September 2008

“ P H YS I C I A N S U N I T E D F O R A H E A LT H Y S A N D I E G O ”

OFFICIAL PUBLICATION OF THE SAN DIEGO COUNTY MEDICAL SOCIETY SEPTEMBER 2008OFFICIAL PUBLICATION OF THE SAN DIEGO COUNTY MEDICAL SOCIETY SEPTEMBER 2008

2008 MAGGIE AWARD WINNER2008 MAGGIE AWARD WINNER

“Physician,INFORMTHYSELF”

SDCMS BRINGS YOU APRIMER ON THE ISSUES.

Contents VOL. 95 | NO. 9

[ D E P A R T M E N T S ]

4 CONTRIBUTORS:This Issue’s Contributing Writers

6 EDITOR’S COLUMN:Fixing Medicare Reimbursement

8 SEMINARS:SDCMS’ 2008 Seminars and Events

10 COMMUNITY HEALTHCARECALENDAR

16 MARK YOUR CALENDARS:SDCMS’ 2009 Seminars and Events

18 INFANT MORTALITY:Still a Need for Action

20 POLITICS AND ADVOCACY10 Pretty Good Rules

12

History of CMS Programs • SGR • GPCI • Bar to the Corporate Practice of Medicine• Pay for Performance • Medi-Cal • MICRA • RICO Lawsuit: Policing the Health Plans• Scope of Practice

22

[ F E A T U R E S ]

“PHYSICIAN, INFORM THYSELF” — THE LEGISLATIVE ADVOCACY ISSUE

BRIEFLY NOTED:Ask Your Physician Advocate, New and RejoiningMembers, and More 44 ONCE IS ENOUGH:

The Long and Fascinating History of Vaccination

38 SDCMS FOUNDATION:“The Pulse”

41 PHYSICIAN MARKETPLACE:Classifieds

2 S A N D I E G O P H Y S I C I A N . o r g | S E P T E M B E R 2 0 0 8


SDCMS BRINGS YOU A PRIMER ON THE ISSUES.


Contributors

Send your letters to the editor to [email protected]

ADDRESS: 5575 Ruffin Rd., Ste. 250, San Diego, CA 92123TELEPHONE: Dareen Nasser, office manager, at (858) 565-8888 or [email protected]

FAX: (858) 569-1334CEO/EXECUTIVE DIRECTOR: Tom Gehring at (858) 565-8597 or [email protected]

COO/CFO: James Beaubeaux at (858) 300-2788 or at [email protected] OF MEMBERSHIP AND MEMBER SERVICES: Janet Lockett at(858) 300-2778 or at [email protected]

PHYSICIAN ADVOCATE:Marisol Gonzalez at (858) 300-2783 or [email protected]

OFFICE MANAGER ADVOCATE: Lauren Wendler at (858) 300-2782 or [email protected]

DIRECTOR OF EVENTS AND LEADERSHIP SUPPORT: Jennipher Ohmstede at(858) 300-2781 or at [email protected]

SDCMS FOUNDATION INTERIM EXECUTIVE DIRECTOR: Tana Lorah at (858)300-2779 or at [email protected]

DIRECTOR OF COMMUNICATIONS AND MARKETING: Kyle Lewis at (858)300-2784 or at [email protected]

ASSISTANT EDITOR AND WEBMISTRESS: Ketty La Cruz at (858) 565-7930or at [email protected]

SPECIALTY SOCIETY ADVOCATE: Karen Dotson at (858) 300-2787 or [email protected]

LETTERS TO THE EDITOR: [email protected] SUGGESTIONS: [email protected]

Get In TouchS D C M S

Joseph Scherger, MD, MPHKyle LewisKetty La Cruz

EDITORMANAGING EDITORASSISTANT EDITOR

Adam Dorin, MDRobert Peters, MDDavid Priver, MDRoderick Rapier, MDJoseph Scherger, MD, MPH

EDITORIAL BOARD

SDCMS EXECUTIVE COMMITTEE

Stuart Cohen, MD, MPHLisa Miller, MDAlbert Ray, MDRobert Wailes, MDSusan Kaweski, MDJoseph Scherger, MD, MPHJeffrey Leach, MDSherry Franklin, MDRobert Peters, MDRobert Hertzka, MDTom Gehring

Theodore Mazer, MDAlbert Ray, MDRobert Wailes, MD

Catherine Moore, MDDiana Shiba, MD

James Hay, MDRobert Hertzka, MD

Albert Ray, MDLisa Miller, MD

PRESIDENTPRESIDENT-ELECTPAST PRESIDENT

SECRETARYTREASURER

COMM. CHAIRDELEGATION CHAIR

BOARD REP.BOARD REP.

LEGISLATIVE CHAIREXECUTIVE DIRECTOR

SDCMS CMA TRUSTEES

OTHER CMA TRUSTEES

AMA DELEGATES

ALTERNATE DELEGATE

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 andlength as well as to reject anymaterial submitted. Not responsible for unsolicitedmanuscripts. Advertising rates and information sent upon request. Acceptance of advertising in San DiegoPhysician in noway constitutes approval or endorsement by SDCMS of products or services advertised. San Diego Physician and SDCMS reserve the right to reject any advertising. Addressall editorial communications to [email protected]. All advertising inquiries can be sent to [email protected] . San Diego Physician is publishedmonthly on the first of themonth.Subscription rates are $35.00 per year. For subscriptions, email [email protected]. [SAN DIEGO COUNTY MEDICAL SOCIETY (SDCMS) PRINTED IN THE U.S.A.]

ACCOUNT EXECUTIVEPROJECT DESIGNER

ADVERTISING ART DIRECTORCOPY EDITOR

1450 Front Street • San Diego, CA 92101 • 619-230-9292 • Fax: 619-230-0493 • 800-600-CITY (2489) • www.sandiegomagazine.com

Published by Dari PebdaniJessica HedbergGeneen MontgomeryAdam Elder

PRESIDENTPUBLISHER

DIR., BUSINESS DEVELOP. &MARKETINGMARKETING & PRODUCTION MNGR.

Jim FitzpatrickMaureen SullivanHeather BackJennifer Rohr

EAST COUNTY DIRECTOR

HILLCREST DIRECTOR

KEARNY MESA DIRECTOR

LA JOLLA DIRECTOR

NORTH COUNTY DIRECTOR

SOUTH BAY DIRECTOR

AT-LARGE DIRECTOR

YOUNG PHYSICIAN DIRECTORRESIDENTPHYSICIANDIRECTORRETIRED PHYSICIANDIRECTORMEDICAL STUDENT DIRECTOR

William Tseng, MDWoody Zeidman, MDRoneet Lev, MDThomas McAfee, MDAdam Dorin, MDSherry Franklin, MDSteven Poceta, MDWayne Sun, MDJames Schultz, MDDouglas Fenton, MDTony Blain, MDVimal Nanavati, MDAnna Seydel, MDJeffrey Leach, MD,Robert Peters, MDDavid Priver, MDWayne Iverson, MDPaul Kater, MDJohn Allen, MDKevin Malone, MDMihir Parikh, MDKimberly Lovett, MDGlenn Kellogg, MDGeraldine Kang

MARISOL GONZALEZ Ms. Gonzalez is your SDCMS physician advocate. She can be reached at (858) 300-2783 or at [email protected] with any ques-tions you may have about your practice or your membership.

TOM GEHRING Mr. Gehring is the CEO/executive director of SDCMS.

JOSEPH E. SCHERGER, MD, MPH Dr. Scherger is clinical professor of family medicine at UCSD. He is also medical director of AmeriChoice, which adminis-ters San Diego County Medical Services. Dr. Scherger, along with editing San Diego Physician, is chair of the SDCMS Communications Committee.

GAYLE WHITE, MPH, RN Ms. White is the maternal and child health coordinator in Maternal, Child, and Family Health Services. She has held this position forthe past six years and oversees the Perinatal Care Network, Comprehensive Perinatal Services program, Fetal and Infant Mortality Review program, and the BlackInfant Health program.


Editor’s ColumnBy Joseph E. Scherger, MD, MPH

hysicians dodged another bulletthis year as Congress overrode thepresident’s veto of legislation to

block the scheduled 10.6 percent cut inphysician reimbursement in the Medicareprogram.With the Sustainable Growth Rate(SGR) formula as law, similar cuts have beenscheduled every year for several years, andeach time a frenzy of activity from organizedmedicine has been able to prevent the cutsfrom being enacted. How long will we goon like this before meaningful reform inMedicare reimbursement takes place?

WeAmericans spend about twice asmuchfor healthcare as other similar countries, yetphysicians in private practice are paid at ratesthat are not sustainable to amedical practice.This paradox hasmany causes, including ex-cessive money spent for administration,profit-taking by health plans, and many im-balances in the reimbursement schedules tofavor gadgets over real care. As I watch theScooter Store commercials, or the ones forpulmonary and diabetic supplies, I wonderhow much profit is built into these compa-nies that have a direct line into Medicarefunds — certainly enough to pay for primetime national television marketing!

I am a registered Democrat hungry for a

new administration in Washington thatplaces the care of people over the profits ofcorporations. Whether Democrat or Re-publican, the membersof the San DiegoCounty Medical Soci-ety unite for the welfareof patients and thephysicians who care forthem. On the eve ofsending the Medicarelegislation to the presi-dent, the following let-ter was sent electronically to the WhiteHouse by past SDCMS president andCMA trustee Ted Mazer:

DEAR MR. PRESIDENT,

The time is late for suggesting that someother means for avoiding the draconian cutsto Medicare physician reimbursementshould not come from overpaid private in-surers, as the entire Medicare access systemis ready to implode. I am a Republicanphysician (although these days I find it hardto defend the Republican positions onhealthcare financing) practicing in SanDiego, California, an area that CMS andCongress still consider to be rural under the

Geographic Practice Cost Index (GPCI)portion of the Medicare RBRVS paymentsystem. After 20 years of practice, I find it

intolerable that we have facedcuts year after year under anacknowledged broken calcu-lation system, only to be toldthat we are ‘saved’ each yearwhen rates are held flat.

In the meantime, MedicareAdvantage PFFS programs arebeing paid 112-119 percentmore per patient than is allot-

ted in the standard Medicare program. Yetthe White House feels that the taxpayershould continue to overpay these programsfor their ‘add-on’ services, while privatephysicians lose the viability of their practicesin the ever-shrinking payment by Medicareand these same private MA programs. Yes,the private payers profit at the expense of thetaxpayer, but those monies are not passed onto the providers of actual care, and, simulta-neously,Medicare pays the providers less andless in real dollars every year. If the privatesector insurers can offer Medicare benefici-aries the same, better, or more services ATTHE SAME COST AS THE REGULARPROGRAM TO THE TAXPAYER, then

P

Fixing MedicareReimbursement

Organizedmedicine stands ready

to work with a new administra-

tion to carve out an improved

Medicare program that is truly

sustainable year after year.

S E P T E M B E R 2 0 0 8 | S A N D I E G O P H Y S I C I A N . o r g 7

by all means I support such an approach toprivatization of Medicare. But such is notthe case in the current MA PFFS programs!

In San Diego County it is even worsewith Medicare underpaying the doctors forfee-for-service (FFS) Medicare more than$30 million a year, despite recognizing theunfairness of the GPCI calculations.

As a loyal Republican, and as a practicingphysician, I implore you to get past the pol-itics and the showdown mentality, and ad-dress the pending collapse of access to carein the Medicare program, by signing thecurrent legislation and moving for futurecorrections to the entire flawed paymentsystem as soon as possible. I have alreadyclosed my practice to new California Med-icaid (Medi-Cal) patients as of the first ofJuly due to 10 percent cuts in that alreadyunderfunded program. Having servedMedi-Cal patients for 20 years, I cannot af-ford to take any more cuts and pay out ofpocket to take care of patients. The samewill be true in the Medicare program shouldthe 10.6 percent cuts be allowed to gothrough. I, and many of my colleagues, willbe left with little choice but to cut the num-ber of new Medicare patients we will see,simply in order to maintain the viability ofour practices. That serves no one at all!

Ted Mazer, MDOtolaryngology, Private PracticePast President, San Diego County Med-ical SocietyTrustee, California Medical Association

Hopefully, this will be the last year thatwe have to scramble just to keep our headsabove water. Medicare does not lack funds,yet it is time that they use them wisely andrecognize the physicians that care so well forseniors. With the Baby Boomers enteringthe Medicare program over the next 20years, waste and inefficiency can no longerbe tolerated. Organized medicine standsready to work with a new administration tocarve out an improved Medicare programthat is truly sustainable year after year.

ABOUT THE AUTHOR: Dr. Schergeris clinical professor of family medicine atUCSD.He is alsomedical director ofAmeri-Choice, which administers San DiegoCountyMedical Services.Dr. Scherger, alongwith editing San Diego Physician, is chair ofthe SDCMSCommunicationsCommittee.

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YOU BEGIN YOUR PRACTICE,”Nov.22, 8:30 a.m. – 3:30 p.m.

2008 San Diego County Medical Society Seminars and Events

NOVEMBER

YOUNG PHYSICIANS SOCIAL

Sep. 13, 3 p.m. – 8 p.m.

SEPTEMBER

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CERTIFIED MEDICAL OFFICE MAN-

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Along with its manysocial events held

throughout the year, theSAN DIEGO COUNTYMEDICAL SOCIETY

(SDCMS) strives to builda robust schedule offree seminars for our

physician members andtheir staffs (attendance

rates for nonmemberphysicians and their

staffs vary by seminar).

For further informationabout any of these seminarsor events, watch your emails

and faxes, visit SDCMS’ websiteat www.SDCMS.org, call SDCMS

at (858) 565-8888, or emailus at [email protected].

Details may change as semi-nars approach –contact

SDCMS to confirm.

Thank you for yourmembership!


NEW ADVANCES IN INFLAMMATORY BOWEL DISEASEThis conference is intended for physicians, nurses,

social workers, and others involved in the care of pa-

tients with Crohn’s disease or ulcerative colitis. Sept.

13 at the Sheraton La Jolla Hotel. $125. Call (858)

652-5486 or email [email protected].

FRESH START’S 2008 SURGERY WEEKENDS — Comejoin together to provide free reconstructive surgery

and related medical services to disadvantaged chil-

dren with physical deformities caused by birth de-

fects, accidents, abuse, or disease. Bothmedical and

non-medical volunteers are needed to make chil-

dren’s transformations possible. Sept. 13–14, Nov. 1–

2 at the Center for Surgery of Encinitas. Call (760)

448-2021 or visit www.freshstart.org.

19TH ANNUAL CORONARY INTERVENTIONS — This

conference features live case demonstrations, lec-

tures, and panel discussions that will focus on the

state-of-the-art concepts and techniques of inter-

ventional cardiology. Sept. 17–19 at the Hilton La

Jolla Torrey Pines. Call (858) 652-5486 or email

[email protected].

2008 UPDATE ON PARKINSON’S DISEASE — This ed-ucational event will highlight all the changes in

Parkinson’s disease management and treatment.

Sept. 20 at the Hilton La Jolla Torrey Pines. Free.

CME available. Call (858) 273-6763 or visit www.pd

asd.org.

2008 HEALTH AND WELLNESS FORUM: DEVELOP-MENTAL DISABILITIES — Conference will include fivesets of workshops focusing on autism, genetics, early

intervention, risk management, and special popula-

tions, as well as keynote presentations and a poster

session/reception. Sept. 24–26 at the Catamaran Re-

sort Hotel, San Diego. Call (858) 534-3940 or email

[email protected].

THE CALIFORNIA HEART RHYTHM SYMPOSIUM — Thisconference will highlight what is known about basic

arrhythmia mechanisms, how our clinical therapeu-

tic strategies are driven by science, and how obser-

vations from clinical therapeutics have created new

avenues for research. Oct. 2 at the Manchester

Grand Hyatt, San Diego. $300. CME: 15.5. Call (858)

534-3940 or email at [email protected].

TEENS WITH MENTAL HEALTH DISORDERS — Youthworkers need to understand and recognize youth

with mental health disorders and differentiate those

at risk from those dealing with normal developmen-

tal issues. Oct. 23 at the San Diego County Office of

Education. $30. CME: 3.5. Call (858) 652-5482 or

email [email protected].

THE LEUKEMIA AND LYMPHOMA SOCIETY’S LIGHTTHE NIGHT WALK — This is a nationwide, annual

fundraising walk to celebrate and commemorate

people whose lives have been touched by cancer.

Oct. 24 at Qualcomm Stadium. Call (858) 427-6651

or email [email protected].

3RD ANNUAL HEART FAILURE AND ARRHYTHMIAS:FROM PREVENTION TO CURE — This program will up-

date the primary care provider and practicing car-

diologist on the latest treatments for heart failure

and atrial arrhythmias, as well as new therapies

being developed. Nov. 1 at the Paradise Point Resort

and Spa, San Diego. Call (858) 652-5486 or email

[email protected].

2008 SAN DIEGO DAY OF TRAUMA — An outstandingfaculty of leading civilian and military trauma sur-

geonswill review themost important lessons from the

war and develop practice recommendations for the

care of the injured at our civilian trauma centers in the

United States. Nov. 7 at the Joan B. Kroc Institute for

Peace and Justice, University of San Diego. $225.

CME: 8. Call (858) 652-5482 or email at med.edu@

scrippshealth.org.

THESCIENCEANDCLINICALAPPLICATIONOF INTEGRA-TIVE HOLISTIC MEDICINE — Lectures followed by Q&Asessions, experiential morning programs, and evening

study groups. Nov. 17–21 at the Paradise Point Resort

and Spa, San Diego. Reduced rates for attendees. Call

(858)[email protected].

NATURAL SUPPLEMENTS: AN EVIDENCE-BASED UP-DATE — This course provides practical informationfor healthcare professionals who make nutritional

recommendations or manage dietary supplement

use. Jan. 22–25, 2009, at the Paradise Point Resort

and Spa, San Diego. CME available. Call (858) 652-

5486 or email [email protected].

Community Healthcare Calendar

To submit a community healthcare event for possible publication, visit www.SDCMS.org, click on“Calendar,” then “Community Events,” then “Submit a Community Event.” All events should bephysician-focused and take place in San Diego County.


By Marisol Gonzalez

UESTION: I had a patientcome in who didn’t have anymoney for the copay. They

have lab results to pick up, and I want tohold onto the results until they pay what isowed. Can I do this?ANSWER:No. You cannot refuse a patient’srequest formedical records because of an un-paid bill for health services. Many practiceconsultants advise that you try and collectcopayments while the patient is still in theoffice. It is far easier to collect at the time ofservice than through a statement latermailedto the patient. Unless you have signed anycontracts prohibiting you fromdoing so (in-cluding Medicare and Medi-Cal contracts),you can charge your patients interest on co-payment amounts that are overdue.

UESTION: I am trying to optmy physician out of Medicare,and the form is asking for a

PTAN number. What is this?ANSWER: PTAN is the acronym for“ProviderTransactionAccessNumber.”Thisnumber can also be referred to as the “legacynumber” or the “Medicare PIN Number.”

UESTION: We have a patientwho is asking for a copy ofher medical records. With

these medical records she also wantsphone messages and emails that weregiven to me in confidence by her family.Should I release these as well?ANSWER: According to CMA ON-CALLdocument #1110, “Confidentiality ofSensitive Medical Information,” a physi-cian sometimes receives informationgiven to them in confidence by membersof a patient’s family or others. There arespecial protections under California lawfor this information. For example, if a pa-tient is requesting information abouttheir own medical care (including med-ical records, which must be disclosed tothe patient), California law exempts “in-formation given in confidence to ahealthcare provider by a person otherthan another healthcare provider or thepatient.”

There are similar exceptions in theLanterman-Petris-Short (LPS) Act pro-tecting the confidentiality of such infor-mation. For example, the LPS Act

permits disclosure of information con-cerning a minor, ward, or conservateeupon the written authorization by his orher parent, guardian ad litem, or conser-vator, “except that nothing in the articleshall be construed to compel a physician,psychologist, social worker, nurse attor-ney, or other professional person to revealinformation that has been given to himor her in confidence by members of a pa-tient’s family.” Another section of the LPSAct exempts confidential informationgiven to the healthcare provider by familymembers from disclosure to a patient’s at-torney. (Welfare & Institutions Code§5328.)

ABOUT THE AUTHOR:Ms. Gonzalez isyour SDCMSphysician advocate. She canbereached at (858) 300-2783 or at [email protected] any questionsyou may have aboutyour practice or yourmembership.

Q

Q

Q

MARISOL GONZALEZ


Copays, PTANs, and Patient InformationGiven By Family Members to Physicians

DOES YOUR OFFICE MANAGER HAVE A QUESTION TOO?Lauren Wendler, your SDCMS office manager advocate, is on staff and ready to help your officemanager with any questions they may have. Feel free to contact Lauren at (858) 300-2782 orat [email protected] for help. And don’t forget to sign up to receive SDCMS’ new officemanager e-newsletter.

NotedBriefly

Ask Your Physician Advocate!

NotedBriefly


he Institute for Medical Quality(IMQ), a subsidiary of the Cali-fornia Medical Association

(CMA), is a 501(c)(3) non-profit organiza-tion dedicated to improving the quality ofcare provided to patients across the contin-uum of healthcare. IMQ offers a wide rangeof educational, accreditation, consultation,and certification programs. IMQ is differentfrom other healthcare quality organizationsin that it makes providing quality care easierand eliminates, rather than creates, barriersto doing so. What makes IMQ special is itsemphasis on education, counseling, and di-rect involvement of practicing physicians.

Some, but not all, IMQ programs in-volve surveys of facilities and medical prac-tices. Each program is carefully developedand continuously updated by physicianswhose practices are similar to those they arecurrently evaluating or advising. Physiciansurveyors make every effort to keep mate-rials relevant, current, and meaningful, anddiscard components that may be outdatedor unnecessarily burdensome. If you are in-

terested in any of the following programsor in becoming a surveyor, please call(415) 882-5151, email [email protected], orvisit www.imq.org.

CME ACCREDITATION PROGRAM: Accreditsproviders within the state of California tooffer AMA PRA Category 1 Credit(s)™ forcontinuing medical education activities.

CME CULTURAL AND LINGUISTIC COMPETENCY

PROGRAM:Provides resources and contacts forcultural and linguistic competency and as-sists California CME providers in comply-ing with Assembly Bill 1195.

CME CERTIFICATION PROGRAM:Assists physi-cians in providing documentation of AMAPRA Category 1 Credit(s)™ and awards afour-year CMA certification in continuingmedical education.

AMBULATORY CARE REVIEW PROGRAM: Ac-credits a wide range of healthcare organiza-tions, including ambulatory surgery centers,occupational health centers, medical of-fices/medical groups, and other outpatientsettings administering anesthesia. Recog-nized by MBC and insurance carriers.

CONSOLIDATED ACCREDITATION LICENSURE

SURVEY PROGRAM: The Joint Commission,the Department of Public Health (DPH),and the Institute forMedicalQuality (IMQ)jointly survey acute-care hospitals for ac-creditation and licensure.

CORRECTIONS&DETENTIONS SURVEY PROGRAM:

Offers onsite reviews ofmedical programs injuvenile halls and jails for consultation andaccreditation.

PEER REVIEW & MEDICAL STAFF CONSULTA-

TIONS:Provides onsite, objective peer reviewof physician clinical practice with a focus oneducation, consultation, and quality im-provement. Consultations individually de-signed for medical staffs.

EDUCATIONAL PROGRAMS: IMQoffers a seriesof educational seminars and webinars thathelp physicians and healthcare organizationsmeet regulatory and accreditation standardsand provide better care. Topics include a se-ries of ethics programs, medical staff educa-tion, disruptive physician, performanceimprovement, peer review,CME, regulatoryrequirements, standards, legal issues, etc.

T

The Institute forMedical QualityIMPROVING THE QUALITY OF CARE PROVIDED TO PATIENTS

One of the best investments I’vemade has been becoming a member of the

San Diego County Medical Society.

— Dr. Chrystal E. de Freitas


riday,Oct. 10, 2009, is the 18thAnnualNa-tional Depression Screening Day. As part ofthis public education campaign, individuals

can fill out a simple questionnaire to see if their stress,sadness, or anxiety could be the result of depression ora related disorder. Thousands of organizations nation-wide will host events [visitwww.MentalHealthScreen-ing.org to locate a site nearyou] where members of thepublic can assess their riskfor depression, learnwhat todo about it, and talk to amental health professionalabout their personal situa-tions. The program is freeand anonymous.

WELCOME NEW AND REJOININGSDCMS-CMA MEMBERS!

TESTIMONIAL

NEW MEMBERS

MARC AARON DAVIS, MD

Emergency MedicineSan Diego, (619) 686-3800

SHANG I. BRIAN

JIANG, MD

DermatologyLa Jolla, (858) 657-8322

MATTHEW R. KIRK, MD

OphthalmologyLa Jolla, (858) 457-3050

MEL M. KURTULUS, MD

Obstetrics and GynecologyLa Jolla, (858) 699-3578

EDITH RACHEL

LEDERMAN, MD

Internal Medicine &Infectious DiseaseSan Diego, (619) 532-7475

JESS MANDEL, MD

Internal Medicine,Pulmonary Disease &Critical Care MedicineLa Jolla, (858) 534-1378

UJWALA DESHMANE

RAJGOPAL, MD

SurgeryEncinitas, (760) 753-5667

NARESH CHAMKUR

RAO, DO

Family MedicineSan Diego, (619) 398-2960

RALPH ERIK

RYNNING, MD

Orthopedic SurgerySan Diego, (619) 286-9480

MICHAEL SHIM, MD

Internal MedicineOceanside, (760) 724-8782

HEATHER SUZANNE

VOLPP, MD

Internal MedicineSanDiego, (858) 458-0940

CLAYTON BOYD

WHITING, MD

Emergency MedicineSan Diego, (619) 686-3800

LAURA ANN

WILLIAMS, MD

Family MedicineAlpine, (619) 445-0204

KENTARO EMIL

YAMADA, MD

OphthalmologySan Diego, (619) 299-1100

TINA ZIAINIA, MD

Obstetrics and GynecologySan Diego, (858) 621-4036

ROBERT MICHAEL

BITER, MD

Obstetrics and GynecologyEncinitas, (760) 642-0800

REJOININGMEMBERS

ROBERT ALAN

FRIEDMAN, MD

Psychiatry & Child andAdolescent PsychiatrySan Diego, (858) 279-1223

JACK JOSEPH

KLEID, MD

Internal Medicine &Cardiovascular DiseaseSan Diego, (858) 274-2560

PHILLIP MARK

MILGRAM, MD

Obstetrics and GynecologySan Diego, (858) 455-6100

HOSSEIN M.

SADEGHI, MD

Internal Medicine,Cardiovascular Disease &Interventional CardiologyChula Vista, (619) 216-3113

VISHAL VERMA, MD

Diagnostic RadiologySan Diego, (858) 752-9735

F

NationalDepressionScreeningDay

“ “


SDCMSMark Your Calendars to AttendSDCMS’ 2009 Seminars and Events

BOTHMEMBER PHYSICIANS

AND THEIR

INVITED TO ATTENDOFFICE STAFF

JANUARY2009Collections Seminar

(Office Managers Forum)Thursday,Jan. 15, 11:30a.m. – 1p.m.

Risk Management WebinarWednesday, Jan. 21,6:30 p.m. – 7:30 p.m.

Risk Management WebinarThursday, Jan. 22,11:30 a.m. – 12:30 p.m.

Marketing the Physician PracticeSeminarWednesday, Jan. 28,6:30 p.m. – 8:30 p.m.

Marketing the Physician PracticeSeminar (Office Managers Forum)Thursday, Jan. 29,11:30 a.m. – 1 p.m.

FEBRUARY2009Contract Negotiations Seminar

Wednesday, Feb. 11,6:30 p.m. – 8:30 p.m.

Contract Negotiations Seminar(Office Managers Forum)Thursday, Feb. 12,11:30 a.m. – 1 p.m.

MARCH2009Insurance Services Seminar

Wednesday, March 18,6:30 p.m. – 8:30 p.m.

Insurance Services Seminar (OfficeManagers Forum)Thursday, March 19,11:30 a.m. – 1 p.m.

APRIL2009Practice Management Seminar

Wednesday,April 15,5p.m.–9p.m.Practice Management Seminar (Office

Managers Forum)Thursday, April 16, 9 a.m. – 1 p.m.

“Preparing to Practice: What You Needto Know BEFORE You Begin YourPractice” (Resident and NewPhysician Seminar)Saturday, April 18,8:30 a.m. – 3:30 p.m.

Risk Management SeminarWednesday, April 22,6:30 p.m. – 8 p.m.

Risk Management SeminarThursday, April 23,11:30 a.m. – 1 p.m.

MAY2009EMR Road Show

Wednesday, May 6,4 p.m. – 8 p.m.

EMR Road Show (OfficeManagers Forum)Thursday, May 7,9 a.m. – 12:30 p.m.

Billing Seminar (Office Managers Forum)Wednesday, May 20,11:30 a.m. – 1 p.m.

JUNE2009Legal Seminar

Wednesday, June 17,6:30 p.m. – 8:30 p.m.

Legal Seminar (OfficeManagers Forum)Thursday,June18,11:30a.m.–1p.m.

“Taking Charge: Steps to EvaluatingRelationships and Preparing forNegotiations — A Focus on PayorContracting” (CMA Seminar)Wednesday, June 24,4:30 p.m. – 8:30 p.m.

“Back to Basics: A Step-by-Step Guideto Maximizing Your Cash Flow”(CMA Seminar — OfficeManagers Forum)Thursday,June25,9a.m. –2p.m.

JULY2009Risk Management Webinar

Wednesday, July 22,6:30 p.m. – 7:30 p.m.

Risk Management WebinarThursday, July 23,11:30 a.m. – 12:30 p.m.


AUGUST2009HIPAA Update (Office

Managers Forum)Wednesday, Aug. 12,11:30 a.m. – 1 p.m.

OCTOBER2009Financial Issues Seminar

(Including Estate Planning)Wednesday, Oct. 14,6:30 p.m. – 8:30 p.m.

Financial Issues Seminar (OfficeManagers Forum)Thursday, Oct. 15,11:30 a.m. – 1 p.m.

Certified Medical Coder (CMC) CourseFive Fridays, Oct. 23, 30 and Nov.6, 13, 20, 8 a.m. – 4 p.m.

NOVEMBER2009Risk Management Webinar

Wednesday, Nov. 18,6:30 p.m. – 7:30 p.m.

Risk Management WebinarThursday, Nov. 19,11:30 a.m. – 12:30 p.m.

“Preparing to Practice: What You Needto KnowBEFOREYou Begin YourPractice” (Resident and NewPhysician Seminar)Saturday, Nov. 21,8:30 a.m. – 3:30 p.m.

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For more information please contact Jamie Smolin at 619.955.6929 or at [email protected]. Visit us online at www.allscripts.com/healthmatics.

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GENERAL INFORMATION COVERING MOSTSDCMS SEMINARS AND EVENTS

WHEN:During lunchtime or dinnertime, with lunch and dinner providedfree of charge.

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ATTENDANCE: Only SDCMSmember physicians and their office staff areallowed to attend. Attendees are asked to pre-register.

COST:Open to SDCMSmember physicians and their staff free of charge.

QUESTIONS: For further information, watch your emails and faxes, visitwww.SDCMS.org, call (858) 565-8888, or email [email protected] may change as seminars and events approach — please contactSDCMS to confirm.


n the United States, we do not oftenhear a lot about infant deaths exceptfor the periodic news reports of the

unfavorable ranking of our infant mortalityrate compared to other countries. The latestestimates place the United States between30th and 40th from the top. Infant mortality,the death of a live-born infant before oneyear of age, is a concern on several differentlevels. Clearly, for the individual family, al-most no event is more tragic than the deathof a baby. For the community, the death ofan infant means the loss of many years ofpotential contributions to society. From apublic health perspective, the infant mor-tality rate has long been considered one ofthe best barometers to measure the healthand wellbeing of populations. Improvingoverall health and reducing the number ofinfant deaths are intertwined. The goodnews is that the infant mortality rate hasbeen decreasing steadily for several decades.The national rate was 26 per 1,000 livebirths in 1960 and had fallen to 6.5 in 2005.

So what about infant mortality in San

Diego County?The leading causes of infantdeaths in San Diego are congenital anom-alies (birth defects), prematurity and lowbirth weight, perinatal complications, andSudden Infant Death Syndrome (SIDS), apattern comparable tothat seen nationwide.In 2005, 230 infantsunder age one died inSan Diego County, aninfant mortality rateof five deaths per1,000 live births. Bycomparison, that sameyear there were 119deaths among chil-dren between the agesof 1 and 17 in SanDiego County, a death rate of 16.5 per100,000.The fact that the two rates are cal-culated using a different denominator tendsto mask the fact that a child is 30 timesmore likely to die during the first year of lifethan at any time during the next 17 years.The majority of infant deaths, about 50–55

percent, occur in the first week of life, andabout two-thirds in the first 28 days. Whileinjury prevention and good medical careduring the first year of life are importantconsiderations, focusing on these measures

alone will not signifi-cantly impact the in-fant mortality rate.

A major concern inthe United Sates is thatAfrican Americanscarry an unequal shareof the infant mortalityburden. In San DiegoCounty in 2005, theAfrican-American in-fant mortality rate was13.2, more than two

and a half times as high as the overall rate.A similar gap between African Americansand all other groups has persisted over time.One factor contributing to this inequalityis a higher rate of premature births amongAfrican Americans, 16.3 percent in SanDiego County in 2005 compared to 11.1

I

County Public Health Officer’s Update

Infant MortalityStill a Need for Action

Note: For a copy of this article with references, email [email protected] GAYLE WHITE, MPH, RN

One promising, yet challenging, focusthat may help unravel the mysteriesof the inequality in infant mortality islooking at the mother’s health and ex-periences over the course of her lifebefore and during the pregnancy.


percent for all other groups. Despite signif-icant advances in neonatal care, very lowbirth weight infants (under 1,500 grams)have a mortality rate of 251/1,000 births.

Nationally, research into the factors con-tributing to African-American infant mor-tality has found thatwhile the rates forall racial and ethnicgroups have been drop-ping, the difference be-tween black infants andother groups has be-come even larger in thelast 10 years. Studiescontrolling for manyrisk factors, includingmultiple births, prema-turity, genetics, mater-nal education, andsocioeconomic status, indicate that these fac-tors do not fully explain the disparity forAfrican Americans.

One promising, yet challenging, focusthat may help unravel the mysteries of theinequality in infant mortality is looking atthe mother’s health and experiences overthe course of her life before and during thepregnancy. Part of the risk for African-American women may come from higherrates of certain chronic or infectious condi-tions. Women who come into a pregnancywith health problems, particularly if theyhave not had access to high quality health-care to help address and control the condi-tions before the pregnancy, run a higher riskof an adverse birth outcome or infantdeath. In addition, some researchers pointto stress on African-American women dueto the undercurrent of racism that has af-fected their life course since childhood. Thephysiological pathway in response to stresscan restrict blood flow to the uterus as wellas contribute to inflammation, which cantrigger premature birth. Racism as achronic, long-term stressor is believed tohave the potential to contribute to such re-sponses. One recent study showed thatwomen who believed that they had beentreated unfairly on the basis of their race,for example, in employment, work, andother settings, had twice the risk of deliver-ing a preterm infant than women who didnot have the same perceptions.

The Maternal, Child, and Family HealthServices branch (MCFHS) of Public HealthServices works with community partners toreduce infant mortality and the inequalityof African-American infant deaths. TheBlack Infant Health program provides an

array of services to pro-mote health and socialsupport during preg-nancy and the baby’sfirst year of life formore than 500 clientseach year. The Fetaland Infant MortalityReview (FIMR) pro-gram identifies gaps inthe community systemof care through in-depth review of infantand fetal death cases

leading to recommendations to improvecare. Focusing on African-American deathssince 2005, FIMR-initiated projects haveincluded an innovative educational tool toinform African-American women of the im-portance of good health before and betweenpregnancies.The tool is currently being dis-seminated through community organiza-tions. MCFHS received a grant from theMarch of Dimes to adapt the tool for Span-ish-speaking and multicultural audiencesduring 2008. Other FIMR recommenda-tions have led to projects raising awarenessof the signs of premature labor and pro-moting a woman-carried portable prenatalrecord so that health information will beavailable in case of emergency.

For information about MCFHS pro-grams working to reduce infant mortalityin San Diego County, please call GayleWhite, maternal and child health coordi-nator, at (619) 692-8667.

ABOUT THE AUTHOR:Ms. White is thematernal and child health coordinator inMaternal, Child, and Family Health Serv-ices. She has held this position for the pastsix years and oversees the Perinatal CareNetwork, Comprehensive Perinatal Serv-ices program, Fetal and Infant MortalityReview program, and the Black InfantHealth program.

Nationally, research into the factorscontributing to African-American infantmortality has found that while the ratesfor all racial and ethnic groups havebeen dropping, the difference betweenblack infants and other groups has be-come even larger in the last 10 years.

SAN DIEGO COUNTYHEALTHCARE STATS

September is National Infant Mortal-ity AwarenessMonth. For more infor-mation, please visit www.healthystartassoc.org.

• In 2005, 11.3 percent of babiesborn in Sand Diego County were atincreased risk of death due to pre-mature birth (before 37 completedweeks of gestation). Mothers under19 and 35 and older had the high-est rates of premature births, 12.5percent and 13.5 percent respec-tively (1).

• More than one-half (55 percent) ofall infant deaths in the UnitedStates in 2004 occurred to the 22percent of infants born at fewerthan 32 weeks of gestation. Infantmortality rates for late preterm (34–36 weeks of gestation) infants werethree times those for term (37–41week) infants (2).

To request additional health statisticsdescribing health behaviors, diseases,and injuries for specific populations,health trends and comparisons tonational targets, please call theCounty’s Community Health Statis-tics Unit at (619) 285-6479. To ac-cess the latest data and data links,including the Regional CommunityProfiles document, go to www.sdhealthstatistics.com.

REFERENCES:1. State of California, Department ofHealth Services, Center for HealthStatistics, Birth StatisticalMaster Files.Prepared by County of San Diego,Health and Human Services Agency,Maternal, Child, and Family HealthServices (MCFHS).2. MathewsTJ,MacDormanMF. In-fant mortality statistics from the 2004period linked birth/infant death dataset. National vital statistics reports; vol55 no 14. Hyattsville, MD: NationalCenter for Health Statistics. 2007.

Politics and Advocacy


10 Pretty Good RulesBy TOM GEHRING

ver the past seven years as yourexecutive director, I’ve had thepleasure of meeting and learn-

ing from many exceptional physicians andphysician leaders. I want to share some ofthese pretty good rules about politics andadvocacy, and start by thanking Dr. BobHertzka (past CMA president), Dr. JimHay (future CMA president), and JoeDunn (CMA CEO).

1) LOOKAT POLITICIANSAS EITHER THOSEWHOVIEW

PHYSICIANS AS PART OF THE SOLUTION OR THOSE

WHO VIEW PHYSICIANS AS PART OF THE PROBLEM.

In the world of political parties, we are se-duced into thinking that the party affilia-tion drives “goodness” or “badness.” Notso. We in the leadership team use a verysimple litmus test: Does the decision makertrust physicians or not? If they do, it mat-ters not whether they are a Republican or aDemocrat.

2) RESPECT THE TRUTH … ALWAYS.

This rule can’t get any easier — and moredifficult to adhere to in the heat of the mo-ment. Never, ever BS. Never, ever fudge.Your reputation, and that of your organi-zation, can be destroyed in 30 seconds by

being (even inadvertently) untruthful. Andremember, few are more respected thanthose who say, “I don’t know, but I will findout,” and then actually find out and informthe legislator.

3) THE MOST POWERFUL SPOKESMAN FOR YOUR

CAUSE IS SOMEONE WHO HAS NO DIRECT STAKE IN

THE OUTCOME.

When you speak to a decision maker, andyou have a clear interest in the outcome, youwill be politely listened to, but your wordswill be assessed in the context of a special in-terest. When those same thoughts comefrom someone without a (perceived) con-flict, those words become (magically) muchmore compelling. So, for example, when afamily physician speaks to the lunacy of let-ting optometrists operate on the eye, that’s apowerful statement — much more so thanif the ophthalmologist, who may in fact bemaking a much more fact-based argument,did the same (see rule #10).

4) COUNT YOUR VOTES BEFORE THE VOTE.

Don’t find out you’re close (or behind) dur-ing the vote. Do everything in your powerto find out who is with you and who isn’t,then lobby the heck out of the issue.

5) FOCUS ON THE PERSUADABLES.

While actual percentages may vary, on anygiven issue, about 30 percent will be in full-throated support, and roughly 30 percentare stridently opposed. Focus 90 percent ofyour energy on the 40 percent who are con-vincible.

6) NO ONE BATS 1.000 IN ADVOCACY.

If you expect to win every issue, you’ve cho-sen the wrong avocation. It’s a game of per-centages. Work for the long haul, and bepatient.

7) IT’S ABOUT THE RELATIONSHIP,

NOT ABOUT THE ISSUE.

• Variation 1: When it’s a core issue, thenit is about the issue.

• Corollary 1:Choose your core issues very,very carefully.

There are a million issues ... choose the onesyou’re willing “to die for” very carefully, butalways remember to treasure the relation-ship! Those you lobby may not agree withyou (see rule #8 below), but the value of therelationship is that you get a fair and fasthearing. Being able to pick up the cell phone(and having the cell phone number) andcalling a state legislator is incredibly useful.

O


8) TODAY’S OPPONENT IS TOMORROW’S

ALLY, AND VICE VERSA.

Note, I did not say enemy... I said oppo-nent (see rule #9 below). Alliances comeand go; accept that the greater good some-times makes for strange bedfellows. There-fore, never, ever personalize a disagreementbecause you may be looking for a partnersomeday soon!

9) RESPECT THE ELECTED OFFICIALS,

THEIR STAFFS, AND YOUR ADVERSARIES.

You haven’t run for office. You haven’t had tofly to Sacramento orWashington, DC, everyweek. You haven’t spent interminable hoursin meetings listening to ...well, let’s just saythat our legislators work incredibly hard, andevery move they make is scrutinized, criti-cized, and second-guessed. Respect them forwhat they do and who they are.

The staff are just as, and sometimesmore, important as the elected official.Never, ever, ever treat the staff with any-thing but respect.They may be young, theymay be underpaid, they may work undervery challenging conditions, but they havethe ear of the decision maker. Make themyour allies, even your advocates!

Bad-mouthing your opponents (or worse,not respecting the truth) will invariably causeyou to be ineffective. And the word getsaround. Quickly!10) IT’S 90 PERCENT ON THE POLITICS,

ONLY 10 PERCENT ON THE MERITS.

• Corollary 1: You don’t get to the meritsuntil AFTER you deal with the politics.

Deal with (and understand) the politics be-fore you speak to the merits.Those of us ed-ucated in deterministic, objective, anddata-driven disciplines (engineering in mycase, medicine in my spouse’s) are resolutelyconvinced that the merits of any argumentwill always prevail. Sadly, in the world of pol-itics and advocacy, that is rarely the case. Infact, many decisions are made in the absenceof, or even contravention of, the facts. Deci-sion makers have to do things, e.g., their

party leadership may demand a vote, maybethey need to vote against something we likethat is passing easily but they have a con-stituency to appease, the list goes on. Getover it! That’s the world we live in.

So who cares about advocacy and poli-tics anyway? You do. If SDCMS and CMAare not building those relationships, mak-ing the case for physicians, walking the hallsof power, then a nonphysician will tell youhow to practice medicine and reach intoyour pockets — and directly affect yourability to provide patient care. Which

brings me to the last, and most importantrule (with apologies to the famous linefrom the 1992 presidential campaign): It’sabout the patient care, stupid. Everythingwe do as advocates for physicians has tofocus on the ultimate goal of healing thesick. Honestly framed as a patient careissue, it’s hard to lose an argument!

ABOUT THE AUTHOR: Mr. Gehring isexecutive director and CEO of the SanDiego County Medical Society.

Everythingwe do as advo-cates for physicians hasto focus on the ultimategoal of healing the sick.

AKT

We are 2,500 physicians in San Diego County who

have chosen, by becoming SDCMS members, NOT

to stand idly by...

To paraphraseThomas Jefferson, “An enlightened physician community is in-dispensable to the proper functioning of a healthcare system.” With that inmind, we would like to begin educating San Diego County’s physician com-munity by informing you of the issues that directly affect your patients andyour practices, as well as our overall healthcare system ... and by describinghow the San Diego County Medical Society (SDCMS) and the CaliforniaMedical Association (CMA) affect these same issues as they get played out bypoliticians, lawyers, corporations, and others throughout the year, and — moreoften than not — year after year.

Although students finish medical school having studied a myriad of sub-jects in preparation for becoming a physician — organ physiology, humananatomy, histology, cell biology, biochemistry, basic neurology, etc. — theyare more and more beginning their medical practices wholly unprepared forthe realities of a healthcare system on the brink of collapse due to ongoingMedicare cuts, underfunded government programs, scope of practice threatsto patient safety, Byzantine health plan contracts, HIPAA requirements, in-creasing professional liability insurance premiums, mandatory CME, gov-ernment agency overregulation, and much, much more.

This is where the San Diego County Medical Society (SDCMS) and theCalifornia Medical Association (CMA) step in. We are approximately 2,500physicians in San Diego County and 25,000 physicians across California whohave chosen, by becoming members, NOT to stand idly by while our col-leagues, our patients, our communities, and our very own practices sufferunder the weight of a system in such need of repair.Thank you to those physi-cians who have stepped forward to take back control of their practices and thecare of their patients by becoming SDCMS and CMA members ... and by be-coming informed, and educated!

NOTE: Look to future issues of San Diego Physician for detailed descriptionsof other issues important to physicians, beginning in October with a look atwhat the Department of Managed Health Care calls “balance billing,” but whatwe prefer to call “billing for services rendered.”



CMS Programs ..............................24SGR ..................................................26GPCI..................................................28Corporate Practice Bar................30Pay for Performance....................31Medi-Cal ..........................................32MICRA ..............................................34RICO Lawsuit..................................36Scope of Practice ..........................37

TABLE OF CONTENTS


“PHYSICIAN,INFORMTHYSELF”

elow are some of the key legislative milestones thathave shaped Medicare, Medicaid (California’s Medi-Cal program), the Clinical Laboratory Improvement

Amendments (CLIA), the Health Insurance Portability and Ac-countability Act (HIPAA), and the State Children’s Health In-surance Program (SCHIP):

1965: Medicare and Medicaid were enacted as Title XVIII andTitle XIX of the Social Security Act, extending healthcoverage to almost all Americans aged 65 or older andproviding healthcare services to low-income children de-prived of parental support, their caretaker relatives, theelderly, the blind, and individuals with disabilities. Sen-iors were the population group most likely to be living inpoverty, with about half having insurance coverage.

1966: Medicare was implemented and more than 19 millionindividuals enrolled on July 1.

1967: An Early and Periodic Screening, Diagnosis, and Treat-ment (EPSDT) comprehensive health services benefit forall Medicaid children under age 21 was established.

1972: Medicare eligibility was extended to individuals underage 65 with long-term disabilities and to individuals withend-stage renal disease (ESRD). Medicare was given theauthority to conduct demonstration programs. Medicaideligibility for elderly, blind, and disabled residents of astate could be linked to eligibility for the newly enactedFederal Supplemental Security Income program (SSI).

1973: The HMO Act provided for start-up grants and loans forthe development of health maintenance organizations(HMOs); HMOs meeting federal standards relating tocomprehensive benefits and quality were given preferen-tial treatment in the marketplace.

1977: The Health Care Financing Administration (HCFA) wasestablished to administer the Medicare and Medicaidprograms.

1980: Coverage of Medicare home health services was broad-ened. Medicare supplemental insurance — also called“Medigap” — was brought under federal oversight.

1981: Freedom of choice waivers (1915b) and home and com-munity-based care waivers (1915c) were established inMedicaid; states were required to provide additional pay-ments to hospitals treating a disproportionate share oflow-income patients (i.e., DSH hospitals).

1982: The Tax Equity and Fiscal Responsibility Act made it eas-

ier and more attractive for health maintenance organiza-tions to contract with the Medicare program. In addi-tion, the act expanded the agency’s quality oversightefforts through Peer Review Organizations (PROs).

1983: An inpatient acute hospital prospective payment systemfor the Medicare program, based on patients’ diagnoses,was adopted to replace cost-based payments.

1985: The Emergency Medical Treatment and Labor Act (EM-TALA) required hospitals participating in Medicare thatoperated active emergency rooms to provide appropriatemedical screenings and stabilizing treatments.

1986:Medicaid coverage for pregnant women and infants (upto one year of age) to 100 percent of the federal povertylevel (FPL) was established as a state option.

1987: The Omnibus Budget Reconciliation Act of 1987(OBRA87) strengthened the protections for residents ofnursing homes.

1988: The Medicare Catastrophic Coverage Act, which in-cluded the most significant changes since enactment ofthe Medicare program, improved hospital and skillednursing facility benefits, covered mammography, and in-cluded an outpatient prescription drug benefit and a capon patient liability. Medicaid coverage for pregnantwomen and infants to 100 percent of FPL was mandated;special eligibility rules were established for institutional-ized persons whose spouses remained in the communityto prevent “spousal impoverishment”; QualifiedMedicare Beneficiary (QMBs) program was establishedto pay Medicare premiums and cost-sharing charges forbeneficiaries with incomes and resources below estab-lished thresholds. The Clinical Laboratory ImprovementAmendments (CLIA) strengthened quality performance re-quirements for clinical laboratories in order to assure ac-curate and reliable laboratory tests and procedures.

1989: The Medicare Catastrophic Coverage Act of 1988 wasrepealed after higher-income elderly protested new pre-miums. A new Medicare fee schedule for physician and

other professional services, a resource-based relative value

scale, replaced charge-based payments. Limits were placed

on physician balance billing above the new fee schedule.

Physicians were prohibited from referring Medicare pa-tients to clinical laboratories in which their physicians,or physicians’ family members, have a financial interest.Medicaid coverage of pregnant women and children


CMSPROGRAMS

B

Key MilestonesMEDICARE, MEDICAID, HIPAA, SCHIP …

under age 6 to 133 percent of FPL was mandated; ex-panded EPSDT requirements were established.

1990: Phased in Medicaid coverage of children ages 6 through18 under 100 percent of FPL was established; Medicaidprescription drug rebate program was established; Spec-ified Low-Income Medicare beneficiary eligibility groupwas established (SLMBs) for Medicaid programs to payMedicare premiums for beneficiaries with incomes atleast 100 percent but not more than 120 percent of FPLand limited financial resources. Additional federal stan-dards for Medicare supplemental insurance were enacted.

1991: Medicaid Disproportionate Share Hospital (DSH)spending controls were established, and provider-specifictaxes and donations to states were capped.

1996: Welfare Reform: The Aid to Families with DependentChildren (AFDC) entitlement program was replaced bythe Temporary Assistance for Needy Families (TANF)block grant; the welfare link to Medicaid was severed; anew mandatory low-income group not linked to welfarewas added; and enrollment/termination of Medicaid wasno longer automatic with receipt/loss of welfare cash as-sistance. The Health Insurance Portability and Accounta-bility Act of 1996 (HIPAA) had several provisions. First, it

amended the Public Health Service Act, the Employee Re-

tirement Income Security Act of 1974 (ERISA), and the In-

ternal Revenue Code of 1986 to provide for new federal

rules improving continuity or “portability” of coverage in

the large group, small group, and individual health insur-

ance markets. CMS implements HIPAA provisions affect-

ing the small group and individual markets. Second, it

created the Medicare Integrity Program, which dedicated

funding to program integrity activities and allowed CMS to

competitively contract for program integrity work. Third, it

created national administrative simplification standards for

electronic healthcare transactions. Fourth, it required HHS

to issue privacy regulations if Congress failed to enact sub-

stantive privacy legislation.

1997: Balanced Budget Act of 1997 (BBA): the State Children’sHealth Insurance Program (SCHIP) was created; limits onMedicaid payments to disproportionate share hospitalswere revised; new Medicaid managed care options andrequirements for states were established. Medicarechanges include:

• Establishing an array of new Medicare managed careand other private health plan choices for beneficiaries,offered through a coordinated open enrollmentprocess;

• Expanding education and information to help bene-ficiaries make informed choices about their health-care;

• Requiring CMS to develop and implement five newprospective payment systems for Medicare services(for inpatient rehabilitation hospital or unit services,skilled nursing facility services, home health services,

hospital outpatient department services, and outpa-tient rehabilitation services);

• Slowing the rate of growth in Medicare spending andextending the life of the trust fund for 10 years;

• Providing a broad range of beneficiary protections;• Expanding preventive benefits;• Testing other innovative approaches to payment andservice delivery through research and demonstrations.

1998: The Internet site www.medicare.gov was launched toprovide updated information about Medicare.

1999: The toll-free number, 1-800-MEDICARE (1-800-633-4227), was available nationwide. The first annualMedicare and You handbook was mailed to all Medicarebeneficiary households.

1999: The Ticket to Work and Work Incentives ImprovementsAct of 1999 (TWWIIA) expanded the availability ofMedicare and Medicaid for certain disabled beneficiarieswho return to work. Established optional Medicaid eli-gibility groups and allowed states to offer a buy-in toMedicaid for working-age individuals with disabilities.The Balanced Budget Refinement Act of 1999 (BBRA)increased payments for some Medicare providers and in-creased the amount of Medicaid DSH funds available tohospitals in certain states and the District of Columbia.Other related legislation improved Medicaid coverage ofcertain women’s health services.

2000: The Benefits Improvement and Protection Act (BIPA)further increased Medicare payments to providers andmanaged healthcare organizations, reduced certainMedicare beneficiary co-payments, and improvedMedicare’s coverage of preventive services. BIPA createda new Medicaid prospective payment system for FederallyQualified Health Centers and Rural Health Clinics, andit modified the amount of Medicaid DSH funds availableto hospitals, while it provided a one-year extension onthe sunset of transitional medical assistance provided tofamilies eligible for welfare.

2003: The Medicare Prescription Drug, Improvement, and Mod-ernization Act (MMA)made the most significant changes toMedicare since the program began. MMA creates a pre-scription drug discount card until 2006, allows for com-petition among health plans to foster innovation andflexibility in coverage, covers new preventive benefits, andmakes numerous other changes. In 2006, the new volun-tary Part D outpatient prescription drug benefit is avail-able to beneficiaries from private drug plans as well asMedicare Advantage plans. Employers who provide retireedrug coverage comparable to Medicare’s will be eligible fora federal subsidy. Medicare will consider beneficiary in-come for the first time; beneficiaries with incomes less than150 percent of the federal poverty limit will be eligible forsubsidies for the new Part D prescription drug program;beneficiaries with higher incomes will pay a greater share ofthe Part B premium starting in 2007.


CMS PROGRAMS


ection 1848(f ) of the Act, as amended by section4503 of the Balanced Budget Act of 1997 (BBA)(Pub. L. 105-33), enacted on Aug. 5, 1997, replaced

the Medicare Volume Performance Standard (MVPS) with aSustainable Growth Rate (SGR) provision. Section 1848(f)(2)of the Act specifies the formula for establishing yearly SGR tar-

gets for physicians’ services underMedicare. The use of SGR targets isintended to control the growth inaggregate Medicare expenditures forphysicians’ services.

The SGR targets are not directlimits on expenditures. Payments forservices are not withheld if the SGRtarget is exceeded by actual expendi-tures. Rather, the fee schedule update,as specified in section 1848(d)(4) ofthe Act, is adjusted to reflect the com-parison of actual expenditures to tar-get expenditures. If expendituresexceed the target, the update is re-duced. If expenditures are less thanthe target, the update is increased.Under the statute, the update for ayear is determined by comparing cu-mulative actual expenditures to cu-mulative target expenditures (referredto as “allowed expenditures” in thestatute) from April 1, 1996 throughthe end of the year preceding the year

at issue. For instance, the 2009 update will reflect a comparisonof cumulative actual to cumulative target expenditures from April1, 1996 through Dec. 31, 2008. Target expenditures for each yearare equal to target expenditures from the previous year increasedby the SGR (which is a percentage figure computed by combin-ing four factors specified below).

The statute specifies a formula to calculate the SGR based


S

SDCMS-CMA — THE FIGHT TO FIX THE (UN)SUSTAINABLE GROWTH RATE FORUMALAThis past July’s Medicare victory in Congress speaks for itself to the powerand value of organized medicine, but this win was not magic, not a miracle,not even amazing. It was, simply put, the product of incredible work by CMAstaff in Washington, DC, by AMA, by county medical societies, and by the hun-dreds of physicians who got involved in California and the thousands whodid so across the nation. The power of physicians to make and shape policyhas lain mostly dormant for years. As CMA works to become a more aggres-sive advocate for physicians, it will be able to better direct and unleash thispower. Instead of constantly fighting to maintain the status quo, we physi-cians will be positioned to advance our cause and our agenda. In the yearsto come, we will need every physician’s voice as we work to find a perma-nent fix to this grossly flawed Medicare SGR formula.

HOW SDCMS HELPS YOU

Unsustainable at Any Measure

MEDICARE’S Sustainable Growth Rate Formula

[NOTE: FROM THE CENTERS FORMEDICARE AND MEDICAID SERVICES]

Future bleak for seniors, baby boomers. Medicareto cut payments as boomers enter the programSources: Physician cost data is from the MEI, a conservative index of practice cost growthmaintained by the Centers for Medicare & Medicaid Services. Medicare physician paymentupdates are from the 2006 Medicare Trustees report, with adjustments for 2008 to reflectthe Congressional Budget Office analysis of the “Tax Relief and Health Care Act of 2006.”Any change in pay that may result from use of the $1.35 billion “physician assistance andquality initiative fund” for 2008 is not included.

on our estimate of the change in each of four factors. Thefour factors for calculating the SGR are as follows:

1. The estimated percentage change in fees for physicians’services.

2. The estimated percentage change in the average numberof Medicare fee-for-service beneficiaries.

3. The estimated 10-year average annual percentage changein real gross domestic product (GDP) per capita.

4. The estimated percentage change in expenditures due tochanges in law or regulations.

Prior to enactment of the Medicare Prescription Drug Im-provement and Modernization Act (also known as theMedicare Modernization Act, or MMA), the statute requiredthe SGR to be calculated using estimated projected growth inreal GDP per capita. That is, the Secretary was required to usean estimate of a single year’s real GDP per capita to determinethe SGR. However, section 1848(f )(2)(c) of the Act, asamended by section 601(b) of the MMA, requires the Secretaryto calculate the SGR using the 10-year annual average growthin real gross domestic product per capita.

Section 1848(d)(1)(E) of the Act requires publication in theFederal Register no later than Nov. 1 of each year (beginningwith 2000) of the actual conversion factor, update and allowedexpenditures that will apply to physicians’ services for the suc-ceeding year. Another section of the law (section 1848(f)(1))requires that we publish in the Federal Register no later thanNov. 1 of each year, using the best available data as of Sept. 1,the SGR for the following year, the contemporaneous year, andthe preceding year. By Nov. 1, 2008, we are required to pub-lish, based on the best data available to us as of Sept. 1, 2008,the SGRs for CY 2007, CY 2008, and CY 2009. We plan toimplement these provisions as part of the physician fee sched-ule final rule for 2009.

Thus, in this document, we are providing (i) our current es-timates (as of March 1, 2008) of the SGRs for CY 2007, CY2008, and CY 2009, (ii) our current estimate of allowed expen-ditures under the SGR system through the end of 2009, and (iii)

our current estimate of the physician fee schedule update andconversion factor for 2009. We will be providing updates of allthis information using more recent data in the physician feeschedule final rule for 2009. The updated values scheduled tobe published in the final rule by Nov. 1, 2008 will be used todetermine the actual update for physician payments in CY 2009.

Table 1 shows our current estimates of the aforementionedSGRs.

Table 2 shows the historical values of the SGR as well as itspredecessor, the Medicare Volume Performance Standard(MVPS). The MVPS applied for FY 1990 through FY 1997.Figures reflect a weighted average MVPS for FY 1991through FY 1993 when there were two different MVPSs(one for surgical services, and one for all other services) andfor FY 1994 through FY 1997 when there were three differ-ent MVPSs (for surgical services, primary care services, andall other services).


determine the SGR. However, section 1848(f)(2)(c) of the Act, as amended by section

601(b) of the MMA, requires the Secretary to calculate the SGR using the 10-year annual

average growth in real gross domestic product per capita.

Section 1848(d)(1)(E) of the Act requires publication in the Federal Register no later than

Nov. 1 of each year (beginning with 2000) of the actual conversion factor, update and

allowed expenditures that will apply to physicians’ services for the succeeding year.

Another section of the law (section 1848(f)(1)) requires that we publish in the Federal

Register no later than Nov. 1 of each year, using the best available data as of Sept. 1, the

SGR for the following year, the contemporaneous year, and the preceding year. By Nov.

1, 2008, we are required to publish, based on the best data available to us as of Sept. 1,

2008, the SGRs for CY 2007, CY 2008, and CY 2009. We plan to implement these

provisions as part of the physician fee schedule final rule for 2009.

Thus, in this document, we are providing (i) our current estimates (as of March 1, 2008)

of the SGRs for CY 2007, CY 2008, and CY 2009, (ii) our current estimate of allowed

expenditures under the SGR system through the end of 2009, and (iii) our current

estimate of the physician fee schedule update and conversion factor for 2009. We will be

providing updates of all this information using more recent data in the physician fee

schedule final rule for 2009. The updated values scheduled to be published in the final

rule by Nov. 1, 2008 will be used to determine the actual update for physician payments

in CY 2009.

Table 1 shows our current estimates of the aforementioned SGRs.

TTaabbllee 11 .. CCuurrrreenntt EEsstt iimmaatteess ooff SSGGRRss ffoorr CCYY 22000077,, CCYY 22000088,,

aanndd CCYY 22000099

CY 2007 CY 2008 CY 2009

Factor 1: Increase in Fees 1.9% 1.9% 2.1%

Factor 2: Increase in Enrollment –2.5% –2.1% –0.2%

Factor 3: Increase in 10-year moving average Real Per Capita GDP

1.9% 1.7% 1.8%

Factor 4: Increase due to changes in Law or Regulations

1.9% 0.4% –2.9%

Total Sustainable Growth Rate 3.2% 1.9% 0.7%

Table 2 shows the historical values of the SGR as well as its predecessor, the Medicare

Volume Performance Standard (MVPS). The MVPS applied for FY 1990 through FY

1997. Figures reflect a weighted average MVPS for FY 1991 through FY 1993 when

there were two different MVPSs (one for surgical services, and one for all other services)

and for FY 1994 through FY 1997 when there were three different MVPSs (for surgical

services, primary care services, and all other services).

TTaabbllee 22 PPhhyyssiicciiaann MMVVPPSS // SSGGRR

Year Physician MVPS / SGR Year Physician MVPS / SGR

FY 1990 9.1% FY 1999 4.2%

FY 1991 7.3% FY 2000 6.9%

FY 1992 10.0% CY 2000 7.3%

FY 1993 10.0% CY 2001 4.5%

FY 1994 9.4% CY 2002 8.3%

FY 1995 7.5% CY 2003 7.3%

FY 1996 1.8% CY 2004 6.6%

FY 1997 -0.3% CY 2005 4.2%

FY 1998 3.2% CY 2006 1.5%

<sidebar>

SDCMS-CMA — The Fight to Fix the (Un)Sustainable Growth Rate Forumala

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word word word word word. Word word word word word word word word word word.





Word word word word word word word word word word. <end>


WHERE DID THE GEOGRAPHIC

PRACTICE COST INDEX COME FROM?

he woeful state of physi-cian reimbursement de-serves careful study. Justhow did we get here and

how can we fix it? It all started withthe development of the relativevalue scale (RVS). At the time inthe mid-1950s, it seemed logicaland efficient to apportion a doc-tor’s daily tasks by difficulty and time consumption so that he couldmore reasonably and correctly bill for his work. In addition, a per-sonalized multiplication factor added to the RVS could reflect over-head costs and that factor could change as overhead costs changed.Further, others could use the RVS and modify their work productwith their own personal multiplication factor. The final result wouldbe a universal formula — a usual, customary and reasonable rate tocharge — and all would be happy.

With this incentive, the CaliforniaMedical Association (CMA) went towork. In 1956, CMA launched a projecttitled “California Relative Value Studies.”First, every possible procedure and diag-nosis was listed as a code number — theCurrent Procedural Terminology, or CPTcode, as it was later named by the Ameri-can Medical Association. Then a relativevalue unit (RVU) reflected the physician’stime, resources, and work intensity neces-sary to accomplish each CPT code. Next,an individual physician assigned a “con-version” factor to the formula based on in-dividual office overhead expenses and local area of practice. Whena physician multiplied the conversion factor by the RVU, the “uni-form” fee was revealed.

At the time, just about every physician’s office had an RVU rateschedule. The booklet was an essential first purchase for any doctorstarting a medical practice. In 1969, CMA published its “CaliforniaRelative Value Studies.” It was revised and published again in 1974.CMA finally published the “California Standard Nomenclature” in1979. The final CMA publication is still referred to as the “RVS book.”

The recommended use of conversion factors to reflect differences

meant that physician fees variedgreatly. Eventually, insurers be-came reluctant to pay at differentrates. A cry of injustice was heardthroughout the land. The mediawarned that doctors were operat-ing outside the law and demandedthat the RVS be eliminated.

In 1979, the Federal TradeCommission charged that theRVS system placed private-prac-

tice physicians in violation of federal provisions against price fixing.Payers were exempt from the ruling. Why were payers allowed to actlike businesses when solo and small-group physicians were not?

The result was that physicians secretly hid their RVS books deepin office file drawers and developed individual billing schedules thatlooked remarkably like the RVS. Young physicians just starting theirmedical practices bought gray market RVS books and kept them

under lock and key.However, when it came time for the gov-

ernment to pay for Medicare and Medicaid,standardized billing was suddenly recognizedas an essential component. The shoe was onthe other foot. The government establishednational standard rates and fees based on adefined and limited total pool of money,which they defined as a “resource.” In 1989,the Health Care Financing Administrationdeveloped a Resource-based Relative ValueScale (RBRVS) to redistribute a fixed budgetof Medicare funds to physicians. Healthcarerationing, disguised as cost containment, rap-idly won legislative approval.

In 1970, projected Medicare spending for 1990 was $16.3 bil-lion. In 1990, the actual cost of Medicare was $109 billion. A fewextra billion here and there, and pretty soon the healthcare deliverysystem added up to major government debt. The RBRVS did not dowhat the RBRVS was supposed to do.

Then, because no good deed goes unpunished, the governmentcame up with an even more confusing dynamic for payment. Fromthe 1991 proposed rule in the Federal Register:

Payment = [{RVUws x GPCIwa} + {RVUpes x GPCIpea} +{RVUms x GPCIma}] x CF


More and more physicians

are considering their alterna-

tives: opting out of Medicare,

opening concierge practices,

limiting their practices, or re-

fusing to contract.

[Note: This article by Ralph Di Libero, MD, then-President of LACMA, was originally published in 2006 in Southern California Physician magazine.]

Inequity

THE GEOGRAPHIC PRACTICE

TIME TO FIX IT

Cost IndexT

• RVUws = Physician work relative value units for the service.• GPCIwa = Geographic practice cost index value reflecting onefourth of the geographic variation in physician work applicablein the fee schedule area.

• RVUpes = Practice expense relative value units for the service.• GPCIpea = Geographic practice cost index value for the practiceexpense applicable in the fee schedule area.

• RVUms = Malpractice relative value units for the service.• GPCIma = Geographic practice cost index value for malpracticeexpense applicable in the fee schedule area.

• CF = Uniform national conversion factor.

All of the above only served as more subterfuge. The resource forMedicare funding was based on Americans having an average life ex-pectancy of 65 years in 1964. By 2000, that life expectancy was 78years and today it is 80 years. The fastest growing segment of oursociety is older people. The resource is grossly inadequate. In an eraof expanding technologies, the amount of funding available forphysician fees from a fixed-dollar resource mathematically decreased.The logical next step was to increase the resource base, but neitherside of the political aisle appears to be in-terested in confronting this painfully obvi-ous solution.

So now, more and more physicians areconsidering their alternatives: opting out ofMedicare, opening concierge practices, lim-iting their practices, or refusing to contract.All of these actions are becoming morecommon, but they do not solve the prob-lem of patient access to physicians in med-ical emergencies.

There is a great void in our Americanhealthcare delivery system. Many emer-gency rooms are closing their doors becausephysician specialists naturally avoid the sig-nificant financial risk in the offering ofemergency care. Perhaps part of the home-land defense budget should be diverted tohealthcare for emergency services. Perhapsour government officials should get theiract together and properly fund programs sothat those who actually deliver healthcareare adequately reimbursed.


SDCMS-CMA — THE FIGHT TO FIX THE GPCI INEQUITYUntil the system is made equitable, SDCMS and CMA will fight for fairMedicare reimbursements that underpay San Diego County’s physi-cians approximately 7 percent per annum ($24 million). In June 2007,after more than four years of sustained advocacy, the County of SanDiego joined six other counties in suing the federal government forretroactive and prospective Geographic Practice Cost Index (GPCI) re-lief to bring Medicare geographic payment equity to San Diego Countyphysicians and other impacted counties and states across the coun-try — approximately $160 million for San Diego County’s physiciansalone, and more than $2.4 billion nationally for physicians in the 174underpaid counties.

HOW SDCMS HELPS YOU


he Medical Practice Act, Business and Professions Code sec-tion 2052, provides that “any person who practices or at-tempts to practice, or who holds himself or herself out as

practicing … [medicine] without having at the time of so doing a valid,unrevoked, or unsuspended certificate … is guilty of a public offense.”Business and Professions Code section 2400, within the Medical Prac-tice Act, provides in pertinent part that “corporations and other artifi-cial entities shall have no professional rights, privileges, or powers.”

The policy expressed in Business and Professions Code section2400 against the corporate practice of medicine is intended to preventunlicensed persons from interfering with or influencing the physi-cian’s professional judgment. [Note: The involvement of corporations inmedical practice gained attention in the early part of the 20th centurywhen mining companies needed to hire physicians to provide care for em-ployees in remote areas. Problems arose when physicians’ loyalties to theiremployers conflicted with patients’ medical needs.] The decisions de-scribed below are examples of some of the types of behaviors and sub-tle controls that the corporate practice doctrine is intended to prevent.From the Medical Board’s perspective, the following healthcare deci-sions should be made by a physician licensed in the State of Califor-nia and would constitute the unlicensed practice of medicine ifperformed by an unlicensed person:

• Determining what diagnostic tests are appropriate for a particu-lar condition.

• Determining the need for referrals to, or consultation with, an-other physician/specialist.

• Responsibility for the ultimate overall care of the patient, in-cluding treatment options available to the patient.

• Determining how many patients a physician must see in a givenperiod of time or how many hours a physician must work.

In addition, the following “business” or “management” decisionsand activities, resulting in control over the physician’s practice of med-icine, should be made by a licensed California physician and not byan unlicensed person or entity:

• Ownership is an indicator of control of a patient’s medicalrecords, including determining the contents thereof, and shouldbe retained by a California-licensed physician.

• Selection, hiring/firing (as it relates to clinical competency orproficiency) of physicians, allied health staff, and medical as-sistants.

• Setting the parameters under which the physician will enter intocontractual relationships with third-party payers.

• Decisions regarding coding and billing procedures for patientcare services.

• Approving of the selection of medical equipment and medicalsupplies for the medical practice.

The types of decisions and activities described above cannot bedelegated to an unlicensed person, including, for example, man-agement service organizations. While a physician may consult withunlicensed persons in making the “business” or “management” de-cisions described above, the physician must retain the ultimate re-sponsibility for, or approval of, those decisions. The following typesof medical practice ownership and operating structures also are pro-hibited:

• Non-physicians operating in a business for which physician own-ership and operation are required: any business advertising, of-fering, and/or providing patient evaluation, diagnosis, care,and/or treatment. These are services that can only be offered orprovided by physicians.

• Physician(s) operating a medical practice as a limited liabilitycompany, a limited liability partnership, or a general corpo-ration.

• Management Service Organizations arranging for, advertising, orproviding medical services rather than only providing administra-tive staff and services for a physician’s medical practice (non-physi-cian exercising controls over a physician’s medical practice, evenwhere physicians own and operate the business).

• A physician acting as “medical director” when the physician doesnot own the practice. For example, a business offering spa treat-ments that include medical procedures such as Botox injections,laser hair removal, and medical microdermabrasion, that contractswith or hires a physician as its “medical director.”

In the examples above, non-physicians would be involved in theunlicensed practice of medicine, and the physician may be aiding andabetting the unlicensed practice of medicine.

SDCMS-CMA — PROTECTING THE BAR TO THE CORPORATE PRACTICE OF MEDICINECMA considers the corporate practice of medicine doctrine “a fun-damental protection against the potential that the provision of med-ical care and treatment will be subject to commercial exploitation.”CMA’s legal counsel defines the corporate practice of medicine barbroadly as a prohibition on lay entities hiring or employing physi-cians or other healthcare practitioners, or interfering with physiciansor other healthcare practitioners’ practice of medicine. Lay entitiesare also prohibited from contracting with healthcare professionals torender services. CMA further notes that the corporate practice ofmedicine bar “… is designed to protect the public from possibleabuses stemming from the commercial exploitation of the practiceof medicine,” and that California’s courts and legislature have up-held the corporate practice of medicine bar to protect physiciansfrom the “pressures of the commercial marketplace.”

HOW SDCMS HELPS YOU


The

Practice of MedicineCORPORATEB A R R E D !

T

[Note: From the Medical Board of California —www.medbd.ca.gov.]


uality-based purchasing, also known as pay-for-performance, is the use of paymentmethods and other incentives to encourage

quality improvement and patient-focused, high-valuecare. There are many models for financial and non-financial incentives used in pay-for-performance programs and strategies. It is important to remember thatpay-for-performance programs should be viewed as onlyone component of a broader strategyof promoting healthcare quality. Atleast 12 states throughout the coun-try have implemented a wide rangeof pay-for-performance initiativesunder Medicaid. The strategies mayalso be of interest to SCHIP.

States use both payment differen-tials and non-financial incentives,such as auto-enrollment and publicreporting, to reward performance.Pay-for-performance is in its earlystages of development, and a greatdeal of work still must be done todetermine the best method of ap-

proaching a comprehensive program. The Centers forMedicare and Medicaid Services (CMS) will providetechnical assistance to those states that voluntarily elect toimplement pay-for-performance programs. CMS alsoplans to work with states to encourage that evolving pay-for-performance programs include an evaluation com-ponent to provide evidence of the effectiveness of thismethodology.

[From the Centers for Medicare and Medicaid Services]

Q

Pay QUALITY BY WHOSE MEASURE?

for PERFORMANCE

It is critically important that physicians be involved in the design of pay-for-performance programs, which are intended to improve the effective-ness and safety of patient care. Collecting and reporting data must bereliable and easy for physicians and should not create financial or otherburdens on physicians or their practices, and program incentives shouldinclude reimbursement for any added administrative costs, including soft-ware purchases, installation, and training. CMA has advocated from thebeginning — and will continue to advocate — that CMS and others workwith physicians when formulating guidelines for shaping pay-for-performance programs.

HOW SDCMS HELPS YOU


WHAT IS MEDI-CAL?

edi-Cal, California‘s Medicaid program, isthe main source of healthcare insurancefor 6.6 million people, or one in six Cali-

fornians. It draws more than $20 billion in federal fundsinto the state‘s healthcare system and accounted for 17percent of General Fund spending in fiscal year 2006–07. Medi-Cal is a complex program that pays providersfor essential primary, acute, and long-term care servicesdelivered to a wide range of beneficiaries, including chil-dren, their parents, seniors, and non-elderly adults withdisabilities. Because it is the single largest source of healthinsurance coverage in California and a major source offunding for safety-net providers, a thorough grasp ofMedi-Cal is essential to understanding how healthcare is

financed and delivered in California. For all itssuccess, Medi-Cal faces numerous chal-

lenges, including enrollment barriers,poor access to specialty care, and

rising healthcare costs.

ABOUT MEDICAID

• Is a program created by TitleXIX of the Social SecurityAct that provides coveragefor acute and long-term careservices to 52 million Amer-icans, including low-incomechildren, parents, seniors, and

people with disabilities.• Is state-administered, gov-

erned by federal and state rules,and jointly funded with federal and

state dollars.• Is an entitlement program that requires

federal and state governments to spend the fundsnecessary to operate mandatory program components.• Is the nation’s largest purchaser of healthcare services,

collectively spending more than $317 billion in fiscalyear 2005 in federal and state dollars.

• Is a 40-year-old program that is continually evolving interms of the populations it covers, the services for whichit pays, and the manner in which care is delivered andfinanced.

ABOUT MEDI-CAL

• Is the nation’s largest Medicaid program in terms ofthe number of people it serves (6.6 million), and is thesecond largest in terms of dollars spent ($40 billion).

• Is the source of health coverage for:• Almost one in five of Californians under age 65;• One in three of the state’s children;• And the majority of people living with AIDS.

• Pays for:• Forty-six percent of all births in the state;• Two-thirds of all nursing home residents;• And almost two-thirds of all net patient revenuein California’s public hospitals.

• Brings in more than $20 billion in federal funds toCalifornia’s healthcare providers.

LOOKING AHEAD

In addition to addressing enrollment barriers, poor ac-cess to specialty care, and rising costs, Medi-Cal facesother important and difficult challenges:• Implementing policy changes at the federal level, suchas the new documentation requirements.

• Making better use of technology to improve quality ofcare and administrative efficiency.

• Continuing to expand community-based alternativesto facility-based long term care.

• Monitoring impact of changes in hospital financingon safety-net providers.

• Measuring and monitoring the effectiveness of the fee-for-service system.

• Planning for healthcare reform.

M

CALIFORNIA’S MEDICAID PROGRAMMedi-Cal



SDCMS-CMA — CAN MEDI-CAL BE FIXED?With the California Department of Health Care Services sched-uled to cut Medi-Cal reimbursement rates to physicians by 10percent on July 1, 2008, CMA turned to the courts in May andfiled a lawsuit against the Department of Health Care Servicesto enjoin the cut. Unfortunately, the state court justice ruledunfavorably in CMA’s lawsuit, denying CMA’s motion for pre-liminary injunction. CMA, as of press time, has been coordinat-ing with plaintiffs in other lawsuits that are seeking to stop theMedi-Cal cuts. CMA and SDCMS continue to fight assiduouslyon behalf of physicians and their patients to make sure physi-cians are reimbursed fairly for the services they provide tothose Californians covered by Medi-Cal.

HOW SDCMS HELPS YOU

Spending per Beneficiary

10 Most Populous States and U.S. Average

Medicaid State Spending Averageper Beneficiary (2007)

Medicaid State Spending per Resident

Medicaid Physician Payment Ratesas Percentage of Medicare

Spending per Resident




THE CRISIS

In the early 1970s, a medical malpractice insurance crisisgripped California. Liability premiums soared more than 300percent because of more frequent and severe liability claims and

larger malpractice jury awards. Many physicians — particularly inhigh-risk specialties such as obstetrics and neurosurgery — were forcedto close their doors, either unable to get insurance or unable to affordinflated rates. Denied access to affordable care, California’s patientssuffered. In 1975, then-Governor Jerry Brown called a special sessionof the California Legislature to solve the “malpractice crisis.”

CALIFORNIA’S RESPONSE

During that special session, on a bi-partisan vote, legislators tookaction to fix the broken system by enacting the Medical InjuryCompensation Reform Act, or MICRA. Specifically, MICRA:• LIMITS ATTORNEY CONTINGENCY FEES. In an action against a health-

care provider for professional negligence, an attorney’s contin-gency fee is limited to 40 percent of the first $50,000 recovered;33 percent and 1/3 of the next $50,000; 25 percent of the next$500,000, and 15 percent of any amount exceeding $600,000.

• LIMITS ON NON-ECONOMIC DAMAGES. Non-economic damages in aclaim against a healthcare provider for medical negligence arelimited to $250,000. Economic damages, such as lost earnings,medical care, and rehabilitation costs, are not limited by statute.California Civil Code Section 3333.2.

• ALLOWS EVIDENCE OF COLLATERAL SOURCE PAYMENTS. A defendant ina medical liability action may introduce evidence of collateralsource payments (such as from personal health insurance) as

they relate to damages sought by the claimant. If a defendant in-troduces such evidence, the claimant may also introduce evi-dence of the cost of the premiums for such personal insurance.California Civil Code Section 3333.1.Ensures compensationfor economic damages such as present and future medical costs,lost wages, future earnings, custodial care and rehabilitation.

• PROVIDES A STATUTE OF LIMITATIONS ON CLAIMS. In California, a claim foralleged medical negligence must be brought within one year fromthe discovery of an injury and its negligent cause, or within threeyears from injury. California Code of Civil Procedure Section 340.5.

• REQUIRES ADVANCE NOTICE OF A CLAIM.To further the public policy ofresolving meritorious claims outside of the court system, MICRArequires a claimant to give a 90-day notice of an intention tobring a suit for alleged professional negligence. If the notice isgiven within 90 days of the expiration of the statute of limita-tions, the statute is extended 90 days from the date of the notice.California Code of Civil Procedure Sections 364 and 365.

• ALLOWS FOR BINDING ARBITRATION OF DISPUTES. Patients and theirhealthcare providers may agree that any future dispute may beresolved through binding arbitration. California statute re-quires specific language for such contracts and also providesthat all such contracts be revocable within 30 days. CaliforniaCode of Civil Procedure Section 1295.

• PROVIDES FOR PERIODIC PAYMENTS OF FUTURE DAMAGES. A healthcareprofessional may elect to pay a claimant’s future economic dam-ages, if more than $50,000, in periodic amounts. This avoids aclaimant’s wasting of an award prior to actual need. CaliforniaCode of Civil Procedure Section 667.7.

MICRA’S IMPACT:

• MICRA has increased patients’ access to healthcare by keepingdoctors, nurses, and other healthcare providers in practice andhospitals and clinics open.

• California now has some of the lowest malpractice premiumsin the United States and the American Medical Association(AMA) and the American Hospital Association (AHA) hailMICRA as a “model.”

• Without MICRA, the decline in the number of obstetric providersin the state will only get worse, further threatening women’s accessto comprehensive, quality reproductive healthcare.

• MICRA saves California’s healthcare system billions of dollarseach year.

• Injured patients receive their awards 26 percent sooner thanpatients in states without MICRA reforms.

• Patients receive the lion’s share of settlements and awards —not attorneys.

I

CALIFORNIA’S Medical Injury Compensation

INCREASING PATIENT ACCESS TO CARE


SDCMS-CMA — PROTECTING MICRAMany organizations, spearheaded by the trial lawyers, wantto weaken, if not overturn, MICRA. CMA legal advocacy hasprevailed in the past in defending MICRA (e.g., Palmer vs. SharpRees-Stealy Medical Group when there was an attempt to definemedical groups as not qualifying as “healthcare providers”under the law and as such as not being protected byMICRA) and will prevail in the future with the help of thosephysicians who’ve decided to defend their practices andtheir patients by joining SDCMS-CMA.

HOW SDCMS HELPS YOU


AKT, LLPAKT has provided audit, tax preparation and planning, accountingassistance, and business consulting to San Diego County clients for

more than 50 years. AKT understands physician practices, and their personal,local, and global services can help you achieve success. SDCMS members re-ceive a 15% discount on standard rates for professional services, with anunconditional satisfaction guarantee: Disappointed clients pay only whatthey thought the work was worth. Call Ron Mitchell (760) 268-0212 oremail him at [email protected].

ALLIANT INSURANCE SERVICESAs California’s largest premier specialty insurance broker, and rank-ing among the 13th largest in the nation, Alliant Insurance delivers a

comprehensive portfolio of insurance products and services. SDCMS membersreceive a savings of 5–10% or more off of the cost of insurance, or cash re-bates related to practice size, a savings of 7–12% on long-term disabilityincome protection, and no-cost human resources consulting.Contact MarkAllan at (800) 654-4609 or at [email protected], call Alliant In-surance Services at (888) 849-1337, or visit www.alliantinsurance.com.

ALLSCRIPTSAllscripts offers substantial discounts to SDCMS members on itsaward-winning practice management and electronic health records.

Allscripts’ solutions provide improved patient care, complete workflow man-agement, P4P and P4Q clinical and financial reporting, e-prescribing with built-in formularies, built-in claims scrubbing, and complete revenue cyclemanagement for your practice. SDCMS members receive special preferredearly-adopter pricing and discounts on HealthMatics EHR and practicemanagement solutions. For more information, call Jamie Smolin at (619)665-6139, call Allscripts at (888) 672-3282, or visit www.allscripts.com/healthmatics.

AMERICAN SECURITY RXAmerican Security Rx (ASRX) is a California Department of Justiceand California Board of Pharmacy approved security printer (SP-9)

to provide tamper-resistant California security prescription forms for controlledmedications. SDCMS members receive discounts on tamper-resistant pre-scription forms.Call American Security Rx at (877) 290-4262, email them [email protected], or visit ww.americansecurityrx.com.

CHMB SOLUTIONSCHMB provides outsourced medical billing, revenue cycle manage-ment services, information technology support, and hardware solu-

tions to physician practices, clinics, and multi-specialty organizations. SDCMSmembers receive a 50% discount on startup fees, a $33 per physician permonth services credit, and a free coding hotline. Contact Ron Anderson(CHMB Solutions) at (760) 520-1340 or at [email protected] your coding question(s) to SDCMS at [email protected].

COASTAL HEALTHCARE CONSULTING GROUP, INC.Coastal Healthcare Consulting Group, Inc., is a specialty consult-ing firm that assists clients with managed care contracting, con-

tract negotiations, credentialing, revenue enhancement and strategic planning.

SDCMS members receive a free consultation, a discount on hourly rates,and a package price on services for contract negotiations. Contact KimFenton at (949) 481-9066, at [email protected], or visitwww.healthcareconsultant.org for more information. For consultation sched-uling, contact Marisol Gonzalez, your physician advocate, at (858) 300-2782or at [email protected].

PRACTICE PERFORMANCE GROUP (PPG)Practice Performance Group provides high performance medicalpractice management services for physicians, including consult-

ing, expert witness, workshops, speaking, and a monthly newsletter. SDCMSmembers receive discounted management consulting on productivityand patient flow, personnel, governance and management, market strat-egy and tactics and practice acquisitions, sales and mergers, and a freeone-year subscription to their newsletter, UnCommon Sense®. PPG alsoconducts free half-day seminars for members and their employees at SDCMS(watch your faxes and emails). Contact Jeffrey Denning or Judy Bee at (858) 459-7878 or at [email protected], or visit www.PPGCon-sulting.com.

THE DOCTORS COMPANY (TDC)TDC enjoys a reputation as the industry vanguard for low Cali-fornia rates, aggressive claims defense, expert patient safety pro-

grams, superior customer service, and exemplary member benefits. Everyday,The Doctors Company relentlessly strives to reduce unreasonable legal lia-bility, improve the environment in which all healthcare professionals prac-tice, lead legislative and judicial reform, and enhance patient safety for thebenefit of its members. Most SDCMS members are eligible for a 5% dis-count on insurance premiums, and a 7.5% dividend credit.To learn more,contact Janet Lockett at (858) 300-2778 or at [email protected].

TORREY PINES BANKTorrey Pines Bank is familiar with the business challenges facingmedical professionals. Their goal is to be a “low maintenance” bank,

meeting business owners’ high expectations, with the absolute minimum timeand effort required of them. They offer a full array of banking services. Approved SDCMS members receive no-fee lines of credit, $1,000 fee dis-counts on commercial real estate loans, waived monthly maintenance feeson personal accounts for practice partners and employees up to$10/month, free first order of standard checks for personal accounts, in-creased deposit interest rates, waived monthly maintenance fee for busi-ness online banking and bill pay services, ATM fees waived up to$15/month, and free courier service or remote deposit service. ContactBenjamin Pimentel at (858) 259-5317 or at [email protected].

TSC ACCOUNTS RECEIVABLE SOLUTIONSTSC Accounts Receivable Solutions has provided personalized,innovative collection and total accounts management services since

1992. This local San Diego family-owned business management team has acombined experience of more than fifty years in the healthcare billing andcollection field. SDCMS members receive a 10% discount on monthlycharges. Contact Catherine Sherman at (888) 687-4240, ext. 14, at [email protected], or visit www.tscarsolutions.com.

BE SURE TO TAKE ADVANTAGE OF THE FOLLOWING MEMBERS-ONLY BENEFITS FROM SDCMS’ ENDORSED PARTNERS!

SDCMS Members

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n May 25, 2000, CMA filed a class-action lawsuit against California’sthree largest for-profit HMOs — Blue Cross/WellPoint, Founda-tion/Health Net, and PacifiCare — seeking to stop their allegedly fraud-

ulent and unfair business practices that improperly interfered with and controlled thephysician-patient relationship. This lawsuit was originally filed in federal court inCalifornia, but was transferred to U.S. District Court in Miami and consolidatedwith numerous other lawsuits filed by physicians and other medical associationsagainst a number of health plans, in front of Judge Federico Moreno.

The lawsuit is based primarily on allegations that 10 for-profit health plans — Hu-mana, Aetna, Prudential (prior to its acquisition by Aetna), CIGNA, Coventry, HealthNet, PacifiCare, United, WellPoint, and Anthem — violated the Racketeer Influ-enced and Corrupt Organizations Act (RICO) by engaging in fraud and extortion ina common scheme to wrongfully deny payment to physicians. CMA’s primary focusin pursuing this litigation was to obtain prospective relief — a court order prohibit-ing the plans from continuing these fraudulent and extortionate practices.

CMA’s RICO LawsuitSTOPPING THE HEALTH PLANS’ FRAUDULENT AND UNFAIR BUSINESS PRACTICES

O

SDCMS-CMA — POLICING THE HEALTH PLANS, BRINGING MILLIONSBACK TO PHYSICIANSCMA’s RICO class-action lawsuit challenging the rapacious tactics of the for-profit managed care industry saw a further settlement in 2007, directingmillions more dollars to San Diego County’s physicians. Of even greater sig-nificance than the $40 million Humana settlement (roughly $1.3 million ofwhich came to San Diego County physicians) is the settlement’s prospectiverelief, which is valued at more than $80 million. The following awardamounts were received in 2007 by San Diego County physician groups, witha total approaching $800,000:• Scripps Medical Group: $188,541• Sharp Rees-Stealy Medical Group: $144,297• UCSD Medical Group: $106,577• Anesthesia Service Medical Group: $103,196• Emergency and Acute Care Medical Corporation: $97,265• Children’s Specialists of San Diego: $45,193• Sharp Mission Park Medical Group: $35,347• Children’s Primary Care Medical Group, Inc.: $24,494• Park Terrace Medical Association: $21,944• Mercy Physicians Medical Group: $14,056

In addition, CMA continued to monitor the health plans in 2007 to ensurethey abided by the terms of their RICO settlements. CMA filed disputes afterdiscovering Health Net, CIGNA, and Blue Cross had each violated the termsof their respective RICO settlements in 2007.

HOW SDCMS HELPS YOU


FOR IMMEDIATE RELEASE: MAY 25, 2000

CMA FILES SUIT FOR INJUNCTIVE RELIEF AGAINST

MAJOR HEALTH PLANS UNDER FEDERAL RICO LAWS

LOS ANGELES — The California Medical Association (CMA) todayfiled a federal lawsuit against the three largest for-profit national healthplans in California for imposing unfair contract terms, unnecessarilydenying and delaying payments for procedures patients need, and re-imbursing physicians at rates that are insufficient to cover costs.

The suit against Wellpoint/Blue Cross of California, HealthNetand Pacificare was filed in U.S. District Court in San Francisco underthe civil RICO (Racketeer Influenced and Corruption Act) laws.The suit, California Medical Association v. Blue Cross of Californiaet. al., claims that racketeering activity by those three plans has dam-aged the businesses of and victimized the patients of California physi-cians. Click here for Questions and Answers Concerning CMA’sParticipation in the Suit.

CMA alleges that the health plans used coercive, unfair and fraud-ulent means to dominate and control physician-patient relationshipsfor their own financial gain to the detriment of both patients andphysicians, the suit further states. CMA is seeking injunctive relief.

CMA President Marie Kuffner, MD, said she hopes the lawsuitwill be the last step in what has been an excruciating and lengthy ef-fort to get the health plans to give physicians the means to carefor their patients.

“It is with sadness that we are forced to this last resort,” saidDr. Kuffner, a UCLA professor of anesthesiology. “We as physi-cians have tried to work with the for-profit HMOs in the mar-ketplace and have attempted to curb the abuses through thelegislative process, all to no avail. We cannot continue to allowour patients’ health to be jeopardized by corporate greed.”

Dr. Kuffner stated, “For years these profit-driven companiesdenied needed services, interfered with medical decisions andvalued dollars more than lives. We are here today to say, ‘Nomore in the State of California.’”

More than nine million Californians, or about two-thirds ofthose covered by for-profit plans in the state, are insured by thedefendant plans. The plans had no intention of keeping theirpromise to provide access to quality care at a reasonable cost,CMA’s suit charges. Instead, these companies have conspired togenerate profits for themselves while delaying payments to doc-tors, denying necessary and timely care to patients, and refusingto provide the data necessary for physicians to treat their patients– hence committing fraud on both physicians and patients.

“CMA’s role as plaintiff shows how crucial the health care problemis in the nation, particularly in California, where 21 million people be-long to a managed care health plan of some kind,” said Archie Lamb,a Birmingham, Ala. attorney who filed the suit on CMA’s behalf.

Lamb already has filed a lawsuit against Aetna, Cigna, Humanaand Prudential on behalf of physicians seeking national class certifi-cation.

“It is ironic that here in the state where the HMO concept wasborn, the abuses of managed care are most egregious,” Lamb said.“We are here today to demand that the HMO industry return to theprinciple on which managed care was founded. The CMA, on behalfof its membership, physicians all over America, and all their patients

say, ‘Enough is enough.’“The for-profit HMOs have engaged in a scheme that included

lying to employers about the benefits for employees, lying to physi-cians about commitment to payment for quality health care and fraud-ulently promising patients that they would be there in the time ofgreatest need. And so, we start here today in California and will takethis fight all the way to the East Coast, until patients can once againtrust that their doctor can provide them with the care they need, freeof interference by companies driven only by greed,” Lamb said.


cope of practice” is used by licensing boards for var-ious professions that define the procedures, actions,and processes that are permitted for the licensed in-

dividual. The scope of practice is limited to that which theindividual has received education and experience, and inwhich he/she has demonstrated competency. Each state hasspecific regulations based on entry education and additionaltraining and practice.

ENSURING PATIENT CAREIS NOT JEOPARDIZED

Scope of Practice

S“

SDCMS-CMA — ENSURING PATIENT SAFETYWhile SDCMS-CMA does not oppose all expansions of scopeof practice, we believe that patients are put at risk whennon-physician practitioners provide care for which they areinadequately trained. SDCMS-CMA believes that any suchproposal must be carefully studied to ensure that patientcare is not jeopardized. In 2007, for example, CMA defeatedall non-physician scope of practice expansion attempts (i.e.,by acupuncturists physical therapists, nurse practitioners,psychologists, and audiologists).

HOW SDCMS HELPS YOU


Thebuilding a healthier San Diego by addressing unmet healthcare needs for all patients and physicians through education, innovation and service

No 42Pulse“WHEN YOU CAN DO THE COMMON THINGS OF

LIFE IN AN UNCOMMON WAY, YOU WILL COMMAND

THE ATTENTION OF THE WORLD.”

— George Washington Carver

Dear Friends:

Volunteering is a way of life for manyin our healthcare community, and volun-teering to do something you already do inan uncommon way will bring to life ourcore mission at the Foundation: to addressunmet San Diego healthcare needs for allpatients and physicians through innova-tion, education and service.

Volunteerism is high on the Founda-tion’s list this month as we continue torecruit physicians and supportive ancil-lary services to serve safety net patientsin the Foundation’s flagship program:Project Access San Diego (PASD). Thisimportant access-to-care initiative de-

pends on our region’s physicians andhealth providers who volunteer theirtime to see one or two patients per yearon a pro-bono basis or at discountedrates. More than ever, patients are inneed with Medi-Cal and Medicare cut-backs affecting the availability of servicesthey can receive.

Every year we see need in our commu-nity — on the news, in the newspaper,and in our offices. Every year, more andmore San Diegans fall through the cracksin the healthcare system, be it a lack of in-surance, a lack of specialty care, or even alack of transportation to receive care for achronic illness. The need for help is on-going, and many San Diego physiciansstep up to the plate, not just with theFoundation, but in other community-based organizations as well. I commendeach and every volunteer!

I urge you to seek opportunities to vol-

unteer in the com-munity. There arenumerous ways tovolunteer usingyour skills and ex-pertise through theSan Diego CountyMedical Society Foundation. Please con-tact Tana Lorah, interim executive direc-tor, at (858) 300-2780 to learn how youcan be a Foundation volunteer.

Eleanor Roosevelt is famous for herquote, “Tomorrow starts today.” Tomor-row’s patients and physicians will benefitfrom the work we are doing today, andthat is a powerful motivator for our Foun-dation. With your support, we are confi-dent that we can make a difference!

Thank you for all that you do for thepatients in San Diego.

Sincerely,

BOARD OF DIRECTORSCarol Young, MD, President, Rheumatology, Escondido

Ralph Ocampo, MD, Secretary/Treasurer,

General Surgery, Retired

James Hay, MD, Immediate Past President,

Family Medicine, Encinitas

Ellen Beck, MD, Family Medicine, San Diego

John Berger, MD, Family Medicine, San Diego

Edgar D. Canada, MD, Anesthesiology, San Diego

Judy Forrester, Consultant, Forrester Enterprises

Tom Gehring, CEO, San Diego County Medical Society

Theodore M. Mazer, MD, Otolaryngology and Head and

Neck Surgery, San Diego

Albert Ray, MD, Family Medicine, San Diego

ADVISORY COUNCILJames Lewis Bowers, PhD, Consultant

for Philanthropy

Steven A. Escoboza, President/CEO, Hospital

Association of San Diego and Imperial Counties

Ronne Froman, RADM, USN Retired, Chief Operating

Officer, City of San Diego

Richard S. Ledford, President, Ledford Enterprises

Michael I. Neil, BGN, USMC Retired, President, Neil,

Dymott, Perkins, Brown and Frank

STAFFTana Lorah, Interim Executive Director

Stephen H. Carson, MD, Chief Medical Officer

Pediatrics, San Diego

Claudia Gastelum, PASD Care Coordinator

MESSAGE FROM THE PRESIDENT

Carol L. Young, MD, President of the Board


Showcasing a Foundation Inititative

MEET DR. ROBERT HERTZKAAnesthesiologist

Former President of SDCMS and CMA

WHEN DID YOU BEGIN PRACTICING MEDICINE?I earned my medical degree from UCSD and completed my residencyand fellowship in anesthesiology at the University of California, San Fran-cisco (UCSF). Following two years on the faculty at UCSF, I have been inprivate practice with Anesthesia Service Medical Group (ASMG) since1987.

WHAT IS YOUR BACKGROUND OF INVOLVEMENT IN THE COMMUNITY?I have long been active in policy development and advocacy for a widevariety of issues, including access to healthcare and improved patient safety.In 1999, I was the president of SDCMS, and, in 2004, I served as thepresident of the 35,000-member California Medical Association (CMA).I have been a member of the CMA board of trustees, chair of the Cali-fornia Medical Political Action Committee, and chaired several policycommittees at CMA. On the national level, I have served a term as thechair of the American Medical Association’s political action committee(AMPAC), the nation’s largest such entity representing physicians.

Advocacy on behalf of medical students and young physicians remains amainstay in my political activities in the community. In partnership withthe SDCMS Foundation, I sponsor medical students on legislative visitsto Sacramento to give them a real-world vision of how our governmentworks and how medicine plays a role in the process.

WHY DO YOU THINK SAN DIEGO COUNTY PHYSICIANS SHOULD GET IN-VOLVED WITH THE SDCMS FOUNDATION?Physicians in San Diego County play an important role in the landscapeof San Diego County politics and culture. With the proximity of the med-ical school at UCSD, we have an opportunity to cultivate future physicianswho plan to start their practices in San Diego County. The Foundationsupports students who are preparing to become doctors by offering med-ical student scholarship awards and loans. The essential political advocacyand legislative policy training will notonly benefit the prospective physician,but serve the entire profession by men-toring our future colleagues. I encour-age San Diego County physicians tojoin the Foundation and learn how tosupport the many initiatives that ele-vate practicing and prospective physi-cians, and positively affect the patientswe serve in our region.

In the Spotlight:Meet a Physician Volunteer

Legislative and Policy Training

One of the core initiatives at the SDCMSFoundation is to assist medical students withtheir education through scholarship awards,loans, and legislative and policy training.

Legislative and policy training for medicalstudents is one of the ways we support studentsas they complete their training to becomephysicians. With the continuing barrage of leg-islative challenges for practicing physicians, it ismore important than ever to give medical stu-dents the tools they will need to thrive in theworld of medicine.

With the help of deeply committed mem-ber physicians, the San Diego County MedicalSociety continually advocates for physicians byhelping to defend, support, and promote thepractice of medicine both regionally andstatewide. The Foundation encourages medicalstudents to reach out and learn the legislativeprocess so they will have the background tochampion their own practices and support thepractice of medicine at large.

Medical students join our CEO, TomGehring, and San Diego County Medical So-ciety Foundation leaders on trips to Sacra-mento on a regular basis. Medical studentswalk the halls of the State Capitol, participatein meetings with elected officials, and learn theart of advocacy.

To find out more about supporting medicalstudents or Project Access San Diego (PASD),contact Tana Lorah at (858) 300-2780 or [email protected].

RETIRED PHYSICIANSSOCIETY EVENTSThursday, October 3, 2008,

Sharp Chula Vista

Thursday, January 22, 2009,

San Diego Zoo Hospital

Save

Robert Hertzka, MD


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TO SUBMIT A CLASSIFIED AD, email Ketty La Cruz at [email protected]. SDCMS members place classified ads free of charge (excepting “Services Offered” ads). Nonmembers pay $250 for a maximum total of 100 words.

ClassifiedsDONATED ITEMS

FREE CPAP MACHINE: This is an opportunity to obtain a usedCPAP machine in excellent condition for a deserving patient or

institution. Call Irv Sherman at (858) 487-6370. [548]

OFFICE SPACE

EL CENTRO OFFICE SPACE: 1,500ft2 medical office space avail-able two blocks from ECRMC for sublease on Mondays, Wednes-

days, and Fridays. Call (619) 644-0488 for details. [620]

SHARED MEDICAL OFFICE SPACE (POWAY):Brand new, built-outspace in high-end medical office building. 3,000ft2, fully furnished,

located close to Pomerado Hospital. Exam rooms, consultation

rooms, procedure room with fluoroscopy unit, spacious waiting

room, private provider area, and free parking. For more informa-

tion, call (858) 668-6502 or email [email protected]. [617]

OFFICE SPACE TO SHARE: Modern, spacious medical office.Close proximity to Alvarado and Sharp Hospitals. Call (619) 668-

0900 for more information. [616]

PREMIUM MEDICAL SPACE AVAILABLE: Approximately 2,600ft2of medical space for sublease in prominent Del Mar Heights

building, fronting El Camino Real. Building is shared with fertility

practice, surgery center, and plastic surgeon. If interested, call

Russ Sande at (858) 794-5500 [612]

MISSION HILLS OFFICE FOR SALE: Rare opportunity to ownprestigious North Mission Hills physician’s office. Beautifully re-

stored house located in the West Lewis Planned District. Classic

hardwood floors, stained glass, craftsmanship woodwork

throughout, recessed lighting, complete exam rooms, two pa-

tient waiting areas, and four offices. Neighborhood atmosphere

for patient care. Perfect for primary or specialty practice. Ample

street parking. Mills Act designation with significant tax savings.

Call Annamarie Clark at (619) 962-2095 for photos and appoint-

ment. [610]

CLAIREMONT MESA BLVD.: Nicely decorated, 3,000ft2 medicaloffice with adjoining treatment rooms, X-ray, and private offices.

Ideal for a medical professional looking for ancillary site for

physical or occupational therapy or need for an open area.

Space has a separate entry, lobby, bathrooms, and small offices

great for reception and billing. Ample free parking. Easy access

to all freeways. Please call Joan McComb at (619) 291-8930 for

more information. [605]

CARMEL VALLEY: Beautiful medical office space available to rentin a Class A+ building, centrally located in an affluent area off

the I-5 and Highway 56 junction. Renter to share suite with

board-certified plastic surgeon. The building also houses a fully

accredited surgical center and spa facility. Address: 11515 El

Camino Real, Ste. 150, San Diego, 92130. If interested, please

call Melanie at (858) 720-1440. [602]

SAN DIEGO: Space available from approximately 800ft2 to1,200ft2. Professional, mixed-use building with medical as major

tenant. Space located in Mission Valley with easy access to I-8

and I-15. Call (619) 398-1862 or (619) 723-0074. [599]

YUMA:Medical space from 1,000ft2 to 2,200ft2 available. Exist-ing medical professional tenants, mixed. Will do tenant improve-

ment to suit. Space located across from hospital. Call (619)

398-1862 or (619) 723-0074. [598]

EL CENTRO:Medical office space up to 5,000ft2 available. Willprovide tenant improvement to suit. Existing medical tenant in

building. Call (619) 398-1862 or (619) 723-0074. [597]

CARMEL VALLEY OFFICE SPACE: Office space to share or sub-lease in busy, solo OB/GYN office. Ideal for OB/GYN, internal

medicine, osteopath, dermatology, or other sub-specialty. Excel-

lent referral potential. Scripps medical office building. Call Liz at

(858) 259-9900. [593]

OFFICE SPACE FOR RENT: Convenient location, free parking, inClairemont (Balboa/Genesee). 1,350ft2, three exam rooms, two

bathrooms, lab, share with one other doctor. Office located next

to lab/draw station, Internet access ready. Reasonable rent. Call

(858) 277-9669 or email [email protected]. [588]

CLAIREMONT MESA: Small, two-office space for rent in newlyconstructed medical office. Not a shared space! Approximately

400ft2, built to maximize space, light and airy. Great for thera-

pist, research, small specialty practice, etc. Building is recently

renovated, common-area bathrooms, break rooms, elevator, TI

available, and free parking. Centrally located between highways

52, 805, 163, and 15 for easy hospital and facility access. Call

(858) 268-1111, ext. 311, for more details. [587]

OFFICE SPACE FOR RENT IN ENCINITAS (92024): Convenient lo-cation five minutes from Scripps Encinitas Hospital. Close to 5

freeway. Features include two spacious exam rooms, private

consultation/doctor’s office, lunchroom, private bathroom, and a

spacious waiting room shared with one other doctor. Share lab,

ultrasound, and bone density equipment. Very affordable rent.

Office located at the corner of Encinitas Boulevard and Man-

chester Avenue. Call (858) 756-3021 or email

[email protected] for more information. [586]

SOLANA BEACH MEDICAL CENTER: 2,274ft2 for lease;$2.25/ft2 plus utilities and janitorial services. Ready to move in

but tenant improvement allowable. Easy access to I-5. Serving

Del Mar through Encinitas. Call (760) 431-4238. [584]

OCEANSIDE OFFICE: Office with ocean view available in 1,000ft2suite. Prefer full time, but part time is available. Share suite with

psychologist. Includes furnished waiting room, lots of storage,

locking file cabinets, and receptionist area. Currently furnished,

but unfurnished is an option. Available immediately. Contact

Michael Samko, PhD, at (760) 721-1111 or at michael@michael-

samko.com. [580]

PRIME OFFICE SPACE TO SHARE: Office currently occupied byorthopedic surgeon situated in highly desirable location in a

beautiful new building at 7910 Frost St. The new hospital under

construction for Sharp Memorial Hospital is directly across the

street. Digital X-ray, MRI, fluoro, CT Scan, pharmacy, PT, and

other in the building. Wired for and using EMR. Please call (858)

220-0700 or email [email protected]. [579]

ACROSS FROM SHARP AND CHILDREN’S HOSPITAL: Beautifullyfurnished 2,000ft2 office, fully equipped, five exam rooms.

Share with part-time physician. Please call (619) 823-8111 or

(858) 279-8111. [385]

SUBLEASE NEW MEDICAL OFFICE IN SAN MARCOS: Premium,class-A medical office space in San Diego County’s fastest grow-

ing city! All or part of an approximately 1,950ft2 newly con-

structed suite in San Marcos’ city hall building. Spacious

reception area, large procedure room with hardwood floors, four

exam rooms, two restrooms, doctor’s office with large window,

and reserved parking. Easy access to I-78. Ample patient park-

ing. Contact Kristina at (760) 942-9028 or at kristina@sdsleep-

clinic.com for more information. [520]

SUBLEASE OPPORTUNITY IN HIGH-END MEDICAL SPA INCARMEL VALLEY: A portion of an upscale, 4,000ft2 medical spaavailable for sublease. Ideal for an ophthalmologist, plastic sur-

geon, ENT, and cosmetic dentist. Sublease includes a spacious

reception and waiting area, six exam/procedure rooms, surgery

suite, two dental chairs, three doctor offices, and consultation

room. Easy access to I-5, 805, 56, and I-15. Located inside a

medical and dental office building within a retail center. Contact

Janice at (858) 481-7701 or at [email protected] for


LEASING, RENEWALS AND SALES: Call theHealthcare Real Estate Specialists atColliers International for a complete in-ventory of all available medical officespace for lease or for sale in San DiegoCounty. Use our knowledge and expert-ise to help you negotiate a new lease, re-newal, or purchase agreement to assureyou obtain the best possible terms.There is no charge for our consultingservices. Contact Chris Ross at (858) 677-5329; e-mail [email protected].

MEDICAL OFFICES FOR SALE FROM 1,500 SF: OWNFOR LESS THAN LEASING! 10—buildingmedical campus. Suites from 1,500 -6,300sq. ft. Strategically located between Tri-City Medical Center & Scripps Encinitas.Purchase your office. Prices startingabout $650,000. Outstanding signageavailable on Melrose Dr. and SycamoreAve. For information call: Jon Walters, Col-liers International at (760) 438-8950;John Hoffmann, Cushman Wakefield at(760) 929-2000. www.premiercrossing.com

"DEAR EDITOR: I wanted to formally thank you for helping me findemployment through your magazine, San Diego Physician. I will be join-

ing a family medicine practice, and found the ad in the classifieds. I re-

ally appreciate the services SDCMS provides, and I plan to be an even

more active member in the organization as I begin my practice. Thanks!"

- SDCMS Member Physician

MEDICAL OFFICE SPACE (SCRIPPS ENCINITAS CAMPUS):OB/GYN-type consultation room and one to two exam rooms with

staff, receptionist, etc. Equipment is available at extra cost. Surgi-

cal center next door. Free parking. Perfect for low-volume hospital

campus consultations one to five half-days per week. Email

[email protected] or call (760) 753-8413. [557]

3998 VISTA WAY, STE. 100 IN OCEANSIDE: Three medical officespaces (approximately 2,000ft2 each) available for lease. Close

proximity to Tri-City Hospital with pedestrian walkway connected

to parking lot, and ground floor access. Lease price:

$2.40/ft2+NNN. Tenant improvement allowance. For further in-

formation, please contact Lucia Shamshoian at (760) 931-1134 or

at [email protected]. [556]

OFFICE SPACE AVAILABLE: Office space at the corner of EighthAvenue and Washington Street in Hillcrest. Surgical center in

building. Ample parking and simple freeway access. Close proxim-

ity to Scripps Mercy Hospital. Call (619) 297-6100 or email

[email protected]. [555]

OFFICE TO SHARE: Office available in desirable building onScripps Encinitas lot. Share elegant office that has just under-

gone complete interior design renovation. Includes doctor’s desk,

your own exam room, front desk, common waiting area, staff

bathroom (including shower), and kitchen. Call us at the San

Diego Vein Institute at (760) 944-9263. [546]

COSMETIC OFFICE AVAILABLE TO SHARE: East County locationwith accredited operating room. Ideal for facial or general plastic

surgeon to use as satellite office. Central location with ample

parking. For more information, please call (619) 701-4786. [542]

OFFICE SPACE FOR SUBLEASE: Office available part time forScripps doctor in desirable Scripps/Ximed building in La Jolla.

Share elegant office. Available full day Mondays and Friday after-

noons. Includes consultation office, two exam rooms, front desk,

common waiting area, staff bathroom, and kitchen. Use of operat-

ing suite or use on other days negotiable. Call Cindi at (858) 452-

6226. [535]

SHARE MEDICAL OFFICE SPACE IN POINT LOMA AREA (OFF MID-WAY): Share fully furnished, six-exam-room/two-office suite withinternist. Ample free parking, great location. Contact Elaine

Watkins at (858) 945-3813 or at [email protected]. [527]

MEDICAL SPACE FOR LEASE: 2,350–11,761ft2 completed shellbuilding on Highway 86 in Imperial County for $2.05ft2/month.

Please contact Dr. Maghsoudy at (760) 730-3536 or at af-


OFFICE SPACE TO SHARE (SOUTH COUNTY):Chula Vista-area fam-ily practice office to sublease at 340 Fourth Ave., Ste. 10, just north

of Scripps Mercy Chula Vista Hospital. Office includes three exam

rooms and one treatment room, and is 1,700ft2. Support staff

available. Call Dr. Jenkin or Dr. Tetteh at (619) 804-7252. [521]

MEDICAL SPA AVAILABLE TO SHARE: Brand new, upscale medicalspa in Eastlake available to sublet a portion of the facility to a

specialist. Ideal for plastic surgeon or aesthetic physician per-

forming minimally invasive procedures. Also open to acupunctur-

ist or wellness/anti-aging physician, which complements the spa

and noninvasive aesthetic services currently being offered. Call

(619) 228-4483 for more information. [519]

MEDICAL OFFICE AVAILABLE TO SHARE: Primary care officeavailable to share. Storefront building with great visibility and re-

cently updated interior. Current physician has been in practice for

10 years and wants to cut down on hours. Lots of opportunities

for a starting physician or specialist. Office staff available to

share if needed. Call (619) 575-4442 or fax letter of interest to

(619) 575-1297. [518]

OFFICE SPACE FOR LEASE (ESCONDIDO): Premier furnished med-ical office space for lease in Escondido. Excellent location near

Palomar Medical Center. Please call (760) 743-1033. [501]

MEDICAL OFFICE SPACE: Approximately 1,289ft2; convenientlylocated about one mile east of Tri-City Hospital in a four-unit

building. Three exam rooms (one leaded) and two baths. Nice lay-

out and ample parking. Office is ideal for a solo practitioner. For

further details, call Wendy Shumate, MD, at (760) 630-4715 or

Aruna Garg, MD, at (760) 724-8562. [478]

MEDICAL OFFICE SPACE AVAILABLE:Medical office space locatedin Hillcrest available. The space is approximately 4,500ft2 with

several advantages for a group of one to four surgical specialists.

There is ample parking, a full outpatient surgical center on first

floor of the building, and a therapy area on the second floor.

Ample medical records storage space and phone and computer

wiring already installed. For more information, please call (619)

299-0007. [462]

OFFICE SPACE TO SUBLET: Internal medicine practice in Escon-dido has office space available for one part-time

physician/healthcare professional. Excellent location near Palo-

mar Medical Center. Please contact office manager at (760) 432-

6644 or at [email protected]. [459]

SPACE FOR LEASE (CORONADO): Brand new building in Coronado.Last space available: 1,105ft2, $2.75+NNN. Call (619) 742-5555 or

email [email protected]. [435]

NORTH COUNTY OFFICE SPACE TO SHARE (POWAY): In-house, ac-credited surgery office available. 3,000ft2 includes exam room,

dexa scanner, and physical therapy. Ideal for a pain management

or newly starting orthopedic physician. Call John at (619) 549-

8870 for more details. [398]

LARGE SUITE (CHULA VISTA): Beautiful suite, 4,550ft2, adjacentto Scripps Hospital, includes large reception and front office, au-

diology lab, private office space as well as three large area rooms,

many built-in storage cabinets, and staff lounge. Previous tenant

was Children’s Hospital. Contact Sammye at (619) 342-7207, ext.

8, or at [email protected]. [389]

CHULA VISTA: Several suites available now at Bay Medical Plaza.We are conveniently located near Scripps Hospital, major free-

ways, and many restaurants and retailers. There’s an onsite phar-

macy, a good parking ratio, and building is secure. This is a great

opportunity to expand or relocate your medical practice in Chula

Vista. For more information, contact Sammye at (619) 342-7207,

ext. 8, or at [email protected]. [387]

BEAUTIFUL, NEWLY RENOVATED OFFICE SPACE TO SHARE: Lo-cated in Hillcrest/Uptown San Diego. Physician with large suite

seeking physician/healthcare professional or other business pro-

fessional to share offices and/or exam rooms and receptionist.

Parking spaces available for rent (off street, covered). Call (858)

354-9833 for further information. [346]

PHYSICIAN POSITIONS AVAILABLE

PART-TIME CARDIOLOGIST NEEDED: One to three days a week. Nohospital call. Please send CV to [email protected] or call (619)

843-9028. [623]

KAISER PERMANENTE IS HIRING FULL-TIME AND PER-DIEMPHYSICIANS:We have daytime primary care staffing needs at allof our North County medical offices, which include Carlsbad, Es-

condido, Rancho Bernardo, San Marcos, and our newest facilities

in Oceanside. We also have morning, afternoon, and evening per-

diem shifts available. For more information on these opportuni-

ties, please contact Dave Horton, area operations administrator,

at (760) 510-5745 or at [email protected]. [614]

PHYSICIAN NEEDED: Part-time or full-time position for board-cer-tified/eligible physician to help two physicians in Chula Vista.

Cheerful work atmosphere, variety of options (office, hospital, or

nursing homes). Very light calls. We are very flexible in job details.

Please call Suzi King at (619) 426-9731. [613]

FAMILY MEDICINE PHYSICIAN: Sharp Rees-Stealy Medical Group,a 350+ physician multi-specialty group in San Diego, is seeking

full-time or half-time job share BC/BE family medicine physicians

to join our staff. We offer a first-year competitive compensation

guarantee, excellent benefits package, and shareholder opportu-

nity after two years. Please send CV to SRSMG, Physician Serv-

ices, 2001 Fourth Ave., San Diego, CA 92101; fax to (619)

233-4730; or email [email protected]. [611]

INTERVENTIONAL CARDIOLOGIST OPPORTUNITY: Income poten-tial well above national average. Immediate opening to take over

20-year private practice in North County. Excellent referral basis,

limited HMO care, new cath lab opening in July. One-in-three in-

terventional call, mature hospitalist program for other call. Office

diagnostic services include: nuclear, holtor, accredited ECHO lab.

Fax CV to office manager at (760) 940-8153. [607]

RIVERVIEW MD SURGERY CENTER: New freestanding ASC underconstruction and set to open late 2009. State-of-the-art, multi-

specialty facility (wholly owned property and center). Potential

surgeon/surgical group investment opportunities. Call (858) 344-

0083 or email [email protected] to discuss. [606]

CARDIOLOGIST NEEDED: Due to a recent accident resulting in dis-ability, North County cardiologist seeks either an invasive or non-

invasive cardiologist to work part-time in an outpatient setting.

No night call. No pager. Hours, days, and number of hours per

week negotiable. Can start immediately. Fax CV to (760) 591-

0924. Call (619) 806-1229 or email [email protected] for


PER DIEM OPENING: BC/BE family practice physician, part time,as needed. Office practice only. Variable days (Monday through

Friday, 8 a.m. to 4 p.m.), half- and full-day shifts depending on

need. California license and unrestricted DEA license required.

Please fax CV to (619) 445-0988, attn: Teresa Mogielnicki, MD, or

email to [email protected]. [601]

MD OR DO WANTED: San Diego occupational/urgent care clinichas opening for a MD or DO to work part- or full-time. Previous

experience in occupational, emergency, internal medicine, or gen-

eral practice preferred. Current unrestricted license to practice

medicine in California and DEA license required. Board certified

or qualified preferred. Fax CV to (858) 565-6932 or email to


URGENT CARE: Busy practice established in 1982 seeks full-timeor part-time physician. Fax CV to (619) 442-2245. [595]

INTERNAL MEDICINE (SAN MARCOS): North County Health Serv-ices, a Joint Commission, federally qualified community health

center, has opportunity for full-time BC/BE internal medicine

physician to work Monday through Friday and one Saturday per

month. Attractive compensation package includes bonus for call

and incentive. Benefits package includes PTO, holidays, malprac-

tice, and reimbursement for CMEs (expense and time) and licen-

sure. Spanish language knowledge helpful. Please send CV to C.

Bekdache at [email protected] or fax to (760)

736-8740. [590]

FAMILY PRACTICE (OCEANSIDE): North County Health Services, aJoint Commission, federally qualified community health center,

has opportunity for BC/BE family practice physician to work Mon-

day through Friday and occasional Saturdays (shared with other

clinicians). Attractive compensation package includes bonus for

call and incentive. Benefits package include PTO, holidays, mal-

practice, and reimbursement for CMEs (expense and time) and li-

censure. Spanish language knowledge helpful. Please send CV to

C. Bekdache at [email protected] or fax to (760)

736-8740. [591]

OB/GYN PHYSICIAN (ENCINITAS): North County Health Services,a Joint Commission, federally qualified community health center,

has an opportunity for BC/BE OB/GYN. Hours and call shared

with other clinicians and NMWs. Attractive compensation in-

cludes call and incentive pay. Benefit program includes PTO, holi-

days, malpractice, and reimbursement for CMEs (expense and

time) and licensure. Spanish language knowledge helpful. Please

send CV to C. Bekdache at [email protected] or

fax to (760) 736-8740. [592]

EXCELLENT OPPORTUNITY FOR OB/GYN: Full service OB/GYN po-sition available in North County. Willing to consider part- and full-

time positions. Advanced 3D/4D ultrasound, in-office procedures

(Essure, endometrial ablations), minimally invasive gynecology,

urogynecology with urodynamics, infertility, and obstetrics.

Amazing future. Combine the best of technology with compas-

sionate care. Email CV to [email protected] or fax to (760)

642-0802. [589]

UROLOGIST NEEDED: We have an immediate opening for a part-time or per-diem urologist to join our multi-specialty medical of-

fice located in La Mesa. We are a busy office with exceptional

staff, and we need an exceptional individual to join our team. We

offer flexibility, independence, and a great office environment.

Please contact Sedrak at (310) 717-9121 or email your résumé to


SPORTS MEDICINE/FAMILY PRACTICE POSITION: Seeking board-eligible/certified family practice physician with an interest in mus-

Classifieds


Classifieds


culoskeletal and sports medicine for a busy multidisciplinary pain

management practice located in Kearny Mesa across from Sharp

Memorial Hospital. The office is state-of-the-art, complete with

procedure room. Part-time or full-time opportunities are avail-

able. No after-hours calls. Fax CV to Hjordis Williams, office man-

ager, at (858) 565-4146, email to [email protected],

or call (858) 565-4117. [578]

PER DIEM/WEEKEND PHYSICIAN INDEPENDENT CONTRACTOR:Temecula independent diagnostic testing facility seeks physician

to monitor patient examinations requiring contrast. Position re-

quires availability of at least two Saturdays a month, typically

scheduled for nine-hour shifts. Candidates must have California

license. Please call Lynn at (619) 819-6577 for more information,

or fax your CV to (619) 241-7790 for immediate consideration.

[572]

PARTNERSHIP OPPORTUNITY: ENT position available immedi-ately in an existing La Jolla practice. Partnership may be quickly

achievable. Please call (858) 458-1287 for details. [564]

VOLUNTEER FP/IM PHYSICIANS NEEDED: Camp Pendleton familypractice residency is looking for a few enthusiastic volunteer

family practice or internal medicine physicians interested in

teaching to help preceptor residents and medical students in our

outpatient family practice clinic. Please call CAPT John Holman

at (760) 725-1398. [511]

PRIMARY CARE JOB OPPORTUNITY: Home Physicians is a fastgrowing group of doctors who make house calls. Great pay ($60–

$100+/hour), flexible hours, choose your own days (full- or part-

time). No weekends, no call, transportation and personal

assistant provided. Call Chris Hunt, MD, at (858) 279-1212. [458]

FAMILY PRACTICE (CHULA VISTA): Seeking a family practicephysician to cover solo physician practice one week every two

months. Contact Ann at (619) 422-1324 or at doctorwp@pac-

bell.net. [451]

FAMILY PRACTICE DOCTORS NEEDED: Full time and part time;days, nights, and weekends available. Fax CV to La Costa Urgent

Care at (760) 603-7719. [449]

NONPHYSICIAN POSITIONS AVAILABLE

FULL-TIME MEDICAL ASSISTANT WANTED: Busy cardiology officein National City needs an MA to work in the front office. Must be

very organized, responsible, detail oriented, and have a good atti-

tude. Experience preferred, but not necessary. Tagalog/Spanish

speaker a plus. Please call Polina at (619) 470-7700 or fax ré-

sumé to (619) 470-0996. [622]

PA OR NP FOR CARDIOLOGY OFFICE: Very busy cardiologistneeds second PA or NP to help with starting IVs, taking history of

patients for nuclear stress tests, and seeing patients in office set-

ting. Spanish speaker a plus. Call Iona at (858) 337-4931 or fax

résumé to (619) 470-0996. [621]

WOMEN’S HEALTH NURSE PRACTITIONER OR PHYSICIAN ASSIS-TANT: Chula Vista office looking for a part-time NP or PA withstrong OB/GYN experience. Flexible schedule, EMR, Spanish

speaker a plus. Fax résumé to (619) 482-8072. [603]

MEDICAL BILLER: Experienced in imaging preferred. Hours areMonday through Friday, 7 a.m. to 3:30 p.m. Friendly staff, good

working conditions. Call (760) 730-3536 or email info@carls-

badimaging.com for salary range and more information. [596]

RN, NP, OR PA: Registered nurse, nurse practitioner, or physicianassistant needed for Encinitas ENT, facial plastic surgery prac-

tice. Dermatology, laser, and filler experience preferred. Call Carol

at (760) 944-4211. [594]

REGISTERED NURSE: Family medicine office in Torrey Hills seek-ing a full-time, experienced RN. Previous clinical experience re-

quired. Salary and benefits are negotiable. Please call (858)

350-8100 or email résumé to


PART-TIME MEDICAL ASSISTANT/BACK OFFICE: Two years expe-rience required including phlebotomy. Busy specialist office near

Alvarado Hospital. Submit résumés via email to dlpotter22@hot-

mail.com. [576]

WOMEN’S HEALTH NURSE PRACTITIONER: Progressive MissionValley office looking for a part-time nurse practitioner with

strong GYN experience including HRT. Fax résumé to (619) 220-

8567. [573]

PHYSICAL THERAPIST: Part-time or full-time PT needed forgroup orthopedic practice. Great opportunity, benefits. Please fax

CV to (619) 229-3933. [565]

MEDICAL RECEPTIONIST/FRONT OFFICE: We are looking for afront office receptionist for a busy OB/GYN practice. Bilingual in

Spanish and OB/GYN experience is a must. Résumés can be

faxed to (858) 565-0033. [563]

NURSE PRACTITIONER: Four-physician internal medicine practicein Chula Vista seeks part-time/full-time nurse practitioner. Work

with a quality group; reasonable hours. Previous experience is

preferable; salary negotiable depending on experience. Call (619)

421-4470 or (619) 421-4000. [488]

PHYSICIAN POSITIONS WANTED

MEDICAL OPHTHALMOLOGIST (PER DIEM): Board-certified med-ical ophthalmologist available two days per week for per-diem or

locums work in the San Diego or nearby areas. Highest ethical

standards. Experienced and skilled in therapeutic and cosmetic

Botox and dermal fillers. Also experienced in clinical trials. Email


CARDIOLOGIST SEEKING EMPLOYMENT:Noninvasive cardiologistwants to join IM or cardiology practice (office based). Board eligi-

ble. Experienced in echo, stress test, nuclear, and CT. Call (858)

922-8354 (cell), (760) 633-3044, or email [email protected]. [558]

PRACTICES FOR SALE

UROLOGY PRACTICE FOR SALE (SAN DIEGO): Practice opportu-nity in San Diego. Busy solo practitioner to retire in October

2008. Thriving practice; multiple contracts; turnkey operation

with Spanish language and laparoscopy skills. Can’t miss. Inter-

ested applicants email [email protected]. [571]

SUCCESSFUL MEDICAL SKIN CARE CLINIC FOR SALE: Small in-vestment for 51 percent ownership. Looking for a new medical di-

rector. Call Leonard Schulkind at (619) 807-5485. [539]

DEL MAR-AREA GENERAL PRACTICE: Prime location, huge poten-tial for practice expansion in fast growing Carmel Valley commu-

nity. Established in 1990; terms available. Inquiries call (858)

755-0510. [185]

MEDICAL EQUIPMENT

ULTRASOUND, STRESS, ECG: HP 2000 ultrasound — cardiac, vas-cular, abdominal, small parts, five transducers: $6,000. Quinton

4000 monitor with Q55 treadmill, recording paper, electrodes,

crash cart, defibrillator: $2,500. HP ECG Pagewriter XLE, lots of

recording paper and electrodes: $700. Call (619) 460-0083 or

(619) 518-9542. [513]

RETIRED SURGICAL PRACTICE OPERATING ROOM/SURGICALEQUIPMENT: Perfect for plastic surgery/oral surgery. Endoscopy,cameras, loupes, tools. Waiting room furniture inventory list is

available upon request. Email [email protected]. [506]

REAL ESTATE

VACATION IN LAKE TAHOE: New, fully equipped one bedroom/onebath condominium (sleeps four) in the brand new Village at

Northstar. The Village offers dining, shopping, roller/ice rink with

open-air bar/eateries and rink-side cabana. Enjoy biking, hiking,

golfing, onsite gym, hot tubs, and ‘saline’ pool. Enjoy the beach,

water sports, a scenic drive, or raft the Truckee River. Fall:

$175.00/night; three-night minimum. Also available in the winter.

Call (858) 412-5239 or email [email protected]. [619]

HOME FOR SALE: Located in an exclusive area of Chicago. North-ern suburb, five-bedroom ranch on one acre of landscaped prop-

erty. Approximately 5,000ft2 living space with more room to

add. Ideal for vacation property or permanent relocation. For pri-

vate showing or more information, call (619) 585-0476 or email


MISSION HILLS OFFICE FOR SALE: Rare opportunity to own pres-tigious North Mission Hills physician’s office. Beautifully restored

house located in the West Lewis Planned District. Classic hard-

wood floors, stained glass, craftsmanship woodwork throughout,

recessed lighting, complete exam rooms, two patient waiting

areas, and four offices. Neighborhood atmosphere for patient

care. Perfect for primary or specialty practice. Ample street

parking. Mills Act designation with significant tax savings. Call

Annamarie Clark at (619) 962-2095 for photos and appointment.

[610]

SERVICES OFFERED

FLASH ELECTRONIC MEDICAL BILLING:Outsource your billing withFLASH for faster claims turnaround and reimbursements. Call us

for all your billing needs. Our medical billers never underestimate

the value. “We simply do it better.” Call (760) 231-1116. [624]

MEDICAL BILLING CONNECTION (MBC): After your patients’ care,the most important aspect of your business is your billing. MBC

provides full-practice management to ensure your billing and col-

lections are optimal. With MBC, expect great services and great

results! The difference is our service. Let MBC make the differ-

ence for you. Call (800) 980-4808, ext. 102. [575]

PRACTICE FINANCING FOR PHYSICIANS: Up to 100 percent fi-nancing available for physicians! Includes purchase of a practice,

equipment, partner buyout, working capital, and real estate. Con-

tact Monica Coburn at CBN Financial at (702) 310-7111 or at


BILLING, CONSULTING, OUTSOURCING:We are committed tomaximizing your bottom line! Our billing service uses state-of-

the-art technology to ensure charge capture, code validation,

electronic submission and remittance, payment postings, patient

statements, structured follow-up and appeals, electronic docu-

ment storage and meaningful reporting. Supplemental services

include online appointment scheduling, automated call re-

minders, scan systems, and other technological advances. Con-

sulting services include accounts payable, auditing, business

development, electronic medical record selection and implemen-

tation, credentialing, contracting (payor, physician, and staff), ex-

ecutive assistant, financial management, information systems,

operational management, practice assessment, practice manage-

ment, relocation management, and other technological advances.

Contact us today for your free consult. Contact Kena Galvan at

(619) 326-0700 or at [email protected]. [452]

RMC VINYL REPAIR PLUS:Medical equipment upholsterer. Expertin repair and replacement of medical fixture upholstery, including

exam room equipment and waiting room furniture. Free esti-

mates and mobile service. Call (619) 443-4060. [400]

MISCELLANEOUS

2005 SEA RAY SUNDANCER 30-FOOT LOADED POWERBOAT(PRICE SLASHED $5,000 6/17/08): Excellent condition; 2K in re-cent/routine maintenance, new front eisenglass, 3.5 years re-

maining on full warranty ($6,000 value), only a paltry100 hours

for two pristine 220-hp engines, GPS, generator,

TV/DVD/stereo/air/heat and much more. Exact boat with less

features costs $150K; $98,000 (firm) to first buyer. (858) 344-

0083. [454]

2003 BMW M3 CONVERTIBLE (RED, MANUAL) (PRICE SLASHED$4,000 6/17/08): Very good condition, low miles, and new tires:$33,750. (858) 344-0083. [453]

History of Medicine


Once Is EnoughTHE LONG AND FASCINATINGHISTORY OF VACCINATION

By WILLIAM P. HANEY, MDgroup of senior citizens was re-cently debating the pros and consof vaccination. Reports had indi-

cated that traces of harmful elements, chem-icals, or compounds could be found invaccines. Autism, retardation, and otherlong-term complications of unknown etiol-ogy were suspected as resulting from thesevaccines. The “hot” question was, “Shouldchildren, or adults for that matter, be sub-jected to such hazards, and do they have theright to refuse and thereby protect them-selves and their loved ones against suchcomplications?” The arguments drifted backand forth.

It is very difficult, I thought, to convincepeople of the dangers of diseases that mostof them have never seen and about whichthey know very little. Consider Sir WilliamOsler’s “most terrifying disease to behold”— smallpox. It has been wiped right off theface of the planet by vaccination. Runninga close second in fear and horror is a diseasethat lurks today in every small animal pop-ulation of the world. The mention of rabiesor hydrophobia chills every doctor’s bonemarrow as it has for several thousand years.

While a second-year medical student, I sawa short, silent, black and white film clip of acase of rabies. A crib held a small child. Thetop of the crib was covered by a net. Thehighly agitated infant was shaking the cribside bars. A small glass of water was held out

and the doomed child went berserk, clawingat the mattress, banging his head, and scream-ing silently. It was an unforgettable experience.

Working with dogs and rabbits, theFrench chemist, Louis Pasteur, found that hecould create immunity to rabies by injectingsmall amounts of air-dried spinal cords ofrabid animals into normal animals. And thereal stroke of genius— truly a serendipi-tous event of the firstmagnitude — was hisdiscovery that hecould treat the nor-mal animal after ithad been bitten butprior to actual signsof disease. Most peo-ple don’t realize whata miracle that was.His message was,“Bring me the victim within the first fewdays after the mad dog, bat, wolf, or raccoonhas bitten, and I can almost guarantee a 100percent cure rate.” Miraculous!

Pasteur’s first case in 1885 was nine-year-old Jacob Meister. The little French lad hadbeen bitten by a mad wolf 15 times. Pasteurhesitated. His work had been with dogs andrabbits. A human child was altogether an-other matter for a scientist who had nomedical training whatsoever. The parents in-sisted. Pasteur went ahead with the injec-

tions, and the stricken child survived. JacobMeister became the gatekeeper of the Pas-teur Institute where he served for manyyears. Ironically, he committed suicide in1940, when the invading Nazis demandedthat he open Pasteur’s crypt, a desecrationhe refused to permit. Jacob’s statue guardsthe entrance of the institute to this day.

Vaccination has along and fascinatinghistory. The terrifyingdiseases that havebeen removed fromour experience needto be occasionally re-visited before mean-ingful decisions aboutits value can be made.

The senior citizendebate continued.Faith healing, holistic

therapy, the power of prayer, God’s will,homeopathic medicine, and trace elementswere discussed. And I thought to myself,maybe these people needed to see a case ofrabies. But for myself, no thanks, once isenough. I never was to see another!

ABOUT THE AUTHOR:Dr. Haney, a re-tired ophthalmologist, has held a long-timeinterest in the history of medicine, oftencontributing articles to San Diego Physician.

A

The “hot” question was, “Should

children, or adults for that mat-

ter, be subjected to such haz-

ards, and do they have the right

to refuse and thereby protect

themselves and their loved ones

against such complications?”

You practice with passion. Our passion protects your practice.

You Should Only Go Bare in the ShowerSelecting the right medical liability insurance is one of the most important decisions you will make. The wrong choice could

expose your practice to the very risks you want to avoid. NORCAL is committed to helping you find coverage you can rely on.

Visit www.norcalmutual.com today, or call 800.652.1051. NORCAL. Your commitment deserves nothing less.

SAN DIEGO COUNTY MEDICAL SOCIETY5575 RUFFIN ROAD, SUITE 250SAN DIEGO, CA 92123

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September 2008

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