2011

san diego county medical society 2011 Annual Report

As you read about our 2011 accomplishments, we hope that you do so with a mixture of pride and hope — pride that as an SDCMS-CMA member physician you are fighting to protect what is important to you and your patients, and hope that our collective strength, vigilance, and dedication will continue to protect the noble profession of medicine.

2011 Annual Report

Medical Staff Independence

Our Legislators » SDCMS physician leaders and staff accompanied nearly 40 member physicians and medical students on trips to Sacramento and Washington, DC, to cultivate strong relationships with state and federal legislators.

Scope of Practice » CMA stopped physical therapists from directly accessing patients without a diagnosis from a physician by killing SB 924. » CMA stopped changes to the Optometry Practice Act by killing SB 920. » CMA blocked the implementation of new standards to certify optometrists to treat glaucoma — without having to treat a single patient with glaucoma — by filing a lawsuit with the California Academy of Eye Physicians and Surgeons. » CMA and the California Society of Anesthesiologists continue to seek reversal of a court decision allowing nurse anesthetists to administer anesthesia unsupervised by a physician by pursuing an appeal.

Medi-Cal » Early 2012 Successes Following Years of Hard Work by CMA: » Because of the efforts of a coalition (which spent more than $1 million in legal fees) led by CMA, a federal judge blocked a 10% MediCal reimbursement rate reduction — a huge win for physicians in California and for the patients they treat! » CMS rejected California’s request to impose mandatory copayments for Medi-Cal patients — another attempt by the state to balance the budget by slashing Medi-Cal. » The U.S. Supreme Court refused to reverse a Ninth Circuit Court of Appeals decision in a lawsuit CMA is a party to that resulted from California’s 2008 and 2009 MediCal rate reductions; the refusal ensures physicians have the ability to sue in order to block Medi-Cal cuts — thank you CMA! » In December The San Diego Union-Tribune published SDCMS’ op-ed: “Medi-Cal’s Hollow Promise.” » CMA commissioned an independent study that found that 36% of Medi-Cal enrollees were unable to see a doctor because the provider did not participate in Medi-Cal — critical data in our efforts to stop Medi-Cal cuts!

Bar to the Corporate Practice of Medicine » Intense lobbying by CMA and grass-roots feedback killed two bills (AB 824 and AB 926) that would have limited physicians’ ability to speak independently for their patients. We preserved the physicians’ unfettered ability to speak for their patients!

» Because CMA had submitted an amicus brief supporting an aggrieved physician in a case, a California court of appeal reaffirmed the importance of an independent, self-governing medical staff, ruling that a hospital’s lay governing board cannot unlawfully usurp a medical staff’s peer review authority.

MICRA » There were rumors — even clear indicators — that there would be a bill or bills directly attacking MICRA in 2011, but in the end there was no bill. There were, however, three bills introduced by consumer attorneys that nibbled around the edges — all three opposed by CMA and either neutered (SB 850) or killed (SB 558 and AB 1062). » In August, CMA defended MICRA before the 5th Appellate District Court, and in September the court upheld the constitutionality of MICRA’s $250,000 noneconomic damages cap, a decision now citable as precedent to oppose plaintiffs’ efforts to introduce evidence with respect to MICRA’s rational basis!

Medicare » In December 2011, the SGR can was kicked down the road for two months to the end of February, and then again in February to the end of 2012. CMA continues to lobby intensely and is integral to the nationwide effort to stop the draconian Medicare cuts permanently. » CMA president Dr. Jim Hay sent a letter to CMS questioning whether the volume of audits requested by Palmetto in 2011 was justified and asked that CMS demand that Palmetto reduce the size of the special study and allow Palmetto to cease mailing any more requests for records.

Gpci: San Diego’s Medicare Rural Underpayment » Three physicians (including one SDCMS physician) and seven California counties sued the Department of Health and Human Services for $3.2 billion, accusing the agency of knowingly using an outdated geographic rate system to pay physicians for more than 10 years. » SDCMS and CMA continue to press for a GPCI solution in every federal conversation to restore our Medicare rates to an urban cost-of-living multiplier (rather than the completely unfair and inaccurate rural multiplier).

Healthcare Reform » CMA developed material to help members understand what is in the ACO regulations and worked to shape the regulations so that ACOs are physician-led, patientcentric, and ensure voluntary participation from physicians. » SDCMS held a membersonly seminar/webinar in June to provide an in-depth review of the ACO regulations and their impact on physicians.

HIPAA » SDCMS and CMA continued to bring beneficial resources to member physicians to help them transition to the new HIPAA 5010 Transaction Standards: • CMA published “Are You Ready for the Transition to HIPAA Version 5010?” and “Physicians Advised to Finalize Preparations for New 5010 HIPAA Standards.”

• SDCMS conducted a webinar in November titled, “Is Your Biller HIPAA Version 5010 Compliant?”

• CMA regularly updated its “5010 Quick Reference Guide.”

2012 State Budget » Children were not moved from Healthy Families into Medi-Cal, thereby avoiding a devastating cut to the safety net and safeguarding access to care for California’s neediest children. » $7.3 million to provide vaccines for low-income, uninsured Californians was preserved. » Secured $4.4 million in additional funds resulting from interest earnings to the Every Woman Counts breast and cervical cancer screening program. » Any diversion of Maddy Fund monies into the state’s coffers was prevented — a significant win for physicians! » Funding for the Emergency Medical Services Commission, which oversees planning for emergency services statewide, was protected. » The Keeping Adults Free From Institutions program to provide adult day health services to eligible individuals was created.

Policing the Health Plans » CMA successfully fought discount health plan regulations that would have legitimized these illegal referral services. » CMA ensured the passage of SB 866 to dramatically streamline and improve the prior authorization process for prescription drugs. » CMA killed AB 52, which would have given insurance companies an excuse to further squeeze dollars out of healthcare delivery. » CMA supported the passage of AB 1059, which will ensure that enforcement actions by the DMHC make physicians and enrollees whole. » CMA supported SB 222, which will require individual health insurance policies to provide coverage for maternity services for all insured covered under the policy. » CMA supported AB 210, which will require group health insurance policies to provide coverage for maternity services for all insured covered under the policy. » CMA worked with DMHC and Blue Cross to ensure understanding of how and when its Healthy Families continuity of care plan transition would occur. » We helped physicians understand Blue Shield of California’s fee schedule changes that took effect in March 2011. » CMA got Blue Cross to conduct a webinar to help physicians understand its new list of services requiring preauthorization. » We continued to help physicians understand how a silent PPO works, how a “rental network” works, how they can detect a silent PPO, and how they can stop unfair discounts on their claims.

» We helped physicians understand Blue Cross’s expanded services list requiring preauthorization. » We helped physicians navigate the Cal-Net Physicians IPA bankruptcy. » CMA petitioned the California Supreme Court to argue that the state had unlawfully misappropriated physician fees from the MBC. » We helped physicians understand Anthem Blue Cross changes to its Prudent Buyer physician fee schedule. » We helped physicians when Operating Engineers Health and Welfare Fund was not paying claims in a timely manner. » CMA asked DMHC to Investigate Improper Overpayment Refund Requests from the Anthem Blue Cross Special Investigations Unit. » CMA published a guide to help physicians understand their rights and options when it comes to health plan refund requests. » CMA published a document to help members with the three CMS audits floating around in 2011. » We helped physicians sort through three different types of “audit” letters from Blue Cross in 2011. » At CMA’s request, MBC reviewed the State Compensation Insurance Fund’s preauthorization requirements for opioid prescriptions. » CMA petitioned for amendments extending the verbal order authentication time period.

Emergency Services » In early 2011, in order to backfill the state’s budget deficit, the California Assembly and Senate voted to raid the Maddy Funds of California’s counties, which reimburse totally uncompensated ER care. SDCMS and CMA pushed hard and saved the Maddy Funds from the budgetary meat cleaver — a multimillion-dollar win for San Diego ER doctors! » CMA continued to support the passage of SB 336 to require every licensed general acute care hospital to assess the condition of its emergency department every four or eight hours and to develop and implement capacity protocols for overcrowding.

2011 Annual Report

Protecting Patients » CMA created medical-legal document #0403, “Responding to Requests for Nonbeneficial Treatment Decisions.” » CMA supported the passage of AB 499, which will allow a minor who is 12 years of age or older to consent to medical care related to the prevention of a sexually transmitted disease. Signed by Governor » CMA negotiated compromise language in AB 378 that will limit reimbursement for physiciandispensed products to a level that will cover a physician practice’s costs to dispense them but won’t provide an unreasonable financial incentive to prescribe and dispense them. » CMA sponsored AB 655 to allow for a reasonable peer review sharing agreement between peer review bodies while maintaining the confidentiality of peer review information and protecting the public health. Signed by Governor » CMA supported SB 100 to improve the care provided in outpatient surgery settings. » SDCMS worked with the County of San Diego in 2011: • to disseminate influenza reports, fact sheets, etc.

• to urge influenza vaccination of all healthcare personnel • to ensure medical vigilance during the 10th anniversary of 9/11 • to promulgate information on potential measles exposures • to ensure San Diego’s middle and high school students had Tdap booster shots • to ensure physicians were using the San Diego Immunization Registry • to publicize its Suicide Prevention Plan • to communicate possible Shiga toxin-producing E. coli O104 infections • to inform physicians of a listeria outbreak associated with a cantaloupe recall

Emergency Preparedness » CMA adopted policy in 2011 to advocate for the reclassification and regulation (not legalization) of medical cannabis to allow for wider clinical research, accountable and quality controlled production of the substance, and proper public awareness — a decision based on a white paper concluding physicians should have access to better research, which is not possible under the current policy.

Community Partners » SDCMS continued in 2011 to work closely with the following organizations to ensure physicians are part of the solution: • Community Health Improvement Partners (CHIP) • San Diego County Childhood Obesity Initiative • San Diego County Healthcare Needs Assessment: Charting the Course • Mental and Behavioral Health, Through Mental Health America and the Suicide Prevention Action Team • Chamber of Commerce Healthcare Committee • Healthy San Diego: County Government Oversight of MediCal Managed Care Patients • Disaster Preparation With the County of San Diego Emergency Medical Services » We worked with San Diego Magazine for the seventh year in a row on its annual “Top Doctors: Physicians of Exceptional Excellence” awards selection and gala, held in 2011 at the Museum of Contemporary Art in La Jolla.

Physician Workforce » SDCMS documented that San Diego’s office-based physician population alone creates $8 billion in economic activity and is responsible for more than 25,000 nonphysician jobs. » SDCMS conducted its fifth biannual San Diego County Workforce and Compensation Survey in 2011, critical tools in our discussions with lawmakers and decisionmakers. Look for the results of our 2011 survey to be published soon.

Physician Leaders James T. Hay, MD, SDCMSCMA member since 1985, became president of CMA in 2011. An article profiling Dr. Hay appeared in a January 2012 issue of The San Diego Union-Tribune: “Encinitas Doctor Heads California Medical Association.”

Theodore M. Mazer, MD, SDCMS-CMA member since 1989, was elected vice speaker of the CMA House of Delegates.

Rodney Hood, MD, SDCMSCMA member since 1977, was a recipient of the 2011 Pride in the Profession Awards, presented by the AMA Foundation, in association with Pfizer Inc. The award recognizes physicians who aid underserved populations in the United States.

» SDCMS held a disaster drill with the County of San Diego to determine our ability to respond to the need for physicians in time of a disaster. » We helped prepare physicians to answer their patients’ questions after the Japanese nuclear crisis. » We worked with the California Health Alert Network to ensure physicians receive the latest and most accurate health information.

Technology » SDCMS presented two backto-back seminars in June to walk physicians and their staff through the EHR Desk Reference. » SDCMS helped member physicians enroll in EHR incentive programs, attest through CMS’ web-based Medicare and Medicaid EHR Incentive Programs Registration and Attestation System, and understand the required meaningful use criteria to successfully attest. » SDCMS received a grant from California Health Information Partnership and Services Organization and worked with the SDCMS Foundation to help physicians with free EHR implementation assistance.

Promoting Your Practice » Members receive a free San Diego County physician mailing list annually. » Members can customize their profiles at www.SDCMS.org, which is highly ranked for many typical patient searches. » San Diego Magazine’s May 2011 “Health Annex” published contact information on SDCMS (and only SDCMS) member physicians. » Members place free practice announcements online and in San Diego Physician magazine. » Members receive 50% off advertising rates in San Diego Physician and SDCMS’ two physician directories. » Members can become SDCMS spokespeople on topics within their specialty for San Diego County media.

Tangible Member Benefits » More than 850 SDCMS members saved nearly $500,000 as a result of SDCMS’ 5% membersonly discount on professional liability insurance with The Doctors Company. » CMA recouped $128,000 for individual SDCMS members in 2011 with one-on-one billing, contracting, and payment assistance. » SDCMS partnered with 4G Wireless to provide members (and their staffs and families) discounts on Verizon equipment, accessories, and service. » SDCMS partnered with STAT Pharmaceuticals to provide members with bottom-line savings on medical supplies and pharmaceuticals. » SDCMS partnered with Disney to provide discounts on tickets and passports to Disneyland Resort.

» SDCMS partnered with Wealth Legacy Group to provide members with discounts on individual disability premiums and more. » Members received free annual physician mailing list, car insurance discounts, free magazine and website classified ads, and the California Emergency Driving Emblem. » CMA started its “CMA Practice Resources” in 2011, a free monthly e-bulletin full of tips and tools to help physicians and their office staff improve practice efficiency and viability. » CMA launched its new and much improved website in 2011. » CMA published guidance on concierge care and private retainer agreements. » SDCMS members with Androidbased smartphones and tablets were able in 2011 to download their free DocBookMD application that allows total access to SDCMS’ directory plus HIPAA-compliant doctor-to-doctor connectivity. » SDCMS published its San Diego County Physician Directory and Pictorial Membership Directory at the end of 2011. » SDCMS members can now save hundreds — if not thousands — thanks to a newly negotiated 22% discount on workers’ compensation insurance through SDCMS’ preferred provider, The Doctors Company Insurance Services. » CMA published medical-legal document #0107 “Covering Physicians (Locum Tenens)” to educate members on how to bill for doctors covering their practice.

Office Manager of the Year!

Your Physician Advocate at Work » In 2011, your physician advocate and office manager advocate worked hard to solve more than 450 member problems, including legal questions, human resources, technology, Medicare, HIPAA, and more. Here are a few specific examples of how SDCMS helped: • To no avail, a solo psychiatrist attempted to appeal repeated Blue Cross denials of medications in doses that were well within the standard of care. CMA connected with the pharmacy division at Blue Cross, and the denials were overturned.

• A nonmember surgeon had an outstanding claim with Health Net that had been denied and appealed several times. In talking to a member physician, the surgeon decided to join to see if we could assist with the issue. CMA was able to get the claim paid, with interest, which paid for the cost of her SDCMS-CMA dues and then some.

• An oncology group ran into several Medicare credentialing obstacles, and every time they contacted Palmetto, they received conflicting answers on what to do. In the interim, Palmetto held all of their claims.

SDCMS worked with Palmetto to communicate to the practice exactly what was needed to get them squared away. Palmetto quickly released $114,000 in back claims.

» SDCMS’ Third Annual “Outstanding San Diego County Medical Office Manager”: Congratulations to Robert O’Meara, office manager for Irwin Goldstein, MD, SDCMS member since 2007.

Seminars, Webinars, and Workshops » In 2011 we conducted 40 seminars, webinars, and workshops to ensure that you and your staff get the most accurate and up-todate information available to keep your practice running smoothly.

• Seminar Attendees: 927 • Webinar Attendees: 852 • Total Registrants: 1,779 » Most Popular Seminars: • The Road to ICD-10 (128) • Changes to Medicare Regulations (128) • Collections Procedures (110) • Medicare Updates (100) • OSHA Updates (100) • HIPAA Updates (98) • Palmetto GBA / Medicare (86) • Treating Patients Right (78) • HIPAA 510 Changes (74) » Workshops: • Advocacy Training Workshop • Media Training Workshops • Microsoft Outlook Workshops • Leader’s Toolbox Workshops • Financial and Legal Life Skills Workshop

2011 Annual Report

SDCMS Expenses …

Member Engagement

Foundation 2%

Specialty Societies 1%

Physician Database 4% Physician Engagement 6%

rent: 11% copier: 1% credit card / bank charges: 2% insurance: 1% miscellaneous expenses: 3% telephone: 1% staff time G&A: 12%

Advocacy 6%

Infrastructure 31%

Infrastructure » In 2011 we made major (and we do mean major) upgrades to the depth and fidelity of our San Diego County physician database, completely rewriting it and shifting it to the “cloud,” making it more accurate, more accessible, and less vulnerable in times of crisis.

Benefits 12%

» SDCMS Socials: • Membership Social in January • Retired Physicians Society Luncheons in March • Resident and Young Physician Social in April With 70+ Physicians and Guests Attending • Membership Pool Party & BBQ in August With 40+ Physicians and Guests

Governance 14%

Communicating Your Message Communications 24%

SDCMS Revenues …

Foundation 2% Credit Card Commission 3%

Specialty Societies 1%

Advertising and Sales 15%

Dues 54% Investments 25%

» SDCMS Installation Dinner and Dance / White Coat Gala on June 4 SDCMS honored our incoming and outgoing presidents, and raised money for the tremendous work of our SDCMS Foundation and its flagship program, Project Access San Diego. This was our most successful event to date, with nearly 300 physicians, local, state, and federal legislators, and many area VIPs attending. » SDCMS’ CEO spoke at 19 hospital general staff and medical executive committee meetings. » The San Diego Magazine “Top Docs” gala in 2011 was attended by more than 500 physicians and guests.

Membership #s » In 2011, recognizing that the weak economy continues to pose financial challenges to our members, we initiated a multiyear dues discount program ($100 discount per year per member). » Membership as of Dec. 31, 2011: 2011: 2,670 2010: 2,652 2009: 2,578 2008: 2,562 2007: 2,419 2006: 2,390 2005: 2,195 2004: 2,163 2003: 2,056 2002: 2,029

» In addition to our 2,670 active physician members, we have 238 resident physician members and 406 medical student members. » As a result of our continuing growth, we have added to our board of directors (one geographic director, one geographic alternate director, and one at-large alternate director). » 95 first-year medical students signed up as members at UC San Diego’s Medical Student Fair in 2011, bringing the next generation into organized medicine.

» We sent out 22 issues of our biweekly, commercial-free enewsletter, “News You Can Use.” » San Diego County’s media outlets continued to turn to SDCMS when looking for the physician’s perspective on stories, including Medi-Cal’s hollow promise, Blue Shield’s 30% premium hikes, the DMHC’s “timely access” regulations, polio’s continued existence, the role of nurse practitioners in the provision of healthcare, Doctors Express franchises opening up in San Diego County, and more. » We began to film brief video updates by our SDCMS leadership in 2011, updating physicians on relevant healthcare issues. » Your monthly San Diego Physician speaks to and for all 8,500+ San Diego County physicians. 2011 issue topics included Health Reform, The Medical Home, Medical Ethics, Consumer/Patient Safety, HIT, Infectious Diseases, Disaster Preparedness, Life After Medicine, and more. » SDCMS delved into social media in 2011 with our own Twitter account and Facebook page. Be sure to “follow” us on Twitter and “like” us on Facebook!

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A N N U A L

R E P O R T

HIGHLIGHTS OF OUR ACCOMPLISHMENTS DURING 2011 600 Physicians Volunteer for PASD Project Access San Diego now counts over 600 specialty care physicians as volunteers, providing specialty healthcare consultations and services to uninsured adult patients.

PASD is recognized throughout the county as the organized vehicle for local healthcare volunteerism. Thanks to our growing number of volunteers, we have been able to increase the number of patients served each month.

2011 Project Access San Diego Highlights Number of patients receiving specialty healthcare services Number of patients assisted to receive public benefits Number of specialty healthcare appointments Number of surgeries Number of volunteer specialty care physicians

673 363 1,863 121 616

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

Vision: Improving health, changing lives

SDCMSF Receives Coveted Ardash S. Mahal, MD Award from CMA Foundation Project Access San Diego and the SDCMSF received the 2011 Adarsh S. Mahal MD Access to Health Care & Disparities Award at the California Medical Association (CMA) Annual Conference and CMA Foundation dinner on Sunday, October 16 for our work in addressing the unmet health care needs of uninsured patients throughout San Diego County.

SDCMS and SDCMS Foundation White Coat Gala On June 4, 2011, the annual SDCMS dinner honored incoming and outgoing SDCMS presidents, and highlighted the efforts of physician volunteers, as well as raised funds for SDCMSF’s flagship program, Project Access San Diego.

858.300.2777 www.sdcmsf.org

March and October 2011 KP Super Saturday Surgery Days PASD coordinated 76 free surgeries and GI procedures in partnership with Kaiser Permanente and Southern California Permanente Medical Group volunteer physicians at its March 26 and October 15 Super Saturday Surgery Days. KP assisted to launch Project Access San Diego with the first Saturday Surgery Day in December 2008. Eight surgery days since inception have resulted in health improved and lives changed for 281 uninsured patients.

New Website Launched in 2011 To improve access to information about SDCMSF, www.sdcmsf.org contains links to current local, regional and national news, as well as better tells the Foundation’s story. Physician volunteers, our heroes, are highlighted on numerous pages. eConsultSD Expands Access to Specialty Healthcare Through the generous support of Kaiser Foundation Hospitals, Southern California Region, and in partnership with the Council of Community Clinics, SDCMSF launched eConsultSD in early 2011 to assist primary care physicians practicing at the area community health centers with fast access to specialty care consultations for their patients. The system is HIPAA compliant, able to accommodate imaging and medical notes from E-HRs, and increases the capacity of PCPs to manage patient care. For those specialists who may not be able to volunteer to see patients in their offices, eConsultSD is an easy way to provide support to PCP colleagues, and improve the health of uninsured patients.

Carlsbad Surgery Center Adds Saturday Surgery Day Capacity More patients are now able to receive general surgeries, including hernia, gallbladder and lipoma removal, thanks to an increased partnership with Surgery One’s Carlsbad Surgery Center. Through the efforts of Adam Fierer, MD and Eileen Natuzzi, MD, the first Saturday Surgery Day improved the health and changed the lives of five patients in August 2011. Two surgery days there are planned annually, in addition to the two Super Saturday Surgery Days at Kaiser Permanente, and the regularly scheduled surgeries at our hospital and outpatient surgical center partners throughout the year.

Text4baby Shown to Improve Maternal and Child Health Text4baby, a national mobile health education program launched locally by SDCMSF in 2010, has been shown to increase users’ health knowledge, improve interaction with healthcare providers, improve adherence to appointments and immunizations, and increase access to health resources. Recent evaluation has demonstrated the potential positive impact of the Text4baby program and mobile health interventions as a whole. The program presented its findings at the 2011 American Public Health Association annual conference.

Text4babySD utilizes localized messages, and by the end of 2011, more than 2,700 expectant and new parents had utilized the text messaging program.

Retired Physicians Society Relaunched Thanks to the efforts of Mitsuo Tomita, MD and Rosemarie M. Johnson, MD, the Retired Physicians Society is taking on new life.

During fall 2011, retired physicians were polled on their interests. On the docket for 2012 are quarterly noon-time educational meetings; many of these will include opportunities to earn CME credits.

Financial Highlights (From Audited Financial Statements year ended September 30, 2011) SDCMSF received an unqualified opinion from Leaf & Cole, LLP, the highest designation from an independent audit.

Total Assets: $963,506 Support & Revenues: $980,020 Expenses: Program Services: Management & General Supporting Services: Fundraising Expense: Special Event Expense:

Contributed medical services:

$757,785

86%

$36,297

4%

$26,611

3%

$61,921

7%

$2,413,905

Medical Student Scholarships 2011 scholarships were awarded to UC San Diego Medical School first year student Omid Yousefian and to new residents Christopher Reid and Kimberly Smith. Congrats to all three!

BOARD OF DIRECTORS: Stuart Cohen, M.D., President Pediatrician, Children’s Primary Medical Group Al Ray, M.D., Secretary/Treasurer Family Medicine, Southern California Permanente Medical Group Will Tseng, M.D., Vice President Internal Medicine, Southern California Permanente Medical Group Ellen Beck, M.D. Family Medicine, UC San Diego Robert Desimone, The Doctors Company Tom Gehring, CEO, San Diego County Medical Society Ron Mitchell, CPA, AKT CPAs and Business Consultants Jeffrey Willmann, Opprime’ Investments, Inc. Carol L. Young, M.D. Internal Medicine/Rheumatology, Arthritis Medical Clinic Ex Officio James Hay, M.D. Family Medicine, PASD Leadership Committee Chair Rosemarie Marshall Johnson, M.D., Medical Community Liaison James Schultz, M.D., Medical Director, Project Access Barbara Mandel, MBA, Executive Director