ip re c ee Society of ent, a re has volunt e California past presid th S f o M Group and t C D en S an and public t presid Johnson is community d,” and pas g ar in w is nt A ro years. Dr. ar nf Ye the ured. She ues co Member of d and unins e many iss ve th er t s u er o nd ab u ts “Physician sen the ncerned n and repre vocate for logists. Co e Foundatio dedicated ad ar a c Anesthesio h n n lt ee o b ea nt H li as iance ent C Johnson h of the All both Presid es y b te s d health, Dr. to u te tr in is o f p do andate was ap f the boar n, whose m ittee. She io m s m is o m C secretary o m y ge o c C Poli lth y chan the CHIP Border Hea ealth polic d affect h SDCMS on .S.–Mexico an U e ry th ve li to de hcare t Bush prove healt and Presiden ture to im c u tr as fr in develop an r. llaboration. ctice and D national co ib gh d private pra an rs throu te to en hc ets unity healt e great ass gans will b both comm ie D in an nd S u f ro am o our te ! lbeing z’s backg lth and wel they are on Dr. Schult ea at h e th th ed r it exc passion fo go. We are Johnson’s ess San Die c c A t c je Pro SDCMSF’s

Partners, Friends and

Kitty Bailey irector Foundation Executive D ical Society ed M y nt u Co San Diego

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All New 2009 California Physician’s Legal Handbook Available

By Francisco J. Silva, Vice President and General Counsel, CMA The California Physician’s Legal Handbook (CPLH) is written by the California Medical Association’s attorneys, who have responded to tens of thousands of calls from physicians. This more than 4,500-page, seven-volume, easy-to-read, comprehensive legal guide to practicing medicine in California is intended to serve as a reference for practicing physicians and those who assist physicians, including attorneys, administrators, office managers, and business advisers.

The 2009 CPLH is even more comprehensive than prior editions and comes in two formats: (1) a print version in an easy-to-handle, soft-cover binding, with a

Please Welcome SDCMS’ New and Rejoining Members

separate volume containing the table of contents and five indices (subjects, laws, forms, websites, and court cases); or (2) a fully searchable and hyperlinked CD-ROM, which contains all the contents of the print version, as well as interactive forms and sample letters physicians can customize using their word processing programs and — new this year — hyperlinks to FindLaw for access to cited court cases. The entire handbook has been updated and expanded to reflect new laws, court cases, and developments in the fast-changing healthcare delivery system.

CMA ON-CALL With few exceptions, the information contained in the CPLH is also available from CMA’s 24-hour, information-on-demand system, CMA ON-CALL. All CMA ONCALL documents are available free of charge to SDCMS-CMA members on CMA’s website at www.cmanet.org. For assistance in logging into CMA’s website, SDCMS members should contact Marisol Gonzalez, your SDCMS physician advocate, at (858) 300-2783 or at MGonzalez@ SDCMS.org.

Get in Touch Your SDCMS Support Team Is Here to Help!

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 Development: Janet Lockett at (858) 300-2778 or at JLockett@SDCMS.org Director of membership Operations and 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

Marshall Edward Lewis, MD Psychiatry and Addiction Psychiatry San Diego (619) 584-5092

Welcome Rejoining Members!

Welcome New Members!

Stephen Peter Gormican, MD Emergency Medicine La Jolla (858) 626-6150

Bruce Lynn Edens, MD Otolaryngology San Diego (619) 528-5621

Edgar Huang Ling, MD Otolaryngology La Jolla (858) 558-8626

Andrew Philip Hartman, MD Orthopedic Surgery and Surgery of the Hand Oceanside

Gregory L. Wakeman, DO Family Medicine Carlsbad (760) 603-3221

Director of Engagement: Jennipher Ohmstede at (858) 3002781 or at JOhmstede@SDCMS.org sdcms foundation executive director: Kitty Bailey at (858) 300-2780or at KBailey@SDCMS.org sdcms foundation associate 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 Specialty society advocate: Karen Dotsonat (858) 300-2787 or at KDotson@SDCMS.org Letters to the Editor: Editor@SDCMS.org General Suggestions: SuggestionBox@SDCMS.org

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Practice Management

I

By Jeffrey J. Denning

New Associates No More Double-dipping?

n some specialties, it’s becoming increasingly hard to attract new associates to practices wishing to replace physicians or grow. Maybe they should rethink the offer package to be more competitive.

In primary care, the problem is well known: Board-certified family physicians and general internists have been hard to recruit for years. They are in shortage, and there are offers all over America, all promising the market rate, good benefits, and a fair amount of security — if not an ownership stake.

Even in attractive but saturated metropolitan centers like San Diego County, where practice opportunities should be most valuable, it’s very difficult to get someone to join without guaranteeing a salary, subsidizing the start-up, and virtually gifting-over an ownership position at the end of a year.

It makes no sense, but try convincing a youngster of that. They get their advice from upperclassmen who tell them it’s insane to invest in your own business these days. Why, with continued growth of megagroups and declining reimbursement, the smartest course is to take a salaried job and wait out the short-run as things shake out.

At least so goes their worldly logic.

Mostly, these individuals are wrong to be so pessimistic. But they want to be shrewd, and they usually regard offers involving partnership with a guarded skepticism bordering on paranoia. They expect to be victimized, so they see oppressors everywhere.

Working From Anecdotes To be fair, they are often operating on a few tales of ugly manipulation of unsuspecting junior associates by greedy senior physicians. The story usually involves the young doctor working for two, three, or more years on the promise that “we’ll work out something fair when the time comes.” He earns for the practice far in excess of his compensation, only to find out that the offer, if it finally comes at all, involves paying for accounts receivable he himself has produced and goodwill he feels he’s already paid.

It’s this notion — that earning lots for the employer and then being asked to pay for the practice is somehow unfair — that contains the seed of the compromise. We are increasingly recommending that the practice credit the new doctor with his

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or her earnings above the compensation package during the first year or two, to be applied to the buy-in calculated price.

For example, if a doctor is paid a total of $170,000 in salary and benefits during the first two years, but she earns $200,000 (when computed the same way as the other owners), the $30,000 difference is credited against her buy-in if partnership is offered and accepted.

While there are arguments on both sides, we think that difficult recruitment situations deserve a look at this new approach. It candidly acknowledges all the issues up front, early in the hiring process.

“We’re going to pay you less than you earn.

If you quit while you’re an employee, we’ll keep that difference. But if you are offered partnership and you accept it, we will apply that difference to the fair value of an equal share in the practice. After you buy in, you’ll be paid the same way all the owners are.” What could be fairer than that?

We commonly recommend the job offer letter contain a rough outline of the entire deal, even though there can be no promise that the new doctor will become a partner or shareholder. But, assuming the parties are comfortable enough to make and accept a job offer, it’s reasonable to come to an understanding before everyone invests time and money in the pre-partner phase. Why risk physician turnover if the terms will be impossible later? While the offer letter will lay out lots of details about the terms of employment, it should cover these key points if there is any prospect of a buy-in down the road.

Realistic Valuation The value of any practice opportunity will have several components. It’s useful to list them separately because they may not all be part of the final negotiated deal. They usually include furniture and equipment, leasehold improvements, supplies on hand, accounts receivable, cash and other incidental assets on hand, liabilities such as loans and accounts payable, and, finally, goodwill.

Most of these items are relatively simple to value fairly. Goodwill and accounts receivable are the big ones and, often, the deal-breakers. Accounts receivable are often regarded by the new doctor as “his” by virtue of his having done the work. Of course, the collection of these receivables will be banked into the employer’s account if the employee were to resign at any point

prior to buying an ownership interest.

And, were he an equal owner of the practice, they would logically go to him if he resigned.

So the logical question becomes, what does the new doctor do to gain access to this asset? Answer: Buy it. But since that imposes a cash flow and tax burden on the new doctor, he is usually allowed to “earn his way in” by taking a reduced paycheck for a period of time. That doesn’t mean

Even in attractive but saturated metropolitan centers like San Diego County, where practice opportunities should be most valuable, it’s very difficult to get someone to join without guaranteeing a salary, subsidizing the start-up, and virtually giftingover an ownership position at the end of a year. the practice is off the hook valuing the receivables, though. If it isn’t done, neither party knows if the correct “earn-in” price has been paid. And you can be sure that at least one party will feel victimized.

Generally, the other asset of controversy is goodwill. It is the amount that an agreeable buyer pays a willing seller above the values of all of the other assets discussed above, both being competent and in possession of the facts. Passions run hot on this issue so a case for the existence of goodwill will have to be made.

The best evidence for goodwill: someone actually paid it recently. If Dr. Five actually agreed to pay (by salary reduction, lump sum, or other mechanism) $50,000 to join the group three years ago, Dr. Six can reasonably expect to do likewise unless things have changed markedly. We generally recommend pegging the number at a percentage of annual collections (common industry practice) and allowing the employee to pass if he or she thinks the price is too high. Our message to the employee: “You can continue to work here — at employee pay — indefinitely; at some point, you will likely have earned for us the entire

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amount of your buy-in, and you may be admitted to ownership status then. If you change your mind and want that to happen sooner, just let us know.”

Make It or Buy It? This approach has the effect of reducing the decision to what is referred to in manufacturing as a “make or buy” proposition.

If it’s cheaper for Boeing to buy 777 toilet seats from a plastics specialist in Taiwan than to set up their own injection molding operation, they contract out the work.

Similarly, our junior physician is evaluating the offer to buy-in by comparing it to other opportunities and the cost of “making” his own practice from scratch.

This latter option is becoming increasingly unattractive, though, which should argue for higher goodwill values. Indeed, as practice gets tougher, the value of joining the exclusive club of self-employed physicians, with its attendant perquisites, should be going up.

And some practices have far better than average potential. We recently worked with a cardiology practice that was negotiating the entrance price of the second physician, in a competitive area of Southern California. The junior will be paying close to a half million dollars to join.

A vast number of his contemporaries will roll their eyes skyward, wondering how dumb a guy could be to agree to that amount for a half interest in a practice in the toughest market in America. The management consultant on the case knows from years of experience, and a good understanding of the individuals, that the deal is a good one for both sides.

A b ou t t h e Au t ho r : Mr. Den-

ning is a management consultant with SDCMS-endorsed partner Practice Performance Group (PPG). SDCMS members receive discounted management consulting on productivity and patient flow, personnel, governance and management, market strategy and tactics, practice acquisitions, sales and mergers, and a free oneyear subscription to UnCommon Sense.

PPG also conducts free, half-day seminars for SDCMS members and their staffs at SDCMS’ offices. Contact Mr. Denning at (858) 459-7878 or at Jeff@PPGConsulting.com. Visit PPG at www.PPGConsulting.com.

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Mental Health

O

n May 24, 1797, legend has it that Dr. Philppe Pinel brought the values of the Enlightenment to the treatment of mental illness when he removed the iron shackles from the limbs of his patients at the men’s asylum of Bicêtre Prison, near Paris. In so doing, he initiated the era of “moral treatment” — the first humane approach to the mentally ill in Western society. This event was ultimately (more than 50 years ago) memorialized in the initiation of the yearly “May is Mental Health Month” celebration.

In fact, the hospital superintendent, Jean-Baptiste Pussin, had already initiated a more sensitive, psychological approach to treatment at the hospital. Though a layperson, Pussin served as Pinel’s mentor.

And, although Pinel has traditionally been credited with “freeing” the inmates, in fact the shackles were often replaced by straight jackets and seclusion. Nonetheless, the era of moral treatment, which produced large, relatively benign, often rural institutions for the warehousing of the mentally ill — what became, in the United States, a system of state hospitals — was a huge advance over the previous fear and abuse of those with psychiatric disorders.

By Marshall E. Lewis, MD

Removing Shackles, Moving Boundaries May Is Mental Health Month

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Sixty percent of the excess mortality for individuals with schizophrenia is due to largely preventable conditions and/or treatable illnesses: cardiovascular, pulmonary, and infectious.

This Mental Health Month, we can celebrate many achievements, including new, effective therapies and medications for psychiatric illness, and the passage of the Mental Health Services Act (“Prop 63”) a few years ago, which provides a “millionaire’s tax” in California, meant to bolster and transform services in the public sector.

But we still face major challenges.

In a 2006 study, the National Association of State Mental Health Program Direc-

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tors (NASMHPD) revealed that, nationally, people with serious mental illness die an average of 25 years earlier than the general public. Suicide and injury account for only 30–40 percent of the increased mortality.

On the other hand, 60 percent of the excess mortality for individuals with schizophrenia is due to largely preventable conditions and/or treatable illnesses: cardiovascular, pulmonary, and infectious. Among the factors contributing to the problem are limited access to physical healthcare and the deleterious effects of some of our newer psychotropic medications, which can cause metabolic syndrome.

Who are the mentally ill? Psychiatric illness is common enough, so there are few of us whose lives are untouched, who haven’t had at least one friend or relative who has experienced a serious psychiatric condition. Over the years I have consulted with, or treated, many members of the families of physician colleagues.

Most psychiatric illness is treatable, controllable, and often curable. People with mental illness can and do recover, all the time. Studies have shown that even “chronic,” long-term patients with schizophrenia, when followed after a number of years, ultimately wind up largely recovered from the worst manifestations of their illness and are able to engage in society in a constructive and meaningful manner.

If quality of life can be achieved by those with mental illness — even resumption of usual employment and relationships — why are these individuals not achieving

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“parity” of physical health status? The San Diego County Health and Human Services Agency (HHSA), of which I am a part, is dedicated to addressing this issue.

If any other minority group suffered such a dramatic, outrageous health disparity, there would undoubtedly be a very visible, public campaign to bring their mortality numbers in line. The reasons for society’s inattention to the medical plight of the mentally ill are complex. Stigma remains a major issue. There are few people of prominence who are willing to self-identify as mentally ill, leaving a relatively small group of social crusaders to champion the cause.

Funding is also a problem, as MediCal and most health insurance providers found it economical to “carve out” mental health services years ago, creating a separate “silo” for psychiatric patients to obtain care. There is often little collaboration between primary and behavioral healthcare providers. A separate healthcare record magnifies the problem.

There’s a moral imperative to bring good, physical healthcare to the mentally ill. But there are several other reasons as well. First, as the Institute of Medicine made clear in its “Crossing the Quality Chasm” report of 2001 and in subsequent updates, efficient, “patient-centered” care is important for everyone. We need to be focused on the whole patient, and we must find ways to economize. As most readers are aware, the United States as a nation ranks number one in healthcare spending

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but is far from the top in healthcare outcomes. If we can find cost-effective ways to coordinate services around the patient’s needs, we should be able to save money and improve outcomes at the same time.

I believe we need to break down barriers between psychiatrists and other medical practitioners, and rethink how we provide behavioral health services. We in psychiatry need to see ourselves more as consultants, akin to other specialists, rather than as entirely separate providers. Doing so can allow us to leverage our mental health resources, to support the provision of more holistic, comprehensive care by primary care providers — care that can include behavioral healthcare even for individuals with serious mental illness whose need is not acute or complex. Isn’t this, after all, the way cardiologists work with primary care providers? The patient with compensated CHF will be treated by a PCP and sent to the cardiologist if there are problems. The cardiologist can take over the solo care of the patient if the cardiac condition becomes more complex or acute, but then, generally, he or she hands the patient back to the PCP.

The reasons for society’s inattention to the medical plight of the mentally ill are complex.

In a sense, one could envision the boundary of traditional “mental health” extending to recognize that much behavioral healthcare is already provided in the physical health realm for the less psychiatrically ill. With the proper supports and incentivizations, I believe that comprehensive medical care — a “medical home” — can be provided within primary care, for at least some of those with more serious mental illness, to include more behavioral health treatment by the PCP and primary care team.

How do we accomplish this kind of strategic shift of services? In meeting with primary care clinic providers, I’ve started to identify an approach, requiring structural changes in the way we provide behavioral healthcare: 1. Primary care clinics could use an integrated behavioral health consultant to provide assistance with diagnosis,

brief treatment of behavioral illness, and a combination of case management and expedited referral for those situations where the patient’s behavioral health needs become more acute. This position could be either a masters- or doctorate-prepared clinician, but the important element is that the consultant must be trained in working flexibly within a primary care team, and must see that team as their “customer.” If it’s 5 p.m. and the PCP’s patient suddenly reveals that his or her psychiatric symptoms are substantially worse, the PCP must be able to hand the patient off to this consultant to do what’s needed for safety.

2. PCPs need access to psychiatrists for informal and formal consultation, on demand — not the traditional “I’ll call you back later this afternoon between sessions,” but real-time conversations while the PCP has the patient in the office.

3. PCPs need the time (or the financial incentive) to be able to spend more time with patients with behavioral illness when that illness requires.

4. P CPs need educational support regarding the use of unfamiliar psychotropic medications.

These innovations could provide the incentives and support needed to allow primary care groups to work directly with a behavioral health system. There is a broader implication too for the fee-forservice sector, and we need to flesh out the ways in which Medi-Cal and other insurers might provide support for collaborative or integrated care.

As we enter Mental Health Month, I hope this discussion will stimulate our medical community to consider ways to move even further beyond iron shackles and straight jackets to commit to reducing the awful physical health disparity that still faces those in our community with mental illness. HHSA and I are looking forward to a positive dialogue with the medical community, aimed at better health outcomes for all.

the Au t ho r : Dr. Lewis, SDCMS and CMA member since 2009, is clinical director of the County of San Diego Health and Human Services Agency Behavioral Health Division.

A b ou t

Do You Know of Any Physician Volunteer Opportunities?

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If you know of any volunteer opportunities for physicians in San Diego County, California, across the United States, or anywhere else in the world, please email the information to Editor@SDCMS.org. SDCMS will publish all physician volunteer opportunities free of charge on our website at SDCMS.org.

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County Public Health Officer’s Update

By Dean E. Sidelinger, MD, MSEd

every

Child, every Time, every Place

May 5 is World Asthma Day

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H

opefully, the title caught your attention, and you’re wondering what the public health topic is this month. You would not be faulted for thinking that the title refers to immunizations (every kid needs them, physicians should update them at each appointment, and different models should be explored to reach adolescent patients where they are for their vaccinations) or even healthy eating (every child deserves nutritious food every day at home, in schools, and throughout their communities). But, in honor of World Asthma Day on May 5, the title is a reference to our jobs as physicians with asthma action plans.

Every child with asthma needs an asthma action plan. While children are the focus of this article, the truth is that every person with asthma needs an asthma action plan. That action plan needs to be updated every time you see the patient.

A child with asthma needs an asthma action plan every place they spend time on a regular basis (whether that’s at home, school, or at Grandma’s house when she babysits).

Asthma action plans are but one aspect of caring for patients with asthma outlined in the “Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma,” from the National Heart, Lung, and Blood Institute (NHLBI: www.nhlbi.nih.gov). The guidelines cover assessment and monitoring, including assessment of asthma severity and control, as well as recommendations for follow-up; education (this is where the asthma action plan comes in); control of environmental factors and comorbid conditions; and medication use, with recommendations to step treatment up and down. Hopefully, all practicing physicians have incorporated these evidence-based guidelines, as well as recommendations from your respective professional organizations, into your care of patients with asthma.

So why the focus on the asthma action plan for children? It is one aspect of asthma care and treatment where we, as physicians, can impact multiple environments. Pediatricians and other physicians who care for children can assist patients (and their parents) with self-management of their illness and can facilitate improvement of care that children receive while at school and in other settings. To provide the best care for children with asthma, all of these environments must be impacted.

This intersection of an individual’s health

with multiple environments is one principle of public health. The more obvious intersection of asthma and environment are the multitude of environmental triggers that exacerbate patients’ asthma, including exposure to tobacco smoke, airborne allergens, and respiratory infections.

The causes of asthma, as well its diagnosis and treatment, are multi-factorial.

Guidelines exist to help clinicians address

So why the focus on the asthma action plan for children? It is one aspect of asthma care and treatment where we, as physicians, can impact multiple environments.

Pediatricians and other physicians who care for children can assist patients (and their parents) with self-management of their illness and can facilitate improvement of care that children receive while at school and in other settings. this serious disease. Yet these guidelines are not always followed. Every day, many children with asthma attend school in San Diego County without asthma action plans. This article is written to remind physicians to examine one aspect of your asthma care (preparation, use, and distribution of asthma action plans) and strive to improve this feature.

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While World Asthma Day also serves as this reminder, also endeavor to improve the asthma care of your patients for the same reason as other local health organizations. Staff from the American Lung Association, County of San Diego Health and Human Services Agency, Price Charities, Rady Children’s Hospital San Diego, San Diego Regional Asthma Coalition, and San Diego Unified School District have been meeting regularly in City Heights to determine what can be done to reduce the burden of asthma in the community. This area is faced with the highest emergency room discharges, hospitalizations, and deaths due to asthma in San Diego County.

Also, in the fall of last year, a middle school student died from the disease. This tragedy should not happen again. All of us have to work together to improve care for children with asthma across all sectors of our community. One aspect of improving care that is needed, and that can be achieved, is more children attending school with asthma action plans. So please join champions in this cause (whether you practice in City Heights or National City; Vista or Chula Vista; Rancho Santa Fe or Rancho San Diego) and remember: Every child, every time, every place.

A b ou t t h e Au t ho r : Dr. Side-

linger, pediatrician and SDCMS and CMA member since 2008, is the deputy public health officer for the County of San Diego. He also serves as the chief of the Maternal, Child, and Family Health Services Branch for Public Health Services.

Dr. Sidelinger is vice president of the local chapter of the American Academy of Pediatrics (AAP) and active on the national level of the AAP.

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Public Health

By Nora Volkow, MD

Science of Addiction A Brain Disease

W

hen scientists first started to study drug abuse, people addicted to drugs were thought to be morally flawed and lacking in willpower. This view has shaped society’s response to drug abuse, treating it as a moral failing rather than a health problem and resulting in punitive rather than preventive and therapeutic actions. Due to groundbreaking scientific discoveries, we now recognize drug addiction as a brain disease that can be successfully prevented and treated.

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What Is Drug Addiction?

Drug addiction is a chronic, relapsing brain disease characterized by compulsive drug seeking and use despite often devastating consequences. It results from a complex interplay of biological vulnerability, environmental exposure, and developmental factors (e.g., stage of brain maturity).

As with many other diseases, vulnerability to addiction stems partly from a person’s genetic makeup. Scientists estimate that genetic factors account for 40–60

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percent of an individual’s vulnerability to addiction, with environmental and developmental variables influencing whether and how particular genes are expressed.

Additional factors, such as conditions at home, at school, or in the neighborhood, can heighten addiction vulnerability. Research also shows that early drug use increases the likelihood of addiction and that people with psychiatric disorders have a higher risk of drug abuse and addiction than the general population.

Research has improved our understanding of the biological mechanisms underlying drug abuse and addiction. All drugs of abuse directly or indirectly target the brain’s reward system by flooding the circuit with dopamine — the neurotransmitter that regulates feelings of pleasure, as well as movement, emotion, cognition, and motivation. Overstimulation of this system produces the euphoric effects sought by people who abuse drugs and teaches them to repeat the behavior. Our brains are wired to repeat activities that bring us pleasure or reward (e.g., eating or having sex) as a way of ensuring our survival. Because taking drugs of abuse stimulates the same circuit, our brains urge repetition of the behavior, and thus people “learn” to abuse drugs without thinking about it. These intense impulses can overcome a person’s willful intent not to take drugs, despite catastrophic consequences, which is really the essence of drug addiction.

Therefore, even though the initial decision to take drugs is mostly voluntary, once drugs take over, they cause brain changes that acutely impair a person’s ability to exert self-control. Brain imaging studies of drugaddicted individuals have revealed physical changes in brain areas critical to judgment, decision-making, learning, memory, and behavior control, which may help explain the compulsive and destructive behaviors associated with drug addiction.

Preventing Drug Abuse The National Survey on Drug Use and Health (NSDUH) estimated that 22.3 million persons (9 percent of the U.S. population aged 12 or older) were classified with substance abuse or dependence in 2007 (based on criteria specified in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition). Of these: • 3.2 million abused or were dependent on both alcohol and illicit drugs; • 3.7 million abused or were dependent on illicit drugs but not alcohol; and

• 15.5 million abused or were dependent on alcohol but not illicit drugs.

Data on teen drug use reflect both encouraging and troubling trends. Although statistics show a 25 percent decline from 2001 to 2008 in past-month use of any illicit drug by students in 8th, 10th, and 12th grades, abuse of marijuana continues to be a problem with approximately 11 percent of 8th graders, 24 percent of 10th graders, and 32 percent of 12th graders reporting use in the past year. Prescription painkillers also continue to be abused at unacceptably high levels, with 1 in 10 high school seniors reporting abuse in the past year. In addition, while past-year abuse of OxyContin held steady among 12th graders, the rate nearly doubled among 8th graders between 2002 and 2006, rising from 1.3 percent to 2.6 percent. Prescription drugs are easily accessible and are often obtained from a friend or relative for free. Moreover, there is a common misperception that because they are prescribed by a doctor, prescription medications are safe, even when used in ways not intended.

Because early use of drugs increases a person’s chance of more serious abuse and addiction, prevention is crucial. NIDA studies have shown that prevention programs backed by science (rationally designed and rigorously tested) can be effective in youth. Such programs work to boost protective factors, reduce risk factors for drug use, and help shape youths’ perceptions about drug-abuse risk.

Medical Consequences of Addiction Illicit drug abuse causes 17,000 deaths annually in the United States and more than $180 billion in annual economic costs. Abuse of nicotine, alcohol, and/ or prescription drugs causes additional morbidity and mortality. Although some medical consequences of drug abuse and addiction are temporary and can be essentially reversed with treatment, others may be more persistent, diminishing the quality of individuals’ health long after drug use has stopped. Whether short-lived or chronic, the many potential health effects from drug abuse and addiction underscore the fact that drug abuse does not exist in medical isolation — it causes a broad array of medical consequences throughout the body (www.nida.nih.gov/consequences).

A few examples follow: • Cardiovascular Effects. Researchers have found a connection between the abuse of most drugs and adverse

cardiovascular effects, ranging from abnormal heart rate to heart attacks.

Injection drug use can also lead to cardiovascular problems, such as collapsed veins and bacterial infections of the blood vessels and heart valves.

Use of marijuana, cocaine, methamphetamine, and inhalants can result in cardiovascular effects.

• Neurological Effects. All drugs of abuse

act in the brain to produce euphoric effects; however, some drugs also cause severe negative consequences in the brain such as seizures, stroke, and widespread brain damage that can impact all aspects of daily life. Drug use can also cause brain changes that lead to problems with memory, attention, and decision-making. Examples of drugs with neurological effects in-

Congratulations to the 2009 Combined Health Agencies

HealtH Heroes Presented by

The 15th annual Health Hero Awards honored individuals and companies selected by each of the members of Combined Health Agencies. These heroes have given freely of their time, talent and resources to improve the health and well-being of our community.

Sponsored in part by:

Pat Brown • Alzheimer’s Association of San Diego Dr. Robert Henry • American Diabetes Association Chef Jeffrey Strauss • American Liver Foundation Mark Johnson • American Lung Association in California Kevin Kouzmanoff • American Melanoma Foundation Ability Center • Amyotrophic Lateral Sclerosis Association Dr. Corrie Broudy • Arthritis Foundation DeeDee Spangler • Autism Society of America Charlie Brown, Viejas Band of Kumeyaay Indians • The Burn Institute Dr. John Person • Crohn’s & Colitis Foundation of America BJ’s Restaurants • Cystic Fibrosis Foundation Charles Curo, Barona Band of Mission Indians • Epilepsy Foundation Dr. Amanda Gosman • Fresh Start Surgical Gifts Amylin Pharmaceuticals • Juvenile Diabetes Research Foundation Elite Racing/Competitor Group • The Leukemia & Lymphoma Society Dr. Carla Rothlin • Lupus Foundation of Southern California Council of Community Clinics • Mental Health America of San Diego County Cal Fire • Muscular Dystrophy Association Frazee Paint & Wallcovering • National Multiple Sclerosis Society TEVA Neuroscience • Parkinson’s Disease Association of San Diego Jan Cetti • San Diego Hospice and The Institute for Palliative Medicine Dr. Jenny Kim • Sickle Cell Disease Association of America Bixi B. Craig • Stepping Stone of San Diego

More information at combinedhealth.org

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increases the risk of heart disease and lung cancer in persons who have never smoked by 25–30 percent and 20–30 percent, respectively. Exposure to tobacco smoke in the home increases severity of childhood asthma and has been associated with sudden infant death syndrome.

Treatment and Recovery Discoveries about the science of addiction have led to advances in drug-abuse treatments that enable people to counteract addiction’s powerful effects on the brain and behavior and regain control of their lives.

Despite the availability of many forms of effective treatment for addiction, the problem of relapse remains the major challenge to achieving sustained recovery. However, relapse rates for addiction are similar to those for other well-characterized chronic medical illnesses such as diabetes, hypertension, and asthma, which also have both physiological and behavioral components.

Treatment of chronic diseases involves

Illicit drug abuse causes 17,000 deaths annually in the United States and more than $180 billion in annual economic costs.

clude cocaine, methamphetamine, inhalants, and ecstasy.

• HIV, Hepatitis, and Other Infectious Diseases. Drug abuse increases the spread of infectious diseases. Injection of heroin, cocaine, and methamphetamine causes more than a third of new AIDS cases and is a major contributor to the spread of hepatitis C. In addition, all drugs of abuse interfere with judgment and increase the likelihood of risky behaviors, which also contribute to the spread of HIV/AIDS and other sexually transmitted diseases.

• Other Health Effects. In addition to the effects various drugs of abuse may have on specific organs of the body, many drugs produce global body changes such as dramatic changes in appetite and increases in body temperature, which may impact a variety of health

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conditions. Withdrawal from drug use also may lead to numerous adverse health effects, including restlessness, mood swings, fatigue, muscle and bone pain, insomnia, cold flashes, diarrhea, and vomiting.

In addition to harmful effects for the addicted individual, drug abuse can result in serious health consequences for others. For example, while the full extent of the effects of prenatal drug exposure on a child is not known, studies show that various drugs of abuse may result in premature birth, miscarriage, low birth weight, and a variety of behavioral and cognitive problems in infants and children. Secondhand exposure to tobacco smoke is another example.

According to the 2006 Surgeon General’s Report, “The Health Consequences of Involuntary Exposure to Tobacco Smoke,” exposure to environmental tobacco smoke

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changing deeply embedded behaviors, and relapse does not mean treatment failure. For the addicted patient, lapses back to drug abuse indicate that treatment needs to be reinstated or adjusted, or that alternate treatment is needed. For most individuals, combining medications with behavioral therapies is the most successful approach.

Different types of medications may be useful at different stages of treatment — during withdrawal to ease symptoms; during treatment to help people stay engaged; and following treatment to prevent relapse.

Medications currently available include those used to treat: • Tobacco Addiction. Nicotine replacement therapies (patch, inhaler, gum), bupropion, varenicline.

• Opioid Addiction. Methadone, buprenorphine.

• Alcohol and Drug Addiction. Naltrexone (helps prevent relapse to alcohol and heroin abuse), disulfiram (helps

Due to groundbreaking scientific discoveries, we now recognize drug addiction as a brain disease that can be successfully prevented and treated. prevent relapse to alcohol abuse and is currently being tested for treating cocaine abuse), acamprosate (helps preB of A_SDP_08:Layout 1 10/9/08 2:38 PM vent relapse to alcohol abuse).

Behavioral treatments help people modify attitudes and behaviors related to drug abuse and increase their ability to handle stressful situations and environmental cues that may trigger intense craving for drugs and prompt relapse. For example: • Cognitive behavior therapy helps people recognize, avoid, and cope with situations in which they are most likely to abuse drugs.

• Motivational incentives treatment uses positive reinforcements (i.e., rewards or privileges) to help people remain drug-free.

• Motivational interviewing is conducted at treatment entry to stoke an individual’s desire to fully participate in treatment and change his or her behaviors.

• Group therapy helps people face their drug abuse realistically, acknowledge the harm it can cause, and increase motivation to not use drugs.

Behavioral therapies can also enhance the effectiveness of medications and help people remain in treatment.

The process of recovery from drug abuse Page 1 or addiction can be long and complex.

When people enter treatment, addiction has often taken over their lives. The compulsion to find and use drugs may have disrupted their families, their professional lives, and their standing in the community. It also may have made them vulnerable to other serious illnesses. Because the effects of drug abuse are far reaching, treatment must address the needs of the whole person to have the best chance for success.

The most effective programs incorporate a variety of rehabilitation services to address a person’s medical, psychological, social, vocational, and legal needs to enhance their recovery process.

At NIDA, we believe that a fuller understanding of the science of addiction will encourage adoption of research-based policies and programs to reduce drug addiction and will increase support for scientific research to improve the health of our citizens. Please visit our recently created website to access a wealth of resources designed to help physicians recognize, diagnose, and treat drug abuse and addiction: www.nida.nih.gov/ medstaff.html. Together, we can continue to leverage the power of science against this devastating disease that causes so much suffering for individuals, communities, and society at large.

the Au t ho r : Dr. Volkow is director of the National Institute on Drug Abuse (NIDA), National Institutes of Health.

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Healthcare Update

SDCMS and CMA Fight to Undo Deeply Flawed Medicare Formulas SGR and GPCI

Note: This first letter, requesting GPCI reform, was sent to all San Diego County U.S. Representatives, asking them to co-sign the following letter to Speaker of the House of Representatives Nancy Pelosi and Representative Sam Farr.

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April 6, 2009 Congresswoman Susan Davis U.S. House of Representatives 1526 Longworth HOB Washington, DC 20515 Dear Congresswoman Davis: The San Diego County Medical Society (SDCMS), representing the more than 8,000 physicians in San Diego County, would like to again express our thanks, on behalf of San Diego County’s doctors and patients, for your efforts in 2005 and 2006 to correct Medicare’s geographic payment system, which continues to inappropriately combine San Diego County and other high-cost counties with the rest of California’s rural counties. The Center for Medicare and Medicaid Services (CMS) and Congress have both acknowledged that the current Medicare payment system results in payments out of alignment with the intent of the geographic adjustment formula (Geographic Practice Cost Index, or GPCI). San Diego County physicians have been directly impacted by more than $30 million in underpayments in the past

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year alone because they are unfairly and inappropriately lumped with other, lowercost counties in California.

Despite years of efforts, nothing has yet been done to correct these significant underpayments for physician services. This results in greater difficulty in maintaining access to care for San Diego County seniors, and, as noted in the report by the Abaris Group regarding San Diego County’s healthcare safety net, adversely impacts access to care for safety-net recipients. The recent Acumen report confirms our prior concerns about the inaccuracy of the GPCI system and calls for correction of such inaccuracies in order to meet the goals intended under Medicare payment rules.

This problem has only grown since the 1997 implementation of the current payment system, based on data not updated since 1966, despite changing demographics and increased costs in formerly rural areas that are now urbanized.

We now have another opportunity to try to address this problem, as Congressman Farr and Speaker Pelosi begin meetings to seek a resolution to the underpayments affecting 10 counties in California and over

140 counties nationwide.

We ask that you co-sign the attached letter to Congressman Farr and Speaker Pelosi, asking them to update the Medicare geographic payment system with immediacy. This is an issue of fairness and of preservation of access to care.

We look forward to your help in resolving this ongoing, significant, and unfair underpayment to San Diego County physicians.

Stuart Cohen, MD, MPH President, San Diego County Medical Society (SDCMS) Enclosure April 6, 2009 Congresswoman Nancy Pelosi Speaker of the House U.S. House of Representatives 235 Cannon HOB Washington, DC 20510 Congressman Sam Farr U.S. House of Representatives 1126 Longworth HOB Washington, DC 20515 Dear Speaker Pelosi and Congressman Farr: On behalf of the Medicare patients and physicians in our districts, we urge you to enact Medicare physician geographic payment locality reform this year. Physicians in 32 states and 174 counties are inaccurately paid up to 14 percent less per year than their Medicare-assigned geographic cost factors, and we are concerned about protecting seniors’ access to doctors in some of these counties. While repeal or modification of the flawed Sustainable Growth Rate (SGR) formula is the top Medicare physician priority because of its impact on physician practices in every state, a Medicare geographic payment locality update is long overdue and urgently needed.

As you are aware, the Medicare fee schedule adjusts payments for physicians based on their geographic practice costs (i.e., office rent, supplies, staff wages, malpractice insurance). However, despite major demographic changes across the country, the Medicare geographic payment localities have not been regularly and fairly updated since 1966 except for a consolidation 10 years ago.

We are concerned that access to doctors

in some of these significantly impacted counties is a real problem. For instance, physicians in California’s Santa Cruz County are paid roughly 10 percent less than what Medicare says it costs to practice medicine in Santa Cruz. They are paid 25 percent less than physicians in neighboring Santa Clara County, which has similar practice costs and is the highest paid Medicare locality in the country. San Diego County is the most fiscally impacted, with physicians being underpaid by more than $30 million annually for services provided to Medicare beneficiaries, compared with what should be paid if San Diego County were under an accurate payment system

This is further compounded by private payers basing their fee schedules on the flawed undervalued Medicare fee schedule for San Diego County. These private payers are underpaying for services — impacting access to care — in large part due to the failure of the Centers for Medicare and Medicaid Services (CMS) and Congress to address this issue for nearly a decade. as required under Medicare rules. This is further compounded by private payers basing their fee schedules on the flawed, undervalued Medicare fee schedule for San Diego County. These private payers are underpaying for services — impacting access to care — in large part due to the failure of the Centers for Medicare and Medicaid Services (CMS) and Congress to address this issue for nearly a decade.

CMS could fix the problem, but they have been unwilling to impose a budgetneutral solution, which is required by law.

While an update significantly helps physi-

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cians in these impacted counties, it simultaneously imposes a payment reduction on rural physicians.

Therefore, we urge you to develop legislation that provides payment accuracy to these underpaid counties while protecting rural physicians from pay cuts. Several proposals to improve both accuracy and administrative simplicity in payment have been put forth, including migrating impacted counties, or even all counties, to an MSA-based system (Metropolitan Statistical Areas) as is used for hospitals and other non-physician providers. Counties whose geographic adjustment factor (GAF) exceeds their locality GAF by 5 percent on an iterative basis need to be made whole in order to maintain access to care for seniors and other Medicare beneficiaries, as well as for the public in general.

You will be reviewing specific proposals for such an update from the California Medical Association (CMA) and the recent Acumen report, which also supports such changes. We urge you to work with these proposals and CMA to expeditiously correct the underpayments while holding harmless the rural counties that might otherwise be negatively impacted by a purely budget-neutral solution. As such proposals become more defined, we request that you keep us informed and allow us to present our input before a final decision is reached, while still moving to fix this broken system as quickly as possible.

Congress must ensure geographic payment accuracy in the Medicare program, which currently does not exist when San Diego is still considered a rural farm town under the Medicare payment system. We can correct years of neglect and bring geographic payment equity to the Medicare program for a relatively minor cost, bringing back required payment accuracy and administrative simplicity. We must protect access to doctors in these impacted counties while not harming patients in rural areas. Thank you for your action on this important issue.

Sincerely, Members of Congress

A b ou t t h e Au t ho r : Dr. Co-

hen, pediatrician and SDCMS and CMA member since 1988, is current president of SDCMS.

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{ UPDATE } Healthcare

Federal Issues Update April 23, 2009

By E liza b eth Mc N eil

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the SGR is an unprecedented investment in physician payment reform. In essence, it wipes the slate clean so that future payment reform and updates are much less costly and therefore achievable.

House Budget Resolution The House Budget Committee adopted a Budget Resolution that waives the “paygo” rules for the Medicare physician SGR as long as any subsequent physician payment reform legislation provides ways for physicians to practice more efficiently.

Five SGR Caps — Starting Point House Ways and Means Health Subcommittee Chair Pete Stark and Energy and Commerce Committee Chair Henry Waxman are using the 2007 CHAMP Act as the starting point for the 2009 physician payment reform legislation. The CHAMP Act replaced the current single SGR spending cap with five SGR specialty-spending caps (E&M Services, Major Procedures, Minor Procedures, Anethesia, and Imaging & Lab).

Physicians still face a 21 percent Sustainable Growth Rate (SGR) cut on January 1, 2010.

SCHIP and HIT Funding for Physicians In February, Congress passed and the president signed into law H.R. 1, the American Recovery and Reinvestment Act of 2009 (ARRA). ARRA provides for additional Medicaid funding to the states, extended COBRA coverage for families who lost their jobs, and up to $41,000 in direct health information technology (HIT) funding to physicians participating in the Medicare and Medicaid programs. Congress also passed H.R. 2 (effective April 1, 2009), the Children’s Health Insurance Program Reauthorization Act of 2009, which extends the State Children’s Health Insurance Program (SCHIP).

Medicare Physician Payment Reform Federal elected officials are making an enormous financial commitment to begin to fix the physician payment system in an environment of healthcare-cost containment and economic crisis. Physicians still face a 21 percent Sustainable Growth Rate (SGR) cut on January 1, 2010.

Obama Budget President Obama introduced his budget plan, which eliminates the Medicare SGR at a cost of $360 billion. Because the federal budget accounts for 10 years of savings from the SGR (40 percent + physician payment cuts), reversing the SGR is extremely costly. The move by Obama to eliminate

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Accountable Care Organizations The House leaders are also working on a plan to move physicians into organizations — referred to by the healthcare researchers as Accountable Care Organizations (ACOs) — to collaborate, coordinate care, and produce efficiencies that would help to prevent unnecessary hospitalizations.

Any savings produced on the hospital side would be used to fund annual physician payment increases. The Senate is also looking to aggressively incentivize physicians to move to provide care through such organizations. According to healthcare economists, existing organizations that use this model are extremely efficient, provide high-quality care, and maintain competitive physician incomes.

While the House is moving toward adoption of the five SGR targets, the Senate is exploring payment options for solo/ small-group physicians who cannot move

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to the ACO model or who do not want to practice in an ACO model.

As healthcare costs continue to rise, governments go broke, and employers drop their coverage, Congress will not rubber-stamp business as usual. However, Congress will be willing to pay physicians more if they are involved in improving quality, coordinating care, and maximizing resources.

Medicare Physician Payment Locality Reform — GPCI On April 16, 2009, on behalf of CMA, Speaker Nancy Pelosi used the power of

her office to bring together House and Senate committee staff leaders for a Medicare GPCI Summit. Congressman Sam Farr was key to convincing Pelosi to call such a summit. The goal was to find solutions to the outdated physician payment locality borders. The summit included staff from the key congressional committees: Ways and Means and Energy and Commerce, as well as the Senate Finance Committee.

CMS, MedPAC, and other representatives were in attendance. CMA physicians Larry DeGhetaldi, MD and Edward Bentley, MD presented the CMA data from their two reports on the issue.

Whether coverage is offered through a public or a private health plan, CMA’s goal to this point has been to argue for a healthcare delivery system that works for physicians and patients and physician payment reform that improves payments.

There was widespread recognition by both House and Senate staff, the Centers for Medicare and Medicaid Services (CMS), and the independent Medicare Payment Advisory Commission (MedPAC) that the locality issue is a significant problem of payment accuracy in the Medicare program. The House leaders gave CMA a firm commitment that they intended to fix the problem this year. While the Senate-House representatives did not agree on a final solution, there was agreement on a narrow group of solutions, including a plan to reorganize all physician payment localities into Metropolitan Statistical Areas (MSAs) so that physicians would adhere to the same geographic organization that Medicare applies to the hospitals. Moreover, the MSA approach results in the most accurate physician payments. CMA was firm that legislation was needed to ensure that the rural counties in California were held harmless from any payment cuts resulting from the restructuring.

CMA is working with Farr and Senator Diane Feinstein to introduce a bill that is consistent with CMA policy.

Health Reform Several weeks ago, CMA President Dev GnanaDev, MD, represented California physicians at Obama’s Health Care Summit in Los Angeles. CMA will also be participating in the stakeholder meetings on the House side on health reform at the invitation of Chairmen Stark and Waxman.

The Senate will move first by bringing

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urged that any health reform be adequately a package of three health-reform bills to financed. Experience has demonstrated committee “mark-up” in June. All of the that 1when programs3:52 are underfinanced, committees with jurisdictionAKT_SDP_08:Layout are holding 8/22/08 PM Page 1 physician budgets are the first ones to be hearings from April through June on the cut, which negatively impacts patients’ abilvarious issues related to health reform. ity to find doctors. CMA has also expressed Health Reform Framework serious concerns with a public plan option There is growing consensus among the that only pays Medicare FFS rates. CMA Democratic leadership to adopt the followhas urged that Congress implement proviing framework: sions that ensure fair competition between • Universal coverage through an individual mandate.

• Expansion of Medicaid coverage for low-income families.

• Tax credit for families to purchase insurance.

• Coverage provided by private health plans competing in a Health Insurance Exchange (HIE).

• The exchange would mandate market reforms (guaranteed issue, community rating, and a medical loss ratio).

• All plans would be required to offer three basic benefit packages.

• There would be a public plan competing with the private plans in the HIE. (The public plan option has become the most controversial aspect of the health reform plan.)

• The plan would be financed by a tax on wealthy families and a pay-or-play payment made by large employers. Both the House and Senate are exploring additional funding mechanisms.

• The Obama budget committed $600 billion-plus to the estimated $1 trillion price tag for health reform.

Personal: A major piece of the health reform pack• Income Tax Planning age will be physician payment incentives that • Wealth Management restructure the healthcare delivery system.

Public Plan Option Congressional advocates have outlined a Medicare FFS type of program for the public plan option as well as a CalPERS type of model. Because Pelosi, Stark, and Waxman (the California legislators in leadership positions who will be writing the health-reform bill) support the public plan option, CMA has been working to keep a place at the negotiating table. The private health plans are strongly opposed to a public plan option.

Whether coverage is offered through a public or a private health plan, CMA’s goal to this point has been to argue for a healthcare delivery system that works for physicians and patients and physician payment reform that improves payments. CMA has

public and private plans so that physicians have negotiating power to move between systems.

Medicaid Rates Increased to Medicare Levels CMA has been focused on improving the Medicaid rates. CMA supports health-reform expansions of Medicaid to additional Continued on page 38

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{ UPDATE } Healthcare

Revisiting the

Medical Home Can We go home again?

By S tuart A . C ohen , M D , M P H

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T

homas Wolfe once opined that “you can’t go home again.”

While it’s true that going back to one’s glorious roots is never quite the same experience, we have reason to believe that it may indeed be gainful for pediatricians to revisit their medical home concept. The idea of the medical home was originally conceived by the American Academy of Pediatrics (AAP) in 1967 — after being nurtured into reality by pioneers such as pediatrician Cal Sia of Honolulu — as a means of improving care and health outcomes for children with special healthcare needs. Round-theclock, comprehensive, culturally sensitive, team-oriented care for the patient under one easily accessible “roof,” that of the primary care physician, was and is the foundation of the medical home.

This idea, promulgated by community pediatrics, survived intact, and indeed thrived occasionally, while remaining untouched and unsullied by other specialties. It marched through tumultuous decades of healthcare system financing change, including the ’70s and ’80s with their indemnity plans, the ’80s and ’90s with PPOs, and the ’90s and beyond with HMOs, as well as through the new millennium with its high-deductible health plans and health savings accounts (HSAs).

More recently, the medical home concept — endorsed by the AAP, the American College of Physicians, the American Academy of Family Physicians, and the American Osteopathic Association — has been revisited as a new payment system whereby, upon meeting certain National Committee for Quality Assurance (NCQA) graded and scored requirements, a physician might receive enhanced payments for coordinating care within the medical home. Why the increased interest by primary care in the medical home?

The answer lies in the entrenched Resource-Based Relative Value Scale (RBRVS) payment system and its predecessor, adopted by Medicare and through osmosis (and various opaque and proprietary conversion factors) by all U.S commercial healthcare payers. The payment system has — to put it mildly — misaligned incentives that favor proceduralists over cognitive care, volume over quality of care and outcome, and “cherry-picking” of healthy patients over ones with chronic conditions and special healthcare needs.

This is, of course, exacerbated by the lack

of connection in the current marketplace between one’s cost of care and one’s ability to determine and choose higher-value return, such as quality of care.

Round-the-clock, comprehensive, culturally sensitive, team-oriented care for the patient under one easily accessible “roof,” that of the primary care physician, was and is the foundation of the medical home.

The payment inequities have led to a distorted choice for medical students and residents — to largely ignore family practice and general internal medicine residencies in order to get on the ROAD (radiology, ophthalmology, anesthesiology, dermatology) to success. Pediatric residencies have survived because of an abundance of women being afforded part-time and job-sharing career opportunities.

So, today’s proffered solution is the Primary Care Collaborative (PCC). Under this proposal, the NCQA will validate and certify a medical home by awarding points for inclusion of various elements, including improved access and communication, enhanced care management and coordination, use of health information technology (IT) to enhance safety and reliability of patient care, support for patient self-care, and performance reporting and improvement (N. Engl. J. Med. 359;12:1202-5). A monthly payment per patient, possibly adjusted for case-mix and chronicity/severity of illness, would “enhance” the basic fee for service or capitated fee payment.

If a practice is large enough and dedicated enough to acquire the full complement of medical home resources, payments may indeed be sufficient to once again make family practice or general internal medicine feasible for medical students as a “choice” career.

Our AAP, through various means, including the private-payer advocacy com-

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The payment inequities have led to a distorted choice for medical students and residents — to largely ignore family practice and general internal medicine residencies in order to get on the ROAD (radiology, ophthalmology, anesthesiology, dermatology) to success.

mittee and liaison with the NCQA and PCC, is aware of the emergence of the medical home as an enhanced payment system, and is working diligently to ensure both that sound principles of medical care are maintained and that ultimate systems of scoring a medical home and judging outcomes are pediatric friendly and developmentally age appropriate for children.

So, what are the barriers to implementation of a medical home? Is it “too good to be true?” I will conclude by listing four main barriers: 1. Foremost, effective case management and care coordination of patients with acute or chronic conditions requires access to information across multiple sites: hospital; lab; primary, specialty, and ancillary care; pharmacy; and rehabilitation. This is possible in a medical foundation model of care or within a clinically integrated delivery system, but not likely within current solo or small-practice groups. It is hoped TCS_SDP_08:Layout 1 8/15/08 10:16 AM Page 1 that through the Recovery Act (formerly some time! the American Recovery and Reinvestment 2. Medicare is a budget-neutral system.

Act) funding, smaller practices will cliniRecent reports of medical home pilot studies cally integrate through shared IT and joint in Medicare show promise of improved paquality assurance initiatives. This will take

tient outcomes and enhanced patient safety, but no initial cost savings. Indeed, added initial monetary outlays were necessary.

The spectacle of class warfare that I witnessed at the last American Medical Association meeting, where the medical home principles (but not any particular method of financing) were endorsed, had specialists of all stripes raging about a wealth transfer to their primary care colleagues.

Solutions lie in a combination of new monies for the PCC, as well as some compromise by the specialists, along with a revenue-sharing incentive at the specialty level for any potential cost savings.

3. Our current data systems have not yielded specific-enough measurement points to analyze medical home effectiveness. Rather than using the current reporting of care as in the Healthcare Effectiveness Data and Information Set (HEDIS) system, measuring effectiveness of “episodes of care” and attendant cost would give us judgments of value and quality of care.

We also need to look incrementally at quality of life and functionality along with traditional outcomes of care and their cost.

Time Well Spent?

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These data points surely must be possible under an integrated electronic medical record system.

4. Momentum for healthcare financing change can be paradoxically lost if healthcare reform moves ahead too quickly.

Under universal coverage there may be less incentive to adopt healthcare financing reform. Given the pace of reform in Washington, I am not too worried about this reality.

We can go home again! Although incomplete and under renovation, our medical home makeover, properly managed and supervised, holds great promise for the next generation of primary care providers in our country. However, without the proper foundation, a poorly rebuilt medical home may just accelerate the demise of primary care as we know it today.

A b ou t t h e Au t ho r : Dr. Co-

hen is in private practice with Children’s Primary Care Medical Group. He is an AAP delegate to AMA and CMA, and is the current president of the San Diego County Medical Society.

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Federal Issues Update Continued from page 33 low-income families as long the rates are increased to Medicare levels. Expanding coverage does not guarantee access to doctors. Waxman has vowed to work with CMA to improve the Medicaid rates in any health reform expansion.

CPLH - an annual publication of CMA’s Center for Legal Affairs answers the legal questions most frequently asked by physicians. This year’s CPLH offers more than 4,500 pages of comprehensive legal information including current laws, regulations, and court decisions related to medical practice in California.

Medicare “Balance Billing” Legislation Pursuant to CMA House of Delegates policy, CMA is supporting legislation to allow physicians to balance bill their patients.

The bill has been introduced by a physician member of Congress, Tom Price.

The handbook is available in a 7-volume print format and on CDROM. The CD-ROM offers all of the content of the print version, plus many enhancements including fully searchable content and hyperlinks that let you navigate within the CD-ROM and onto the web for more information on the cited court cases.

Family Planning, Access, Care, and Treatment Program (FPACT) In early April, the Obama administration announced it would continue California’s successful Medicaid waiver for the FPACT program through September 2009. President Obama also included a permanent continuation of the program in his budget.

CMA is working to continue the program through legislation.

Print _________________ $960 nonmember ($798 CMA Member)

Physician Anti-trust Relief CMA continues to urge Congress to allow physicians to collectively negotiate on a level playing field with the powerful health plans. Recently, CMA worked with the House Judiciary Committee to send a letter to the Federal Trade Commission (FTC) asking whether the provisions of H.R. 1 — the American Recovery and Reinvestment Act — related to health information technology and quality reporting would meet the FTC’s requirements for clinical integration, which would allow physicians to collectively negotiate.

CD-rom _________________ $480 nonmember ($398 CMA Member)

Combination: Print + CD-rom _________________

$1080 nonmember ($899 CMA Member)

All orders must be pre-paid.

Prices do not include shipping, handling and sales tax.

CPLH 2009 is produced through the generous support of our partners, the Cooperative of American Physicians, Medical Insurance Exchange of California, NORCAL Mutual Insurance Company and The Doctors Company.

To order, call 800.882.1262 or visit CMA’s Bookstore at cmanet.org.

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Medical Device Safety Act — Medical Liability Protection for Physicians CMA is supporting the Medical Device Safety Act (Waxman and Kennedy). This bill would reverse the use of the preemption doctrine to immunize medical-device manufacturers from lawsuits as illustrated by the Supreme Court’s recent ruling in Riegel v. Medtronic. CMA believes medical-device manufacturers must be held accountable for their products to ensure patient safety; otherwise, patients will be forced to inappropriately seek redress from physicians who cannot afford unwarranted exposure to medical liability.

Because AMA has not taken a position

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on the legislation, CMA is directly urging other state medical associations to support the bill and garner co-sponsors from their congressional delegations.

Improving Access to Care in Rural California CMA is urging Congress to improve the supply of physicians in rural areas by expanding the Medicare Scarcity Area program, the Health Professional Shortage Area (HPSA) program, and allowing more specialists to participate in the HPSA and J-1 VISA Waiver programs. CMA is supporting the expansion of student loan forgiveness programs and seeking opportunities to use Steven Thompson funds to draw down federal matching funds. CMA is also exploring ways for rural California communities to use local government and other community funding to draw federal matching funds to attract and maintain physicians.

Strategies to Address Antimicrobial Resistance (Starr) Act The CMA Foundation has been a national leader in promoting appropriate antibiotic prescribing and use across the country through its Alliance Working for Antibiotic Resistance Education (AWARE) Project.

CMA is working with the Foundation to gain passage of the STARR Act (Matheson and Ferguson). The bill would provide authority for the federal government to combat antibiotic resistance.

Increasing Access to Culturally Competent Care CMA is working with Congressman Xavier Becerra to introduce legislation that would improve access for Medicare and Medicaid patients to linguistically appropriate and culturally competent care. Such legislation would include provisions to reduce the burden on physicians to arrange and pay for interpreter services. It would also provide video monitors in physician offices through demonstration projects based on the successful experience of two projects funded by the California Endowment in San Francisco and Alameda counties.

A b ou t t h e Au t ho r : Ms. Mc-

Neil is CMA’s vice president of federal government relations.

Merchant Services: Credit/Debit Card Processing Potential Value: $1,500 for high-dollar, high-volume cost!

Chase Paymentech provides member physicians fast, secure, and cheaper credit card payment processing, excellent customer service, and innovative payment options. SDCMS members receive upgraded customer service, free online reporting, and a guaranteed 10–20 percent savings from current costs. Let Chase Paymentech provide you with a competitive quote today by sending three months of merchant statements to Janet Lockett at JLockett@SDCMS.org, by fax to (858) 569-1334, or call her at (858) 300-2778.

Technology Solutions Potential Value: $1,000!

Soundoff Computing Corporation provides bestof-breed hardware, software, and network technologies for your medical practice, utilizing best practices for all aspects of IT implementations.

SDCMS member physicians receive free site inspection and subsequent infrastructure recommendations; free inventory and assessment of network and hardware computing assets; free analysis of Internet/telco/ data activity and subsequent ROI recommendations.To learn more, visit www.soundoffcomputing. com or contact Ofer Shimrat at (858) 569-0300 or at ofer@ soundoffcomputing.com.

Banking Products and Services Potential Value: $2,500!

Torrey Pines Bank is a “lowmaintenance” bank that meets business owners’ high expectations while requiring of them the absolute minimum of time and effort. Approved SDCMS members receive no-fee lines of credit, $1,000 fee discounts on commercial real estate loans, waived monthly maintenance fees on personal accounts for practice partners and employees up to $10 per month, free first order of standard checks for personal accounts, increased deposit interest rates, waived monthly maintenance fee for business online banking and bill pay services, ATM fees waived up to $15 per month, and free courier service or remote deposit service.

Contact Benjamin Pimentel at (858) 259-5317 or at bpimentel@ torreypinesbank.com.

Insurance Products and Services Potential Value: $1,000–$2,500!

Alliant Insurance Services, Inc., is California’s largest premier specialty insurance broker and ranks among the 13 largest in the

nation. SDCMS members receive discounts on a comprehensive portfolio of insurance products and services, including savings of 5–10 percent or more off of the cost of insurance, or cash rebates related to practice size, a savings of 7–12 percent on long-term disability income protection, and no-cost human resources consulting. Contact Mark Allan at (800) 654-4609 or at mallan@ alliantinsurance.com. Visit Alliant Insurance Services online at www. alliantinsurance.com.

Tamper-resistant Prescription Pads Potential Value: $300!

American Security Rx, which is a California Department of Justice and California Board of Pharmacy approved Security Printer (SP-9), provides tamperresistant California security prescription forms for controlled medications. SDCMS members receive discounts on tamperresistant prescription forms.

Contact American Security Rx at (877) 290-4262 or at info@ americansecurityrx.com. Visit American Security Rx online at www.americansecurityrx.com.

Billing Solutions Potential Value: $1,000!

CHMB Solutions provides outsourced medical billing, revenue cycle management services, information technology support, and hardware solutions to physician practices, clinics, and multi-specialty organizations.

SDCMS members receive a 50 percent discount on startup fees and a $33 per-physician-permonth services credit, 10 percent off of outsourced IT support, 10 percent off of already discounted Dell hardware solutions, and a free coding hotline. Contact Ron Anderson at (760) 520-1340 or at randerson@chmbsolutions.com.

Email your coding question(s) to SDCMS at Coding@SDCMS.org.

Visit CHMB Solutions online at www.chmbsolutions.com.

Contract Analysis Potential Value: 10 percent of Net Revenue!

Coastal Healthcare Consulting Group, Inc., is a specialty consulting firm that assists clients with managed care contracting, contract negotiations, credentialing, revenue enhancement, and strategic planning. SDCMS members receive a free contracting analysis, a discount on hourly rates, and a package price on services for contract negotiations, including health plan contracts!

Contact Kim Fenton, president, at (949) 481-9066 or at kimf@healthcareconsultant.

org. Visit Coastal Healthcare Consulting Group online at www. healthcareconsultant.org. For consultation scheduling, contact Marisol Gonzalez, your SDCMS physician advocate, at (858) 300-2783 or at MGonzalez@ SDCMS.org.

Practice Management Consulting Potential Value: $1,000–$2,500!

Practice Performance Group (PPG) provides high-performance medical practice management services for physicians, including consulting, expert witness, workshops, speaking, and a monthly newsletter. SDCMS members receive discounted management consulting on productivity and patient flow, personnel, governance and

and a 7.5 percent dividend credit.

To learn more, contact Janet Lockett at SDCMS at (858) 3002778 or at JLockett@SDCMS. org. Visit TDC online at www. thedoctors.com.

Collections Services Potential Value: $350–500!

TSC Accounts Receivable Solutions has provided personalized, innovative collection and total accounts management services since 1992.

This local, family-owned business’ management team has combined experience of more than 50 years in the healthcare billing and collection field. SDCMS members receive a 10 percent discount on monthly charges. Contact Catherine Sherman at (888) 687-

SDCMS

Endorsed Partner Benefits

Total Potential Value to SDCMS Members:

$10,000–$17,000 management, market strategy and tactics, practice acquisitions, sales and mergers, and a free one-year subscription to their newsletter, UnCommon Sense.

PPG also conducts free half-day seminars for SDCMS members and their staffs at SDCMS’ offices.

Contact Jeffrey Denning or Judy Bee at (858) 459-7878 or at Jeff@PPGConsulting.com. Visit PPG at www.PPGConsulting.com.

Professional Liability Insurance Potential Value: $500–$2,500!

The Doctors Company (TDC) enjoys a reputation as the industry vanguard for low California rates, aggressive claims defense, expert patient safety programs, superior customer service, and exemplary member benefits. Most SDCMS members are eligible for a 5 percent discount on insurance premiums M AY

4240, ext. 14, or at csherman@ tscarsolutions.com. Visit TSC online at www.tscarsolutions.com.

Accounting Services Potential Value: $500–$2,000!

AKT CPAs and business consulting LLP has provided audit, tax preparation and planning, accounting assistance, and business consulting to San Diego County clients for more than 50 years. SDCMS members receive a 15 percent discount on standard rates for professional services, with an unconditional satisfaction guarantee: “SDCMS members who are not completely satisfied with the work AKT performs for them pay only what they thought the work was worth.” Contact Ron Mitchell at (760) 268-0212 or at rmitchell@ aktcpa.com. Visit AKT at www. aktcpa.com.

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Corporate Legal Services Receive a free consultation and discounts on corporate legal services. Call Ladd Young Attorneys at Law at (619) 5646696.

San Diego County Physician Mailing Lists Receive one free physician mailing list annually and a discount on all additional mailing lists requested in the same year.

Contact SDCMS at (858) 5658888.

SDCMS Membership Certificate Receive a free SDCMS membership certificate. Contact SDCMS at (858) 565-8888.

Investments Invest with Dunham & Associates and discount your SDCMS dues by $150. Call Jeff Dunham at (619) 308-9700.

SDCMS Pictorial Membership Directory Appear in SDCMS’ annual pictorial membership directory.

Receive a free directory each year and a 50% discount on additional directories purchased, as well as discounts on directory advertising. Contact SDCMS at (858) 565-8888.

Coding Hotline Access a free coding hotline (provided by CHMB Solutions).

Email your coding question(s) to SDCMS at Coding@SDCMS.org.

San Diego Physician Magazine Receive a free subscription to the voice of San Diego County’s physicians. Place free classified ads and discounted display ads.

Contact SDCMS at (858) 5658888.

San Diego Magazine Receive a gift subscription (active physician members) or a discounted subscription (resident physician members).

To sign up, contact SDCMS at (858) 565-8888. To update your subscription address, contact San Diego Magazine at (888) 3500963 or at sdgm@kable.com.

SDCMS Email Newsletter, “News You Can Use” Receive the latest in medical, local, state, and federal news critical to your practice … free to members and free of advertising.

Contact SDCMS at (858) 5658888.

SDCMS Seminars SDCMS member physicians and their office staff attend free

S A 40 40

of charge all SDCMS seminars (including Office Managers Forums), covering legal issues, HIPAA, risk management issues, how to begin your practice, contract negotiations, getting paid, billing, and much more.

Contact SDCMS at (858) 5658888.

involved in any of a broad spectrum of engagement opportunities both SDCMS and CMA afford their member physicians, including joining an SDCMS or CMA committee or becoming a physician leader.

Contact SDCMS at (858) 5658888.

California Emergency Driving Emblem Receive a free California physician emergency driving emblem and additional emblems discounted at $10. Contact SDCMS at (858) 565-8888.

Hertz Discounts Save up to 15% on daily Hertz car rental rates. Special international discounts are also available. Visit www.Hertz.com or call Hertz at (800) 654-2200. Frequent traveler miles and bonus points may be earned for qualifying rentals. An SDCMS-CMA members-only code is needed to take advantage of this discount — email MGonzalez@SDCMS.org to receive your code.

Local, State, and Federal Physician Advocacy SDCMS and CMA continue to be vigilant in our protection of MICRA, in fighting against non-physician scope of practice expansions, in working closely with our political representatives and other healthcare stakeholders to fix our broken healthcare financing system, and in doing everything we need to do to protect physicians’ interests wherever they are challenged.

Contact SDCMS at (858) 5658888.

Full-time SDCMS Physician Advocate Have a question? Don’t know where to begin? Contact your fulltime, SDCMS physician advocate, Marisol Gonzalez, free of charge, to get the answers to all your questions, at (858) 300-2783 or at MGonzalez@SDCMS.org.

Full-time SDCMS Office Manager Advocate Let your office manager and staff know that they have a full-time office manager advocate on staff at SDCMS ready to help them with any questions they may have, free of charge. Contact Lauren Wendler at (858) 3002782 or at LWendler@SDCMS.org.

SDCMS News Alerts Stay informed of the news that affects your bottom line and your patients’ health with faxed and emailed alerts sent by SDCMS to you, free of charge … and free of advertising! Contact SDCMS at (858) 565-8888.

SDCMS and CMA Websites Access members-only SDCMS and CMA websites to find valuable resources, such as a list of San Diego County physician NPIs, updated weekly. Contact SDCMS at (858) 565-8888.

Engagement in Healthcare Issues Be part of the solution! Become

residents receive a 50% discount.

Contact Epocrates at (800) 2302150 or visit www.cmanet.org.

CMA ON-CALL Documents You can access, free of charge, thousands of pages of medical-legal, regulatory, and reimbursement information, through CMA’s online library.

Contact CMA at (415) 882-5144, at legalinfo@cmanet.org, or visit www.cmanet.org.

CMA’s Weekly Newsletter, “Alert” Delivered directly to you, free of charge, via email or fax. Contact Katherine Gallia at CMA at (916) 551-2074 or at kgallia@cmanet. org.

Free CMA Reimbursement Hotline (888) 401-5911

SDCMS Other

Member Benefits See Page 39 for a Listing of Our Endorsed Partner Benefits

Auto Insurance Along with your spouse, receive 4.5–14% discounts on all lines of coverage from the Automobile Club of Southern California.

Contact SDCMS at (858) 5658888.

HIPAA Compliance Receive a discount on a complete, do-it-yourself HIPAA privacy and security compliance toolkit (CD ROM). Call David Ginsberg at PrivaPlan at (877) 218-7707.

Epocrates Clinical Reference Guides Receive a 30% discount off of a one-year subscription and a 35% discount off of a two-year subscription to Epocrates’ clinical reference guides. Students and

NS AD NI E DG IOE GP OH YP SHI YC SI A I CN I . Ao Nr g . o | M r g | A A Y pri 2 0 0l 9 2 0 A 0 pri 9 l

Free CMA Legal Hotline (415) 882-5144 Free CMA Legislative Hotline (866) 462-2819 Free CMA Physician Confidential Line A 24-hour phone service for physicians, dentists, medical students, residents, and their families and colleagues who may have an alcohol or other chemical dependence or mental/behavioral problem. Completely confidential.

Using it will not result in any form of disciplinary action or referral to any disciplinary body. Call (213) 383-2691.

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SDCMS Foundation Project Access San Diego Project Access San Diego is a NEW and INNOVATIVE project designed to coordinate healthcare volunteerism here in San Diego County. Together we can ensure that our vulnerable populations have access to needed healthcare services.

Your commitment to Project Access is required for our success. We want to make it easy for you to participate, so Project Access provides the following case-management services to enrolled patients: • Enrolling Patients Based on Need: We verify financial status so that you can be assured that your volunteer service is reaching those who are most in need.

• Making Appropriate Referrals: We use referral guidelines that ensure that when a Project Access patient comes to your office, he or she can take full advantage of the visit.

• Providing Enabling Services: We provide services such as transportation and translation so that you don’t have to wonder if a patient is going to miss an appointment or if there will be a language barrier.

• Providing Case Management Services: We work with each patient one-on-one to coordinate follow-through on all medical needs.

• Providing All Needed Services: Through our partnerships, we ensure that a full scope of services is available to all of our patients, from office visits, hospital services, and even a defined pharmacy benefit.

Project Access is actively recruiting physicians, hospitals, and ancillary service providers to participate in the program.

Please make a commitment today.

Visit our website at SDCMSF.org to learn more and sign up.

Sign up NOW at SDCMSF.org

We need your volunteer commitment to help even one patient.

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Classifieds OFFICE SPACE UTC MEDICAL OFFICE SPACE AVAILABLE: One day a week. UTC area. Telephone (619) 229-5340 or email pam@sdspineinstitute.com.

[704] SCRIPPS ENCINITAS CONSULTATION ROOM / EXAM ROOMS: Available consultation room with two examination rooms on the campus of Scripps Encinitas. Will be available a total of four days per week. Receptionist help provided if needed. Contact Stephanie at (760) 753-8413.

[703] 3998 VISTA WAY, SUITE D, IN OCEANSIDE: Medical office space (approximately 2,080ft2) 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. Move in incentives offered: tenant improvement allowance and rent abatement. For further information, please contact Lucia Shamshoian at (760) 931-1134 or at shamshoian@coveycommercial.com. [702]

Leasing, Renewals & 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 your area, or for valuable vacancy and absorption information. Use our knowledge and expertise to help you negotiate a new lease, renewal, or purchase to assure you obtain the best possible terms. There is no charge for our consulting services.

Contact Chris Ross at 858.677.5329 email chris.ross@colliers.com

LA MESA OFFICE SPACE TO SHARE: Over 6,000ft2 OB/GYN office of four doctors with one leaving, available immediately. Space is ideal for a medical practice or clinical studies, and is located on Grossmont Hospital campus. Contact La Mesa OB/GYN at (619) 463-7775 or fax letter of interest to (619) 463-4181. [648] MEDICARE-CERTIFIED SURGERY CENTER: Reasonable rates for use of Medicare-certified surgery center. Call (619) 464-9876 and speak to Mira. [694] LA MESA OFFICE SPACE: Office space available in beautiful Victorian house in La Mesa. Call (619) 464-9876 and speak to Mira. [693] SPACE FOR LEASE: Beautiful office space available for lease in a booming location — located just outside of downtown San Diego, with ocean views, and a beautiful skyline. The space available includes two exam rooms and a physician’s office. Common areas include a third exam room for overflow, a lobby, kitchen, chart room, storage, front desk, and nurse station.

The practice is fully equipped and fully staffed.

Includes an EMR system, which means this is a paperless office! The staff is very friendly, and the office manager extremely experienced. New doctor may choose to join the team or practice solo. This is a family practice, but the team also includes a PT chiropractor and podiatrist. Please contact info@promed-financial.com or (888) 277-6633 for details. [692] NEWLY REMODELED CORNER BUILDING IN HILLCREST (1295 UNIVERSITY AVE, 2ND FLOOR): Flexible space between 300 and 10,000ft2, space can be configured according to requirements, front offices have large windows overlooking University Avenue. Covered, secured parking, two elevators, granite flooring in the entrance, staircase, and elevators; ADA bathrooms and electric doors. Near major hospitals, freeway 163, public transportation and Ralphs shopping center. Generous tenant improvement allowances possible with long-term lease. Lease terms and rent negotiable. Available April 2009.

Please call (858) 212-4562 or email samimi9@ gmail.com for more information. [689] OFFICE AVAILABLE ON SCRIPPS ENCINITAS LOT: In desirable building on Scripps Encinitas lot. Share elegant office that has just undergone complete interior designer 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. [688]

NEW MEDICAL BUILDING ALONG I-15: Pinnacle Medical Plaza is a new 80,000 SF building recently completed off Scripps Poway Parkway. The location is perfect for serving patients along the I-15 from Mira Mesa to Rancho Bernardo and reaches west with easy access to Highway 56. Suites are available from 1,000—11,000 SF and will be improved to meet exact requirements. A generous improvement allowance is provided.

For information, contact Ed Muna at 619-702-5655, ed@lankfordsd.com www.pinnaclemedicalplaza.com MEDICAL OR PROFESSIONAL OFFICE SUITES FOR LEASE, EL CENTRO, CA: In historic downtown area, near County offices, courthouse, and El Centro Regional Medical Center. Prime location; build to suit, and competitive rates with tenant incentives. 6,000ft2 can be divided; with private entrances. Near I-8 and public transportation with ample parking. Visit website for 441 West State Street at http://info.svn.com/Dottie.

Surdi. Direct inquiries to (858) 349-2007 or dottie.surdi@svn.com. [686] MEDICAL OR PROFESSIONAL OFFICE SUITES FOR LEASE, YUMA AZ: Directly across from new Yuma Regional Medical Center.

Prime location; build to suit, and competitive rates with tenant incentives. Ideal for sole practitioners. 1,000ft2 suite with private entrance or

700ft2 within the clinic. Ample onsite parking, public transportation nearby. Visit website at 2475 South Avenue A http://info.svn.com/Dottie.Surdi. Direct inquiries to (858) 349-2007 or dottie.surdi@svn.com. [685] SUITES FOR LEASE, MISSION VALLEY PROFESSIONAL MEDICAL/OFFICE BUILDING: Prime location, build to suit, and competitive rates with tenant incentives make this a fabulous value. Suites approximately 1,000ft2. At RT 15 and RT 8, just minutes from six major hospitals. Ample parking. Easy freeway access and public transportation nearby. Visit website for Riverview Center, 3633 Camino del Rio South at http://lease.svn.com/3633Camino. Direct inquiries to (858) 349-2007 or dottie.surdi@svn. com. [684] POWAY OFFICE SPACE TO SUBLET: Newly remodeled, 3,000ft2 office space to sublet.

Ground level, high-end medical office building with easy access from both the 56 and 15. Separate administrative space with possible procedure room available. Please contact (858) 6686502 or hsears@sdcpms.com. [683] OFFICE SPACE TO SHARE: Low-volume family medicine physician has space to share in his 1000ft2 office at 285 N. El Camino Real in Encinitas. Can reserve as little as one half-day per week. Please call or email Marty at (760) 4367464 or at mschulman@ucsd.edu. [682] MEDICAL OFFICE SPACE FOR LEASE IN ENCINITAS: Available August 2009. Share space with established physician-owner. Office located in new LEED-certified professional office development on Encinitas Blvd., close to 5 freeway, Scripps Hospital, and public transportation. Free parking, private bathroom, front desk area, and additional storage space included. One to two offices 11x14 are available full or part time. Affordable lease rate in desirable area. Contact Wendy Khentigan, MD, at (760) 845-0434 or at wendykmd@aol.com. [646] PHYSICIAN POSITIONS AVAILABLE SIHC MEDICAL DIRECTOR: Southern Indian Health Council, Inc., in Alpine is seeking a boardcertified medical director/physician. Great benefits and competitive wages! Please call (619) 445-1188, ext. 291, for details or visit our website at www.sihc.org under “Employment” then “Medical.” [708] BC/BE INTERNAL MEDICINE/FAMILY PRACTICE/HOSPITALIST NEEDED: Spanish-speaking (Portuguese-speaking a plus) BC/BE internal medicine/family practice/hospitalist needed for immediate opening in fast-growing community.

Salary, benefits, and generous incentives. H1B and J1 VISA waiver qualified. Send resume to sdhospitalist@hotmail.com. [706] PHYSICIANS NEEDED: Full-time, part-time, and per-diem opportunities available for family medicine, pediatric, and OB/GYN physicians. Vista Community Clinic is a private, nonprofit, outpatient clinic serving the communities of North

To submit a classified ad, email Kyle Lewis at KLewis@SDCMS.org. SDCMS members place classified ads free of charge (excepting “Services Offered” ads). Nonmembers pay $250 (100-word limit) per ad per month of insertion.

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Classifieds San Diego County. Must have current Calif. and DEA licenses. Malpractice coverage provided. Bilingual: English/Spanish preferred. Forward resume to hr@ vistacommunityclinic.org or fax to (760) 414-3702.

Visit our website at www.vistacommunityclinic.org.

EOE/M/F/D/V [700] PER DIEM/WEEKEND PHYSICIAN INDEPENDENT CONTRACTOR: Temecula independent diagnostic testing facility seeks physicians to monitor patient examinations requiring contrast. Position requires availability of at least two Saturdays a month. Typically scheduled for nine-hour day shifts.

Candidates must have California license. Please contact Robert at (619) 819-6528 for more information, or submit your CV via fax to (619) 342-4733 for immediate consideration. [699] URGENT CARE: Busy practice established in 1982 in East County seeks a part-time (with possibility of becoming full-time) physician. Please fax CV to (619) 442-2245. [698] OB/GYN: Well-established, busy OB/GYN practice next door to Mary Birch Women’s Hospital needs part-time associate with option to transition to full time. Inquires (858) 560-6200. [687] PRIMARY CARE PHYSICIAN FOR VETERANS HOME CHULA VISTA: The Veterans Home Chula Vista is currently seeking an additional primary care physician to provide medical care for veterans. The Veterans Home Chula Vista is a multi-care level facility with capacity for 400 residents consisting of three independent living retirement units with 165 beds; a Residential Care Facility for the Elderly (RCFE) assisted living unit with 55 beds; and a Skilled Nursing Facility (SNF) with 180 beds. The tentative start date is July 2009. This position requires experience in adult primary care medicine and preferably longterm care medicine. If you are interested in a career with our agency, please contact Paul Wagner, MD, at paul.wagner@cdva.ca.gov. [680]

experience seeking part-time employment. Call (949) 492-0198. [651]

Practice management

MEDICAL EQUIPMENT

PRACTICE MANAGEMENT SERVICES/PRACTICE MANAGER/KEY STAFF JOB SEARCHES: Let the

SMARTSOUND ULTRASOUND MACHINE: For cellulite treatment, deep tissue massage, and muscle pain — and promotes post-operative healing: $3,950. Item originally purchased for $15,000. Machine is like new, was placed in storage shortly after purchase, and in perfect working condition. Willing to negotiate price. Please call (858) 693-3000 for more information. [695]

practice professionals find you the right person. Plus, you are not identified. We place the ads, receive the applications, interview the better candidates, do reference checking and bring you the best 2 to 4 candidates for final interviewing.

We also do the salary and benefits negotiation with the preferred candidate. We know the medical office and can pinpoint what you need. Reasonable fees.

MEDICAL EQUIPMENT FOR SALE: Contour operating table, plastic surgery components, now Dexta surgical. Perfect for oral surgery, plastic surgery, ENT dermatology. Built in mayo stands, monitor brackets, equipment brackets, power foot controls, arm boards, head rest, Burton surgical light, heavy duty casters, table lock, auto trendelenberg, dual back rest position controls, articulating back. A mobile operating room! Contact Keith Wahl, MD, at kwahl@san.rr.com or on cellular at (858) 518-2190.

[681]

Contact Regina Reading or George Conomikes of Conomikes Associates, Inc.; (858) 720-0379 or email rreading@conomikes.com.

NONPHYSICIAN POSITIONS AVAILABLE

Miscellaneous NURSE PRACTITIONERS NEEDED: Part-time and per-diem opportunities available for family medicine, pediatric, and OB/GYN nurse practitioners. Vista Community Clinic is a private, nonprofit, outpatient clinic serving the communities of North San Diego County. Must have current Calif. license.

Malpractice coverage provided. Bilingual: English/ Spanish preferred. Forward resume to hr@vistacommunityclinic.org or fax to (760) 414-3702. Visit our website at www.vistacommunityclinic.org. EOE/ M/F/D/V [701] PHYSICIAN POSITIONS WANTED MD SEEKING PART-TIME EMPLOYMENT: Elderly MD in North San Diego with prior legal, weight, etc.,

“

Do hobbies make better doctors?: Eric Anderson, MD, a local, now-retired physician­— and an occasional contributor to San Diego Physician in the '80s—has an assignment from Medical Economics to write about physicians' hobbies and whether the hobbies might help them be better doctors. For example, does photography make a physician more observant? Does the discipline of flying make a physician more organized in the office? Dr. Anderson would appreciate the chance to talk to any physicians about their hobbies. Interested physicians should contact Dr. Anderson at eander1@cox.net, at (619) 794-0005, or on his cell at (858) 775-0774.

[707]

When times are good, you should advertise. When times are bad, you MUST advertise.*

”

Advertise in the San Diego County Medical Society 2010 Pictorial Membership Directory The SDCMS Pictorial Membership Directory is published annually and mailed to all member physicians (approximately 3,000). It is also available for purchase by non-member physicians and other interested parties. Advertising in the SDCMS Pictorial Membership Directory is a cost-effective and profitable way to get referrals and put your message in front of physicians, office staff, and patients who utilize this critical resource on a daily basis.

SDCMS Member Physicians Receive

25% off

advertising rates

Color advertisements and premium positions are limited and available on a first-come, first-served basis. Contact Dari Pebdani today: 858-231-1231 or DPebdani@SDCMS.org *From an article by American Business Media entitled “Making a Recession Work for You.”

M AY

2 0 0 9 | S A N D I E G O P H Y S I C I A N . o r g

43

Healthcare Financing

Spending on Health* A

G lo b al

O verview

4%

Other

33%

19%

General Government (Excluding Social Insurance)

Private Insurance

• Country With Lowest Total Spending per Person per Year on Health: Burundi ($2.90)

Total Global Expenditure for Health per Person per Year

$639

• Country With Lowest Government Spending per Person per Year on Health: Burundi ($0.70)

18%

Out-of-pocket

26%

Social Insurance

Total Global Expenditure for Health:

$4.1 trillion +

World Health Expenditure Composition

Country With Highest Total Spending per Person per Year on Health: United States

$6,103

Country With Highest Government Spending per Person per Year on Health: Norway

$4,508

• Country With Highest Annual Out-of-pocket Household Spending on Health: Switzerland ($1,787)

• Percentage of the World’s Total Financial Resources Devoted to Health Currently Spent in OECD Countries: 80%

• Country With Lowest Annual Out-of-pocket Household Spending on Health: Solomon Islands ($1.00)

• Annual Spending by the Municipal Government of New York City (Population 8.2 million) on Health: $429 million

• Average Amount Spent per Person per Year on Health in Countries Belonging to the Organization for Economic Co-operation and Development (OECD): $2,716

• Annual Spending by the Government of Bénin (Population 8.2 million) on Health: $86 million

• Percentage of the World’s Population Living in OECD Countries: 18%

• WHO Estimate of Minimum Spending per Person per Year Needed to Provide Basic, Lifesaving Services: $35–$50

*Based on World Health Organization (WHO) data from 2004 and 2005.

44

S A N D I E G O P H Y S I C I A N . o r g | M A Y

2 0 0 9

Superior Standards.

“

From the business structure of this physcian owned and governed company, to the proactive approach to risk management, CAP’s priorities are consistent with my own style of practice and business philosophies.

“

– Tammy Wu, MD CAP District Council Member

The Cooperative of American Physicians, Inc. (CAP)

is the only physician owned and governed company whose

core product, Mutual Protection Trust, is Rated A+ (Superior)

by A.M. Best Company. Superior physicians are dedicated to excellence. They should expect nothing less from their medical professional liability provider.

For more than 30 years, CAP has rewarded the dedication of superior physicians with superior protection for less. We keep our costs low by keeping our standards high. Membership might not come easy,

but once you get in, you know you’re in good company. To find out more, call 800-252-7706, or visit www.superiorphysicians.com.

C ooperative

of

SAN DIEGO

a meriCan p hysiCians , i nC . | 333 s. h ope s t ., 8 th f loor | l os a ngeles , Ca 90071 |

ORANGE

|

LOS ANGELES

|

PALO ALTO

|

SACRAMENTO

The Mutual Protection Trust (MPT) is an unincorporated interindemnity arrangement among physicians authorized by Section 1280.7 of the California Insurance Code. Members do not pay insurance premiums. Instead, they pay tax-deductible assessments, based on risk classifications, for the amount necessary to pay claims and administrative costs. No assurance can be given as to the amount or frequency of assessments. Members also make a tax-deductible Initial Trust Deposit, which is refundable according to the terms of the MPT Agreement.

$5.95 | www.SANDIEGOPHYSICIAN.org San diego County Medical Society 5575 RUFFIN ROAD, SUITE 250 SAN DIEGO, CA 92123 [ RETURN SERVICE REQUESTED ]

PRSRT STD U.S. POSTAGE PAID DENVER, CO PERMIT NO. 5377