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U.S. Surgeon General Jerome Adams On the Opioid Epidemic and the Fight Against Tobacco

Are Your Patients Giving You FIVE STAR REVIEWS? CAP’s Free Guide Can Help You Optimize Patient Experience and Improve Your Ratings!

The Physician’s Action Guide to an Outstanding Patient Experience is about optimizing the fundamentals of your medical practice so patients: • Feel cared for • Are fully prepared to comply with your course of treatment • Feel confident of your expertise and the ability of your staff • Are happy to recommend you to friends and in online reviews As a leading California provider of superior medical malpractice coverage, the Cooperative of American Physicians (CAP) is pleased to offer California physicians this important guide free for the asking.

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MAY 2017




Editor: James Santiago Grisolia, MD Editorial Board: James Santiago Grisolia, MD; David E.J. Bazzo, MD; Robert E. Peters, MD, PhD; William T-C Tseng, MD MARKETING & PRODUCTION MANAGER: Jennifer Rohr SALES DIRECTOR: Dari Pebdani ART DIRECTOR: Lisa Williams COPY EDITOR: Adam Elder OFFICERS President: David E. J. Bazzo, MD President-elect: James H. Schultz, MD Secretary: Holly B. Yang, MD Treasurer: Sergio R. Flores, MD Immediate Past President: Mark W. Sornson, MD, PhD 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: Jamie M. Jordan, MD Kearny Mesa #2: Alexander K. Quick, MD La Jolla #1: Laura H. Goetz, MD 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: Veena A. Prabhakar, DO South Bay #1: Irineo “Reno” D. Tiangco, MD South Bay #2: Maria T. Carriedo, MD GEOGRAPHIC ALTERNATE DIRECTORS East County: Heidi M. Meyer, 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: Franklin M. Martin, MD South Bay: Karrar H. Ali, DO AT-LARGE DIRECTORS #1: Thomas J. Savides, MD; #2: Paul J. Manos, DO; #3: Alexandra E. Page, MD; #4: Nicholas J. Yphantides, MD (Board Representative to Executive Committee); #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


ADDITIONAL VOTING DIRECTORS Communications Chair: William T-C Tseng, MD Finance Committee Chair: J. Steven Poceta, MD Resident Physician Director: Trisha Morshed, MD Retired Physician Director: David Priver, MD Medical Student Director: Margaret Meagher


8 U.S. Surgeon General Jerome Adams Discusses the Opioid Epidemic

departments 4 Briefly Noted: Public Health Advocacy, Public Payer Issues, Practice Management, Patient Protection, New and Returning SDCMS-CMA Members

14 High Rate of Return: CMA’s 2017-18 Legislative Wrap-Up, Part 2



20 CMA’s Year in Review

22 AB 72: The Independent Dispute Resolution Process and How to Appeal BY JULIE REAVIS

24 Diagnosis … Fun!



Physician Classifieds




ADDITIONAL NON-VOTING MEMBERS 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 Trustee: William T-C Tseng, MD CMA Trustee: Robert E. Wailes, MD CMA Trustee: Sergio R. Flores, MD CMA TRUSTEES Robert E. Wailes, MD William T-C Tseng, MD, MPH Sergio R. Flores, MD 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 At-large AMA Delegate: Theodore M. Mazer, MD At-large AMA Alternate Delegate: Robert E. Hertzka, MD At-large AMA Alternate Delegate: Holly B. Yang, MD


Member Profile of Dr. Davis Cracroft

FDA Seeks to Restrict Teens’ Access to Flavored E-Cigarettes

AT-LARGE ALTERNATE DIRECTORS #1: Karl E. Steinberg, MD; #2: Steven L-W Chen, MD, FACS, MBA; #3: Susan Kaweski, 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

The Perfect New Year’s Resolution BY HELANE FRONEK, MD, FACP, FACPh

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 San Diego Physician is published monthly on the first of the month. Subscription rates are $35.00 per year. For subscriptions, email [San Diego County Medical Society (SDCMS) Printed in the U.S.A.]

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Additional information can be found at the Practice Management Resources page at SAN DIEGO PHYSICIAN.ORG


/////////BRIEFLY /////////////////NOTED //////////////////////////////////////////////////////////////////////// PUBLIC HEALTH ADVOCACY PUBLIC PAYER ISSUES

CMA Announces Opposition to Proposed Trump Immigration Rule THE CALIFORNIA MEDICAL ASSOCIATION (CMA) announced its opposition to a proposed rule by the Trump administration that could jeopardize public health and deter millions of people from receiving critical healthcare services. The new proposed rule would make it more difficult for noncitizens who follow all legal requirements to enter the country and advance through the immigration process. The policy change would deny entry or permanent legal status for noncitizens who may receive one or more public benefits, including Medicaid, Medicare Part D subsidies, the Supplemental Nutrition Assistance Program (SNAP), and several public housing programs. “This proposed rule is a step in the wrong direction, one that could lead thousands of Californians to avoid needed healthcare,” says CMA President David H. Aizuss, MD. “We are particularly concerned about the chilling effect it could have on children’s health if parents are fearful that utilizing healthcare services could jeopardize their immigration status. Instead of focusing on divisive policies that jeopardize patients’ health, we should be working together to find ways to make care more affordable and more accessible to all Californians.” In formal comments to the Department of Homeland Security on Monday, CMA raised concerns that the rule could cause confusion and panic among many immigrants, even those not subject to the rule, and lead millions of people to forego essential healthcare services. Scores of California doctors have filed their own comments with DHS urging the administration to withdraw the proposed rule. 4


Ninety-Five Percent of Physicians Avoided a Negative Medicare Payment Adjustment in 2017 THE CENTERS FOR Medicare and Medicaid Services (CMS) recently released additional performance data for the 2017 Medicare Quality Payment Program (QPP). According to CMS, 93 percent of more than 1 million Merit-Based Incentive Payment System (MIPS)-eligible clinicians received a positive payment adjustment for their performance in 2017, and 95 percent overall avoided a negative payment adjustment. Seventy-one percent earned a positive adjustment and an adjustment for exceptional performance; 22 percent earned a positive payment adjustment only; 2 percent received no increase or decrease; and 5 percent received a negative payment adjustment. The maximum positive payment adjustment for exceptional performance was a modest 1.88 percent, resulting from the budget neutrality requirements in MIPS, as established by law under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). From a scoring perspective, the overall national average score for MIPS-eligible clinicians was 74.01 points, and the national median was 88.97 points. Clinicians participating in MIPS as individuals or groups received an average score of 65.71 points and a median score of 83.04 points. Clinicians participating in MIPS through an alternative payment model received an average score of 87.64 points and a median score of 91.67 points. For more details of the 2017 performance data, visit the CMS website.


CMA Publishes Prop 56 Payment Monitoring Worksheet THE CALIFORNIA HEALTH CARE, Research and Prevention Tobacco Tax Act of 2016 (Prop. 56) created new revenues dedicated to the Medi-Cal program. Physicians receive supplemental payments in both fee-for-service and Medi-Cal managed care when providing Medi-Cal services under certain CPT codes. A total of $325 million was allocated for physician payments in the budget for 2017–18, with $488 million proposed for 2018–19. To help physician practices monitor their Prop 56 supplemental payments, the California Medical Association (CMA) has published a Prop. 56 Payment Monitoring Worksheet. The worksheet will automatically calculate the supplemental payment amount by CPT code so you can ensure that you are receiving your share of the supplemental tobacco tax money. The worksheet is available free to CMA members at

////////////////////////////////////////////////////////////////////////////////////////////////// ADVOCACY

Download CMA’s New Mobile App CMA’s new members-only mobile app is now available. Free and available for Android and iOS, our CMAdocs app will keep you up to date and informed on issues critical to the practice of medicine in California. Visit to learn more!


Long-Term Care Ombudsman Program at Center of Ensuring Quality Care for Seniors BY K R I S T I N R I G S B E E

Not enough people have heard the term “ombudsman,” and significantly less know what an ombudsman does. Since we are all aging, and may need care at a long-term care facility, it is important to know who is on your side. Aging is not what people want to think about. Unfortunately time catches up with all of us, a crisis strikes, and we need a long-term care facility. It is now that we realize we are not fully prepared to deal with the crisis. The Long Term Care Ombudsman is your resource. The ombudsman program is a federally mandated volunteer program to act as advocates for residents in long-term care facilities. The ombudsman ensures a regular presence in each facility, establishes rapport with the residents, and monitors for any issues. Residents are encouraged to contact the ombudsman for any issues that they have with their care at the facility. The ombudsman only advocates for the resident and must have the resident’s consent to disclose any information. If the resident does not wish for our assistance, then we will not disclose any information to the facility or family. If a resident would like our assistance, we will develop with the resident a plan to address the concern. The resident must be involved and in full agreement with this plan. If the resident lacks the capacity to consent, then consent must be given by their responsible agent. The ombudsman is an invaluable resource to individuals residing in a long-term care facility. They are able to provide support, guidance, resources, and advocacy to ensure resident wishes are being observed and concerns addressed appropriately to ensure resident satisfaction. The ombudsman is here for you. Call 1 (800) 640-4661 or (858) 560-2507 for assistance.

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Kristin Rigsbee has worked in long-term care in San Diego for the past 25 years. She works for Aging and Independence Services for the County of San Diego, and recently addressed the Retired Physician Section Luncheon sponsored by Champions for Health. SAN DIEGO PHYSICIAN.ORG


/////////BRIEFLY /////////////////NOTED //////////////////////////////////////////////////////////////////////// MEMBERSHIP

Welcome New and Returning SDCMS-CMA Members! Welcome New Members! M Abdou, MD General Surgery East County (800) 290-5000 Christina Adams, MD Cardiovascular Disease La Jolla (858) 824-5373 Zia Agha, MD Internal Medicine La Jolla (858) 705-3279 Riaz Ahmed, MD Cardiovascular Disease La Jolla (760) 633-7275 Jeffrey Andrey, MD Hematology La Jolla (619) 554-8566 Jennifer Avila, MD Emergency Medicine La Jolla (310) 379-2134 Diosdado Baja, MD Anesthesiology Kearny Mesa (858) 565-9666 Cameron Barr, MD Orthopaedic Surgery La Jolla (858) 554-9300 Nasaria Barreras, MD Family Medicine Hillcrest (858) 694-3900



Josef Bauer, MD Internal Medicine La Jolla (858) 554-9100

Susan Chu, MD Gastroenterology Kearny Mesa (858) 939-6531

Craig Beach, MD Psychiatry Hillcrest (858) 694-3900

Clinton Colaco, MD Pulmonary Disease La Jolla (858) 554-8845

Vedka Begovic, MD Internal Medicine La Jolla (858) 554-8500

Ana Cox, MD Anesthesiology Kearny Mesa (858) 565-9666

Walter Biffl, MD General Surgery La Jolla (858) 824-5001

Graham Davis, DO Anesthesiology North County (858) 673-6100

Lisa Brown, MD Obstetrics and Gynecology Hillcrest (619) 528-2000

Michael Doan, MD Anesthesiology Kearny Mesa (858) 565-9666

Monica Budianu, MD Rheumatology La Jolla (619) 245-2355 Paul Cattafi, DO Anesthesiology Kearny Mesa (858) 565-9666 Aleen Chin, MD Pediatrics North County (858) 793-1011 Tepsiri Chongkrairatanakul, MD Nephrology Kearny Mesa (858) 637-4700

Agnieszka Golian, DO Anesthesiology Kearny Mesa (858) 565-9666 Vanessa Greenwood, MD Psychiatry Hillcrest (858) 490-8040 Kenneth Grudko, MD Pulmonary Critical Care Medicine La Jolla (619) 354-8860 Tuan Ha, MD Diagnostic Radiology East County (619) 460-2770

Steven Escobar, MD Pulmonary Disease La Jolla (858) 554-9766

Jeffrey Halldorson, MD Transplantation Surgery Kearny Mesa (858) 637-4800

Humberto Gallego, MD Dermatology Hillcrest (619) 644-6401

Jennifer Hamrick, MD Pediatrics North County (858) 565-9666

Jennifer Gastelum, MD Anesthesiology Kearny Mesa (858) 534-8930

Justin Hamrick, MD Pediatric Critical Care Medicine Kearny Mesa (858) 565-9666

Juliana Gazallo, MD Internal Medicine East County (619) 528-5000

Heinz Hoenecke, MD Orthopaedic Surgery La Jolla (858) 554-8262 William Hooper, MD Pulmonary Disease North County (760) 230-8994

Matthew Jones, MD Internal Medicine La Jolla (858) 554-6158 Jason Kanel, MD Anesthesiology Kearny Mesa (858) 565-9666 Kathy Khaing, MD Internal Medicine South County (619) 427-1144 Patrick Kinnaird, MD Anesthesiology Kearny Mesa (858) 565-9666 John Kuldau, MD Gastroenterology La Jolla (858) 554-9100 Patricia Lee, MD Pediatrics North County (760) 436-4511 William Lennard, MD Anesthesiology Kearny Mesa (858) 565-9666 Arash Liaghat, MD Anesthesiology Kearny Mesa (916) 734-5031 Ni-Cheng Liang, MD Pulmonary Disease North County (760) 230-8994 Yuan Liu, MD Plastic Surgery North County (619) 528-5000 Laura Marcus, MD Pediatrics South County (619) 426-7910

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Krupa Patel, MD Anesthesiology North County (858) 673-6100

Nushin Sherkat, MD Family Medicine La Jolla (858) 605-7912

Soyoung McFarland, MD Internal Medicine East County (619) 528-5000

Lance Patel, MD Anesthesiology Kearny Mesa (858) 565-9666

Angela Shin, MD Internal Medicine East County (619) 528-5000

Jessica Peatross, MD Internal Medicine La Jolla (619) 345-3111

Albert Su, MD Pathology Hillcrest (619) 297-4900

David Miller, MD Family Medicine La Jolla (858) 605-7166

Kathleen Piacquadio, MD Maternal and Fetal Medicine Kearny Mesa (858) 266-6900

Hossein Tabriziani, MD Nephrology Kearny Mesa (619) 299-5298

Adnan Mirza, MD Critical Care Medicine North County (619) 862-6673

Hany Rayan, MD Anesthesiology Kearny Mesa (858) 565-9666

Leslie Mukau, MD Emergency Medicine North County (619) 543-6400

Brian Rebolledo, MD Orthopaedic Surgery La Jolla (858) 554-9100

Erik Nagel, DO Anesthesiology North County (858) 673-6100

James Rice, MD Nephrology La Jolla (619) 354-4310

Shilpa Naik, MD Pediatrics East County (619) 442-2560

Michael Ryan, MD Orthopaedic Surgery North County (619) 528-5000

Arvin Narula, MD Internal Medicine Kearny Mesa (858) 244-6800

Mamie SefaBoakye, MD Family Medicine North County (619) 528-5000

Tory Twito, DO Pediatrics South County (619) 426-7910

Shivak Sharma, MD Cardiovascular Disease North County (619) 528-5000

Jon Umlauf, MD, MPH Nuclear Medicine East County (619) 528-6567

Kathryn McHenry, DO Family Medicine North County (760) 520-8100

Jesse Nelson, DO Anesthesiology Kearny Mesa (858) 565-9666 Richard Nodurft, MD Gastroenterology La Jolla (858) 605-7151

Gilda Tafreshi, MD Vascular Neurology La Jolla (858) 824-5400 Zachary Thomas, MD Family Medicine Hillcrest (619) 515-2400 Whitney Tolpinrud, MD Dermatology North County (760) 758-5340 Sheri Tran, MD Pulmonary Disease North County (760) 230-8994

Parag Agnihotri, MD Internal Medicine Hillcrest (619) 499-2600

Leigh Van Vranken, MD Internal Medicine La Jolla (858) 605-7180

Anton Kushnaryov, MD Otolaryngology North County (760) 726-2440

Rishi Vashishta, MD Anesthesiology Kearny Mesa (858) 565-9666

Jessica Thackaberry, MD Psychiatry La Jolla (619) 543-7795

Lan Vu, DO Anesthesiology North County (858) 673-6100 Huan Wang, MD Anesthesiology Kearny Mesa (858) 565-9666 Welcome Returning Members!

Herman Skorobogaty, MD General Surgery La Jolla (858) 554-8984

Perry Montoya, MD Internal Medicine South County (858) 499-2707 Scott Harman, MD Vascular and Interventional Radiology East County (866) 558-4320 Daniel Hoefer, MD Family Medicine East County (619) 636-2600 Carter Wahl, MD Dermatopathology Hillcrest (619) 499-2600 Rachel Castle, MD Anesthesiology Kearny Mesa (858) 565-9666 Pany Robinson, MD Family Medicine North County (858) 499-2705



U.S. Surgeon General Discusses the Opioid Epidemic A Conversation With Jerome Adams, MD, MPH



The Doctors Company 2018 Executive Advisory Board meeting — a gathering of some of the leading figures in medicine in the United States — featured a conversation between The Doctors Company’s Chairman and Chief Executive Officer, Richard Anderson, MD, FACP, and the United States Surgeon General, Vice Admiral Jerome Adams, MD, MPH. Dr. Anderson and Dr. Adams discussed the opioid epidemic’s huge impact on communities and health services in the United States. DR. ANDERSON: Dr. Adams, you’ve been busy since taking over as surgeon general of the United States. What are some of the key challenges that you’re facing in this office?

So, our nation’s poor health is not just a matter of diabetes or heart disease 20 or 30 years down the road. We are literally a less safe country right now because we’re an unhealthy country.

DR. ADAMS: You know, there are many challenges facing our country, but it boils down to a lack of wellness. We know that only 10% of health is due to healthcare, 20% of health is genetics, and the rest is a combination of behavior and environment. My motto is “better health through better partnerships” because I firmly believe that if we break out of our silos and reach across the traditional barriers that have been put up by funding, by reimbursement, and by infrastructure, then we can ultimately achieve wellness in our communities. You asked what I’ve been focused on as Surgeon General. Well, I’m focused on three main areas right now. Number one is the opioid epidemic. It is a scourge across our country. A person dies every 12 and a half minutes from an opioid overdose, and that’s far too many. Especially when we know that many of those deaths can be prevented. Another area I’m focused on is demonstrating the link between community health and economic prosperity. We want folks to invest in health because we know that not only will it achieve better health for individuals and communities, but it will create a more prosperous nation. And finally, I’m raising awareness about the links between our nation’s health and our safety and security—particularly our national security. Unfortunately, seven out of 10 people between the ages of 18 and 24 years old in our country are ineligible for military service. That’s because either they can’t pass the physical, they can’t meet the educational requirements, or they have a criminal record.

DR. ANDERSON: Regarding the opioid epidemic, what are some of the programs that are available today that you find effective? What would you like to see us do as a nation to respond to the epidemic? DR. ADAMS: Just yesterday, I was at a hospital in Alaska where they have implemented a neonatal abstinence syndrome protocol and program that is being looked at around the country — and others are attempting to replicate it. We know that if you keep mom and baby together, baby does better, mom does better, hospital stays are shorter, costs go down, and you’re keeping that family unit intact. This prevents future problems for both the baby and the mother. That’s just one small example. I’m also very happy to see that the prescribing of opioids is going down 20–25% across the country. And there are even larger decreases in the military and veteran communities. That’s really a testament to doctors and the medical profession finally waking up. And I say this as a physician myself, as an anesthesiologist, as someone who is involved in acute and chronic pain management. Four out of five people with substance use disorder say they started with a prescription opioid. Many physicians will say, “those aren’t my patients,” but unfortunately when we look at the PDMP data across the country we do a poor job of predicting who is and who isn’t going to divert. It may not be your patient, but it could be their son or the babysitter who is diverting those overprescribed opioids.

One thing that I really think we need to lean into as healthcare practitioners is providing medication-assisted treatment, or MAT. We know that the gold standard for treatment and recovery is medicationassisted treatment of some form. But we also know it’s not nearly available enough and that there are barriers on the federal and state levels. We need you to continue to talk to your congressional representatives and let them know which barriers you perceive because the data waiver comes directly from Congress. Still, any ER can prescribe up to three days of MAT to someone. I’d much rather have our ER doctors putting patients on MAT and then connecting them to treatment, than sending them back out into the arms of a drug dealer after they put them into acute withdrawal with naloxone. We also have too many pregnant women who want help but can’t find any treat-

10% of health is due to healthcare, 20% of health is genetics, and the rest is a combination of behavior and environment. SAN DIEGO PHYSICIAN.ORG


The Dangers of E-Cigarettes DR. ANDERSON and Dr. Adams also discussed the dangers of e-cigarettes and the movement to population health. DR. ANDERSON: The Surgeon General’s office has been relentless in highlighting the dangers of cigarette smoking. My impression is that despite a decades-long reduction in the overall incidence of smoking, the percent of smokers in the United States is still very high — I think something around 20%, which leads us to a major controversy — and that is the role of e-cigarettes, vaping, and nicotine substitutes for cigarettes. It’s a complex issue with a lot of tentacles, but we would be grateful if you would give us some of your thoughts about that. DR. ADAMS: This is a very important and personal topic for me. I’ve got three young kids. I’m not just dealing with this as a surgeon general or as a physician; I’m dealing with it as a dad. Respectfully, I think that folks are purposely making it a complicated issue. I don’t think it’s that complicated. We know that the combustible cigarettes are bad. We know that nicotine is addictive. E-cigarettes and vaping can be two things at once. There can be harm reduction compared to combustible cigarettes for current smokers, but they can also be a dangerous initiation into the world of smoking. I believe, and I hope all of you in the audience can say it loudly: No young person should be vaping. No young person should be using e-cigarettes. No one should be marketing these products with flavors like cotton candy and bubble gum to young children. I’m working with the FDA and Commissioner Scott Gottlieb on this issue. We know the brain continues to develop up until age 26, and we know the folks are susceptible to developmental delays and effects on the brain, which prime it. DR. ANDERSON: The healthcare delivery system in the United States is undergoing a kind of once in-a-hun-



dred-year-cycle of change in the way care is delivered in almost every parameter of care; there are new technologies, new medications, new surgical potential, as well as different ways of accessing care throughout the system. But an important part of the conversation in that transformation is the discussion of population health versus the traditional doctor-patient and the individual patient and the individual office. It’s really struck me that this conversation is very much akin to the entire discipline of public health — which, after all, is focusing primarily on population health. How do you find that your background in public health helps you? How does it affect the way you see this national transformation? DR. ADAMS: A lot of our problems stem from the fact that we don’t teach enough about public health and population health to our medical students or nursing students. We don’t teach enough about how to discuss proper diet, how to talk about exercise, or how to talk about smoking cessation — all things that are promoted as part of public health. That said, we’re all quickly being forced to get to grips with that because of changes in payment models. We found that in paying for procedures, cutting things up piecemeal and then reimbursing for them is not only ineffective, it’s costlier. And so now when we look at paying for outcomes, we’re having to embrace population health. The good news is doctors, nurses, and healthcare professionals are all more satisfied when they’re able to do that. When systems are put in place that give them that freedom, flexibility, and the tools they need, it allows them to serve the patient. It empowers professionals to refer patients or to write a prescription for food; it allows them to refer patients to community recreation centers where they can exercise — and ultimately, that patient becomes healthier because of something that you’ve been able to facilitate as a medical practitioner. So, we’re shifting in that direction. Some people are kicking and screaming; others are embracing it.

ment because no one out there will take care of pregnant moms. We need folks to step up to the plate and get that data waiver in our ob-gyn and primary care sectors. Ultimately, we need hospitals and healthcare leaders to create an environment that makes providers feel comfortable providing that service by giving them the training and the support to be able to do it. We also need to make sure we’re coprescribing naloxone for those who are at risk for opioid overdose. DR. ANDERSON: Just so we are clear, are you in favor of regular prescribing of naloxone, along with prescriptions for opioids? Is that correct? DR. ADAMS: I issued the first Surgeon General’s Advisory in more than 10 years earlier this year to help folks understand that more than half of our opioid overdoses occur in a home setting. We all know that an anoxic brain injury occurs in four to five minutes. We also know that most ambulances and first responders aren’t going to show up in four to five minutes. If we want to make a dent in this overdose epidemic, we need everyone to consider themselves a first responder. We need to look at it the same as we look at CPR; we need everyone carrying naloxone. That was one of the big pushes from my Surgeon General’s advisory. How can providers help? Well, they can co-prescribe naloxone to folks on high morphine milligram equivalents who are at risk. If grandma has naloxone at home and her grandson overdoses in the garage, then at least it’s in the same house. Naloxone is not the treatment for the opioid epidemic. But we can’t get someone who is dead into treatment. I have no illusions that simply making naloxone available is going to turn the tide, but it certainly is an important part of it. DR. ANDERSON: From your unique viewpoint, how much progress do you see in relation to the opioid epidemic? Do you think we’re approaching an inflection point or do you think there’s a long way to go before this starts to turn around? DR. ADAMS: When I talk about the opioid epidemic, I have two angles. Number one, I want to raise awareness about the

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We still prescribe over 80% of the world’s opioids to less than 5% of the world’s population. So, we still have an over-prescribing epidemic, but we’ve surpassed the inflection point there. Prescribing is coming down. 12


opioid epidemic — the severity of it, and how everyone can lean into it in their own way. Whether it’s community citizens, providers, law enforcement, the business community, whomever. But in addition to raising awareness, I want to instill hope. I was in Huntington, West Virginia, just a few weeks ago, at the epicenter of the opioid epidemic. They’ve been able to turn their opioid overdose rates around by providing peer recovery coaches to individuals and making sure naloxone is available throughout the community. You save the life and then you connect them to care. We know that the folks who are at highest risk for overdose deaths are the ones that just overdosed. They come out

of the ER, where we’ve watched them for a few hours, and then we send them right back out into the arms of the drug dealer to do exactly what we know they will do medically because we’ve thrown them into withdrawal and they try to get their next fix. If we can partner with law enforcement, then we can turn our opioid overdose rates around. A story of recovery that I want to share with you is about a guy named Jonathan, who I met when I was in Rhode Island. Jonathan overdosed, but his roommate had access to naloxone, which he administered. Jonathan was taken to the ER and then connected with a peer recovery coach. He is now in recovery and has actually become a peer recovery coach himself. Saving this

one life will now enable us to save many more. Yet we still prescribe over 80% of the world’s opioids to less than 5% of the world’s population. So, we still have an over-prescribing epidemic, but we’ve surpassed the inflection point there. Prescribing is coming down. But another part of this epidemic was that we squeezed the balloon in one place, and as prescribing opioids went down, lots of people switched over to heroin. That’s when we really first started to see overdose rates go up. It’s important for folks to know that through law enforcement, through partnerships with the public health community, through an increase in syringe service programs, and through other touch

points, heroin use is now going down in most places. Unfortunately, now we’re seeing the third wave of the epidemic, and that’s fentanyl and carfentanil. Dr. Adams is the 20th Surgeon General of the United States. He holds degrees in both biochemistry and psychology from the University of Maryland. In addition, the Surgeon General has a master’s degree in public health from the University of California at Berkeley, and a medical degree from the Indiana University School of Medicine. Dr. Adams is a boardcertified anesthesiologist and associate clinical professor of anesthesia at Indiana University.







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CMA’s 2017–2018 Legislative Wrap-Up, Part 2 BY JANUS L. NORMAN


The California Medical Association has one of the most aggressive and successful legislative advocacy operations in Sacramento. In last month’s issue of San Diego Physician, we focused on legislation that had been passed or negotiated with CMA’s involvement. What is often even more important is the legislation that CMA defeats, which are against the best interests of California’s doctors and their patients. This month we cover legislation that CMA opposed in the past Legislative Session.



AB 221 (GRAY) WORKERS’ COMPENSATION: LIABILITY FOR PAYMENT Current law requires an employer to provide all medical services reasonably required to cure or relieve the injured worker from the effects of the injury. This bill would provide that for claims of occupational disease or cumulative injury filed on or after Jan. 1, 2018, the employee and the employer would have no liability for payment for medical treatment unless one or more of certain conditions are satisfied, including that the treatment was authorized by the employer. Status: Failed in the Assembly Insurance Committee. AB 1110 (BURKE) PUPIL HEALTH: EYE AND VISION EXAMINATIONS Would require, during the kindergarten year or upon first enrollment or entry at an elementary school, a pupil’s eyes and vision to be examined by a physician, optometrist, or ophthalmologist, unless the pupil’s parent or guardian submits a written waiver to the school. The bill would require, in a pupil’s kindergarten

year or upon first enrollment or entry at an elementary school that is not a charter school, the pupil’s vision to be appraised in accordance with the above-specified provisions only if the pupil’s parent or guardian fails to provide the results of the eye and vision examination. Status: Failed in the Assembly Appropriations Committee. AB 1612 (BURKE) NURSING: CERTIFIED NURSE-MIDWIVES: SUPERVISION Would repeal the requirement that a certified nurse-midwife be under the supervision of a licensed physician and surgeon. The bill would authorize a certified nurse-midwife to consult, refer or transfer care to a physician and surgeon as indicated by the health status of the patient and the resources and medical personnel available in the setting of care. The bill would provide that a certified nurse-midwife practices within a variety of settings, including the home setting. The bill would specify that nurse-midwifery care emphasizes informed consent, preventive care, and early detection and referral of complications. Status: Failed in the Assembly Appropriation Committee.

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AB 2078 (DALY) SEX OFFENSES: PROFESSIONAL SERVICES This bill would expand the crime of sexual battery to apply to a person who performs professional services that entail having access to another person’s body and who touches an intimate part of that person’s body while performing those services, and the touching was against the person’s will and for the purpose of sexual arousal, sexual gratification, or sexual abuse. The bill would expand the definitions of each of the crimes of rape, sodomy, oral copulation, and sexual penetration to include any of those crimes performed against a victim’s will by a professional whose services entail having access to the victim’s body, if the conduct is performed by the professional while performing those services. Because this bill significantly broadens the situations in which allegations of sexual battery can be made, the potential exists for physicians to be swept up in this change should a patient withdraw consent during a routine exam or procedure. Status: Failed in the Senate Appropriations Committee. AB 2668 (ALLEN) PUPIL IMMUNIZATIONS: PUPILS NOT IMMUNIZED This bill would delete private institutions, including private elementary and secondary schools, child care centers, day nurseries,


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AB 1795 (GIPSON) EMERGENCY MEDICAL SERVICES: COMMUNITY CARE FACILITIES This bill would authorize a local emergency medical services agency to submit, as part of its emergency medical services plan, a plan to transport specified patients who meet triage criteria to a behavioral health facility or a sobering center. The bill would make conforming changes to the definition of advanced life support to include prehospital emergency care provided during transport to a behavioral health facility or a sobering center. The bill would authorize a city, county, or city and county to designate, and contract with, a sobering center to receive patients, and would establish standards that apply to sobering centers, as specified. Status: Failed in the Assembly Appropriations Committee.

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////////////////////////////////////////////////////////////////////////// nursery schools, family day care homes, and development centers from certain immunization requirements, thereby allowing pupils who do not meet those immunization requirements to enroll in those institutions. Status: Failed in the Assembly Health Committee. AB 2741 (BURKE) PRESCRIPTION DRUGS: OPIOID MEDICATIONS: MINORS This bill sets a five-day cap on the supply of a schedule II opioid that may be prescribed to a minor, except in very limited circumstances. It also requires signed informed consent from a minor’s parent or guardian before being prescribed a schedule II opioid. The consequences of a violation of these provisions would be unprofessional conduct and could subject a prescriber to action against their license. Status: Failed in the Senate Business, Professions, and Economic Development Committee. AB 2789 (WOOD) HEALTHCARE PRACTITIONERS: PRESCRIPTIONS: ELECTRONIC DATA TRANSMISSION Current law provides for the regulation of healthcare practitioners and requires prescription drugs to be ordered and dispensed in accordance with the Pharmacy Law. The Pharmacy Law provides that a prescription is an oral, written, or electronic data transmission order and requires electronic data transmission prescriptions to be transmitted and processed in accordance with specified requirements. This bill, on and after Jan. 1, 2022, would require healthcare practitioners authorized to issue prescriptions to have the capability to transmit electronic data transmission prescriptions, and would require pharmacies to have the capability to receive those transmissions. Status: Signed by the Governor (Chapter 438, Statutes of 2018). AB 3087 (KALRA) CALIFORNIA HEALTHCARE COST, QUALITY, AND EQUITY COMMISSION This bill would create the California Health Care Cost, Quality, and Equity Commission, an independent state agency,



to control in-state healthcare costs and set the amounts accepted as payment by health plans, hospitals, physicians, physician groups, and other healthcare providers, among other things. Status: Failed in the Assembly Appropriations Committee. SB 538 (MONNING) HOSPITAL CONTRACTS This bill would prohibit contracts between hospitals and contracting agents or healthcare service plans from containing certain provisions, including setting payment rates or other terms for nonparticipating affiliates of the hospital, requiring the contracting agent or plan to keep the contract’s payment rates secret from any payer that is or may become financially responsible for the payment, and requiring the contracting agent or plan to submit to arbitration, or any other alternative dispute resolution program, any claims or causes of action that arise under state or federal antitrust laws after those claims or causes of action arise, except as provided. The latest amendment requires health plans and health insurers to be responsible for including and disclosing relevant terms of the provider contract with the third-party payer. The bill would make any prohibited contract provision void and unenforceable. Status: Failed in the Assembly Health Committee.

from one or more financially interested healthcare providers. SB 1156 links Medicare reimbursement rates to private sector payers’ fee schedules. This is a rate-setting bill because it would mandate that providers who treat patients that receive charitable premium assistance to temporarily maintain commercial insurance for their family, receive Medicare reimbursement rates while allowing the healthcare service plan or health insurer to continue to collect the full cost of the private-market-based monthly insurance premium. Status: Vetoed by the Governor. SB 1229 (STONE) PHARMACISTS: OPIOID MEDICATIONS: CONSULTATION This bill would require a pharmacist to provide oral consultation to a patient or the patient’s agent before dispensing any opioid medication in accordance with regulations adopted by the California State Board of Pharmacy. The bill would prohibit the pharmacist from dispensing the medication if the patient or the patient’s agent declines the consultation. Status: Failed in the Senate Business, Professions, and Economic Development Committee.

SB 562 (LARA) THE HEALTHY CALIFORNIA ACT This bill, the Healthy California Act, would create the Healthy California program to provide comprehensive universal singlepayer health care coverage and a healthcare cost control system for the benefit of all residents of the state. Status: Failed in the Assembly.

SB 1238 (ROTH) PATIENT RECORDS: MAINTENANCE AND STORAGE This bill would require certain healthcare providers at the time of creation of a patient record to provide a statement to the patient, or the patient’s representative, that sets forth the patient’s rights and the intended retention period for the records. The bill would require certain healthcare providers that plan to destroy patient records to notify the patient at least 60 days before a patient’s records are to be destroyed. Status: Failed in the Assembly Appropriations Committee.

SB 1156 (LEYVA) HEALTH CARE SERVICE PLANS AND HEALTH INSURANCE: 3RD-PARTY PAYMENTS SB 1156 establishes requirements for any entity making third-party premium payments if that entity is a provider that receives a direct or indirect financial benefit from the third-party payments, or if that entity receives the majority of funding

SB 1240 (STONE) PRESCRIPTION DRUGS: CURES DATABASE This bill would require a prescription, if in writing or transmitted electronically, to include an International Statistical Classification of Diseases, 10th revision (ICD-10) code or a legible clear notice of the condition or purpose for which the drug is being prescribed, unless the patient

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requests this information to be omitted and would require a prescription transmitted orally to include either an ICD-10 code of a description of the condition or purpose for which the drug is being prescribed. Status: Failed in the Senate Business, Professions, and Economic Development Committee.

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SB 1285 (STONE) HEALTHCARE COVERAGE: ADVANCED PRACTICE PHARMACIST This bill would require coverage for services provided by an advanced practice pharmacist performed within the scope of his or her practice, including comprehensive medication management services in a healthcare service plan contract and health insurance policy, and, to the extent that federal financial participation is available, in a Medi-Cal managed care plan. Status: Failed in the Senate Health Committee. SB 1322 (STONE) MEDI-CAL: COMPREHENSIVE MEDICATION MANAGEMENT This bill would provide that comprehensive medication management services are a covered benefit under the Medi-Cal program, and would require those services to include, among other things, the development and implementation of a written medication treatment plan that is designed to resolve documented medication therapy problems and to prevent future medication therapy problems. Status: Failed in the Senate Health Committee. SB 1325 (MOORLACH) PEACEFUL AND NATURAL DIGNITY ACT: THE RIGHT OF SELF-QUARANTINE Current law sets forth various civil rights of individuals and provides a civil cause of action for a violation of those rights. This bill would recognize the right of selfquarantine, and would establish a civil cause of action for violation of that right. Status: Failed in the Senate Health Committee. Mr. Norman is CMA senior vice president, Centers for Government Relations and Political Operations.

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Profile of Davis Cracroft By James Santiago Grisolía, MD

“EVERY SHIFT IN THE Emergency Department satisfies,” says Davis Cracroft, MD, senior vice president for physician development at ScrippsHealth. “As leader of your emergency team, you’re the orchestra conductor, trying to shape the disorder of rehearsal into a polished symphony.” Cracroft isn’t sure why, but he always felt drawn toward medicine, coming from a family of businessfolk and English professors without a doctor in sight. His vague feeling crystallized instantly in high school, when he and some friends were returning from a summer swim at the reservoir. They happened on a fresh rollover accident of other teens, one dead at the scene and others critically injured. Not knowing what to do propelled Cracroft into a lifelong search



for mastery in crisis situations. Despite this epiphany, his route meandered from Columbia University back to the University of Utah, where he finished college and then medical school. A daring team of urologists let him do a nephrectomy, a real high point as a medical student. He came to UC San Diego as a surgical resident under Marshall Orloff. Moonlighting in EDs during his research year turned into a convenience, then slowly into a calling. Eventually, during a management crisis, the Mercy chief of staff asked Cracroft if he’d consider taking over as chief of Emergency Medicine. A competitive bidding process left him, as the winning director, to work out an employment deal with the winning medical services provider on the spot.

Refashioning the emergency department of San Diego’s oldest and now largest hospital into an efficient, egalitarian organization remains one of his greatest satisfactions, and one that brought him to organized medicine. Cracroft took a crash course in medical leadership at that year’s ACEP (American College of Emergency Physicians) conference, getting syllabi from every course he couldn’t attend. And that’s when he joined SDCMS/CMA. “I decided I needed to learn from other leaders and wiser heads” to guide him in shaping his new department, he says. And he wanted to learn more about state and national issues, and how they impact delivery of emergency services. “I learned a lot about politics and the value of CMA’s lobbying work. I could see the value of tobacco tax dollars and other revenues that help us keep the doors open,” Cracroft says, noting Scripps-Mercy’s mission to serve all comers, from the homeless to CEOs, and everyone in between. Cracroft also appreciates the SDCMS CEO making regular reports to the Medical Executive Committee and the medical staff, which he finds keeps physicians engaged with state and national issues. After the transformation of the ScrippsMercy Emergency Department, Davis points to medical missions as other great moments. The Mercy MOST team affords chances for him to perform minor surgeries on their outreach trips in Mexico, and he joined the Scripps team for disaster relief in Houston after Hurricane Katrina. Cracroft says working in the Ben Taub Hospital ED “was like batting in Yankee Stadium for an ER doc,” where the trauma and medical desperation were nearly overwhelming. When he responded with Scripps to the Cedar Fire, the primary problems were respiratory, but it was gratifying to help people in need. “With volunteering, the benefit you get is even greater than what you give to the patients,” Cracroft says. Dr. Grisolía, SDCMS-CMA member since 1980, is editor of San Diego Physician.


FDA Seeks to Restrict Teens’ Access to Flavored E-Cigarettes, Ban Menthol in Cigarettes

THE FOOD AND DRUG Administration (FDA) has announced it will take steps to prevent youth access to flavored tobacco products, including electronic nicotine delivery systems (ENDS). The agency said it also plans to ban menthol cigarettes and flavored cigars. Youth use of e-cigarettes is a serious and growing public health crisis. According to the 2018 National Youth Tobacco Survey, 3.6 million people under 18 report using ecigarettes, up from 1.5 million the previous year. More than two-thirds (67.8 percent) are using flavored e-cigarettes. The survey found a 78 percent increase from 2017 to 2018 in current e-cigarette use among high school students, and a 48 percent increase among middle school students. While the FDA stopped short of an outright ban on flavored e-cigarettes — despite recent suggestions it would do just

that — the agency said stores would only be allowed to sell such products from closed off-areas inaccessible to teenagers. “I will not allow a generation of children to become addicted to nicotine through e-cigarettes,” said FDA Commissioner Scott Gottlieb, MD, in a statement. “We won’t let this pool of kids, a pool of future potential smokers, of future disease and death, to continue to build. We’ll take whatever action is necessary to stop these trends from continuing.” The policy would apply to all ENDS products, including e-liquids, cartridge-based systems and cigalikes, in all flavors except tobacco, mint, and menthol. For instance, the proposed policy would apply to flavors such as cherry, vanilla, crème, tropical, melon, and other flavors that specifically appeal to children. The FDA said it would also take steps to

ensure strong age-verification procedures for retail and online sellers. “This policy will make sure the fruity flavors are no longer accessible to kids in retail sites, plain and simple,” Dr. Gottlieb said. “That’s where they’re getting access to the e-cigs, and we intend to end those sales.” The FDA also announced it will pursue a ban on menthol in combustible tobacco products, including cigarettes and cigars, informed by the comments on its Advanced Notice of Proposed Rulemaking. Menthol cigarettes account for about 35 percent of cigarette sales in the United States. Scientific data shows that menthol use is likely associated with increased smoking initiation by youth and young adults. The California Medical Association (CMA) has long recognized that tobacco use is a costly habit that often leads to illness and poor health. In 2016, CMA produced a white paper that assessed evidence and research on the impact of flavored and mentholated tobacco products on public health, particularly among priority populations. The white paper found that flavored and menthol tobacco products are “starter” products that establish daily habits and promote addiction to tobacco products, make it harder to quit, and increase the use of multiple tobacco products concurrently. Flavorings used in tobacco products do not reduce the health impacts and risks associated with tobacco use, and are not safer than non-flavored tobacco products. Further, youth, certain racial/ethnic groups, and other targeted priority populations are particularly vulnerable to sweet flavors and menthol, and are largely driving the uptake and sustained use of flavored tobacco products. CMA submitted comments urging the FDA to weigh these concerns as it moves forward with its regulatory action. For more information, see CMA’s white paper: “Flavored and Mentholated Tobacco Products: Enticing a New Generation of Users.” SAN DIEGO PHYSICIAN.ORG



Secured Governor Jerry Brown’s signature on the Proposition 56 supplemental budget bill, which appropriates more than $1 billion in funding for improved access to care — including $220 million to establish a loan repayment program to incentivize physicians and dentists to serve Medi-Cal patients, and $40 million for the University of California to support, retain, and expand physicians trained in California.



Helped elect Gavin Newsom as governor and Eleni Kounalakis as lieutenant governor.

Recouped nearly $11 million from payers on behalf of CMA’s physician members — a record year!

Stopped predatory practices by health insurance companies, including attempts to substantially limit same-day services (modifier -25 payments) and automatically downcode emergency services based upon the ultimate diagnosis.

Defended the medical profession and patients from dangerous legislation, including AB 3087 (Kalra), which would have limited access to healthcare providers, created state-sanctioned rationing, and increased out-of-pocket costs for patients; and SB 562 (Lara), which would have dismantled California’s healthcare marketplace and destabilized the state’s economy.

Secured a $30 million commitment from Blue Shield of California to support the launch of a Physician Services Organization (PSO). This partnership will support a new model that provides Californians access to quality, comprehensive, and sustainably affordable care to improve the health of individuals and their communities.

Achieved a record-setting 6.24% increase of membership, with a 92% retention rate.

Launched a membersonly mobile app, as well as updated brands and websites for CMA, PHC, CALPAC, and 20-plus component medical societies.

Drafted and filed a 2020 Sugar-Sweetened Beverages (SSB) tax ballot initiative in response to the cynical sodaindustry-backed bill to stifle SSB taxes and their corresponding public health protections.



Helped the Tulare Regional Medical Center medical staff reach a favorable and historic legal settlement to restore independence and self-governance against the hospital, resulting in the hospital reopening on Oct. 15.

Secured the Proposition 56 supplemental budget bill, which appropriates more than $1 billion in funding for improved access to care.

Achieved record-setting 6.24% increase in membership with a 92% retention rate.

Drafted and filed a 2020 Sugar-Sweetened Beverages tax ballot initiative.

Stopped predatory practices by health insurance companies, including attempts to substantially limit same-day services (modifier -25 payments).

Launched a mobile app, as well as updated brands and websites for CMA, PHC, CALPAC, and 20+ component medical societies.

Defended the medical profession and patients from dangerous legislation, including AB 3087 (Kalra).

Helped the Tulare Regional Medical Center medical staff restore independence and self-governance against the hospital.

Recouped nearly $11 million from payers on behalf of CMA’s physician members – a record year!

Secured a $30 million commitment from Blue Shield of California to support the launch of a Physician Services Organization.

Secured $200 million to establish a loan repayment program and $40 million for the University of California to support, retain, and expand physicians trained in California.

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AB 72 A NEW CALIFORNIA LAW took effect last year that changed the way that noncontracted physicians bill and are paid for providing non-emergency care at in-network facilities including hospitals, ambulatory surgery centers, and laboratories. This out-of-network billing and payment law (AB 72) was designed to reduce unexpected medical bills when patients go to an innetwork facility but receive care from an out-of-network doctor. While patients with out-of-network benefits can consent to treatment from out-ofnetwork providers, absent a valid consent form, health plans and insurers are required to reimburse out-of-network physicians at an interim payment rate. Without a signed consent, patients are only responsible for



The Independent Dispute Resolution Process and How to Appeal By Julie Reavis

their in-network cost sharing. The interim rate is the greater of the plan/insurer’s average contracted rate (ACR), or 125 percent of the Medicare fee-for-service rate for the same or similar services in the general geographic region in which the services were rendered, unless otherwise agreed to by the noncontracting provider and the payer. (By Jan. 1, 2019, both regulators will have adopted a standardized methodology that all payers are required to use to compute the average contracted rate.) Can I challenge the interim payment? The law does include a mechanism for physicians to challenge the payment amount if they are dissatisfied — the independent

dispute resolution process (IDRP). Payers are required to participate in the IDRP once a physician begins the process. The first step is to determine whether you are eligible for IDRP. This step is important, as there are fees involved, which are split equally between the payer and the physician. To be eligible for IDRP a physician must first appeal in writing to the payor for additional payment. If the physician is not successful in resolving the dispute through the payor’s internal appeal process, the physician may then file an IDRP through the appropriate regulator — either the Department of Managed Health Care (DMHC) or the California Department of Insurance (CDI), depending on the product type. Claims are only eligible for the IDRP for

AB 72 Resources

CMA has a a number of resources to help physicians navigate this new law. These are all available free to members at out-of-network-billing. • FAQ: A Physician’s Guide to AB 72: Questions and Answers • A Physician’s Guide to the AB 72 Independent Dispute Resolution Process • Instructions and Sample Form for Obtaining Patient Consent Under California’s New Law • Sample Payor Appeal Letter for Interim Payments • Billing Requirements and Payment for Out-of-Network Services at In-Network Facilities • AB 72 Payment Monitoring Workbook • Health Law Library Document #7508: Non-Contracting Physicians • Balance Billing Toolkit

365 days from the date of the payer’s written response to the appeal. If a physician attempted the appeal process but the payer was non-responsive, the 365-day limit to file IDRP will begin after 45 business days have passed from the date of receipt of the physician’s appeal. Instances where physicians have had patients sign written consent forms for the use of out-of-network benefits are not eligible for IDRP. The IDRP process for both regulators is web- and email-based, and conducted through the regulators’ portals, with no parallel paper process. Physicians may bundle up to 50 claims in a single IDRP application. These claims must all be for services provided by the same physician, for the same payer (health plan, insurer, or delegated entity), and for the same or similar services. While DMHC does not define same or similar services, CDI defines them as those that fall within the same subheading in the CPT or HCPCS manual. Each application will need to include a copy of the original claim form, corresponding explanation of benefits, and a copy of the determination letter from the payer or the physician dispute resolution, if applicable. CDI also requires an IDRP request form with a final offer indicated, an IDRP request claim information spreadsheet when submitting bundled claims, copies of all correspondence between the provider and insurer, both sides of the patient’s ID card, and the assignment of benefits, if applicable. For both regulators, a copy of the appeal to the payer is also recommended. While not required, it is encouraged that each IDRP application submitted include a narrative summary justification. This should explain the physician’s billed charges or final offer for all claims at issue, including the physician’s training, qualifications, length in practice, the fees usually charged by the physician, other economic aspects relevant to the physician’s practice, any unusual circumstances, and other relevant factors. Physicians should also include supporting documentation, as the independent review organization conducting the IDRP will base its decision on the information submitted when rendering a decision. Supporting

documentation may be a citation referenced in the narrative summary justification, or include a provider directory report demonstrating network adequacy concerns, timely access enforcement actions, and appropriate reimbursement amounts from other payers. There is no page limit for either the narrative summary justification or the supporting documentation. The DMHC and CDI’s IDRP processes have many differences including arbitration types. DMHC uses traditional arbitration, meaning the arbiter can select any reimbursement amount he/she determines is appropriate. CDI uses baseball-style arbitration, meaning the arbiter will select one of two the parties’ final offers and no other amount. In both cases, prior to remitting IDRP fees, the parties may agree to a settlement of the claim(s). In all cases of IDRP, the arbiter’s decision is binding on both parties. Payers are required to implement the decision obtained through the IDRP. If dissatisfied, either party may pursue any right, remedy, or penalty established under any other applicable law. Physicians are encouraged to utilize IDRP, as regulators are required to consider information from the IDRP when establishing methodology for determining average contracted rates, which in turn will likely impact payer contracting practices going forward. For more information on IDRP eligibility, identifying the regulator, the submission processes and what to include in the narrative summary justification and/or the supporting documentation, the California Medical Association (CMA) has created an IDRP guide, “A Physician’s Guide to the AB 72 Independent Dispute Resolution Process.” This and many other valuable resources on navigating the out-of-network billing and payment law can be found in CMA’s AB 72 Resource Center: cmadocs. org/out-of-network-billing. Practices with additional questions or concerns can contact CMA’s Reimbursement Helpline at (800) 786-4262 or Julie Reavis is associate director of CMA’s Center for Economic Services. SAN DIEGO PHYSICIAN.ORG



Diagnosis … Fun! By Adama Dyoniziak

A THREE-DAY WEEKEND is a great opportunity to relax, spend quality time with family and friends, and have fun in the sunshine and fresh air of the outdoors — just like people from every corner of San Diego did on Nov. 10 at the Solana Beach Sunset 5K Run/Walk and Wellness Expo. There were so many fun activities to choose from: stretching with Stretch Lab, yummy foods and cooking tips from Beaming Foods and Cooking 4 Life, Kids Zone games with Skinny Gene Project, Bulky Jones tunes to rock the 5K, yummy tacos and frozen yogurt from Los Banditos and FroYo food trucks, dancing caped crusaders for prevention, and much more! This family-friendly event at Fletcher Cove Beach Park in Solana Beach is Champions for Health’s fifth annual fundraiser benefit-



ting our community wellness and diabetes prevention programs. Congratulations to more than 500 runners, walkers, teams, and sponsors for helping us raise $50,000! While Project Access San Diego gets people healthy via pro bono specialty healthcare, our Community Health & Wellness programming that addresses preventable and chronic diseases keeps people healthy. Our wellness activities include: screenings for blood pressure and colorectal cancer; the Live Well San Diego Speaker’s Bureau; a CDC certified diabetes prevention program; and immunizations for the flu, Tdap, Hepatitis A, and PCV13. This year alone, the 500-plus volunteer physicians and healthcare professionals provided 20,000 blood pressure screenings at 160 locations, more than a hun-

dred healthy living topic presentations throughout the community, and 2,500 free vaccinations at 50 sites. Champions for Health is the third highest flu vaccine provider in the County Health and Human Services Agency’s state-funded immunization program. Sarah Pinto, state flu vaccine coordinator, says, “We think Champions for Health is doing an amazing job, and everyone appreciates how hard you and your team are working this season. Thanks so much!” Live Well San Diego Speaker’s Bureau physicians speak of the personal and professional benefit these opportunities to volunteer their expertise present, and see it is an extension of their original commitment to enter the medical profession. “It’s my role as a medical provider to be here and ensure

people have access to information and services no matter what their income level may be,” says one physician about the program in a survey response. And participants echo how important and meaningful a personal connection with a physician can be: “It’s nice to see a physician take time out of their busy day to come and speak to us,” according to an audience member in the survey. “It reminds us that they are human too.” Champions for Health’s evidence-based diabetes prevention program, a collaborative partnership with the Skinny Gene Project, provides personalized coaching, weekly group meetings, healthy living tips, physical activities, and nutritional counseling over a 12-month period to people with risk factors for developing diabetes. Skinny Gene Project’s intervention has already been shown to reduce our participants’ risk of developing Type 2 diabetes by at least 58%, with 5–10% sustained weight loss. Since more than 46% of San Diegans

continue to have an increased risk of developing diabetes within the next five years, physicians are encouraged to refer clients at risk for diabetes to Champions for Health. The glue that holds all these free services together is the dedication of the physician volunteers who first envisioned being of service to the community at the San Diego County Medical Society. These physicians created the San Diego County Medical Society Foundation, which is now Champions for Health. All interested physicians, healthcare professionals, hospitals, and surgery centers who would like to volunteer their talents and facilities for Project Access San Diego and our Community Health and Wellness programs can contact Adama Dyoniziak at or (858) 300-2780. Join the fun and transform lives one person at a time! Ms. Dyoniziak is executive director of Champions for Health.



Seeking FM/DO/IM Physicians in San Diego and Orange Counties



Position: Full-time and part-time. Full benefits package and malpractice coverage is provided by clinic. Requirements: California license, DEA license, CPR certification and board certified in family medicine. Bilingual English/Spanish preferred. Send resume to: or fax to 760-414-3702

Vista Community Clinic is a private, nonprofit outpatient community serving people who experience social, cultural or economic barriers to health care in a comprehensive, high quality setting. EEO/AA/M/F/Vet/Disabled



CLASSIFIEDS VOLUNTEER OPPORTUNITIES 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. 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 MediCal 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, or visit [282] SHORT-TERM MEDICAL VOLUNTEERS NEEDED FOR HAITI: Global Health Teams is looking for physicians, mid-level providers and nurses for one-week, primary-care medical clinics in rural Haiti every February, June, and October. 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. GHT is an experienced U.S.-based nonprofit and 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 bob@ if you are interested in applying. Visit to see what we do and learn about the clinics and volunteer experience. PHYSICIAN OPPORTUNITIES

OUTPATIENT PRIMARY CARE OPPORTUNITY San Diego Internal Medicine Associates (SDIMA) is looking for a strong MD candidate to join our 6 physicians and 6 physician assistants in providing excellent care in a private practice setting. SDIMA is a well-established office with board certified internists and med/peds physicians. No hospital call. Please send your CV, or any questions you may have to FAMILY PRACTICE/INTERNAL MEDICINE PHYSICIAN NEEDED: Our company is looking for a board certified primary care physician. Time will be split between our La Mesa and National City locations. Hours are 8-5 Monday – Friday no night calls or weekend. Please email your CV to (Posted 11/19/2018) CARDIOLOGIST POSITION AVAILABLE: Seeking a cardiologist to work part-time in an outpatient cardiology practice in North San Diego County. Practice opportunities from Mon.-Friday. Hours are from 8 to 5 p.m. There is no night calls, or holidays work days. The contracted cardiologist would decide from the days available which days to work. Please fax resume to 760.510.1811 or via e-mail at FAMILY PRACTICE MD/DO: Family Practice MD/DO wanted for urgent care and family practice office in Carlsbad, CA. Flexible weekday and weekend shifts available for family practice physician at busy, well-established office. FAX or email CV to (760) 603-7719 or PRACTICE OPPORTUNITY: Internal Medicine and Family Practice. SharpCare Medical Group, a Sharp HealthCareaffiliated practice, is looking for physicians for our San Diego County practice sites. SharpCare is a primary care, foundation model (employed physicians) practice focused on local community referrals, the Patient Centered Medical

Home model, and ease of access for patients. Competitive compensation and benefits package with quality incentives. Bilingual preferred but not required. Board certified or eligible requirement. For more info visit or email interest and CV to

and treat our staff like family. Opportunity to do medical, cosmetic and surgical dermatology (including MOHs) in a medical office with state of the art tools and instruments. Please call Practice Administrator at (858) 761-7362 or email for more information.


OUTPATIENT PRIMARY CARE OPPORTUNITY: San Diego Internal Medicine Associates (SDIMA) is looking for a strong MD candidate to join our 6 physicians and 6 physician assistants in providing excellent care in a private practice setting. SDIMA is a well-established office with board certified internists and med/peds physicians. No hospital call. Please send your CV, or any questions you may have to

FT/PT positions available. Competitive pay and flexible schedule with complete autonomy. Add revenue to your current practice. For more information, contact us: P: 1-877-878-3289 F: 1-877-817-3227 or email CV to: JOBS@ADVANTAGEWOUNDCARE.ORG PART-TIME MEDICAL DOCTOR WANTED - IMPERIAL RADIOLOGY: Our company is an outpatient diagnostic radiology facility in search of a part-time Medical Doctor to help cover contrast administration. All Candidates must have an active California Medical License. Please contact via email with your resume if this position is of interest to you. (Posted 8/16/2018) FAMILY PRACTICE/INTERNAL MEDICINE PHYSICIAN NEEDED: Primary care physician wanted for established private practice in San Diego. La Jolla Village Family Medical Group has been caring for patients of all ages for 29 years in the UTC/La Jolla area of San Diego. We provide comprehensive preventive medicine, illness management, travel medicine, sports medicine, evidencebased chiropractic care, weight management, and more. Call responsibilities minor, hours consistent with a healthy work/life balance. Our office is modern, clean, and well appointed. Our staff is supportive, cohesive, and friendly. This a real family practice. Board-certified, California licensed MD and DO physicians who are passionate about medicine and interested in this opportunity should send their CV and cover letter addressed to Tricia at officemanager@ljvfmg. com. Let us grow your practice according to your unique specialty interests and style. Responsibilities include: Provide excellent care, become part of a cohesive team, light call, maintain accurate and detailed medical records using HER, comply with all laws applicable to family practice/internal medicine, including HIPAA, recommend lifestyle changes as appropriate to improve quality of life, Full-time, Part-time. (Posted 8/16/2018) MEDICAL DIRECTOR, CALIFORNIA CHILDREN’S SERVICES: The County of San Diego invites qualified individuals to apply for the position of MEDICAL DIRECTOR, CALIFORNIA CHILDREN’S SERVICES (Job Classification: Public Health Medical Officer). Under the direction of the Deputy Public Health Officer or designee, this unclassified management position will be responsible for the medical oversight of County of San Diego, Health & Human Services Agency, California Children’s Services Division. Residency in Pediatrics or Family Medicine is highly desirable. Please view the detailed brochure for information regarding the position, duties, and benefits. | Job Number 18412807CCSU PHYSICIAN NEEDED: Family Practice MD. San Ysidro Health is looking for an MD for our Family Practice center. The Family Practice MD manages and provides acute, chronic, preventive, curative and rehabilitative medical care to patients and determines appropriate regimen in specialized areas such as family practice, prenatal OB/GYN, pediatrics and internal medicine. Bilingual preferred but not required. Medical school graduate, CPR, CA MD and DEA License, board certified or eligible in primary care specialty. For more info on San Ysidro Health, visit: http://www.syhealth. org/ If interested, please email CV to Meagan.underwood@ DERMATOLOGIST NEEDED: Premier dermatology practice in beautiful San Diego seeking a full-time/part-time BC or BE eligible Dermatologist to join our team. Existing practice taking over another busy practice and looking for a lead physician. This is a significant opportunity for a motivated physician to take over a thriving patient base. Work with two energetic dermatologists and a highly trained staff in a positive work environment. We care about our patients

PRACTICE FOR SALE RHEUMATOLOGY SOUTH SAN DIEGO MEDICAL PRACTICE FOR SALE: Located in Chula Vista and has been in existence for >30 years. Established patient base and excellent insurance contracts including HMOs, PPOs, and Medicare with rates that have been negotiated over years. Gross collections >$450,000 with low overhead. Asking for $10,000 for medical records to be transferred and equipment. Would also ask that lease be taken until June 4, 2020 or you can negotiate longer with the manager of the building. Long term trained staff and Electronic Medical Record, which could be kept in place if needed. For immediate consideration, forward your details including your contact phone or email to: Run your own practice with potential earnings above and beyond an employed position without the bureaucracy and make your own schedule! (Posted 11/15/2018) HIGHLY PROFITABLE MEDSPA NOW AVAILABLE TO LICENSED PHYSICIAN: Southern California | Asking Price: $1,050,000 | Cash Flow: $410,419 | This profitable and expandable company performs non-invasive cosmetic procedures, including dermal fillers, Botox, and laser treatments. Experienced staff plans to stay, and protects current physician/owner at 30 hours/week max. If you’re ready to see online financials, a studio-quality video of their story, an industry-leading assessment, and more – visit: for a summary. Interested? Click on “Private Access” to sign an instant nondisclosure and unlock the entire story. Full financials available on request. Prefer a personal touch? Contact Doug Miller: (208) 762-3451. OB/GYN PRACTICE FOR SALE IN SAN DIEGO: Asking $480,000,00. FY 2017 Gross $1,445,688,00. Established practice for 38 years. Suburban district. Easy freeway access. Dedicated and experienced staff able to stay on board through sale. Situated within a modern, high-end building. The region’s fast-growing population assures for an expanding client base. Features 3200 sq ft of working space; 6 fully equipped patient rooms (5 exam & 1 surgery rooms with surgical lighting and fully adjustable treatment tables). Furnished waiting room and reception area; doctor’s private office, sterilization area, staff lounge and storage. ADA compliant. Contact: PRACTICE AVAILABLE IN EL CAJON: Mature board certified Family physicians grossing $ 1 million per year are selling this practice in El Cajon, California. This is a busy practice , on the Allscripts EHR in a busy neighborhood and contracted with local IPAs. I will lease the 1500 sqft office condo to you as well. Send an inquiry to Dennis O Dominguez or send text to 619 2464548 and I will call you. PRACTICES WANTED PRIMARY OR URGENT CARE PRACTICE WANTED: Looking for independent primary or urgent care practices interested in joining or selling to a larger group. We could explore a purchase, partnership, and/or other business relationship with you. We have a track record in creating attractive lifestyle options for our medical providers and will do our best to tailor a situation that addresses your need. Please call (858) 832-2007. 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 MEDICAL OR DENTAL SPACE AVAILABLE: For lease a medical or dental related practice or business in a small boutique office space located close to Moonlight Beach in Encinitas. First floor with 570 square feet and peek ocean views. Available February 1st. Physician/Dentist parking spot comes with lease and lease would be until December 31, 2020. Sinks in 2 exam rooms, office space for physician/dentist and laboratory storage area in addition

TO SUBMIT A CLASSIFIED AD, email SDCMS members place classified ads free of charge (excepting “Services Offered” ads). Nonmembers pay $150 (100-word limit) per ad per month of insertion.



to lobby/reception area. Asking: $2,000/month. Terms are negotiable. This will rent fast so hurry! Please contact: | (858) 603-2068. (Posted 11/18/2018)

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 | SHARED OFFICE SPACE: Office Space, beautifully decordated, to share in Solana Beach with reception desk and 2 rooms. Ideal for a subspecialist. Please call 619-606-3046. OFFICE SPACE/REAL ESTATE AVAILABLE: Scripps Encinitas Campus Office, 320 Santa Fe Drive, Suite LL4 It is a beautifully decorated, 1600 sq. ft. space with 2 consultations, 2 bathrooms, 5 exam rooms, minor surgery. Obgyn practice with ultrasound, but fine for other surgical specialties, family practice, internal medicine, aesthetics. Across the hall from imaging center: mammography, etc and also Scripps ambulatory surgery center. Across parking lot from Scripps Hospital with ER, OR’s, Labor and Delivery. It is located just off Interstate 5 at Santa Fe Drive, and ½ mile from Swami’s Beach. Contact Kristi or Myra 760-753-8413. View Space on Looking for compatible practice types. SHARED OFFICE SPACE AVAILABLE: Shared Office Space: Very attractive 1 or 2 exam rooms available, medical spa office ‘Exquisite Md Spa’ in Bankers Hill near Balboa Park. Available 5 days per week. Reasonable rates. Call Claudia at 619-5014758. (Posted 8/16/2018) OFFICE SPACE AVAILABLE: La Jolla (Near UTC) office for sublease or to share: Scripps Memorial medical office building, 9834 Genesee Ave-great location by the front of the main entrance of the hospital between 1-5 and 1-805. Multidisciplinary group and available to any specialty. Note we are in great need of a psychiatrist. Excellent referral base in the office and on the hospital campus. Please call (858) 4557535 or (858) 320-0525 and ask for Sofia or call Dr. Shurman, (858) 344-9024. (Posted 8/10/2018) OFFICE SPACE FOR RENT: Multiple exam rooms in newer, remodeled office near Alvarado Hospital and SDSU. Convenient freeway access and ample parking. Price based on useage. Contact Jo Turner (619) 733-4068 or OFFICE SPACE AVAILABLE IN MISSION VALLEY: Unique space for lease in Mission Valley. 1300 sq. ft office space in medical/surgical office building, single story, ample free parking. Is currently in use as physical therapy suite with reception area, small waiting room, private treatment room, separate office, bathroom in suite and hook ups for washer/ dryer. Easy access to all freeways. Available approximately August 1, 2018. Please contact Joan McComb, Executive Director, CA Orthopaedic Institute. (619) 291-8930 or cell (619) 840-0624. NORTH COUNTY MEDICAL SPACE AVAILABLE: 2023 W. Vista Way, Suite C, Vista, CA 92083. Newly renovated, large office space located in an upscale medical office with ample free parking. Furnishings, décor, and atmosphere are upscale and inviting. It is a great place to build your practice, network and clientele. Just a few blocks from Tri-City Medical Center and across from the urgent care. Includes: Digital X-ray suite, multiple exam rooms, access to a kitchenette/break room, two bathrooms, and spacious reception area all located on the property. Wi-Fi is NOT included. Contact Harish Hosalkar at or call/text (858) 243-6883. (Posted 6/11/2018) SHARED OFFICE SPACE AVAILABLE: Established orthopedic group seeks additional orthopedic surgeon for partnership or overhead sharing opportunity. Our office is centrally located in Kearny Mesa near Highway 163 and Balboa, easy access to freeways, affiliations with Sharp, Scripps. Extensive referral base, EMR/”paper-light” office, experienced MA/surgery scheduler/referral coordinator. Please call Terry Sanchez, practice administrator, at (858) 278-8300 or email tsanchez@ (posted 11/19/2018) SCRIPPS ENCINITAS CAMPUS OFFICE: 320 Santa Fe Drive, Suite LL4 It is a beautifully decorated, 1600 sq. ft. space with 2 consultations, 2 bathrooms, 5 exam rooms, minor surgery. Obgyn practice with ultrasound, but fine for other surgical specialties, family practice, internal medicine, aesthetics. Across the hall from imaging center: mammography, etc and

also Scripps ambulatory surgery center. Across parking lot from Scripps Hospital with ER, OR’s, Labor and Delivery. It is located just off Interstate 5 at Santa Fe Drive, and ½ mile from Swami’s Beach. Contact Kristi or Myra (760) 753-8413. View Space on Website: Looking for compatible practice types. (Posted 4/4/2018) MEDICAL OR DENTAL SPACE AVAILABLE: For lease a medical or dental related practice or business in a small boutique office space located in the center of “Hillcrest/ Bankers Hill”. Just renovated! The second story of this beautiful two story building is available for lease. A private gated entrance leads to a 1,139 square foot upstairs with 4 to 5 consultation rooms, waiting room with adjoining private deck and full bathroom. Additional security gate and mailbox. Separate address. Wood floors, refinished windows, natural light, quiet street, walkable to restaurants. On-site parking with up to 8 parking spaces available! Asking: $3,000/month. Terms are negotiable. This will rent fast so hurry! CLICK HERE for photos. Please contact: | (858) 775-5075 OFFICE SPACE FOR RENT: La Jolla -- LEASE - Medical or dental related practice or business in a small boutique office space located in the center of beautiful La Jolla, California. Perfect opportunity for Psychiatrist, Psychologist, Counselor, Dentist, Physician, Surgeon. Any dental or medical related occupation welcom. Located in medical/dental building. Come join these great practices. Classy second floor suite with elevator. Perfect for entrepeneur. Partially equipped for dental or surgical practice. Terrific Opportunity. 612 square fee. $4.90/sq ft per month. Triple net lease. Contact Kevin Gott: MEDICAL OR DENTAL SPACE AVAILABLE: For lease a medical or dental related practice or business in an office space with other medical offices located in downtown Chula Vista close to Scripps Chula Vista hospital. First floor with ~1000 square feet. Available January 1st. 2 physician/dentist parking spots comes with lease and lease would be until June 4, 2020 or longer should you negotiate with the building manager. Sinks in 3 exam rooms, office space for physician/ dentist, bathroom, and laboratory area or additional exam room in addition to lobby/reception area. There is a long term subleasor on Fridays, so rent could be lower if you are willing to keep the subleasor, but asking: $2,000/month. Terms are negotiable. Please contact: | (858) 603-2068. OFFICE SPACE / REAL ESTATE WANTED MEDICAL OFFICE SPACE SUBLET DESIRED NEAR SCRIPPS MEMORIAL LA JOLLA: Specialist physician leaving group practice, reestablishing solo practice seeks office space Ximed building, Poole building, or nearby. Less than full-time. Need procedure room. Possible interest in using your existing billing, staff, equipment, or could be completely separate. If interested, please contact me at MEDICAL EQUIPMENT/FURNITURE FOR SALE HIGH TECH FACIAL IMAGING FOR SALE: New Reveal® Imager for sale. Ideal for MedSpa or cosmetic practice. The Reveal® Imager clearly demonstrates sun damage, brown spots, red areas and more. Create a personalized printed treatment record for the patient. Contact info@ or 858-224-2281 if interested. MEDICAL EQUIPMENT AVAILABLE FOR DONATION: Carlsbad Imaging has medical equipment available for donation. Afinion HbA1c-Used, Siemens clinitek status+-Used, FastPack-Used. Please contact if interested. (Posted 8/16/2018) NON-PHYSICIAN POSITIONS AVAILABLE 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 (Posted 11/19/18) PART-TIME, REMOTE MEDICAL CODING AND DATA ENTRY POSITION: Part-time, remote medical coding and data entry position available. All work is done remotely by logging into our EMR eclinical works. ICD-10 medical coding experience and familiarity with risk-adjusted diagnosis codes required. Experience with eclinical works a plus. Potential to increase work to full-time possible. Please submit a letter of interest and your resume to (Posted 11/19/18) NON-MEDICAL PROVIDER WANTED: San Diego Medical Group is a well-established and busy Internal Medicine practice. We seek an experienced NP to work independently

as a primary care provider for our current NP’s patient panel who plans to leave the practice after 10 years for family needs. Work hours are Monday through Friday 7:30/8:30 AM to 4:30/5:30 PM. There is no call. After hours remote preparation for clinics and maintaining desktop duties (labs, imaging reports, consult notes, patient emessages, etc.) is required. Applicants must have prior experience in this capacity and be able to assume responsibility for patient care immediately. Patients range from healthy adults to medically complex seniors. You must have experience providing medical care in Internal Medicine. In addition you need a DEA number, have familiarity prescribing Schedule II-V medications, be able to provide office gynecology, provide Tehehealth visits and perform basic dermatology procedures. Other duties may apply as deemed necessary. Spanish and/or experience with eClinicalWorks is a plus. Benefits include vesting into a 401k profit sharing retirement plan. Our office is located directly across the street from Scripps Mercy Hospital in the prestigious Mercy Building and we are staffed by two Internists and 8 additional staff. Salary $95,000-$120,000 annually. Contact (Posted 11/19/18) PUBLIC HEALTH NURSE. COUNTY OF SAN DIEGO. FLUENCY IN THE SPANISH LANGUAGE IS REQUIRED: The County of San Diego invites qualified individuals to apply for the position of Public Health Nurse. Salary is $70,470.40 - $86,632.00 Annually. Public Health Nurse is the journey level class in the Public Health Nurse series. Under general supervision, a Public Health Nurse performs the full range of public health nursing duties in homes, public health centers, and other community settings. For more information and to apply CLICK HERE (Posted 10/30/18) POSITION FOR A PHYSICIAN ASSISTANT (PA-C) OR NURSE PRACTITIONER FOR ENDOCRINOLOGY PRACTICE IN CHULA VISTA: This is a very rewarding practice managing patients from teenagers to nonagenarians, from a spectrum of ethnic groups and socioeconomic levels. It is also rewarding due to the opportunity for consultations as well as fostering a relationship with many of the patients who continue with the practice for years. Salary is competitive and commensurate with experience with benefits including Health (Kaiser), dental, vision, 6 days PTO per year, major holidays and the opportunity to participate in a Simple IRA retirement plan. Please send resume and references to or call 619-606-3046 (Posted 10/23/2018) PLASTIC SURGERY AND FRONT DESK COORDINATOR: The ideal position for someone with a background in plastic surgery, dermatology, ophthalmology, or medical spa. Will consider those with a background in a high-end hospitality setting. The Coordinator is primarily responsible for the dayto-day creation of an office environment that fosters highly personalized customer service. Responsible for the front/ back office daily operations including patient care, scheduling, and optimizing surgical closure rates and sale of skin care lines. Contact with resume. Salary commensurate with experience. (Posted 9/4/2018) MEDICAL OFFICE MANAGER/CONTRACTS/BILLING PERSON: MD specialist leaving group practice, looking to reestablish solo private practice. Need assistance reactivating payer contracts, including Medicare. If you have that skill, contact I’m looking for a project bid. Be prepared to discuss prior experience, your hourly charge, estimated hours involved. May lead to additional work. PRODUCTS / SERVICES OFFERED CLASSICS OF MEDICINE LIBRARY AVAILABLE: The Friends of the San Diego Public Library are in search of a good home for a Classics of Medicine Library [Gryphon Edition]. These collectible volumes are leatherbound, facsimile reprints of classics from Hippocrates and Galen, through Virchow, Lister, and Jenner. The books are BEAUTIFUL! This particular collection contains 60 titles in total, all in like-new condition. A full list is available upon request. We are asking $550 and would prefer to sell them as a complete set. 100% of proceeds from our book sales support the programs and collections of the San Diego Public Library. Please call Lisa Heinz at (619) 572-1274 or email for more information. DATA MANAGEMENT, ANALYTICS AND REPORTING: Rudolphia Consulting has many years of experience working with clinicians in the Healthcare industry to develop and implement processes required to meet the demanding quality standards in one of the most complex and regulated industries. Services include: Data management using advanced software tools, Use of advanced analytical tools to measure quality and process-related outcomes and establish benchmarks, and the production of automated reporting. (619) 913-7568 | | www.rudolphia. consulting A VALUABLE EDUCATIONAL RESOURCE: Extensive Medical Articles File for sale. Charts, illustrations, articles. Emphasis on Emergency Medicine and Internal Medicine. Collected since 1973. Fills a large filing cabinet. (Cabinet not included.) Would make a useful gift for a medical student or resident. Best offer takes. Will accept offers for 30 days after the publication of this newsletter. View in person at a North County location by appointment. (858) 451-6517.



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

The Perfect New Year’s Resolution Simple, Doable, and Impactful By Helane Fronek, MD, FACP, FACPh

AS MEMORIES OF the holiday season fade and we contemplate what the new year might bring, it’s natural to consider how we want our lives to be different. Weight loss, more exercise, finally conquering the clutter/journals/EHR challenges frequently top our list. We hope these accomplishments will make us happier, relieve our stress, and improve our relationships and lives. Instead, I’d like to offer a suggestion that has the potential to truly change our experience in ways we cannot even imagine. At the SoCal Women in Medicine conference, a former president of the California Medical Association, a medical school dean, and the medical director and chief of staff of a large healthcare system were asked what helped them most in their leadership roles. Their unanimous answer? Mindfulness.



One attendee laughed on hearing that the most significant leadership training these powerhouse physician leaders had received was “yoga.” What does this say about the potential of this practice to transform our lives? Have you ever become lost in thought, unaware of what you passed since starting your car minutes ago, or “zoned out” while people you care about told you something important? Being present in each moment makes our life feel fuller and richer as we truly experience its sights, sounds, smells, tastes, and textures. Have you felt irritated and reacted impatiently toward someone when that irritation originated in a prior interaction? Mindfulness helps us release worries and frustration so we see each person and interaction clearly, and respond

more kindly and appropriately. Arriving home preoccupied with the stresses of our day renders us impermeable to the love and joyfulness of our children and spouses. Opening to that source of joy can restore our sense of balance. A multitude of physiologic benefits also await: reduced heart rate and blood pressure, decreased impulses in the amygdala (our fear center), reduction of pain, and diminished activity in the default mode network, which decreases mind wandering and increases our happiness. Support for beginning a mindfulness practice abounds in San Diego and includes online, in-person, and app-based courses and groups. Mindfulness practice is simple — we commit to spend time focusing on our breath, a mantra, or the feeling of our body. When thoughts come, as they naturally do, we learn to return our attention to our present moment experience without making our thinking “bad” or judging ourselves. This repetitive exercise sharpens our awareness of when thoughts have hijacked our attention, builds our ability to return to present moment awareness so we experience our life as it happens, and helps us accept what is true in each precious moment. The present moment is the only moment we ever have. Make the most important commitment of the new year by starting a mindfulness practice — a priceless gift that will benefit you and everyone in your life. Learn to experience each moment and feel the joy and meaning of your life all throughout the year. 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


Champions for Health’s collaborative partner in diabetes prevention, Skinny Gene Project, has been providing their CDC evidencebased intervention in San Diego County with successful results: 5.2% - 10% sustained weight loss over 12 months. That is a 58% reduction in diabetes…a delay in the onset of diabetes by 4-10 years!


to start the process!

• • • •

Be at least 18 years old Be overweight (body mass index ≥ 25; ≥23 if Asian) Have no previous diagnosis of type 1 or type 2 diabetes Have a blood test result in these ranges within the past year: • Hemoglobin A1C: 5.7% -6.4% or • Fasting plasma glucose: 100-125mg/dl or • Two-hour plasma glucose (after a 75 gm glucose load): 140-199 mg/dl • Be previously diagnosed with gestational diabetes

Screen, Test, Refer to Skinny Gene Project’s Diabetes Prevention Program

When you screen, test, and refer patients to a CDC-twice recognized diabetes prevention program, your patients will receive the guidance, accountability, and support they need to reduce their risk of type 2 diabetes.

More about the program…

While your patients receive a minimum of 22 sessions during a year of support, you can remain informed with patient reports. Family and community support via walking buddies and dietary changes transforms communities with healthier patients and families. Workshop locations are near patients’ homes. Trained, peer-based, lifestyle coaches can become an extension of your care team. Let’s start 2019 right…let’s get healthy!

619-793-2008 As of Jan 2019, this program is a covered benefit for both Medicare and Medi-Cal beneficiaries. SAN DIEGO PHYSICIAN.ORG


$5.95 |

San Diego County Medical Society 5575 Ruffin Road, Suite 250 San Diego, Ca  92123 [ Return Service Requested ]

Working continuously to balance the

SCALES OF JUSTICE. We’re taking the mal out of malpractice insurance. As a relentless champion for the practice of good medicine, we continually track, review, and influence federal and state bills on your behalf. All for one reason: when you can tip the scales in favor of the practice of good medicine, you get malpractice insurance without the mal. Find out more at



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