January 2013

San Diego Physician

celebrates

100

official publication of the san diego county medical society january 2013

years

Remembering David Knetzer

SDCMS CEO from 1979 to 2001 “Physicians United For A Healthy San Diego”

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1

this month Volume 100, Number 1

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

features REMEMBERING DAVID KNETZER; SDCMS CEO FROM 1979 TO 2001 30 David Knetzer, 1936–2012

30

31 His Memory Will Always Be With Me

BY ALLAN H. GOODMAN, MD

departments

31 The David Knetzer I Knew

BY DAVID PRIVER, MD

4 Briefly Noted

Calendar • Real Estate Trends • Welcome New and Rejoining Members • And More …

SDCMS Board of Directors Officers President: Sherry L. Franklin, MD (CMA TRUSTEE) President-elect: Robert E. Peters, PhD, MD Treasurer: J. Steven Poceta, MD Secretary: William T-C Tseng, MD, MPH Immediate Past President: Robert E. Wailes, MD (CMA TRUSTEE) geographic and geographic alternate Directors East County: Alexandra E. Page, MD, Venu Prabaker, MD Hillcrest: Theodore S. Thomas, MD (A: Gregory M. Balourdas, MD) Kearny Mesa: John G. Lane, MD, Jason P. Lujan, MD (A: Sergio R. Flores, MD) La Jolla: Geva E. Mannor, MD, Wynnshang “Wayne” Sun, MD (A: Matt H. Hom, MD) North County: Niren Angle, MD, Douglas Fenton, MD, James H. Schultz, MD (A: Anthony H. Sacks, MD) South Bay: Vimal I. Nanavati, MD, Michael H. Verdolin, MD (A: Andres Smith, MD)

At-large Directors Karrar H. Ali, MD, David E.J. Bazzo, MD, Jeffrey O. Leach, MD (DELEGATION CHAIR), Mihir Y. Parikh, MD (EXECUTIVE COMMITTEE BOARD REP), Peter O. Raudaskoski, MD, Kosala Samarasinghe, MD, Suman Sinha, MD, Mark W. Sornson, MD (EXECUTIVE COMMITTEE BOARD REP) At-large ALTERNATE Directors James E. Bush, MD, Theresa L. Currier, MD, Thomas V. McAfee, MD, Carl A. Powell, DO, Elaine J. Watkins, DO, Samuel H. Wood, MD, Holly Beke Yang, MD, Carol L. Young, MD

8 Thank You to Our Third of a Century Members!

10 Who Needs AMA?

other voting members Communications Chair: Theodore M. Mazer, MD (CMA SPEAKER)

BY JAMES T. HAY, MD, ROBERT E. HERTZKA, MD, ALBERT RAY, MD, AND LISA S. MILLER, MD

Young Physician Director: Van L. Cheng, MD Retired Physician Director: Rosemarie M. Johnson, MD

12 Early Morning Awakenings

Medical Student Director: Suraj Kedarisetty

by DANIEL J. BRESSLER, MD

OTHER NONVOTING MEMBERS

14 Covered California: California’s HIE

by SHERRY L. FRANKLIN, MD

18 New Year’s Resolutions, Anyone?

by HELANE FRONEK, MD, FACP, FACPH

14

20 UCSD School of Medicine in Mozambique

by FARHANA ALI, ROBERT SCHOOLEY, MD, AND CAROLYN KELLY, MD

22 Countdown to 2014: An Interview With Robert E. Hertzka, MD, on the ACA

Young Physician Alternate Director: Renjit A. Sundharadas, MD Retired Physician Alternate Director: Mitsuo Tomita, MD SDCMS Foundation President: Stuart A. Cohen, MD, MPH CMA Past Presidents: James T. Hay, MD (AMA DELEGATE), Robert E. Hertzka, MD (LEGISLATIVE COMMITTEE CHAIR, AMA DELEGATE), Ralph R. Ocampo, MD CMA Trustee: Albert Ray, MD (AMA ALTERNATE DELEGATE) CMA Trustee (OTHER): Catherine D. Moore, MD CMA SSGPF Delegates: James W. Ochi, MD, Marc M. Sedwitz, MD CMA SSGPF Alternate Delegates: Dan I. Giurgiu MD, Ritvik Prakash Mehta, MD

by SAN DIEGO PHYSICIAN

34 Physician Marketplace

Classifieds

36 San Diego Physician Celebrates 100 Years

22 2 jan uary 2013

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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brieflynoted calendar SDCMS Seminars, Webinars & Events SDCMS.org/event

For further information or to register for any of the following SDCMS seminars, webinars, or workshops, visit www.SDCMS. org/event or contact Jen at (858) 300-2781 or at JOhmstede@ SDCMS.org.

Preparing to Launch: Essentials to Consider for Doctors Contemplating Their Future in the Real World (workshop) FEB 2 • 8:00am–3:30pm The Leader’s Toolkit (workshop) MAR 16–17 • 8:00am–4:00pm, 8:00am–12:00pm Medicare Updates (seminar/ webinar) MAR 21 • 11:30am –1:00pm Certified Medical Coder (course) MAR 22, 29, APR 5, 12, 19 • 8:00am–4:00pm

Cma Webinars

CMAnet.org/events

Healthy Families: Important Program Changes Practices Need to Know FEB 5 • 12:15pm–1:15pm

HIPAA Compliance: The Final HITECH Rule FEB 6 • 12:15pm–1:15pm Impact of ICD-10 FEB 7 • 12:15pm–1:45pm E/M Services Review 1: Documentation Requirements and Overview FEB 12 • 12:15pm –1:45pm E/M Services Review 2: History as Key Component in Selecting E/M Level FEB 13 • 12:15pm–1:45pm E/M Services Review 3: Examination as Key Component in Selecting E/M Level FEB 19 • 12:15pm –1:45pm E/M Services Review 4: Medical Decision Making as Key Component in Selecting E/M Level FEB 20 • 12:15pm –1:45pm Practice Mergers: How to Successfully Merge Physician Practices FEB 27 • 12:15pm–1:15pm

Community Healthcare Calendar

To submit a community healthcare event for possible publication, email KLewis@SDCMS.org. Events should be physician-focused and should take place in or near San Diego County.

UC San Diego Perioperative Transesophageal Echocardiography FEB 16–18 • Catamaran Hotel, San Diego • cme.ucsd.edu/echo/ registration.html Volunteer for the Women’s Half Marathon FEB 22–24 • womenshalf. competitor.com/sandiego (click “Volunteer” on the top menu bar) Aces for Health Golf Tournament FEB 28 • Del Mar Country Club • Benefitting the SDCMS Foundation’s Project Access • (858) 565-7930 Musculoskeletal Medicine for Primary Care Providers: A Symposium From UCSD Sports Medicine MAR 22–23 • 7:45am–4:45pm on the 22nd, 8:00am–4:20pm on the 23rd • Paradise Point Hotel, San Diego • ucsdsportsmedcme.com Volunteers Needed for RAM California Expedition (free medical, dental, and vision clinic) APR 4–7 • Riverside / Indio Fairgrounds • www.ram-ca.org RCMA’s “Cruisin Thru CME” — French Waterways: Highlights of Burgundy & Provence JUL 1–13 • Call RCMA at (800) 472-6204

SDCMS Member Physicians:

If you are interested in learning more about joining the San Diego Physician editorial board, please email Editor@SDCMS.org.

4 jan uary 2013

get in touch Your SDCMS and SDCMSF Support Teams Are Here to Help!

SDCMS Contact Information 5575 Ruffin Road, Suite 250, San Diego, CA 92123 T (858) 565-8888 F (858) 569-1334 E SDCMS@SDCMS.org W SDCMS.org • SanDiegoPhysician.org CEO • EXECUTIVE DIRECTOR Tom Gehring at (858) 565-8597 or Gehring@SDCMS.org COO • CFO James Beaubeaux at (858) 300-2788 or James.Beaubeaux@SDCMS.org DIRECTOR OF ENGAGEMENT Jennipher Ohmstede at (858) 300-2781 or JOhmstede@SDCMS.org DIRECTOR OF MEMBERSHIP SUPPORT • PHYSICIAN ADVOCATE Marisol Gonzalez at (858) 300-2783 or MGonzalez@SDCMS.org DIRECTOR OF RECRUITING AND RETENTION Brian R. Gerwe at (858) 300-2782 or at Brian.Gerwe@SDCMS.org DIRECTOR OF MEMBERSHIP OPERATIONS Brandon Ethridge at (858) 300-2778 or at Brandon.Ethridge@SDCMS.org DIRECTOR OF COMMUNICATIONS AND MARKETING • MANAGING EDITOR Kyle Lewis at (858) 300-2784 or KLewis@SDCMS.org OFFICE MANAGER • DIRECTOR OF FIRST IMPRESSIONS Betty Matthews at (858) 565-8888 or Betty.Matthews@SDCMS.org LETTERS TO THE EDITOR Editor@SDCMS.org GENERAL SUGGESTIONS SuggestionBox@SDCMS.org

SDCMSF Contact Information 5575 Ruffin Road, Suite 250, San Diego, CA 92123 T (858) 300-2777 F (858) 560-0179 (general) W SDCMSF.org EXECUTIVE DIRECTOR Barbara Mandel at (858) 300-2780 or Barbara.Mandel@SDCMS.org project access PROGRAM DIRECTOR Francesca Mueller, MPH, at (858) 565-8161 or Francesca.Mueller@SDCMS.org Patient Care Manager Rebecca Valenzuela at (858) 300-2785 or Rebecca.Valenzuela@SDCMS.org Patient Care Manager Elizabeth Terrazas at (858) 565-8156 or Elizabeth.Terrazas@SDCMS.org RESOURCE DEVELOPMENT DIRECTOR Nicole Hmielewski at (858) 565-7930 or Nicole.Hmielewski@SDCMS.org IT PROJECT MANAGER Rob Yeates at (858) 300-2791 or Rob.Yeates@SDCMS.org IT PROJECT MANAGER Victor Bloomberg at (619) 252-6716 or Victor.Bloomberg@SDCMS.org

Submarket Snapshot: UTC

real estate trends

By Chris Ross Negotiating a Lease or Renewal There are two simple ways to minimize your occupancy costs when renewing or relocating your office. The first and the more obvious one is to plan ahead. Health practitioners and other medical tenants are extremely busy and tend to put off dealing with their lease until three to six months before the expiration date, when they have lost most if not all of their leverage. Starting the evaluation and negotiating process 12–18 months prior to the end of the lease term will allow plenty of time to negotiate competitive terms.

Secondly, even if you are not considering relocation, it is a good idea to get a thorough understanding of the terms and concessions other buildings in your submarket are agreeing to. Asking rates

and what your colleague or neighbor is currently paying is one thing, but unless you consult with a broker who is active and experienced in medical office leasing, you may leave money on the table in rent, tenant improvement allowance, abatement, parking concessions, or other deal points.

Knowing the landlord’s true bottom line and going about a lease or renewal negotiation in a strategic manner can help cut your overall leasing costs — sometimes significantly — and may allow you to obtain nonmonetary provisions that you may not realize are available to you.

Construction Spotlight The new Palomar Medical Center in Escondido, which opened in August, recently received an award from Engineering NewsRecord for California’s Project of the Year as well as national Best of the Best Health Care Project.

The La Jolla / UTC healthcare real estate market comprises 827,000 square feet of medical office space. Most of the area’s providers are housed in low-rise Class ‘B’ buildings completed in the 1980s. Home to Scripps Memorial Hospital, Scripps Green Hospital, UC San Diego Thornton Hospital, and VA Hospital, UTC remains one of the “healthiest” of the nine submarkets in San Diego County, mainly due to its dynamic combination of strong hospital presence, access, amenities, and surrounding demographics.

In contrast with many other areas of San Diego County, UTC contains a balanced group of on-campus and off-campus buildings, as well as mixed office/medical buildings — those containing both traditional office tenants and healthcare providers.

Historically, UTC has proven to be extremely stable, never exceeding 12.1% vacancy at any time between 2000 and 2009, and reaching a low of 6.4% in 2007.

While 2010 posted a 10-year high of 14.9% vacancy, it dropped rapidly to 10.7% in 2011 and currently sits at 11.1%. The current average rental rate in UTC is $3.10/ SF gross, up from $2.87 a year ago — even though 2012 leasing activity was down significantly from 2011.

With the exception of the proposed Ximed II medical building on the Scripps campus (tentatively scheduled for completion in 2015), no new medical office construction has been announced in the La Jolla / UTC submarket. Zoning constraints and lack of developable land will limit new medical development and put steady upward pressure on the market in the years ahead.

Mr. Ross is vice president of healthcare real estate services at Colliers International. He is a commercial real estate broker, specializing exclusively in medical office and healthcare facilities in San Diego County. He can be reached at (858) 677-5329 or chris.ross@colliers.com.

SAN DI EGO PHYSICIAN.org 5

brieflynoted SDCMS membership

Welcome Our New and Rejoining SDCMS-CMA Members!

New Members Daniel L. Brockett, MD Psychiatry San Diego • (858) 480-1044 Chi-Bew Chan, MD Anesthesiology San Diego • (858) 565-9666 Nina Chaya, MD Anesthesiology San Diego • (858) 565-9666 Gilberto Cota, MD Family Medicine Alpine • (619) 445-6200 Douglas M. Daub, MD Family Medicine Santee • (619) 961-5158 Robert W.E. Fry, MD Orthopaedic Surgery San Diego • (619) 229-3932 Jamie M. Hoffman, MD Pediatrics San Diego • (858) 279-0100 Puya Hosseini, MD Anesthesiology San Diego • (858) 565-9666 Leslie Q. Hsieh, MD Pediatrics • La Jolla (858) 457-2043 Tung-Chin Hsieh, MD Urology San Diego • (619) 543-2626 Juliette A. Humsi, MD Anesthesiology San Diego • (858) 565-9666 Siavash Jabbari, MD Radiation Oncology La Mesa • (619) 460-2770 Kathleen M. Judd, MD Rheumatology • Encinitas Jeannie Kim, MD Critical Care Medicine San Diego • (619) 582-3516

Roshan Kotha, MD Rheumatology San Diego • (619) 461-1920 Katherine H. Lee, MD Anesthesiology San Diego • (858) 565-9666

L–R: Arthur Gruen, MD, Sherry Dollarhide, James Beaubeaux, Sergio Flores, MD, Susan Kaweski, MD, James Bush, MD, Patricia Leach, Jeffrey Leach, MD, Silvia Estrella-Tamsen, Mark Tamsen, MD, Caroline Thornton, MD, Mark Sornson, MD, Robert Peters, PhD, MD

Robin T. Li, MD Cardiac Anesthesia San Diego • (858) 565-9666 Zhe Li, MD Anesthesiology San Diego • (858) 565-9666 Michael D. Linden, MD Anatomic Pathology and Clinical Pathology San Diego • (619) 297-4900 Ursula G. Pertl, MD Pediatrics Oceanside • (760) 547-1010 Michael J. Sasevich, MD Thoracic Surgery La Jolla • (858) 455-6330 Stephen D. Schneider, MD Pediatrics Escondido • (760) 746-2641 Perry W. Sexton, MD Family Medicine Encinitas • (760) 274-1385 Crystal M. Singewald, MD Pediatrics El Cajon • (619) 442-2560 Danny L. Valentine, MD Anesthesiology San Diego • (858) 565-9666 Elizabeth J. Waters, MD Pediatrics San Diego • (619) 262-8624 Rejoining Member Sabah N. Chammas, MD Geriatric Psychiatry Encinitas • (760) 730-4540

SDCMS Tours the USNS Mercy On Dec. 1, 2012, a group of SDCMS member physicians, spouses, and SDCMS staff took a tour of the USNS Mercy, one of two Military Sealift Command hospital ships that provide rapid, flexible, and mobile acute medical and surgical services to support Marine Air-Ground Task Forces deployed ashore, Army and Air Force units deployed ashore, and naval amphibious task forces and battle forces afloat.

The USNS Mercy also provides mobile surgical hospital service for use by appropriate U.S. government agencies in Humanitarian Civic Assistance, disaster or humanitarian relief, or limited humanitarian care incident to these missions or peacetime military. For further information, visit www.med.navy.mil/sites/usnsmercy/.

“

January gray is here, like a sexton by her grave; February bears the bier, March with grief doth howl and rave, and April weeps — but, O ye hours! Follow with May’s fairest flowers.

”

— Percy Bysshe Shelley, English Poet (1792–1822) 6 jan uary 2013

SAN DI EGO PHYSICIAN.org 7

SDCMS Membership

Congratulations and Thank You to the Following Physicians Who Have Been SDCMS Members for a Third of a Century and Longer!

SDCMS Member Physician’s Name, Years of Membership

Edward J. Sheldon, MD, 50

Ernest E. Pund, MD, 49

Richard M. Braun, MD, 46

Garry E. Goldfarb, MD, 46

Richard N. Learn, MD, 45

Robert Penner, MD, 45

Allan H. Rabin, MD, 44

Donald J. Ritt, MD, 44

Kevin P. Glynn, MD, 43

H. Douglas Engelhorn, MD, 42

Ronald J. Goldman, MD, 42

Sidney H. Levine, MD, 42

Merritt S. Matthews, MD, 42

Richard D. Perlman, MD, MPH, FACS, 41

William A. Pitt, MD, 40

Russell Stuart Weeks, MD, 40

Steven A. Balch, MD, 39

Franklin Crystal, MD, 39

George David Gibson, MD, 39

Michael Goldhamer, MD, 39

Stephen L. Reitman, MD, 39

David J. Shaw, MD, 39

San C. Hsieh, MD, 38

Howard G. Milstein, MD, 38

Jon M. Robins, MD, 38

Joseph Shurman, MD, 38

James P. Tasto, MD, 38

Vincent J. Guzzetta, MD, 37

Leonard M. Kornreich, MD, 37

Steven M. Leshaw, MD, 37

Victor H. Lipp, MD, 37

Stuart C. Marshall, MD, 37

8 jan uary 2013

G. Douglas Moir, MD, 37

Norman W. Pincock, MD, 37

William F. Resh, MD, 37

Robert J. Santella, MD, 37

David R. Schmottlach, MD, 37

O. Douglas Wilson, MD, 37

Harry C. Henderson, MD, 36

Kenneth Ott, MD, FACS, 36

David F. Polster, MD, 36

Bruce M. Prenner, MD, 36

Robert S. Scheinberg, MD, 36

Robert Singer, MD, 36

Arthur B. Warshawsky, MD, 36

Robert E. Brucker, MD, 35

James E. Bush, MD, 35

Stewart L. Frank, MD, 35

Daniel Gardner, MD, 35

David P. Hansen, MD, 35

Gary L. Isley, MD, 35

Jerry Kolins, MD, 35

William P. Mann, MD, 35

Lawrence J. McCarthy, MD, 35

Rodrigo A. Muñoz, MD, 35

Thomas G. Neglia, MD, 35

Robert C. Pace, MD, 35

Barry M. Scher, MD, 35

Larry N. Ayers, MD, 34

John Randolph Backman, MD, FACC, FACP, FACSM, 34

Lawrence D. Eisenhauer, MD, 34

Athanasios J. Foster, MD, 34

Paul M. Goldfarb, MD, 34

Roy Alan Kaplan, MD, 34

Charles R. Kossman, MD, 34

Arthur C. Perry, MD, 34

Michael J. Rensink, MD, 34

Jeffrey A. Sandler, MD, 34

Lance L. Altenau, MD, 33

Clyde H. Beck, MD, 33

David C. Campbell, MD 33

William T. Chapman, MD, 33

Richard G. Friedman, MD, 33

Paul M. Goodman, MD, 33

Andrew G. Israel, MD, 33

Charles Jablecki, MD, 33

Marc J. Lebovits, MD, 33

Dom Antonio LopezVelez, MD, 33

Jeffrey B. Mazin, MD, 33

Jose E. Otero, MD, 33

Steven R. Ruderman, MD, 33

Michael J. Thoene, MD, 33

Bernard J. Urlaub, MD, 33

Raymond M. Vance, MD, 33

SAN DI EGO PHYSICIAN.org 9

Organized Medicine

Who Needs AMA?

by James T. Hay, MD, Robert E. Hertzka, MD, Albert Ray, MD, Lisa S. Miller, MD

The majority of U.S. physicians aren’t members and apparently ask that question. At times, so do many of us who are members and who are active in the organization itself. We don’t always agree with each other and we don’t always agree with the conclusions, but we decide collectively rather than letting someone else decide for us. Nonmembers let others decide for them. The recent November meeting of AMA’s House of Delegates (HOD), which prompted this article, produced few things that would make the headlines or stimulate nonmembers to join. But the overwhelming need for physicians to be united on the things that matter to us and to our patients creates an absolute requirement for an organization that speaks for all physicians. Let’s look at why.

Legislative AMA still is the voice of medicine for Congress and the White House. Our specialty societies represent our more parochial interests and professional needs, but only 10 jan uary 2013

AMA speaks for the entire profession. Every legislator knows that. When we differ on policy or turf issues, everyone loses. When we speak with one voice, we don’t always win, but our chances improve substantially. While the SGR cliff is infuriating evidence of Congress’ inability to resolve serious fiscal issues, the fact that we haven’t fallen of that cliff yet is certainly due to the extremely strong objection Our AMA raises every year. The delay in implementation of ICD-10 is also to AMA’s credit and for now saves each of us not only the hassle of that transition, but also its significant cost.

Adopted at this HOD was a report with extensive policy to strengthen Medicare for current and future generations, and for which AMA will now be advocating on Capitol Hill. It outlined the provisions necessary for Medicare to transition to a “defined contribution” instead of a defined benefit plan as it is currently structured and whose rising cost has the potential to bankrupt the country. Those provisions include, among others:

1. Enabling beneficiaries to purchase insurance from a wide variety of plans all subject to appropriate oversight and regulation.

2. Preserving traditional Medicare as one of the options.

3. Requiring participating plans to meet guaranteed issue and renewability requirements and prohibit cancellation except in the case of outright fraud.

4. Applying risk adjustment to the defined contribution to be sure the older and sicker can afford them. And adjusting the contributions annually based on the true changes in the cost of healthcare.

5. Requiring the baseline defined contribution to be the cost of traditional Medicare.

Also adopted at this meeting were California resolutions to (1) “decouple” Social Security recipients from the mandate to participate in Medicare — in other words, to give those who wish to stay with their own health plan the right to do so; (2) outlaw “Pay for Delay” policies that many pharmaceutical companies use to keep their branded, more expensive drugs from competition by generic companies; and (3) oppose general CMS audits of E&M codes without due cause. All these are issues we want Our AMA to “win” for us, and should matter to each and every doctor in the country.

Legal AMA has an extensive and powerful legal team that goes into action when needed.

California need look no further than the story at San Buenaventura Hospital, where a new CEO sought to impose hospital bylaws and hospital-chosen physician leadership on an unwilling medical staff. CMA asked AMA’s legal team to assist in the fight, and together we not only reversed this outrageous assault on self-governance, but followed up with passage of a California law now guaranteeing medical staff self-governance by statute. That fight was won in large part due to the intersession of Our AMA. More recently, AMA partnered with two state societies in a successful lawsuit settled for a $350 million return to the physicians who were systematically underpaid for their out-of-network services by United’s use of its Ingenix coding software. And just this past December, Aetna, which used the same United-owned Ingenix software, settled a similar lawsuit by AMA and several other state societies and will be returning $120

million to physicians, including those of us in California. Perhaps even more importantly, United has ceased its use of Ingenix, and AMA continues in its lawsuit to see that Aetna does likewise.

Political Not only does AMA, through its PAC, engage in political campaigns to assist candidates who believe physicians are part of the solution instead of part of the problem (Bob Hertzka’s favorite criteria), but they also conduct a campaign management school and one for candidates themselves to help physicians and their family members prepare to enter public office. It is no small feat that there are now 17 physician members of the House of Representatives, and three physician senators.

Networking Rank-and-file physicians don’t care how any part of organized medicine does its work, I’m sure, including whether we have a house of delegates or councils or committees. We care about the results — specifically, about how well they make physicians’ lives better and help doctors help their patients. All of organized medicine should be judged by those criteria.

However, effectiveness is totally dependent on who is represented and if they have a voice in the process. Meetings like the HOD allow us to hear what is happening elsewhere in the country and what others have done to be successful in their states or specialties. Since all specialties and all states are represented at AMA, it can be said that nearly all doctors belong to one or another of the components that come together there.

However, if a physician isn’t participating, his or her voice is lost to the discussion. Objecting to the direction Our AMA has taken used as an excuse to not belong merely cedes the battlefield to the enemy.

So in these very difficult times, “Who needs the AMA?” Every American physician and every one of those physicians’ patients. That’s who.

Contact Us, Participate Your AMA delegates and alternates want to hear from you: • Dr. Hay: jthay@ncfmg.com • Dr. Hertzka: bob@hertzka.com • Dr. Ray: albert.x.ray@kp.org • Dr. Miller: (858) 467-1899.

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SAN DI EGO PHYSICIAN.org 11

Poetry and Medicine

Early Morning Awakening The hum of the cars on the freeway Old love songs that play in my head The voices of friends and of family The words of those living and dead.

Remnants of dreams on my pillows Yesterday’s pains in my bones Smoke from my conscience that billows For sins I have yet to atone.

Early Morning Awakenings

by Daniel J. Bressler, MD

Dream interpretation goes back into the mists of history. Shamans (the original healers) drew part of their power from their firsthand knowledge of the spirit world where dreams were said to be born. Sigmund Freud’s theory of dreams was an essential part of his division of the mind into the ego, id, and superego. Dreams were the venue where the primitive id could symbolically express the impulses and urges that would be unacceptable to the ego and superego during ordinary (Victorian) waking experience. Along with Freud, many dream interpreters have sought a reliable system of translation of dream symbols. A basement means one thing; a bird something else; your mother’s hairbrush a third. Such specific mapping of dream symbols to psychologic issues has never been scientifically validated but continues to play out as a theme in the popular imagination, from The Wizard of Oz to No Country for Old Men. Dreams have always fascinated me.

At times, I’ve kept “dream journals” by the bedside, doing my best to capture the fleeting images before the day begins in earnest. My own dreams are frequently amusing and sometimes 12 jan uary 2013

startling. My own working theory holds that, although dreams are typically just a mishmash of the waking life’s events, they occasionally reach beyond the mundane, and, like great art, invite one to accompany them on a journey of insight and integration.

Most of my working hours as a primary care physician involve the practical facts of human biology: blood pressure, electrolytes, skin lesions, rashes, etc. The power of medical science derives in large part from its huge collection of reliable facts that allow for the predictable therapeutic alteration of pathologic processes.

Perhaps, in dreams, my mind seeks a kind of balance to the logic and predictability of medical science by presenting me with absurdity, novelty, and provocation.

Tomorrow morning before jumping out of bed, why don’t you too spend a moment and see if your dreams might have brought you a gift.

Dr. Bressler, SDCMS-CMA member since 1988, is chair of the Biomedical Ethics Committee at Scripps Mercy Hospital and longtime contributing writer to San Diego Physician.

My dog’s curled up in the corner He sleeps more contented than I And wakes not a sheik nor a mourner But the same hound who lay down last night That’s so unlike me who’s astonished When my dreams drop me off on the shore Sometimes lauded and sometimes admonished At what happened behind slumber’s door A prince adored by his minions A scoundrel of character foul A writer of startling opinions Or a fiend with a permanent scowl.

A farmer cut down by a fever A crow that transmutes to a horse A maiden whose lover deceives her A prisoner’s futile discourse These phantasms give no instructions Though I used to believe that they might Explain life’s puzzling constructions Loose knots that the daytime ties tight They’re not grandiose or important To anyone other than me They don’t steer the world’s comportment Or reveal what the future might be.

Yet these chapters are more than amusing More than just residued scenes Though seemingly weird and confusing They ask me to find what they mean They’re clues from my personal riddle There’s news scattered in with the muck They’re tunes from my unconscious fiddle Whose strings I must tune and then pluck.

So tonight when I lie down to doze off I’ll swim in the darkness beneath And explore what my shadow side knows of And wake up with pearls in my teeth.

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Healthcare Reform

Covered California California’s Health Insurance Exchange

by Sherry L. Franklin, MD, President, SDCMS

14 Jan uary 2013

President Obama’s reelection Nov. 6 pushed aside the final obstacle in a year filled with uncertainty about federal healthcare reform in California and across the country. With the adoption of the Affordable Care Act (ACA), federal law now dictates that a health insurance exchange (HIEx), either developed by the state or the federal government, must be fully certified and operational in each state by Oct. 1, 2013. California was one of the first to begin laying the groundwork, long before the Supreme Court made its decision.

The California Healthcare Exchange, now officially known as Covered California, will be the primary individual health insurance marketplace in California when the individual mandate of the ACA takes effect in just over a year. Beginning in October 2013, uninsured individuals (through the individual exchange) and small businesses with fewer than 50 employees (through the Small Business Health Options Program or SHOP) will be able to purchase health insurance using tax subsidies and credits. Initially, these tax credits will be provided by the federal government, but there is concern that this will then be shifted to the states.

The Exchange board is acting as an “active purchaser” for the state of California.

Most other states are acting as “passive purchasers.” The Exchange will set the package of benefits and will vet and negotiate directly with health insurers for the “best rates,” while assisting consumers and small businesses in selecting plans from five categories: platinum, gold, silver, bronze, and the “catastrophic plan,” which is limited to adults under age 30. Each plan is based on its cost and the level of benefits provided. Insurers must offer “essential health benefits,” a comprehensive set of services that would be covered in a typical health plan provided by an employer. Other states such as Utah have adopted the “passive purchaser”

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model, allowing an open marketplace (with a good analogy being priceline. com) of plans to compete to provide the most desirable product for the consumer.

It remains to be seen if an active purchasing model, passive purchasing model, or either will keep costs contained while still providing the level of care and access to physicians expected by Americans.

Physician networks or provider panels are being established by several plans in

Several states, including Oklahoma, Kansas, and Wisconsin, have refused thus far to create an exchange; if they continue down that road, the federal government will create exchanges for them.

The ACA assesses a tax on all health insurance companies based on their net premiums written, and many economists feel that new taxes on health insurance companies inevitably will translate to new costs passed along to physicians and hospitals. Large employers can self-insure, rather than pay premiums and file claims through a typical insurance provider, and are therefore not affected by the tax.

Most small-business owners do not have a large enough pool of employees to do this and must instead purchase health insurance in the fully insured market, where the costs the insurer has accrued are passed on to the customer in what is called “cost shifting.” Rep. Charles Boustany of Louisiana has introduced H.R. 1370, a bill that would repeal the health law’s tax on insurance plans.

The Exchange is governed by a fivemember board, appointed by the governor and the Legislature. Currently, four out of five of the board members were appointed by the Schwarzenegger administration. By law, the board is explicitly prohibited from having physicians play a role on the board.

Considering the ACA and the creation of the HIX is the most significant overhaul to the U.S. healthcare system since 1965, and that by 2016 when many employers are expected to drop coverage for their employees thus leaving most coverage in California in the Exchange, it is conceivable that Governor Brown may wish to have some of his own people involved in what is now and will likely forever be identified as Covered California.

It remains to be seen if an active purchasing model, passive purchasing model, or either will keep costs contained while still providing the level of care and access to physicians expected by Americans. order to demonstrate that such access will exist, but the results of the plans’ proposals to reimburse at significant discounts to current commercial rates may impede the development of adequate networks for patients in the Exchange. It has been clear that the Exchange board has not been receptive to physician testimony concerning even current adequacy of physician networks with private plans. In order to assure adequate physician networks, contract revisions will likely contain provisions requiring participation in their exchange product in order to continue participating in their other, non-exchange products.

Consumers will be able to interact with the Exchange through the Internet, by telephone, and by submitting paper applications through the mail. The Exchange will begin enrolling applicants next fall in order to have coverage available for each on Jan. 1, 2014.

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Physician-Patient Communications

As the New Year begins, we often consider how we want our life to be different — and we vow to make it that way. Unfortunately, those well-intentioned ideas rarely serve to change anything, especially our sense of being able to follow through on our resolutions! As Patterson et al discuss in Change Anything: the New Science of Personal Success, change doesn’t happen by accident.

Just as we helped ourselves succeed during medical school with a quiet place to study, friends who understood our time demands, and probably lots of coffee, we need to consider what will help us have success in other changes we want to make.

Patterson’s group Both motivation gave two groups and ability played a of children $40 to exchange for candy role in the children’s or toys, or to save for spending patterns. something special.

The first group, exposed to people who encouraged them to buy, spent 68% of their earnings. The second group, encouraged to save, spent only 15%. Both motivation and ability played a role in the children’s spending patterns, and the researchers defined six sources of influence that can make or break our attempts to change:

New Year’s Resolutions, Anyone?

by Helane Fronek, MD, FACP, FACPh

18 Jan uary 2013

Personal Motivation: Clearly formulate your motivation for seeking your goal: How will your life be different once you achieve this? Each time you have an impulse to give up on your plan, reconnect with your motivation. Place visual cues of your goal in locations where you will see them.

Personal Ability: Changing old ways of doing things always requires that we learn new skills. If you want to become more organized, a class on using your new electronic calendar system might be useful. If your goal is to save for a vacation, a discussion

with your investment counselor can identify an appropriate savings vehicle.

Social Motivation: As Patterson says, “Bad habits are almost always a social disease.”

Get your friends, colleagues, and family on your side. Tell them what you intend to do and why, and ask for their support and encouragement.

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Social Ability: Changing something that’s been a habit is easier when we get help — a trainer, coach, or mentor can be invaluable as you establish a new way of doing things.

Structural Motivation: Create a set of short-term goals, with tangible rewards as you achieve them and penalties if you fall short. Perhaps you treat yourself to a movie once you’ve read the journals that have been sitting on your desk, or you have to donate $100 to a charity that supports a cause you abhor if you don’t.

Structural ability: Adjust your environment to make it easier for you to succeed. If you want to exercise regularly, join a gym that’s on your way home from work or put exercise equipment in front of the TV. Change is not easy — for anyone. Many people throw up their hands as they fail and lament, “I guess I just don’t have much willpower.” But as Patterson’s group clearly proves, willpower is not all it’s cracked up to be. By structuring the six sources of influence, you just might find yourself successful in changing almost anything.

Dr. Fronek, SDCMS-CMA member since 2010, is a certified physician development coach, certified professional co-active coach, and assistant clinical professor of medicine at the UCSan Diego School of Medicine. You can read her blog at helanefronekmd.wordpress.com.

“think SDCMS FIRST!” Start by contacting SDCMS at (858) 565-8888 or at SDCMS@SDCMS.org.

SAN DI EGO PHYSICIAN.org 19

Healthcare Abroad

UCSD School of Medicine in Mozambique

The Maputo Teaching Stethoscope Project

by Farhana Ali, MSII, Robert Schooley, MD, and Carolyn Kelly, MD

20 jan uary 2013

In 2007, the UCSD School of Medicine forged a partnership with Mozambique’s national university, Universidade Eduardo Mondlane (UEM), in efforts to address the nation’s severe shortage of well-trained physicians. The UCSD/Maputo partnership is supported under the Medical Education Partnership Initiative (MEPI), a funded program sustained by the collaborative efforts of the Office of the U.S. Global AIDS Coordinator and the National Institutes of Health (NIH). MEPI aids institutions in subSaharan Africa by enhancing their models of medical education and building clinical and research capacity as part of an effort to retain well-trained physicians in locations where they are most needed. Located in Mozambique’s capital, Maputo, the medical school at UEM graduates 125 students per year, similar to the size of the UCSD School of Medicine. However, Mozambique’s 1,000

Photo courtesy of Farhana Ali (2); Photo courtesy of Robert Schooley, MD

Making rounds at Maputo Central Hospital .

Inset: The exterior of Maputo Central Hospital .

Right: Medical students in Maputo, Mozambique.

Stethoscopes Needed!

Dear SDCMS Members,

physicians serve a population of 12 million citizens; this compares to 98,000 physicians for the 37 million people of California.

Every month, internal medicine residents from UCSD are sent to Maputo to engage in a four-week rotation of clinical and research opportunities. During their rotation, UCSD residents work alongside Mozambican residents, medical students, and faculty associated with the Maputo Central Hospital, which serves as Mozambique’s only academic teaching hospital.

In the summer of 2012, two secondyear medical students from UCSD had the opportunity to work for two months on clinical research projects at Maputo Central Hospital under the supervision of Robert Schooley, MD, chief of the Division of Infectious Disease at the UCSD School of Medicine. During the course of that work, one of the UCSD students, Farhana Ali, recognized an important need for better stethoscopes for the Mozambican medical students.

Upon return to the UCSD School of Medicine in the fall of 2012, she put together a proposal to raise funds to purchase a teaching set of stethoscopes for the Mozambican students. Below please find a letter from Farhana to the membership of the San Diego County Medical Society outlining the project and how you can help.

Ms. Ali, SDCMS-CMA member since 2013, is a second-year medical student at UCSD. Dr. Schooley, SDCMS-CMA member since 2013, is professor and head of the Division of Infectious Diseases at the UCSD School of Medicine. Dr. Kelly, SDCMS-CMA member since 2007, is professor of medicine at the UCSD School of Medicine.

While shadowing alongside our UCSD residents in Maputo’s wards, I could see that the Mozambican medical students were examining patients with sub-standard stethoscopes that made it difficult to listen to heart and lung sounds properly. Our residents realized the students were reporting lung and heart findings that they couldn’t possibly have heard themselves. When we pointed at their stethoscopes and asked how they knew, the medical students confessed that they had borrowed the resident’s stethoscope in order to do the physical exam. After speaking further with the Mozambican residents and medical students, we learned that many medical students cannot afford the nicer stethoscopes that all the residents have. These are more expensive in Mozambique than in the U.S. because of high shipping costs and limited availability. Instead, the medical students try to purchase nicer stethoscopes during their final (sixth) year of med school as they prepare to work in the districts, but by this time they are working under less well-supervised circumstances and have missed out on five years of mentored supervision with adequate equipment as a medical student. After becoming aware of their situation, I became invested in addressing this disadvantage faced by Mozambican medical students. With the support of our UCSD faculty attending physician who resides in Maputo, Dr. Susannah Graves, we formulated the idea to raise funds to buy new, inexpensive yet efficacious stethoscopes that can be used by Mozambican medical students for teaching purposes.

Our goal is to purchase 170 new, single-colored stethoscopes in efforts to appear as a uniform set that can be used for years to come.

These stethoscopes are inexpensively priced (~$20 each) yet comparable in quality to the standard stethoscopes used by the residents.

They would remain on the medicine wards and would be lent out daily for use. With a set of new, functional stethoscopes, there is great opportunity for teaching and learning by all parties, both the rotating UCSD residents and the Mozambican students. This will ultimately empower the Mozambican students and help prepare them to be competent physicians. $20 buys one stethoscope, $200 buys 10, and $560 buys enough for one medicine ward! If you are interested in donating to this cause, checks can be made to “UC Regents” and sent to: Maputo Teaching Stethoscope Fund, c/o Farhana Ali, MS 2 1 Miramar Street, #929173 La Jolla, CA 92092 Please write “Maputo Teaching Stethoscope Fund” on your check.Your donations are tax deductible. Please include your return address and we will send you a receipt for your tax purposes.

Thank you for your time and consideration.

With warm regards, Farhana Ali, MSII

SAN DI EGO PHYSICIAN.org 21

Federal Healthcare Reform

Countdown

to 2014 An Interview With Robert Hertzka, MD, on the Patient Protection and Affordable Care Act

22 jan uary 2013

T

his is the third in an annual series of interviews about the Affordable Care Act (ACA) that San Diego Physician has conducted with California Medical Association Past President Robert E. Hertzka, MD. Dr. Hertzka’s commitment to expanding access to healthcare goes back two decades, and includes the fact that he made addressing that issue a major priority of his 2004–05 CMA presidency. Under his leadership, CMA adopted an innovative approach to solving the problem of the medically uninsured that would have decreased the number of uninsured in the United States by 50% without raising taxes.

Much of what is in the ACA ran counter to that proposal, as well as to other bipartisan proposals, so much so that Dr. Hertzka became — and remains — quite concerned about how well the ACA will or will not work. As we begin 2013, we are checking in once again.

San Diego Physician (SDP): Since we last talked one year ago, the Supreme Court has upheld the core provisions of the Affordable Care Act, or ACA — now referred to by all sides as Obamacare. And the November 2012 reelection of President Obama now means that Obamacare is going full steam ahead. There will be mandates on individuals, viewed as an act of taxation by the Supreme Court, hundreds of billions in subsidies flowing through Health Insurance Exchanges (HIEs), and even more hundreds of billions in taxes and Medicare cuts to pay for all of this. Do you

still view all of these things as negative developments for the healthcare system?

Robert E. Hertzka, MD: As you state the question, not necessarily, and in fact I actually support all of those provisions in concept. If structured properly, strong tax incentives to drive individuals to obtain health insurance can work just fine, properly structured HIEs can allow individuals to have the purchasing power of a group, expanding access by subsidizing either government programs or health insurance will in fact require revenue, and getting a handle on Medicare spending is imperative for the program to survive. At a conceptual level, people understood most if not all of these things, and so, in the end, President Obama’s rhetoric on healthcare probably worked in favor of his getting reelected.

My issues with the ACA remain separate and apart from its basic goals, which remain meritorious. My problem — and in fact the problem that many analysts from across the political spectrum have — is that as written, the ACA may well do more harm than good.

The issues that we discussed last year, including the substantial Medicaid expansion, the weakness of the individual mandate, the potential price control power of the HIEs, and the underlying funding mechanisms of the ACA — which will actually bend the so-called “cost curve” up rather than down — all remain as problematic as ever.

Taken collectively, they still seem likely to destabilize what

is already a troubled healthcare system.

SDP: Not to rehash all of what we discussed last year, but can you remind us about what you perceive to be the problems with the Medicaid expansion?

Dr. Hertzka: There remain three indisputable problems, and nothing has changed about that since all of the studies that I cited a year ago.

First of all, the number of new Medicaid enrollees (Medi-Cal in California) that will arise from the ACA still appears to be significantly underestimated. Second, payment rates for physicians are still abysmal, and that is particularly true in California, where both the Obama administration and now the federal courts have just upheld a 10% decrease in what were already among the lowest reimbursement rates in the nation. And third, nothing has been done to address access to physicians, particularly specialty physicians, which remains abysmal and will likely further decline with additional threatened cuts, particularly here in California, just as millions of additional patients are handed Medicaid cards and seek care.

Put those three problems together, and one can predict with confidence that precious few of these new patients will actually have doctors to see them. This will likely result in a sustained surge of new emergency room visits — at a time where ERs nationwide are closing, and for those that remain, maintaining on-call panels is already a struggle.

The likely surge in Medicaid

SAN DI EGO PHYSICIAN.org 23

patients going to or being sent to the ER for specialty care may overwhelm those on-call panels and thus destabilize ER care all around the country.

SDP: But isn’t the federal government picking up the full cost of the ACA Medicaid expansion?

Dr. Hertzka: Just for the first couple of years, and then it phases down to a 90–10% match, with no guarantee that it will stay at 90%. But even with that, the feds do not pick up any of the administrative costs that the states will be facing, which look like they may be substantial. And as to the feds’ maintaining that 90% match level, it was amazing to see that during the 2011 federal “debt ceiling” negotiations, the Obama administration was already offering to decrease the 90–10% match rate to 80–20% as a proposed federal spending reduction. To me, this foreshadows what is to come when the actual costs of the Medicaid expansion inevitably exceed the current projections. When that happens, look for Washington to do what it does best, which will be to dump more and more of these costs on to the states. No less than California’s own Governor Brown voiced this concern just a few weeks ago.

SDP: But didn’t the Supreme Court limit the extent of the Medicaid expansion in their ruling last June?

Dr. Hertzka: Not exactly. By a 7–2 margin, including liberal justices Elena Kagan and Stephen Breyer, the Court found that the Medicaid expansion “exceeded Congress’s power” and so repealed it as a state

24 Jan uary 2013

mandate, instead leaving it as an option for the states to choose to either “opt in” or “opt out.”

This actually seemed wise, and so as of last fall, while most if not all “red states” looked like they would “opt out,” most “blue states,” including California, seemed inclined to go ahead and try at least a partial expansion of what had been struck down. As you may recall, that “excessive” ACA mandate was a blanket expansion of Medicaid to at least 20 million adults whose incomes fall below 138% of the federal poverty level (FPL), which is currently about $15,500/year in income for an individual, $21,000 for a couple, and $32,000 for a family of four.

SDP: Just starting out with a “partial” expansion seems reasonable.

Dr. Hertzka: It was reasonable, to the point where many ACA critics felt much better about its implementation. But five weeks after the election, the Obama administration decreed that there will be no partial Medicaid expansions — states will either be all-in or all-out. So at this point, just 14 states, including California, will opt in to the full Medicaid expansion, and 14 other states definitely will not. The remaining 22 states continue to be at some level of consideration about it, but, with the “all-or-none” decree, I suspect that most of those 22 will be inclined to take a pass on the expansion.

SDP: Why would any of these states even take the risk of what will likely be a major future funding burden?

Dr. Hertzka: I can cite at least two reasons. One is that there has been and will continue to be huge pressure from the hospital lobby in every state that is considering “opting out” of the Medicaid expansion. And that is because the ACA dramatically reduced what are called Disproportionate Share Funds (DSH), which are designed to assist hospitals with high rates of Medicaid and uninsured patients. From the hospital’s point of view, the patients will still be coming in the door, but with fewer federal dollars to support them. The states, on the other hand, see many billions of dollars of obligations in their near-future budgets and so want to steer clear of that obligation. Some of these state legislative battles figure to be epic.

The second is that the establishment left is all-in for pushing the Medicaid expansion.

Whether it is the various liberal federal or state think tanks or the left-of-center editorial boards like that of our own Los Angeles Times, there are loud voices out there that scream that this is all “free” in 2014.

Well, hundreds of billions of federal dollars are never actually “free,” and any responsible person looking to evaluate this expansion should be looking long term to 2016 and beyond, when the costs to a state like California will hardly be free; rather, they will be in the multiple billions of dollars.

SDP: What about the Health Insurance Exchanges (HIEs)? Last year you were concerned that two years would not be enough time for the states to put these entities together. Now, with a start date of October 2013, we are literally months away. How is it looking?

Dr. Hertzka: We know that a majority of the states believe that they will have so little control over what happens in their state exchange that they are letting the federal government set it up — and pay for it themselves — while only a minority are trying to do it on their own.

In those states that will have 100% federally run exchanges, we are nine months out and we still do not really know how they will operate. And frankly, even in California, where an appointed board has been working nonstop since the fall of 2010 to get our exchange working, there are still more questions than answers about how it will operate, and even who will participate.

Remember, these exchanges are, without question, the single biggest regulatory undertaking in history. Among other things, health plans will be micromanaged at an unprecedented level, while benefit levels will need to be decided, and subsidies must be allocated on a sliding scale based on family income up until 400% FPL — currently about $45,000 for an individual, $60,000 for a couple, and $92,000 for a family of four. This latter act is not trivial: Every person who obtains insurance through the exchanges will qualify for their own personal subsidy based not just on their income, but on that of the family income.

How are the state workers at the exchange supposed to be able to solicit, track, and verify family income data on 6 to 8 million individuals?

SDP: So what do you see as the biggest problem with the exchanges?

Dr. Hertzka: At the most basic

level, it is that it is just too big of an undertaking for the government to handle. Consider what happened recently over one of the simplest provisions of the ACA: that primary care services under any ACA-related Medicaid expansion would be paid at Medicare rates in 2013 and 2014. This has been known since March of 2010, and with repeal impossible before Jan. 1, 2013, this provision was always a done deal.

Well, it turns out that despite 33 months of notice, California’s state workers will not be able to implement that increase for another six months or so. If something that simple cannot be handled in 33 months, how can 50 state bureaucracies be ready in just nine months to organize an entire health insurance system for tens of millions, including, again, the processing of federal subsidies that will be different for each and every individual?

SDP: But can’t all the programmatic issues with the HIEs be resolved?

Dr. Hertzka: In theory, of course they can, given enough time and effort, but not before disrupting the healthcare of tens of millions of patients, let alone hundreds of thousands of physician practices.

But what cannot be overcome with “better bureaucrats” is the underlying model of some exchanges — California’s in particular — that will have a very high level of mandated benefits while trying to regulate and limit premiums.

Ask someone like CMA Immediate Past President Jim Hay, MD, and he will tell you that under the California HIE, which will have some of the most generous benefits



The substantial Medicaid expansion, the weakness of the individual mandate, the potential price control power of the HIEs, and the underlying funding mechanisms of the ACA — which will actually bend the so-called “cost curve” up rather than down — all remain as problematic as ever.

in the country along with some of the tightest controls on insurance premiums, a provider payment squeeze is inevitable. If you promise great benefits to patients but only allow insurers to collect below-market payments, the only way this works is to turn the reimbursement levels for physicians, hospitals, and others into what Dr. Hay refers to as “Medi-Cal Lite.”

SDP: Wow, not good. I remember how you have been describing the ACA as a 2014 “brick” covered in tasty 2011 insurance reform frosting — all of which was being promoted as a cake.

I guess that you still think the analogy holds.

Dr. Hertzka: Sadly, yes. And the shame is that it did not have to be designed this badly or funded this poorly. But the sad history of how politics overcame policy on this, or of all the legislative shenanigans that went on with it, is no longer important — what we all have to do now is strategize to how to survive it.

SDP: You mention funding, which is what we wanted to bring up next. However poorly these provisions may be designed, the federal government will need money to fund the Medicaid expansion, whether at a 100% match, a 90% match, or even less. And they will certainly also need funds to subsidize the cost of insurance for all those in the exchanges. Sounds like quite a bit of federal money.

Dr. Hertzka: Yes, the funding issue. The original projection of cost for both the Medicaid expansion and the subsidies for the exchanges was about $1 trillion over the first 10

years. The best current estimates for cost are now actually more like $2 trillion, but let’s put that aside for now. Even if one accepts the $1 trillion cost figure, the sources of that $1 trillion to support both the Medicaid expansion and the subsidies for the exchanges have been problematic all along.

SDP: How so? Why are they problematic?

Dr. Hertzka: Well, half of that $1 trillion is supposed to come from Medicare cuts so extreme that no one actually thinks they will happen, but they are in the law and so the Congressional Budget Office “scores” them as occurring. To give you an idea, the ACA projects that physician reimbursements will drop 30% this year or next because the “doc fix” will no longer happen, and after that, physician reimbursements will drop another 40% by the end of the decade — to sub-Medicaid rates. The ACA also includes $400 billion in new cuts to hospitals over the next decade on the basis of unprecedented and to-bedetermined “efficiencies.”

When the independent Medicare actuary reviewed these numbers in 2010, he found them so preposterous that for the first time in history he has begun issuing an annual “alternative scenario” to the annual Medicare Trustees Report, in which he made the wise presumption that future Congresses would never let such things happen. Among other things, he projected that if the ACA rolled out as written, that at least 15% of all full-service hospitals would have to refuse Medicare patients or else go bankrupt.

SAN DI EGO PHYSICIAN.org 25

Now we know that Congress is terrified of angry senior citizen voters, so they will not let physician payments under Medicare drop below Medicaid rates, and thus give Medicare patients sub-Medicaid access. And they will also not let hospital payments under Medicare drop to where 15% — or more — of hospitals close their doors to Medicare patients. So right out of the gate half of the projected funding in the ACA is almost all phantom money, created by budgetary sleightof-hand. This money simply does not exist.

SDP: What about the other half of projected ACA funding?

Dr. Hertzka: That $500 billion comes from new taxes, many of which started on Jan. 1 of this year. Unfortunately, some of those are also problematic because they violate a simple principle — which is that healthcare access expansions should be funded by taxes that do not get cost-shifted back into health insurance premiums. A simple example of something that works is to tax tobacco and alcohol. Such a tax raises revenue, and, as an economic result, sellers of tobacco and alcohol have lower profits. Their obvious response to that is to raise prices, but that price increase only affects smokers and drinkers — it does nothing to the overall cost of healthcare.

By contrast, if one taxes medical products, devices, or services, making a manufacturer or provider less profitable such that they raise prices, in healthcare that means that they demand more from insurers. When that happens, it means higher premiums for

26 Jan uary 2013



If you promise great benefits to patients but only allow insurers to collect below-market payments, the only way this works is to turn the reimbursement levels for physicians, hospitals, and others into what Dr. Hay refers to as “Medi-Cal Lite.”

all of us, the end result being that the entire cost of healthcare goes up.

In healthcare, the biggest current cost-shift in the entire system — at well over $150 billion per year — is the overall underpayment of Medicare, which in the aggregate, again per the Medicare actuary, currently pays about 80% of commercial contract rates.

This is despite the fact that, overall, Medicare patients are more challenging and consume more provider time and resources than commercial patients. So even before we mention any other funding source, the dramatic reductions in Medicare reimbursements mandated by the ACA will have a major additional cost-shifting effect, as physicians, hospitals, and others try to recoup those Medicare losses by cost-shifting even more to private patients, and thus driving up health insurance premiums.

The next biggest cost-shift we deal with today — another $100 billion or so per year — is the overall underpayment of Medicaid, which in the aggregate, again per the Medicare actuary, currently pays about 58% of commercial contract rates. So, obviously, the substantial increase in deeply underfunded Medicaid patients will be another source of even more cost-shifting, as once again, just like with Medicare, physicians, hospitals, and others try to recoup those Medicaid losses by cost-shifting even more to private patients, and thus further driving up health insurance premiums.

Now over on the tax side, about half of the $500 billion raised is from a new 0.9% increase in the payroll tax on all income over $200,000, and a

new 3.8% “payroll tax” on all investment income for those with incomes over $200,000.

But the majority of the other $250 billion comes from taxation of pharma products, medical devices, and insurance premiums themselves.

Starting in 2014, the health insurance companies will pay an “industry tax” of $8 billion per year, which rapidly escalates to $14 billion by 2017 and rises with premium inflation in perpetuity.

Now I am no fan of health insurers; rather, I have spent many a day tangling with their representatives in one legislative hearing after another on behalf of CMA. But while we are often on opposite sides of policy issues, I am also aware that health insurer profit margins run at a consistent 4–6% level, well below that of most hospitals and of most pharmaceutical companies.

If we tax them $14 billion per year, that $14 billion will find its way back into the premium structure, period. In fact, this past November, a study from the group Oliver Wyman concluded that the tax on health insurers alone could raise family premiums by more than $7,000 over the next 10 years.

So here is the big irony.

If back in 2009, President Obama had put together a task force and directed them to develop a health access funding plan designed to make health insurance premiums as high as possible, that group would have had to struggle to match the job that the ACA did: a vast expansion of an underfunded Medicaid program, deep cuts in an already underfunded Medicare program, and hundreds of billions in direct health industry taxation. And this does not even

mention what we discussed at some length last year, which is that the weakness of the individual mandate will mean that many millions of healthy people will decline to obtain insurance and thus make insurance even more expensive for everyone else.

And yet the ACA stands for Affordable Care Act. So much for the claim of ACA proponents that its provisions will “bend the cost curve down.”

SDP: Can any of this be fixed?

Dr. Hertzka: Hard to imagine.

Many governors will refuse the Medicaid dollars, which should be better financially in the long run for their states as a whole, but will be a real hit on some of their hospitals.

“Fixing” that would require repeal of the Medicaid expansion and restoration of the DSH funding, which the Senate is unlikely to pass and the president would never sign.

The Medicare cuts are largely fiction, but every attempt will be made to make them stick to help pay for the ACA, so no repeal there. And while some of the industry taxation, such as that on medical devices, is even opposed by many Democrats, this president seems quite unlikely to sign any repeal of any of those.

Finally, as to the conundrum of a weak mandate combined with limited subsidies to help people buy benefitladen insurance, there is no way that Congress will pass stronger penalties, as the mandate remains the least popular part of the bill. And with a GOP House, there is no way that taxes will be increased even further to increase the subsidies.

This “weak mandate” issue

is so prominent that health insurers are currently pleading with the feds to impose some kind of “mandate plus” rules, such as strictly limiting enrollment periods or some kind of late enrollment penalties. But I don’t see the feds doing any kind of “punishment” that would be unpopular with the general public.

So right now, this bill is here to stay — as is.

SDP: This has been, once again, quite a bit of information to absorb. Is there a way to simplify your concerns so that the average person can understand?

Dr. Hertzka: Yes, there is a tremendous amount of information to be digested when one is talking about the ACA — it is, after all, well over 2,000 pages of legislative text. One way to simplify it is to just look at it through the eyes of those most affected, including the currently uninsured, as well as the employers who currently may or may not offer coverage.

What I have brought are two charts that each list five scenarios: one chart for the currently uninsured individual who will soon have the “benefits” of the ACA, and another for employers who now face new mandates and/ or fines as a result of the ACA. Each scenario for individuals represents the situation of literally millions of Americans, and each one for employers represents the situation of literally thousands of businesses.

SDP: Let’s look at the chart for individuals first — we will call it Figure 1 in the article.

Dr. Hertzka: What Figure 1 shows is the situation at five

different income levels for an uninsured individual aged 27 and up. No longer eligible for their parent’s policy, they represent the vast majority of the currently uninsured — and two-thirds of them are under the age of 40. For rounding purposes, I have used $11,000 as the federal poverty level (FPL).

At each income level, there is a specific penalty to be paid if one does not obtain health insurance. The second column of Figure 1 shows the full 2.5% of income penalty, which takes effect in 2016, after being just 1% of income in 2014 and then 2% in 2015.

The third and fourth columns are what one will pay for a subsidized policy, and what the out-of-pocket maximums are. The cost for the “mandated” policy is on a sliding scale, starting at just 2% of income for those at 100% FPL, rising to 9.5% at 400% FPL. The out-of-pocket maximums rise with income as well, and are actually quite substantial, considering the resources that lower income individuals have.

Finally, the fifth and final column is a best guess of the likely decision that the majority of each category of income will make, based on their penalty, their cost of insurance, plus out-of-pocket maximums. Remember that, under the ACA, anyone can obtain insurance at any time, even if one does so only after discovering that they will have healthcare needs. All of this plays into what someone is likely to do.

I would also note that when one is above 400% FPL, there are no subsidies available, and so there are also no penalties for remaining uninsured.

And due to the massive levels of cost-shifting from the ACA that I discussed earlier, unsubsidized insurance costs will be far higher than any levels seen today. In the end, for those over 400% FPL, they will have guaranteed access to insurance that does not discriminate against them for preexisting conditions and such, but, for most people, what will be available will likely be much less affordable than the options available today.

The ones who will really be shocked will be those in their late 20s, because the ACA takes away much of their advantage of being younger.

The cost to insure a 64-yearold is about seven times that of a 27-year-old, which is very consistent with their predicted healthcare utilization. But as one of a laundry list of gifts to the AARP, the ACA restricts this so-called “age banding” to 3:1, which will, per a study this month in a journal published by the American Academy of Actuaries, increase the cost of a young person’s policy by 42%. The National Association of State Insurance Commissioners has officially labeled this phenomenon “rate shock” — and I could not agree more.

SDP: Why are the individuals at 250% and 400% FPL listed as possibly paying no penalty? I thought that you just said that all those up to 400% FPL have to pay penalties?

Dr. Hertzka: Good observation.

Yes, the ACA is clear in that all those below 400% FPL are supposed to pay a penalty. But the ACA also states that there will be a blanket exemption from any penalty for anyone

SAN DI EGO PHYSICIAN.org 27

for whom the lowest cost plan available exceeds 8% of their income. Given that the best deal out there may well be the subsidized plans in the exchange, and given that those at 250% FPL will need to pay 8.05% of their income to obtain that policy, it becomes clear that penalties may not apply to the many millions of individuals between 250% and 400% FPL. SDP: So what are the bottom lines of Figure 1?

Dr. Hertzka: As one looks at the income levels, by 2016 most of those at the 100% FPL level would be expected to become insured, either through Medicaid — if available in their state — or by buying a policy that actually costs less than their penalty.

By the time that you get to 200% FPL, the situation is less clear. Will people making only $22,000 per year pay nearly $1,400 a year for a policy that has co-pays and deductibles that could reach nearly $3,000? The penalty for noncompliance in 2014 is only 1% of income, or $220, and will never exceed $550.

Given those numbers, and given that one can still obtain insurance at any time, I would see this group as one where the majority may not purchase insurance. They may even underreport income so as to obtain Medicaid coverage if they are in a state where that is an option.

For the 250% FPL and 400% situations, as I just discussed, there will in fact be no penalties, but the insurance policy costs will be much higher than those in the lower income groups. I see these many millions of people as unlikely to

28 Jan uary 2013

buy insurance.

Finally, for those above 400% FPL, they are out there in the unsubsidized insurance world, where costs may be prohibitively high. In fact, I would look for those with incomes only slightly above 400% FPL to underreport their income so that they can at least have the protection of a 9.5% of income limit on the cost of a policy.

All in all, a substantial number of people, particularly young and healthy people, will actually not obtain insurance despite somewhat substantial subsidies from an HIE. SDP: What about the employer situations?

Dr. Hertzka: They are simpler to explain than the scenarios

for individuals, but in the end no more encouraging. Each line represents a different size of employer. The first column lists the number of employees, the second column the penalty for not providing insurance, and the third column lists the approximate cost of providing health insurance.

Note that employers do not receive subsidies and cannot

Scenarios

Figure 1: Single Individual (age > 26) Annual Income

Cost of Penalty (2.5% income)*

Cost of Subsidized Policy in HIE

Out-of-pocket Maximum

$11,000 (100% FPL)

$275

$220 (2% of income)

$1,964

Sign up for Medicaid if available; otherwise, will buy insurance.

$22,000 (200%)

$550

$1,386 (6.3%)

$2,975

May not buy insurance; incentive to under-report income if Medicaid available.

$27,500 (250%)

$688**

$2,214 (8.05%)

$2,975

Unlikely to buy insurance.

$44,000 (400%)

$1,100**

$4,180 (9.5%)

$3,987

Unlikely to buy insurance.

$45,000 (409%)

NONE

No subsidy — pay full cost (Could be as high as $10,000)

Market Rate

Unlikely to buy insurance; may try to lower income.

Likely Decision***

*Penalties in 2014 and 2015 are only 1% and 2% of income respectively. The 2.5% figure is for 2016 and beyond. **The ACA waives all penalties if the lowest cost available insurance costs more than 8% of income, so many of those above 250% FPL may in fact have no penalties. ***The decision is whether to buy insurance in the HIE that will have premiums and out-of-pocket levels that low-income individuals may find excessive.

Figure 2: Employers # Employees

Cost of Penalty to Drop Cost to or Not Provide Coverage Insure**

45

None

$225,000– $450,000

Not offer coverage / send to HIE ***; keep workforce < 50.

55

$50,000 (25 x $2000)*

$275,000– $550,000

Not offer coverage / send to HIE ***; reduce workforce to < 50.

75

$90,000 (45 x $2000)*

$375,000– $750,000

Not offer coverage / send to HIE ***; try to reduce full-time workforce to < 50.

100

$140,000 (70 x $2000)*

$500,000– $1,000,000

Not offer coverage / send to HIE ***; try to reduce full-time workforce to < 50.

1,000

$2,000,000

$5,000,000– $10,000,000

If medium to high-wage, probably offer coverage If low-wage, may instead send employees to HIE *** All will look to increase sub-30 hours/week workforce

Likely Decision

*Penalties are $2,000 per employee but only apply to businesses over 50 employees (first 30 exempted), and do not include those working < 30 hours/week.

Note: Penalties are not deductible as a business expense. **Very conservative assumption that insurance costs per employee post-ACA are only $5,000–$10,000 per employee, despite all of the effects of ACA cost-shifting and despite the fact that dependent coverage is also mandated ***Workers below 400% FPL will have access to HIE subsidies, but workers above 400% FPL will be paying market rates for insurance that will reflect all of the ACA cost-shifting.

utilize the HIEs. The fourth and final column lists the “likely decision” of the majority of that size of employer. Sadly, in all situations it is a much better deal financially for employers to not provide health insurance, whether those are employers who are dropping the coverage they provide or employers who are already not providing coverage.

And, in addition to that, the ACA gives strong incentives to employers with approximately 50 full-time workers to make sure that they keep their full-time workforce below 50, whether that means laying off a few people or not hiring a few extra people. And, for employers of any size, the financial incentives are also strong to

convert as much of one’s workforce as possible to part-time.

And finally, I would add that the workforces that will be converted to part time are not just factory workers and retail clerks — The Wall Street Journal just ran a story about how tens of thousands of adjunct professors at colleges and universities around the nation are being converted to sub-30 hour per week status as we speak.

SDP: Final comments?

Dr. Hertzka: As time goes on, I feel stronger by the day that the ACA will harm far more people than it may help.

Aside from the programmatic problems with the Medicaid expansion and the rush to

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create 50 state HIE bureaucracies, and beyond the funding streams that are both inadequate and problematic, the incentives to individuals are to not buy insurance — even with a mandate in place — and the incentives to businesses are to not hire, to convert their current workers to part-time, and to drop whatever coverage that they currently offer.

None of this is good — it looks like we will have a very troubling couple of years.

Frankly, my only solace is that, at least in California, I know that CMA’s officers and CMA’s staff are as informed about this as any physicians and any association staff in the nation, and hopefully they will be able to mitigate some of the damage, at least in California.



The incentives to individuals are to not buy insurance — even with a mandate in place — and the incentives to businesses are to not hire, to convert their current workers to part time, and to drop whatever coverage that they currently offer.

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SAN DI EGO PHYSICIAN.org 29

in

Memoriam

David Knetzer 1936â&#x20AC;&#x201C;2012 R e t i r e d M e d i c a l S oc i e t y C E O

30 jan uary 2013

O

ur friend and former executive director of the San Diego County Medical Society, David Knetzer, passed away on May 26, 2012.

David, born Oct. 15, 1936, was a native of Marion, Indiana, and graduated with a degree in mechanical engineering from Purdue University in 1958. He joined Sandia Corporation at the Lawrence Radiation Laboratory in Livermore, California, but took military leave from 1960 to 1963 to serve in the U.S. Army at Sandia Base, New Mexico, where he was awarded the Army Commendation Medal.

In 1965, David joined Blue Cross in Oakland, California, serving as computer operations liaison between Blue Cross and the State of California on Medi-Cal programs. In 1974, he became the assistant executive director of the San Mateo County Medical Society and assumed his duties as executive director of the San Diego County Medical Society in 1979, retiring in 2001.

David was president of the San Diego Blood Bank in 1985–1986, chaired the California Medical Executives Conference in 1987–1988, served on the board of directors of United Way/ CHAD, served on the board of directors and executive committee of the American Lung Association from 1994 to 2000, and served on the executive committee of the California Medical Association Political Action Committee from 1985 to 1993. He was a Paul Harris Fellow in Rotary International, a member of the San Diego Automotive Museum, and the San Diego Antique Motorcycle Club. After retirement, David found great pleasure in volunteering at the Air and Space Museum in Balboa Park, continuing his genealogical studies, and riding his BMW classic motorcycle.

Surviving family are his wife, Leean, and daughters Shoshana Socher of University Heights, Ohio, and Sarah Davis of Woodland Hills, California; also, grandchildren Naomi, Anna, Jacob, Daniel, Dalia, and Bayla Socher, and Sophia and Lily Davis; great-grandchild Rutie Sanders was born just a week before David passed away.

David was both a humble man and competent manager. All of those who worked with him felt rewarded by his friendship. He was a role model for the injunction by the prophet, Micah: “He has showed you, O man, what is good. And what does the LORD require of you? To act justly and to love mercy and to walk humbly with your God.” (Micah 6:8)

His Memory Will Always Be With Me

I

am very sad to read of the “passing” of David Knetzer. He was the executive director of the San Diego County Medical Society at a time when I was more active in the leadership of the Medical Society. With his guidance, the San Diego County Medical Society became a very important part of physicians’ practice of medicine. Under his leadership we maintained an excellent physical plant, had many important programs, and generated many of the medical leaders of San Diego. SDCMS attracted most of the outstanding physicians to membership and exerted a strong voice from San Diego to the California Medical Association.

Please extend my sympathy to his family and friends. The memory of David Knetzer will always be with me in the future. — Allan H. Goodman, MD

The David Knetzer I Knew

I

t will come as no surprise to those who’ve been there that serving as SDCMS president can be a thankless job. Presiding over an organization comprised of more than 2,000 type-A, anxietyprone physicians can quickly come to resemble a “Complaint Department” as members take out their various practice-related frustrations on the most convenient target: their president. Well aware of this potentially discouraging phenomenon, David Knetzer, executive director of the San Diego County Medical Society for more than 20 years, made it his business to go out of his way to protect his presidents by providing them with constant positive reinforcement and reassurance that they were doing a good job even when many others disagreed.

By so doing, he saw to it that presidents operated out of a sense of security and confidence so necessary during the tumultuous changes with which they all had to deal almost daily.

But what I remember and cherish most about David was something he did for me sometime after my term as president. A grievance had been filed against me by a patient who was unhappy about the care I provided her. She wrote to her insurance company and suggested that I be disenrolled from the provider panel for reasons that I no longer recall, but that were obviously powerful in her mind. I was subsequently summoned to attend a hearing at the insurer’s headquarters in Orange County. I was told that I would be entitled to bring a “character witness” if I wished. It was apparent that this was a serious matter with major potential ramifications for me. As was my custom as a past president, I stopped

by David’s office and happened to mention this worrisome matter and to see if he had any suggestions about whom I might bring with me to the hearing.

Without a moment’s hesitation, he volunteered to be my witness.

On the day of the hearing, he drove me to the site, spent several hours attending the hearing, and gave eloquent testimony on my behalf. To this day, I continue to believe that among the major reasons why I was “acquitted” of the charges against me was the manner in which David responded to questions about not just my competence as a physician, but why I was a person of insight, compassion, and integrity. It is not an overstatement to conclude that David’s selfless and caring act preserved the viability of my practice. The beauty of all this is that David would have done the same for any of his members who faced a crisis.

Those of us who had the privilege of knowing and working with David understand what a unique and caring person he was. He truly set the stage for the evolution of SDCMS as the powerful voice for San Diego physicians it is today.

— David Priver, MD, SDCMS President 1996–1997 SAN DI EGO PHYSICIAN.org 31

YOU HERO YOU ARE ARE OUR HERO thank youfor forgiving givingaccess accessto tohealthcare healthcare for those thank you those without! without!

San Diego County Medical Society Foundation’s Mission Is To Improve Health, Access San Diego County Medical Society Foundation’s Mission Is To Improve Health, Access To Care, And Wellness For Patients And Physicians Through Engaged Volunteerism.

To Care, And Wellness For Patients And Physicians Through Engaged Volunteerism.

You are the Heart & Soul of Project Access San Diego YouThrough are the Heart & Soul of Project Access San Diego your support of our flagship program, Project Access San Diego, we have

Through your to support our1,850 flagship program, Project San to Diego, we have been able assist of over uninsured adults in ourAccess community improve their been able to assist over 1,850 uninsured adults in our community to improve health through access to specialty healthcare services. You have provided their over health through access to specialty healthcare services.

You have provided $5.8 million in contributed healthcare services to community members sinceover our $5.8 million beginnings in contributed healthcare services to community members since our program’s in December 2008! program’s beginnings in December 2008!

Thanks to more than 625 volunteer physicians providing specialty healthcare services Thanks to more volunteer physicians providing specialty healthcare to those whothan most625 need our help, we are getting people back to work, andservices able to care for their families. to those who most need our help, we are getting people back to work, and able to care for their families.

Without the generous support and dedication of all of our physician volunteers, hospitals outpatient surgery imaging, labs, therapy,volunteers, and other Without the and generous support andcenters, dedication of all of physical our physician ancillary health providers, hundreds of hard-working but uninsured adults would go hospitals and outpatient surgery centers, imaging, labs, physical therapy, and other without care every year.

Thank you for being a hero to our community! ancillary health providers, hundreds of hard-working but uninsured adults would go

without care every year. Thank you for being a hero to our community!

Get Involved

Diego County Medical Society Foundation needs you! Join us to volunteer for GetSan Involved

Project Access, or provide specialty consultations to primary care physician colleagues San Diego County Medical Society Foundation needs you! Join us to volunteer for through eConsultSD, our HIPAA-compliant, web-based system from the comfort of Project Access, or provide specialty consultations to primary care physician colleagues your home or office. Attend an event, assist us to recruit fellow physicians, or provide through eConsultSD, our HIPAA-compliant, web-based system from the comfort of educational opportunities for primary care physicians or medical students. Our first your home or office. Attend an event, assist us to recruit fellow physicians, or provide annual Golf Tournament is scheduled for Thursday, February 28, 2013 at Del Mar educational opportunities for primary care physicians or medical students. Our first Country Club; we hope you can join us! To register or for more information, go to annual Golf Tournament is scheduled for Thursday, February 28, 2013 at Del Mar sdcmsf.org/golf.

Please consider making a contribution to SDCMS Foundation to Country Club; we hope you can join us!

To register or for more information, go to support our efforts at www.sdcmsf.org, or call us at 858.300.2777. sdcmsf.org/golf. Please consider making a contribution to SDCMS Foundation to support our efforts at www.sdcmsf.org, or call us at 858.300.2777.

5575 Ruffin Road, Suite 250, San Diego, California 92123 p: 858.300.2777 f: 858.569.1334 n

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5575 Ruffin Road, Suite 250, San Diego, California 92123 p: 858.300.2777 f: 858.569.1334 n

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classifieds PRACTICE ANNOUNCEMENTS NEW DERMATOLOGY PRACTICE: Board-certified dermatologist and dermatopathologist, Heidi Gilchrist, MD, practices medical dermatology for all age groups. She offers same-day and next-day appointments, including Saturdays, and accepts all major insurance plans. Dr. Gilchrist emphasizes a holistic and integrated approach to skin health and disease prevention, and she is open to patients who prefer natural or alternative approaches.

She specializes in individualized care and spends at least as much time listening as she does talking. Cosmetic services are also available upon request. 345 Saxony Road, Suite 201, Encinitas, CA 92024; office (760) 230-2537; fax (760) 230-5386; gilchristdermatology.com; info@ gilchristdermatology.com. [100] PRACTICE FOR SALE INTERNAL MEDICINE PRACTICE FOR SALE: Established practice for 20 years; solid stable patient base.

Clairemont area. Recently remodeled office space. Gross $550K per year. Call for details: (858) 344-2591. [102] PHYSICIAN POSITIONS AVAILABLE Pediatric Physician — North County Health Services, Oceanside: Full-time lead pediatrician position in FQHC community health center. Please email your CV to Araceli Mercado at araceli.mercado@nchshealth.org or fax to (760) 736-8740. [108] UNIQUE OPPORTUNITY: ONE LIFE, a San Diego-based medical weight loss company, is seeking highly qualified physicians or nurse practitioners to apply for the position of Medical Director. The ideal candidate is one who possesses a high level of social skills, is adept at building relationships quickly, enjoys the role of teaching, and has the ability to balance efficiency with an unhurried personal approach. The position offers the opportunity to truly change people’s lives. The work is incredibly fulfilling and the patients are highly appreciative. The position requires no call, no hospital coverage, no night shifts, and no holiday hours. Please send your CV to HR@ OneLifeDiet.com. [107a] PHYSICIAN OR NURSE PRACTITIONER: Physician or nurse practitioner to perform housecalls in North San Diego County Monday thru Friday. 10-12 patients per day.

Please forward CV. Full time. Excellent time management skills required. Pager one week per month, no hospital rounds. Established patient base. Independent contractor position with great income potential. NP’s-home health experience a plus. Please respond by email only to mobiledoctor@sbcglobal.net. Thank you. [106a] INTERNAL MEDICINE OR FAMILY MEDICINE PHYSICIAN — RAMONA: North County Health Services is looking for family medicine or internal medicine physician.

Work-life balanced hours, include occasional Saturdays (shared with other clinicians). Compensation including bonus for call and incentive. Benefit program includes PTO, holidays, malpractice, and reimbursement for CMEs (expense and time). This is an opportunity to make a difference in the lives of patients who are under-insured or do not have insurance coverage. Please send CV to A. Mercado at araceli.mercado@nchs-health.org or fax to (760) 736-8740. [105] FULL-TIME FAMILY MEDICINE PHYSICIAN: The San Diego American Indian Health Center is seeking a BC/ BE full-time family medicine physician for an ambulatory care clinic. Clinic hours are Monday through Friday, 8:00am to 5:00pm. Light telephone call. No hospital duties. No weekends. Malpractice covered. Benefits. Disclaimer: Preference is given to qualified American Indian applicants in accordance with the Indian Preference Act of 1934 (Title 25, USC Section 472). Please email CV to Natalie Cadena at natalie.cadena@sdaihc.com. [904] MID-CAREER PEDIATRICIAN: Great opportunity for a mid-career pediatrician with kind manner and strong entrepreneurial spirit to work FT/PT in small solo progres-

sive practice. This position is a partnership track. Night call is minimal but must be willing to work some Saturdays and one evening/week to help grow the practice.

Space available to expand. Nice mix of parents in great school area. Salary DOE. Nice, stable office staff with EMR. Send CV to cvp315@sbcglobal.net. [057] THREE CONTRACT PHYSICIANS: Profil Institute for Clinical Research is looking for three clinical contract physicians. Requirements: One year of clinical experience in adult medicine and/or equivalent + unrestricted California MD license. Research experience not necessary. Responsibilities: Perform medical histories, physical exams, admit, discharge, and monitor subjects, including reviewing labs results, EKGs and telemetry as part of clinical research trials. Weekend shift hours (Saturday) + occasional weekday shift. Interested parties please apply online at www.profilinstitute.com under “Career Opportunities” — search for position under “Contract Physician,” and apply to the job online. [097] CHIEF, MATERNAL AND CHILD HEALTH: The County of San Diego Health and Human Services Agency is seeking a qualified medical doctor to fill the position of chief, Maternal, Child, and Family Health Services (MCFHS) branch. The chief is responsible for the management and administration of public health programs that improve the health of mothers, children, and their families. For more information on the position, including minimum requirements and how to apply, please visit www.sdcounty. ca.gov. [092] ADULT PSYCHIATRIST — PART TIME: The County of San Diego’s Health and Human Services Agency is seeking a psychiatrist for 10-hour weekdays, part-time shifts for adult outpatient clinic work. Our psychiatrists work with a dynamic team of medical and nursing professionals to provide outpatient treatment, telepsychiatry, inpatient and emergency services, and crisis intervention.

More information about psychiatrist positions can be found at www.sdcounty.ca.gov/hr. Interested candidates may contact Lita Santos at (619) 563-2782 or email a CV to lita.santos@sdcounty.ca.gov. [091] ADULT PSYCHIATRISTS: County of San Diego’s Health & Human Services Agency seeks FT/PT psychiatrists for key components in the Behavioral Health Division’s continuum of care. Our psychiatrists work with a dynamic team of medical and nursing professionals to provide outpatient treatment, telepsychiatry, inpatient and emergency services, and crisis intervention. More information about psychiatrist positions can be found at www. sdcounty.ca.gov/hr. Interested candidates can contact Gloria Brown at (858) 505-6525 or email CV and cover letter to gloria.brown@sdcounty.ca.gov, and Marshall Lewis, MD, Behavioral Health clinical director, at marshall.lewis@sdcounty.ca.gov. Please specify clinical area of interest. [090] FAMILY PRACTICE PHYSICIAN: For a busy federally qualified health center. MHCS (www.mtnhealth.org) is a mission-driven organization that serves both rural and urban residents of San Diego County. We have been in business for over 35 years and offer a competitive salary, medical benefits, vacation, paid holidays, sick time, malpractice, life, AD&D, long-term disability, long-term care, monthly incentive, CME / license reimbursement, plus a sign-on bonus. Board certified and bilingual English/ Spanish preferred. Send CV to tfindahl@mtnhealth.org or (619) 478-9164. You may contact HR directly at (619) 478-5254, ext 30. [089] SENIOR PHYSICIAN: The County of San Diego, Health and Human Services Agency’s HIV/STD/Hepatitis clinic has an immediate opening for a licensed physician with at least three (3) years of recent post-internship training or experience in internal medicine or as a general practitioner to manage a team responsible for planning and directing clinic services. Must be available to work flexible schedules at multiple sites, including some evenings is expected. Please read more about the senior physician job description, benefits, and application process at www. sdcounty.ca.gov/hr. Please include a copy of your CV

along with your online application. For questions, please contact Gloria Brown, human resources analyst, at (858) 505-6525 or at gloria.brown@sdcounty.ca.gov. [088] PHYSICIAN TO STAFF VARIOUS SAN DIEGO DETENTION FACILITIES: The Department of Emergency Medicine (http://emergencymed.ucsd.edu) at UC San Diego, committed to academic excellence and diversity within the faculty, staff, and student body, is initiating a search for a physician to staff various San Diego detention facilities. The applicant must have a background in family medicine, internal medicine, or emergency medicine and be eligible for a California medical license. Appointment level in the academic series will be commensurate with experience and qualifications, with salary based upon established UCSD salary scale. UCSD is an affirmative action / equal opportunity employer with a strong institutional commitment to excellence through diversity. Interested individuals should send their CV, a reference list, and separate statement summarizing their experience to mcarey@ucsd.edu. [087] PHYSICIAN AND PSYCHIATRIST NEEDED FOR AMBULATORY CLINIC: Southern Indian Health Council is seeking a FT board-certified physician Mon–Fri, 8:00am– 4:30pm, as well as a PT psychiatrist. Must have current CA medical license, DEA license, ACLS, BLS. We offer a competitive salary, health benefits, vacation, holidays, sick, CME and license reimburse, and malpractice coverage. Forward resume to jobs@sihc.org or fax to (619) 6593145 or website at www.sihc.org. Contact jobs@sihc.org or HR phone (619) 445-1188, ext. 308 or ext. 307. [048] OPPORTUNITY KNOCKS FOR BC/BE DERMATOLOGISTS: Live in one of the country’s most desirable locations and practice with a premier San Diego multispecialty medical group! Sharp Rees-Stealy Medical Group is looking for BC/BE dermatologists. Competitive first-year compensation guarantee, excellent benefits, and shareholder eligibility after two years. Unique opportunity for professional and personal fulfillment while living in a vacation destination. Please send CV to Physician Services, 2001 Fourth Avenue, San Diego, CA 92101. Fax: (619) 2334730. Email: Lori.Miller@sharp.com. [084] SUPERB INTERNAL MEDICINE PRACTICE OPPORTUNITY: The position is available in August of 2013.

You will be joining one of the premier internal medicine groups in North County San Diego. No hospital work or ER call. Competitive salary including benefits plus the opportunity to begin a partnership track if desired. Beautiful office building, excellent staff, ideal for either first year in practice or for an experienced practitioner. Contact Jon LeLevier, MD, at (760) 310-2237 or Jeff Leach, MD, at (760) 846-0464 for more information. [081] FAMILY HEALTH CENTERS OF SAN DIEGO: JOIN OUR FAMILY! As we continue to grow, we currently have great career opportunities for: Family Practice Physicians; Internal Medicine Physicians; Internal Medicine / Pediatric Physicians. With 33 locations that include 13 clinics and growing, we offer a wide variety of flexible career choices for you to select from as well as a positive work environment, grateful patients, and a competitive salary and excellent comprehensive benefits packages. To talk to someone directly about provider careers at Family Health Centers of San Diego, please contact our Recruitment Supervisor, Anna Marie Jameson, at (619) 906-4591 or at ajameson@fhcsd.org. [046] PRIMARY CARE JOB OPPORTUNITY: Home Physicians (www.thehousecalldocs.com ) is a fast-growing group of house-call doctors. Great pay ($140–$220+K), flexible hours, choose your own days (full or part time).

No ER call or inpatient duties required. Transportation and personal assistant provided. Call Chris Hunt, MD, at (858) 279-1212 or email CV to hpmg11@yahoo.com. [037] PHYSICIANS WANTED: Vista Community Clinic, a private, nonprofit clinic serving the communities of North San Diego County, has openings for part-time and perdiem positions. Five locations in Vista and Oceanside.

Family medicine, OB/GYN medicine, pediatric medicine.

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.

34 jan uary 2013

Requirements: California license, DEA license, CPR, board certified, one (1) year post-graduate clinic experience. Bilingual English/Spanish preferred. Benefits: malpractice coverage. Email resume to hr@vistacommunityclinic.org or fax to (760) 414-3702. Visit website at www.vistacommunityclinic.org. EOE/M/F/D/V [035] SEEKING BOARD-CERTIFIED PEDIATRICIAN FOR PERMANENT FOUR-DAYS-PER-WEEK POSITION: Private practice in La Mesa seeks pediatrician four days per week on partnership track. Modern office setting with a reputation for outstanding patient satisfaction and retention for over 15 years. A dedicated triage and education nurse takes routine patient calls off your hands, and team of eight staff provides attentive support allowing you to focus on direct, quality patient care. Clinic is 24–28 patients per eight-hour day, 1-in-3 call is minimal, rounding on newborns, and occasional admission, NO delivery standby or rushing out in the night. Benefits include tailcovered liability insurance, paid holidays/vacation/sick time, professional dues, health and dental insurance, uniforms, CME, budgets, disability and life insurance. Please contact Venk at (619) 504-5830 or at venk@gpeds. sdcoxmail.com. Salary $ 102–108,000 annually (equal to $130–135,000 full-time). [778]

includes a fish pond. The available space (approximately 1200 sf) consists of 3 large exam rooms, medical assistant/lab area, office and a shared waiting area. Other half of space is occupied by a family physician. Rent is 2.50/sf and includes all utilities (electricity, internet, phone, security, water). Available 1/2/2013. Contact: santeemedicaloffice@yahoo.com. [099] 3998 VISTA WAY, IN OCEANSIDE: Four medical office spaces approximately 1,300–2,800 square feet available for lease. Close proximity to Tri-City Hospital with pedestrian walkway connected to parking lot of hospital, and ground-floor access. Lease price: $1.55+NNN. Tenant improvement allowance to customize the suites is available. For further information, please contact Lucia Shamshoian at (760) 931-1134 or at shamshoian@coveycommercial.com. [096] SPACE FOR SUBLEASE IN POOLE BUILDING ON SCRIPPS MEMORIAL LA JOLLA CAMPUS: Office on entry level facing main hospital, which is 50 yards away — BEST location on campus. Own consultation room and two shared exam rooms available at least two full days a week. Equipped for minor surgery / procedures. Receptionist and medical assistant help can be provided. Call Ilana at (858) 558-2272 for details. [085]

PRACTICE WANTED WE BUY URGENT CARE OR READY MED-CLINIC: We are interested in purchasing a preexisting urgent care or ready med-clinic anywhere in San Diego County. Please contact Lyda at (619) 417-9766. [008] OFFICE SPACE / REAL ESTATE FOR SALE: APPROXIMATELY 8,345 SF OFFICE BUILDING CLOSE TO HOSPITALS: Near Rady Children’s and Sharp Hospital. Right off Ruffin Road and Aero Drive intersection. Zoned medical. Standalone, single-story building. High-end, attractive property. LEED Certified Gold Commercial Interiors (CI). Neighboring medical tenants in business park. With 10% down OWN FOR LESS than rent. Call Melissa Foster at CBRE at (858) 546-4658 or email her at melissa.foster@cbre.com for more information. [103] LUXURIOUS / BEAUTIFULLY DECORATED DOCTOR’S OFFICE NEXT TO SHARP HOSPITAL FOR SUBLEASE OR FULL LEASE: The office is conveniently located just at the opening of Highway 163 and Genesee Avenue. Lease price if very reasonable and appropriate for ENT, plastic surgeons, OB/GYN, psychologists, research laboratories, etc. Please contact Mia at (858) 2798111 or at (619) 823-8111. Thank you. [836] SCRIPPS XIMED MEDICAL CENTER BUILDING, LA JOLLA: Office Space to sublease occupied by vascular and general surgeons. One room consult office available, with one or two exam rooms, to a physician or team. Located on the campus of Scripps Memorial Hospital, XiMed Building is the office space location of choice for anyone doing surgeries at the hospital or seeking a presence in the La Jolla area. Reception and staff available if needed.

Full ultrasound lab onsite in office for anyone interested in this service. For more information, call Irene at (619) 840-2400 or at (858) 452-0306. [101] MEDICAL OFFICE SPACE FOR LEASE: Medical office space of 1,846 square feet located at 15721 Pomerado Road, Poway, CA 92064 in the Gateway Medical Center available for immediate lease. This recently remodeled facility has a shared waiting room, medical records storage area, front desk reception area, three exam rooms, nursing station, private office, shared bathroom. The larger space is shared with an internal medicine group and is blocks away from Pomerado Hospital. Imaging is located in an adjacent building. The lease rate is $1.69/SF NNN with a 3% annual increase. The NNNs are currently running $0.73/SF. Tenant will be responsible for pro rata share of utilities and janitorial in addition to NNNs. Great opportunity in this affluent community. Call Angie at (858) 605-9966. [065] MEDICAL OFFICE SPACE IN SANTEE: Beautiful calming space in an office/business park located adjacent to a major shopping center in Santee. Newer building (2007), and recently remodeled into a premier medical office. Plenty of free parking, and nice outside courtyard

NORTH COAST OFFICE SPACE TO SUBLEASE: North Coast Health Center, 477 El Camino Real, Encinitas, office space to sublease. Newly remodeled and beautiful office space available at the 477/D Building. Occupied by seasoned vascular and general surgeons. Great window views and location with all new equipment and furniture.

New hardwood floors and exam tables. Full ultrasound lab and tech on site for extra convenience. Will sublease partial suite for two exam rooms and office work area or will consider subleasing the entire suite, totally furnished, if there is a larger group. Plenty of free parking. For more information, call Irene at (619) 840-2400 or at (858) 4520306. [041] FULL- AND PART-TIME OFFICE SPACE IN UTC: in 8th floor suite with established neuropsychologists and psychiatrists in Class A office building. Features include private entrance, staff room with kitchen facilities, active professional collegiality and informal consultation, private restroom, spacious penthouse exercise gym, storage closet with private lock in each office, soundproofing, common waiting room and parking. Contact Christine Saroian, MD, at (619) 682-6912. [862] 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 — EXTREMELY LOW RENTAL RATE INCENTIVE — EASTLAKE / RANCHO DEL REY: Two office/medical spaces for lease. From 1,004 to 1,381 SF available. (Adjacent to shared X-ray room.) This building’s rental rate is marketed at $1.70/SF + NNN; however, landlord now offering firstyear incentive of $0.50/SF + NNN for qualified tenants and five-year term. $2.00/SF tenant improvement allowance available. Well parked and well kept garden courtyard professional building with lush landscaping. Desirable location near major thoroughfares and walkable retail amenities.

Please contact listing agents Joshua Smith, ECP Commercial, at (619) 442-9200, ext. 102. [006] POWAY / RANCHO BERNARDO — OFFICE FOR SUBLEASE: Spacious, beautiful, newly renovated, 1,467 sqft furnished suite, on the ground floor, next to main entrance, in a busy class A medical building (Gateway), next to Pomerado Hospital, with three exam rooms, fourth large doctor’s office. Ample parking. Lab and radiology onsite. Ideal sublease / satellite location, flexible days of the week. Contact Nerin at the office at (858) 521-0806 or at mzarei@cox.net. [873] SHARE OFFICE SPACE IN LA MESA: Available immediately. 1,400 square feet available to an additional doctor on Grossmont Hospital Campus. 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]

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] SHARE OFFICE SPACE IN LA MESA JUST OFF OF LA MESA BLVD: 2 exam rooms and one minor OR room with potential to share other exam rooms in building.

Medicare certified ambulatory surgery center next door.

Minutes from Sharp Grossmont Hospital. Very reasonable rent. Please email KLewis@SDCMS.org for more information. [867] NONPHYSICIAN POSITIONS AVAILABLE UNIQUE OPPORTUNITY: ONE LIFE, a San Diego-based medical weight loss company, is seeking highly qualified physicians or nurse practitioners to apply for the position of Medical Director. The ideal candidate is one who possesses a high level of social skills, is adept at building relationships quickly, enjoys the role of teaching, and has the ability to balance efficiency with an unhurried personal approach. The position offers the opportunity to truly change people’s lives. The work is incredibly fulfilling and the patients are highly appreciative. The position requires no call, no hospital coverage, no night shifts, and no holiday hours. Please send your CV to HR@ OneLifeDiet.com. [107b] PHYSICIAN OR NURSE PRACTITIONER: Physician or nurse practitioner to perform housecalls in North San Diego County Monday thru Friday. 10-12 patients per day.

Please forward CV. Full time. Excellent time management skills required. Pager one week per month, no hospital rounds. Established patient base. Independent contractor position with great income potential. NP’s-home health experience a plus. Please respond by email only to mobiledoctor@sbcglobal.net. Thank you. [106b] NURSE PRACTITIONER OR PHYSICIAN’S ASSISTANT: Established, busy pain management practice in Mission Valley is looking for a nurse practitioner or physician’s assistant, preferably experienced in pain management or family practice. Knowledge of controlled substance prescriptions and regulations is required.

Interpretation of diagnostic tests and the ability to apply skills involved in interdisciplinary pain management is necessary. We offer a competitive salary and benefit package that provides malpractice coverage, CME allowance, as well as an excellent professional growth potential. Please email your curriculum vitae/resume to sdpainclinc@yahoo.com. [094] MEDICAL ASSISTANT: Internal medicine practice looking to fill a full-time position for a busy internist in Poway.

Position requires five-plus years experience in internal medicine, good communication skills, compassion toward seniors, electronic health record exposure a plus. Strong references. Please fax your resume to practice manager at (858) 618-5976. [086] PHYSICIAN ASSISTANT OR NURSE PRACTITIONER: Needed for house-call physician in Coachella Valley (Palm Springs / Palm Desert). Part time, flexible days/hours.

Competitive compensation. Call (619) 992-5330. [038] Medical Equipment ELECTRONIC TOUCH SCREEN MEDICAL CHECK IN SYSTEM FOR SALE: Eliminate staff interruptions and increase your office efficiency with this easy-touch patient sign-in kiosk in your waiting room. The average signin time for patients with a Medical Check In touch-screen kiosk takes fewer than 10 seconds. With this reduction in interruptions and the clear, organized communication of patient information to your receptionist’s computer, Medical Check In will reduce the time for the patient sign in process, reduce congestion for your reception area and save you money. Compatible with all electronic health records. Still under warranty. Cost for new Medical Check In is $2,500. Great price for this at $995. For more information please see medicalcheckin.com. Email KLewis@ SDCMS.org. [982]

SAN DI EGO PHYSICIAN.org 35

San Diego Physician Celebrates 100 Years!

The Bulletin of the San Diego County Medical Society February 20, 1920

In celebration of 100 years of publication of San Diego Physician (formerly known as The Bulletin), we will be reprinting throughout the year excerpts from past issues, and we will devote our December 2013 issue to recognizing the achievements of the official “Bulletin” of the San Diego County Medical Society. If you would like to contribute in any way to our December issue, please email Editor@SDCMS.org. Thank you!

the bulletin LAW YER S

CHALLENGE

DOCTOR S

STAT E OF CALIFOR NIA )

) as* County of San Diego ) *Short Stop KNOW ALL MEN BY THE SE PRES ENT S. That we, as you claim, but which we deny, the lineal descendants, off-spring and heirsat-law of that august body of disciples of Hippocrates, to-w it: The Physicians, Surge ons, Medicine Men, Specialists and other advance agents and friends of the undertakers, do by these presents call, invite, beg, challenge , implore, dare and defy the aforementione d aggregation, to meet us, the honored and respe cted followers of Hammurabi, Moses, Man u, Solomon, Justinian and Blackstone, to a nine inning game of the national pastime, more commonly know n as baseball, to be playe d in the City of San Diego, County of San Dieg o, State of California, but more particularly at the Stadium bowl, on the afternoon of Saturday, February 21st, 1920, at the hour of 2:30. And to that end we, by these presents firmly bind ourse lves, our heirs, exec utors, administrators and assigns to meet you at the time and place afore said.

Wherefore, you and each of you, are hereb y commanded all and singular (or plura l) business and bum excuses set aside, to appe ar before us properly uniformed, gloved and mask ed, to show cause, if any there be (which you know there is not) why you should not be releg ated in 36 jan uary 2013

baseball to the prehistoric age, where you admit (and we do not deny) you belong profe ssionally and otherwise. And herein fail not.

Done at the City of San Diego, State of California, the 6th day of February, A.D. 1920 ; A.L. 5920 and the 144th year of the Independ ence of the United States, and the 3rd year of the reign of Louis J. Wilde.

THE LAW YERS’ BASEBALL TEAM.

By EUGENE DAN EY, Jr.

Baseball Manager.

CASE RECORD

PATIENT’S NAME: The Lawyers’ Base ball Team of San Diego.

SYMPTOM ATOLOGY: First delusion appeared on Saturday, Feb. 2, 1919, when the patient had the nerve to challenge the Doctors’ team to a contest and insinuated that it was possible to beat the Doctors. Also, patie nt has show n suspicious of his neighbors and is always look ing for trouble. Furthermore, on sever al occasions he has been seen to gather with other lawyers and to whisper, as if contempl ating bodily harm.

DIAGNOSIS: GEN ERAL PARE SIS, with MEGALOMAN IA and DELUSIONS OF POW ER (PAR ANOIA, etc.).

TREATMENT: Operation, without anes thetic, at The Stadium on a date to be arran ged by the managers. (The operation will be a success but the patient will die.)

Manager,

Doctors’ Baseball Team.

We Celebrate Excellence – James Strebig, MD CAP member, internal medicine physician, and former President of the Orange County Medical Association.

800-252-7706 www.CAPphysicians.com San Diego orange LoS angeLeS PaLo aLTo SacramenTo

For 35 years, the Cooperative of American Physicians, Inc. (CAP) has provided California’s finest physicians, like Irvine internal medicine specialist James Strebig, MD, with superior medical professional liability protection through its Mutual Protection Trust (MPT).

Physician owned and physician governed, CAP rewards excellence with remarkably low rates on medical professional liability coverage – up to 40 percent less than our competitors.

CAP members also enjoy a number of other valuable benefits, including comprehensive risk management programs, best-in-class legal defense, and a 24-hour CAP Cares physician hotline. And MPT is the nation’s only physician-owned medical professional liability provider rated A+ (Superior) by A.M. Best.

We invite you to join the more than 11,500 preferred California physicians already enjoying the benefits of CAP membership.

Superior Physicians. Superior Protection.

37

mayapril 2011 2012 SAN DIEGO P HY SICIA N. o rg 37 SAN DI EGO PHYSICIAN.org

$5.95 | www.SANDIEGOPHYSICIAN.org PRSRT STD U.S. POSTAGE PAID DENVER, CO PERMIT NO. 5377

San diego County Medical Society 5575 RUFFIN ROAD, SUITE 250 SAN DIEGO, CA 92123 [ RETURN SERVICE REQUESTED ]

We hate lawsuits. We loathe litigation. We help doctors head off claims at the pass. We track new treatments and analyze medical advances. We are the eyes in the back of your head. We make CME easy, free, and online. We do extra homework. We protect good medicine. We are your guardian angels. We are The Doctors Company.

Donald J. Palmisano, MD, JD, FACS Board of Governors, The Doctors Company Former President, American Medical Association

The Doctors Company is devoted to helping doctors avoid potential lawsuits. For us, this starts with patient safety. In fact, we have the largest Department of Patient Safety/Risk Management of any medical malpractice insurer. And, local physician advisory boards across the country. Why do we go this far? Because sometimes the best way to look out for the doctor is to start with the patient. The San Diego County Medical Society has exclusively endorsed our medical malpractice insurance program since 2005. To learn more about our program for SDCMS members, call us at (800) 852-8872 or visit www.thedoctors.com.

Endorsed by

www.thedoctors.com 38 jan uary 2013