March 2018

MARCH 2018 OFFICIAL PUBLICATION OF SDCMS

THE DEBATE IN CALIFORNIA FOR SINGLE PAYER HEALTHCARE

Medical Coalitions Join Forces to Educate Politicians

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LOMAS SANTA FE COUNTRY CLUB

Save The Date: Monday, March 26, 2018

11:30 am Golf Registration & Luncheon 12:30 Shotgun Start Time; Scramble Format 1:30 pm Tennis Round Robin Tournament & Exhibition 5:30 pm Health Heroes Awards Reception & Dinner Golf & Tennis Package includes: Golf or tennis play, gift bag and reception/dinner

Golf Foursome: $1,000; Individual Players: $300 Tennis Players: $100 each player Health Heroes Reception/Dinner only: $75 For more information call 858.300.2780 or visit: www.AcesForHealth.org

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MARCH

CONTENTS

VOLUME 105, NUMBER 3 EDITOR: James Santiago Grisolía, MD EDITORIAL BOARD: James Santiago Grisolía, MD • Mihir Parikh, MD • Robert E. Peters, MD, PhD • J. Steven Poceta, MD MARKETING & PRODUCTION MANAGER: Jennifer Rohr SALES DIRECTOR: Dari Pebdani ART DIRECTOR: Lisa Williams COPY EDITOR: Adam Elder OFFICERS President: Mark W. Sornson, MD, PhD President-elect: David E.J. Bazzo, MD Secretary: James H. Schultz Jr., MD Treasurer: Holly B. Yang, MD Immediate Past President: Mihir Y. Parikh, MD GEOGRAPHIC DIRECTORS East County #1: Venu Prabaker, MD East County #2: Rakesh R. Patel, MD East County #3: Jane A. Lyons, MD Hillcrest #1: Gregory M. Balourdas, MD Hillcrest #2: Thomas C. Lian, MD Kearny Mesa #1: Sergio R. Flores, MD (Board Representative to Executive Committee) Kearny Mesa #2: Alexander K. Quick, MD La Jolla #1: Geva E. Mannor, MD, MPH La Jolla #2: Marc M. Sedwitz, MD, FACS North County #1: Patrick A. Tellez, MD North County #2: Christopher M. Bergeron, MD, FACS North County #3: Michael A. Lobatz, MD South Bay #1: Irineo “Reno” D. Tiangco, MD South Bay #2: Maria T. Carriedo, MD GEOGRAPHIC ALTERNATE DIRECTORS East County: Susan Kaweski, MD Hillcrest: Kyle P. Edmonds, MD Kearny Mesa #1: Anthony E. Magit, MD Kearny Mesa #2: Eileen R. Quintela, MD La Jolla: Wayne C. Sun, MD North County: Neelima V. Chu, MD South Bay: Paul Manos, DO AT-LARGE DIRECTORS #1: Thomas J. Savides, MD; #2: Karrar H. Ali, DO, MPH; #3: Alexexandra E. Page, MD; #4: Nicholas J. Yphantides, MD; #5: Stephen R. Hayden, MD (Delegation Chair); #6: Marcella (Marci) M. Wilson, MD; #7: Toluwalase (Lase) A. Ajayi, MD (Board Representative to Executive Committee); #8: Robert E. Peters, MD

features

AT-LARGE ALTERNATE DIRECTORS #1: Karl E. Steinberg, MD; #2: Steven L-W Chen, MD, FACS, MBA; #3: Erin L. Whitaker, MD; #4: Al Ray, MD; #5: Preeti Mehta, MD; #6: Vimal I. Nanavati, MD, FACC, FSCAI; #7: Peter O. Raudaskoski, MD; #8: Kosala Samarasinghe, MD

20 California Health Bill Pushes Unrealistic, Empty Promises

ADDITIONAL VOTING DIRECTORS Communications Chair: J. Steven Poceta, MD Young Physician Director: Edwin S. Chen, MD Resident Physician Director: Trisha Morshed, MD Retired Physician Director: David Priver, MD Medical Student Director: Meghana Pagadala

BY THEODORE M. MAZER, MD

22 Congress Races the Clock in Quest to Bring Stability to the Individual Insurance Market

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BY JULIE ROVNER

departments 4 Briefly Noted: Calendar • Giving Back • New & Returning Members

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To Discuss … or Not to Discuss

BY HELANE FRONEK, MD, FACP, FACPh

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How Lawmakers are Tackling the Opioid Epidemic

California Medical Association Launches Coalition to Protect Patients’ Access to Care

BY DENNIS W. CHIU, JD

BY CALIFORNIA MEDICAL ASSOCIATION

8 EHRs Can Advance Good Medicine

BY DAVID B. TROXEL, MD

10 Changing the Way We Look at Dementia

BY JUDITH GRAHAM

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ADDITIONAL NON-VOTING MEMBERS Alternate Young Physician Director: Heidi M. Meyer, MD Alternate Resident Physician Director: Zachary T. Berman, MD Alternate Retired Physician Director: Mitsuo Tomita, MD\ San Diego Physician Editor: James Santiago Grisolia, MD CMA Past President: James T. Hay, MD CMA Past President: Robert E. Hertzka, MD (Legislative Committee Chair) CMA Past President: Ralph R. Ocampo, MD, FACS CMA President: Theodore M. Mazer, MD CMA TRUSTEES Robert E. Wailes, MD William T-C Tseng, MD, MP

AMA DELEGATES AND ALTERNATE DELEGATES: District 1 AMA Delegate: James T. Hay, MD District 1 AMA Alternate Delegate: Mihir Y. Parikh, MD At-large AMA Delegate: Albert Ray, MD (appointed by CMA) At-large AMA Delegate: Robert E. Hertzka, MD (appointed by CMA) At-large AMA Alternate Delegate: Theodore M. Mazer, MD (appointed by CMA)

AND SAN DIEGO COUNTY MEDICAL SOCIETY

26 Physician Marketplace: Classifieds

28 CMA-Sponsored Bill Would Require Physician-Conducted Autopsies

Opinions expressed by authors are their own and not necessarily those of San Diego Physician or SDCMS. San Diego Physician reserves the right to edit all contributions for clarity and length as well as to reject any material submitted.

Not responsible for unsolicited manuscripts. Advertising rates and information sent upon request. Acceptance of advertising in San Diego Physician in no way constitutes approval or endorsement by SDCMS of products or services advertised. San Diego Physician and SDCMS reserve the right to reject any advertising. Address all editorial communications to Editor@SDCMS.org.

All advertising inquiries can be sent to DPebdani@SDCMS.org. San Diego Physician is published monthly on the first of the month. Subscription rates are $35.00 per year. For subscriptions, email Editor@SDCMS.org. [San Diego County Medical Society (SDCMS) Printed in the U.S.A.]

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GIVING BACK

VOLUNTEER OPPORTUNITIES Email Your Volunteer Opportunity Ads to Editor@SDCMS.org

MARCH 26: Champions for Health “Aces for Health” Golf and Tennis Tournament benefitting Champions for Health, Lomas Santa Fe Country Club MARCH 27: “Hippocratic 18 Experiments in Gently Shaking World” reception and private film screening APRIL 18: CMA Legislative Advocacy Day. Sacramento, CA MAY 5: Annual SDCMS White Coat Gala at Paradise Point Resort May 23: The 30th Annual Western States Regional Conference on Physicians’ WellBeing, UC Riverside Extension Center JUNE 22-24: San Diego Academy of Family Physicians 61st Annual Family Medicine Update 2018, Paradise Point Hotel in Mission Bay. This is an AAFP and AOA CME accredited program. Register at www.sandiegoafp.org October 13-14: CMA House of Delegates.

Sacramento, CA

SDCMS Social Events 2018 May 5 (Sat) SDCMS White Coat Gala, Paradise Point Resort July 14 (Sat) Family Pool Party Oct 25 (Thurs) Physician Networking Mixer *dates subject to change.

PHYSICIANS: HELP US HELP IMPROVE THE HEALTH LITERACY OF OUR SAN DIEGO COUNTY COMMUNITIES by giving a brief presentation (30–45 minutes) to area children, adults, seniors, or employees on a topic that impassions you. Be a part of Champions for Health’s Live Well San Diego Speakers Bureau and help improve the health literacy of those with limited access to care. For further details on how you can get involved, please email Andrew.Gonzalez@ ChampionsFH.org.

CHAMPIONS FOR HEALTH PROJECT ACCESS: Volunteer physicians are needed for the following specialties: endocrinology, ENT or head and neck, general surgery, GI, gynecology, neurology, ophthalmology, orthopedics, pulmonology, rheumatology, and urology. We are seeking these specialists throughout all regions of San Diego to support those that are uninsured and not eligible for Medi-Cal receive short term specialty care. Commitment can vary by practice. The mission of the

“

Champions for Health’s Project Access is to improve community health, access to care for all, and wellness for patients and physicians through engaged volunteerism. Will you be a health CHAMPION today? For more information, contact Andrew Gonzalez at (858) 300-2787 or at Andrew.

Gonzalez@ChampionsFH.org, or visit www.ChampionsforHealth.org.

SHORT-TERM MEDICAL VOLUNTEERS NEEDED FOR HAITI: We are looking for physicians, mid-level providers and nurses for one-week, primary-care medical clinics in rural Haiti in June and October 2018. This is a rewarding and fun opportunity to work with the people of Haiti and provide care in a rural clinic in a medically under served area. Seattle-King County Disaster Team (a U.S.-based nonprofit) has been operating these clinics since 1998. We coordinate all in-country travel and logistics. Please contact Bob Downey at (619) 905-7157 or at labboy@earthlink. net if you are interested in applying.

Visit www.skcdteam.org for further information

QUOTE OF THE MONTH

The quality of a leader is reflected in the standards they set for themselves.

— Ray Kroc (October 5, 1902 – January 14, 1984)

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TrusT

Congratulations to Dr. Robert Hertzka for his selection as one of the San Diego Business Journal’s 2018 Health Care Heroes.

MEMBERSHIP

Welcome New and Returning SDCMSCMA Members!

Welcome New Members!

Beatrice Elena Baez, MD Paulette Tucciarone Cazares, MD Tanushree Ghosh, DO Michael A. Hogarth, MD Thomas Joseph Kozak, MD Bassam Kadury Nassir, MD Margarita Paula Schneider-Munoz, MD Simon Zimnowodzki, MD Welcome Returning Members!

Gurinder Kaur Dabhia, MD David D’arcy Dowling, Jr., MD Alexander Raul Medina, MD Steven Frank Ritter, DO Maryam Zarei, MD LIVE WELL CENTER

New Live Well Center to Open in Southeastern San Diego Plans for a huge new County Live Well Center are in the works. The newest Live Well Center will be in southeast San Diego. County Supervisors Greg Cox and Ron Roberts, City Council President Myrtle Cole and community leaders made the announcement. When it’s finished, the 80,000-square-foot center will offer numerous health and social services under one roof.

CONFERENCES

CMS to host National Provider Enrollment Conference in San Diego April 24–25 The Centers for Medicare and Medicaid Services (CMS) will be hosting the 2018 CMS National Provider Enrollment Conference on April 24–25 at the San Diego Convention Center. This conference offers participants an opportunity to interact directly with CMS and Medicare Administrative Contractor provider enrollment experts. Conference participants can hear directly from the leadership of CMS’ Provider Enrollment and Oversight Group on how enrollment works, the new initiatives in provider enrollment, revalidation, how CMS protects the program and how to avoid potential sanctions.

The California Medical Association encourages practices to attend this free conference as minor mistakes during revalidation, failure to revalidate in a timely manner, or failure to update Medicare on changes in the practice’s enrollment record can significantly affect a practice and its ability to be paid

by Medicare.

To register or learn more about this conference go to: www.med.noridianmedicare.com/web/medicare/nationalprovider-enrollment-conference.

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H E A LT H C A R E L E G I S L AT I O N

How Lawmakers Are Tackling the Opioid Epidemic

By Dennis W. Chiu, JD

WHEN THE OPIOID EPIDEMIC hit the news — not just in scientific journals but in the popular media as well — it spurred Congress and state legislatures to offer public healthcare policy solutions. This has resulted in increased funding for treatment, more regulations for prescribing opioids, measures to increase the availability of opioid antagonists, and a reduction in liability for the administration of opioid antagonists.

Celebrity Tragedy and National Statistics In 2016, the autopsy of pop music legend Prince found that the singer died from a “self-administered” dose of the opioid fentanyl. Prince’s tragic demise was only one of many celebrity deaths attributed to opioidrelated causes. Celebrity deaths brought the dangers of opioids to the public’s attention, and statistics for the general population support the perception of an opioid addiction epidemic. Centers for Disease Control (CDC) Director Dr. Tom Frieden noted: “We know of no other medication routinely used for a nonfatal condition that kills patients so frequently.”1 Between the media attention and the preponderance of evidence that opioid usage had become a major public health problem in America, legislators were spurred to address the problem.

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Legislation and Administrative Action Lawmakers typically attempt to solve problems in two ways: (1) providing funding for programs, and (2) enacting regulations through legislation.

As an indicator of the level of concern of U.S. lawmakers, the usually gridlocked Republican Congress and Democratic President Barack Obama united to address the issue. On Dec. 13, 2016, both houses of Congress and the president worked together to approve legislation that granted $1 billion to state opioid abuse programs.

This was a sharp increase in funding from earlier in the year and from previous years.

(The Senate passed the law by a vote of 94–5, and the House of Representatives passed the law by a vote 355–77.)

On Oct. 26, 2017, President Donald Trump declared the opioid addiction crisis a public health emergency via the Public Health Service Act, though minimal new funding accompanied the declaration.

The White House and Congress will need to work together to increase the depleted Public Health Emergency Fund. Two states—Colorado and Indiana—have since created funding for opioid treatment pilot programs. The Maine legislature overrode its governor’s veto to ensure access to opiate addiction treatment under its Medicaid program. Delaware and New Jersey have enacted laws requiring healthcare insurers to provide coverage for opioid addiction treatment.

Legislators have also passed laws regulating the prescribing of opioids.

Requiring Physicians to Check Prescription Databases Prescription drug databases, originally intended to be used by law enforcement, have been widened to allow healthcare providers and prescribers to review a patient’s prescription history for signs of overprescribing or addiction. Every U.S. state with the exception of Missouri has a

prescription monitoring database.2 Some states have gone even further.

By 2016, 18 states had passed legislation requiring medical professionals to consult a state database: California, Connecticut, Kentucky, Maine, Maryland, Massachusetts, Nevada, New Hampshire, New Jersey, New Mexico, New York, Ohio, Oklahoma, Pennsylvania, Rhode Island, Tennessee, West Virginia, and Wisconsin. State laws and regulations mandating prescribers to query the database vary as to requirements, but in general, most require the prescriber to check: (1) before initially prescribing a controlled substance to a patient in an opioid treatment program, (2) in workers’ compensation cases, and (3) prior to initially prescribing or dispensing an opioid analgesic or benzodiazepine in any setting.3 Most often, the penalty for prescribers for failure to check the database is referral to the department or board that enforces violation of professional standards.4 Opioid Antagonist Access Laws and Good Samaritan Protections5 Legislators have also sought to decrease deaths from prescription opioid abuse by increasing access to opioid antagonists.

These drugs have no abuse potential and counteract the life-threatening effects of an overdose, allowing the victim to breathe normally once administered.

Previously, access to these lifesaving medications was limited because a doctorpatient relationship needed to exist for a prescription to be issued. This requirement was ineffective because family and friends are often in the best place to administer an antagonist during an overdose, but they did not have access to a prescription.

In 2001, New Mexico became the first state to enact legislation increasing access to opioid antagonists. Over the past 15 years, 47 states and the District of Columbia have passed similar laws. In the 2017 legislative year, Montana, North Carolina, Nevada, Tennessee, Texas, Virginia, Wis-

consin, and West Virginia enacted laws making opioid antagonists more available.

In conjunction with increasing access to opioid antagonists, many states have passed Good Samaritan laws to limit liability for healthcare professionals and “laypersons” for administering opioid antagonist medications. For immunity to apply, laws typically require that a person must have a reasonable belief that someone is experiencing an overdose emergency, must remain on scene until help arrives, and must cooperate with emergency personnel. For healthcare personnel, immunity will usually apply unless there is gross negligence in the administration of the opioid antagonist.

Good Samaritan laws for the administration of opioid antagonists have been passed in 37 states and the District of Columbia. The 13 states that have yet to pass opioid antagonist Good Samaritan laws are Arizona, Idaho, Iowa, Kansas, Maine, Missouri, Montana, Nebraska, Oklahoma, South Carolina, South Dakota, Texas, and Wyoming.

Florida lawmakers will consider proposed legislation, Senate Bill 458, during the 2018 legislative session. If enacted in its current form, this bill will: • Limit a controlled opioid prescription to a seven-day supply.

• Limit refill or subsequent controlled opioid prescriptions to a 30-day supply.

• Provide exceptions to supply limits for certain patients.

• Require a prescriber to access a patient’s drug history in the prescription drug monitoring program’s database before prescribing the drug, and at least every 90 days thereafter for continuing treatment.

• Require a healthcare practitioner to complete a continuing-education course as a condition of initial licensure and biennial licensure renewal.

In 2017, Florida House Bill 477 added synthetic opioids to the list of controlled substances.

Conclusion The legislative response to the opioid epidemic includes expanding healthcare providers’ ability to access databases that track opioid prescriptions. Lawmakers are also working to ensure easier access to opioid antagonists and immunity to those who administer opioid antagonists. Legislators are also providing more public funding for existing programs for treatment of opioid-addicted patients.

At this point, there is insufficient data to evaluate the effectiveness of the recently passed legislation, but lawmakers and public health advocates hope to see a decline in opioid-related deaths when data becomes available.

Mr. Chiu is a government relations specialist for The Doctors Company.

References 1. Guideline for prescribing opioids for chronic pain [press briefing transcript].

Centers for Disease Control and Prevention; March 15, 2016. www.cdc.gov/media/ releases/2016/t0315-prescribing-opioidsguidelines.html. Accessed January 5, 2017.

2. 49 states combat opioid epidemic with prescription database. [transcript]. Morning Edition. National Public Radio. May 10, 2016. www.npr. org/2016/05/10/477449821/as-opioidcrisis-escalates-missouri-is-withoutmonitoring-database.

3. National Alliance for Model State Drug Laws. 2015 annual review of prescription monitoring programs. www.namsdl. org/library/1810E284-A0D7-D440C3A9A0560A1115D7/. Published September 2015. Accessed January 11, 2017.

4. Mass Ann Laws ch 94C, §24A; Md HB 437 (2016); Cal SB 482 (2016).

5. Drug overdose immunity and Good Samaritan laws. National Conference of State Legislatures Website. www.ncsl.org/ research/civil-and-criminal-justice/drugoverdose-immunity-good-samaritanlaws.aspx. August 1, 2016. Accessed January 11, 2017.

SAN DIEGO PHYSICIAN.ORG

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R I S K M A N AG E M E N T

EHRs Can Advance Good Medicine If Doctors Are Aware of the Risks by David B. Troxel, MD

HISTORICALLY, THE DOCTOR-patient relationship has been at the heart of medical practice, with administrative tasks and record-keeping at the border.

Today, that critical balance is at risk.

Nearly all hospitals and 80 percent of medical practices use electronic health records (EHRs), presumably to help improve access to health information and increase productivity. The problem is that none of these digital tools was designed specifically to advance the practice of good medicine.

Consider these stark statistics: Every hour doctors spend with patients, they dedicate nearly two more hours to maintaining EHRs and clerical work. Yet even when physicians are with patients, they’re spending approximately 37 percent of their time interacting with EHRs or other desk work.

We are now witnessing the highest levels

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of physician burnout on record. Indeed, the rise of documentation demands and decrease of meaningful patient interactions has led to major physician frustrations— while making it harder for physicians to deliver quality care.

For these reasons and more, the EHR has introduced patient safety risks and unanticipated medical liability risks. According to a new study from The Doctors Company, the nation’s largest physician-owned medical malpractice insurer, the number of EHR-related medical malpractice claims has risen over the past 10 years.

Factors Behind EHR Errors For the most part, the EHR is a contributing factor in an EHR-related claim and not the primary cause. This and their low frequency (0.9 percent of all claims) suggest

that EHRs infrequently result in adverse events of sufficient severity to develop into a malpractice claim.

When EHRs are a factor in a claim, the study showed that user factors (such as data entry errors, copy-and-paste issues, alert fatigue, and EHR conversion issues) contributed to nearly 60 percent of claims. As computer users, we all copy and paste. Therefore, it’s no surprise that time-pressured physicians embrace the same habits when using EHRs. In fact, the University of California San Francisco Medical Center — today considered a top five medical center in the United States — reviewed more than 23,000 of its own progress notes over an eight-month period and found that, on average, clinicians manually entered just 18 percent of the text in each note, while 46 percent was copied and 36 percent was imported.

System factors (such as data routing problems, EHR fragmentation, and inappropriate drop-down menu responses) contributed to 50 percent of claims.

EHR fragmentation was among the most prominent system factors, contributing to 12 percent of errors. This factor means that different components of a single patient encounter might not be located together in the EHR. Consequently, doctors must check in different places to find laboratory and x-ray results, histories and physicals, etc. — resulting in important information being overlooked or unidentified.

Reclaiming the Doctor-Patient Relationship One overwhelming response to adjust to burdens introduced by EHRs has been the rapid growth of medical scribes. Nearly 20 percent of medical practices are using scribes to help untether physicians from the EHR, with many doctors citing improved efficiency and satisfaction. Yet while scribes can offer great advantages, they can be a double-edged sword. According to a survey of hundreds of physicians from The Doctors Company, the lack of standardized training and variability in experience among scribes poses risks to data accuracy and delivery of care — which could increase liability for the patient and physician alike.

With or without scribes, lowering risk begins with each patient visit. At the beginning of each new session, doctors should inform patients of the purpose of

the EHR and emphasize they are listening closely even though they might be typing during the appointment. Practices can set up treatment rooms so the patient can watch the screen and see what is being typed. It is also helpful to summarize or read the note to the patient to demonstrate that you have listened, and ask, “Do I have it right?” If the doctor is using a medical scribe to untether them from their EHR, the same principle applies.

Patients must also become their own advocates. They can ask their doctor to read back the EHR notes or review what has been written. Patients can interact with their health record online through patient portals and review their medical record as well as disease-specific educational materials and drug safety information. It is important that they communicate any er-

rors they find as well as personal information updates to the physician.

What the Future Holds As with any challenge of major proportions, progress will take time. But I’m optimistic that the EHR will evolve over the next five to 10 years and improve both the quality of medical care and patient safety.

Optimizing the EHR will involve: • Redesigning EHR workflows to reflect clinical practice workflows in hospital, clinic, and office environments. It is essential that physicians and other healthcare providers be involved in this endeavor.

• Developing standardized diagnostic and treatment protocols.

• Researching medical artificial intelligence (AI). This is underway and

will doubtless play a significant role in future medical practice.

• Making EHR interoperability a high priority.

• Applying “big data” techniques to healthcare. This is underway and, like AI, will lead to new knowledge insights that will change the practice of medicine.

Today, what I hear from The Doctors Company’s 80,000 member physicians is encouraging. Doctors are eager to “reclaim” their profession and refocus patient relationships amid the new demands of today’s digital age. Into the future, new protocols, policies, and training programs must take these small successes to a large scale.

Dr. Troxel is medical director at The Doctors Company

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M E N TA L H E A LT H

Changing the Way We Look at Dementia

By Judith Graham

IN NOVEMBER, SIX PEOPLE with Alzheimer’s disease and related types of cognitive impairment stood before an audience of 100 in North Haven, Conn. One by one, they talked about what it was like to live with dementia in deeply personal terms.

Before the presentation, audience members were asked to write down five words they associated with dementia. Afterward, they were asked to do the same, this time reflecting on what they’d learned.

“Without exception, the words people used had changed — from ‘hopeless’ to ‘hope,’ from ‘depressed’ to ‘courageous,’ from ‘empty’ to ‘fulfilled,’” says Erica DeFrancesco, a clinical assistant professor of occupational therapy at Quinnipiac University who helped organize the event.

The session, followed by an hour-long discussion about dementia, is part of a new grass-roots movement in the U.S. aimed at

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educating people about Alzheimer’s disease and other forms of dementia, dispelling the painful stigma associated with these conditions and enhancing public understanding. A centerpiece of that effort, known as “Dementia Friends,” began just over a year ago under the auspices of Dementia Friendly America, an effort spearheaded by 35 organizations across the country.

Currently, more than 13,200 people are registered as Dementia Friends in the U.S., and organizations in 14 states (Arizona, California, Connecticut, Hawaii, Illinois, Indiana, Maryland, Massachusetts, Michigan, Minnesota, Ohio, North Carolina, Virginia, Wyoming) are hosting events to sign up more. Globally, almost 14 million people in 33 countries are involved in the movement, which originated in Japan.

To become a Dementia Friend, most people attend an hour-long presentation focused on several themes: Disease vs. typical aging. Alzheimer’s disease and other types of dementia are

illnesses of the brain, not a natural consequence of aging.

Scope of symptoms. Dementia triggers a wide array of symptoms, not just memory loss.

Quality of life. People with dementia can live well, often for years.

Maintaining identity and respect.

People with dementia retain a sense of self and aren’t defined exclusively by this condition. (Testimonials by people with dementia are sometimes, but not always, included.)

“If we can change the way people look at dementia and talk about it, we can make a big difference in people’s lives,” says Philippa Tree, who spearheads a well-established Dementia Friends program in England and Wales, with about 2.3 million members, that has licensed its model to the U.S. “It’s about increasing awareness and empathy so that if you encounter someone in the community who needs some help, you have some basic skills,” adds Meredith

2018

White Coat Gala AN EVENING CELEBRATING 148 YEARS OF HEALING

presented by welcoming

The San Diego County Medical Society & Champions for Health David E. Bazzo, MD, FAAFP SDCMS President 2017–2018

W. Sornson, MD, for thanking Mark His Service As Immediate Past President

Saturday, May 5, 2018 Paradise Point Resort

1404 Vacation Road, San Diego 6:00 – 7:30 PM

No-Host Cocktail Hour 7:30 – 9:00 PM

Dinner & Program 9:00 – 10:30 PM

Dessert & Dancing BLACK TIE OPTIONAL

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M E N TA L H E A LT H

Hanley, project lead for Dementia Friends USA. William Anderson, chief of police for St. Cloud, Minn., went to a session of this kind late last year, with about 40 members of his department. One exercise — writing down all the steps involved in making a peanut butter and jelly sandwich — made an especially strong impression.

“I’d never thought about everything that goes into something that simple: taking the peanut butter and jelly out of the cabinet, unscrewing the tops, getting a knife, spreading the sides of the bread, putting the pieces on top of each other, cutting it down the middle,” Anderson says, adding that this was only a partial list. “The point they were making was that folks with dementia might remember some of these steps but not others. At some point, they’ll get distracted or forget what they were doing and go on to something else. To me, that was eye-opening; it explained a lot.”

Now, Anderson thinks about “how we can make life more manageable for these folks, in simple ways.” An example: The St. Cloud Police Department’s building has a large vestibule, with two big glass doors.

“If you have dementia, you’re going to

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“What people with dementia want most is ‘emotional connection — that feeling of love that we had, that we may have lost.’” walk into that vestibule and probably turn around in circles because the doors don’t have an identifier saying ‘police,’” he says, adding that introducing new signage is under consideration.

Committing to a concrete action — visiting or phoning a family member with Alzheimer’s regularly, watching out for a neighbor, volunteering with a community organization or trying to make public venues easier to navigate, for instance — is required to become a Dementia Friend, though sponsors don’t check if people follow through.

“This is a social action movement,” says Emily Farah-Miller, executive lead for ACT on Alzheimer’s, a statewide effort in Minnesota to create dementia-friendly communities and disseminate best practices regarding dementia in healthcare settings.

More than 10,000 U.S. Dementia Friends come from Minnesota, which began recruiting residents for the program two years ago, before it became a national initiative. This year, Minnesota ACT on Alzheimer’s leaders are working with African-American, Hispanic, American Indian, West African and Hmong communities in their state to make culturally sensitive adaptations to their programs.

And they’re piloting a modified version of Dementia Friends in several elementary schools “to create a dementia-friendly generation of youth,” Farah-Miller says.

Individuals can also earn a “Dementia Friends” designation by watching an introductory video on Dementia Friends’ USA website, as well as a second video about dealing with people with dementia in various settings such as restaurants,

stores, banks, libraries, pharmacies, faith communities and public transportation.

If you encounter someone who seems confused and disoriented on a bus, train, taxi or subway, try to understand what that person might need, one of these videos advises. Speak slowly, using short, simple sentences and give the person adequate time to respond. Remain calm and reassuring and avoid arguing or embarrassing the person, who may have forgotten where they’re going.

Bob Savage, an 86-year-old diagnosed two years ago with Alzheimer’s disease, became a Dementia Friend last year and now speaks to groups in Connecticut that are promoting the program. Some of what he tells them: “As soon as people learn you have Alzheimer’s, you’re stigmatized.

People treat you different, like you don’t understand, and that’s very upsetting.”

Even if memory is lost, intuition and emotional understanding remain intact, Savage explains.

What he and other people with dementia want most is “emotional connection — that feeling of love that we had, that we may have lost” when a diagnosis was delivered and a sense of being a burden to other people descended.

In 2016, Savage moved to a campus in Southington, Conn., where 133 people with dementia reside in assisted living or a skilled nursing facility. Stephani Shivers, chief operating officer of LiveWell (formerly the Alzheimer’s Resource Center), which owns the campus, is leading Connecticut’s Dementia Friends initiative.

“What I’ve seen is that barriers seem to dissolve for people who attend” information sessions, she says. “Whether it’s ‘I’m not sure what to say to someone with dementia’ or ‘I’m nervous about being with someone with dementia,’ the ‘I don’t know what to do’ falls away.

“It becomes me relating to you, a person with dementia, as another human being — a human being living with a cognitive disability, just like people living with physical disabilities.”

Ms. Graham, is a freelance journalist based in Denver and former topic leader on aging for AHCJ. She has written for The New York Times, Kaiser Health News, The Washington Post, the Journal of the American Medical Association, STAT News, The Chicago Tribune, and other publications.

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CMA MEMBER HELP LINE! Be it legal information, help with a problematic payor, or details about your member benefits, call CMA’s Member Help Line: (800) 786-4262

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P E R S O N A L & P R O F E S S I O N A L D E V E LO P M E N T

We discuss vaccinations, seat belts, smoking, and other sensitive attitudes that lead to decisions affecting our patients’ health. Why not political or policy issues as well?

To Discuss … or Not to Discuss

By Helane Fronek, MD, FACP, FACPh

A SINGLE-PAYER SYSTEM is championed by some and criticized by others. Physicians may long for freedom from the complicated maze of policies and for the simplicity of one set of clearly defined rules. Or we may look to the inefficiencies of government-administered programs and wonder what other unpleasantries await us if all healthcare were paid this way. Whatever our opinion, discussions about a single-payer system often become charged and difficult. Still, these discussions are imperative for us as a profession, and as a community at large.

As providers of healthcare, do we have a responsibility to discuss these issues with the patients who will feel their impact? We discuss vaccinations, seat belts, smoking,

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and other sensitive attitudes that lead to decisions affecting our patients’ health. Why not political or policy issues as well?

Years ago, a patient became excited when she learned I grew up in the state of a particular vice presidential candidate. “You must be so excited!” she exclaimed. When I replied that I didn’t support him, she stopped talking. Attempting to bridge the chasm that had suddenly opened between us, I gently explained my view that, as Americans, we should share our beliefs in order to understand each other and find solutions together.

She never returned.

Presenting our beliefs can create a minefield for patients and our relationship with them. Trust is an essential component

of the doctor-patient relationship, and as Charles Feltman writes in The Thin Book of Trust, care is one of the four components of trust. When people care about what we care about, we are more likely to trust them.

Since my political bent was different than my patient’s, she believed I must not care about what she cared about. Knowing this can help us frame any issue to emphasize our shared concerns. One such issue is always our commitment to our patient’s best health.

In addition to highlighting shared concerns, Patterson and Grenny offer a great communication skill called “contrasting” in their excellent book, Crucial Conversations. When we worry that someone will have a negative reaction to our comments, we can begin by naming our fear, state our intention, and then share the comment we want to make. In discussing our opinion of a single-payer system, we might open with, “I don’t want to push my policy beliefs on you or jeopardize our relationship,” and then follow it with, “Our trusting relationship is important to me, and I am always focused on how to support you in being healthy.”

We can then introduce our belief about how the single-payer system might impact their health — why we believe it is a good or bad idea.

As physicians, we want to use all of our knowledge and experience to create better health for our patients. By considering how we present potentially divisive issues, we can widen our range of discussable concerns so we can enlist our patients as true partners in every issue that impacts their health.

Dr. Fronek, SDCMS-CMA member since 2010, is assistant clinical professor of medicine at UC San Diego School of Medicine and a certified physician development coach who works with physicians to gain more power in their lives and create lives of greater joy. Read her blog at helanefronekmd.com.

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P O L I T I C A L AC T I O N

CMA Launches Coalition to Protect Patients’ Access to Care

by California Medical Association and San Diego County Medical Society

THE CALIFORNIA MEDICAL Association (CMA) has launched a new coalition of more than 100,000 California physicians, dentists, nurse practitioners, community clinics, and pharmacists to protect the gains California has made under the Affordable Care Act (ACA) and improve California’s healthcare system.

The Coalition to Protect Access to Care (www.protectaccessca.org) will actively oppose efforts in Washington, DC, to repeal

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and replace the ACA, as well as provide a more realistic and responsible solution to California’s SB 562 — flawed legislation that would dismantle the healthcare marketplace and destabilize the state’s economy.

The Coalition also seeks to tie the current federal and state healthcare debate to practical realities that healthcare providers experience throughout the state.

The Golden State has made great strides under the ACA, expanding care to more

than 5 million Californians who were previously without health coverage. According to the Public Policy Institute of California, nearly 60 percent of Californians view the ACA favorably, and only 18 percent want the law repealed. The Coalition will work with policymakers to protect and expand coverage to the remaining 2–3 million without access to care.

The Coalition also believes that with so much uncertainty in our nation’s politics, now is not the time to walk away from the ACA in favor of establishing a new and undefined healthcare system.

“We believe that every Californian deserves access to timely, quality healthcare and affordable coverage,” says CMA President Theodore M. Mazer, M.D. “Unfortunately, SB 562 would wreak havoc on the market, forcing existing successful models aside while destabilizing the state budget — it’s simply unaffordable and fails to recognize real-world access and market dynamics.”

SB 562 would eliminate Medi-Cal, Medicare, all private insurance, and the Covered California exchange for a singular healthcare insurance product provided by the state, without offering any way to pay for it. This measure threatens the healthcare marketplace for millions of California and is based on erroneous assumptions regarding how California can utilize healthcare funds provided by the federal government. It also ignores the fact that the state does not have the same powers as the federal government to effectuate a single-payer system.

In a letter addressing our opposition of SB 562 to Assembly Health Committee Chairman Jim Wood, the Coalition made the following statements: “California is proof that the ACA can work. Since implementation, California has extended health coverage to nearly 5 million previously uninsured people. Our state has seen the nation’s largest drop in the uninsured rate. Nearly 60 percent of Californians view the ACA favorably, according to the Public Policy Institute of California — and only 18 percent want the law repealed.”

“SB 562 would eliminate Medi-Cal, Medicare, all private insurance, and the Covered California exchange in favor of a singular healthcare insurance product provided by the state, without offering any way to pay for it and threatening the health care marketplace for millions of Californians.

The measure is based on many erroneous assumptions about how California can use healthcare funds provided by the federal government and ignores the fact that the state does not have the same powers as the federal government to effectuate a singlepayer system.”

The coalition has also pointed to a recent report from the Legislative Analyst’s Office (LAO), which found that the proposal could “require new state tax revenues in the low hundreds of billions of dollars” and “could result in a lower minimum funding requirement for schools and community colleges” under Proposition 98. In other words, SB 562 would pit healthcare groups against public education advocates in an annual battle for state budget dollars, forcing Californians to choose between quality education and quality healthcare — an unfair, irresponsible, and unnecessary request.

The Coalition is committed to the following principles: • Aggressively protect and expand access to healthcare by building upon the successes of the Affordable Care Act. • Work to expand access to care to the remaining 2–3 million Californians who are still without coverage.

• Oppose efforts to repeal or undermine the Affordable Care Act. • Oppose Senate Bill 562 and any other healthcare proposal that destabilizes California’s healthcare system by calling for unrealistic revenue increases that could destabilize our state budget.

• Commit to improving and expanding care for all Californians through an approach that builds upon California’s existing healthcare delivery system.

California needs pragmatic and implementable solutions that benefit patients instead of scoring political points.

“A pluralistic healthcare delivery system can work, and we are committed to real solutions that improve and expand the current system without hurting patients or the economy of California,” Dr. Mazer says.

In addition to CMA, Coalition members include the American College of Obstetricians and Gynecologists (District IX), California Association of Nurse Practitioners, California Dental Association, California Pharmacists Association, the Central California Partnership for Health, and Kaiser Permanente.

For more information, please visit ProtectAccessCA.org.

Please join the San Diego County Medical Society and your fellow physician colleagues on Tuesday, March 27, 2018 at the UCSD MET Auditorium. We will be hosting a private reception and exclusive screening of the film

HIPPOCRATIC

18 EXPERIMENTS IN GENTLY SHAKING THE WORLD featuring Dr. MR Rajagopal (or Dr. Raj as he is known), followed by an in person Q&A with Dr. Raj himself.

This is a must-see documentary for all those interested in the power of the human spirit, human rights and social justice. It is essential viewing for anyone working in health care, medicine, nursing and public health.

Space is limited and RSVPs are required so please visit www.tiny.cc/HippocraticFilm for more information and to register to attend!

SAN DIEGO PHYSICIAN.ORG

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CALIFORNIA HEALTH BILL PUSHES UNREALISTIC, EMPTY PROMISES

BY THEODORE M. MAZER, MD

T

comers — yet it is not anchored in reality — and the bill does HE AFFORDABLE CARE ACT (ACA) helped nothing to raise the billions needed to pay for this expensive California lead the way in expanding healthcare healthcare system. The current MediCal woes regarding accoverage to millions of previously uninsured cess and attracting provider participation make the promised people. In San Diego County, more than 385,000 dream of Senate Bill 562 appear a nightmare. people who were previously without insurance now have Rather than dally in fantasy, leaders in Sacramento should health coverage — a drop of almost 30 percent in our county’s be committed to protecting the significant ACA gains we’ve uninsured rate. made over the last several years, as well as providing real acWe must continue our work to ensure that all Californians cess as our healthcare system remains under attack from both have coverage and access to timely and quality care. Working the right and the left wings of our political parties. within the current pluralistic approach to health access, we That’s why a new coalition of physicians, nurses, community must achieve this in an affordable — and realistic — way. health clinics, and others has come together to work with lawBut to disrupt access and the current healthcare market makers on practical solutions that will protect patients’ access with unrealistic and empty promises from the currently proto healthcare without major disruptions posed single-payer and government-run to a healthcare delivery system that alsystem, which would cost over twice the ready works for most Californians. amount of the entire budget of California, A coalition of We must not lose sight of what matmakes little sense. physicians, nurses, ters. Every Californian deserves access Thanks to the ACA, California has imcommunity health to timely, quality healthcare and affordproved preventive care and patient acclinics, and others able coverage. Unfortunately, Senate Bill cess to their doctor, instead of emergency 562 would wreak havoc on the market, rooms. We must continue to reduce unhas come together to forcing existing successful models aside necessary emergency room visits by the work with lawmakers while destabilizing the state budget. It is uninsured and underinsured, especially for on practical solutions simply unaffordable and fails to recogthe one-third of Californians who rely on that will protect nize real-world access and market dyMediCal; provide a wide variety of coverpatients’ access to namics. age options; and maintain the safety net for Our state has shown that we can inthose who need public support. healthcare without crease access to care and provide better Unfortunately, the gains of recent years major disruptions to outcomes for millions of Californians. are now under threat. Congress has rethe state’s healthcare We must continue to work on expanding pealed one of the central tenets of the ACA, delivery system. coverage to the remaining 2 million to 3 which could have ripple effects throughout million Californians who are still uninthe entire health care system, negatively sured, as well as find innovative ways to impacting millions of Californians. drive down the costs of healthcare for everyone. And we should Some well-meaning but misinformed state legislators are not cede control to a state with a poor record of addressing the pushing a bill, Senate Bill 562, which promises “coverage for real economics and delivery of healthcare. all,” but in reality would further throw our healthcare system California has come too far and made too much progress to into turmoil. Senate Bill 562 is an irresponsible plan that ofthrow it all away on a disruptive, unproven, and unaffordable fers no realistic way to pay for the estimated $400 billion cost plan. We know that a pluralistic healthcare delivery system can associated with the measure. Implementing the bill would work, and we are committed to real solutions that improve and require the largest (personal and business) tax increase in expand the current system for all Californians — without hurtstate history, and it could restrict the ability of patients to see ing patients or the economy. their physician. It also relies on improbable transfers of fedThis article was originally published in The San Diego eral healthcare dollars ($200 billion) and control of programs Union-Tribune. like Medicare to Sacramento.

Like our current MediCal program, Senate Bill 562 is nothing more than an empty promise of access to all services for all Dr. Mazer is president of the California Medical Association.

SAN DIEGO PHYSICIAN.ORG

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CONGRESS RACES THE CLOCK IN QUEST TO BRING STABILITY TO THE INDIVIDUAL INSURANCE MARKET

BY J U L I E ROV N E R 22

MARCH 2018

C

ONGRESS IS RUNNING OUT OF TIME if members want to come up with legislation to stabilize the individual insurance market.

While Republicans and Democrats still feud over the fate of the Affordable Care Act, a bipartisan group of senators and House members has been working since last summer on measures to keep prices from rising out of control and undermining the individual market where people who don’t get insurance through work or the government buy policies.

They hope to attach a package of fixes to what should be the year’s final temporary spending bill, due in late March.

The lawmakers are up against not just the legislative clock, but also the insurance companies’ timeline. Insurers have until summer to decide if they want to continue to sell policies in the ACA marketplaces, but many start making preliminary decisions as early as April.

In the absence of congressional action, insurers say premiums will go up in 2019 due to the uncertainty — raising costs for consumers and the government.

It is by no means clear whether any package could gain the votes needed in the House and Senate. Most Republicans are loathe to be seen “fixing” Obamacare, although opinion polls clearly show they will be blamed for problems with the law going forward.

The bipartisanship extends beyond Capitol Hill. Recently five governors (three Democrats, one Republican, and one Inde-

“In the absence of congressional action, insurers say premiums will go up in 2019 — raising costs for consumers and the government.”

pendent) released a blueprint for a health system overhaul that includes several of the stabilization ideas under consideration in Congress. About 18 million people buy their own policies, both inside and outside the ACA insurance marketplaces.

Lawmakers are looking at two primary fixes, although they could be combined.

One, pushed by Senators Susan Collins (R-Maine) and Bill Nelson (D-Fla.), is called “reinsurance.” It is a way to guarantee the insurance companies do not face large losses. The idea is that if insurers don’t have to worry about covering the expenses for their highest-cost patients, they can keep premiums lower for everyone.

The ACA actually had a temporary reinsurance program from 2014 to 2016. It was intended to help insurers get started in a market where sick people were able to buy their own insurance for the first time. Prior to the law, most insurers did not cover many people with preexisting health conditions.

If they did, it was at an extremely high cost.

Since the federal program ended, several states, including Minnesota and Alaska, have adopted, with some success, their own reinsurance programs in an attempt to hold premiums down.

The other proposal, negotiated by Senators Lamar Alexander (R-Tenn.) and Patty Murray (D-Wash.), would guarantee insurers federal reimbursement for so-called cost-shar-

ing reduction subsidies. Those are discounts that the ACA requires insurers to provide to their lower-income enrollees to help reduce their deductibles and other out-of-pocket costs.

President Donald Trump cut off federal reimbursement of those payments in October.

Senate Majority Leader Mitch McConnell (R-Ky.) pledged to Collins in exchange for her vote on the GOP tax plan in December that he would support bringing both bills to the floor for debate.

That has not happened, although in a statement, Collins said she is “continuing to have productive discussions” with Senate and House leaders about both bills.

Meanwhile, a lot has changed, including new questions about whether the fixes would work.

For starters, state insurance regulators managed to find a workaround for Trump’s sudden cancellation of the federal cost-sharing payments. Most states allowed insurers to offset the loss of these funds by increasing the premiums for the “silver” level plans that determine how much help enrollees get to pay those premiums. So the increases end up being paid by the federal government anyway, through higher premium subsidies. The result is that most people who get government help pay the same (or, in some cases, less), while insurers are effectively being paid back for the discounts, albeit through a different mechanism.

That means, however, if the cost-sharing reduction payments were reinstated for 2018, as the original legislation called for, insurers would have to give the excess money back to the government.

Analysts agree that would only add to the confusion.

Restoring the federal payments for this year, said Joseph Antos of the conservative American Enterprise Institute, “does not lower premiums this year, so it does absolutely no good to the average person.”

Some advocates have suggested that Congress should guarantee the payments for 2019 and 2020. But Antos said that “also makes no sense, because the insurers would then think ‘Are we going to go through this again?’” They might raise premiums even more to make up for the uncertainty.

Antos — and many other analysts — agree that restoring or creating a new reinsurance program would likely do more to control premium increases.

Reinsurance “will protect premiums for the people who are actually most subject to them,” says Sherry Glied, a former Obama administration health official now at New York University. She was referring to those in the individual market who do not get government help and have been footing large premium SAN DIEGO PHYSICIAN.ORG

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increases for the past several years. That’s because having protection against the largest bills would allow insurers to lower premiums across the board.

Then there are the political considerations.

Many Republicans in Congress have called the cost-sharing reduction payments in particular a “bailout” to the insurance industry, and are resistant to reinstate the payments.

Republicans seem more amenable to the idea of reinsurance, because they consider it a type of “high risk pool,” which they have been pushing for years. House Speaker Paul Ryan said at an event in Wisconsin in January that “I think there might be a bipartisan opportunity there to get risk pools, risk mechanisms.”

But Republicans have made clear they want something in return for what could be considered a “fix” to the health law they despise.

Health and Human Services Secretary Alex Azar was careful to say in a meeting with reporters that the Trump administration has no formal position yet on the stabilization efforts. But, he said, “I think it would need to be part of an entire set of reforms there that we would want to see.” That would likely include more flexibility for states to opt out of some of the health law’s coverage requirements.

The delay has made Democrats more demanding, too. The repeal of the ACA’s penalties next year for people who don’t have insurance has changed the situation dramatically, said Senator Murray.

“As I have made clear, the bipartisan bill I originally agreed on

with Chairman Alexander will not make up for this latest round of Republican healthcare sabotage,” she said in a statement. “In fact, there are changes that now need to be made to our bill to ensure it meets its intended goals of keeping premiums down and stabilizing markets.”

But while Congress decides if it will take action, insurers are warning that doing nothing will lead to still higher premiums.

Premium rates for a “benchmark” silver plan could rise by 27 percent in 2019, the Blue Cross Blue Shield Association said earlier this month.

Congressional action on reinsurance and cost-sharing, the association predicted, would help push premium rates 17 percent below this year’s levels.

“Health plans are looking for certainty in the market,” says Justine Handelman, senior vice president in the association’s policy shop.

Ideally, Congress would include the funding in measures adopted in February or March, said Handelman, who spoke with reporters during a briefing at the association’s Washington, D.C., headquarters: “Most plans are filing premium rates by April.”

Julie Rovner, the Robin Toner Distinguished Fellow, is Chief Washington Correspondent at Kaiser Health News.

Kaiser Health News senior correspondent Julie Appleby contributed to this story. This story also ran on NPR.

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CLASSIFIEDS PRACTICE ANNOUNCEMENTS NEW CONCIERGE CLINIC IN LA JOLLAKAIZEN BRAIN CENTER: NEW Concierge Clinic in La Jolla - Kaizen Brain Center. With a team of experts, we offer an integrated multidisciplinary approach. We specialize in TBI/Concussion and Cognitive/Memory Disorders. We offer comprehensive exams, transcranial magnetic stimulation treatments, neuronpsychological testing, neurologic PT, medical nutrition consultations, and cognitive rehab therapy. Please call us at 866-277-2659 or visit www.kaizenbraincenter.com.

CLINICAL TRIAL VOLUNTEERS NEEDED WE ARE LOOKING FOR VOLUNTEERS TO PARTICIPATE IN CLINICAL TRIALS: Currently enrolling volunteers who suffer from rheumatoid arthritis, lupus, psoriasis, and psoriatic arthritis. Qualified volunteers may receive: no-cost investigational study medication, no-cost study-related care from a study doctor. There is compensation available for time and travel. All study-related care will be at no cost, and volunteers can continue seeing their primary care doctor during the study. Health insurance and doctor referrals are not required to participate. Please email Joy at joy@rheumSD.com for more information. [607] PHYSICIAN POSITIONS AVAILABLE

PART TIME OR FULL-TIME SUB-INVESTIGATOR Work under the supervision of the Medical Director/Principal Investigator performing a variety of scientific clinical research activities to include the direct assessment of study participants and execution of protocol specific procedures.

Required Education and Experience: M.D., Board Certification (or Board eligible) in Internal medicine, Family practice or Emergency Medicine, Skills/Competencies: Excellent professional communication, punctual and responsible, friendly and outgoing demeanor, must demonstrate a passion for direct patient interaction.

Demonstrate clinical competence, positive leadership and ability to work collaboratively with a multidisciplinary team. Send resume to: eliku@artemis-research.com FAMILY PRACTICE MD/DO needed for urgent care and family practice office in Carlsbad. Flexible afternoon, evening and weekend shifts available for family practice physician. Exceptional office staff and flexible scheduling options at this busy, wellestablished private practice. Please fax or email CV to (760) 603-7719 or gcwakeman@ sbcglobal.net.

PHYSICIAN POSITIONS AVAILABLE: A fulltime position is immediately available for a Primary Care/Long Term Care physician at the Veterans Home of California - Chula Vista. Employment is through the State of California within the California Department of Veterans Affairs (Calvet). Training in primary care (Internal Medicine or Family Practice) is required and additional experience and/ or training in Long Term Care Medicine or Geriatric Medicine is preferable. Salary range is $17,113.00-$19,969.00/month. Benefits package includes, but is not limited to, vacation, CME, medical, dental, vision and pension. For more information or to apply please use the following URL at http://bit. ly/2BPKDFK (Posted 2/21/2018)

PER DIEM PHYSICIAN NEEDED: The County of San Diego Health and Human Services Agency is seeking a physician to work with California Children’s Services (CCS).

Applicants (MD or DO) must hold a current California medical license. Board certification in Pediatrics, Child Neurology, Orthopedic Surgery, Physical Medicine and Rehabilitation, Family Medicine or Preventive Medicine is desired, but not required. Applicants must have previous experience in providing medical care for children with disabilities and willing to work a minimum 60 hours per month. If interested, please e-mail your CV to Dr. Marie Green, CCS Medical Director, at Marie.Green@ sdcounty.ca.gov or call (619) 528-4010.

MEDICAL CONSULTANT: The County of San Diego, Health and Human Services Agency’s Behavioral Health Division is looking for Board Certified Family Practice or Internal Medicine physicians to provide care for residents at Edgemoor Distinct Part Skilled Nursing Facility (DP/SNF), an award winning, 192-bed rehabilitation and care facility located in the San Diego suburb of Santee.

The individual chosen for this vacancy will provide medical care for a younger Medi-Cal population, most of which have brain injuries and significant disabilities, as well as complex physical, social and psychological problems.

Visit our website: www.sdcounty.ca.gov/hr for more information on how to apply.

FAMILY PRACTICE OR INTERNAL MEDICINE: Spanish-speaking family medicine or internal medicine physician (Board Certified) for Borrero Medical Group located in South San Diego next to Chula Vista. The practice is growing and needs to hire a new physician. Borrero Medical Group is a well-established practice, 22 years in the community, exceptional office staff. Every member of our team plays an important role in improving the health of our patients. We offer an excellent comprehensive benefits package that includes Malpractice Coverage, Health Insurance, Competitive & Attractive Salaries, and Bonus. If interested, please submit inquiry and CV to rosa10borrero@att.net

TO SUBMIT A CLASSIFIED AD, email Editor@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.

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PART TIME PHYSICIAN: Progressive Medical Specialists is an outpatient medication assisted treatment program located in San Diego, CA. We are currently in need of a parttime Physician to work 1-3 days per week. The Program Physician is responsible for providing the day-to-day medical care and treatment for all program patients. The Program Physician performs all duties in compliance with the California Code of Regulations for Narcotic Treatment Programs. Training is provided.

Please send your CV to tboylan@pms911.com or call 619-286-4600. 12/5 OB/GYN POSITION AVAILABLE: A MultiSpecialty Group is seeking a full-time OB/GYN must be BC/BE to join a busy OB/GYN and Uro-gynecology practice, group of a physician and a nurse practitioner. Located in Southern California 1 ½ hours East of San Diego and Palm Springs; We offer a Competitive compensation, full benefits and opportunity for partnership. If interested, please e-mail CV to ekmoukarzel@aol.com or fax to : 760-3526221. Visit our website: www.feminacareourogyn.com for additional information on our practice. 11/30 INTERNAL MEDICINE POSITION AVAILABLE: Unique opportunity to practice outpatient internal medicine in beautiful North San Diego County. Practice is part of a well-established internal medicine group with a long history of outstanding care in the community, seeking physician who enjoys providing thoughtful, personalized patient care. Exceptional office staff, small group environment, autonomy and very high quality patient care are among the many benefits of this opportunity. Office is located near San Diego coastal communities, accessible from all parts of San Diego County as well as Orange County. Seeking BC/BE applicants. Please send CV to portofino3@aol.com or call 619248-2324. 11/2 PRACTICE FOR SALE FOR SALE. BUSY FAMILY PRACTICE POTENTIAL URGENT CARE: Established family practice for 27 years located in Chula Vista near H Street at 805 in upscale mall setting. Ideal location with free and easily accessible parking. Spacious 2600 ft. office space with CLIA Certified Lab and X-ray.

Practice accepts and experienced in billing: Medicare; Tricare, Immigration Exams, DOT Certification; Workers Comp. Contact: S.J.Anderson (858)736-5818 or Email: marva. winchi.garcia@gmail.com 11/3 PRACTICES WANTED

PRIMARY CARE PRACTICE WANTED

I am looking for a retiring physician in an established Family Medicine or Internal Medicine practice who wants to transfer the patient base.

Please call 858-257-7050

OFFICE SPACE / REAL ESTATE AVAILABLE

KEARNY MESA MEDICAL OFFICE - FOR LEASE 7910 Frost Street. Class A medical office building adjacent to Sharp Memorial and Rady Children’s hospitals.

Suites ranging from 1,300-5,000 SF. For details, floor plans and photos contact David DeRoche (858) 966-8061 | dderoche@rchsd.org

OFFICE SPACE/REAL ESTATE AVAILABLE: Furnished office space with licensed surgical center available for full or part time rent.

Location 8705 Complex Drive in Kearny Mesa.

Call 858-715-1822. (Posted 2/27/2018) SHARED OFFICE SPACE: Very attractive 4 exam room, medical office in Bankers Hill near Balboa Park. Available 5 days per week.

Reasonable rates. Call Claudia at 619-5014758. (Posted 2/21/2018) SOUTH BAY OFFICE SPACE AVAILABLE: Monthly sublease, 3 exam rooms, medical office, 5 days per week. Reasonable rates.

Directly across from Scripps Mercy Hospital, Chula Vista. If interested, please call, 619-4222000. (Posted 2/21/2018) OFFICE SPACE AVAILABLE: Rent by the hour, day, week, month. Reasonable rates.

Free parking. Quiet office building. Free Wi-Fi. Perfect for Consultants, Therapists, CPA’s/ Bookkeepers, Web Designers, Real Estate, Insurance, Meetings, Etc. Located in central east county. Referral Potential. Please call Marlene at: 619-401-1430 or email: saben615@ sbcglobal.net (Posted date 2/21/2018) MEDICAL OFFICE IN SOUTH BAY AVAILABLE TO SUBLEASE: Located next to Paradise Valley Hospital, this large, recently renovated office consists of 6 exam rooms and 1 procedure room. The office is currently utilized by Orthopedic Surgeons and a Cardiologist, but can accommodate any practice. Facility provides easy access the PVH Operating Room, Physical Therapist, Imaging Center, Laboratory, and Wound Care Center and has easy freeway access. Opportunity for Orthopedic ER Call at Paradise Valley Hospital and patient referrals. For more information, please contact Jeff Craven: jeff@sdmiortho. com or 858-245-9109 (Posted 2/21/2018) SHARED OFFICE SPACE AVAILABLE: Office space, beautifully decorated, to share in Solana Beach with reception desk and 2 rooms. Ideal for a subspecialist. Please call 619-606-3046 (POSTED 2/14/2018) OFFICE SPACE AVAILABLE –LA JOLLA UTC AREA: Looking for like-minded professionals interested in a small furnished office space a couple of days a week/part-time basis. Modern design. For details and pricing, Contact Newshaw at 866-277-3659 and visit our website www.kaizenbraincenter.com for information about our practice.

MEDICAL OFFICE SPACE, SUBLEASE HM POOLE BUILDING SCRIPPS LA JOLLA CAMPUS: Very attractive, comfortable suite with two offices, two exam rooms and two person receptionist area, and beautiful waiting room. Excellent location on the campus of Scripps Memorial Hospital La Jolla. Large windows with open, peaceful garden views, available for full time rental with the option to rent time at the adjacent surgical suite.

Rent also includes small kitchenette with sink, electricity, and janitorial service. Call 858344-7342 OFFICE SPACE/REAL ESTATE AVAILABLE IN SOUTH BAY: Available for monthly sublease, 3 exam room, medical office, 5 days per week. Reasonable rates. Directly across from Scripps Mercy Hospital, Chula Vista. If interested, please call 619-422-2000.

NONPHYSICIAN POSITIONS AVAILABLE MA OR LVN POSITION AVAILABLE: This patient centered medical practice requires a skilled and professional individual with exceptional empathy, integrity, maturity and passion for patient care. You must have 5+ years of experience in the field as either an MA or LVN and be comfortable with front and back office work, be able to perform blood draws and injections, understand how to verify insurance, obtain prior authorizations, collect copays and balances. You are driven, diligent, organized, efficient, a clear communicator, honest and constantly wanting to improve.

Please submit a detailed resume and 3 references from your last three positions to 92024medical@gmail.com.

PART-TIME PHYSICIAN ASSISTANT: Looking for a part-time Physician Assistant for a rheumatology office in Escondido. 20-30 hrs a week. Spanish desired. To start as soon as possible. Please send resume and references to info@rheumSD.com. 12/5 MEDICAL ASSISTANT IN BUSY RHEUMATOLOGY OFFICE. FULL TIME. Wonderful opportunity for learning and growth.

We are looking for someone who is organized, capable of multi-tasking, takes instruction well, and has a positive helpful attitude. Tasks

include, but are not limited to: Front desk answering phones, make calls to patients, collect fees, set appointments and filing. Back office: Rooming patients and taking vitals, helping with therapy, keeping things organized and running smoothly, and cleanup. Spanish desired. Salary is based on experience. Please email info@rheumSD.com 11/30 SEEKING A DYNAMIC BUSINESS OFFICE MANAGER for a busy medical practice located on Convoy Street, close proximity to the 163/805 freeway. Responsible for the overall operations of the medical practice and reports directly to the CEO. This position ensures that the medical practice is running smoothly, effectively and efficiently rendering a high standard of quality and customer service. Accountable for operational systems, processes and policies in support of the organization’s mission. Required Education and Experience: Requires at minimum 3 years of significant work related experience in a private or group medical practice setting; supervised at least 10 F.T.E.’s and ability to collaborate with a minimum of 4 physicians in a practice setting. Preferred Education and Experience: AA or higher in Health Management or Business Administration education; Familiarity with health care laws, regulations and standards; Proficient in Excel and Word. We are offering a competitive salary, excellent benefits. Please email resume to businessofficemanager2017@gmail.com. 11/3 PRODUCTS / SERVICES OFFERED PHYSICIAN OFFICES IN NEED OF ASSISTANCE FOR MEANINGFUL USE ATTESTATION of their electronic health records can avail themselves of technical assistance from Champions for Health, the sister organization to SDCMS. Practices attesting on the Medi-Cal Incentive Program with at least 30% of patients billed to MediCal can receive free assistance thanks to a federal funding source. Medicare practices can receive the same great service at a very reasonable rate, and SDCMS-CMA members receive a discount. For more information, email Barbara.Mandel@ChampionsFH.org or call (858) 300-2780. [559]

PLACE YOUR AD HERE Contact Dari Pebdani at 858-231-1231 or DPebdani@SDCMS.org

SAN DIEGO PHYSICIAN.ORG

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C M A AC T I O N

CMA-Sponsored Bill Would Require Physician-Conducted Autopsies THE CALIFORNIA MEDICAL Association (CMA) is sponsoring a bill (SB 1303) that would require counties with populations of 500,000 or more residents to replace the office of the coroner with an office of the medical examiner. Current law allows nonmedically trained individuals to conduct autopsies, and SB 1303 would require that the medical examiner be a licensed physician and surgeon duly qualified as a specialist in pathology. SB 1303 is authored by State Senators Richard Pan, M.D., and Cathleen Galgiani.

The legislation is the result, in part, of a high-profile case in San Joaquin County. In December 2017, the county’s longtime Chief Medical Examiner, Bennet Omalu, M.D., and

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forensic pathologist, Susan Parson, M.D., resigned over the “routine practice” of interference from Sherriff-Coroner Steve Moore.

Moore, according to Dr. Omalu, regularly interfered with death investigations and used his political office to protect law enforcement officers in cases of persons who died while in custody or during arrest.

“Physicians have a unique obligation to put the patient first, and thus, they must be empowered to work independently,” says CMA President Theodore M. Mazer, M.D. “Allowing non-physicians to influence the practice of medicine in any way, shape or form, puts all patients at risk. No family should have to worry about their loved one’s autopsy being corrupted, and SB 1303 would

restore public trust by removing the possibility of conflict of interest.”

The issue of diminished public trust in the autopsy process is not new. The Santa Clara County Board of Supervisors recently voted to adopt the independent medical examiner model after similar allegations came to light.

Nationally, California is one of the last states to make the change to a medical examiner system.

Drs. Parson and Omalu have stated that once the autonomy and independence of the San Joaquin County Coroner’s Office can be guaranteed, they will both consider withdrawing their resignations and returning to their jobs.

“In addition to preventing the improper influence or corruption of autopsies, SB 1303 is smart and responsible policy as it only applies to the largest counties that have the resources to establish an independent medical examiner’s office,” says San Joaquin Medical Society (SJMS) President R. Grant Mellor, M.D. “California is facing a physician shortage, which is felt acutely in San Joaquin County, and we must retain these talented physicians and get Drs. Parson and Omalu back to work as soon as possible.”

SB 1303 is also co-sponsored by the Union of American Physicians and Dentists (UAPD).

Litigated Cases That All Physicians Can Learn From As a leading California medical professional liability provider, CAP is committed to protecting our physician members with not only superior coverage, but also valuable resources, including our most-requested risk management publication, Medicine on Trial: Risk Management Lessons from Litigated Cases.

We are pleased to offer this updated edition to all California physicians for a limited time, free for the asking. Each vignette serves to demonstrate how the adoption of simple policies, procedures, and personal practices can help keep you out of the courtroom.

Request your free copy: 800-356-5672 CAPphysicians.com/MOT18 md@CAPphysicians.com

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