June 2013

San Diego Physician

official publication of the san diego county medical society june 2013

100 celebrates

years

Micra attacks

Scope Expansions

Medi-Cal cuts

Corporate Bar challenges

“Physicians United For A Healthy San Diego�

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B

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Contents june

Volume 100, Number 6

MANAGING EDITOR: Kyle Lewis EDITORIAL BOARD: Theodore M. Mazer, MD, James Santiago Grisolía, MD, Robert E. Peters, PhD, MD, David M. Priver, MD, Van C. Johnson, MD, Roderick C. Rapier, MD MARKETING & PRODUCTION MANAGER: Jennifer Rohr SALES DIRECTOR: Dari Pebdani ART DIRECTOR: Lisa Williams COPY EDITOR: Adam Elder SDCMS BOARD OF DIRECTORS OFFICERS PRESIDENT: Robert E. Peters, PhD, MD PRESIDENT-ELECT: J. Steven Poceta, MD TREASURER: William T-C Tseng, MD, MPH (CMA Trustee) SECRETARY: Mihir Y. Parikh, MD IMMEDIATE PAST PRESIDENT: Sherry L. Franklin, MD (CMA Trustee)

departments

features

4 Briefly Noted: Calendar • Get in Touch • Commercial Real Estate Tips & Trends • And More …

20

8

22

HELANE FRONEK, MD, FACP, FACPH

Join the Fight to Protect Medicine Medical Injury Compensation Reform Act (MICRA) Attacks

26

Allied Health Professional Scope of Practice Expansions

30

The Richness of Diversity: Broadening Our Perspective

10

Questions From a Death Certificate

DANIEL J. BRESSLER, MD

12

Health Reform Heats Up

Medi-Cal Reimbursement Rate Cuts

CALIFORNIA MEDICAL ASSOCIATION

32

16

Bar to the Corporate Practice of Medicine Challenges

Act Now to Avoid Medicare Penalties in 2015

CALIFORNIA MEDICAL ASSOCIATION

18

Curmudgeon Redux

GEOGRAPHIC AND GEOGRAPHIC ALTERNATE DIRECTORS EAST COUNTY: Venu Prabaker, MD, Alexandra E. Page, MD, Jay P. Mongiardo, MD (A: Susan Kaweski, MD (CALPAC Treasurer)) HILLCREST: Gregory M. Balourdas, MD, Thomas C. Lian, MD (A: Sunny R. Richley, MD) KEARNY MESA: Jason P. Lujan, MD, John G. Lane, MD (A: Anthony E. Magit, MD, Sergio R. Flores, MD) LA JOLLA: Geva E. Mannor, MD, Wayne Sun, MD (A: Lawrence D. Goldberg, MD) NORTH COUNTY: James H. Schultz, MD, Eileen S. Natuzzi, MD, Michael A. Lobatz, MD (A: Anthony H. Sacks, MD) SOUTH BAY: Reno D. Tiangco, MD, Michael H. Verdolin, MD (A: Elizabeth Lozada-Pastorio, MD) AT-LARGE DIRECTORS Jeffrey O. Leach, MD (Delegation Chair), Karrar H. Ali, MD, Kosala Samarasinghe, MD, David E.J. Bazzo, MD, Mark W. Sornson, MD (Board Representative), Peter O. Raudaskoski, MD, Vimal Nanavati, MD (Board Representative), Suman Sinha, MD AT-LARGE ALTERNATE DIRECTORS Karl E. Steinberg, MD, Phil Kumar, MD, Holly B. Yang, MD, Perry N. Willette, MD, Samuel H. Wood, MD, Elaine J. Watkins, DO, Carl A. Powell, DO, Theresa L. Currier, MD OTHER VOTING MEMBERS COMMUNICATIONS CHAIR: Theodore M. Mazer, MD (CMA Vice Speaker) YOUNG PHYSICIAN DIRECTOR: Edwin S. Chen, MD RESIDENT PHYSICIAN DIRECTOR: Jane Bugea, MD RETIRED PHYSICIAN DIRECTOR: Rosemarie M. Johnson, MD MEDICAL STUDENT DIRECTOR: Jason W. Signorelli OTHER NONVOTING MEMBERS YOUNG PHYSICIAN ALTERNATE DIRECTOR: Renjit A. Sundharadas, MD RESIDENT PHYSICIAN ALTERNATE DIRECTOR: Erin Whitaker, 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 AMA ALTERNATE DELEGATE: Lisa S. Miller, MD

STEVEN BROZINSKY, MD, FACP, FACG

34

Physician Marketplace: Classifieds

36

8 2 j u n e 2013

San Diego Physician Celebrates 100 Years: April 1975

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.]

ADVANCED HEART FAILURE. ALLERGY & IMMUNOLOGY. ANESTHE AUDIOLOGY. BLOOD & MARROW TRANSPLANT. CARDIOLOGY. CAR THORACIC SURGERY. CARDIOVASCULAR SURGERY. COLON & REC SURGERY. CONCIERGE MEDICINE. CRITICAL CARE MEDICINE. DER EMERGENCY MEDICINE. ENDOCRINOLOGY. ENDOVASCULAR SURGE GASTROENTEROLOGY. GENERAL SURGERY. GERIATRIC MEDICINE. GYNECOLOGIC ONCOLOGY. HEPATOLOGY. HEMATOLOGY. HYPERBA MEDICINE. INFECTIOUS DISEASES. INTEGRATIVE MEDICINE. INTE RADIOLOGY. LARYNGOLOGY. MALE INFERTILITY. MATERNAL-FETA MEDICAL ACUPUNCTURE. MEDICAL GENETICS. MEDICAL ONCOLO NEONATAL & PERINATAL MEDICINE. NEPHROLOGY. NEUROSURGER NEUROCRITICAL CARE. NEUROLOGY. NUCLEAR MEDICINE. MINIMA INVASIVE SURGERY. OBSTETRICS & GYNECOLOGY. OCCUPATIONA ENVIRONMENTAL MEDICINE. ONCOLOGY. OPHTHALMOLOGY. ORTH SURGERY. OSTEOPATHIC MEDICINE. OTOLARYNGOLOGY. PAIN MA PALLIATIVE MEDICINE. PATHOLOGY. PELVIC FLOOR DISORDERS. P NERVE. PHYSICAL MEDICINE & REHAB. PLASTIC SURGERY. PSYC PSYCHOLOGY. PULMONARY DISEASE. RADIATION ONCOLOGY. RAD REPRODUCTIVE ENDOCRINOLOGY. RHEUMATOLOGY. SPORTS MED SURGICAL CRITICAL CARE. SURGICAL ONCOLOGY. THORACIC SUR TOXICOLOGY. TRANSPLANT SURGERY. TRAUMA. URO-GYNECOLOG

80 + SPECIALTIES OnE numbEr 855-543-0555 gives you access

Physician Access is a dedicated line that allows you to speak directly with one of our physicians at UC San Diego Health System. This number gives you real and immediate access to a fellow physician, and a trusted partner. So whether you want to talk about a particular case, facilitate a transfer or refer your patient for highly specialized care, our physicians are standing by to take your call.

855-543-0555 | health.ucsd.edu/access

/////////briefly ///////////////////noted ////////////////////////////////////////////////////////////////////// calendar SDCMS Seminars, Webinars & Events SDCMS.org

For further information or to register for any of the following SDCMS seminars, webinars, workshops, and courses, email Seminars@SDCMS.org.

Hospital Discharge Planning: Lost in Transition (webinar) JUL 18: 11:30am–12:30pm Taming Microsoft Outlook (workshop) JUL 20: 8:00am–12:00pm Employee OSHA Training (seminar/webinar) AUG 15: 11:30am–1:00pm

Cma Webinars CMAnet.org/events Protect and Preserve Your Patient Relationships JUL 24: 12:15pm–1:15pm HIPAA Compliance: The Final HITECH Rule AUG 21: 12:15pm–1:15pm Medicare: Proposed Changes for 2014 AUG 28: 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.

SDAFP Symposium, Family Medicine Update: 2013 JUN 28–30 • Paradise Point Hotel, Mission Bay • www.sandiegoafp.org RCMA’s “Cruisin Thru CME” — French Waterways: Highlights of Burgundy & Provence JUL 1–13 • Call RCMA at (800) 472-6204 Coordinating Physician Health Activities in California: A Workshop for Physician Health Committees JUL 13 • UCSD Hillcrest Campus, Multipurpose Facility • cppph.org/regionalnetworks/san-diego-region Scripps Conferences www.scripps.org/forhealth-care-professionals__ continuing-medicaleducation-cme (click on course calendar on the right navigation bar for a full list)

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

Become an SDCMS Featured Member!

SDCMS would like to feature some of our member physicians for their noteworthy accomplishments in these pages. If you would like to be considered for our next “Featured Member” spotlight, please email Editor@SDCMS.org. Thank you for your membership in SDCMS and CMA!

4 j u n e 2013

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 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

/////////////////////////////////////////////////////////////////////////////////////////////////// Commercial Real Estate Tips & Trends

By Chris Ross

Lease Negotiations: Two Subtle Things That Can Cost (or Save) You Money Overview There are a number of business points that landlords and tenants negotiate in a lease proposal or lease contract that on the surface are very straightforward, but here are two subtleties tenants should pay particular attention to during the negotiations: Rent Abatement: Landlords are still paying concessions such as free rent to new and renewing tenants in most submarkets in San Diego County. Tighter submarkets such as North County Coastal are offering up to about a halfmonth of free rent per year of term for new deals (little to no abatement for renewals), while submarkets with lower occupancy rates are still providing close to one month per year of

“

term. The question is, if most buildings in your submarket are paying X months of free rent, does said abatement include or exclude NNN expenses? The difference could cost or save you 20–33% of the total amount of abated rent.

Renewal Options: Most leases include one or two five-year options to renew the lease at fair market rent. Straightforward enough, right? But how is fair market rent determined, what is the mechanism that kicks in should the landlord and tenant not agree on a fair market deal (if there is such a mechanism), and does the renewal option contain language that states that in no event can the tenant’s rent decrease?

Does the overall fair market package include concessions or refurbishment allowances?

Keep in mind, also, that many times it is best to negotiate your new lease terms outside of the renewal options. This can help avoid being tied to the processes and costs (i.e., appraisals) that may be in place for the determination of fair market terms.

Mr. Ross is vice president of healthcare solutions for Jones Lang LaSalle. He is a commercial real estate broker specializing exclusively in medical office and healthcare properties in San Diego County. He can be reached at (858) 410-6377 or at chris. ross@am.jll.com.

The youth of America is their oldest tradition. It has been going on now for three hundred years.

”

— Oscar Wilde, Irish Writer and Poet (1854–1900)

Construction Spotlight Palomar-affiliated Arch Health opened its new 7,600-squarefoot clinic at 211 13th Street in Ramona, developed in partnership with Pacific Medical Buildings. Arch Health is the sole occupant of the new and attractively designed freestanding building.

By the Numbers: Q1 2013

2

The number of medical office properties that are currently available for sale in North County Coastal (Carmel Valley up to Carlsbad). Both are medical condominiums in Carlsbad.

The number of medical condo locations available in all of San Diego County. Five of these are Class A/B+ and the rest are Class B/B-/C. Nine are in the South County and Oceanside/Vista submarkets, with the other five spread throughout Carlsbad, San Marcos, Mission Valley, and Poway. Each of the projects in Carlsbad, Mission Valley, and Poway has only one unit available.

14

0

The number of medical buildings that are on the market for sale as investment property in North County Coastal.

11.5% The current vacancy rate among Class A medical buildings. In 2006, Class A vacancy recorded its 10-year low of 7.0%. It peaked at 38.9% during the tail end of the construction boom (Q4 2009) since most of the county’s new development fell into this class.

The increase in the countywide weighted average rental rate among Class A MOBs over the past 24 months.

13.5% SAN DI EGO PHYSICIAN .org 5

/////////briefly ///////////////////noted ////////////////////////////////////////////////////////////////////// legislator birthdays

SDCMS Leadership

Results of SDCMS’ 2013–14 Board of Directors Elections President: Robert E. Peters, MD, PhD President-elect: J. Steve Poceta, MD

One way to let your legislators know that you’re paying attention and that you vote is by wishing them a happy birthday!

Marty Block (District 39) E: senator.block@sen.ca.gov E: (via website) http://sd39.senate.ca.gov Sacramento Office: State Capitol, Room 4090 Sacramento, CA 95814 T: (916) 651-4039 • F: (916) 327-2188 San Diego Office: 701 B Street, Suite 1840 San Diego, CA 92101 T: (619) 645-3133 Birthday: June 28 Greg Cox (District 1) E: greg.cox@sdcounty.ca.gov W: www.gregcox.com 1600 Pacific Highway, Room 335 San Diego, CA 92101 T: (619) 531-5511 • F: (619) 235-0644 Birthday: July 2 David Alvarez (District 8) E: davidalvarez@sandiego.gov City Administration Building 202 “C” Street, 10th Floor San Diego, CA 92101 T: (619) 236-6688 • F: (619) 231-7918 Birthday: July 27

6 j u n e 2013

Treasurer: William T-C Tseng, MD, MPH Secretary: Mihir Y. Parikh, MD East County Geographic Director #1: Venu Prabaker, MD Hillcrest Geographic Director #1: Gregory M. Balourdas, MD Hillcrest Geographic Director #2: Thomas C. Lian, MD North County Geographic Director #2: Eileen S. Natuzzi, MD South County Geographic Director #1: Reno D. Tiangco, MD Hillcrest Alternate Geographic Director: Sunny R. Richley, MD Kearny Mesa Alternate Geographic Director #1: Anthony E. Magit, MD La Jolla Alternate Geographic Director #1: Lawrence D. Goldberg, MD At-large Director #3: Kosala Samarasinghe, MD At-large Director #5: Mark W. Sornson, MD At-large Director #7: Vimal I. Nanavati, MD At-large Alternate Director #1: Karl E. Steinberg, MD At-large Alternate Director #2: Perry N. Willette, MD At-large Alternate Director #4: Piyush Kumar, MD At-large Alternate Director #6: Elaine J. Watkins, DO Young Physician Director: Edwin S. Chen, MD Young Physician Alternate Director: Renjit Sundharadas, MD Resident Physician Director: Jane Bugea, MD Resident Physician Alternate Director: Erin Whitaker, MD AMA Alternate Delegate #1: Albert Ray, MD AMA Alternate Delegate #2: Lisa S. Miller, MD

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Personal & Professional Development

The Richness of Diversity Broadening Our Perspective

by Helane Fronek, MD, FACP, FACPh Summer is here! For many, it’s a time to travel and experience places and cultures that are new and exciting. We meet people who have a very different experience of life than we do. They view the world in a different way; their cultures and religions have different values, approaches, and customs; and they speak in ways that are not understandable to us. As travelers, we find these differences novel and interesting.

However, for people from other countries who live in the United States, our culture and norms can seem bewildering and sometimes even frightening. This is especially true when they become ill and have to negotiate our medical establishment to obtain the care they need. Can you imagine the frustration and anxiety of not being able to communicate when you’re already worried about what might be causing your symptoms? Fortunately, there are several practices that serve us well when dealing with people of different cultures or who speak a different language. Showing interest in their country and customs will help to establish rapport and build relationship. Speaking slowly, using visuals, paraphrasing, and periodically checking for understanding during the visit are essential to ensure accurate transmission of information. Beware of gestures, as they often do not translate well. For instance, our “thumbs up” gesture is considered lewd in many cultures.

A more profound connection occurs when we realize what our patients believe about their illness. Anne Fadiman illustrates this in her fascinating book, The Spirit Catches You and You Fall Down, which recounts the disastrous confrontation between the beliefs of the family of a Hmong child with epilepsy and her American doctors. Patients have strong ideas 8 j u n e 2013

about the significance of their illness, its cause, and its potential cure that affect their acceptance of and response to treatment.

Medical anthropologist Arthur Kleinman proposes eight questions to help us discover this important information: 1. What do you call the problem?

2. What do you think has caused the problem?

3. Why do you think it started when it did?

4. What do you think the sickness does?

How does it work?

5. How severe is the illness? Will it have a short or long course?

6. What kind of treatment do you think the patient should receive? What are the most important results you hope to receive from this treatment?

7. What are the chief problems the sickness has caused?

8. What do you fear most about the sickness?

Population estimates reflect the increasing diversity of America. As physicians, we are entrusted with the health of all who seek our help — those who share our backgrounds and those who don’t. Limiting ourselves to only the medical aspects of a patient’s condition does just that, it limits us. But with these insights and practices, we can better understand and thus help each of our patients, regardless of their background or culture. The gift to us of broadening our perspective is our enhanced enjoyment of the richness and diversity of human experience that we are privileged to encounter every day as physicians.

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 UC San Diego School of Medicine.

You can read her blog at helanefronekmd. wordpress.com.

JUNE IS MEN’S HEALTH MONTH JUNE IS MEN’S HEALTH MONTH 1 1

2 MILLION 2 MILLION

AMERICAN AMERICAN MEN HAVE OSTEOPOROSIS MEN HAVE OSTEOPOROSIS

3 3

12 2 2

80,000 80,000 MEN/YEAR MEN/YEAR FRACTURE FRACTURE A HIP A HIP

MILLION MILLION MEN MEN AT AT RISK RISK

4 4

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*Source: National Osteoporosis Foundation *Source: National Osteoporosis Foundation

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9

POETRY AND MEDICINE

Questions From a Death Certificate

Questions From a Death Certificate Introduction

by Daniel J. Bressler, MD By my best estimate, I’ve filled out between 100 and 200 death certificates during my career. Usually the sad task is completed hurriedly and somewhat perfunctorily; it is a final bureaucratic chore that is as legally necessary as it is anticlimactic. The timeframe to complete one is typically 24 hours from the time of death.

What if the act of completing a death certificate were an opportunity to reflect deeply about the person now gone, the rich details that adhere to a whole lived life, not just the cold, clinical details of the final days or weeks? What if the questions of the death certificate created an invitation to remember and to imagine?

10 j u n e 2013

What was the decedent’s name?

What was his date of birth?

What level of education did he complete?

What was he always curious about?

What was the exact moment of his death?

Where did he die?

Is that where he wanted to die?

What were his final words or wishes?

Was his death natural, accidental, or a result of homicide or suicide?

Did his job kill him?

Did he ever lose his desire to live?

Did he have any premonitions that his death was imminent?

What were the three main diseases he died from?

What kept him alive?

What other conditions did he have?

What conditions was he most afraid of?

Was it just his time to go?

Did he have an operation for any of the conditions listed above?

How long have you known the decedent?

What was your first impression of him?

How did you feel when you saw his name on your office schedule?

What did you learn from the decedent?

If you were not his doctor, would you have been his friend?

What do you wish you had said to him before he died?

Could you have done more to save him?

Has this death been reported to the coroner?

Has an autopsy been performed?

What will you miss most about him?

If he were to be reincarnated as an animal, what kind would it be?

Is he survived by a spouse or children?

Who will remember him one hundred years from now?

Here is one version of such a certificate.

I have interspersed questions from the actual California certified document with questions of my own invention. You may find that many are relevant to both the living as well as the dead.

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.

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Contact Dari Pebdani today: 858-231-1231 or DPebdani@SDCMS.org

SAN DI EGO PHYSICIAN.org 11

Health Reform

Health Reform Heats Up

Many Provisions Set to Take Effect on Jan. 1, 2014 by the California Medical Association

12 j u n e 2013

The Next Major Milestone The next major milestone toward full implementation of the Affordable Care Act (ACA) is set to take place on October 1, 2013, when state exchanges will begin preenrollment. In the first years, more than 32 million currently uninsured Americans are expected to gain coverage either through an exchange plan or the ACA’s massive expansion of the Medicaid program. Some analysts expect as many as 5 million of these newly insured to come from California.

On January 1, 2014, exchanges are set to go live, meaning that millions of Americans will, for the first time, be able to purchase coverage using the federal subsidies promised in the ACA. In order to navigate this massive undertaking, states will need to decide which plans will be offered through their exchanges, construct the actual online marketplaces through which consumers will purchase coverage, and implement major public outreach campaigns to ensure that these citizens — many of whom have never had the benefit of “open enrollment” or a similar purchasing period — understand how and where they can sign up for coverage.

The task is daunting on its own, but, with a deadline looming only months out, skeptics would be forgiven for questioning whether such a task is even possible.

California Leads the Way Despite the uncertainty swirling around the ACA’s implementation, California looks to be on track to meet the coming deadlines.

In the days following the ACA’s passage, California was the first state to establish a health benefit exchange and has been working toward implementation ever since.

That exchange, named Covered California, has already launched its online consumer marketplace, www.coveredca.com, and is one of 25 states that have gained conditional approval from the federal government to operate its own insurance marketplace.

There is, however, still much work to be done at the state level.

Unlike most other states, California opted to adopt an “active purchaser” model when building its new exchange, meaning Covered California’s board of directors is responsible for selecting which insurance providers will be allowed to offer products on the exchange.

In late May, following months of crafting its benefit standards, gauging payor inter-

est, and tweaking its competitive bidding process, Covered California revealed the list of “qualified health plans” (QHPs) that consumers across the state’s 19 rating regions will be able to purchase beginning in 2014.

In the end, 13 different insurance providers were selected to offer products on the new marketplace.

Protecting Physician Interests Unfortunately, several recent decisions by the exchange board have placed California’s physician community on its heels.

CMA has been an active participant in stakeholder hearings and is working to ensure that the interests of physicians and their patients are taken into consideration as the exchange prepares to open for business.

Several issues of concern arose when the board was working to finalize the benefit standards that interested payors will be required to meet in order to have their products considered for the QHP designation.

One major concern for physicians is how the exchange plans to deal with monitoring and ensuring network adequacy among of QHPs. Throughout the benefit design conversation, exchange staff continued to favor the existing method of network monitoring, which calls for the Department of Managed Health Care (DMHC) and the Department of Insurance (DOI) to be responsible for ensuring that plans offered to consumers have enough participating providers — in other words, status quo. Several stakeholders, including CMA, have noted that DMHC and DOI are currently unable to ensure adequate networks among existing plans and would likely be overwhelmed by the added task of monitoring additional exchange products. While CMA asked that the exchange take an active role in monitoring networks beginning in 2014, the DMHC/DOI method remained in the final benefit standards adopted by Covered California’s board of directors in August, meaning it could become the norm once the state’s marketplace goes live.

CMA also voiced concern over the exchange’s handling of the “grace period” provision included in the ACA. Under current California law, patients who are delinquent on their premiums are allowed a full 90 days to settle up before their policy is terminated for nonpayment; however, under the ACA’s grace period provisions, exchange plans will be allowed to suspend SAN DI EGO PHYSICIAN.org 13

Health Reform

Medical Professional Liability Protection, and more!

800-356-5672 www.caPphysicians.com

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payment for services rendered if an enrollee is more than one month delinquent. If the patient fails to settle up within the threemonth grace period, the plan can then terminate coverage for nonpayment and deny all pending claims for services. In this scenario, physicians could potentially be on the hook for 60 days worth of services with no avenue for recourse.

The final version of the exchange model contract included a provision that requires 15 days advance notice to physicians when a patient has entered the second month of the grace period, but still leaves the burden of 60 days worth of unpaid claims on the physician and the patient.

cleared their house of origin, but remained stalled as budget negotiations dominated conversations in the Capitol. Following the announcement of a “budget deal” in early June, both bills were approved by the second house’s Committee on Health and were sent onward to Appropriations.

There’s also a considerable amount of activity related to health reform taking place outside of the special session, specifically regarding scope of practice expansions as a way of addressing the access to care issues that will inevitably take place when millions of currently uninsured Californians gain coverage beginning in 2014.

Three bills, all authored by Covered Sen. Ed Hernandez, seek to California’s expand the respective scope Action Under the Dome board of of practice for pharmacists, With all of the moving pieces optometrists, and nurse present between the federal directors is practitioners, while a fourth, government and California’s responsible authored by Sen. Fran Pavexchange board, it’s somefor selecting ley, would call for a similar times easy to forget that which expansion for physicians the state Legislature is also assistants. playing a large role in ACA insurance The ACA had two major implementation. So large, in providers goals: First, to expand access fact, that Gov. Jerry Brown will be to health coverage to all, and saw fit to call for a special sessecond, to ensure efficient, sion dedicated to healthcare allowed high quality care. Those who reform in California. to offer are now invoking the ACA A total of six bills — three products as the sole justification for identical proposals being heard on the allowing nonphysicians to in both houses of the Legisladiagnose and treat Califorture — were introduced during exchange. nia patients and perform the special session, seeking complex medical procedures to address individual market are attempting to achieve reforms, Medi-Cal expansion, the first goal by undermining the second. and a proposal to establish a “bridge plan” Allowing nonphysicians to practice beyond that would allow for a seamless transition their training can only lead to inferior outbetween Medi-Cal and exchange plans for comes, higher costs, and greater fragmenthose individuals whose income may fluctutation of care. ate past the income thresholds called for in CMA will be closely following and fightthe ACA. ing these scope bills, working to ensure While there was little action taken on that California meets the ACA’s objectives these bills before the Legislature’s “soft without eroding quality or jeopardizing deadline” of the spring recess, activity surpatient safety. rounding the state budget appears to have To be sure, the next few months will be jolted the proposals back to life. some of the most important and tumultuIn late April, the market reform bills banous times the medical community has ning pre-existing conditions, establishing faced in recent memory, but as a CMA community rating, and requiring “guaranmember you have the comfort of knowing teed issue” were approved by the Legisthat your interests are being advocated for lature and signed by the governor shortly in front of all the key players driving the after. Meanwhile, the Medi-Cal expansion nation’s reform efforts. bill and “bridge plan” proposal had both

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Incentives Programs To help physicians understand the bonuses and penalties associated with key Medicare initiatives, the California Medical Association (CMA) hosted a webinar for members, titled “Quality Reporting Programs: What Physicians Need to Know and Do Now to Improve Care and Avoid Penalties.” The webinar is now available for on-demand viewing in the CMA resource library at www.cmanet.org/webinars.

During the webinar, CMS Region 9 chief medical officer Betsy L. Thompson, MD, discusses the major quality reporting and ehealth incentive programs currently under way for eligible professionals. The session covers the basics of the Physician Quality Reporting System, the Medicare and Medicaid Electronic Health Records Incentive Programs, the Medicare E-prescribing Incentive Program, and the new value-based payment modifier. The content is geared toward physicians, nurse practitioners, and physician assistants, and what they need to know, although other healthcare professionals and medical officers may find the information useful as well.

If you are not already familiar with each of these programs, the time to learn about them is now.

Below is a brief summary of the programs and key dates that were discussed in the CMA webinar.

Act Now to Avoid Medicare Penalties in 2015 by the California Medical Association 16 j u n e 2013

Over the past six years, the Centers for Medicare and Medicaid Services (CMS) has launched a number of initiatives that offer physicians the opportunity to increase their net revenue by participating in quality reporting programs. Until now, these programs have been voluntary, and physicians have received bonuses for participating. That’s about to change. Failure to participate now means physicians could face significant penalties.

The American Academy of Family Physicians estimates that participating in these initiatives in 2013 — rather than waiting until 2014 — could save a physician $19,000 in avoided penalties.

Meaningful Use Meaningful use is the set of criteria on which physicians must report in order to receive federal incentive payments for EHR adoption under the Medicare and Medicaid Electronic Health Records (EHR) Incentive Programs. Meaningful use is also the necessary foundation for all impending payment changes involving patient-centered medical homes, accountable care organizations, bundled payments, and value-based purchasing.

• Bonuses: For the Medicare EHR incentive program, your cumulative payment amount depends on the first year of participation. Physicians who start participating in 2013 can receive up to $39,000; physicians who start in 2014, up to $24,000. The last year to begin participation in the Medicare EHR incentive program is 2014. For the Medicaid (Medi-Cal) incentive program, physicians can receive up to $63,750.

• Penalties: Physicians who do not demonstrate meaningful use by 2015 will be subject to Medicare payment penalties.

These reductions increase from 1 to 2% of total Medicare charges in 2015, to 2% in 2016, and 3–5% in 2017 and beyond. Medicaid rates will not be adjusted for failure to achieve meaningful use.

Electronic Prescribing Medicare’s e-prescribing program provides incentive payments for physicians who e-prescribe and payment penalties for physicians who do not.

• Bonuses: This year is the last year to receive a bonus for e-prescribing. To qualify for the 0.5% bonus in 2013, you must have successfully reported e-prescribing activity for at least 25 patient visits between Jan. 1 and Dec. 31, 2012.

• Penalties: Starting in 2012, physicians who did not electronically transmit their prescriptions became subject to payment penalties on all Medicare-allowed charges. The penalty in 2013 is 1.5%, and in 2014, 2%.

measures group to receive a 0.5% bonus. Physicians participating in a maintenance-of-certification program are eligible for an extra 0.5% bonus, for a total bonus of 1%.

• Penalties: The Affordable Care Act calls for PQRS payment penalties starting in 2015. In the 2012 Medicare Physician Fee Schedule, CMS announced that 2015 program penalties will be based on 2013 performance. Therefore, physicians who do not successfully report on at least one individual measure in 2013 or elect to participate in the administrative claims reporting option will receive a 1.5% payment penalty in 2015. The penalty goes up to 2% in 2016 and beyond.

Physician Quality Reporting System The Physician Quality Reporting System (PQRS) is a voluntary quality-reporting program that provides incentive payments to eligible professionals who report data on quality measures for services provided to Medicare beneficiaries.

• Bonuses: Physicians must report on three individual measures or one

Value-based Payment Modifier Program The value-based payment modifier was mandated by Congress under the Affordable Care Act. It will adjust physician payment based on the quality and cost of the care they provide. It will take effect in 2015 using 2013 data for groups of 100 or more physicians. By 2017, this modifier will be

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implemented for all physicians.

• Bonuses: Participating physicians may receive bonuses based on their quality and cost scores.

• Penalties: Participating physicians may be penalized up to 1% based on their quality and cost scores. Physicians who choose not to participate will be docked 1%.

Each of these programs has specific deadlines and reporting requirements, some of which are overlapping, and are not always simple to understand. CMA’s webinar will give physicians the information they need to successfully participate in each program.

During the webinar, Dr. Thompson helps participants understand which programs they are eligible for, the associated incentives and penalties for each program, and the deadlines and requirements for participation.

The on-demand webinar is available free to SDCMS-CMA members at www.cmanet. org/webinars. Nonmembers can purchase the webinar for $99. Contact CMA’s member service center at (800) 786-4262 or at memberservice@cmanet.org.

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One Doctor’s Opinion

Curmudgeon Redux

by Steven Brozinsky, MD, FACP, FACG

NOTE: Share Your Opinion — Email Editor@SDCMS.org Actually, I never left. In 2005 a peer review journal saw fit to publish my letter bemoaning that our subspecialty had become too procedure-oriented (Brozinsky, S., “Genesis of a Curmudgeon,” The American Journal of Gastroenterology 100 (2005): 2600). Alas, things have only gotten worse. Where is the outrage when patients are recalled for colonoscopies at intervals far shorter than the recommended guidelines?

Why are we looking the other way when our colleagues are endoscoping that college coed with no dysphagia and no anemia, just some heartburn when she eats pizza? How about colonoscoping that asymptomatic nonagenarian with a normal hemoglobin because she thought she had polyps in her colon 10 years previously, when some delving into the medical record divulged that it 18 j u n e 2013

was pockets (’tics) that she had?!

It’s not just the gastroenterologists who are at fault. Many emergency room doctors, under the pretext of practicing defensive medicine, are ordering CT scans before even seeing the patient, especially if the triage nurse lists abdominal pain anywhere on the admission sheet.

Just last week, a 35-year-old woman came into a nearby emergency room complaining of malaise and a rash and vague abdominal pain. The very first thing ordered was a CT scan (no physical exam yet), which revealed a slightly thickened gallbladder wall, which prompted an ultrasound to be requested — no stones — and then finally some labs returned: WBC was normal, but the ALT and AST came back greater than 2500 u/L! But that didn’t stop another physician from ordering an MRCP! Oh yes, the hepatitis A IgM antibody that came back the next day was positive. Duh.

The gastroenterologist who was consulted afterwards was a bit amused but reluctant to even diplomatically educate the emergency room and admitting physician, fearful of potentially alienating them and decreasing his referral base.

We are doing a lousy job of policing ourselves. We are wasting three years of training in internal medicine when we seek out unsuspecting orifices to be intubated without reasonable indication. We have squandered our once valid claims of patient advocacy.

I don’t see it getting any better when, in our exam rooms, we initiate eye contact with electronic note pads to complete a template for the coders. Hey fellas, there is a patient out there!

It could be your mother.

Dr. Brozinksy, SDCMS-CMA member since 1987, is board certified in internal medicine and gastroenterology.

YOU ARE OUR HERO thank you for giving access to healthcare for those without!

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

You are the Heart & Soul of Project Access San Diego Through your support of our flagship program, Project Access San Diego, we have been able to assist over 1,850 uninsured adults in our community to improve their health through access to specialty healthcare services. You have provided over $6.3 million in contributed healthcare services to community members since our program’s beginnings in December 2008!

Thanks to more than 625 volunteer physicians providing specialty healthcare services 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 and outpatient surgery centers, imaging, labs, physical therapy, and other 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 San Diego County Medical Society Foundation needs you! Join us to volunteer for Project Access, or provide specialty consultations to primary care physician colleagues through eConsultSD, our HIPAA-compliant, web-based system from the comfort of your home or office. Attend an event, assist us to recruit fellow physicians, or provide educational opportunities for primary care physicians or medical students. Our first annual Golf Tournament on Thursday, February 28, 2013 at Del Mar Country Club was a huge success; we hope you can join us next year! Watch for news on our Fall Heroes de la Salud event. And 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

n

Daniel “Stony” Anderson, MD Sandra Freiwald, MD Paul Bernstein, MD And the Kaiser Permanente Saturday Surgery Day Team Spirit of Volunteering Drs. Anderson, Freiwald and Bernstein have championed Saturday Surgery Days at Kaiser Permanente since Project Access’ beginnings; October 2012 marked our 10th Surgery Day at KP. More than 150 physicians, nurses, physician assistants, and medical staff assure that patients regain their health through surgeries and GI procedures. The KP team is recognized as our heroes thanks to their dedication to Project Access patients; 342 patients have benefited from their care.

The majority of PASD patients require just office consultations and procedures. 30% of patients require surgery or GI procedures, which occur during a Carlsbad or Kaiser Permanente Surgery Day, or are accommodated at our partnering hospitals and outpatient surgery centers throughout the year.

Thank you to all of our physician volunteers-- you are all our heroes!!

www.sdcmsf.org SAN DI EGO PHYSICIAN.org 19

Join the Fight to Protect Medicine Your Voice Is Key to Our Success Critical issues affecting today’s physicians are being debated in the legislative arena at a fast and furious pace. MICRA, scope of practice, Medi-Cal, and the corporate bar are just a few of the vital issues being debated and voted on by decision-makers in Sacramento.

CMA has some of the best lobbyists, lawyers, and other advocates in the Capitol, but the most powerful weapon in advancing the cause of physicians and their patients is you. Understand the issues, and know the arguments — hearing from physicians with experience from the frontlines of medicine can make all the difference for a legislator facing a complicated healthcare issue.

20 j u n e 2013

Medical Injury Compensation Reform Act (MICRA) Attacks

page 22

Allied Health Professional Scope of Practice Expansions

page 26

Medi-Cal Reimbursement Rate Cuts

page 30

Bar to the Corporate Practice of Medicine Challenges

page 32

SAN DI EGO PHYSICIAN.org 21

Medical Injury Compensation Reform Act (MICRA) Background

California’s landmark 1975 Medical Injury Compensation Reform Act (MICRA) is a law that ensures injured patients receive fair compensation while preserving every Californian’s access to healthcare. MICRA has kept the doors of medicine open for nearly 40 years, protecting California’s healthcare safety net by keeping medical malpractice insurance available and affordable.

Prior to MICRA, out-of-control medical liability costs were forcing clinics, doctors, and other healthcare providers to leave the practice of medicine altogether. MICRA has helped stabilize medical liability costs, keeping more providers and clinics open and treating patients — and more stability means healthcare providers of all types have been less likely to close their doors because of skyrocketing liability premiums.

Weakening MICRA’s intent or protections will result in higher healthcare costs overall, no improvement in quality, and reduced access to services.

Even with MICRA, many specialty services today, like obstetricians, nurse midwives, community clinics, emergency providers, and rural providers, remain particularly vulnerable to any liability increases or weakening of MICRA’s reforms.

We only need to look at other states to see how important it is to preserve MICRA. States with medical liability reform are able to attract more doctors, and are less likely to suffer from shortages of specialty providers leading to the closing of hospitals, clinics, and trauma centers.

According to the Texas Alliance for Patient Access, Texas enacted medical liability reforms in 2003 and has since added more than 14,000 in-state, active physicians. Additionally, 35 rural Texas counties have added at least one obstetrician, including 16 counties that previously had none; 46 counties that did not have an emergency medicine physician now do; and 15 counties that did not have a cardiologist now do.

In New York, a state without reforms, 19 counties are without obstetricians, 22 are without internal medicine specialists, and 15 do not have surgical specialty doctors, according to a 2010 study by The Center for Health Workforce Studies. According to a July 2012 story in The New York Times, several hospitals in New York City are partially or completely without liability insurance due to the high cost of liability premiums.

22 j u n e 2013

Threats On May 2, 2013, a coalition — including the Consumer Attorneys of California and the trial lawyer-funded Consumer Watchdog group — announced intentions to seek to overturn MICRA through legislation or, failing that, a ballot initiative.

Consumer Attorneys of California recently paid $6,635 to install a billboard in Sacramento featuring an infant who died from whooping cough in 2010, with text that reads, “Medical Negligence Kills,” and then beneath it, “But a 38-year-old law says Mia’s life was worth only $250,000. Call your legislator.” The coalition pushing to eliminate the $250,000 cap is committed to spending $1 million to do so.

The group has until September to submit a proposed initiative to qualify for the November 2014 general election ballot. If successful, the trial attorney’s efforts will cause malpractice rates to skyrocket and re-create the same conditions that threatened to throw California’s healthcare system into crisis during the early 1970s. Increasing the amount of noneconomic damages allowed under MICRA from $250,000 to $500,000 would raise healthcare costs in California by at least $9.5 billion annually, according to the State’s former nonpartisan legislative analyst; that translates into approximately $1,000 annually for a family of four.

Argument Against MICRA: The $250,000 cap on pain and suffering was passed nearly 40 years ago.

Shouldn’t it be raised, at least to keep up with inflation?

and increasing the noneconomic damages cap will help improve quality by holding doctors accountable. They say there are 98,000 medical deaths each year due to error.

Response: Remember that patients receive unlimited compensation for all economic damages. In other words, wages, medical costs, and punitive damages are all paid on an unlimited basis, and these payments are going up at more than twice the rate of inflation.

The reasonable $250,000 cap on noneconomic damages is an effective way to limit meritless lawsuits and keep healthcare costs lower, but, not surprisingly, it has been targeted by trial lawyers because it restricts the amount of money they can collect in damage awards. The trial lawyers and their allies would benefit from increased lawsuit payouts, but we would all pay through higher healthcare costs and reduced access to healthcare providers.

Prior to MICRA there were no incentives to limit meritless litigation. As a result, lawyers were suing doctors, clinics, and other healthcare providers out of California. Obstetricians, community clinics, and others couldn’t afford the high cost of litigation and insurance, and they were shutting down or leaving. Patients were losing access to their doctors and other healthcare providers.

That’s why MICRA put these reasonable limits on noneconomic damages in place.

For almost 40 years, MICRA has been successful in limiting meritless lawsuits, in helping keep healthcare costs lower, and in preserving access to care for all Californians.

Response: First, we believe even one medical error is too many, but changing MICRA won’t do anything to reduce medical errors (or improve quality). Instead, it will create a whole new set of problems by reducing access to healthcare services for some of our most vulnerable populations and increasing the cost of healthcare for all Californians. Make no mistake, this is just an attempt by trial lawyers to increase their lucrative payouts.

Argument Against MICRA: Sponsors of this initiative say that changing the MICRA laws

Argument Against MICRA: Those who don’t have high economic damages are sometimes limited to $250,000 in noneconomic damages. Is that fair?

Response: Remember that, under MICRA, patients will be made whole for loss of any and all economic damages, or out-of-pocket costs, that they have paid in the past or will pay in the future. But, if we change MICRA and healthcare costs increase as expected, it’s exactly California’s lower-income individuals and seniors who will be hurt the most because they are already struggling to afford medical coverage.

If the cap is increased, lawyers will have more incentive to file meritless claims. Lawsuits increase the cost of healthcare for everyone, and those on the lower end of the socioeconomic scale will be hurt the most. And keep in mind that these individuals will still have to pay a premium even under federal healthcare reform. More lawsuits do nothing to improve healthcare; they just enrich trial lawyers at everyone else’s expense.

Argument Against MICRA: Under MICRA, if a baby is unable to make it past delivery, and fault is found with the medical provider, MICRA limits the family to $250,000 in noneconomic damages. Is that fair?

Response: My heart goes out to any parent who loses a child, no matter how young or old.

I’m sure everyone would agree there’s no amount of compensation that could make up for the loss of a loved one. But we need to remember why MICRA was passed in the first place.

Before MICRA, lawsuits were forcing doctors’ medical liability premiums to skyrocket so high that they couldn’t afford to practice medicine. Physicians were quitting medicine or leaving California to treat patients in other states.

Patients were losing access to healthcare services.

MICRA has stabilized healthcare, it has provided fair compensation to injured patients, it has allowed doctors to remain in practice treating patients, and it has kept healthcare costs lower by limiting meritless lawsuits. More lawsuits do nothing to improve healthcare. It only enriches trial lawyers, and we all pay.

Argument for MICRA: MICRA protects access to healthcare services.

Explanation: Prior to MICRA, out-of-control medical liability costs were forcing community clinics, health centers, doctors, and other healthcare providers out of practice. MICRA was intended to, and has been successful in, stabilizing liability costs.

MICRA is especially critical in protecting specialty and high-risk services, including women’s healthcare, community clinics, health centers, and rural providers that can

Prior to MICRA, out-of-control medical liability costs were forcing clinics, doctors, and other healthcare providers to leave the practice of medicine altogether. MICRA has helped stabilize medical liability costs, keeping more providers and clinics open and treating patients — and more stability means healthcare providers of all types have been less likely to close their doors because of skyrocketing liability premiums.

SAN DI EGO PHYSICIAN.org 23

In Order to Be Victorious in This Fight, We Need Your Help!

DONATE: A fight of this magnitude will be extremely costly. CMA is urging all physicians to consider a donation to CMA's political action committee (CALPAC), which for the past 38 years has served as the first line of defense for California’s historic physician protections.

Call (800) 225-7229.

JOIN: If you are not already a member of SDCMS-CMA, please consider joining today. By joining SDCMSCMA, you will help to ensure that the voice of California’s physicians is heard loud and clear in the capitol and beyond. Together, our unified voice can move mountains.

Call (858) 565-8888.

24 j u n e 2013

least afford skyrocketing costs. States without medical liability reform suffer from shortages of providers leading to the closing of hospitals, clinics, and trauma centers, and leaving patients with no doctors in their immediate vicinity.

When we are trying to implement federal healthcare reform and provide access to healthcare for all Californians, this is the worst possible overreach at the worst possible time. With millions of patients entering the healthcare system under the Affordable Care Act and reimbursements from Medicare, Medi-Cal, and Denti-Cal being slashed, changing MICRA will worsen this situation.

Argument for MICRA: MICRA protects against rising healthcare costs.

Explanation: Increasing the amount of noneconomic damages allowed under MICRA from $250,000 to $500,000 would raise healthcare costs in California by at least $9.5 billion annually, according to the State’s former nonpartisan legislative analyst. That translates into approximately $1,000 annually for a family of four. Any legislation attempting to circumvent MICRA’s intent and protections will result in higher healthcare costs and reduced access to services.

The threat of a ballot measure is nothing more than a money grab by trial lawyers that will come at the expense of higher healthcare costs for all patients and decreased access for patients and clinics already struggling to keep their doors open.

Argument for MICRA: MICRA protects patients’ rights and preserves access to the courts.

Explanation: MICRA preserves patients’ access to fair compensation when they have justifiable claims, including economic damages for all past and future medical costs; economic damages for lost wages, lifetime earning potential, and for any other conceivable economic losses; punitive damages, which seek to punish a defendant; and up to $250,000 available for noneconomic damages, sometimes called pain and suffering awards.

Under MICRA, the average size of medical liability awards in California has increased faster than the rate of inflation. MICRA limits attorneys’ fees so patients, not lawyers, receive more from awards.

Argument for MICRA: MICRA protects California’s strong patient safety record.

Explanation: California has a strong patient safety record. Between 2003 and 2009, according to the Agency for Healthcare Research and Quality, California had far fewer adverse patient safety events per 100,000 people than the average of all other states.

Argument for MICRA: MICRA is supported by a large and diverse coalition of patient advocates and healthcare providers across California.

Explanation: MICRA’s supporters consist of more than 700 groups, including doctors and healthcare providers, local governments, public safety and labor groups, community clinics and health centers, organizations committed to disease prevention, hospitals, medical and dental societies, medical groups, healthcare provider-owned professional

Weakening MICRA’s intent or protections will result in higher healthcare costs overall, no improvement in quality, and reduced access to services. liability carriers, and many more from around the state.

Time and time again, the trail lawyer-funded Consumer Watchdog group has tried to undermine the care afforded to California’s neediest patients with threats. Time and time again, patients, advocacy groups, constituents, and hundreds of organizations have rallied behind MICRA’s merits. Trial lawyers should take the hint: The people have spoken, and they don’t want to change a successful policy that would just siphon millions of dollars away from patients and into the pockets of wealthy trial lawyers. In the most recent polling, voters support MICRA by more than a 2–1 margin, with 56% in support and 25% opposed to the law.

Physician Local San Diego

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

SAN DI EGO PHYSICIAN.org 25

Scope of Practice Background

CMA both supports utilizing allied health professionals — physical therapists, optometrists, nurse anesthetists, pharmacists, nurse practitioners, psychologists, audiologists, chiropractors, podiatrists, dentists, clinical social workers, naturopaths, etc. — to the top of their training and recognizes the important role they play in the healthcare delivery team. Allied health professional scope of practice expansions must be examined carefully to ensure that patient care is not jeopardized, i.e., that allied health professionals have the proper experience, training, and education to treat patients safely, and that the physician is the final decision-maker.

26 j u n e 2013

Threats • SB 491 would expand the scope of practice for California’s nurse practitioners, allowing them to establish independent practices without the supervision of a physician partner.

• SB 492 initially sought to dramatically expand the scope of practice for California’s optometrists.

Through amendments, all of the surgical procedures and most of the treatments generally reserved for ophthalmologists have been removed from the bill.

• SB 493 initially sought to expand the scope of practice of California’s pharmacists to allow them to prescribe a wide variety of drugs without physician supervision. Following a round of amendments, much of the prescribing authority has been removed from the bill, but CMA continues to have major concerns.

Allied health professional scope of practice expansion bills that are a threat to patient safety are introduced in the California Assembly and Senate every year.

Argument Against Allied Health Professional Scope of Practice Expansions: These scope expansions lead to inferior outcomes.

Explanation: Recklessly allowing certain health professionals to operate outside of their training puts patients in harm’s way. Simply changing the law cannot duplicate the years of graduate training, full-time residencies, and thousands of hours of clinical rotations physicians undergo to equip them with the necessary knowledge and understanding of complicated and hard-to-diagnose, hardto-treat diseases.

Argument Against Allied Health Professional Scope of Practice Expansions: Addressing the physician shortage in California is a funding issue.

Explanation: The severe underfunding of medical residency programs in California has forced thousands of new MDs to leave the state for their residencies, where the majority of them stay to join or open practices. Increasing the number of residency slots for physicians educated in California will keep those physicians in the state and can provide immediate relief for newly insured patients looking for quality medical care as the Affordable Care Act goes into effect.

Argument Against Allied Health Professional Scope of Practice Expansions: We need to increase access to care for patients in California.

Explanation: The solution is not to devalue the primary role of trained physicians — it’s to

attract and retain more physicians. Expanding allied health professional scope of practice will not ensure access to care.

California needs more medical schools. In August of this year, UC Riverside will open the doors of its full-time medical school; however, to stay operational, the school will need to secure additional funding, which AB 27 (Medina) and SB 21 (Roth) aim to achieve.

Argument Against Allied Health Professional Scope of Practice Expansions: These expansions will lead to greater fragmentation of care.

Explanation: The new healthcare laws were specifically written to increase reliance on team-based care, in which physician assistants, nurse practitioners, medical assistants, and other professionals work under the supervision of highly trained and experienced physicians. This model leverages the skills and experience of all health professionals and has a proven record of quality and efficiency based on clinical integration.

Proposals to expand socalled “scope of practice” would only further fragment the healthcare delivery system, encourage overreliance on specialty referrals, and create a dangerous disincentive away from the proven model of physician-supervised, teambased care.

The Affordable Care Act has offered a chance for the medical community to be innovative and groundbreaking in the way healthcare is delivered to patients. We must seize this opportunity to show that integrated care led by a physician is not only the safest but the most efficient and costeffective way to make the ACA a success.

California can accomplish

both of the ACA’s objectives — expanding access to health coverage to all while ensuring the high quality of medical practice in California — without eroding quality or jeopardizing patient safety, providing access to safe and high-quality care for everyone.

Argument Against Allied Health Professional Scope of Practice Expansions: Scope expansions don’t close the provider gap.

Explanation: Of the 19 states that allow independent practice by nurse practitioners, the majority have a higher percentage of underserved individuals than California.

Supporters claim that expanding the scope of practice for allied health professionals will increase primary care capacity in underserved areas. However, there is no strong evidence to support this claim. A number of states have already enacted expanded scope of practice laws. Despite that, there has been little or no reduction in the underserved population in the majority of those states.

This is a thinly veiled power grab by these groups seeking to benefit from healthcare reform. Scope expansion is a windfall for medical specialists. If these laws are passed, they will be able to perform lucrative medical procedures — such as administering Botox injections — even if they are not trained to do so.

Proponents of the bills claim that they were introduced in response to the passage and implementation of the Patient Protection and Affordable Care Act. It is true that the ACA will expand access to healthcare to an estimated 2 million Californians. These newly insured individuals will undoubtedly put a strain on a healthcare system already

Recklessly allowing certain health professionals to operate outside of their training puts patients in harm’s way.

SAN DI EGO PHYSICIAN.org 27

stretched thin. However, it is disingenuous for supporters to claim that the bills were solely a response to the ACA. The majority of nurse practitioners, optometrists, and pharmacists are practicing in the same regions as physicians, not in the areas with a shortage of providers.

Medical professionals are unlikely to relocate from densely populated, urban areas to parts of the state that lack access — primarily lowincome and rural communities — simply because their scope of practice is being expanded.

The majority of California’s physicians are located in greater Los Angeles, the Bay Area and the Central/Sierra region. Most of the state’s nurse practitioners and other medical professionals are located in those same regions.

Simply expanding the scope of practice for allied health professionals is not going to impact areas lacking in physicians, because those professionals are not located in those areas.

Argument Against Allied Health Professional Scope of Practice Expansions: Scope expansions create substandard care for underserved communities.

Explanation: Instead of addressing the state’s physician shortage, particularly in poor and rural areas, scope expansions create a two-tier system of care, one in which those in underserved areas rely on allied health professionals for primary care treatment, while the rest of the population receives care from physicians and physician-led teams.

Under these bills, nurse practitioners, optometrists, and pharmacists will have the power to act like a doctor minus the same level of medical training. The individuals most

28 j u n e 2013

likely to rely on these specialists for primary care are those with low incomes and those who will be newly insured under the Affordable Care Act. In fact, scope expansion actually undermines one of the primary intentions of the ACA, which was to increase access to quality, team-based medical care. Currently, nurse practitioners and other paraprofessionals consult with physicians in solving complex patient care problems. Allowing these professionals to open and operate their own medical practices without physician supervision erodes the collaborative nature of team-based care.

Argument Against Allied Health Professional Scope of Practice Expansions: Training and collaboration count in medicine.

Explanation: Nurse practitioners, optometrists, and pharmacists are trained medical professionals, but they are not physicians. Allowing them to diagnose and prescribe and treat patients in areas in which they have not received training places patients at serious risk.

In California, licensed physicians are required to have four years of medical school and up to seven years of additional residency and training. In comparison, most nurse practitioners receive the same amount of education as a second-year medical student.

Experts agree that quality medical treatment requires a team-based approach where nurse practitioners, medical assistants, and other trained professionals work under the supervision of a physician. By removing the supervisory role, the bill package eliminates that collaborative aspect.

The same concern applies when expanding the scope of

practice for optometrists and pharmacists to treat patients for conditions that require a physicians’ expertise.

Argument Against Allied Health Professional Scope of Practice Expansions: These healthcare extenders have less accountability.

Explanation: All three bills set a dangerous precedent of allowing allied health professionals to practice medicine without being subject to the Medical Practice Act (MPA), which regulates the practice of medicine and in which violations may result in the loss of a medical license and possibly criminal prosecution.

Ultimately, nurse practitioners, optometrists, and pharmacists would be providing the same services as physicians, with less training, while being held to a lower standard of care.

Argument Against Allied Health Professional Scope of Practice Expansions: These expansions would ultimately incur greater cost.

Explanation: Since the advent of nurse practitioners and physician assistants in our area, I have noted that they order many more tests than the medical doctors whom they work for. This has been consistent for the past 15 years. They lack the judgment and medical knowledge of physicians and overutilize tests, which drive up healthcare costs.

Argument Against Allied Health Professional Scope of Practice Expansions: These scope expansions would threaten patient privacy.

Explanation: SB 492 would expand pharmacists’ scope of practice to include primary care. Many pharmacies are owned and operated by major retailers, such as Wal-Mart and Rite-Aid. The handling of medical histories and other sensitive information in a retail setting compromises a patient’s right to privacy.

SB 492 raises serious concerns about privacy issues with regard to medical records. The bill would expand pharmacists’ scope of practice to include primary care. In other words, pharmacists would be able to diagnose and treat certain diseases and alter prescriptions, much like a physician.

This bill is troublesome with regards to privacy. A pharmacy is a very different setting from a doctor’s office.

Many pharmacies are owned and operated by major retailers. Allowing these entities access to medical histories and other sensitive information compromises a patient’s right to privacy.

Confidential patient information should be shared only with members of a healthcare team who are authorized to handle such information. The handling of this data in a retail setting should give patients real reason for pause.

Argument Against Allied Health Professional Scope of Practice Expansions: There is a better solution.

Explanation: Rather than rely on a short-sighted fix, a responsible alternative is to focus on increasing primary care provider training; recruiting more physicians from outside California; and creating incentives for working in underserved areas. The California Medical Association supports the following approach:

TrusT • SB 21 and AB 27 allocate $15 million annually for the new UC Riverside School of Medicine; • AB 565 expands the Steve Thompson Loan Repayment Program to help repay medical school loans in exchange for students agreeing to practice medicine in underserved areas; • AB 1176 creates residency positions in medically underserved communities by instituting insurer fees; and • AB 1288 requires the Medical Board of California to prioritize applications for physician licenses from those who plan to treat members of a medically underserved population.

The California Medical Association is promoting legislation to fund a shortage of physician training slots that forces medical students out of state, and legislation to keep paltry Medi-Cal funding from being cut even further. We hope the Legislature will agree.

The most immediate way we can add more physicians is by increasing the number of residency slots throughout the state. Assembly Bill 1176, introduced by Assemblyman Raul Bocanegra, D-Los Angeles, would do just that. The bill will follow the example of other states by creating a funding source for California residency training programs, which are now grossly underfunded.

Allied health professional scope of practice expansions must be examined carefully to ensure that patient care is not jeopardized, i.e., that allied health professionals have the proper experience, training, and education to treat patients safely, and that the physician is the final decision maker.

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Medi-Cal Background

Enacted in 1965 through amendments to the Social Security Act, Medicaid is a health and long-term care coverage program that is jointly financed by states and the federal government. Each state establishes and administers its own Medicaid program and determines the type, amount, duration, and scope of services covered within broad federal guidelines. States must cover certain mandatory benefits and may choose to provide other optional benefits.

Federal law also requires states to cover certain mandatory eligibility groups, including qualified parents, children, and pregnant women with low income, as well as older adults and people with disabilities with low income. States have the flexibility to cover other optional eligibility groups and set eligibility criteria within the federal standards. The Affordable Care Act of 2010 creates a new national Medicaid minimum eligibility level that covers most Americans with household income up to 133% of the federal poverty level. This new eligibility requirement is effective Jan. 1, 2014, but states may choose to expand coverage before this date.

The Children’s Health Insurance Program (CHIP) was created in 1997 through an amendment to the Social Security Act to provide healthcare coverage to low-income children not already eligible for Medicaid. Like Medicaid, CHIP is jointly financed by states and the federal government. States have the option of using CHIP funds to expand their existing Medicaid program, create a separate standalone CHIP, or do a combination of both.

In October 2011, the Centers for Medicare and Medicaid Services (CMS) approved California’s plan to reduce rates for Medi-Cal (Medicaid in California) providers by 10% (adopted to deal with the state deficit), retroactive to June 1, 2011. In December 2012, a three-judge panel of the 9th U.S. Circuit Court of Appeals overturned a district court ruling to stop the retroactive 10% cut. Healthcare providers then asked the full 9th Circuit court to review the case. In May 2013, the full 9th Circuit Court upheld the cut, and, as a result, the 10% rate reduction must now be implemented unless plaintiffs appeal the case to the U.S. Supreme Court and the high court blocks the cut while the case is heard and decided.

California lawmakers could also block the cut by approving legislation that draws enough support to sustain a possible veto by the governor. Meanwhile, the governor included the rate reduction in his revised fiscal year 2013–2014 budget proposal. The cuts, which are based on funding levels from fiscal year 2008– 2009, could result in a 25% reduction to Medi-Cal services.

Physicians, who work to protect patients, believe the state’s action flies in the face of the intent of federal laws intended to assure that Medicaid patients have access to medical care, and undermines the goals of healthcare reform. California is below the national average with respect to Medicaid reimbursement rates: Medi-Cal reimburses 51% of Medicare’s reimbursement rates for the same services compared to 66% of Medicare’s rates nationally. In San Diego, 42% of healthcare providers accept Medicaid.

30 j u n e 2013

Threats CMA held off the 10% MediCal cut in the courts for several years, but the judicial process is now exhausted. We are now working to solve this problem through the legislative budget process. Our biggest concern is that the Medi-Cal reimbursement clawback, i.e., the state’s asking for 10% of past MediCal reimbursements back, be limited or eliminated.

State’s Financial Argument: A spokesperson for the state Department of Finance said that the cut will allow the state to save $458.8 million in the 2013–2014 fiscal year, which starts July 1, and $725 million the following year. He said, “We cannot repeat the mistakes of the past and commit the state to an ongoing higher level of spending than the state can sustain.”

Response: These cuts will raise, not lower, the overall cost of care. There may be less spent up front, but it is the unspoken consequences that cost our state, and individuals, so much more. Where will these patients go when they cannot find a primary care doctor, or their clinic cannot find a specialist to see them under Medi-Cal? To the emergency room, where care is notably more costly than timely care in the doctor’s office.

Never mind that the transition to the ER for non-emergent needs affects urgent access to needed care for all patients in the ER. The pain doesn’t stop there. The cost shifting whereby private pay or insured

patients are asked to subsidize public insurance plans that don’t cover the actual costs of care will only accelerate, raising insurance premiums and costs to paying patients.

State’s Access Argument: A spokesperson for DHCS said that the state has and will continue to monitor access to care for Medi-Cal beneficiaries. In a statement, he said the state’s monitoring efforts “will help ensure that the rate reductions will not unacceptably impact member access, and that if problems occur, we will quickly address them.”

Response: Existing MediCal payments are the worst in the nation. Medicare pays $73 for the most common level of office visit — Medi-Cal a paltry $23. The cost to provide medical care — rent, salaries, equipment, consumables, etc. — has risen year after year above inflation, without any significant increase in MediCal reimbursements for over two decades. The governor wants to cut these already abysmal, access-limiting rates even further, hoping doctors will continue to see Medi-Cal patients by paying even more out of their own pockets. This hope is, at best, delusional.

The likely scenario is further erosion of already limited access to care as more physicians find it impossible to continue to care for the current and expanding Medi-Cal population.

Data from multiple, broadbased SDCMS surveys could not be clearer: The number of doctors taking Medi-Cal, already below federal standards due to years of underfund-

ing, is decreasing. Reducing already-inadequate reimbursements will dramatically accelerate physician departure from Medi-Cal participation.

In San Diego we have seen an erosion of the number of doctors who will see Medi-Cal patients, and surveys asking what San Diego doctors would do in the face of a mere 5% cut to reimbursements showed that a drop of at least another 20% would be likely in private practices. Absent increases in Medi-Cal rates and other reforms, we will sentence a large number of San Diegans to quixotic searches for specialists, and all patients will potentially wait longer for services, especially at the ER.

Opponent of Cuts Argument: This is the worst possible time to be cutting already abysmally low Medi-Cal rates.

Explanation: Some 800,000 children are being moved from the relatively successful but now dissolved Healthy Families program into this failed Medi-Cal program. The ACA will add yet another 2–3 million Californians to the MediCal roles. If there is already inadequate physician access, and if more physicians are forced out of participation by further cuts and hassles, who will see these new enrollees, let alone the current patients?

So much for the state’s ability to continue to serve Medi-Cal patients with quality care … another hollow political boast while balancing the budget on the backs of our most vulnerable patients and those who actually are still willing provide them healthcare.

California is below the national average with respect to Medicaid reimbursement rates: Medi-Cal reimburses 51% of Medicare’s reimbursement rates for the same services compared to 66% of Medicare’s rates nationally. In San Diego, 42% of healthcare providers accept Medicaid.

SAN DI EGO PHYSICIAN.org 31

Bar to the Corporate Practice of Medicine Background

California law prohibits any person from practicing medicine in this state without a valid certificate of licensure (Bus. & Prof. Code section 2052). This prohibition not only applies to lay individuals but, with limited exceptions, also to corporations and other artificial entities that have “no professional rights, privileges, or powers” under California’s Medical Practice Act (Bus. & Prof. Code section 2400).

The bar to the corporate practice of medicine — corporate bar — is designed to protect the public from possible abuses stemming from the commercial exploitation of the practice of medicine. It ensures that those persons who make decisions affecting the provision of medical care understand the quality of care implications of those decisions, possess the professional ethical obligation to place the patient’s interests foremost, and are subject to the full panoply of enforcement powers of the Medical Board of California, which is charged with the administration of the Medical Practice Act. The corporate practice of medicine prohibition has been interpreted broadly to encompass not only direct medical decisions, but “business” and “administrative” decisions that have medical implications as well. For example, the prospective purchase of a piece of radiological equipment could be impacted by business considerations, medical considerations, or by an amalgam of factors emanating from both business and medical areas.

32 j u n e 2013

Threats The corporate bar protects patients and preserves physician autonomy by keeping hospitals and other commercial entities from directly hiring physicians and from dictating clinical decisions based on profit. With tightening economic pressures, hospitals and others are constantly seeking to erode the corporate bar. They would like to directly hire doctors and control physician freedom and patient access to care. Compromising physicians’ professional judgment would result in higher healthcare costs and diminished quality of care for our patients.

It is critical for the integrity of patient care that physicians remain independent from the corporate influence of hospital administrators and CEOs, who must answer to priorities other than patient care.

When hospitals are allowed to directly employ and charge for physician services, quality of care suffers because hospitals derive income from patient beds being filled.

Argument Against the Corporate Bar: Isn’t there a shortage of physicians in some areas that limits access to care?

Response: There are ways to address physician shortages in California without allowing hospitals to control physician employment. Increasing slots to allow residents to train in California, developing the medical schools at UC Merced, UC Riverside, and expanding access to California’s loan repayment program will truly ensure physicians go to and stay in rural and underserved areas.

Simply allowing hospitals to employ physicians may actually result in reduced access and increased costs.

Hospital employment of physicians eliminates competition for outpatient services and instead forces all care to be delivered through the hospital. As hospitals gain market share in small communities, physicians not employed will likely be forced out of business, and surgery centers outside the hospital will likely be forced to close.

This results in fewer options for patients and increased costs as the hospital is able to charge higher rates with the elimination of competition.

Allowing a hospital to directly employ a physician will not increase access to physician services. The hospital will push patients to their preferred provider thereby controlling the competitive market. Other non-employed physicians will not be able to compete and will likely be forced out of town, resulting in no increased access.

Argument Against the Corporate Bar: Bills to eliminate the corporate bar would not have an effect on the quality of care in California’s hospitals.

Response: These bills would give hospital CEOs and administrative staff, who have different motivations, control over physicians who should be making treatment decisions.

This will create conflicted loyalties in an institution that must remain true to the patient’s interests, and will erode the quality of care patients receive in California hospitals.

In fact, hospitals are already interfering with medical staffs’ ability to ensure quality care through independent selfgovernance. For example, some hospitals have adopted medical management protocols that have resulted in inappropriate hospital tests, procedures, and stays, jeopardizing patients and increasing costs.

Argument Against the Corporate Bar: Physicians’ independent medical judgments would not be compromised.

Response: Placing doctors under the oversight of hospital administrators and CEOs who are under enormous pressures to cut costs or increase revenue would threaten the independent medical judgment necessary to ensure patients are protected. A recently released study shows the hospitals’ interest in acquiring physician practices is based on financial and anti-competitive motivations, not just to increase access for patients.

Argument Against the Corporate Bar: CMA isn’t doing anything to increase patient access to physicians.

Response: CMA supports policies that will truly increase access to care, without compromising the quality of care. CMA supported bills that now are providing more than

$2 million in medical school loan repayments for physicians who agree to practice in underserved areas. Since loan repayment obligation is one of the primary reasons physicians will not go to underserved areas, this will attract physicians to these areas without compromising the quality of care patients receive.

Argument Against the Corporate Bar: It’s difficult for hospitals in California to recruit physicians.

Response: Hospital districts already have numerous financial incentives they can use to recruit physicians. Proponents of eliminating the corporate bar, including hospital districts, have failed to show why allowing corporate entities to directly hire physicians would work where these incentives have failed. A list of incentives currently available to hospitals and hospitals districts include: • guarantee to a physician and surgeon a minimum income for a period of no more than three years from the opening of the physician and surgeon’s practice, • guarantee purchases of necessary equipment by the physician and surgeon, • provide reduced rental rates of office space in any building owned by the district or any of its affiliated entities, and • provide other incentives to a physician and surgeon in exchange for consideration and upon terms and conditions the hospital district’s board of directors deems reasonable and appropriate.

None of these incentives grant hospitals or hospital districts the control over the actions of physicians, which they seek through the ability to hire physicians — the real goal of eliminating the patient protections of the corporate bar.

The corporate bar protects patients and preserves physician autonomy by keeping hospitals and other commercial entities from directly hiring physicians and from dictating clinical decisions based on profit.

SAN DI EGO PHYSICIAN.org 33

classifieds PHYSICIAN POSITIONS AVAILABLE FULL-TIME URGENT CARE PHYSICIAN: Busy practice in El Cajon, established in 1982, seeks a full-time physician. Please send CV to jeff@ eastcountyurgentcare.com or fax to (619) 4422245. [148] PRIMARY CARE JOB OPPORTUNITY: Home Physicians (www.thehousecalldocs.com) is a fastgrowing 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 (619) 9925330 or email CV to drhunt@thehousecalldocs. com. [037] PART-TIME PHYSICIAN NEEDED FOR URGENT CARE IN SCRIPPS RANCH: Board-certified in family practice / IM or ER. PA considered with minimum of three years urgent care experience, DEA licence, and control substance class.

Please email your CV to mdtodayurgentcare@ gmail.com or fax to (858) 622-1417. Please include references. [147] SHARP HEALTHCARE IS SEEKING A PHYSICIAN REVIEWER: For the medical direction of Authorization Review for Sharp Health Plan, and to ensure quality of care and appropriate utilization in the most cost-effective, appropriate, and professional manner. Must have an MD degree, current license, and five years minimum experience practicing primary care physician with knowledge of managed care and the process for prior authorization review required. To apply online, please visit http://bit.ly/10DvzMU. Sharp Experience is our unique, system-wide commitment to transforming the healthcare experience in San Diego by becoming the best place to work, practice medicine, and receive care. EOE. [143] SEEKING FULL-TIME BC/BE INTERNAL MEDICINE PHYSICIANS: Sharp Rees-Stealy Medical Group, a 400+ physician multi-specialty group in San Diego, is seeking full-time BC/BE internal medicine physicians to join our staff.

We offer a first-year competitive compensation guarantee and an excellent benefits package. Please send CV to lori.miller@sharp.com or upload CV at https://home2.eease.adp.com/ recruit/?id=6795752. [136] PHYSICIANS NEEDED: Family medicine, pediatrics, and OB/GYN. Vista Community Clinic, a private nonprofit outpatient clinic serving the communities of North San Diego County, has opening for part-time, per diem positions. Must have current CA and DEA licenses. Malpractice coverage provided. Bilingual English/Spanish preferred.

Forward resume to hr@vistacommunityclinic.org or fax to (760) 414-3702. Visit our website at www. vistacommunityclinic.org. EOE/MF/D/V [912] RECRUITING A CARDIOLOGIST TO VOLUNTEER ONCE A MONTH: The UCSD Student-Run Free Clinic Project is recruiting a cardiologist to volunteer once a month (Monday in downtown San Diego OR Wednesday evening in Pacific Beach). This is a unique opportunity to serve the community as well as teach the eager medical students that will become tomorrow’s physicians. If you are interested in learning more about this vol-

unteer position, please contact Dr. Michelle Johnson at mlj001@ucsd.edu and / or visit our website at http://meded.ucsd.edu/freeclinic. [131] HIRING BC/BE PSYCHIATRISTS: Hiring BC/ BE psychiatrists for full-time, home call, and weekend rounding positions at award-winning Palomar Health. Competitive pay. Contact Susan Linback at (760) 739-2973 or send CV to susan. linback@palomarhealth.org. [130] PER DIEM PHYSICIANS: Imaging Healthcare Specialists is actively seeking per diem physicians to monitor patient examinations requiring contrast. Current openings are for Saturday and Sunday shifts. Applicants must be available a minimum of three weekend days per month and to work at multiple locations. For more information, please contact Brandy at (858) 658-6589 or email a copy of your updated CV / resume to careers@imaginghealthcare.com. [129] MEDICAL DIRECTOR: Part-time medical director needed for a medical spa in East County.

Retired physicians welcome. Malpractice and salary will be paid. Please call Nancy at (619) 456-4555. [128] FAMILY MEDICINE OPPORTUNITY IN NORTH COASTAL SAN DIEGO COUNTY (VISTA): This is with a long-established group, which is physician owned and governed. Board-certified / board-eligible candidates only. Full time. If interested, please send CV to judy@cassidymg.com or call (760) 630-5487. [123] 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 tail-covered 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] PRACTICE WANTED WE BUY URGENT CARE OR READY MEDCLINIC: 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 BANKERS HILL PRIMARY CARE AND RESEARCH OFFICE SPACE TO SUBLEASE: 50year established primary care practice and clinical research office with currently two internists has space to sublease to another primary care doctor (or two) to help curb overhead and help with acute overflow patients needs. Also can

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 j u n e 2013

provide opportunity to get into clinical research.

Contact Cindy at allmedgrp@hotmail.com. [146] SUBLEASE IN PRESTIGIOUS UTC BUILDING: Sublease beautifully appointed 2100-square-foot office in prestigious building in UTC, starting on July 1, 2014. Ideal for plastic surgeon, urologist, orthopedic surgeon, or pain specialist. Direct access to AAAASF-certified surgical center with existing contracts with Blue Cross, UnitedHealthcare, workers' compensation, and Aetna. Fraxel repair laser, hand fluoro, endoscopic and powerassisted liposuction equipment available at premises. Please call or email Ines Ustare at (858) 4578686 or ines@solteromd.com. [145]

CreekView Medical Park in Vista Quality Medical / Office Condos or Buildings / For Sale Lease. New sustainable construction near Tri-City Hospital, Healing Environment, Signage Available / Perfect opportunity for inpatient & overnight stay facility, assisted living, skilled nursing, educational, research, hospice, therapy, specialty hospitals, surgery centers, rehabilitation facilities, medical & dental offices & more! 1,494 - 48,268 SF Available 1910-1968 Via Centre Drive, Vista Visit www.creekviewmedical.com Call 760.431.4201

OFFICE SPACE TO SHARE: Office space to share in National City with a well-respected physician who has been in private practice for 30 years. Office is about 900 square feet with two exam rooms and an additional office/multi-purpose space. Office is currently being used parttime, Monday through Wednesday, but hours are flexible to accommodate another part-time practice. Physician planning to retire within one year.

Bilingual (English/Spanish) speaking helpful. If interested, please contact me at bpmedina@ msn.com. [141] OFFICE SPACE AVAILABLE IN MISSION VALLEY: Seeking psychologist / psychiatrist or other similar provider for Mission Valley office space.

Beautiful large room available in centrally located urgent care / family practice / occupational medicine practice. Psychologist or psychiatrist would be optimal provider, as we will be happy to refer you patients in need of your services — a win-win situation. Please contact Brenda at brenda@missionvalleymedical.com or myself at drpohl@missionvalleymedical.com, or on my cell at (619) 8468156. Office is available on July 1. [140] OFFICES FOR RENT: UTC/La Jolla area, fulltime office in 8th-floor suite with established psychologists and psychiatrists. In Class A building with pleasant view. Features include private entrance, staff room with kitchen facilities, active professional collegiality and informal consultation, private restroom, spacious penthouse gym, storage closet with private lock in each office, soundproofing, common waiting room, and abundant parking. Telephone Manuel D. Tobias, PhD, or Thomas J. Wegman, PhD, at (858) 3628779. [139] LA JOLLA (NEAR UTC) OFFICE FOR SUBLEASE: Scripps Memorial medical office building, 9834 Genesee Ave. (great location by the front of the main entrance of the hospital between I-5 and I-805). Multidisciplinary group. Excellent refer-

ral base in the office and on the hospital campus.

Please call (858) 455-7535 or (858) 320-0525 and ask for the secretary, Sandy. [127] GET 1 MONTH FREE RENT: A 1215 sq.ft. office space is available for rent in a well-maintained professional building. This space is ready for move in. It has three large offices, a break room, a common space, a private bathroom, and a big reception area. Excellent for accounting office, insurance, medical office, chiropractor, real estate, complementary/alternative medicine, physical therapy, chiropractic, acupuncture, massage/body work, etc. Located close to Rancho Bernardo, Scripps Ranch, 4-S Ranch, Poway. Get one month of free rent in the form of two halfmonths of rent. $1,400 net is all you pay, no NNN added. Please call Heather for any questions at (858) 909-9033 or email olgald@palomar-neurosurgery.com. [124] OFFICE SPACE IN ENCINITAS — 477 N. EL CAMINO REAL: 1600sf beautiful office occupied by a dermatologist. One or two rooms available.

May have the space to yourself for a full day and some half days. Prime location in a multi-specialty, four-building complex with an outpatient surgery center. Close to Scripps Encinitas Hospital. Available immediately and staff available if needed. Great for solo physician or a small group seeking a presence in North County. Please contact Dana at (760) 436-8700 or at dana@doctorlashgari.com [122] LUXURIOUS / BEAUTIFULLY DECORATED DOCTOR’S OFFICE NEXT TO SHARP HOSPITAL FOR SUB-LEASE 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) 279-8111 or at (619) 823-8111. Thank you. [836] 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] POWAY / RANCHO BERNARDO — OFFICE FOR SUBLEASE: Spacious, beautiful, newly renovated, 1,467 sq-ft 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] 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 / WANTED

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 RECEPTIONIST / SECRETARY: Cosmetic / plastic surgical practice in Bankers Hill.

Must possess proper phone etiquette and have a professional attitude and appearance. 32 hours,

Monday – Thursday. AS degree plus 2 years experience in a medical office. Contact Grace at (619) 297-4433, ext. 308. [144] NEED A PART-TIME NURSE PRACTITIONER: Apreva Hospice needs a part-time nurse practitioner for home hospice visits. Once a week at this time, but opportunity for more work available. Please email KLewis@SDCMS.org. [138] EXPERIENCED MEDICAL RECEPTIONIST FOR FULL-TIME EMPLOYMENT: My name is Ashley Richards. I recently moved to the San Diego area, and I am looking for employment.

Collectively, I have 6+ years medical reception / management experience in optometry, audiology, and ENT offices. All included high call volumes, team work, EMR, insurance verification, and copay collections. References on request.

Thank you. Cell: (805) 433-2983. Email: sff_mo@ yahoo.com. [137] NORTH COUNTY PRACTICE SEEKS RNP: Multi-specialty practice in need of part- or fulltime RNP for growing practice. Prefer internal medicine / nephrology experience. Ehr experience a plus. Please send CV with references to rnpvacancy@gmail.com. [134] 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 sign-in time for patients with a Medical Check In touchscreen 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]

Place your ad here Contact Dari Pebdani at 858-231-1231 or DPebdani@sdcms.org SAN DI EGO PHYSICIAN.org 35

San Diego Physician Celebrates 100 Years!

The Bulletin of the San Diego County Medical Society April 1975

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

Had a Suit Pressed Lately?

Comm Statement to the California Assembly Select Good Morning Gentlemen:

ittee on Medical Malpractice By Franklin S. Glanz

nundrum that threatens to close off all medical care. is What seems to be forgotten is that this insurance the t protec to ial essent is It necessary for our patients. obile public. We require liability insurance for autom negfrom rians pedest our t drivers in this state to protec prosame the to d entitle are s citizen Our nts. accide ligent als. tection in our offices and hospit by Our workmen are secured in their occupations nce.

Insura Workmen’s Compensation Our patients are entitled to similar security in our

before I want to thank you for the privilege of appearing ng. you this morni I am Dr. Franklin S. Glanz, a family physician from al San Diego and chairman of the San Diego County Medic Society’s Medical Malpractice Committee.

Today I am representing the 2,000 doctors of the San lties Diego County Medical Society. We include all specia phyfamily and y primar the ing includ ine, of our discipl practices. tuents sicians who render the medical care to your consti no It is obvious that 25,000 doctors in California can ts. patien who are our under s citizen million 17 of risk longer insure the medical Our citizens are in danger of losing their doctors and shed our present system. Another forum must be establi reand rated amelio is crisis this unless als their hospit to deal with this dilemma. solved quickly.

A new method of compensating legitimate comprequoted been ly recent have s doctor family Some new pensable injury must be developed. We believe this is no miums that exceed $15,000.00 per year and there ComInjury al Medic a by served be best would system t possible way they can afford to pay these rates withou pensation Act. raising their fees to astronomical levels. […] insurthis of e expens the time recent the Up until The medical profession, our hospitals and the public fees al hospit and t ance has been passed on to the patien must be provided with this essential protection. place charged for medical care. The new costs would In less than 75 days the doctors of San Francisco and s. citizen our health services beyond the reach of rn California counties will be without insurnorthe six its A concern as great as the price of this insurance is m ance. Coverage will no longer be available at a premiu availability. night last s doctor to spoke I pay. to afford can public the Over 200 doctors in our medical society have had ing from the Northern California area. They are prepar notheir insurance cancelled recently on only 10 days are Others 1st.

May on leave and offices their close to left tice. A number of these essential physicians were to plan others still and es beginning to cull their practic uswithout a carrier and subsequently precluded from area. the leave ing the hospitals.

The doctors are anxious, their patients are frightened of An excellent anesthesiologist with over 20 years not and I know you are concerned. My profession has quoted practice and a clean record of no claims or suits was wiped Plague ic Bubon the since faced such a critical crisis a premium in excess of $24,000.00. he stopped practic has out half the doctors in Philadelphia in 1778, and never only with left was area our in tion institu one ing. At least one what on much so ed depend the health of our people one anesthesiologist to serve an entire hospital. committee may recommend. ce existen the denies sion profes al medic the in No one We urge you to act now. Please give your recom unthe to ry recove fair of malpractice nor the right of a tion. legisla ial essent this to rt suppo and tion menda tjustly injured patient. But our present system of evalua Thank you. a coing and pursuing these complaints has resulted in 36 j u n e 2013

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