October 2017

OCTOBER 2017 OFFICIAL PUBLICATION OF SDCMS

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SATURDAY, OCTOBER 1 FLETCHER COVE, SOLANA BEACH

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PROMENADE DENTISTS

OCTOBER

CONTENTS

VOLUME 104, NUMBER 10 EDITOR: James Santiago Grisolía, MD EDITORIAL BOARD: James Santiago Grisolía, MD • Mihir Parikh, MD • Robert E. Peters, MD, PhD • J. Steven Poceta, MD MARKETING & PRODUCTION MANAGER: Jennifer Rohr SALES DIRECTOR: Dari Pebdani ART DIRECTOR: Lisa Williams COPY EDITOR: Adam Elder OFFICERS President: Mark W. Sornson, MD, PhD President-elect: David E.J. Bazzo, MD Secretary: James H. Schultz Jr., MD Treasurer: Holly B. Yang, MD Immediate Past President: Mihir Y. Parikh, MD GEOGRAPHIC DIRECTORS East County #1: Venu Prabaker, MD East County #2: Rakesh R. Patel, MD East County #3: Jane A. Lyons, MD Hillcrest #1: Gregory M. Balourdas, MD Hillcrest #2: Thomas C. Lian, MD Kearny Mesa #1: Sergio R. Flores, MD (Board Representative to Executive Committee) Kearny Mesa #2: Alexander K. Quick, MD La Jolla #1: Geva E. Mannor, MD, MPH La Jolla #2: Marc M. Sedwitz, MD, FACS North County #1: Patrick A. Tellez, MD North County #2: Christopher M. Bergeron, MD, FACS North County #3: Michael A. Lobatz, MD South Bay #1: Irineo “Reno” D. Tiangco, MD South Bay #2: Maria T. Carriedo, MD GEOGRAPHIC ALTERNATE DIRECTORS East County: Susan Kaweski, MD Hillcrest: Kyle P. Edmonds, MD Kearny Mesa #1: Anthony E. Magit, MD Kearny Mesa #2: Eileen R. Quintela, MD La Jolla: Wayne C. Sun, MD North County #1: Neelima V. Chu, MD South Bay: Paul Manos, DO AT-LARGE DIRECTORS #1: Thomas J. Savides, MD; #2: Karrar H. Ali, DO, MPH; #3: Alexexandra E. Page, MD; #4: Nicholas J. Yphantides, MD; #5: Stephen R. Hayden, MD (Delegation Chair); #6: Marcella (Marci) M. Wilson, MD; #7: Toluwalase (Lase) A. Ajayi, MD (Board Representative to Executive Committee); #8: Robert E. Peters, MD AT-LARGE ALTERNATE DIRECTORS #1: Karl E. Steinberg, MD; #2: Steven L-W Chen, MD, FACS, MBA; #3: Erin L. Whitaker, MD; #4: Al Ray, MD; #5: Preeti Mehta, MD; #6: Vimal I. Nanavati, MD, FACC, FSCAI; #7: Peter O. Raudaskoski, MD; #8: Kosala Samarasinghe, MD ADDITIONAL VOTING DIRECTORS Communications Chair: J. Steven Poceta, MD Young Physician Director: Edwin S. Chen, MD Resident Physician Director: Trisha Morshed, MD Retired Physician Director: David Priver, MD Medical Student Director: Meghana Pagadala

4 features

15 San Diego’s Battle with Infectious Diseases

departments 4 Briefly Noted: Calendar • Office Manager Contest • Sunset 5K Photos • And More…

6

12 Five Best Practices to Meet Macra Requirements by the End of the Year

2

OCTOBER 2017

CMA TRUSTEES Robert E. Wailes, MD William T-C Tseng, MD, MP

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

BY KIM HATHAWAY, MSN, CPHRM

26 Physician Marketplace Classifieds

28 What Strengths Reside in Those Dark, Hidden Places of Ourselves?

San Diego Medical Office Market

BY CHRIS ROSS

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

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

We WeWe understand understand understand

that that one one size size does does not not fitfit all.all. that one size does not fit all.

WithWith location, location, accessibility, accessibility, size,size, officeoffice layout layout and and specific specific medical medical requirements requirements to consider, to consider, we will we find will find the right the fitlocation, forfityou. for you.

HaveHave you seen you seen what what is available is available in specific the inmedical the medical medical office office market market lately? lately?

Withright accessibility, size, office layout and requirements to consider, we will find the right fit for you. Have you seen what is available in the medical office market lately?

Genesee Genesee PlazaPlaza Nordahl Nordahl Medical Medical Centre Centre 4S Health 4S Health Center Center 9333-9339 9333-9339 Genesee Genesee Avenue Avenue 838 Nordahl 838 Nordahl Road Road 16918 16918 Dove Dove Canyon Canyon Road RoadCenter Genesee Plaza Nordahl Medical Centre 4S Health UTC UTC San Marcos San Marcos Rancho Rancho Bernardo Bernardo 9333-9339 Genesee Avenue 838 Nordahl Road 16918 Dove Canyon R up toup 10,488 to 10,488 s.f. available s.f.UTC available up toup 14,920 to 14,920 s.f. available s.f.San available 5,7505,750 s.f. available s.f. available Marcos Rancho Bernardo For Lease For Lease For Lease or Sale or Sale For Sublease 5,750 s.f. available up to 10,488 s.f. available For Lease up to 14,920 s.f. availableFor Sublease For Lease

For Lease or Sale

CreekView CreekView Medical Medical Park Park 1940 1940 5th Avenue 5th Avenue 1968 1968 Via Centre Via CentreCreekView Medical Park Bankers Bankers Hill Hill 1940 5th Avenue Vista Vista 11,108 11,108 s.f. available s.f. available 1968 Via Centre Bankers Hill up toup 5,000 to 5,000 s.f. available s.f. Vista available For Sale For with Sale income with income 11,108 s.f. available For Lease For Lease up to 5,000 s.f. available For Sale with income For Lease

For Sublease

RyanRyan PlazaPlaza 1194311943 El Camino El Camino Real RealPlaza Ryan Del Mar DelHeights Mar Heights11943 El Camino Real up toup 7,152 to 7,152 s.f. available s.f. Del available Mar Heights For Lease For Lease up to 7,152 s.f. availab For Lease

JLL Healthcare JLL Healthcare Practice Practice Group Group Paul Braun Paul Braun ChrisChris Ross Ross Kelly Kelly Moriarty Moriarty 8910 8910 University University Center Center Lane Lane Suite Suite 100 100 Managing Managing Director Director Senior Senior Vice President Vice President Associate Associate JLL Healthcare Practice Group Paul Braun Chris Ross Kelly Moriarty San Diego, San Diego, CA 92122 CA 92122 858.410.6388 858.410.6388 858.410.6377 Senior Vice 858.410.6359 858.410.6359 Associate 8910 University Center Lane Suite 100 Managing858.410.6377 Director President sdmedicalrealestate.com sdmedicalrealestate.com paul.braun@am.jll.com chris.ross@am.jll.com chris.ross@am.jll.com kelly.moriarty@am.jll.com kelly.moriarty@am.jll.com San Diego, CA 92122 paul.braun@am.jll.com 858.410.6388 858.410.6377 858.410.6359 Lic. #: Lic. 00891709 #: 00891709 Lic. #: Lic. 01469025 #: 01469025 Lic. #: Lic. 01963162 #: 01963162kelly.moriarty@a sdmedicalrealestate.com paul.braun@am.jll.com chris.ross@am.jll.com Lic. #: 00891709

Lic. #: 01469025 Lic. #: 301963162 SAN DIEGO PHYSICIAN.ORG

/////////BRIEFLY /////////////////NOTED //////////////////////////////////////////////////////////////////////// CALENDAR 2017 San Diego Day Of Trauma conference November 3, 2017 Kona Kai Resort and Spa Emergency Care

By The Bay November 16, 2017 Kona Kai Resort and Spa National Healthcare Coalition Preparedness Conference November 28-30, 2017 San Diego Sheraton Hotel and Marina Taking Control of Your Diabetes Conference November 18, 2017 San Diego Convention Center Bioethics Training Conference November 29, 2017 SDCMS Conference Room AACR-IASLC International Joint Conference: Lung Cancer Translational Science from the Bench to the Clinic January 8-11, 2018 Hard Rock Hotel San Diego

CHAMPIONS FOR HEALTH

Solana Beach Sunset 5K! It was a beautiful day for diabetes prevention at Fletcher Cove! On October 7, 800 runners, walkers, and strollers hit the beach to raise funds for our diabetes prevention program, Jump Start for Health! Before the race, participants browsed our Wellness Expo, featuring Aloha Acai, FroYo By the Sea, Kashi, FitWall, Cal Coast Credit Union, and much, much more! We raised over $70,000 for atrisk communities throughout San Diego County to learn healthy habits and live to their full potential!

SDCMS Social Events 2018

Mark your calendars for next year!

Feb 23 (Fri) Physician Networking Mixer April 26 (Thurs) Vendor Fair July 14 (Sat) Family Pool Party Oct 25 (Thurs) Physician Networking Mixer *dates subject to change.

GIVING BACK

December’s San Diego Physician magazine will feature SDCMS providers who are giving back.

Are you actively involved with an organization or a cause? Would you like your fellow members to consider supporting those efforts? The December magazine will select 4 providers and the organization they are involved in to feature in the “Giving Back” issue. To be considered for a feature story, submit a letter about the efforts and why it is important to editor@sdcms.org.

4

OCTOBER 2017

/////////////////////////////////////////////////////////////////////////////////////////////////// OFFICE MANAGERS

9th Annual SDCMS “Outstanding Medical Office Manager” Contest Now Accepting Nominations!

SDCMS wants to recognize San Diego County’s most outstanding medical office manager/practice administrator, i.e., someone who goes above and beyond his or her job description, who anticipates problems before they arise, who works efficiently with the practice’s time and resources, and who strikes the right balance between exercising control and boosting morale when supervising staff.

SDCMS Member physicians can nominate their office managers by explaining in writing (up to 600 words) why their office

manager is the BEST in San Diego County.

Nominations will be accepted through Friday, November 10, 2017. The winner will receive a $200 gift card and recognition as San Diego County’s Outstanding Medical Office Manager for 2017! Contest results will also be published in the January 2018 issue of San Diego Physician magazine.

Please email your nominations to Eric.

Ayaso@SDCMS.org. Remember, only submissions from physician members will be considered.

HEPATITIS A UPDATE

SDCMS Hosts Providers Meeting on Hepatitis A More than 100 medical professionals joined the San Diego Medical Society’s GERM Commission along with the County’s Health and Human Services Agency Public Health Services at a “Providers Meeting” on the Hepatitis A outbreak.

The meeting was open to all healthcare providers, administrators and trainees who work in inpatient and outpatient settings.

The medical community was updated on the Hepatitis A outbreak, best practices across institutions, and what they could do to assist during the outbreak.

TrusT A Common sense ApproACh To InformATIon TeChnology

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SDCMS joins Mayor Faulconer and county leaders at a press conference to address the Hepatitis A outbreak. Dr. Will Tseng spoke on behalf of SDCMS.

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CHAMPIONS FOR HEALTH

Exciting Job Opportunity:

Champions for Health Executive Director Champions for Health (CFH) is a nonprofit, 501(C) 3 organization founded by San Diego County physicians and the leadership of the San Diego County Medical Society in 2004. Its mission is to improve community health and wellness, access to care for all, and support for physicians through engaged volunteerism. CFH operate on a budget of roughly $700,000 per year, with a mix of grants, contracts, and fundraising.

Reporting to the Board of Directors and the San Diego County Medical Society CEO, the Executive Director (ED) will have operational responsibility for CFH staff, programs, expansion, and execution of its mission. The ED will be a self-directed entrepreneurial leader with a diverse skill set who is comfortable driving success in a dynamic environment.

For more information, email jobs@ChampionsFH.org.

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SAN DIEGO PHYSICIAN.ORG

5

C O M M E R C I A L R E A L E S TAT E T I P S & T R E N D S

THE SAN DIEGO MEDICAL OFFICE MARKET CONTINUES TO EXHIBIT SOLID GROWTH

by Chris Ross

Market Conditions and Trends If there is one word to describe the current state of the San Diego healthcare real estate market and its growth, it is steady. Large lease and build-to-suit transactions have been limited of late, as most of the large healthcare providers have already established regional ambulatory centers in most areas of the county, and nearly all of the new medical buildings being constructed on hospital campuses are projects that health systems are developing themselves.

Most of the leasing activity is coming from 3- to 6-physician practices as a higher percentage of doctors coming out of school or residency are either joining large systems or existing practices.

These group practices are also more

6

OCTOBER 2017

stable than smaller practices. If one doctor leaves the group unexpectedly or some other event occurs that affects revenues, the profitability of the practice is not as severely impacted since the overhead of the office can likely be sustained across the rest of the group until another provider is brought into the practice. This allows these physician groups to structure more favorable lease transactions as it is easier for them to sign long-term leases, which generally come with slightly lower rental rates and much larger tenant improvement allowances and concession packages.

There are also more building purchase opportunities in this size range (±4,00015,000 SF) — albeit still very limited — than there are for smaller offices.

The San Diego County medical office market saw net absorption of 106,986 SF over the past 12 months. At just 0.86% of the market’s total rentable building area, this is somewhat of an underwhelming number; however it represents approximately 10% of the county’s available space being absorbed, and overall vacancy is now down to 6.8%. Direct vacancy rates for higher-quality medical office buildings remain particularly low, with Class A at 5.3% and Class B at 7.7% — having dropped significantly from peak recession figures of 33.3% for Class A and 13.7% for Class B. This fact that may surprise you: the four submarkets with the lowest vacancy rates are Kearny Mesa (4.1%), East County (5.0%), South County (5.7%) and Uptown/ Hillcrest (6.2%). This is mainly due to next to nil development of multi-tenant medical office product in these communities over the past ten years. The average asking rental rate in San Diego County has been pushed to $3.23 per square foot on a full service gross basis, up from $3.08 in Q2 2016 — a 4.9% increase over a 12-month period. This rising tide is even more pronounced in Class A and B buildings, which boast average asking rents of $4.13 and $3.63 PSF, respectively.

75

Pric East County South County South County Other Other

Uptown/Hillcrest East County

Valley Uptown/Hillcrest

6.8%

La Mesa/Mission Jolla/UTC/Sorrento Kearny Valley Kearny Mesa/Mission

North County Coastal I-15 Corridor

Marcos NorthEscondido/San County Coastal

Oceanside/Vista Escondido/San Marcos

% Direct vacancy rate % Under construction SF Under construction SF Quarterly leasing SF Quarterly leasing SF 2017 net absorption SF 2017 net absorption SF 12-mo.Countywide rent % change % 12-mo.Direct rent % change % Vacancy Average asking rent $3.23 FS Average asking rent $3.23 FS Oceanside/Vista

Demand Demand

0.0%

I-15 Corridor La Jolla/UTC/Sorrento

Supply Supply

2.0% 0.0% Direct vacancy rate

Average asking rent $3.23 FS Average asking rent $3.23 FS

Net absorption vs. direct vacancy Net absorption vs. direct vs. vacancy Net Absorption Direct Vacancy Net absorption

400,000

Direct Vacancy

16% 14% 16% 12% 14%

300,000 200,000 200,000 100,000 100,000 0

12-month net absorption (s.f.)

- 100,000 0 -57,142 s.f. (Q2 2017) - 200,000 - 100,000

- 200,000

Net absorption Direct Vacancy $3.25 $3.02 $3.50 $2.80 $2.75 $2.74 $2.83 $4.50 $3.00 $4.15 $3.98 $3.95 Net absorption Direct Vacancy $2.30 $4.00 400,000 16% $2.50 $3.25 $3.02 $3.50 $2.00 $2.83 $2.80 $2.75 $2.74 14% 400,000 16% $3.00 300,000 $1.50 $2.30 $2.50 $1.00 12% 14% 300,000 $2.00 200,000 $0.50 10% 12% $1.50 $0.00 200,000 $1.00 100,000 8% 10% $0.50 6% 100,000 8% $0.00 0 4% 6% - 100,000 0 2% 4% - 200,000 0% - 100,000 2% 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 YTD 2017 - 200,000 0%

Net absorption

MOB camp

Direct Vacancy

400,000 300,000

106,986

Direct asking rental rates - By submarket Net absorption vs. direct vacancy $4.50 $4.15 $3.98 $3.95 Net absorption vs. direct vacancy Direct asking rental rates - Byvs. submarket Net Absorption Direct Vacancy $4.00

10% 12% 8% 10%

4.9%

12-month Rent Growth $3.23 FS Average Asking 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 YTD 2017

JLL Healthcare Practice Group

6% 8% 4% 6% 2% 4% 0% 2%

0%

2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 YTD 2017

MOB, none buildings are on Classof A these and BAnew direct asking rents* Class and B Direct Asking Rents* campus or even walking distance from campus.

ClassBA direct Direct Asking Rentrents*Class B Direct Asking Class A and asking

Rent

East County South County South County Other Other

Uptown/Hillcrest East County

Valley Uptown/Hillcrest

La Jolla/UTC/Sorrento Kearny Mesa/Mission Valley Kearny Mesa/Mission

I-15 Corridor La Jolla/UTC/Sorrento

North County Coastal

4.9%

I-15 Corridor

Escondido/San North County Coastal Marcos

Oceanside/Vista Escondido/San Marcos

North$4.25 County Coastal: The recently $4.13 Class A Direct Asking Rent Class B Direct Asking Rent completed $4.00 North Coast Medical Plaza (still offering $4.25competitive deals on their remaining $4.13 $3.75 vacancy) and the three new proposed medical $4.00 $3.50 $3.63 buildings in Encinitas and Carlsbad – which $3.75 $3.25 total approximately 125,000 SF – are the only $3.50 $3.00 $3.63 buildings providing some potential relief $3.25 $2.75otherwise tightening availability and from the 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Q2 $3.00pressure on rents across Coastal North upward 2017 County. bar rents has been raised and everything *Asking weighted by available sf and grossed to FSG $2.75The 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 YTD 2006 2007 2008 2009 2010 NNN, 2011 2012 of good quality is now over $3.00 with 2013 a 2014 2015 2016 Q2 2017 2017 few buildings pushing north ofTri-City’s $4.00 NNN. It Oceanside / Vista: outpatient *Asking rents weighted by available60,000-SF sf and grossed to FSG ClassClass A and BAdirect asking rents* and B Direct Asking Rents* remains thebuilding higest rent submarket inquestion the county, remains the big mark as it has and its vacancy rate is equal to the countywide been inare various stagesor ofeven limbowalking for 5+ years on campus distance cians mayRent continue to either hunkernow down Forecast ClassBA direct Direct Asking Rentrents*Class B Direct Asking Class A and asking average of 6.8%. from campus. in their lower-rent buildings downtown Health systems and multi-physician and no one seems to know when the litigation Oceanside/Vista

%

12.0% 11.1% 10.7% 9.6% 12.0% 10.0% 11.1% 10.7% 9.6% Last -Month LastQtr Qtr 12 12 -Month 7.0% 6.8% Key8.0% marketindicators indicators 10.0% 6.2% Key market Change 5.7% Forecast Change Forecast 7.0% 5.0% 6.8% 4.5% 8.0% 6.0% 6.2% 4.1% Supply SF 5.7% Supply SF 5.0% 4.5% 6.0% 4.0% 4.1% Total availability SF / % 2.0% 4.0% Total availability SF / %

Pricing Pricing

2 17

Vacancy rates- By submarket Vacancy rates- By submarket

$4.25 will continue to drive real estate County Coastal: The recently or opt for an economical lease or purchase practices $4.13 will ever reach North the finish line. The submarket Class A Direct Asking Rent Class B Direct Asking Rent completed North Coast Medical at Nordahl Medical Centre as several activity $4.00 throughout the San Diego region I-15 corridor: I-15 vacancy hassingle-digit sharply risen finally dipped into vacancy, whichPlaza is (still offering competitive deals on their remainpractices$4.13 have done recently, which has to keep $4.25 pace with the strong local and nafrom 5.6% toincredibly 10.7% over the past given 12 months, $3.75 impressive the fact that 473,000 ing vacancy) and the three new proposed contributed toward the area’s decline in tional economy and the growth in demand $4.00 but the numbers are deceiving – this submarket $3.50 square delivered in this medical buildings inrelatively Encinitassmall and Carlsvacancy $3.63 from 13.7% to 11.1% over the past feet was for healthcare services. With quality Class remains extremely tight.

Over half of the current $3.75 service area bad between 2007 and 2013, a 95% 125,000 — which total approximately 12 months.

A space $3.25so difficult to find, the Class B invacancy came from Sharp former SF Rees-Stealy’s —inventory. are the only buildings some Oceanside / Vista: Tri-City’s 60,000ventory has been riding the coattails, with increase in total What may beproviding even $3.50 $3.00 $3.63 potential relief from the otherwise tightSF outpatient building remains big impressive 57,000-SFthe building on Via Tazon when they more leasing activity and increased rents. more is this: of the 473,000 square feet, $3.25 $2.75 ening availability and upward pressure on question mark as it has expanded now been in various Unless medical office development starts and relocated toremains their new 100,000-SF only 20,000 SF available (excluding any 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Q2 $3.00 rents across Coastal North The stages of limbo for 5+ years and no one accelerating unexpectedly, this trend will building on that Westmay Bernardo Drive.

Should the Via County.

2017 come to market once Tri-City’s building bar has been raised and everything of good seems to know when the litigation will ever only continue, and better located Class C $2.75 *Asking rents weighted by available sf and grossed to FSG Tazon building be absorbed by another medical isfinally cleared); and with exception of the Tri-City quality isthe now over $3.00 NNN, with a few reach2015 the2016 finishQ2line. The submarket buildings2006 should a similar “waterfall” 2007see 2008 2009 2010 2011 2012 2013 2014 group or be converted tobuildings an officepushing building,north I-15 of $4.00 NNN. It dipped into single-digit vacancy, which is effect over the next 12-24 months.

2017 would be sittingremains at approximately Oceanside / Vista:byTri-City’s outpatient the higest 4.9%, rent submarket in the incredibly given the fact that *Asking rents weighted available60,000-SF sf and grossed to FSG impressivevacancy county, and its vacancy 473,000 square feet was delivered in this second lowest of any submarket in the county. rate is equal to the Submarkets Tipsremains and Trends building the big question mark as it has countywide average of 6.8%. relatively areaarea’s between 2007 average Escondido/San Marcos: Escondido is limbo for weighted asking rate is also now been in various stages of 5+ yearssmall service The I-15 corridor: I-15 vacancy has sharply and 2013, a 95% increase in total inventory. perhaps the most difficult-to-assess subbeing affected by this building.

In reality, I-15 and no one seems to know when the litigation risen from 5.6% to 10.7% over the past 12 What may be even more impressive is this: market in the county. JRMC’s development rental rates are still steadily increasing. will ever reach the finish line. The submarket months, but the numbers are deceiving – of the 473,000 square feet, only 20,000 SF next to the new hospital has just broken finally1: dipped vacancy, whichavailable is this submarket remains extremely tight. remains (excluding any that may ground (Phase 75,000 into SF), single-digit but will local La Jolla / UTC / Sorrento: Imagine two impressive given the fact that 473,000 Over half of the current vacancy came from come to market once Tri-City’s building physiciansincredibly pay top-dollar rates for a brand submarkets.

One gave back 16,000 SF of space Sharp Rees-Stealy’s former 57,000-SF is cleared); new on-campus this seemingly squarebuilding feet wasin delivered in this relatively small and with the exception of the in the 2nd quarter and 56,000 SF over the past building on Via Tazon when they expanded Tri-City MOB, none of these new buildings rent-sensitive submarket?

Most physiservice area between 2007 and 2013, a 95%

increase in total inventory. What may be even more impressive is this: of the 473,000 square feet,

12 months. It has six buildings with over 12,000 SF of space on the market, and its vacancy rate SAN DIEGO PHYSICIAN.ORG 7 climbed from 4.7% to 7.0% over the past year.

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Other

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Kearny Mesa/Mission Valley

6

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La Jolla/UTC/Sorrento

campus. This submarket is still going strong.

I-15 Corridor

San Diego Medical Office Overview | Q2 2017

North County Coastal

Escondido/San Marcos

Oceanside/Vista

Other

South County

East County

Uptown/Hillcrest

Kearny Mesa/Mission Valley

La Jolla/UTC/Sorrento

I-15 Corridor

North County Coastal

Escondido/San Marcos

Oceanside/Vista

Pricing

Demand

Escondido/S

Ocean

Direct vacancy % absorption has been relatively quiet ofrate late. Net has been substantially flat over theSFpast quarter Under construction subsequent consolidation of several clinical and year. About 6,000 SF was absorbed during and administrative functions into the building.

Quarterly leasing SF C O M M E R C I A L R E A L E S TAT E T I P S & T R E N D S the past 12 months, bringing vacancy down Three buildings – the three largest MOBs in the 60 basis points 6.2%, just belowSF the county 2017to net absorption submarket, all on Frost Street – contain 40,000 average. The weighted average asking rent 12-mo. rent % change % ticked up slightly from $2.77 to $2.80. Most of Average asking rent $3.23 FS- By Submarket the area’s vacancy currently lies within Mercy Vacancy Rates - By Submarket Direct Asking Rental Rates the area during that time, and has a Vacancy rates-vacate By submarket Direct asking rental rates - By submarket Medical Building (4060 4th Ave) and Hillcrest limited amount of Class A space available.

12.0% 11.1% 10.7% $4.50 $4.15 $3.98 $3.95 9.6% Medical Centre (4033 3rd Ave). Being two of $4.00 10.0% $3.25 $3.02 The two submarkets are one and the same: the better located buildings in Hillcrest, this $3.50 $2.83 7.0% $2.75 $2.74 6.8% Net absorption vs. direct vacancy $2.80 8.0% 6.2% $3.00 5.7% above $2.30 UTC. The spike in vacancy mentioned vacancy will likely not remain on the market 5.0% $2.50 4.5% 6.0% 4.1% came from PRA (an office/non-medical tenant) for very Netsee absorption Direct Vacancy long, and we may vacancy $2.00 4.0% $1.50 consolidating out of 27,000 SF at University approach the 4% mark like neighboring $1.00 2.0% 400,000 16% Pacific Centre and UCSD relocating about submarket $0.50 Kearny Mesa.

0.0% 14% $0.00 43,000 of office and research functions out of 300,000 12% The Campus on Villa La Jolla (formerly known East County: Two years ago, you could hear 200,000 10% a pin drop in East County. In 2015 it went the as La Jolla Village Professional Center) to the 8% entire 100,000 calendar year without a new lease signed new ACTRI research building on UCSD’s east Q2 -5% 20062007200820092010201120122013201420152016 Center on Kearny Villa Road and Genesis’ 2017

6%

C

$4

$4

$3

$3

$3

$3

$2

4%

- 100,000

of the approximately 60,000 square feet of

2%

8

$4.50 $4.00 OCTOBER 2017 $3.50 $3.00

$2.74 $2.83

Other

South County

East County

Uptown/Hillcrest

Pricing

Demand

Other

South County

East County

Uptown/Hillcrest

Kearny Mesa/Mission Valley

Kearny Mesa/Mission Valley

$4.15

La Jolla/UTC/Sorrento

La Jolla/UTC/Sorrento

I-15 Corridor

I-15 Corridor

North County Coastal

North County Coastal

Escondido/San Marcos

Escondido/San Marcos

Oceanside/Vista

Oceanside/Vista

Supply

200,000 was absorbed over the past 12-months, and and relocated to their new 100,000-SF vacancy was just shy of 10%. If you had 0% on the market.

Owners the2014 area2015 maythe YTD 2012in 2013 grade Drive. hospitals are performing well inrate the is now at 4.1%,vacancy the vacancy lowest2007 in 2008 2009 building on West Bernardo Should said2010 that2011 by 2017 it would have2016 second 2017 Class A Direct Vacancy Class B Direct Vacancy not always feel that things are this tight since the county. the Via Tazon building be absorbed an- Kearny lowest vacancy in the county, no one would medical officeby sector.

Mesa hasMost beenof that absorption came there areDr. a few mixed office/medical buildings fromsquare Genesis Healthcare Partners’ and other medical group or beexception. converted to an 18,000 have believed you. It has now posted eight Direct35% asking rental rates - ByAnother submarket no feet of Michael Lenihan’s JV acquisition of Coast office building, I-15 vacancy would be sitstraight quarters of declining to which a handful of physician practices havevacancy, vacancy (nearly 25% of the total available $4.50 $4.15second$3.98 $3.95 Last Qtr 12-Month Medical Center on Kearny Villa RoadAand ting at approximately 4.9%, lowest with much of the rising occupancy coming 25% relocated, the true non-mixed medical Class andbut B direct asking rents* Key market indicators space) was absorbed over the past 12 months, $4.00 $3.25 Change Forecast Genesis’ subsequent consolidation of sevof any submarket in the county.

The area’s from modest expansion of existing physi$3.02 $3.50 buildings as a whole are experiencing strong $2.75 in $2.74 $2.83 and the vacancy rate is $2.80 now 4.1%, lowest eralat clinical and administrative functions weighted$3.00 average cian groups.

Opposite the trend we are Supply SF 15% asking rate is alsobeing $2.30 Class Aand Direct Asking Rent Class B Direct Asking Rent occupancy rent growth. the county.

Most came *#*) from into the building.

Three buildings – the affected$2.50 by this building.

In reality, I-15of that absorption seeing in most areas of the county, most of $2.00 Totalthe availability SFEast / % County during three largest MOBs in the submarket, all on $4.25 rental rates are5% still steadily spaces leased in Genesisincreasing.

Healthcare Partners’ and Dr. Michael $4.13 the $1.50 Uptown / Hillcrest: The Hillcresthave submarket (#%) 40,000 of Street – contain the apLa Jolla past 12 months been between 1,000 $1.00/ UTC / Sorrento: Lenihan’s Imagine JV acquisition ofFrost Coast Medical $4.00 Direct vacancy rate % absorption has been relatively quiet ofSF. late. Net $0.50 proximately 60,000 square feet of vacancy two submarkets. gave back 16,000 SF and 2,500 20062007200820092010201120122013201420152016 Q2 -5% One Center on Kearny Villa Road and Genesis’ $3.75 on the market. Owners in the area of space$0.00 in the 2nd quarter and 56,000 SF South The County subhasmay been substantially flatCounty: over theSF pastSouth quarter 2017 Under construction subsequent consolidation of several clinical not always feel that things are$3.50 this tight over the past 12 months. It has six buildmarket saw positive net absorption both and year. About 6,000 SF was absorbed during $3.63 administrative into theare building.

Quarterly leasing SF since there a few mixed office/medical ings with over 12,000and SF of space on the functions in the second quarter (3,691 SF) and in ag$3.25 the past 12 months, bringing vacancy down Three – the three largest MOBs in the buildings to which a handful of physician market, and its vacancy ratebuildings climbed from gregate over the past 12 months (9,513 SF).

60 basis points 6.2%, just belowSF the county 2017to net absorption $3.00 practices have40,000 relocated, but the true non4.7% to 7.0% over thesubmarket, past year. The other Current direct vacancy of 82,000 SF seems all on Frost Street – contain average.

The weighted average asking rentof space for this $2.75 are mixed medical buildings as a whole submarket boasts a nearly 15% climb in its like a substantial 12-mo. rent % change amount % 2006 2007 2008 2009 2010 2011 2012 2013 2015 2016 Q2 ticked up slightly from $2.77 to $2.80.

Most ofbuildings experiencing strong occupancy and rent average asking rent since the 2nd quarter submarket to absorb, but2014 the 2017 Average asking rent $3.23 FS the area’s vacancy currently lies Mercyare generally of last year, has not seen a medical tenant - By growth. housing most of within the vacancy Vacancy Rates Submarket Vacancy rates - By submarket *Asking rents weighted by available sf and grossed to FSG Uptown / Hillcrest: The Hillcrest subvacate the area during that time, and has a spread out across Chula Vista, Eastlake Medical Building (4060 4th Ave) and Hillcrest 12.0% 10.7% market has been relatively quietMedical of late. Centre Net (4033 limited amount of Class A 11.1% space available. and Bonita; andBeing at 5.7% it is over 9.6% 3rd Ave). twovacancy of 10.0% absorption has been substantially flat over The two submarkets are one and the 100 basis points below the 6.8% countythe better located buildings in Hillcrest, this 6.8% Net vs. direct vacancy and year. About 6,000 SFabsorption same: UTC. The8.0% spike in vacancy men- 7.0% the past wide average.

Rents ticked up from $2.95 to 6.2%quarter 5.7% not on remain the market 5.0% during was absorbed the past 12vacancy months,will likely tioned above came $3.02 a fullon service basis, a result of the 4.5% 6.0% from PRA (an office/ 4.1% Netsee absorption Direct Vacancy forpoints very long, and we may vacancy bringing vacancy down 60 basis to non-medical tenant) consolidating out of tightening vacancy.

South County has not 4.0% approach mark 6.2%, just below the county average.

The the 4% 27,000 SF at University Pacific Centre and been as like highneighboring of a priority in terms of capital 2.0% 400,000 16% weighted average asking rent ticked up UCSD relocating about 43,000 of office investment submarket Kearny Mesa. from the larger health systems 0.0% 14% slightly from $2.77 to $2.80. Most of the and research functions out of The Camin the region, but it will be interesting to 300,000 area’s vacancy currently lies within Mercy pus on Villa La Jolla (formerly known as see how that evolves as the area’s popula12% East County: Two years ago, you could hear 200,000 Medical Building (4060 4th Ave) and La Jolla Village Professional Center) to the tion and its insurance coverage continue to 10% a pin drop in East County. In 2015 it went the Hillcrest Medical Centre (4033 3rd Ave). new ACTRI research building on UCSD’s expand.

100,000 8% entire calendar year without a new lease signed Being two of the better located buildings east campus. This submarket is still going 6% in Hillcrest, this vacancy will likely not 0 strong.

News and updates 4% remain on the market for very long, and we Kearny Mesa / Mission Valley: Most Kaiser Permanente San Diego Medical 6 - 100,000 may see vacancy approach the 4% mark submarkets across California that have Center opened its doors and began admit2% like neighboring submarket Kearny Mesa. multiple highgrade hospitals are perting patients on April 25, ahead of sched- 200,000 0% East County: Two years ago, you could 2007 forming well in the medical office secule2008 and2009 under at $850M. 2010budget 2011 2012 2013 2014The 2015new 2016 YTD hear a pin drop in East County. In 2015 tor. Kearny Mesa has been no exception.

617,215 square-foot hospital is certified as 2017 it went the entire calendar year without Another 18,000 square feet of vacancy LEED Platinum and considered one of the Direct asking rental rates - By submarket a new lease signed over 3,500 SF, and (nearly 25% of the total available space) most technologically advanced medical $3.98 $3.95 $3.25

$3.02

$2.80 $2.30

Class A and B direct asking rents* $2.75

Class A Direct Asking Rent

Class B Direct Asking Rent

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9

C O M M E R C I A L R E A L E S TAT E T I P S & T R E N D S

centers in the world. The hospital capacity is currently 321 beds, with the ability to expand to 461 beds with future development.

Qualcomm Inc. has partnered with Scripps Health to offer its employees and their dependents a custom health plan under the accountable care organization (ACO) model. The option will be available to Qualcomm employees starting in 2018.

Investment Sales Spotlight A significant changing of the guard is taking place in San Diego. Ten years ago, there were only three or four MOB owners that were institutional, multi-market players who specialized in healthcare. PMB, HCP and Montecito come to mind. Even as recently as 2015, there was still a very limited amount of such institutional capital in town.

Today at least a dozen of these firms own healthcare real estate in San Diego County.

Welltower, Ventas, CNL, Anchor, Carlisle, Northstar, ARC and Virtus have all acquired medical buildings recently, and nearly every other household name wants to join the party. They used to almost exclusively chase on-campus or health-system-anchored buildings, but as more investors entered the space and these core acquisition opportunities dried up, they all began chasing offerings in the next tier of MOBs: well-located offcampus properties, primarily in suburban markets where health systems and physicians are looking to provide better access to patients.

Given the number of these properties that

have been developed over the past 10-12 years — most of which by local and regional developers that aren’t necessarily long-term holders — more of these properties are hitting the market than ever before, which is contributing to the changing landscape of owner profiles.

The combination of the influx of offerings, unprecedented demand for these properties and the sheer number of deep-pocket buyers hawking the San Diego market has resulted in the most consistently high annual sales volumes that San Diego has ever seen. Over the past 12 months there have been 13 sales over 10,000 SF totaling $168M. Total square footage sold: 348,000 square feet. Averages

for these buildings were a 6.6% cap rate, $432/SF and 93.5% occupancy. 2017 will likely come to a close with record-setting metrics across the board in volume, cap rate and price-per-square-foot. With strong market fundamentals in this sector, both sellers and buyers are winning: it is a great time to sell healthcare property, but it is also a great time to own it.

Chris Ross is co-leader of JLL San Diego’s Healthcare Practice Group, a brokerage team that has been specializing exclusively in healthcare real estate leasing and sales since 1991. His primary specialty is tenant representation and owner-user sales.

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11

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

FIVE BEST PRACTICES TO MEET MACRA REQUIREMENTS

BY THE END OF THE YEAR

by Kim Hathaway, MSN, CPHRM

As the end of the third quarter of 2017 approaches, practices that have not yet developed their Medicare Access and CHIP Reauthorization Act (MACRA) plan face great urgency to complete their plan — and those who have started may be feeling overwhelmed. Regardless of the reporting stage, these steps can help guide practices to succeed: 12

OCTOBER 2017

1.

Review past performance in quality measures such as the Physician Quality Reporting System (PQRS) or specialty measures that your practice has reported. These are strong indicators of how your practice will do in the future. Align activities and quality measures with what you are already doing in your practice and determine how to make capturing the needed data part of your team’s workflow.

Educate and engage the entire workforce about what you are trying to accomplish and why.

Ask for input from the frontline of your practice about the most efficient ways to collect the necessary data elements. Even if you participated in PQRS in the past, there are differences that will require a team effort to be successful. Don’t try to do it alone. Consider making quality measurement part of the annual review for employees.

2.

Study the specifications for measures you are reporting to better understand its value. For claims or registry reporting, go to the Quality Payment Program website and choose the appropriate file under “Documents and Downloads.” If you are reporting through your electronic health record (EHR), the vendor can be very helpful in choosing your measures. In fact, not all EHRs will report all measures, and there are some that collect data but don’t report to the Centers for Medicare and Medicaid Services (CMS). Clarify with the EHR vendor when and how the documentation is captured and counted toward the measure.

The same applies to the various registries. Be sure to do your homework and know about pricing and any requirements related to system compatibility.

requirements for the cost category in 2017. CMS will provide feedback on cost for the 2017 performance period, but it will not be counted in the final composite score for 2017 or 2018.

3.

Monitor your data on a weekly or bi-weekly basis. Compare the reports that you run in your office to those generated by your EHR or registry. Investigate any discrepancy so that it can be corrected now by coaching the team on documentation or timeliness of reporting. Don’t wait until the end of the reporting period to look at your performance data.

There may not be time nor the ability to correct it later.

4.

Understand that the scoring process for the quality measures is very different than it was in PQRS. Under PQRS, if you reported the measure enough times, you received credit. And if you reported on one patient, you would get a pass.

Under the PQRS scoring process (based on 100 patients): • Provider 1: 95 patients’ performance met, 5 patients’ performance not met = PASS • Provider 2: 5 patients’ performance met, 95 patients’ performance not met = PASS Under the quality measure, your rate will determine your score (based on 100 patients): • Provider 1: 95 patients’ performance measure met, 5 patients’ performance not met = 95% Performance Rate • Provider 2: 5 patients’ performance met, 95 patients’ performance not met = 5% Performance Rate On top of the change in how much you report versus the performance rate, the scores will be determined based on national

benchmarks, with the highest performing deciles receiving a greater point value.

5.

Review the Quality Resource Utilization Report (QRUR) to fully understand how the practice performs in quality and cost. Use the 2015 or 2016 QRUR (publishing fall 2017) to identify potential weaknesses and address them before cost returns as a scored category in 2019 — because cost will carry a weight of 30 percent toward the MIPS composite score. This is a complex report that requires familiarity to truly understand its content. The biannual report outlines the quality and cost data from PQRS and compares it to a national benchmark.

Costs are determined by claims data. There are no reporting

Groups and solo practitioners may access their QRUR through the CMS Enterprise Portal. The person who accesses this report for the group will need to create a login at CMS’ Enterprise Identity Management (EIDM) system. This is a very secure site. It contains questions to verify and confirm the identity of the person registering, as well as information about specific providers in the group.

Security is very strict around these reports because they include patient health information so that groups may identify which patients may be attributed to them. For help with interpreting the information on your QRUR, consult the CMS website regarding QRUR analysis and payment. You will find additional resources and links to the EIDM System and what to do if you believe your QRUR is not accurate.

Ms. Hathaway is a healthcare quality and risk consultant with The Doctors Company.

SAN DIEGO PHYSICIAN.ORG

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OCTOBER 2017

INFECTIOUS DISEASE SDCMS’s GERM Commission advises the SDCMS board of directors on antibiotic-resistant microorganisms and provides expert input on infectious disease and bioterrorism. The following stories have been written by members of the GERM Commission.

16

Latent Tuberculosis in San Diego

18

Getting to Zero HIV Infections

20

Middle East Respiratory Syndrome Coronavirus (MERS-COV)

22

Sexually Transmitted Diseases in San Diego County

SAN DIEGO PHYSICIAN.ORG

15

INFECTIOUS DISEASE

LATENT TUBERCULOSIS IN SAN DIEGO Test-and-Treat for TB Elimination

BY SUSANNAH GRAVES, MD, MPH

16

OCTOBER 2017

Since 2006, San Diego County has had approximately 250 cases of active tuberculosis (TB) annually with a corresponding rate of 7.8 cases per 100,000 population per year. This is a significant decrease from the surge of active TB disease in the early 1990s when the peak number of cases was 469 in 1993. To build on this momentum, in 2015 the California Task Force for TB Elimination was convened with a goal to achieve TB elimination — meaning less than one case per million people — by 2040. For San Diego, this would mean an interim target of less than 10 cases per million by 2025 and a decrease of 16.7% per year.

“80% of local cases result from reactivation of latent tuberculosis infection (LTBI), and most of these latent infections were acquired outside the United States. The reservoir of latently infected individuals is a major barrier to TB elimination here.”

Tuberculosis is spread from person to person through aerosolized particles released when someone with the disease coughs, sneezes or laughs. However, this kind of transmission is very infrequent in San Diego. Instead, 80% of local cases result from reactivation of latent tuberculosis infection (LTBI), and most of these latent infections were acquired outside the United States. The reservoir of latently infected individuals is a major barrier to TB elimination here.

There are an estimated 150,000 people with LTBI in San Diego County. For reference, this is approximately the same number as the entire population of Escondido!

Without treatment, people with latent infection have a 5–10% lifetime risk of

developing active TB disease, and certain common conditions increase that risk. In San Diego, diabetes is the most commonly identified predisposing factor present in 23% of cases last year, followed by drug use (12%), HIV (6%), other immune-suppressed states (7%), and end-stage renal disease (4%).

Screening for TB is an important part of primary care. In September 2016, the U.S. Preventive Services Task Force (USPSTF) recommended screening for those at higher risk for TB infection and disease due to a history of foreign birth or living in a highrisk congregate setting (e.g., shelters, jails or prisons), which is in line with public health guidelines from the California Department of Public Health (CDPH) and the Centers for Disease Control and Prevention (CDC). Testing and treatment guidelines for adults and children, as well as college and university students, are available on the CDPH website: https://www.cdph. ca.gov/Programs/CID/DCDC/Pages/TBRisk-Assessment.aspx Targeted screening should be undertaken with the intent to treat for LTBI, if diagnosed. The tuberculin skin test (TST) has been used for decades to identify those with TB infection. However, among foreign-born patients — particularly those who received Bacillus CalmetteGuerin (BCG) vaccination — newer interferon gamma release assays, such as QuantiFERON®-TB and T-SPOT®TB, are preferred because they have less crossreactivity with BCG. The higher specificity of these tests can help you encourage acceptance of LTBI treatment among your patients who have been BCG vaccinated

previously.

Before embarking on treatment of LTBI, it is important to thoroughly exclude active TB disease. This may mean delaying the start of treatment until mycobacterial cultures of sputum, or other specimens, are finalized. In the meantime, it is also important to avoid therapy with any antibiotic that has activity against tuberculosis (such as fluoroquinolones), even if it is given for another indication. This will avoid the possibility of developing drug resistance if active TB is ultimately diagnosed.

Another recent development in LTBI care is the introduction of shorter regimens for LTBI therapy. Previously a treatment course of isoniazid lasting nine months was standard. However, recent studies have shown that shorter treatment regimens are effective and patients are more likely to complete therapy. Because of higher rates of completion, four months of daily rifampin, or three months of weekly rifapentine + isoniazid are now preferred for most patients.

In addition to the CDPH resources above, local guidelines for targeted testing, diagnosis, and treatment of TB and LTBI are available at the San Diego County TB Control website: www.sandiegotbcontrol.org.

Dr. Graves is the Chief of Tuberculosis Control and Refugee Health at San Diego County’s Health and Human Services Agency. She completed clinical training in Internal Medicine and Infectious Diseases at UC San Diego and also served as the Site Director for UC San Diego’s Global Medicine Residency in Maputo, Mozambique.

SAN DIEGO PHYSICIAN.ORG

17

INFECTIOUS DISEASE

GETTING TO ZERO HIV INFECTIONS

BY MICHAEL BUTERA, MD AND WINSTON TILGHMAN, MD

18

OCTOBER 2017

THE SAN DIEGO COUNTY MEDICAL Society was invited to participate in the Healthcare Advisory Committee for the County of San Diego Getting to Zero initiative, which is the County’s approach to engage public and private healthcare systems in its effort to end the HIV epidemic in the region. The committee, comprising representatives from all local hospitals, community clinic networks, healthcare organizations, and other key HIV stakeholders, met for the first time on August 24, 2017. A total of 19 people, including County personnel, attended.

The primary focus of the committee is to increase routine HIV testing in the local healthcare system to reduce the number of people who are infected, but unaware of their diagnosis. The number of those unaware that they are HIV-positive is estimated at 1,740. In 2006, the Centers for Disease Control and Prevention (CDC) rec-

ommended routine voluntary (i.e., opt-out) HIV testing for all adults and adolescents, aged 13 to 64 years, with or without risk factors. This recommendation requires that providers inform patients that HIV testing will be performed and give them the opportunity to decline the test, but it removes the requirement for a separate written informed consent for HIV testing and intensive pre-test counseling.1 In 2013, the United States Preventive Services Task Force (USPSTF) expanded its recommendation for routine HIV testing for patients between the ages of 15 and 65 years to include adults and adolescents without risk factors, and affirmed the opt-out approach recommended many years earlier by CDC.2 Despite these recommendations, multiple barriers have limited implementation of routine HIV testing in healthcare settings.

These include provider discomfort with disclosure of a positive HIV test result, logistical challenges of test follow-up in settings with high patient turnover such as emergency rooms, challenges in covering the costs of testing uninsured patients, and low prioritization of HIV testing in busy primary care settings. The committee will work to address these barriers, educate the provider and hospital communities about HIV, and prioritize areas for implementation of routine testing to have maximal impact on HIV transmission. The group also will work to optimize mechanisms for linkage to HIV primary care for individuals who

are newly diagnosed with HIV infection.

One of the other objectives of the committee is to increase awareness in the provider community about the resources available through the County. Disease investigators in the HIV, STD, and Hepatitis Branch (HSHB) of the Public Health Services Division in the County Health and Human Services Agency, routinely disclose positive HIV test results and provide partner services to people living with HIV. In addition to these activities, HSHB has implemented a new program that utilizes HIV surveillance laboratory data (i.e., CD4+ T-lymphocyte counts and HIV viral loads) to identify people who are not receiving HIV primary care and work with those individuals to get them linked to and retained in care. HSHB also links individuals who are newly diagnosed with HIV through one of the County’s testing programs to HIV primary care within 30 days of diagnosis.

Despite advances in HIV treatment and availability of biomedical HIV prevention methods, such as pre-exposure prophy-

laxis (PrEP) and post-exposure prophylaxis (PEP), there were 490 new HIV diagnoses in San Diego County in 2015 (the last year for which complete surveillance data are available). Of these, approximately 25% progressed to stage 4 HIV illness (acquired immune deficiency syndrome or AIDS) within one year of HIV diagnosis. This indicated that they had been infected with HIV for several years prior to being tested and there may have been missed opportunities for testing.

The Getting to Zero initiative was adopted by the County Board of Supervisors on March 1, 2016 and is based on the recommendations of an Ad-Hoc Task Force that was called by Supervisor Ron Roberts and former Supervisor Dave Roberts. The Task Force outlined six general recommendations that form the basis of the Getting to Zero Implementation Plan: (1) Promoting awareness of HIV as a major public health concern; (2) Engaging private health care systems in Getting to Zero; (3) Implementing PrEP and PEP to reduce new HIV infections; (4) Using HIV and STD surveil-

lance data to improve health outcomes for persons living with HIV, as well as identify individuals at high risk for HIV infection; (5) Developing specific strategies to reduce disproportionalities among key populations; and (6) Pursuing policies that will help achieve Getting to Zero. Getting to Zero is a key strategic initiative of the Live Well San Diego vision to achieve healthy, safe, and thriving communities in our region. For more information please visit http://www. sdplanning.org/download/getting-tozero-implementation-plan/.

1. Branson BM, Handsfield HH, Lampe MA, Janssen RS, Taylor AW, Lyss SB, et al; Centers for Disease Control and Prevention (CDC). Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR Recomm Rep. 2006;55(RR-14):1-17.

2. Moyer, Virginia. Screening for HIV: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2013;159:51-60.

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19

INFECTIOUS DISEASE

MIDDLE EAST RESPIRATORY SYNDROME CORONAVIRUS (MERS-COV)

BY ROBERT E. PETERS, MD, PHD

20

OCTOBER 2017

IN MAY 2014, CDC CONFIRMED TWO cases of MERS in the United States: one in Indiana, the other in Florida. Both cases were among healthcare workers who lived and worked in Saudi Arabia. Both traveled to the United States from Saudi Arabia, where they are believed to have been infected. Both were hospitalized and made a full recovery.

There have been no MERS cases reported in the United States since May 2014. The global confirmed cases since 2012 is 2,045 with 733 deaths. Outcome of MERS-CoV since 2012 include: 994 (58.7%) recoveries, 686 (40.5%) deaths, and 13 (0.8%) active.

The number of laboratory-confirmed cases of MERS reported in Eastern Mediterranean Region in January 2017–July 2017 include: 114 (76.5%) survived and 35 (23.4%) deaths, with the predominant cases from Saudi Arabia.

The potential for MERS-CoV to spread is real and just a plane ride away. The Centers for Disease Control is diligently working with global partners to better understand the nature of the virus, including how it affects people, and how it spreads.

Middle East Respiratory Syndrome (MERS) is a viral respiratory illness that is new to humans. MERS first emerged in the Arabian Peninsula (Saudi Arabia) in 2012. The virus that causes MERS is called Middle East Respiratory Syndrome Coronavirus (MERS-CoV).

Coronaviruses are common viruses that most people get in their lifetime. Human coronavirus usually causes mild to moderate cold-like illnesses. MERS-CoV is different from any previous coronavirus found in humans.

MERS-CoV likely came from an animal source on the Arabian Peninsula. Researchers have found MERS-CoV in camels. We don’t know if camels are the source of the virus in human infection. Studies are ongoing.

What can you do as a healthcare provider? Identification is important because MERS can spread and people have died. Most people infected with MERSCoV developed severe respiratory illness.

Some infected people had mild symptoms or none at all. Be aware of the clinical spectrum of reported illness. There have been reported gastrointestinal symptoms, which included diarrhea and nausea-vomiting, and kidney failure. Obtain a travel

history early in evaluation. Has there been any travel to affected areas in the past two weeks? Has there been any camel contact or healthcare contact?

Inform Epidemiology Program to facilitate testing. Three specimens are needed (upper tract, lower tract, and serum).

Specimens go to CDPH lab with a 24-hour turnaround. Counsel patients prior to travel to take precautions.

MERS-CoV is thought to spread from an infected person to others through respiratory secretions, such as coughing. The actual ways the virus spreads is not well understood.

There is no vaccine to prevent MERSCoV infection. CDC recommends doing the following for protection from respiratory illnesses: • Cover cough • Wash hands often • Avoid close contact with people who are sick • Avoid touching their eyes, nose and

mouth with unwashed hands • Disinfect frequently touched surfaces The current CDC travel notice to countries in or near the Arabian Peninsula is an Alert (Level 2), which provides special precautions for travelers. Because the spread of MERS has occurred in healthcare settings, the alert advises travelers going to countries in or near the Arabian Peninsula to provide healthcare services to practice CDC’s recommendations for infection control of confirmed or suspected cases and to monitor closely, Travelers who are going to the area for other reasons are advised to follow standard precautions, such as hand washing and avoiding contact with people who are sick.

Dr. Peters, a 20 year-member of SDCMSCMA, is board-certified in family medicine, is a member of the SDCMS GERM Commission, is past president of SDCMS, and former delegation chair to CMA’s House of Delegates.

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INFECTIOUS DISEASE

SEXUALLY TRANSMITTED DISEASES IN SAN DIEGO COUNTY

BY WINSTON TILGHMAN, MD

22

OCTOBER 2017

RATES OF THE REPORTABLE sexually transmitted diseases (STDs), namely chlamydia, gonorrhea, and syphilis, continue to rise in San Diego County, based on 2016 surveillance data released by the County of San Diego Health and Human Services Agency.

Chlamydia continues to be the most common reportable communicable disease in San Diego County and nationwide. A total of 18,904 cases were reported in San Diego County in 2016, representing an 8.5% increase from 2015, and the overall rate of chlamydia was 574.8 cases per 100,000 population. Consistent with previous years, rates were higher among women than among men (713.6 versus 434.7 cases per 100,000 population), and the highest rates were observed among women aged 15 to 24 years.1 Due to the potential for untreated chlamydia (and gonorrhea) to cause pelvic inflammatory disease, tubal scarring, infertility, and increased risk of ectopic pregnancy, and the high incidence of chlamydia in young women of reproductive age, regular screening is critical. Providers can prevent these long-term complications by screening all sexually active women under the age of 25 years for chlamydia and gonorrhea, in accordance with national guidelines, and screening women aged 25 years or older with risk factors.2 The largest increase in morbidity between 2015 and 2016 was observed for gonorrhea.

In 2016, a total of 4,992 gonorrhea cases, including 1,096 extragenital (i.e., pharyngeal or rectal) infections, were reported, representing a 35% increase from 2015. The overall rate of gonorrhea was 151.8 cases per 100,000 population, and the overall rate of infection among men was over twice that of

women (212.0 versus 90.2 cases per 100,000 population). Although data on race/ethnicity of gonorrhea cases were limited by a high percentage of case reports that were missing this information, highest rates were observed in men who were African-American/ Black or of mixed race.1 Progressive development of widespread resistance to penicillins, tetracyclines, and fluroquinolones has reduced gonorrhea treatment options to a single recommended regimen: ceftriaxone 250 mg intramuscularly plus azithromycin 1 gram orally in a single dose.3 The percentage of Neisseria gonorrhoeae isolates from San Diego County with tetracycline resistance in 2015 was 43.5%,4 and doxycycline is no longer recommended as part of first-line combination therapy for gonorrhea.3 Based on national surveillance of N. gonorrhoeae susceptibility, the percentage of N. gonorrhoeae culture isolates with reduced susceptibility to third-generation cephalosporins decreased from 0.4% and 1.4% for ceftriaxone and

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The total number of syphilis cases of any stage in 2016 was 1,381. This includes 523 cases of primary and secondary syphilis, the early symptomatic and most infectious stages of syphilis, which increased by 6.7% since 2015 and by 1,837% since 2000. Syphilis has a disproportionate impact on MSM, who accounted for 82.6% of primary and secondary syphilis cases.

Of the primary and secondary syphilis cases reported among MSM, 44% also had HIV infection. Rates were higher among

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INFECTIOUS DISEASE African American/Black men compared to men of other racial/ethnic groups (56.3 cases per 100,000 population versus 35.3 and 25.5 cases per 100,000 population for Hispanic and White men respectively). The rate of female primary and secondary syphilis cases increased by 25% from 0.9 cases per 100,000 population in 20155 to 1.2 cases per 100,000 population in 2016, although the actual number of cases was relatively low (19), and no cases of confirmed congenital syphilis or syphilitic stillbirth were reported in San Diego in 2016.1 Penicillin remains highly effective for syphilis treatment, with no cases of resistance reported despite decades of use. However, there is a nationwide shortage of the long-acting form of benzathine penicillin G (Bicillin L-AÂŽ) that is recommended for most stages of syphilis (excluding neurosyphilis and ocular syphilis, for which intravenous aqueous crystalline penicillin G is required).

Invasion of the central nervous system and/ or ocular structures by Treponema pallidum

is possible during any stage of infection, so providers should have a high index of suspicion for syphilis in at-risk patients who present with neurological or ocular signs and symptoms and should rule out these complications in patients with syphilis and neurological/ocular signs or symptoms through cerebrospinal fluid examination and ophthalmology consultation.3 The County of San Diego operates four categorical STD clinics and a chlamydia/ gonorrhea home-testing program. For more information about County resources for STDs, and for publicly available 2016 STD data slides, please visit http://www.stdsandiego.org.

References 1. County of San Diego Health and Human Services Agency, Division of Public Health Services, HIV, STD and Hepatitis Branch. July 2017. Sexually Transmitted Diseases in San Diego County, 2016 Data Slides. Accessed 08/22/17 from www.

CMA MEMBER HELP LINE! Be it legal information, help with a problematic payor, or details about your member benefits, call CMA’s Member Help Line: (800) 786-4262 24

OCTOBER 2017

STDSanDiego.org.

2. LeFevre ML, U.S. Preventive Services Task Force. Screening for chlamydia and gonorrhea: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2014 Dec 16;161(12):902-10.

3. Frieden TR, Jaffe HW, Cono J, et al.

Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep 2015;64(No. RR-3):60-68. Available at: http://www.cdc.gov/std/tg2015/tg-2015print.pdf.

4. Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance 2015: Gonococcal Isolate Surveillance Project (GISP) Supplement and Profiles. Atlanta: U.S. Department of Health and Human Services; 2017.

5. County of San Diego Health and Human Services Agency, Division of Public Health Services, HIV, STD and Hepatitis Branch.

July 2016. Sexually Transmitted Diseases in San Diego County, 2015 Data Slides. Accessed 08/29/17 from www.stdsandiego.org.

Robotics in Orthopedic Surgery for Improved Outcomes Cancer Immunotherapy: Progress to Date and Discovery David Fabi, MD, SD Orthopaedic Associates Medical Group John Austin, MD, California Orthopaedic Institute

Donald Durden, MD, PhD, Vice-Chair for Research, UC San Diego Dept. of Pediatrics

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CLASSIFIEDS CLINICAL TRIALS

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

Competitive compensation, full benefits. If interested, please e-mail CV to Amy Laughner (ALaughner@sycuan.com) or apply online at www.sycuan.com.

OFFICE SPACE / REAL ESTATE AVAILABLE

KEARNY MESA MEDICAL OFFICE - FOR LEASE 7910 Frost Street. Class A medical office building adjacent to Sharp & Rady Children’s. Ready-to-occupy suites ranging from 1,300-5,000 SF with mix of exam rooms and offices. Will consider short-term & long-term leases.

For details, floor plans and photos contact David DeRoche (858) 966-8061 | dderoche@rchsd.org

PHYSICIAN POSITIONS AVAILABLE

SEEKING A FULL/PART TIME DERMATOLOGIST to join a co-op situation at a brand new Medical and Day spa. Share space with two Licensed Massage Therapist and Esthetician in a new start up office on Miramar Rd/805. Opportunity to do Cosmetic, Cool sculpting, Botox, Fillers, and Laser procedures.

3,000 sq ft office with reception area, lobby, kitchenette, bathroom. Free parking, handicap access. Short term or up to a 5-year lease available. $1,300/per month. Have 3 extra large offices available. Please call 760-8153236 or email me at mpear4560@gmail.com PART TIME OR FULL-TIME SUBINVESTIGATOR: Work under the supervision of the Medical Director/Principal Investigator performing a variety of scientific clinical research activities to include the direct assessment of study participants and execution of protocol specific procedures.

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

Demonstrate clinical competence, positive leadership and ability to work collaboratively with a multi-disciplinary team. Send resume to: eliku@artemis-research.com FAMILY MEDICINE POSITION AVAILABLE: The Sycuan Medical Dental Center is a tribal health center, located on the Sycuan Indian Reservation in El Cajon, CA. This is a full-time position to provide outpatient care, no OB. Current CA and DEA licenses required. Student loan repayment possible. Must be BC/BE.

CLASS “A” MEDICAL OFFICES, VISTA

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Strong primary care referral base. Fully renovated offices with today’s modern finishes. Close hospital proximity.

Multiple sizes available ranging from 1,200-6,800 SF. For more information, including floor plans, please call Greg Petree at (858) 792-0696 x112 or visit www.vistamedicalplaza.com/leasing SHARED OFFICE SPACE: Very attractive 3 exam room, medical office near Alvarado Hospital. Available for 1, 2 or 3 days per week.

Reasonable rates. Call Pat at 858-344-5020.

MESA MEDICAL OFFICE SPACE AVAILABLE FOR SUBLEASE: 1500 sq.ft Frost Street office with 2 exam rooms, 2 offices, front office area, bathroom, kitchenette and lobby. Easy access to Sharp Memorial Hospital and Rady Children’s Hospital and the 163 and 805 freeways. Up to 4 month lease with possible extension. Please call (858)467-1899.

POWAY OFFICE SPACE AVAILABLE PART-TIME: Spacious 5 exam room office including large treatment room. Located across the street from Palomar Medical Center Poway (aka Pomerado Hospital). Well suited for surgical or medical specialty. Contact bmorales@genhp.com.

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

26

OCTOBER 2017

MEDICAL EQUIPMENT / FURNITURE FOR SALE

USED OFFICE FURNITURE FOR SALE: Exam tables, stools, chairs, x-ray view boxes, executive desk, waiting room chairs, tables, filing shelves and cabinets. Please call (858)467-1899.

NONPHYSICIAN POSITIONS AVAILABLE

CHAMPIONS FOR HEALTH EXECUTIVE DIRECTOR: Candidate should have a minimum of 5 years non-profit or public management/leadership experience, with history of increasing responsibility. Seeking proven success in financial development, fostering and expanding innovative programs.

Bachelor’s degree is required, with relevant advanced degrees desirable. To apply, email cover letter, resume, 3 professional references and optional letters of recommendation to jobs@ChampionsFH.org.

POSITION AVAILABLE FOR DYNAMIC NURSE PRACTIONER OR PHYSICIAN ASSISTANT to join our team of Women Healthcare providers specializing in Reproductive Medicine. We are offering a competitive salary, excellent benefits and a flexible schedule. Requirements: Obtain detailed medical history, review medical records, and collaborate with physician in developing a thorough infertility evaluation and treatment plan. Perform transvaginal sonograms for follicular measurements and collect data to monitor IVF cycles. Perform early OB ultrasounds and monitor early pregnancy lab values. Master’s in Nursing or equivalent. 2-4 years experience in OB/GYN. Fertility experience preferred. Please email klopez@cacrm.com or call 760-274-2000. Visit our website at cacrm.com.

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

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

Demonstrate clinical competence, positive leadership and ability to work collaboratively with a multi-disciplinary team. Send resume to: eliku@artemis-research.com RECEPTIONIST POSITION AVAILABLE: Solo private practice Menopause Management office in Hillcrest. Back-office experience is not required. Free parking is available onsite. Please fax CV and last two years work experience only to (619) 794-2942.

PRODUCTS / SERVICES OFFERED

PHYSICIAN OFFICES IN NEED OF ASSISTANCE FOR MEANINGFUL USE ATTESTATION of their electronic health records can avail themselves of technical assistance from Champions for Health, the sister organization to SDCMS. Practices attesting on the Medi-Cal Incentive Program with at least 30% of patients billed to Medi-Cal can receive free assistance thanks to a federal funding source. Medicare practices can receive the same great service at a very reasonable rate, and SDCMS-CMA members receive a discount. For more information, email Barbara.

Mandel@ChampionsFH.org or call (858) 3002780. [559] PRACTICE FOR SALE

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

As society rejects certain aspects of our personality, we put them into our “black bag.”

WHAT STRENGTHS RESIDE IN THOSE DARK, HIDDEN PLACES OF OURSELVES?

by Helane Fronek, MD, FACP, FACPh

I LOVE HALLOWEEN. I recall the childhood excitement of trick-or-treating and the glee of trading candy with my sisters. Later in life, I delighted in watching our baseballobsessed son dress as Mike Piazza or our feisty, athletic daughter become one of the Power Rangers. Halloween is a chance to adopt another persona as we allow our hidden impulses to emerge in the form of a mean villain, a privileged princess, or a fearless pirate. Usually, we try to show only the acceptable aspects of our personalities, making great attempts to hide the characteristics that we, or our culture, are uncomfortable with. On Halloween, we permit ourselves to let these “darker” sides of ourselves out.

In fact, we each have both light and dark aspects of our personalities. And each has its strength, beauty, and benefit.

28

OCTOBER 2017

As a girl growing up in the Midwest in the 1950s, I was repeatedly told to “be nice.” I was to be calm, cooperative, polite, thoughtful, submissive, and considerate. If I was loud, aggressive, demanding, too honest, or called attention to myself, I was definitely “not nice.” A proclamation of “nice” elicited a smile, whereas “not nice,” would invoke a frown. I was then expected to immediately snap to attention with a nicer version of myself.

As the writer Robert Bly explains, as society rejects certain aspects of our personality, we put them into what he calls our “black bag.” Jungian psychology terms this our “shadow.” The more we portray ourselves as only “good,” the larger our shadow becomes.

Although we believe we have safely hidden these undesirable aspects of ourselves,

they manage to sneak out in our words and actions. They seek to again become a part of us and, in fact, they bring with them power, strength, discernment, and a sense of wholeness that we once felt.

Years ago, I created a series of masks that portrayed the wholeness of my psyche.

Although I am usually quiet and thoughtful, there was a ferociousness in several masks, and I was startled to recognize those “not nice” parts of myself. Then I realized that they were the very parts that had strengthened me through the rigors of medical training, propelled me out of bad relationships, fueled powerful presentations, and compelled me to continually seek to serve people who are suffering. I recalled a childhood filled with climbing trees, racing bikes through our neighborhood, and playing sports to win decisively before “nice” became the ultimate prize. Yet, there was always an aggressive streak in me that was not considered “nice” and thus not welcomed, but has served me well at many times.

What “dark and sinister” or simply unacceptable qualities have you hidden in your black bag? How have those qualities served you? What would it be like to welcome them back into your whole being, to feel the aliveness they bring, and to experience a greater wholeness again?

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

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