September 2010 by San Diego Physician

✖ SDCMS Celebrates Its 140th Anniversary in 2010 ✖ Reaching 8,500 Physicians Every Month

september 2010

official publication of the san diego county medical society

““"ACO"...

What’s that?! p.18

What Have We Done for You Lately? p.14

“Physicians United For A Healthy San Diego”

We reward loyalty. We applaud dedication. We believe doctors deserve more than a little gratitude. We do what no other insurer does. We proudly present the Tribute® Plan. We honor years spent practicing good medicine. We salute a great career. We give a standing ovation. We are your biggest fans. Richard E. Anderson, MD, FACP Chairman and CEO, The Doctors Company

We are The Doctors Company.

You deserve more than a little gratitude for a career spent practicing good medicine. That’s why The Doctors Company created the Tribute Plan. This one-of-a-kind benefit provides our long-term members with a significant financial reward when they leave medicine. How significant? Think “new car.” Or maybe “vacation home.” Now that’s a fitting tribute. The San Diego County Medical Society has exclusively endorsed our medical professional liability program since 2005. To learn more about our program for SDCMS members, including the Tribute Plan, call us at (800) 328-8831, extension 4390, or visit www.thedoctors.com/tribute.

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S A N D I E G O P HY S I CI A N .or g se pte m b e r 2010

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CHMB DELIVERS THE HIGHEST LEVEL OF SERVICE AND EXPERTISE TO ENSURE A SWIFT, SMOOTH AND SUCCESSFUL EHR COMPLETION.

thismonth Volume 97, Number 9

features Accountable Care Organizations 18 ACOs: The Basics by the California

Medical Association

Mike Couris, MD, and Ted Steuer

Past President (AMA Alternate Delegate) Lisa S. Miller, MD President-elect (CMA District 1 Trustee) Robert E. Wailes, MD Secretary (SDCMS At-large Director) Robert E. Peters, MD, PhD

geographic and geographic alternate Directors East County William T. Tseng, MD, Heywood “Woody” Zeidman,

22 An Aco: Sharp Community Medical Group’s Journey by John E. Jenrette, MD

26 ACOs, EHRs, HIEs, Oh My! XiMED Medical Group by Thomas Sounhein

MD (A: Venu Prabaker, MD) Hillcrest Niren Angle, MD, Steven A. Ornish, MD Kearny Mesa John G. Lane, MD (A: Jason P. Lujan, MD) La Jolla J. Steven Poceta, MD, Wynnshang “Wayne” Sun, MD (A: Matt H. Hom, MD) North County James H. Schultz, MD, Doug Fenton, MD (A: Steven A. Green, MD) South Bay Vimal I. Nanavati, MD, Mike H. Verdolin, MD (A: Andres Smith, MD) At-large and At-large alternate Directors Jeffrey O. Leach, MD, Bing S. Pao, MD, Kosala Samarasinghe, MD, David E.J. Bazzo, MD, Mark W. Sornson, MD, Mihir Y. Parikh, MD (A: Carol L. Young, MD (sdcms foundation president), Thomas V. McAfee, MD, Ben Medina, MD, James E. Bush, MD, Alan A. Schoengold, MD)

departments

other board members

4 SDCMS Seminars, Webinars and Events

Communications Chair Theodore M. Mazer, MD Young Physician Director Van L. Cheng, MD

4 Community Healthcare Calendar

Alternate Young Physician Director Kimberly M. Lovett, MD Resident Physician Director Katherine M. Whipple, MD

6 Briefly Noted SDCMS Medical Office Manager Bulletin Board, and More … by Walt Ekard

SDCMS Board of Directors Officers President Susan Kaweski, MD

Treasurer Sherry L. Franklin, MD

20 Aco Plans: Scripps Mercy Physician Partners by Davis Cracroft, MD,

10 Bureaucrats Are Human Too

Managing Editor Kyle Lewis Editorial Board Van L. Cheng, MD, Adam F. Dorin, MD, Kimberly M. Lovett, MD, Theodore M. Mazer, MD, Robert E. Peters, MD, PhD, David M. Priver, MD, Roderick C. Rapier, MD Marketing & Production Manager Jennifer Rohr Sales Director Dari Pebdani Project Designer Lisa Williams Copy Editor Adam Elder

Alternate Resident Physician Director Steve H. Koh, MD Retired Physician Director Rosemarie M. Johnson, MD Alternate Retired Physician Director Mitsuo Tomita, MD Medical Student Director Adi J. Price

CMA Speaker of the House James T. Hay, MD

ex-officio, nonvoting board members

14 What Have We Done for You Lately?

by Susan Kaweski, MD, and Tom Gehring

34 Physician Marketplace

CMA Past Presidents Robert E. Hertzka, MD, Ralph R. Ocampo, MD CMA district I Trustees Theodore M. Mazer, MD, Albert Ray, MD,

Robert E. Wailes, MD CMA Trustee (other) Catherine D. Moore, MD,

Classifieds

CMA Solo and Small-group Practice Forum Delegates

36 Natural Laws

Michael T. Couris, MD, James W. Ochi, MD Alternate CMA Solo and Small-group Practice

by Daniel Bressler, MD

Forum Delegate Dan I. Giurgiu, MD AMA Delegates James T. Hay, MD, Robert E. Hertzka, MD Alternate AMA Delegates Lisa S. Miller, MD, Albert Ray, MD

What Hfoavr Ye ou We Donteely? La

web exclusive • HIT Update

Navigate the HIT Adoption Process and Optimize Your Ability to Obtain Federal Subsidies

“Physicians United o” for a Healthy San Dieg

14 2

S A N D I E G O P HY S I CI A N .or g septe m b e r 2010

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

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calendar

sdcms Seminars / Webinars / Events Free to member physicians and their staff. For further information, contact Sonia Gonzales at (858) 300-2782 or at SGonzales@SDCMS.org, or visit SDCMS.org. ACOs and Medical Foundations (seminar/webinar/event) Mon., Sept. 13 11:30am–1:00pm, and 6:00pm–7:30pm E-town hall (T) (event) Wed., Sept. 15 11:30am–12:30pm Palmetto / Medicare (seminar/webinar) Thurs., Sept. 16 11:30am–1:00pm Media Training (seminar) Sat., Sept. 18 9:00am–12:00pm “The Art of the Appeal” (billing seminar/webinar) Thurs., Sept. 30 11:30am–1:00pm Certified Medical Coder Course (seminar) 5 Fridays, Oct. 1–29 8:00am–4:00pm Economic Survival (seminar/webinar) Thurs., Oct. 7 11:30am–1:00 pm

“Expert Witness, Medical Board Interactions” (legal issues seminar/webinar) Thurs., Nov. 4 11:30am–1:00pm Membership Social (T) (event) Fri., Nov. 12 6:00pm–9:00pm “Physician Leader’s Toolbox” (seminar) Fri.–Sat., Nov. 12–13, 8:00am–4:00pm “Emerging Patient Safety Issues Impacting Office Practices” (risk management webinar) Wed., Nov. 17 6:30pm–7:30pm “Emerging Patient Safety Issues Impacting Office Practices” (risk management webinar) Thurs., Nov. 18 11:30am–12:30pm “Preparing to Practice” (seminar) Sat., Nov. 20 8:00am–4:00pm

Community Healthcare Calendar Southwest Regional Integrated Behavioral Health Conference

Sept. 8–9 • Crowne Plaza Hotel, San Diego • $299 • mhsinc.org/ calendar

American Society for Bioethics and Humanities 12th Annual Meeting

Oct. 21–24 • Hilton San Diego Bayfront Hotel • asbh.org

SBIRT (Screening, Brief Intervention, Referral to Treatment) Conference

Cutting Edge Strategies in Diabetes Care: Making the Connection

SBIRT Conference (Screening, Brief Intervention, Referral to Treatment)

Sharp Grossmont Hospital Vascular Conference 2010: “Advancing Awareness, Prevention and Treatment of Vascular Disease”

Sept. 9–10 • San Diego Marriott Mission Valley • louise.lecklitner@sdcounty.ca.gov

Sept. 9–10 • San Diego Marriott Mission Valley • louise.lecklitner@ sdcounty.ca.gov Infertility and Pregnancy Loss: Getting Your Patients the Emotional Help They Need

Sept. 25 • Skaggs School of Pharmacy, La Jolla • regonline. com/IPL0 Nine Girls Ask? for a cure for Ovarian Cancer

Sept. 25 • 11:00am • San Diego Marriott, La Jolla • (619) 9487280, ninegirlsask@live.com, ninegirlsask.com 5th Annual Frontiers of Clinical Investigation Symposium: Pain 2010 Bench to Bedside

Oct. 14–16 • Estancia La Jolla • cme.ucsd.edu/b2b2010 Challenges in the Perioperative Management of OSA Patients

Oct. 30 • San Diego Convention Center • cme.ucsd.edu

Nov. 6 • Hard Rock Hotel, San Diego • (619) 740-4550, shelley.berthiaume@sharp.com 4th Annual UCSD Hands-on NOTES and Single Site Surgery Symposium

Nov. 11–13 • Omni San Diego Hotel • cme.ucsd.edu/notes West Coast Geriatric Psychiatry Conference

Feb. 16–19, 2011 • Catamaran Resort Hotel, San Diego • cme.ucsd.edu

Topics and Advances in Internal Medicine

Mar. 7–13, 2011 • San Diego Marriott, La Jolla • cme.ucsd.edu Topics and Advances in Pulmonary and Critical Care Medicine

Mar. 13–14, 2011 • San Diego Marriott, La Jolla • cme.ucsd.edu

Oct. 15 • Location TBD • cme.ucsd.edu

The Complete Scope of Cosmetic Surgery (CACS 11th Annual Meeting)

Oct. 15–17 • Hard Rock Hotel, San Diego • 17 Hours CME • calcosmeticsurgery.org

To submit a physician-focused, San Diego County healthcare event for possible publication, email KLewis@SDCMS.org.

S A N D I E G O P HY S I CI A N .or g septe m b e r 2010

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sept ember 2010 SANâ&#x20AC;&#x2C6; DIEGOâ&#x20AC;&#x2C6; P HY SIC I A N. o rg

brieflynoted

SDCMS Medical Office Manager By Sonia Gonzales, Your Office Manager Advocate Calling All Outstand!ing Office Managers er in t you’re the best office manag Does your physician think tha wants to nt to hear about it! SDCMS San Diego County? We wa l office dica me ’s most outstanding recognize San Diego County or her job o goes above and beyond his manager, i.e., someone wh e, who works s problems before they aris description, who anticipate o strikes time and resources, and wh efficiently with the practice’s ising erv sup en control and morale wh the right balance between staff. nagers can nominate their office ma SDCMS member physicians ce manager to 600 words) why their offi by explaining in writing (up sent to be uld nty. Nominations sho is the best in San Diego Cou , San 250 es, 5575 Ruffin Road, Suite SDCMS, Attn.: Sonia Gonzal DCMS.org. d to Sonia at SGonzales@S Diego, CA 92123, or emaile as SDCMS’ 0 gift card and recognition The winner will receive a $25 tions will be Manager for 2010! Nomina Outstanding Medical Office published in and contest results will be accepted until Oct. 1, 2010, ia with any Diego Physician. Contact Son the December issue of San .org. 2 or at SGonzales@SDCMS questions at (858) 300- 278

Receive Physician San Diego in PDF Every Mon Format th! Email Sonia G onzales at SGonzales@ SDCMS.org to sign up to receive San Diego Ph ys ic ian magazine via email.

S A N D I E G O P HY S I CI A N .or g septe m b e r 2010

Physicians Get Noticed … Wish Your Le g a Happy Birt islators hday!

Physicians: that you’re pa Let your legislators know ying att by wishing th ention and that you vote em a happy b irthday! Birthday: October 3 S tate Senator Christine Keh oe E: sen

ator.kehoe@ sen.ca.gov Capitol Office : State Capitol , Room 5050 Sacramento , CA 95814 T: (916) 6514039 F: (916 ) 327-2188 San Diego O ffice: 2445 Fifth A ve., Suite 20 0 San Diego, C A 92101 T: (619) 6453133 F: (619 ) 645-3144

Birthday: Oc

State Senato tober 27 r Mark Wyla nd E:

senator.wyl and@sen.ca. gov Capitol Office : State Capitol , Room 4048 Sacramento , CA 95814 T: (916) 6514038 F: (916 ) 446-7382 Carlsbad Offi ce : 1910 Palom ar Point Way , #105 Carlsbad, C A 92008 T: (760) 9312455 F: (760 ) 931-2477

[SAVE THE DATES!]

fice Ask Your Ofoca te! v d A r e g a n Ma

✓ SEP 13: CMA on ACOsions

and Medical Foundat SEP 16: Palmetto/Medicare SEP 30: The Art of the Appeal

✓ ✓ ✓ OCT 1-29: Certified Medical Coder Course (5 Fridays) ✓ OCT 7: Economic Survival Safety ✓ NOV 18: Emerging Patient Practices

s ofd calls from companie We recently receive les sa eir cost. Th a pretty substantial at ng ini tra 0 -1 ICD fering take this ating that we had to st cs cti ta e ar sc ed pitches includ n’t be processed or our claims would 10 20 r be to Oc by course e? by Medicare. Is this tru

Question:

w to ay start preparing no No. Although you m jec t start re tition, Medicare will no ns tra th oo sm a re ensu til Oct. 1, 2013. ICD-10 compliance un ing claims for lack of compliant with transactions must be e ar hc alt he nic tro Elec ur reference we e Jan. 1, 2012. For yo Version 5010 effectiv CMS … pliance timeline from have included a com

Issues Impacting Office

Answer:

iego San D s s e c Event c n A o Projecl Otffice Manager Appreciati ty

ICD-10 and Version 5010 Com pliance Timelines Everyone affected by the Version 5010 and ICD-10 transitions — healthcare providers, payers, soft ware vendors, and clearinghou ses/ third-party billers — needs to prepare to meet the following time table to ensure compliance. For the com plete Medicare overview of ICD -10 information, visit cms.gov/ICD10.

Inaugura

nd the coun ers from arou ag an of m ce anniversary , 2010, offi the one-year On August 10 e cruited at re br D le S ce PA gether to first year, e th In ). ents D gathered to S go (PA insured pati ess San Die rvices for un se ee ho fr Project Acc w e s id prov manager ecialists to over 85 office ns ea over 125 sp ap m y el so e extrem unity. That al ! While we ar D ns’ S in the comm ia ic PA r ys fo of the ph te services e, the efforts ic rv help coordina e, se ’ ud ns it ia at the physic ow our gr oked. To sh preciative of any fun en go overlo oft s ities, and m er un ag office man king opport or ce tw offi l ne al h, ed lunc nk you to PASD provid ndance. Tha ician te ys at ph in e D S os r th k with a PA or w incentives fo ho es of w s manager nce in the liv ake a differe m u s is Yo es r. cc A ee volunt Project ts every day. en ti pa d re uninsu u! cause of yo a success be nt: rt of This Eve r Your Suppo fo u Yo nk Tha • Padres ions • Target • DiVal Creat s ke ca ub P • San Diego • Sea World

Date

Compliance step

Jan. 1, 2010

Payers and providers should begi n internal testing of Version 5010 standards for elec tronic claims.

Dec. 31, 2010

Internal testing of Version 5010 must be complete to achieve Level I Version 5010 com pliance.

Jan. 1, 2011

Dec. 31, 2011

Jan. 1, 2012

Oct. 1, 2013

• Payers and providers should begin external testing of Version 5010 for electronic claim s. • CMS begins accepting Version 5010 claims. • Version 4010 claims continue to be accepted. External testing of Version 5010 for electronic claims must be complete to achieve Leve l II Version 5010 compliance. • All electronic claims must use Version 5010. • Version 4010 claims are no long er accepted. • Claims for services provided on or after this date must use ICD-10 codes for med ical diagnosis and inpatient procedures. • CPT codes will continue to be used for outpatient services.

PASD healthcare access manager Lauren Radano (right) presents two Sea World day passes to Joan McComb with the office of PASD volunteer Steven Tradonsky, MD.

sept ember 2010 SAN DIEGO P HY SIC I A N. o rg

brieflynoted e to er H re A l so ri a M d n a ia n o S

Help!

r physician advocate, ocate, and Marisol Gonzalez, you adv r age man e offic MS SDC r you g SDCMS member physicians Both Sonia Gonzales, tacts in the healthcare field, givin con e nsiv exte and . Sonia dge wle kno possess expansive they do best: caring for patients so that they can focus on what d nee they -2783 help 300 ) the (858 at staff e hed offic and their and Marisol can be reac 2 or at SGonzales@SDCMS.org, -278 300 ) (858 at hed reac be can or at MGonzalez@SDCMS.org.

erviews Soneiayou from a physician’s Marisol Intactu ally stol

Marisol: We for about five months office, and you’ve been with us now. How do you like it? y have a heart for physiSonia: I love the work. I trul e of all the changes in cians and their staff. Becaus labor of love for physihealthcare, it’s definitely a n. It feels like what I cians to keep their doors ope t perspective. It’s used to do, just from a differen our healthcare comextremely interesting to view the practice that just of munity as a whole, instead I truly didn’t but , MS I worked for. I knew of SDC s to create take it k wor of understand the depth

with membership, to stay informed. They’re free their fields. It’s defiin erts and the speakers are exp ce managers because nitely a win-win for our offi . It’s a powerful tool for there’s a social side to it too it’s motivating in your building relationships, and normal routine. job to take a break from the

these resources.

office manager out there Marisol: Let’s say there’s an help. If you were that who’s hesitant to call you for t would you tell them? wha r, little voice on their shoulde you can make as an ofSonia: The biggest mistake e. So if the most correct fice manager is to waste tim phone call away, then and current answer is just a physician, and your you owe it to yourself, your staff to call SDCMS.

subject of the “depth” of Marisol: Since we are on the were working as an office SDCMS’ resources, when you you call SDCMS for help? manager, how many times did est, I used to just pay Sonia: To be 100 percent hon I only called a and ns, the dues for my physicia only reason I The ce. stan couple of times for assi sicians had urged me to. called was because my phy e answered efficiently Although my questions wer back into the bad and thoroughly, I just slipped arch myself for queshabit of doing all of the rese to. tions I didn’t have answers e to utilize SDCMS? Marisol: Why didn’t you continu that it was a perk of and erst und Sonia: I didn’t truly . I also felt somewhat my physician’s membership e I felt that I should insecure about calling becaus wers, so I would just do have already known the ans the research myself. y grind for an office Marisol: I imagine that the dail r opinion what’s the you In ing. manager can be demand rs up-to-date on the age man e offic best way to keep our latest issues? inars are the best way Sonia: Our seminars and web

S A N D I E G O P HY S I CI A N .or g septe m b e r 2010

Marisol nt thing about Sonia Intervit’sews the most importa

Sonia: Wha membership? erous obstacles, Marisol: Physicians face num pany’s failing to whether an insurance com that allows nonphysireimburse them or a new law . All they want to do cians to prescribe medication the sick. Physicians l is practice medicine and hea and membership e, voic ve need to have a collecti ical Society and Med nty Cou with the San Diego allows them to tion ocia Ass ical the California Med have that united voice. t topic” physicians are Sonia: What’s the current “ho calling about? ns IPA financial insolMarisol: The Cal-Net Physicia es right now. issu est vency is one of the bigg MS for almost four Sonia: You have been with SDC nge you’ve seen since you years. What’s the biggest cha started? n’t have a background Marisol: Before SDCMS, I did I was overwhelmed in healthcare. When I started,

you take care of the san diego communit y ’s health. we take care of san diego’s

healthcare communit y. 3 Income Tax Planning

with all of the issues physicians and their staff had to go through on a daily basis. The biggest change I’ve seen is with reimbursement issues. Whether it be Medicare or a private insurance plan, it’s just ridiculous sometimes what an office has to go through to get paid.

3 Wealth Management 3 Employee Benefit Plans 3 Profitability Reviews 3 Outsourced Professional Services (CFO, Controller)

Sonia: Which physician advocacy issue are you most proud of accomplishing? Marisol: When Palmetto took over as the intermediary for California, our physicians were having problems left and right with everything from enrolling to getting claims paid. With the assistance of CMA, I was able to access important contacts at Palmetto, and, with their help, I was able to get our members’ problems taken care of. Sonia: What’s your advice for physicians to get the most out of their memberships? Marisol: I know physicians are busy. We make it our business to know what’s going on in the healthcare arena and to communicate it to our members via “News You Can Use” and San Diego Physician. We create quality seminars and webinars to keep physicians and their staff informed. I want our members to know that we are an extension of their medical offices. Give us a call, and let us show you how we can help you!

3 Organizational and Compensation Structure 3 Succession Planning 3 Practice Valuations 3 Internal Control Review and Risk Assessment

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Sonia and Marisol

sept ember 2010 SAN DIEGO P HY SIC I A N. o rg

publichealth By Walt Ekard

In case you missed it in the newspaper … oh, that’s right, you couldn’t find it in the newspaper. But … Something really good happened at the County Board of Supervisors meeting on July 13, 2010. A veritable plethora of important regional players — from the healthcare industry and business to nonprofit agencies and community activists — were on hand to support the supervisors in launching their new health strategy agenda we call “Building Better Health.” This exciting new initiative is a blueprint for improving the health of our community and the quality of our lives over the next decade. It’s a framework that will focus on a smarter delivery of services and helping San Diegans lead healthier lives. It is about enabling. It is about informing. It is about providing the tools we all need to help us make good choices.

This exciting new initiative is a blueprint for improving the health of our community and the quality of our lives over the next decade.

Bureaucrats Are Human Too I have been known to spend most of a Sunday in the comfort of a La-Z-Boy … 10

S AN D I E G O P HY S I CI A N . or g se pte m b e r 2010

One thing it is not about is spending money we don’t have. There’ll be no raising of taxes or borrowing from our kids. It is about spending the tax dollars we have in a more targeted, focused fashion. You’ll be hearing a lot about “3-4-50” in the coming months and years. Did you know that three risk factors (tobacco use, poor diet, and physical inactivity) contribute to four of the most prevalent chronic diseases (cancer, cardiovascular disease, type 2 diabetes, and respiratory disease), which are responsible for more than 50 percent of all deaths worldwide? It’s even worse in San Diego, where 57 percent of local deaths are attributed to those four diseases. The fact is the statistics for us granola-eating San Diegans are no better than for those fried chicken-chomping Kentuckians or those strung-out, stressed-out New Yorkers.

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publichealth

behaviors

Tobacco use poor diet no exercise



diseases

heart disease type 2 diabetes lung disease cancer



percent

A study several years ago estimated the annual healthcare cost in our community just for these four chronic diseases at nearly $4 billion. That’s almost as big as the entire County budget this year. The County’s new health strategy is designed to do something about that. We’re going to challenge you Marlboroloving, French-fry-eating couch potatoes to at least think a little more about your health. We want to help you live a lot longer than you probably otherwise will. Now, don’t get me wrong, I don’t like government trying to tell me what I can and can’t do any more than the next guy. The health strategy is not about telling you which health provider you must use or what kind of insurance you have to have. (I think someone’s already working on that!) It’s about empowering each of us to take command of our own health. I don’t smoke, but I do admit to occasionally forgetting about the importance of the five basic food groups. I don’t exactly eat carrot sticks while watching NASCAR races (yes, I do watch NASCAR races). And I have been known to spend most of a Sunday in the comfort of a La-Z-Boy. So I am not one to preach on this. If you want to smoke … well, then go ahead and smoke. (Just don’t do it in restaurants, bars, outdoor patios, cars with kids in them, big buildings, small buildings, parks, beaches, mountains, apartment buildings, condominiums, or stadiums.) If you want to chow down, then enter all the hot dog eating contests you want. (Just chew with your mouth closed, please!) If you want to wear out the cushions on your couch, by all means go ahead. (Our economy needs a boost, and Jerome’s could surely use the business!)

of deaths

Did you know that three risk factors contribute to four of the most prevalent chronic diseases, which are responsible for more than 50 percent of all deaths worldwide? But the truth is, just because we’re allowed our bad habits doesn’t mean we should otherwise ignore the ramifications of our behavior. It seems to me that the County’s job as a public health leader in this region should be to provide you with objective information about what unhealthy habits do to your longevity, and then let you decide whether longevity matters to you. (I can tell you for sure it matters to me. I plan to do whatever is necessary to ensure I get to see my grandchildren graduate from college, even if it means I have to cut back on my bacon intake!) If the health strategy agenda can provide the motivation for rethinking our behavior, we’ve not only helped add years to our lives, but we’ve helped control the exploding cost of healthcare. And, in the end, isn’t that what real healthcare reform should be about? I hope I’ve piqued your interest a little bit in what we plan to do. We have much work ahead with our community partners and stakeholders to put flesh on the bones (that’s 96 percent lean flesh!) of our plan and to determine the best way to measure our progress. So stay tuned for more … and I’ll see you at the gym! Until next time …

{About the Author}

Mr. Ekard is chief administrative officer of the County of San Diego.

S AN D I E G O P HY S I CI A N . or g se pte m b e r 2010

MRI Open MRI Breast MRI CT Digital Mammography Breast Ultrasound Breast Biopsy Ultrasound X-Ray Interventional Pain Management

Since 1971, Valley Radiology has been improving the lives of North County residents by providing state-of-the-art imaging and radiology services. Utilizing the most advanced imaging technology, our fellowship-trained, Board-certified radiologists provide accurate and detailed reports in their various sub-specialties (and with fast turn-around times). We also strive to meet the needs of our patients by offering timely and efficient appointment scheduling. One of our specialties is providing the best breast diagnosis available through state-of-the-art MRI technology. Our facilities have earned accreditation in all of ACR’s voluntary breast imaging programs, thereby achieving for Valley Radiology the highly-desired status of Breast Imaging Center of Excellence. Our recent addition of a high-performance breast coil – Sentinelle Medical’s Vanguard – optimizes image quality, improves patient comfort and minimizes procedure time.

Valley Radiology Awarded Breast Imaging Center of Excellence Status Having access to the latest tools to provide the most accurate diagnoses available enables Valley Radiology to serve your patients confidently, appropriately and timely. When it comes to the health of your patients, would you really want to settle for anything less? Valley Radiology – instant access to reports and images online, quick response available for radiology consults, and same-day appointment scheduling. ESCONDIDO IMAGING CENTER 355 E. Grand Avenue Suite 3 Escondido, CA 92025 Tel. 760.480.6519 Fax. 760.480.1012

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sdcmscma By Susan Kaweski, MD, and Tom Gehring

e v a H t a h W for You We Donteely? La “Physicians United ” iego for a Healthy San D

S AN D I E G O P HY S I CI A N . or g se pte m b e r 2010

September 1, 2010

Dear SDCMS-CMA Member Physician, Periodically, we want to let you know “what SDCMS and CMA have done for you lately.” Here’s a summary of how we’ve created value for our members since our last letter.

MEMBERSHIP: • Even in these challenging economic times, we continue to grow — giving us more resources for more advocacy and more member support. • SDCMS’ membership increased by 107 physicians in 2010 to 2,579 members currently. We are now California’s second largest county medical society.

ADVOCACY: • CMA legal action returned $28M to California’s physicians for the illegal 2009 10% cut in Medi-Cal rates — roughly $3M to San Diego. • We successfully fought efforts to weaken the prohibition on the practice of medicine by corporations — California’s longstanding legal principle that only physicians (not corporat ions, not health plans, not hospitals) practice medicine. • Your membership dues pay for perpetual vigilance on MICRA, the law that keeps California professional liability rates reasonable. For example, every viable San Diego County 2010 candidate for the California Legislature that SDCMS recommended be endorsed by CALPAC , whether Republican or Democrat, supported MICRA. • SDCMS locally, and CMA nationally, were heavily involved in stopping the draconian cuts in Medicare rates. Our long-term advocacy resulted in strong support from San Diego’s congressional delegation. • Exceptional CMA and SDCMS advocacy to repeal the Geographic Practice Cost Index (GPCI) inequity resulted in thrice getting literally to within days of GPCI’s repeal — before concerns over ballooning deficits and political exigencies (out of SDCMS’ control) scotched final repeal. But we’ll be back! • Paralleling the GPCI legislative fight, in federal courts we received a favorable ruling from the U.S. Ninth Circuit Court of Appeals to reinstate the standing for our GPCI lawsuit. Like MICRA, we will never stop on GPCI.

HEALTH REFORM: • We were engaged at all levels of health reform throughout 2009 and into 2010, ensuring bills were amended to account for California’s socioeconomic differences, health status differences, and geographic differences in practice costs. Had the rural states prevailed, i.e., had CMA not fought this fight, California’s physician reimbursements would have been cut by up to 22%! • Health reform, love it or hate it, has passed. Now it will simultaneously be about both the implementation as well as the various attempts to amend it. Rest assured that CMA and SDCMS will remain intimately involved with every aspect of this issue. You can downloa d a detailed timeline for 2011–18, as well as analyses of how health reform will affect physicians, at SDCMS. org/WHWDFYL/September2010.

sept ember 2010 SAN DIEGO P HY SICIA N. o rg

organizedmedicine

BENEFITS: • Check out our filled-to-the-brim educational seminar schedule — all free to members and their staff — at SDCMS.org/Event. Since our last communication, SDCMS has conducted 21 free, members-only seminars that were attended by 570 member physicians and their office staff. Like almost all SDCMS training, our recent OSHA and HIPAA seminars were recorded and can be accessed anytime at SDCMS.org/Webinars. For information on our next few seminar s — “Changes to Medicare Billing,” “Navigating the Appeals Process,” and “Accountable Care Organiz ations” — and for a complete list of SDCMS seminars and webinars, visit SDCMS.org/Event. • We had the largest turnout in seven years of balloting for “Physicians of Exceptional Excellence” — with more than 13,000 votes cast by 880 physicians. • Our physician advocate, Marisol Gonzalez, and our office manage r advocate, Sonia Gonzales (no relation), provide “concierge care” service to our members and their staff. As an example, one of the 335 solved problems resulted in obtaining $80,000 in back paymen ts and denied claims for a two-doctor group. • Call us if you have human resource issues; we have access to an expert panel on call! • The Doctors Company, SDCMS’ endorsed professional liability carrier, offers a 5% membersonly discount on professional liability insurance. More than 800 SDCMS physicians saved nearly $500,000 as a result of this discount alone. • SDCMS’ endorsed partners offer members and their practices significa nt savings on the cost of insurance, accounting services, security prescription pads, billing solution s, IT support, computer hardware, contract negotiations services, practice management consulti ng, banking, legal services, and collections. • Are you getting your free annual physician mailing list, car insuranc e discounts, free classified ads, and the free California Emergency Driving Emblem?

COMMUNICATIONS: • We created and published our fourth bi-annual Workforce and Compen sation Survey, including San Diego specific physician salary data, again accessible at SDCMS. org/WHWDFYL/September2010. • SDCMS published, for the first time, a free directory of all San Diego County physicians (but highlighting member physicians), which includes NPIs. For a snapshot, visit SDCMS.org/WHWDFYL/ September-2010. • Check out our 2009–10 annual report — printed with the June 2010 issue of San Diego Physician — at SDCMS.org/WHWDFYL/September-2010. • Your monthly San Diego Physician speaks to and for all 8,500+ San Diego County physicians. Our bi-weekly, commercial-free e-newsletter, “News You Can Use” (NYCU) goes to 4,000+ physicians. If you’re not getting NYCU, send me an email at Gehring@SDCMS.org and we’ll sign you up. • Your free classifieds in San Diego Physician reach 8,500+ physicians in San Diego County.

ENGAGEMENT: • We’ve held three member networking socials and one young/resident physician networking social. • We’ve presented “10 Things in 10 Minutes: What Every Physician Needs to Know” at 12 hospital medical staff meetings. We’d love to come to yours!

S AN D I E G O P HY S I CI A N . or g se pte m b e r 2010

ership training for physipolitical advocacy training, and lead • We’ve conducted media training, cian leaders. other VIPs joined us for our legislators, healthcare leaders, and • Two hundred thirty physicians, and our SDCMS leaderoring the work of our Foundation 2010 White Coat Gala — jointly hon seven years. ship — our largest annual event in

INF RA STR UC TU RE :tion technology hardware, software, and middleware to the leading

• We brought our informa edge. your COO, James Beaustreamline operations and to allow • We hired a business manager to munity. beaux, to get more time in the com

WH AT’S COM ING :

in September: HIPAAion 3 of our website will do for you • Here’s just a sampling of what Vers sively improved marmember-to-patient messaging, mas compliant member-to-member and anced physician search customized physician profiles, enh keting through individualized and sers, plus improved acgation for both searchers and brow functionality, improved content navi for those with disabilities. cess for non-English speakers and a free iPad/iTouch/iPhone/ n directory at your fingertips with • The San Diego County physicia Droid app. bership database that uses we will shift to a brand-new mem • Concurrent with V3 of the website, s. the latest technologies and processe on or about Oct. 1, 2010. ice invo • Expect to see your 2011 dues nizations. See SDCMS. to learn about Accountable Care Orga • Come join us on Monday, Sept. 13 org/Event for details. whom we serve — what Membership Survey — as we ask you, We put a lot of thought into our 2010 bership survey today mem to do). Please take our eight-minute you want us to do (or don’t want us /September-2010! by visiting SDCMS.org/WHWDFYL are interested in serving. directors — please contact us if you of d We have openings on our boar you need us to do on your do e mor at us to know about? Wh What are you doing that you’d like CMS.org and Gehring@SDemail addresses are President@SD behalf? Contact us directly. Our CMS.org respectively. t SDCMS and CMA are ng your nonmember colleagues wha Finally, we ask for your help in telli SDCMS.org so that we can fulnonmember physicians to join at accomplishing. Please encourage for a Healthy San Diego.” fill our vision of “Physicians United

Susan Kaweski, MD

President, SDCMS

Tom Gehring

CEO/Executive Director, SDCMS

sept ember 2010 SAN DIEGO P HY SICIA N. o rg

Accountable

Care Organizations

By the California Medical Association

S AN D I E G O P HY S I CI A N . or g se pte m b e r 2010

ACOs: The Basics Q: What are ACOs? A: ACOs are accountable care organizations, a designation established by recently passed healthcare reform legislation to encourage greater coordination of care under Medicare. An ACO is a collection of physicians who join together to coordinate care, share clinical information, and report on quality measures. Q: Why create an ACO? A: ACOs that meet spending benchmarks will receive bonus payments. These payments will be based on the percent of Medicare Part A hospital savings and Part B physician savings in the community served by the ACO. The idea behind the policy is that greater coordination will improve quality of care, prevent costly hospital visits, and ultimately produce a more cost-effective healthcare system. Q: What is allowed to be an ACO? A: ACOs can be networks of individual physician practices, such as solo and smallgroup physicians; an Independent Provider Association (IPA) or a large medical group; or a fully integrated physician-hospital system, but an ACO does not have to involve a hospital. Most IPAs, medical groups, and physician organizations would qualify as ACOs as they currently exist. Q: How do you set up an ACO? A: That is still to be determined. The healthcare reform bill only provides general terms for the creation of ACOs. Before ACOs are actually implemented, the Centers for Medicare and Medicaid Services (CMS) will issue detailed regulatory guidelines.

Q: How will physician payments under Medicare work with an ACO? A: Physicians in an ACO will be paid for services provided to their Medicare patients under the traditional Medicare fee-for-service program. An ACO that meets spending benchmarks and other requirements, such as sharing information through electronic health records and reporting on quality measures, will be eligible for additional bonus payments. Q: How will ACO spending benchmarks be determined? A: CMS will take the last three years of Medicare expenditures for the patients served by the ACO and adjust the benchmark based on risk for the patient population, growth in national per-capita expenditures, and many other factors. Q: How will patients be assigned to an ACO? A: CMS will assign Medicare patients to an ACO based on the physician(s) who have historically provided primary care services to that patient. ACOs must have at least 5,000 Medicare beneficiaries assigned to it in order to participate. Q: What’s next? A: The law requires CMS to implement ACOs no later than Jan. 2, 2012. We expect more details from the federal government in coming months. Q: Where can I get more information about ACOs? A: CMA will be providing regular updates, as regulations take shape, and offer members legal and administrative guidance on how to set up and qualify as an ACO.

About the Author: The California Medical Association (CMA) represents 35,000 physicians in all modes of practice and specialties. CMA is dedicated to the health of all patients in California.

sept ember 2010 SAN DIEGO P HY SICIA N. o rg

Accountable

Care Organizations

By Davis Cracroft, MD, Mike Couris, MD, and Ted Steuer

S AN D I E G O P HY S I CI A N . or g se pte m b e r 2010

ACO Plans: Scripps Mercy Physician Partners As a physician organization, Scripps Mercy Physician Partners (Partners) embraced the concept of ACOs before they were the rage. Partners’ primary mission is to help sustain private practice in the tumultuous world of San Diego medicine by reducing practice costs and by increasing revenue. Partners was formed as a messenger model IPA to offer substantially better fee-for-service contracts for its member physicians than those that could be obtained individually, and to provide a variety of options to decrease practice costs in the private office. The leadership of Partners, like others in the industry, recognized that the cost of medical care as currently provisioned was unsus-

After a period of deliberation within the organization, the concept of clinical integration won out over economic integration since most of our members wished to maintain full control of their individual practices. tainable. As physicians often bear the brunt of cutbacks disproportionately to other large and powerful players in the healthcare system, Partners investigated ways to at least maintain and hopefully improve physicians’ economic interests in the face of the forces that constrain physician reimbursement. After a period of deliberation within the organization, the concept of clinical integration won out over economic integration since most of our members wished to maintain full control of their individual practices. Clinical integration is an arduous task in the face of a multitude of private practices and the idiosyncrasies of solo and small-

group physicians. At first, a common electronic medical record and practice management system was considered as a means to achieve clinical integration, but this solution was quickly dismissed as a nonstarter due to the varied information-technology needs of members. Barriers to adoption, including cost, were also key in rejecting this course of action. In late 2008, physician portals, or hubs, were becoming popular on a national basis. Low-cost, subscription-based physician portals leverage the power and access of the Internet with the concept of data sharing in an easy-to-use format. This concept led to the creation of VIP Health Connect, a still-nascent health information exchange that currently offers integration with more than 400 practice management systems, e-prescribing with Allscripts, and HIPAA-compliant messaging. Further development of the portal’s capabilities, including lab and imaging reporting and EMR interoperability, will allow seamless medical information sharing, reduction in duplication, more efficient care, and hopefully better reimbursement for our physicians. Of course, our group recognizes that payers, both government and commercial, need to see the benefit of an IT backbone leading to an ACO before they share more of their funds with physicians. It follows that one mode of failure for the ACO concept is a lack of cooperation on the part of both private and government payers, or the institution of unattainable goals like those that permeate many pay-for-performance programs. As we see things today, the ACO concept is still pretty fuzzy. While ACOs are currently popular for the Medicare sector, their applicability to the commercial market is also very

intriguing. Nonetheless, several things are clear: 1. The driving force for the ACO concept is to manage cost while increasing quality from improved provider coordination. 2. Improved communications should benefit all parties. 3. We believe that technology can be utilized to share information, decrease unnecessary costs, and improve quality. 4. Risk and reward factors need to be clearly identified and well understood. 5. Our healthcare system is a pluralistic delivery system. 6. Physicians’ role in an ACO is significant. This substantial role needs to be accompanied by a major voice in governance. 7. The ACO is a collaborative effort requiring alignment and collaboration of payers, physicians, and hospital partners. Physician Partners group is actively sharing information regarding ACOs with our members. We continue to enhance the features and utility of our physician portal. We will continue to evaluate ACOs and other opportunities with the goal of improving the delivery of healthcare and maintaining the key role of physicians. Though still taking shape, we anticipate that Partners and its physicians will continue to play significant roles in the delivery system. The ACO is not the first effort to reorganize healthcare providers and, undoubtedly, it won’t be the last. Many previous efforts have failed and some have backfired. While the ACO may result in major changes for the healthcare delivery system as we know it today, success will certainly hinge on the inclusion of physicians in planning and acknowledging that patients and physicians need to be the center of the system.

About the Authors: Mr. Cracroft is president of Scripps Mercy Physician Partners, Dr. Couris, SDCMSCMA member since 2001, its vice president, and Mr. Steuer its executive director.

sept ember 2010 SAN DIEGO P HY SICIA N. o rg

Accountable

Care Organizations

By John E. Jenrette, MD

S AN D I E G O P HY S I CI A N . or g se pte m b e r 2010

An Accountable Care Organization:

Sharp Community Medical Group’s Journey Sharp Community Medical Group (SCMG) is certainly on the road to becoming an accountable care organization (ACO) in all interpretations of the current definition and under emerging regulatory requirements. A bold statement? A true statement? Let’s take a look … It is easy to see the connection between the coordinated care model that SCMG has successfully operated under for the past 20 years and the emerging ACOs. As an organization, and with our partners Graybill Medical Group, Sharp HealthCare, and Palomar Pomerado Health, we have provided services to an HMO population that includes the following characteristics and programs: • Partnerships with local hospitals to create synergies for cost-effective care. • Physician compensation programs and incentives that are aligned with providers. • Systemwide measurements of quality and efficiency that reflect the practice of evidence-based medicine. • Systems to understand and manage the total cost of care for a population. • Providers with access to and use of a common electronic health record (EHR) system. • Registry databases of patients with chronic conditions.

• Chronic care management programs to manage patients with high-volume, highcost chronic disease. • Predictive analytic tools to identify patients at high risk for poor outcomes or high cost who are then prospectively managed by experienced case managers. • Timely outpatient follow-up and aggressive case management post-hospital-discharge and of patients at risk for readmissions. With all of these achievements already an integral part of SCMG, the journey to become an ACO is straightforward and well under way as one of SCMG’s major initiatives under its five-year strategic plan. Currently, SCMG is working with our hospital partners and several major payers to implement commercial ACO models far in advance of the 2012 Centers for Medicare and Medicaid Services (CMS) demonstration projects. These models have several interesting challenges and require operational changes to achieve success. To begin, an “attributable population” consisting of fee-for-service patients must be established that is at the center of the ACO and its activities. This population generally comprises existing PPO patients who have not received the services of a coordinated care

delivery system. The attribution methods generally involve a historical connection of patients to a primary care physician or medical specialist since these physicians are most likely to have an existing relationship with the patient and/or are in a position to best coordinate their care or manage their chronic illness within the ACO. Another method of attribution is based on “episodes of care,” whether that be medical or surgical — such as a series of treatments for pneumonia, or a hip replacement with all the preoperative and post-follow-up care. The patient is then assigned to the ACO based on the majority of medical or surgical episodes that have occurred within the medical group serving as the ACO. Once the size and make-up of the attributed population is determined, patients receive services to the extent possible as outlined above. The theory under the ACO is that patients, through the coordination of services, will receive the right care at the right time and location, while reducing the redundancy, fragmentation, and unnecessary care this population generally encounters, thereby lowering cost and improving outcomes. A common question that arises regarding the ACO concept is, “How does an ACO coordinate services, direct care, and lower cost

sept ember 2010 SAN DIEGO P HY SICIA N. o rg

Accountable

Care Organizations

The theory under the ACO is that patients, through the coordination of services, will receive the right care at the right time and location, while reducing the redundancy, fragmentation, and unnecessary care this population generally encounters, thereby lowering cost and improving outcomes.

when this attributable population of PPO patients still has choice and can self-refer?” The answer to the question lies in the ability and knowhow of an organization like SCMG to develop a robust and quality network of physicians, create loyalty through high levels of patient satisfaction, and utilize electronic patient communication and patient engagement tools such as interactive personal health records (including the provision of email) to involve patients in their own care and achievement of their health status goals. In addition, physicians share a common medical record and are able to coordinate services among primary care physicians, specialists, hospitalists, and case management teams to better coordinate care, reduce fragmentation and redundancy, and create a “medical home” for all care needs. Additional requirements of a successful ACO include changes in the reimbursement or payment mechanism to the IPA and subsequently to physicians. From the payer or health plan perspective, reimbursement comes in the form of monthly fees to pro-

vide the coordination of care services and additional financial rewards based on performance as a group against established metrics with a strong emphasis on quality. Additional payment from payers is also realized through shared-savings incentives as SCMG achieves a reduction in total cost of care for the attributed population. Changes in payment to physicians include increases in standard fee-for-service payments for participation and cooperation with care coordination services and also individual financial incentives or rewards based on performance and achievement of established goals for both primary and specialty care physicians. These goals are centered on delivering cost-effective care under established quality-driven metrics; the elements essential to be accountable for a population of patients. These are just a few of the elements necessary to become a successful ACO. This journey is clear for SCMG and its partners, and we are well ahead of the curve to achieve that goal.

About the Author: Dr. Jenrette MD, SDCMS-CMA member since 2010, is chief executive and medical officer of Sharp Community Medical Group.

S AN D I E G O P HY S I CI A N . or g se pte m b e r 2010

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Accountable

Care Organizations

By THOMAS SOUNHEIN

S AN D I E G O P HY S I CI A N . or g se pte m b e r 2010

ACOs, EHRs, HIEs, Oh My!

“Privileged to Provide Care and Clinical Research Since 1975” The San Diego Arthritis Medical Clinic proudly announces Mahmood Pazirandeh, M.D. and Soumya Rao, M.D. will be joining our practice on September 1, 2010.

XiMED Medical Group

Does it seem like healthcare has an overabundance of three-letter acronyms these days? If so, you can thank the federal government. Yes, the same people who are bringing you a $1 trillion bureaucratic experiment are busy at work infiltrating the vernacular with three-letter acronyms. It’s as if a project can’t get federal funding unless it can be reduced to three letters. So here is my take on three of them. Accountable care organizations (ACOs) are the talk of the healthcare community these days. ACOs are regulatory entities given life by the Patient Protection and Affordable Care Act. The intent is that ACOs will take “accountability” for managing the costs and improving the quality of healthcare for a population of patients in exchange for a higher reimbursement. In other words, the hope is that ACOs will make healthcare more efficient. Isn’t that what they said about HMOs? Forgive me Yogi Berra, but “it’s like déjà vu all over again.” In order to be considered an ACO, the act requires that the organization must: • have established a mechanism for shared governance; • be willing to be accountable for the quality, cost, and overall care of the patient; • participate in the program for not less than a three-year period; • have a formal legal structure that allows the organization to distribute payments to providers; • have a sufficient number of primary care physicians for the number of Medicare

beneficiaries assigned to it; • be able to accept at least 5,000 Medicare beneficiaries; • have a leadership and management structure in place that includes clinical and administrative systems; • define processes to promote evidencebased medicine and have the ability to report on quality and cost measures, and coordinate care using technology; and • demonstrate that it meets patient-centeredness criteria specified by HHS. Since this sounds like an HMO, what makes an ACO different? Unfortunately, despite widespread interest in the concept, no one is quite sure of the operational structure under which they should operate. Some suggest the ACOs should consist of primary care physicians, specialists, and at least one hospital, while others suggest that only integrated delivery systems (IDS) or physicians-hospital organizations (PHO) are capable of managing such a model. What is common to both is the increased reliance on the primary care physicians playing a strong central role. Now that is truly novel — sarcasm noted! The problem with any of these concepts is that none of them is based on any analysis or evidence that a particular option is better than the other. This should not be surprising given that there is very little evidence to suggest that any particular organizational structure couldn’t control either cost or quality, at least in theory. What this tells you is that, at its heart, an accountable care organization is not a structure at all. It’s an outcome! Spe-

MAHMOOD PAZIRANDEH, M.D. Board Certified in Rheumatology and Internal Medicine, Dr. Pazirandeh has had a long-term private practice in Cleveland, Ohio. He brings with him a wealth of clinical expertise as well as academic accolades as an Associate Professor of Medicine at Case Western. Dr Paziandeh will be an outstanding member of our medical community and we are privileged that he is joining our group. SOUMYA RAO, M.D. Dr. Rao is Board Certified in Internal Medicine and completed her fellowship in Rheumatology at the University of Pennsylvania. Dr. Rao is known for her exemplary work ethic and her ability to tailor treatment plans to fit the individual needs of her patients. We are excited to have Dr. Rao as a member of our team.

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At its heart, an accountable care organization is not a structure at all. It’s an outcome!

cifically, it’s the outcome of reducing costs while improving the quality of care, and therein lies the rub. So, if ACOs are to be designated based on the ability to control costs and improve outcomes, and since outcomes can only be known after the fact, how do you know what the organizational structure should look like to begin with? Wait, there’s more! To be successful, an ACO will certainly have to implement an electronic health record (EHR) system to share information and to quantify outcomes. EHRs are defined as a systematic collection of electronic patient information that will include patient demographics, medical history, medications, immunizations, lab results, X-rays, and billing information that can be shared from physician to physician. Unfortunately, EHR systems cost thousands of dollars to purchase and even more to maintain, so the government decided it would help offset the cost to physicians by paying up to $44,000 per system for a total cost of around $17 billion. What is remarkable about all of

this is that physicians were free to choose any system that would meet “meaningful use” criteria. The problem is that there are at least 50 EHRs that meet these criteria, and, of course, they are incapable of talking to one another. So now what? Well, since the EHRs don’t talk to each other, a new system was needed that would allow communication between different systems. Enter the Health Information Exchange (HIE), which is a data storage repository that will electronically move clinical information among disparate healthcare information systems while maintaining the meaning of the information being exchanged. The goal of HIE is to facilitate access to and retrieval of clinical data to provide safer, more timely, efficient, effective, equitable, patient-centered care. Unfortunately, there are currently no HIE-type organizations in the San Diego area currently under construction. Still confused? Don’t worry, so is everyone else!

About the Author: Mr. Sounhein is the chief executive officer of XiMED Medical Group.

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classifieds office space OFFICE SPACE AVAILABLE IMMEDIATELY: Adjacent to Tri-City Medical Center and North Coast Surgery Center. Provide large consultation room, two exam rooms. Conditions are negotiable. Full or part time. Free parking. Easy access to 76 or I-5. If interested, please email jean@tricitycts. com <mailto:jean@tricitycts.com> or call (760) 726-2500. [840] OFFICE SPACE FOR LEASE: Medical Office space available 800–2,000ft2. Valet parking, walking distance to Mercy Hospital. To view call (619) 733-7497 or email crownpointbuilders@hotmail.com. [838] OFFICE SPACE IN HILLCREST: Office space available in Hillcrest at the Mercy Medical Building. Located directly across from Scripps Mercy Hospital. Excellent staff, state-of-the-art office and equipment. Please send letter of interest to KLewis@sdcms.org. [810]

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. FREE RENT INCENTIVES and a generous improvement allowance is provided. For information, contact Ed Muna at 619-702-5655, ed@lankfordsd.com www.pinnaclemedicalplaza.com LUXURIOUS / BEAUTIFULLY DECORATED DOCTOR’S OFFICE NEXT TO SHARP HOSPITAL FOR SUB-LEASE: The office is conveniently located just at the opening of Highway 163 and Genesee Avenue. Lease price is very reasonable and appropriate for ENT, plastic surgeons, OBGYN, psychologists, research laboratories, etc. Please contact Mia at (858) 279-8111 or at (619) 823-8111. Thank you. [836] BUILD TO SUIT: Up to 1,900ft2 office space on University Avenue in vibrant La Mesa/East San Diego, across from the Joan Kroc Center. Next door to busy pediatrics practice, ideal for medical, dental, optometry, lab, radiology, or ancillary services. Comes with 12 assigned, gated parking spaces, dual restrooms, server room, lighted tower sign. Build-out allowance to $20,000 for 4–5 year lease. $3,700 per month gross (no extras), negotiable. Contact venk@cox.net or (619) 504-5830. [835] 3998 VISTA WAY IN OCEANSIDE: Two medical office spaces approximately 2,000ft2 available for lease. Close proximity to Tri-City Hospital with pedestrian walkway connected to parking lot of hospital, and ground floor access. Lease price:

$2.20 +NNN. Tenant improvement allowance. For further information, please contact Lucia Shamshoian at (760) 931-1134 or at shamshoian@coveycommercial.com. [834] CARMEL VALLEY OFFICE SPACE FOR SHARED LEASE OR SUBLEASING: 2,900 square feet located in the Scripps Medical Offices on El Camino Real and High Bluff. Busy women’s health office ideal for physician seeking exposure to new patients. Convenient practice ready space ideal for a solo physician. Possibility for shared staff and/or overhead. Contact Mrs. Kim at cvwh858@gmail. com or at (858) 259-9821. [790] SCRIPPS ENCINITAS CONSULTATION ROOM/ EXAM ROOMS: Available consultation room with two examination rooms on the campus of Scripps Encinitas. Will be available a total of 10 half days per week. Located next to the Surgery Center. Receptionist help provided if needed. Contact Stephanie at (760) 753-8413. [703] NEW COMMERCIAL BUILDING IN LA MESA • SPACES FOR RENT/PRE-LEASE: Very close to Grossmont Hospital and highways 8 and 125. New building being constructed at 5980 Severin Dr., La Mesa. Near corner of Severin Dr. and Amaya, just north of the Brigantine restaurant. Beautiful and functional design. Spaces available from 1,000 to 5,500ft2. Pre-leasing/renting spaces. Call Nathan at (619) 787-3422 or email hythams@att.net. [823] SHARE OFFICE SPACE IN LA MESA — AVAILABLE IMMEDIATELY: La Mesa (Grossmont Hospital Campus) 1,400ft2 available to an additional doctor. Separate receptionist area, physician’s own private office, three exam rooms, and administrative area. Ideal for a practice compatible with OB/GYN. Call (619) 463-7775 or fax letter of interest to La Mesa OB/GYN at (619) 463-4181. [648] OFFICE SPACE TO SHARE: Currently occupied by orthopaedic surgeon. Great location close to Scripps/Mercy and UCSD Hospital. Looking to share with part-time or full time physician. Fully furnished, fully equipped with fluoro machine and 4 exam rooms and staff. (NEGOTIABLE) Please contact Rowena at (619) 299-3950. [804]

disorder, stroke, and Botox treatment, as well as Parkinson’s disease. One of our physicians is the stroke director at Scripps Memorial Hospital, La Jolla. Outstanding earning potential and the option to expand into other areas is certainly a possibility. Email mrsbinx@hotmail.com. [837] FAMILY PRACTICE PHYSICIAN: Family practice clinic located south of San Diego is seeking a family practice physician. This is a fully renovated, familyfocused office with cutting-edge equipment and close access to specialists and additional services (MRI, CT, X-ray, pharmacy …). The ideal physician would be one who wants to serve the low- and middle-income patient population and provide personalized, timely care that meets the standards of excellence set by the practice’s current physicians. Four days / nine hours a day, Monday–Thursday. Twenty-four-month partnership track. No call. Spanish speaker strongly preferred. Contact Nick Glover at (503) 443-6008, ext. 131, or email nickg@ uhcsolutions.com. BC/BE [832] NORTH SAN DIEGO COUNTY FAMILY PRACTICE: We are a Joint Commission-accredited, federally qualified community health center, celebrating 40 years of service, and serving more than 60,000 patients in multiple locations in North San Diego County. We have opportunities for BC/BE physicians. Compensation includes attractive base, incentive, and great benefit programs, malpractice, reimbursement for CME/ licensure. This is an opportunity to make a difference in the lives of patients who are under- or uninsured without having the expense of overhead or management concerns, and provides work-life balanced hours. NHSC loan repay may also be available. Email cynthia.bekdache@nchshealth.org, call (760) 736-8632, or fax to (760) 736-8740. [794] ARE YOU STRUGGLING WITH YOUR PRIMARY CARE PRACTICE?:If you love your patients and you want to practice medicine the way you want, then Harmony Medical Group is a solution. We know the way to increase your productivity, cut expenses, and turn your practice from a nightmare to a joy. Please email us at harmonymedicalgroup@ gmail.com and our business coordinator will meet and answer all your questions. [827]

PHYSICIAN POSITIONS AVAILABLE OBSTETRICIANS NEEDED: La Maestra Clinic is seeking to contract with obstetricians willing to do deliveries of our patients at Sharp Mary Birch, Scripps Mercy, or Grossmont Hospitals. We do all prenatal care, transfer to you at 36 weeks, then we resume care post-partum. No high-risk cases. Excellent opportunity! Interested? Contact David Priver, MD, OB/GYN Medical Director, at (619) 9873092 or at dpriver@aol.com. [839] LOOKING FOR 1–2 NEUROLOGISTS TO JOIN OUR PRACTICE IN LA JOLLA: We are located on the campus of Scripps Memorial Hospital. This is a well-established (35+ years) practice. We have a strong referral base. Our practice treats neurodegenerative diseases with emphasis on dementias. We see a large number of movement

FAMILY MEDICINE PHYSICIANS — FULL AND PART TIME: SHARP Rees-Stealy Medical Group, a 400+ physician multi-specialty group in San Diego, is seeking full-time or half-time job share BC/ BE family medicine physicians to join our staff. We offer a first-year competitive compensation guarantee and an excellent benefits package. Please send CV to SRSMG, Physician Services, 2001 Fourth Ave., San Diego, CA 92101. Fax: (619) 2334730. Email: Lori.Miller@sharp.com. [825] ORTHOPEDIST WANTED: Orthopedic office looking for an orthopedist, preferably a foot/ankle specialist. Please send CV and contact info to footandankleortho@gmail.com. [824] PSYCHIATRIST NEEDED: Home Physicians (thehousecalldocs.com) is a fast-growing group

To submit a classified ad, email Kyle Lewis at KLewis@SDCMS.org. SDCMS members place classified ads free of charge (excepting “Services Offered” ads). Nonmembers pay $150 (100-word limit) per ad per month of insertion.

S AN D I E G O P HY S I CI A N . or g se pte m b e r 2010

of house-call doctors. Great pay ($140–$200+K), flexible hours, choose your own days (full or part time). No weekends or inpatient duties. Transportation and personal assistant provided. Call Chris Hunt, MD, at (858) 279-1212 or email CV to hpmg11@yahoo.com. [801] PART-TIME AND FULL-TIME OPENINGS FOR PRIMARY CARE PHYSICIANS: Board-certified family practice or internal medicine physicians wanted to join our prominent East County private medical group. One year or more experience preferred. Located on the Grossmont Hospital campus, our primary care group practices full-spectrum family medicine, including hospital care. Sharp Community Medical Group providers. Ownership opportunities available. Interested applicants please send CV to brad.kesling@gfmg.net. For further information, visit us at www.gfmg.net. [808] UNIQUE, PART-TIME INTERNAL MEDICINE OPPORTUNITY IN NORTH SAN DIEGO COUNTY: Tired of working too much? Want more flexibility? Then this may just what you’re looking for. Wellestablished internal medicine practice in North County seeking part-time, board-certified internist on a long-term basis. This is a rare chance to enjoy the rewards of private practice in a well-respected, single-specialty group setting and still have plenty of free time for other work or family commitments. If interested, call (619) 248-2324. [806]

pare comprehensive patient care plan. Submits healthcare plan and goals of individual patients for periodic review and evaluation by physician. Prescribes or recommends drugs or other forms of treatment such as physical therapy, inhalation therapy, or related therapeutic procedures. May refer patients to physician for consultation or to specialized health resources for treatment. Call (760) 639-1204. Fax (760) 630-1252. Email ncmaoceanside@hotmail.com. [830] OFFICE MANAGER WANTED: Mature, responsible adult with experience as office manager in cosmetic dermatology and surgery. Would also need to have experience in reception/front office and be willing to fill in there as needed. Sales experience helpful. Position would start part time and grow into full time. Would need to be available to cover vacations and sick call. We are a growing cosmetic dermatology/primary care practice with some minor office-based surgery. Duties would be primarily office managerial but would require occasional filling in when other employees are out. You would need to be able to manage employees, inventory, and be second point of contact for patients with questions or complaints. Good people

skills are a must as well as a personable, sunny disposition. Starting pay $18 with performance increase in three months. Please email your resume with business references to drkenstanley@yahoo. com. [828] RECEPTIONIST WANTED: Mature, responsible adult with friendly, outgoing disposition for reception/front-office position. Experience in cosmetic dermatology preferred. Sales experience a must. Responsibilities include answering the phone, making appointments, collecting payments, selling products, and answering questions about services and products. You will be the primary point of contact for patients and potential patients. Must be willing and prepared to perform multiple roles as needed. Pay starts at $12/hour with a performance increase in three months. Please email your resume with business references to drkenstanley@yahoo.com. [829] MEDICAL EQUIPMENT BONE DENSITOMETER: Hologic. Full size hip and spine. Slightly used. $12,000. Call (760) 703-0691. [755]

PHYSICIAN POSITION WANTED PHYSICIAN POSITION WANTED: Female OB/ GYN in solo practice for over 20 years in Southern California seeking part- or full-time position in San Diego area. Insured. Clean background. Please contact norplex@hotmail.com. [833] PRACTICE FOR SALE DEL MAR-AREA GENERAL PRACTICE: Prime location, huge potential for practice expansion in fast growing Carmel Valley community. Established in 1990; terms available. Inquiries call (858) 755-0510. [185] NONPHYSICIAN POSITIONS AVAILABLE MEDICAL ASSISTANT: Full-time medical assistant position available for general practice office. Four, 10-hour day shifts: Monday, Tuesday, Thursday, Friday. Office closed on Wednesday. Experience required. Please fax resume with cover letter to (858) 756-5952. If you have any questions, please call (858) 756-2340. [831] LOOKING FOR EXPERIENCED / LICENSED NURSE PRACTITIONER: Part time / full time, for a busy private primary care practice. Spanish helpful. National certification required. Location: Oceanside/Tri-City area. Compensation: competitive. The nurse practitioner will provide general medical care and treatment to patients in the office. Under the direction of physician: Performs physical examinations and preventive health measures within prescribed guidelines and instructions of physician. The nurse practitioner orders, interprets, and evaluates diagnostic tests to identify and assess patient’s clinical problems and healthcare needs. Records physical findings, and formulates plan and prognosis, based on patient’s condition. Discusses case with physician to pre-

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theartofmedicine By Daniel J. Bressler, MD

Natural Laws Natural Laws Sunflowers grow in Fibonacci Bee hives build in hexagons Rivers branch in slender fractals Symmetries and paragons The tides return in rhythmic patterns Novae swirl and planets spin Strong and weak the binding forces Apply the same: without, within Heart cells twitch in tight precision Enzymes order: “now do this” The cytoplasmic plot progresses Proteins flex and solutes fizz Squared sides of a right triangle Sum to squared hypotenuse 2 pi r attains circumference No excesses, no excuse Amidst this seeming mindless matter Of graceless rocks and random plants Each mote a perfect demonstration Of this: the natural cosmic dance

Tweak a universal constant? Edit out a decimal place? A false economy would enter And send us hurtling into space When humankind seems bent on chaos And life’s momentum all seems wrong The laws of nature stun me humble The Uni-Verse sings this: One Song

The Anthropic Principle was first coined in the early ’70s by astrophysicist Brandon Carter to address certain “coincidences” regarding fundamental properties of the universe. Why is it that the density of matter is such to allow planetary systems such as ours to exist? Why is it that the age of the sun happens to result in a level of temperature on our little planet that allows the development and survival of carbon-based life forms, including human beings? The Anthropic Principle offers an explanation that is at once tautological (true as in, a Homer Simpson “duh”) and provocative (as in, late one night, gazing up at the stars, scratching your head and saying to yourself, “Gee, I never thought about that before …). The Principle claims that the physical qualities of our universe are “ideal” for the existence of human beings, who can ponder those qualities. At a fundamental level, the universe is “friendly” or, perhaps more accurately, “permissive” to

S AN D I E G O P HY S I CI A N . or g se pte m b e r 2010

our existence. The Anthropic Principle is neither religious nor anti-religious, although its variations and interpretations have been used by both creationists and atheists to champion their cause. “Natural Laws” was written in response to a rash of global bad news: famine, flood, pestilence, war, hatred, greed, injustice, and economic meltdown. In the microcosm of my garden, from the embedded stones marking the walking path, to flowers following mathematical growth cycles, to the branches of the Jacaranda tree pointing toward the late afternoon sun, there was a reminder of a deeper order, one that I like to believe is ultimately benevolent.

{About the Author}

Dr. Bressler, SDCMS-CMA member since 1988 and board-certified in internal medicine, is a longtime contributor to San Diego Physician.

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