november 2010

✖ SDCMS CelebrateS ItS 140th annIverSary In 2010 ✖

“ P h y s i c i a n s U n i t e d F o r a h e a l t h y s a n d i e g o ”

n o v e m b e r 2 0 1 0 official publication of the san diego county medical society

reaching 8,500 Physicians every Month

Patterns oF disease aFter natUral disasters Page 20

aPocalyPse! crisis! disaster! Pestilence! Page 24

PreParednessDisaster

a 7.2 hits on sUnday

aPril 4, 2010 Page 28

the arc is seeking

local medical ProFessionals

Page 30

,

B SAN DIEGO PHYSICIAN.OrG November 2010

We fight frivolous claims. We smash shady litigants. We over-prepare, and our lawyers do, too. We defend your good name. We face every claim like it’s the heavyweight championship. We don’t give up. We are not just your insurer. We are your legal defense army. We are The Doctors Company.

The Doctors Company built its reputation on the aggressive defense of our member physicians’ good names and

livelihoods. And we do it well: Over 82 percent of all malpractice cases against our members are won without a

settlement or trial, and we win 87 percent of the cases that do go to court. So what do you get for your money?

More than a fighting chance, for starters. The San Diego County Medical Society has exclusively endorsed our

medical professional liability program since 2005. To learn more about our benefits for SDCMS members, call

(800) 328-8831, extension 4390, or visit us at www.thedoctors.com/sdcms.

Endorsed by

Robert D. FrancisChief Operating Officer, The Doctors Company

http://www.thedoctors.com/sdcms

November 2010 SAN DIEGO PHYSICIAN.OrG 1

http://www.ucprx.com

2 SAN DIEGO PHYSICIAN.OrG November 2010

thismonthvolume 97, Number 11

departments 4 sdcms seminars, Webinars, and events

4 community healthcare calendar

6 briefly noted SDCMS Medical Office Manager Bulletin Board, and More …

10 sdcms Foundation and net chemistry introduce econsults to san diego by Lauren Radano

12 don’t take it out on them: make sure you are billing for accurate amounts! by Melissa Brown

14 cma Practice resources: october/november 2010

18 sharp rees-stealy medical group: delivering 21st-century ideal healthcare by Donald C. Balfour III, MD

34 Physician marketplace Classifieds 36 a summer at the capitol: an insider’s view into the daily activities of running our country by Rachel Hogen, MS-II

sdcms.org exclusive • haiti impressions January 23–26 and Jan. 28–Feb. 3, 2010 by A. Brent Eastman, MD, Scripps Health

MANAGING EDItOr Kyle lewisEDItOrIAl BOArD Van l. cheng, md, adam f. dorin, md, Kimberly m. lovett, md, theodore m. mazer, md, Robert e. peters, md, phd, david m. priver, md, Roderick c. Rapier, mdMArkEtING & PrODuCtION MANAGEr Jennifer RohrSAlES DIrECtOr dari pebdaniPrOjECt DESIGNEr lisa WilliamsCOPY EDItOr adam elder

sdcms board oF directorsoFFicersPrESIDENt susan Kaweski, mdPASt PrESIDENt (AMA AltErNAtE DElEGAtE) lisa s. miller, mdPrESIDENt-ElECt (CMA DIStrICt 1 truStEE) Robert e. Wailes, mdtrEASurEr sherry l. franklin, mdSECrEtArY (SDCMS At-lArGE DIrECtOr) Robert e. peters, phd, md

geograPhic and geograPhic alternate directorsEASt COuNtY William t. tseng, md, heywood “Woody” Zeidman, md (A: Venu prabaker, md)HIllCrESt niren angle, md, steven a. ornish, md kEArNY MESA John g. lane, md (A: Jason p. lujan, md)lA jOllA J. steven poceta, md, Wynnshang “Wayne” sun, md (A: matt h. hom, md)NOrtH COuNtY James h. schultz, md, doug fenton, md (A: steven a. green, md)SOutH BAY Vimal i. nanavati, md, mike h. Verdolin, md (A: andres smith, md)

at-large and at-large alternate directorsJeffrey o. leach, md, bing s. pao, md, Kosala samarasinghe, md, david e.J. bazzo, md, mark W. sornson, md, mihir y. parikh, md (A: carol l. young, md (SDCMS fOuNDAtION PrESIDENt), thomas V. mcafee, md, ben medina, md, James e. bush, md, alan a. schoengold, md)

other board members

COMMuNICAtIONS CHAIr theodore m. mazer, mdYOuNG PHYSICIAN DIrECtOr Van l. cheng, mdAltErNAtE YOuNG PHYSICIAN DIrECtOr Kimberly m. lovett, mdrESIDENt PHYSICIAN DIrECtOr Katherine m. Whipple, mdAltErNAtE rESIDENt PHYSICIAN DIrECtOr steve h. Koh, mdrEtIrED PHYSICIAN DIrECtOr Rosemarie m. Johnson, mdAltErNAtE rEtIrED PHYSICIAN DIrECtOr mitsuo tomita, mdMEDICAl StuDENt DIrECtOr adi J. priceCMA SPEAkEr Of tHE HOuSE James t. hay, md

ex-oFFicio, nonvoting board members CMA PASt PrESIDENtS Robert e. hertzka, md, Ralph R. ocampo, mdCMA DIStrICt I truStEES sherry l. franklin, md, albert Ray, md, Robert e. Wailes, mdCMA truStEE (OtHEr) catherine d. moore, md, CMA SOlO AND SMAll-GrOuP PrACtICE fOruM DElEGAtES michael t. couris, md, James W. ochi, mdAltErNAtE CMA SOlO AND SMAll-GrOuP PrACtICE

fOruM DElEGAtE dan i. giurgiu, mdAMA DElEGAtES James t. hay, md, Robert e. hertzka, mdAltErNAtE AMA DElEGAtES lisa s. miller, md, albert Ray, md

OpiniOns expressed by authors are their own and not necessar-ily those of San Diego Physician or SDCMS. San Diego Physician reserves the right to edit all contributions for clarity and length as well as to reject any material submitted. Not responsible for unso-licited manuscripts. Advertising rates and information sent upon request. Acceptance of advertising in San Diego Physician in no way constitutes approval or endorsement by SDCMS of products or services advertised. San Diego Physician and SDCMS reserve the right to reject any advertising. Address all editorial communications to [email protected]. All advertising inquiries can be sent to [email protected]. San Diego Physician is published monthly on the first of the month. Subscription rates are $35.00 per year. For sub-scriptions, email [email protected]. [san DiegO COunty MeDiCal sOCiety (sDCMs) printeD in the u.s.a.]

featuresdisaster Preparedness 20 Patterns of disease after natural disasters: time to broaden our Focus by Robert E. Peters, PhD, MD

24 apocalypse! crisis! disaster! Pestilence! Physicians need to know What to do as individuals and how to Work Within their healthcare system by Susan Shepard

28 a 7.2 hits on sunday, april 4, 2010: observations From imperial county by Thomas W. Henderson

30 the american red cross: seeking local medical Professionals by Joe W. Craver20

12

36

November 2010 SAN DIEGO PHYSICIAN.OrG 3 CHMB DELIVERS THE HIGHEST LEVEL OF SERVICE AND EXPERTISE TO ENSURE A SWIFT, SMOOTH AND SUCCESSFUL EHR COMPLETION.

CHMB – The Choice for EHR & Successful AdoptionImproved business performance starts with CHMB—ranked among the top providers in California for EHR Adoption & Implementation Services. Here’s why hundreds of physicians have selected CHMB for building and installing the Allscripts EHR application into their community practices:

NATIONAL AND LOCAL EXPERTISE

• Established footprint with 1,000 community physicians and clinics statewide

• Experts who know the full story– Hardware Selection & Procurement, Network Configuration, Application Support

TARGETED SOLUTIONS

• World Class Portfolio – Clinical and Business Solutions – Allscripts, Dell, Cox Business

• Flexible approach to drive efficiencies and meet diverse needs, from multi-specialty and specialty, to single provider, to multiple providers

• Innovative technology that delivers at the speed you need

PROVEN RESULTS

• Real Utilization – 95% of physicians are at Meaningful Use with CHMB EHR Services

• Superior Support – 98% client satisfaction on CHMB Clinical & IT Services during implementation & on-going support

• Outstanding ROI – 97% of physicians believe CHMB’s services met all expectations, including cost, training, implementation, and application optimization

As your business partner, let us navigate your entire EHR project and create the right solution to fit your practice. Count on us to train you to use the EHR at its optimal level. It’s time to trade up to EHR and discover Meaningful Use with CHMB.

San Diego County — 1121 East Washington Ave., Escondido, CA 92025Orange County — 7700 Irvine Center Drive, Ste 290, Irvine, CA 92618

760.520.1400 • 800.727.5662 • www.chmbsolutions.com

ARE YOU READY FOR EHR?

“ CHMB has been our trusted

business partner for more than

six years. It made perfect sense

that when we decided to move

forward with EHR in our practice,

we entrusted our implementation

of Allscripts to them as well. They

have been there for us every step

of the way!”

ELIZABETH SILVERMAN, MD

PartnerNorth County OB/GYN Medical Group

Call today for your FREE EHR Readiness Assessment!

Ron Anderson • 1.760.520.1340

Marianne Gregson • 1.760.520.1333

Geoff Doyle • 1.760.520.1343

CHMB DELIVERS THE HIGHEST LEVEL OF SERVICE AND EXPERTISE TO ENSURE A SWIFT, SMOOTH AND SUCCESSFUL EHR COMPLETION.

CHMB – The Choice for EHR & Successful AdoptionImproved business performance starts with CHMB—ranked among the top providers in California for EHR Adoption & Implementation Services. Here’s why hundreds of physicians have selected CHMB for building and installing the Allscripts EHR application into their community practices:

NATIONAL AND LOCAL EXPERTISE

• Established footprint with 1,000 community physicians and clinics statewide

• Experts who know the full story– Hardware Selection & Procurement, Network Configuration, Application Support

TARGETED SOLUTIONS

• World Class Portfolio – Clinical and Business Solutions – Allscripts, Dell, Cox Business

• Flexible approach to drive efficiencies and meet diverse needs, from multi-specialty and specialty, to single provider, to multiple providers

• Innovative technology that delivers at the speed you need

PROVEN RESULTS

• Real Utilization – 95% of physicians are at Meaningful Use with CHMB EHR Services

• Superior Support – 98% client satisfaction on CHMB Clinical & IT Services during implementation & on-going support

• Outstanding ROI – 97% of physicians believe CHMB’s services met all expectations, including cost, training, implementation, and application optimization

As your business partner, let us navigate your entire EHR project and create the right solution to fit your practice. Count on us to train you to use the EHR at its optimal level. It’s time to trade up to EHR and discover Meaningful Use with CHMB.

San Diego County — 1121 East Washington Ave., Escondido, CA 92025Orange County — 7700 Irvine Center Drive, Ste 290, Irvine, CA 92618

760.520.1400 • 800.727.5662 • www.chmbsolutions.com

ARE YOU READY FOR EHR?

“ CHMB has been our trusted

business partner for more than

six years. It made perfect sense

that when we decided to move

forward with EHR in our practice,

we entrusted our implementation

of Allscripts to them as well. They

have been there for us every step

of the way!”

ELIZABETH SILVERMAN, MD

PartnerNorth County OB/GYN Medical Group

Call today for your FREE EHR Readiness Assessment!

Ron Anderson • 1.760.520.1340

Marianne Gregson • 1.760.520.1333

Geoff Doyle • 1.760.520.1343

http://www.chmbsolutions.com


calendar

“Physician leader’s toolbox” (seminar)fri.–sat., nov. 12–13, 8:00am–4:00pm

“emerging Patient safety issues impacting office Practices” (risk management webinar)Wed., nov. 17, 6:30pm–7:30pm

“emerging Patient safety issues impacting office Practices” (risk management webinar)thurs., nov. 18, 11:30am–12:30pm

“Preparing to Practice” Workshop (seminar)sat., nov. 20, 8:00am–4:00pm

sdcms membership socialsun., Jan. 30, 5:00pm–8:00pm

sdcmsSeminars / Webinars / Events

free to member physicians and their staff. for further information, contact sonia gonzales at (858) 300-2782 or at [email protected], or visit sdcms.org.

4th annual Ucsd hands-on notes and single site surgery symposiumNov. 11–13 • Omni San Diego Hotel • cme.ucsd.edu/notes

“Parkinson’s disease Update for a new decade”Nov. 13 • Hilton La Jolla Torrey Pines • Free • 4 CMEs • pdasd.org or (858) 273-6763

“brain tumors: First annual collaborative care conferences”Jan. 15 • 7:30am • $25–$65 • UC San Diego Moores Cancer Center Goldberg Auditorium • cme.ucsd.edu/braintumors/index2.html

West coast geriatric Psychiatry conferenceFeb. 16–19, 2011 • Catamaran Resort Hotel, San Diego • cme.ucsd.edu

topics and advances in internal medicineMar. 7–13, 2011 • San Diego Marriott, La Jolla • cme.ucsd.edu

topics and advances in Pulmonary and critical care medicineMar. 13–14, 2011 • San Diego Marriott, La Jolla • cme.ucsd.edu

annual san diego science FestivalMar. 19–26 • Petco Park • sdsciencefestival.com/host-an-event.html

community Healthcare Calendar

to submit a physician-focused, San Diego County healthcare event for possible publication, email [email protected].


http://www.imaginghealthcare.com

SDCMS Medical Off ice Manager

By Sonia Gonzales, Your Off ice Manager Advocate

brieflynoted

Question: If we have a patient who we suspect may

be getting controlled prescription medications from

different physicians, or going to different pharmacies. Is

there a centralized way that we can look into/report this

possibility?

Answer: Yes. The state has a database known as the

Controlled Substance Utilization Review and Evalua-

tion System (CURES), which contains more than 100

million entries of controlled substance drugs that are

dispensed in California. This real-time access Prescrip-

tion Drug Monitoring Program (PDMP) system allows

pre-registered users, including licensed healthcare pre-

scribers, pharmacists, law enforcement, and regulatory

boards, to access real-time patient controlled substance

history information. The role of PDMP entrusts that

well-informed prescribers and pharmacists can and will

use their professional expertise to evaluate their patients’

care and assist those patients who may be abusing con-

trolled substances.

To obtain access to the PDMP system, prescribers

and pharmacists must first register with CURES by

submitting an application form electronically at pmp.

doj.ca.gov/pmpreg. In addition, your registration must

be followed up with a signed copy of your application

and notarized copies of your validating documenta-

tion, which include: Drug Enforcement Administra-

tion (DEA) registration, state medical license, and a

government-issued identification. You can mail your

application and notarized documents to:

Bureau of Narcotic Enforcement (BNE)

Attention: PDMP Registration

P.O. Box 160447

Sacramento, CA 95816

Another option would be to forgo the notary and pres-

ent your documents in person, where sworn personnel

will validate and collect your supporting documenta-

tion. San Diego’s Bureau of Narcotic Enforcement office

is located at:

9425 Chesapeake Drive

San Diego, CA 92123-1302

Telephone: (858) 268-5300

Fax: (858) 268-5353

You can also fill out a manual Patient Activity Report

(PAR) should you not wish to register online. This report

can be obtained at ag.ca.gov/bne/pdfs/BNE1176.pdf.

HIPAA and all confidentiality and disclosure provi-

sions of California law cover the information contained

in this database. All users must comply with HIPAA

Privacy Rule requirements when using the Prescription

Drug Monitoring Program System.

Question: I’m assuming that if I find multiple physi-

cians who have written narcotics on one of my patients,

there will not be a “confidentiality” problem with me

notifying these other doctors without the patient’s con-

sent. Is there actually an obligation for me to do that?

Answer: According to CMA ON-CALL document

#0515, “Drug Prescribing: Unauthorized,” “Generally,

unless a patient’s medical information is protected by

the federal confidentiality laws governing drug and

alcohol abuse treatment information or by state laws

governing information pertinent to a state drug treat-

ment program, it is lawful for a physician or pharmacist

to convey information regarding a patient’s potential

abuse of prescriptive substances to another healthcare

professional or pharmacist.” This document also has

a section titled, “No Legal Duty to Report,” in which

it is stated, “Moreover, although there is no statutory

duty to share such information with other healthcare

practitioners or pharmacists, unless prohibited by law,

such information should be shared with other treating

providers where such communication is required by

the standard of care to protect the patient’s health. In

addition, physicians should warn the patient about the

hazards of drug abuse.” SDCMS-CMA members can

obtain this CMA ON-CALL document by contacting

SDCMS at (858) 565-8888.

asK YOUr PHYsiCiaN aDVOCate


Ask Your office MAnAger AdvocAte!Question: Our physician has been having difficulty getting reim-bursed from a certain health plan. I think they are having financial difficul-ties because they are giving me the runaround when I call to follow up. What can I do at this point?

Answer: You have a few options. First, continue to follow up with the health plan and track the communication and progress on a spread-sheet. For IPA solvency issues, submit the claims for payment to the underlying health plans and notify them that the claims remain unpaid by the IPA. Request that they pay the claims and deduct the capitation from the IPA.Your other option is to have your physician request a meet-and-confer with the medical director of the IPA. Send the request by certified mail with return receipt and ask that the meet-and-confer be scheduled within two weeks. Let the IPA know you want to continue to provide quality care to their enrollees but are concerned they are not paying you within the timeframe specified by California law.

Another option is to file a formal complaint with the Department of Managed Health Care (DMHC). You can do this via webportal at dmhc.ca.gov — click on “File a Provider Complaint.” CMA has developed a payor solvency checklist to assist you in navigating through these issues — search “payor solvency checklist” at SDCMS.org. For further informa-tion regarding payor solvency, consult CMA ON-CALL document #1051, “Physician Complaints About Managed Care,” and #0131, “Insolvency of Health Plan, IPA, or Other Entities That Contract With Health Plans (Pre-bankruptcy or Closure).”


[SAVE THE DATES!]

✓ november 20: “Preparing to Practice” Workshop✓ January 13: “Collection Procedures”

Seminar/Webinar✓ January 20: “Palmetto Gba/Medicare Provider enrollment” Seminar/Webinar

✓ January 26–27: “Simple approaches to Informed Consent and Informed refusal” Seminar/Webinar✓ February 3: “treating Patients right” Seminar/Webinar

CODING CORNERMichelle Pena, CPC, CHMB (CAHealth.com)

QUestion: How can I prevent denials for office visits when billing for

the administration of therapeutic injections (CPT 96372)?

ansWer: According to the Correct Coding Initiative (CCI), new patient

and established patient office/outpatient visits are considered compo-

nents of the admin code. If there is documentation to support a “signifi-

cantly, separately identifiable evaluation and management service by

the same physician on the same day of the other service,” a -25 modifier

may be appended to the office visit CPT. It is important to review specific

payer payment policies as not all payers apply their bundling edits ac-

cording to the CCI.

QUestion: Why is Medicare denying the biopsy of a lesion (CPT

11100) with destruction of actinic keratoses (CPT 17000)? The documen-

tation does support separate lesions, therefore we append -59 modifier

to the destruction.

ansWer: Commonly, the -59 modifier is appended to the CPT with the

lower RVU or fee. This is not the correct placement of the modifier per

coding edits. The modifier should be placed on the column II or compo-

nent CPT. In this case, when reviewing the Correct Coding Initiative (CCI)

edits, the -59 modifier should be placed on the 11100 due to its being

considered the second code in the CCI pair.

References:

OIG: http://oig.hhs.gov/oei/reports/oei-03-02-00771.pdf•

EncoderPro: http://www.encoderpro.com/epro/cciHandler.do•

Office Manager “to Do” list

Check out version 3 of our website at SDCMS.org. •

It has some new and improved features.

need an osha new hire checklist?•

Go to SDCMS.

org, click on Publications/Webinars, and then scroll

down to “OSHA Refresher Course” (recorded August

18, 2010).

Email your Office Manager Bulletin Board questions •

to [email protected].

8 SAN DIEGO PHYSICIAN.OrG November 20108 SAN DIEGO PHYSICIAN.OrG OCTOBER 2010

brieflynoted


It has been a great honor to be chosen as the 2009

“Outstanding Office Manager” by SDCMS. It

was a joy to read the letter of nomination sent to

SDCMS by the North County Internal Medicine

(NCIM) physicians. I was certainly fortunate

some 17+ years ago to be selected as their office

manager. It has been a pleasure to work with this

group of professionals, who are not only excellent

clinicians, but take an active interest in all areas of

their business. Every Friday at noon, you will find

us, agendas in hand, participating in our weekly

management meeting. During this hour, group,

individual physician, and management problems

or concerns are addressed.

As all office managers and practice administra-

tors know, we are sometimes too busy mov-

ing about our days to acknowledge all those

who contribute to a successful workplace. This

honor, awarded to me by SDCMS, belongs to

all employees of NCIM for their individual and

group contributions to a top-notch organization.

Their support, energy, and team effort creates an

environment of positive support, not only for our

patients but for the physicians and management

of NCIM.Here are a few of my ideas on how to build a

successful team:

Hire employees who meet the skill set and 1.

personality for the position.

Create a relationship of trust with employees. 2.

Take the time to learn their strengths and

weaknesses, and, whenever possible, incorpo-

rate their strengths into their job duties.

Administrative flexibility. We all have 3.

families, as well as “real lives” after 5 p.m.

Some days real lives need to begin at 3 p.m.

Acknowledging and accommodating employ-

ees’ “real lives and needs” will reap rewards.

Employees need permission to problem-4.

solve. They may need a bit of direction, but in

most cases it does not require management

involvement. If a problem persists, ask them

to identify the problem in writing along with

a list of their suggested solutions.

Cross-train. At some point we all get bored 5.

with our day-to-day duties. Whenever pos-

sible, let the employee choose the desired po-

sition and allow them to expand their skills.

Managers should never become “friends” 6.

with the staff. It is imperative that you remain

objective and neutral as a whole and not to an

individual.

Work through generational quirks. If we are 7.

all working toward a common goal, we will

find that there is always more than one right

way to solve a problem.

I am very fortunate to be surrounded by em-

ployees who never fail to offer me assistance. After

a recent week’s vacation, I arrived at the office

to find my desk was neat and organized. Dene,

my partner, dragon slayer, and gift from heaven,

had, once again, created order out of chaos. There

were three packed folders: “Before you get coffee,”

“When you finish the first,” and the third folder

labeled “Whenever.” I quickly opened my drawer

to write her a thank-you note and discovered that

my supportive, resourceful, dependable Lisa had

cleaned and organized my “junk” drawer. Who

knew that I had 50 Pilot pens in that tiny drawer?

I like this place. It’s a comfortable home away

from home. – Anne Billeter

MessAge froM our 2010

OFFiCe MaNaGer OF t He Year

“thank you, anne, for being such an inspiration to

all the off ice managers in san Diego County! — Sonia Gonzales, Your SDCMS Office Manager Advocate!


aktAKT LLP, CPAs and BUSINESS CONSULTANTS

ron mitchell, cpadirector of

health services

CARLSBAD ESCONDIDO SAN DIEGO

760-431-8440 WWW.AKTCPA.COM

[email protected]

3 Income Tax Planning

3 Wealth Management

3 Employee Benefit Plans

3 Profitability Reviews

3 Outsourced Professional Services (CFO, Controller)

3 Organizational and Compensation Structure

3 Succession Planning

3 Practice Valuations

3 Internal Control Review and Risk Assessment

you take care of the san diego community’s health.

we take care of san diego’s healthcare community.

sdcms contact inFormation5575 Ruffin Road, suite 250 san diego, ca 92123t (858) 565-8888f (858) 569-1334E [email protected] SDCMS.org • SanDiegoPhysician.orgCEO/ExECutIvE DIrECtOr tom gehring at (858) 565-8597 or [email protected]/CfO James beaubeaux at (858) 300-2788 or [email protected] Of MEMBErSHIP DEvElOPMENt Janet lockett at (858) 300-2778 or at [email protected] Of MEMBErSHIP OPErAtIONS AND PHYSICIAN ADvOCAtE marisol gonzalez at (858) 300-2783 or [email protected] Of MEDICAl OffICE MANAGEr SuPPOrt AND OffICE MANAGEr ADvOCAtE sonia gonzales at (858) 300-2782 or [email protected] Of ENGAGEMENt Jennipher ohmstede at (858) 300-2781 or at [email protected] Of COMMuNICAtIONS AND MArkEtING Kyle lewis at (858) 300-2784 or at [email protected] BuSINESS MANAGEr nathalia aryani at (858) 300-2789 or [email protected] ASSIStANt betty matthews at (858) 565-8888 or at [email protected] tO tHE EDItOr [email protected] SuGGEStIONS [email protected]

sdcmsF contact inFormation5575 Ruffin Road, suite 250 san diego, ca 92123t (858) 565-8888f (858) 560-0179W sdcmsf.orgExECutIvE DIrECtOr Kitty bailey at (858) 300-2780 or [email protected] ACCESS PrOGrAM DIrECtOr brenda salcedo at (858) 565-8161 or at [email protected] ACCESS MANAGEr lauren Radano at (858) 565-7930 or at [email protected] CArE MANAGEr Rebecca Valenzuela at (858) 300-2785 or at [email protected]

Your SDCMS and SDCMSF Support Teams Are Here to Help!

Get in touch

25% off

advertising in this publication.

Contact Dari pebdani at 858-231-1231 or [email protected]

SDCMS member physicians receive � SDCMS CELEBRATES ITS 140TH ANNIVERSARY IN 2010 �

“PHYSICIANS UNITED FOR A HEALTHY SAN DIEGO”

O C T O B E R 2 0 1 0

OFFICIAL PUBLICATION OF THE SAN DIEGO COUNTY MEDICAL SOCIETY

Reaching 8,500 Physicians Every Month

Infectious DISEASE

Stopping the Dominos From Falling

http://www.aktcpa.com

mailto:[email protected]


brieflynoted

BIrtHDAY: NOvEMBEr 1u.S. representative Darrell IssaE: (via website) house.gov/issaCapitol Office:T: (202) 225-3906 F: (202) 225-3303District Office:1800 Thibodo Rd., Ste. #310, Vista, CA 92081T: (760) 599-5000 F: (760) 599-1178

BIrtHDAY: NOvEMBEr 7State Assemblymember lori SaldanaE: [email protected] Office:California State AssemblyP.O. Box 942849, Sacramento, CA 94249-0076T: (916) 319-2076 F: (916) 319-2176San Diego Office:1557 Columbia St., San Diego, CA 92101T: (619) 645-3090 F: (619) 645-3094

BIrtHDAY: NOvEMBEr 11U.S. Senator Barbara BoxerE: (via website) boxer.senate.govCapitol Office:T: (202) 224-3553 F: (202) 228-2382San Diego Office:600 B St., Ste. 2240, San Diego, CA 92101T: (619) 239-3884 F: (202) 228-3863

Physicians: Let your legislators know that you’re paying attention and that you vote by wishing them a happy birthday! NOTE: Due to mail handling procedures for government office buildings, postal mail to Washington, DC, offices may be delayed by several weeks or even months. Please fax or email if possible.

Physicians Get Noticed!

Wish Your Legislators a Happy Birthday!

The SDCMS Foundation is pleased to announce a partnership with software development company Net Chem-istry1 to bring an e-consult system to San Diego. eConsults will revolution-ize the way physicians communicate about patient care and ultimately re-duce the need for specialty visits for underserved populations.

Through the e-consult system, pri-mary care physicians (PCPs) at com-munity clinics will be able to elec-tronically connect with specialists for “curbside consultations.” With more than 90 sites throughout the county, community clinics provide primary care for the vast majority of safety-net patients in San Diego. These clinic

PCPs are frequently forced to make specialty referrals for issues that they could likely manage at the clinic if they had the input of a specialist. Fortunately, eConsults will allow clinic PCPs to engage in an electronic curbside consultation with a variety of appropriate specialists who are seeking an easier way to provide care for the safety net.

PCPs will be able to log onto a user-friendly, HIPAA-com-

pliant, web-based e-consult system that allows them to share patient information and receive a timely re-sponse through secure messaging from a specialist. eConsults is an in-novative, simple way to reduce health-care costs while providing critically needed care for the most vulnerable residents of San Diego.

Are you a specialist interested in using eConsults? If so, please contact Lauren Radano, healthcare access manager, at (858) 565-7930 or [email protected].

{ABOuT THE AuTHOR} Ms. Radano is your SDCMS Foundation healthcare access manager.

sdcms Foundation and net chemistry introduce econsults to san diegoIncreasing Access for the Uninsured

1. Net Chemistry is an Internet solutions provider to the health and financial services industries whose systems have handled billions of dollars in transactions. Net Chemistry specializes in web-based information enrollment, distribution, and tracking systems comprised of secure, scalable software modules that can be rapidly customized to fit each client’s unique business parameters.

BY lAurEN rADANO

dennis F. coughlin, mdAdditional Address: 7920 Frost St., Ste. 304, San Diego, CA 92123

Zahra ghorishi, mdTelephone: (858) 939-4198

allan h. rabin, mdBoard-certified Specialties: Child and Adolescent Psychiatry, and Addiction Psychiatry

smitha chiniga reddy, mdNo additional addresses.

Fane l. robinson, mdPrimary Address: 7695 Cardinal Ct., Ste. 100, San Diego, CA 92123Website: sdretina.com

mark d. smith, mdPrimary Address: 7695 Cardinal Ct., Ste. 100, San Diego, CA 92123Website: sdretina.com

Please make the following corrections to your copy of SDCMS’ 2010–11 Pictorial Membership Directory. Thank you.

MEMBERSHIP DIRECTORY ERRATA


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practicemanagementBy Melissa Brown, RHIA, CPC, CPC-I, CFPC

DON’T TAkE IT OuT ON THEmMake Sure You Are Billing for Accurate Amounts!


With code changes for a new year once again on our radar, make sure you look for “quantity” changes. HCPCS Level II drug codes particularly are ripe for error if you aren’t checking carefully.

check your mathTo assign the HCPCS Level II codes cor-rectly, billing staff must calculate the units billed from how the drug is supplied and the amount given to the patient. Recognize that the dosage unit administered and/or listed on the package does not always match the billing unit. Failure to convert the bill-ing units properly could cost you money.

The simplest calculations can be seen in this example. A total of 500 mg of Tet-racycline (J0120 Injection, Tetracycline, up to 250 mg) is administered to a patient. To capture full payment, bill two units of J0120 (500/250 = 2).

The conversions are not always straight-forward. For instance, two 2 mL syringes, each containing 1,200,000 units of Bicil-lin C-R (J0559 Injection, penicillin G ben-zathine and penicillin G procaine, 2,500 units), are administered. When converting this information, you must make two cal-culations:

for the two vials, and1. to convert the vials to units.2.

The amount injected is 2,400,000 units (1,200,000 x 2). The units administered then must be converted to billing units. The billing unit in this example is 2,500; therefore, the bill should reflect J0559 with 960 units (2,400,000/2,500 = 960).

check the changesAlthough it’s too soon to tell what the changes for 2011 are, we can look at some examples from the 2010 changes that make the point very clear.

The 2,400,000 units of Bicillin C-R above was coded as J0550 Injection, penicillin G benzathine and penicillin G procaine, up to 2,400,000 units in 2009. Notice the im-portance of accounting for the unit change (2,400,000 in 2009 to 2,500 in 2010). If you fail to adjust the billing units accordingly on your claims (960 billing units in 2010 vs. 1 billing unit in 2009), you could be losing payment for 959 billing units of the drug! For Medicare patients, that could be a dif-ference of getting paid $0.08 vs. $77.68.

know What and Where you are reportingIf making calculations for billing units was not challenging enough, the required re-porting of the NDC number and units on the claim cannot be left out of the equation. As previously mentioned, the unit number associated with package (thus the NDC) does not always match the billing unit. In our Bicillin C-R example, the billing unit was 960. The medication is supplied in 2 ML syringes, so the line with the NDC units would be reported as ML4 because each sy-ringe used contained 2 ML (2 x 2 = 4).

don’t eat the WasteOne final calculation that needs to be ac-counted for is the amount of drug left over after the patient has received the appropri-ate amount prescribed (assuming single-use vials or packages are used). These leftover units are often referred to as waste. Rather than eating the cost of the waste units, these units should be reported on a separate line item with modifier JW Drug or biological amount discarded/not administered to any patient. By reporting the waste, you may be able to recoup the cost of the drug that can-not be used on other patients. Make sure the medical documentation includes the details related to the amount given and rea-son for the waste amount.

Why the math mattersFrom the examples discussed above, you can see why it’s important to capture every opportunity to recoup the cost of the drugs and biologicals. It’s equally important to check the changes to make sure you aren’t inadvertently overbilling for your drugs. Mistakes that over-report the units will raise red flags and put the practice at risk for charges of fraud. Taking the time to under-stand how to account for and report the bill-ing units and NDC units properly is critical in making sure you get every penny due to you. So is making sure you know how the code changes will affect your calculations. Happy counting!

{ABOuT THE AuTHOR} Ms. Brown is manager of education and reim-bursement at the University of Florida Jack-sonville Physicians, Inc.

Taking the time to understand how to account for and report the billing units and NDC units properly is critical in making sure you get every penny due to you.


practicemanagementBy the California Medical Association

CmA PRACTICE

RESOuRCESOctober / November 2010


aetna notifies Physicians of new consult code reimbursement PolicyAetna recently notified 12,750 contracting physicians that the in-surer will no longer recognize or reimburse for consult codes, effec-tive Nov. 15, 2010. The notification, dated Aug. 15, 2010, was sent to physicians contracted with Aetna on a “current Medicare Physician Fee Schedule.” The policy change does not apply to physicians who are contracted with Aetna with a fee schedule based on a method-ology other than the current Medicare Physician Fee Schedule.

As previously reported in the May 2010 issue of CPR, Medicare is no longer recognizing inpatient and outpatient consultation codes. Effective Jan. 1, 2010, physicians must instead bill using E/M codes from the Office and Other Outpatient Services, Initial Hos-pital Care, and Initial Nursing Facility sections of the 2010 CPT. To assist physicians with this issue, CMA has published a Medicare consultation code billing guide. In addition, CMA has published a “Managed Care Consultation Code Quick Reference Guide,” which provides up-to-date information on which major payers in California have or will be changing their own payment policies as the result of this change. CMA’s consultation code billing guides are available free to members at the members-only website at www.cmanet.org/ces.

Physicians are encouraged to carefully review all proposed amendments to health plan or medical group/IPA contracts. CMA has published “Contract Amendments: An Action Guide for Physi-cians,” which is designed to help physicians understand their rights and options when a health plan notifies them of a material modi-fication to a contract, manual, policy, or procedure. CMA has also developed a simple worksheet to help physicians analyze proposed fee schedules and assess the impact fee schedule changes may have on physician practices based on commonly billed CPT codes.

CMA RESOURCES: CMA’s “Managed Care Consultation Code Quick Reference Guide,” CMA’s “Medicare Consultation Code Bill-ing Guide,” “Contract Amendments: An Action Guide for Physi-cians,” and CMA’s “Financial Impact Worksheet.”

Unfair Payment Practice: timely Filing denialsHealth plans usually impose claim-filing deadlines, which require physicians to submit a claim within a certain time period after the date of service. If the physician fails to meet the deadline, the health plan will not pay for the service provided. California law prohibits health plans and insurers from imposing claim-filing deadlines that are less than 90 days for contracted physicians or 180 days for noncontracted physicians after the date of service. If the payer is not the primary payer under coordination of benefits (COB), the payer cannot impose a deadline for submitting a COB claim that is less than 90 days from the date of payment or date of denial from the primary payer.

Moreover, even if the physician fails to submit the claim on time, California law provides a “good cause” exception that requires pay-ers to accept and adjudicate a claim if the physician demonstrates, upon appeal, “good cause” for the delay.

Below are steps you can take to prevent timely filing denials:Submit claims as quickly as possible after services are ren-1. dered.Where possible, file claims electronically.2. Retain payer acknowledgement of receipt of claim. As dis-3. cussed in the August 2010 issue of CPR, California law requires health plans to acknowledge receipt of an electronic claim within two days and a paper claim within 15 days of receipt.Appeal all claims that have been incorrectly denied for timely 4. filing in writing. Include a copy of the payer’s acknowledg-ment of receipt of the claim with your appeal.Review health plan contracts to ensure that deadlines for fil-5. ing claims are no less than 90 days.Report health plan violations of the timely filing laws to the 6. appropriate regulator and to the California Medical Associa-tion.

For a summary of California’s unfair payment practices, see “Know Your Rights: Identify and Report Unfair Payment Practices,” available at SDCMS.org.

TIP: As previously reported in the August 2010 issue of CPR, an ac-knowledgement of receipt of a claim from a clearinghouse is not an acknowledgement that the claim has been transmitted to and received by the payer. Check with your clearinghouse to determine its process for tracking health plan receipt of claims.

CMA RESOURCES: CMA ON-CALL document #0146, “Payment Denials by Managed Care Plans and IPAs,” document #1070, “Man-aged Care Contractual Protections,” and document #1051, “Physi-cian Complaints About Managed Care Plans,” “Know Your Rights: Quick Guide for Appeals,” and “Know Your Rights: Identify and Report Unfair Payment Practices.”


practicemanagement

cma advocacy results in changes to United coverage determination guidelineUnitedHealthcare recently proposed a coverage determination guideline that would have added an administrative burden to phy-sician practices and potentially compromised patient care.

The originally proposed guideline, which was to become effec-tive Oct. 1, 2010, would have required physicians to submit not only written documentation, but also a CT scan and seven “high-quality color” photographs prior to performing rhinoplasty, septoplasty, and turbinate resection. In addition to the administrative burden, these requirements could have exposed the patient to unnecessary doses of CT radiation.

After discussing the pitfalls of its proposed policy with CMA, United agreed to revise its guideline. The guideline no longer re-quires a CT scan if a patient refuses the scan or the physician be-lieves it to be unnecessary. In such cases, United will accept detailed clinical documentation that adequately demonstrates chronic and consistent nasal obstruction that is unresponsive to medication. Additionally, the requirement for photographs has been eliminat-ed for all cases except those in which there is a post-traumatic nasal deformity. The revised policy will be effective Dec. 1, 2010.

For more information, including United’s revised guideline, visit http://bit.ly/91Qy0U.

have you received your erx incentive Payment?Successful participants in the Medicare Electronic Prescrib-ing for 2009 program should have received their lump sum payment from Palmetto GBA by Oct. 22, 2010. Paper EOBs associated with the payment contained the message “This is an eRx incentive payment.” Electronic remittances con-tained an indicator of LE to reflect an incentive payment, along with RX09 to identify the payment as the 2009 eRx incentive payment. If you have questions about the status of your eRx incentive payment, please contact the Palmetto GBA Provider Contact Center at (866) 931-3901.

Physician feedback reports will be available on the Physi-cian and Other Health Care Professionals Quality Reporting Portal at www.qualitynet.org/pqri starting the second week of November.

For more information on an alternate way to receive the report, and for available resources for assistance with the portal or reports, please visit www.cms.gov/MLNMattersAr-ticles/downloads/SE0922.pdf.

has your contracted health Plan or iPa stopped Paying claims?CMA’s Center for Economic Services has recently received an in-crease in calls regarding physician concerns that a medical group/IPA with whom they contract is experiencing financial difficulties. One of the symptoms of an insolvent health plan, IPA, or other payer is the failure to pay claims in a timely manner. Another in-dication of financial distress is a payer that cuts checks within the statutory timeframes but does not release the checks in a timely manner.

If you are experiencing repeated payment delays, you should investigate the financial health of the payer. To help physicians monitor the financial health of their contracted payers, CMA has put together a “Payer Solvency Checklist.” This resource includes instructions on how to research and monitor the financial solven-cy of your contracted medical groups/IPAs and discusses options available to physicians in the event a payer stops paying claims.

CMA RESOURCES: CMA’s “Payer Solvency Checklist,” CMA ON-CALL document #0223, “Risk-bearing Medical Groups, Includ-ing IPAs: Regulation of Solvency,” document #1031, “Insolvency of Health Plan, IPA, or Other Entities That Contract With Health Plans (Pre-bankruptcy or Closure),” and document #0106, “Bank-ruptcy of IPAs or Health Plans.”

did you know?CMA’s Center for Economic Services provides our members with up-to-date profiles on each of the major payers in Cali-fornia, including Aetna, Anthem Blue Cross, Blue Shield of California, CIGNA, Health Net, United Healthcare, Medicare/Palmetto, and Medi-Cal. Each profile includes key information on market penetration, a description of the plan’s dispute resolution process, as well as key con-tact information for payer medical directors, provider rela-tions, and contracting-related issues. Don’t waste your time searching the Internet for this information. Payer profiles are free to members for download at www.cmanet.org/ces.


Let us take care of the paperwork so you can take care of your patients.

T: 925.249.9510 • E: [email protected]

SDCMS Tweets!Follow SDCMS on Twitter to keep abreast of the latest in health reform changes, regulatory news, scope of practice issues, practice management tips, and more!

health Plan Provider newslettersTo make sure that you are aware of impor-tant news from your contracting health plans, we encourage you to regularly read plans’ provider newsletters and bulletins. Follow the links below to access the current issues:

AETNA:• www.aetna.com. Click on “Health Care Professionals” in the main menu, then on “News for Providers” in the left sidebar.BLUESHIELD:• www.blueshieldca.com. Click on “I’m a Provider,” then on “Announcements” under “News and Features.”CIGNA:• www.cigna.com. Click on “Health Professionals” under “Customer Care” in the main menu, then scroll down and click on “Newsletters.”ANTHEMBLUECROSS:• www.anthem.com/ca. Click on “Providers” in the main menu, then on “Professional Net-work Update” under “Spotlight.”HEALTHNET:• www.healthnet.com. Click on “I’m a Provider” and then “Cal-ifornia.” Enter username and password, and then click “Online News.”MEDI-CAL:• www.medi-cal.ca.gov. Click on “Publications” in the main menu, then on “Provider Bulletins.”MEDICARE/PALMETTOGBA:• www.palmettogba.com/j1b. Click on “Pub-lications” in the left sidebar, then on “Medicare Advisory.”UNITEDHEALTHCARE:• www.united-healthcareonline.com. Click on “Tools & Resources” in the main menu, then on “Network Bulletin.”

CMA RESOURCE: Find up-to-date pro-files on each of the major payers in Califor-nia at www.cmanet.org/ces.

{ABOuT CPR} CMA Practice Re-sources (CPR) is a free, monthly bulletin from the California Medical Association’s Center for Economic Services. This bulletin is full of tips and tools to help physicians and their office staff improve practice efficiency and vi-ability. To sign up for a free subscription, visit www.cmanet.org/news/cpr.

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fromsandiegocountyhealthleadersBy Donald C. Balfour III, MD

Note: Dr. Balfour’s article is one in an occasional series of articles from San Diego County’s health-care leaders published in San Diego Physician. Opinions expressed are not necessarily endorsed by SDCMS or CMA.

Founded in 1923, Sharp Rees-Stealy Medi-cal Group is the region’s oldest multispe-cialty medical group, nationally known for superior clinical practices and recipient of numerous awards and recognition. One of the largest medical groups in the state, we have been committed since our inception to providing the finest in personalized medical care, where the health of our patients always comes first. We provide care at 19 locations throughout the region with 1,850 employees and more than 400 physicians representing virtually every medical specialty. In 2009, our medical group had more than 1 million patient visits, with about 70 percent of the population covered by one of several man-aged care health plans.

In 2001 our leadership team set out on a

journey to transform our organization’s cul-ture and unify our entire workforce to create a best-in-class healthcare system. The results of our efforts are broad, with breakthrough improvements in clinical performance, fi-nancial growth, and physician, employee, and patient satisfaction. Although our trans-formational improvement in reportable measures has gained the most attention, our greatest change has been in our cul-ture, a measurement not tallied in national benchmarks. We have unified our workforce around a rededication to our patients, using systemic changes to positively impact the lives of others. Working as a team we have become the providers of care we had hoped to be when we joined this profession.

We created six pillars of excellence repre-senting the strategic focus areas of quality, service, people, finance, growth, and com-munity to make targets concrete and assure execution of our strategic plan. We have achieved breakthrough results in each of the pillar focus areas. (See figure 1)

In August 2008, the Commonwealth Fund issued the report “Organizing the U.S. Healthcare Delivery System for High Performance,” identifying six attributes of an ideal healthcare delivery system. Sharp Rees-Stealy’s redesign efforts incorporate each of the Commonwealth Fund’s at-tributes, and continue to be supported by the methods and processes helping us to achieve our vision.

1. EHR Information Access: We use a state-of-the-art EHR system to consolidate data for analysis and feedback, provide de-cision support, and engage patients in their healthcare. All primary care physicians, specialists, and in-network emergency rooms and hospitals share access to the system. Disease registries with robust data mining capture gaps in care for entire popu-lations of patients. This has led to dramatic improvements in the multidisciplinary co-ordination and integration of personalized care for each patient.

2. Coordination of Patient Care: Our medical group assigns a primary care phy-sician to every patient assuring a high level of continuity of care. In 2007 we developed the Continuity of Care Unit to capture inte-grated EHR data allowing nurses to moni-tor all patients’ post-hospital stays and af-ter-emergency room discharges. Dramatic improvement in patient care resulted from the coordination of this critical transition across care settings.

3. Accountability Across the Care Team: We use consolidated EHR data to report patient outcomes by site, depart-ment, and individual physician, allowing for overall and individual review. This ac-countability and transparency drove the initial fundamental changes and continue to provide the basis for measuring prog-ress. Shared behavior models, goals, and incentives reinforce the collaborative work environment in which all members of the healthcare team unite to provide the best healthcare.

4. Ease of Access for Patients: A patient portal, mySharp, provides access to lab

PIllAr rESult

Quality#1 in California’s P4P program for four consecutive years 2006–09, recognizing performance in clinical quality, patient experience, and information technology.

ServiceDramatic increase in patient satisfaction rates from 12th to 81st percentile on national Press-Ganey ratings.

PeopleEmployee engagement index in the 99th percentile for healthcare organizations. Physician satisfaction has improved over 20%.

Finance35% decrease in heart failure admissions resulting in over $1.5 million annual savings.

Growth 11.5% increase in patient visits.

CommunityTens of thousands of community volunteer hours logged by physicians and employees.

Sharp Rees-Stealy medical Group

Figure 1: key results by Pillar of excellence

Delivering 21st-century Ideal Healthcare


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fromsandiegocountyhealthleadersresults, prescriptions, patient/provider e-messaging, and convenient online patient scheduling. A 24/7 telephone nurse advice line provides support, and patients have open access for same- or next-day primary care appointments. Diverse staff and phy-sician backgrounds provide multicultural understanding and service in a wide range of languages to meet the needs of the com-munities we serve.

5. Accountability for Total Care: The collection of data, reporting, and analytics combined with our renewed focus on the patient experience has led to accountability for total patient care. Information systems allow close monitoring of key quality indi-cators and cost-of-care drivers. Regardless of funding source or type of insurance, our commitment to providing a consistent pa-tient experience is our priority. Since more than 70 percent of the medical group’s rev-enue is full-risk capitation, business success demands financial accountability for the total cost of care. Physician quality and

service are reported with full transparency, institutionalizing peer pressure to improve performance.

6. Continuous Innovation and Learn-ing: As we use more accurate data and ana-lyze what achieves results, we have new op-portunities to support continuous learning and system innovation. We allocate human and financial resources to leadership devel-opment, quality improvement, physician and staff coaching, and team building. As an organization we are now more account-able for quality results using selected six-sigma methodologies. These same process-es are now used with a number of projects that support our pillars of excellence. We participate in state and national learning collaboratives and exchange best practices with other leading medical groups. At our quarterly leadership institute, we capture lessons learned and share successes from our organization and other healthcare en-vironments and industries.

We are proud of what we have become.

Performance, transparency, and account-ability are fully integrated into Sharp Rees-Stealy’s culture. We are patients, families, physicians, healthcare administrators, nurses, allied health professionals, and staff who have come together, working together, helping and supporting each other to care better for patients and their families. Our journey continues as we find new and inno-vative ways to create the best place to work, the best place to receive care, and the best place to practice medicine.

{ABOuT THE AuTHOR}Dr. Balfour, SDCMS-CMA member since 1978, has been president of the Sharp Rees-Stealy Medical Group (SRSMG) board of directors since 1985 and currently serves as the presi-dent and medical director. SRSMG includes more than 376 physicians representing 27 medical specialties at 17 medical centers throughout San Diego County, and provides comprehensive medical care to 140,000 HMO patients, including 14,000 seniors.

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DisasterPreParedness

DISEASEpatterns of

Time to Broaden Our Focus

RobeRt e . PeteRs , PhD, MD

after natural Disasters


Note: To read an extended version of this article, please visit SanDi-egoPhysician.org.

Infectious disease epidemics, with resulting high morbid-ity and mortality, commonly follow disasters, whether natural or the result of human activities. Large-scale disasters often result in associated social disruption, including reduced availability of healthcare services and/or access to the typically available healthcare infrastructure. After a survey of post-disaster circumstances from a community healthcare perspective, I suggest that we need to expect a potential epidemic of an infectious disease or diseases. Too often, the “disaster planning” focus of the healthcare infrastructure has the relatively limited focus of triage planning and large-scale management of trauma patients. It must also include planning for highly likely, post-event infectious disease epidemic(s).

Consider the case of a 51-year-old previously healthy woman of Scandinavian descent. She was a victim of the southeast Asian tsunami. The initial medical problems included a deep cutaneous wound (Acinetobacter bauman-nii, Stenotrophomonas maltophil-ia, Achromobacter xylosoxidans) to her legs, multiple fractured pelvis, ruptured bladder (Entero-coccus faecium) and pneumonia (Pseudomonas spp.). Two weeks later she developed a thigh abscess (Nocardia africanum).

Eight weeks later she developed altered mental status due to brain abscess (Scedosporium apiospermum). Three months later she had a persistent drain-ing wound (Mycobacterium cheloniae) from the tibial region (osteomyelitis excluded). A healthy but immunologically naïve host from the other side of the world, massively inocu-lated with tropical organisms on top of severe trauma, will act like an immunocompromised host. But even local popula-tions, subjected to trauma and massive inoculation, can ex-perience large-scale infectious complications.

How often do disasters result in infectious disease outbreaks? Experts disagree on both the incidence and the specific infectious agents involved. De-finitive causal relationships can be difficult to confirm, as pre-disaster baseline surveillance is often weak to nonexistent. Post-event, population-based sur-

Too often, the “disaster planning” focus of the healthcare infrastructure has the relatively limited focus of triage planning and large-scale management of trauma patients. It must also include planning for highly likely, post-event infectious disease epidemic(s).

veillance may be a low priority in the initial weeks and months following disaster, yet difficult to accomplish at a later time. Lastly, origin of an outbreak is typically multifactorial.

In order to consider a sugges-tion that infectious epidemic(s) should be anticipated for public health planning following a disaster, consider the follow-ing phases of a disaster. Think in terms of individual patients proximal to a disaster loca-tion and associated responses required by the healthcare infrastructure.


Impact Phase: Zero to Four Days

Extrication/trauma.•Hypothermia/heat illness/•dehydration.Early soft-tissue infections. •Infectious complications in tsunami survivors often are the result of crushing or impaling injuries from wood, rock, concrete, or metal. Wounds become contami-nated with tsunami water, soil, or particulate matter. Even minor wounds and abrasions could lead to over-whelming infection with Staphylococcus, Streptococcus, and water-borne organisms: Vibrio, Aeromonas, Pseudomo-nas, Burkholderia spp, and fungi.

Post-Hurricane Katrina, a •Dallas evacuation facility had a cluster of 30 adult and pe-diatric patients with MRSA. Following the same disaster, an increase in mortality was reported by CDC from Vibrio vulnificus and parahaemo-lyticus soft-tissue infections. Risk factors included wading in contaminated flood waters (60 percent of cases are wound infections) and 40 percent resulted from raw shellfish consumption. Contact with brackish salt water, prevalent in Gulf states. Necrotizing fasciitis may occur. Overall mortality is 40 percent — 20 percent in the subset with Vibrio from wounds. Another soft-tissue infection caused by Aeromo-nas hydrophilia is associated with brackish fresh water. This infection is associated with eating infected fish or with leech bites.

Post-impact Phase: Four Days to Four Weeks

Waterborne and foodborne •illnesses from contaminated drinking water (cholera, bac-terial dysentery, cryptospori-diosis, rotavirus, norovirus, typhoid and paratyphoid, giardiasis, hepatitis A and E or dermal/mucosal contact with flood waters (Lep-tospirosis).Communicable respiratory •infections. Predicting the most probable infections in a given disaster area is of course predicated on the pathogens known to be either endemic or most frequently observed during non-disaster time frames. Po-tential pathogens will proba-bly include: Viral (Influenza, RSV, Adenoviruses) bacterial (Strep pneumoniae, Pertusis, Tuberculosis, Legionella, Mycoplasma pneumoniae), and diseases transmitted via the respiratory route (e.g., Measles, Varicella, Nisseria meningitides).

Recovery Phase: After Four Weeks

Diseases with longer incuba-•tion periods.Vectorborne: malaria, •Western/St. Louis encepha-litis, dengue, yellow fever, and West Nile. For flooding disasters, there appears to be a complex relationship: Incidence may initially drop as flood waters wash away stagnant breeding sites for mosquitoes, but later, stand-ing water pools may increase, with associated increasing in-cidence. Behavioral changes caused by disaster, such as sleeping outside, may result in additional vectorborne illnesses.Exacerbations of chronic •disease. We tend to focus on acute trauma, but prevention of chronic disease exacerba-tion is paramount.Iatrogenic complications •(e.g., transfusion-related infections).

What are the variables to consider in post-disaster planning regarding infectious diseases? First, environmental considerations: cold climate fa-vors airborne agents, and warm climate favors waterborne agents/vectors. Broadly speak-ing, winter favors influenza and summer favors enteroviruses.

An important variable is, of course, endemic organisms. Infectious organisms endemic to a region will also be present after the disaster. Agents not endemic before the event are not as likely to create problems. Consider “normal” incidence observed of pathogens such as coccidiomycosis (valley fever)


as we consider healthcare infrastructure planning programs for disaster circumstances, the goal of planning tends to intuitively gravitate to improving the health status of disaster victims one person at a time. We are beginning to realize that such planning is insufficient.


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Project4:Layout 1 9/22/08 11:22 AM Page 1

or similar disease agents that may be periodic or minor prob-lems during normal periods.

An important parameter to consider, which varies as one moves from one geographical area to another, is popula-tion demographics. What is baseline immunity to specific diseases, population age (elderly or children), typically observed chronic diseases, malnutrition, diabetes, heart disease, etc.?

As we consider healthcare infrastructure planning programs for disaster circum-stances, the goal of planning tends to intuitively gravitate to improving the health status of disaster victims one person

at a time. We are beginning to realize that such planning is insufficient. Growing evidence from analysis of post-disaster data confirms that we must also plan for large-scale infectious disease outbreaks among the patients and cohorts of the disaster population, and the potential epidemics — if not anticipated and planned for — can overwhelm the healthcare system just at the point it is be-ginning to gain ground on care for the post-disaster trauma population.

Disaster medicine planning must avoid situations where the healthcare infrastructure becomes overwhelmed. The

goal is improving the health of the largest possible number of persons post-event. That requires not only planning for trauma care of the individual, but also planning for potential epidemics of infectious disease following in the wake of the initial disaster.

About the Author: dr. Peters, sdCMs-CMa member since

2000, is a family physician in private practice. He is a member

of sdCMs’ GerM Commission, is secretary of sdCMs, is a

member of the san diego academy of Family Physicians

board of directors, co-chairs sharp HealthCare’s Primary Care

Conference, is a member of the infectious disease committee

at sharp Memorial Hospital, and is chairman of CMa’s Council

on ethical affairs. dr. Peters also serves as a consultant to the

biomedical and pharmaceutical industry.

Are You Getting Your Reimbursement

Issues Resolved?

Have a question? Don’t know where to begin? Contact your full-time, SDCMS physician advocate, Marisol Gonzalez, free of charge, to get the answers to all your questions, at (858) 300-2783 or at [email protected].

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Physicians Need to Know What to Do As Individuals and How to Work Within Their Healthcare System

CRISIS! DISASTER!

apocalypse!

by susan shePaRD

pestilence!


Work with your local medical •society, hospital, and other healthcare agencies involved in disaster preparation — accredited hospitals are required to plan and practice community-wide disaster drills based upon communi-ty-specific risks.Be aware of your responsibili-•ties as a medical staff member at hospitals where you have privileges.Physicians and physician •practices need to be involved with planning for the care of their patients to ensure critical services are not inter-rupted. This is especially true for patients with special needs, chronic diseases, the aged, and those with limited mobility.Patients who will need to be •in a special medical needs shelter should be identified to the emergency operation center (EOC) so that early transportation and shelter availability is ensured.

Check with the home health •agencies that are caring for your patients and their plans to adequately provide services in the home.You may be called upon •to be available to help staff shelters.The physician plays a key role

in community preparedness. You may be the first to identify that a biological attack is taking place, as was the case in Florida with the first anthrax case in 2001.

Be familiar with the clinical •manifestations, diagnostic tests, and treatment regi-mens for the major biological agents.Understand your hospital’s •incident command struc-ture.

Participate in hospital ¤drills and community exercises.

Maintain a relationship with •the local health agency that is monitoring the health of the community and report suspected cases. The local health agency may be the primary source for treatment guidelines.A disaster plan for your office,

including plans for communi-cating with staff and patients and resuming full operations following a disaster, can reduce recovery time. The plan would include:

Disaster planning checklist •of items to consider as you plan to preserve assets and communicate with your staff and patients. It would be timed so that items are considered based upon priority and can be matched to weather-related informa-tion, such as in the case of hurricanes.

Living in the San Diego area, disasters are an ever-present reality — from potential mudslides, fires, or earthquakes. Improving health sys-tem preparedness to deal with terrorism and mass casualty events can seem overwhelming, but it should be one of our highest priorities. Without adequate planning, practice, and preparation, the conse-quences to those afflicted can become horrific. As part of the national commitment to improve health systems in support of patient safety, physicians need to know what they can do as individuals as well as how to work within their healthcare system.



Disaster recovery checklist •with steps to follow upon your return from an evacu-ation.Full-circle call tree and •instruction, which is a directional plan of who will contact whom in the event of a disaster.Instructions on setting up •instant messaging groups at Yahoo.com to enable your staff to communicate when cells phones may not work.During the aftermath of Hur-

ricane Katrina, one of the most problematic areas of recovery was with medical records. Wa-ter, fire, and even disruptions in electricity can affect the re-covery of medical records. Loss

of records not only can disrupt care but can be compounded by the concerns about privacy issues and identify theft.

One of the most effective •ways to minimize medical record continuity gaps is through the use of an elec-tronic medical record and office management system that is web-based and HIPAA-compliant.The Centers for Disease •Control and Prevention have provided a method to provide patients with a personal medical informa-tion form that is a concise record patients can keep with them. This temporary record lists medical care and other

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a disaster plan for your office, including plans for communicating with staff and patients and resuming full operations following a disaster, can reduce recovery time.

Does Your Office Manager Have an Ally

She Can Turn To?

Let your office manager and staff know that they have a full-time office manager advocate at SDCMS ready to help them with any questions they may have, free of charge. Contact Sonia Gonzales at (858) 300-2782 or at SGonzales@SDCMS.




About the Author: Ms. shepard is director of patient safety

education for sdCMs-endorsed The doctors Company.

health information and can be adapted. It is not intended to replace hardcopy or the EMR but is an interim com-munication tool. The tool — known as Keep It With You — is available at bt.cdc.gov/disasters/pdf/kiwy.pdf.You may want to consider •having an attestation of med-ical record loss or destruction on file for documents that were partially or completely destroyed as a result of a disaster.Planning for and respond-

ing to disasters are managed by multiple entities to include federal, state, and local govern-ments; regional level, state, and local emergency management

authorities (EMA); hospitals ac-credited by the Joint Commis-sion; and volunteer organiza-tions, such as the Red Cross and Salvation Army.

Be familiar with your com-•munity. Ask the hospital you work in what your role is and how you fit into the plan. Accredited hospitals are re-quired to work with the other agencies when developing their disaster preparedness plans and would be an excel-lent source of information.Emergency physicians and •occupational health physi-cians frequently have local organizations with planning activities. You can talk to your peers about their roles

and activities.Participate in the devel-•opment of a community disaster plan and provide input into the state and local offices of emergency medical services and EMA.Ask yourself these questions:•Where should I go during a ¤disaster?How will I be notified if I ¤am needed to respond to a disaster?How will I be identified as a ¤physician?How will my patients be ¤transferred or discharged?

Your actions during a disaster will be predicated on the disaster plan, thus the need for familiarity with the plan. Once the disaster is recognized, the physician should institute office and home disaster plans and participate in the community or hospital predesigned plan. You can provide your patients with an emergency supply checklist and home disaster plan to promote their safety.

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Unnecessarily?SDCMS has endorsed TSC Accounts Receivable Solutions, which has provided personalized, innovative collection and total accounts management services since 1992. This local, family-owned business’ management team has combined experience of more than 50 years in the healthcare billing and collection field. SDCMS members receive a 10% discount on monthly charges. Contact Catherine Sherman at (760) 681-5012, or at [email protected]. Visit TSC online at TSCARSolutions.com.

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7.2 Hits on sunDay, april 4, 2010

a

Observations From Imperial County

by thoMas W. henDeRson


We were so lucky the earth-•quake happened on a Sunday. Lots of patient record cabi-nets fell over. The potential for injury to staff was huge due to their proximity to staff working areas. Anything on wheels rolled. Some equip-ment was heavy and could have caused serious injury. Wheeled equipment should either be locked or secured when not in actual use.Everyone should ensure •their hot water heaters are strapped. New laws require it, but older units may not be strapped. In fact, in our build-ing one of the heaters broke its strap due to the magnitude of the earthquake.Water pipes broke and folks •were unaware of that due to the time lag between the earthquake and when individuals were able to check their offices. Owners had to get in touch with water removal services, which were swamped.

Mr. Henderson, in addition to being the executive director of the ICMS, is an administrator of a building that experienced extensive damage during the 7.2-magnitude earthquake that struck 20 miles southeast of Mexicali on Sunday, April 4, 2010. They received a $996,000 loan from the Small Business Administration for repairs. Following are a few of Mr. Henderson’s personal observations:

We had 13 physicians dis-•placed because the building could not be occupied. Doc-tors had to scramble to find places to move temporarily.

Doctors had to reroute ¤phone numbers or change phones; ads had to be placed in newspapers.Medical records had to be ¤removed and stored.Leased equipment had to ¤be returned, and access to the building for those companies had to be coordinated to ensure compliance with the city’s restrictions.Multiple issues, including ¤the proper handling of medication samples, had to be resolved. This issue was important because the city initially imposed ac-cess exclusion to all except workers, later to all except those working to stabilize the building.

SBA loans are available in •disasters like this, and I can’t overemphasize how simple the disaster loan processing is compared to other loans, including loans for economic damages.Owners were approached •within days by individuals purporting to represent major construction companies. In one case we had an individual want to make a bid on repairs. A search revealed his licensed had been revoked.Because access to the site was •blocked for several days, doc-tors who did not have backup offsite had no access to any of their computer information.Arranging to get fax lines •moved was as difficult as get-ting temporary offices. Some docs had to change their fax numbers.I spent a fair amount of time •tracking down new locations and information to distribute to other members for referral purposes.

About the Author: Mr. Henderson is the executive director

of the Imperial County Medical society.



As the American Red Cross moves forward into the new year, we continue to prepare for emergencies that can happen anywhere to anyone at any-time. Every year the Red Cross responds to more than 70,000 disasters, including approxi-mately 150 home fires every day. The American Red Cross is one of the world’s most renowned humanitarian organizations, and it relies on volunteers to help with the mission of provid-ing care and comfort to those affected by disaster. The scope and magnitude of disasters has created a unique opportunity for medical professionals to provide services in new roles.

Traditionally, Red Cross medi-cal volunteers support local hospital and emergency services response plans, extending the availability of medical services. This role is very effective when the disaster does not evacuate a large number of people remain-ing in their home locations or disrupt primary medical services. However, when large populations are being affected this way, a secondary disaster begins to occur in the safe evacuation locations. In addi-tion, the displaced population overwhelms the community’s medical, infrastructure, trans-portation, waste, and security resources. Often, medical doc-tors from within the affected area may also find themselves evacuated and seeking shelter.

Medical doctors who are not affected or a part of the affected area’s emergency response ele-ments can work with American Red Cross relief operations to

provide triage units within Red Cross shelter facilities. Utilizing doctors’ experience in combi-nation with Disaster Health Services (DHS) protocols could create a unique paradigm of “battle field” aid station triage providing major relief during critical evacuation.

There are many ways health professionals can lend their services to disaster relief opera-tions. Red Cross DHS volun-teers not only provide medical services, but mental health and crisis counseling situations as well. For example, DHS volun-teers provide health assessments and referrals for care, and assist victims in obtaining essential medications or equipment. With the generosity of more doctors, nurses, and other medi-cal professionals, the Red Cross will be able to provide better re-lief for the hosting community’s medical services while offering better quality living and safety situations to those affected by disasters.

The American Red Cross is now seeking local medical professionals to join us in our mission to provide relief to victims of disasters and help people prevent, prepare for, and respond to disasters. To learn about volunteer opportunities at your local American Red Cross, please visit SDARC.org or call (858) 309-1200.

The American Red Cross greatly appreciates the con-tinued support from health professionals and looks forward to expanding these partnerships in the future.

About the Author: Mr. Craver is CeO of the american red

Cross, san diego/Imperial Counties chapter.

Seeking Local Medical Professionals

by joe W. CaRveR

american RED

cross

tHe


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Project Access San Diego is modeled after a successful, nationwide program being implemented in 50

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not have private or public health insurance to receive the medical care they need. The SDCMS Founda-

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services. Physicians set their own volunteer commitment and ideally see one patient per month in

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tO SubMIt a ClaSSIFIeD aD, email Kyle lewis at [email protected]. SDCMS members place classified ads free of charge (excepting “Services Offered” ads). nonmembers pay $150 (100-word limit) per ad per month of insertion.

classifiedsOffiCe spaCe

OffiCe spaCe in utC: Full-time office in 8th floor suite with established psychologists, marriage and family therapist, and psychiatrist in Class A office building. Features include private entrance, staff room with kitchen facilities, active professional collegiality and informal consultation, private restroom, spacious penthouse exercise gym, storage closet with private lock in each office, soundproofing, common waiting room, and abundant parking. Contact Christine Sa-roian, MD, at (619) 682-6912. [862]

MeDiCal OffiCe OWner/user OppOrtunity — aDJaCent tO sCripps MerCy hOspital: Two-story medical building for sale, located on the corner of Lewis St. and 3rd Ave. at 233 Lewis Street, adjacent to Scripps Mercy Hospital. Property has tremendous foot traffic, a flexible floor plan, 10 off-street parking spaces, and is elevator-served. Take advantage of this exclusive opportunity to own on-campus via SBA Financing (with as little as 10% down) for effectively less than renting in Hillcrest’s dense medical office submarket. For more informa-tion or to schedule a property tour, contact Nic Lyon or Evan Kovac at (858) 373-3100 or email [email protected]. [859]

neW spaCe tO share in Kearny Mesa: Lo-cated directly across from Sharp Memorial Hospital in a Class A medical office building. The 2400ft2 space is perfect for a part-time or full-time, shared office ar-rangement. The reception area was designed to com-fortably accommodate those with disabilities. Dual windows facilitate easy check-in. There are ample, built-in staff work stations. Staff also enjoy a private lounge. A furnished office and dedicated exam room are available for the physician. The office suite also includes a leaded room for minor procedures. Terms negotiable. Please contact [email protected] for more information. [857]

MeDiCal OffiCe spaCe fOr rent in enCini-tas: Convenient location five minutes from Scripps Encinitas Hospital. Close to 5 freeway. The 800ft2 space includes two spacious exam rooms, private consultation/doctor’s office, private bathroom, lunch-room, and a spacious waiting room shared with one other doctor. Very affordable rent. Office located at the corner of Encinitas Blvd. and Manchester Ave. Call (760) 519-0102 or email [email protected] for more information. [855]

sCripps ranCh OffiCe spaCe tO share: Lo-cated at 10672 Wexford St. in San Diego with easy access to I-15. 4,000ft2 office with nine exam rooms (four available) and digital X-ray suite in a class A med-ical building. Office is currently occupied by an ortho-pedic surgeon looking to share space. Options avail-able for space sublease or cost sharing of staff, X-rays, and office equipment. Practice currently uses CCHIT certified eClincalWorks EMR with e-prescribing. For more information, please contact Ian at (858) 536-9500 or email at [email protected]. [852]

DOWntOWn OffiCe spaCe aVailaBle: Family practice physician in downtown San Diego has office space available. Preferably a primary care physician, but open to any healthcare provider. If interested, please call (858) 270-7633. [735]

OffiCe spaCe aVailaBle iMMeDiately: Ad-jacent to Tri-City Medical Center and North Coast Surgery Center. Provide large consultation room, two exam rooms. Conditions are negotiable. Full or part time. Free parking. Easy access to 76 or I-5. If inter-ested, please email [email protected] or call (760) 726-2500. [840]

OffiCe spaCe fOr lease: Medical Office space available 800–2,000ft2. Valet parking, walking dis-tance to Mercy Hospital. To view call (619) 733-7497 or email [email protected]. [838]

OffiCe spaCe in hillCrest: Office space avail-able in Hillcrest at the Mercy Medical Building. Located directly across from Scripps Mercy Hospital. Excellent staff, state-of-the-art office and equipment. Please send letter of interest to [email protected]. [810]

luXuriOus / Beautifully DeCOrateD DOC-tOr’s OffiCe neXt tO sharp hOspital fOr suB-lease: The office is conveniently located just at the opening of Highway 163 and Genesee Avenue. Lease price is very reasonable and appropriate for ENT, plastic surgeons, OBGYN, psychologists, re-search laboratories, etc. Please contact Mia at (858) 279-8111 or at (619) 823-8111. Thank you. [836]

BuilD tO suit: Up to 1,900ft2 office space on Uni-versity Avenue in vibrant La Mesa/East San Diego, across from the Joan Kroc Center. Next door to busy pediatrics practice, ideal for medical, dental, optom-etry, lab, radiology, or ancillary services. Comes with 12 assigned, gated parking spaces, dual restrooms, server room, lighted tower sign. Build-out allowance to $20,000 for 4–5 year lease. $3,700 per month gross (no extras), negotiable. Contact [email protected] or (619) 504-5830. [835]

3998 Vista Way in OCeansiDe: Two medical office spaces approximately 2,000ft2 available for lease. Close proximity to Tri-City Hospital with pedes-trian walkway connected to parking lot of hospital, and ground floor access. Lease price: $2.20 +NNN. Ten-ant improvement allowance. For further information, please contact Lucia Shamshoian at (760) 931-1134 or at [email protected]. [834]

sCripps enCinitas COnsultatiOn rOOM/eXaM rOOMs: Available consultation room with two examination rooms on the campus of Scripps Encinitas. Will be available a total of 10 half days per week. Located next to the Surgery Center. Recep-tionist help provided if needed. Contact Stephanie at (760) 753-8413. [703]

share OffiCe spaCe in la Mesa — aVailaBle iMMeDiately: 1,400 square feet available to an ad-ditional doctor on Grossmont Hospital Campus. Sepa-rate receptionist area, physician’s own private office, three exam rooms, and administrative area. Ideal for a practice compatible with OB/GYN. Call (619) 463-7775 or fax letter of interest to La Mesa OB/GYN at (619) 463-4181. [648]

OffiCe spaCe tO share: Currently occupied by orthopaedic surgeon. Great location close to Scripps/Mercy and UCSD Hospital. Looking to share with part-time or full time physician. Fully furnished, fully equipped with fluoro machine and 4 exam rooms and staff. (NEGOTIABLE) Please contact Rowena at (619) 299-3950. [804]

physiCian pOsitiOns aVailaBle

internist neeDeD: Group practice. Minimum 40+ hrs./week. Night call on as-needed basis. Competitive salary, non-negotiable. No medical/dental insurance covered. No retirement plan. No paid vacation. Con-tact by email at [email protected]. [863]

internal MeDiCine, part-tiMe pOsitiOn, pri-Vate praCtiCe, WOnDerful JOB OppOrtu-nity!: Outstanding opportunity to work part time or more in a mature, premiere private practice setting in North San Diego County, outpatient only. This unique position blends the rewards of private practice and traditional continuity of care with scheduling flexibility. Perfect for any physician who wants to transition from the demands of a full-time position, or who wants to maximize job satisfaction in an extremely high quality work environment while still working part time. Contact (619) 248-2324 for more information. [861]

psyChiatrist Or faMily praCtiCe/psyChi-atry Or internal MeDiCine/psyChiatry: Full-time position (40 hours per week) open at our behavioral health clinic in Escondido. The staff psy-chiatrist primarily provides evaluation and medication management services through psychiatric evaluation, diagnostic assessment, medication management, psycho-education, and follow-up. Candidates must have a current California medical license, DEA and CPR certifications. Graduation from a psychiatry resi-dency is required. Please send CVs to Dr. Jim Schultz via email at [email protected] or fax to (760) 796-4021, “Attn: Psychiatry — Date”. [860]

internal MeDiCine physiCian: Internal medi-cine physician to join a well-established turnkey prac-tice located near Alvarado Hospital. New physician will take over existing practice, weekend call one in five weekends. Full laboratory, dexa machine, 2D echos, and vascular studies done in the office. Traditional in- and out-patient practice. Benefits and salary leading to partnership. Interested candidates should contact

neW MeDiCal BuilDing alOng i-15: pinnacle medical plaza is a new 80,000 sF building recently completed off scripps poway parkway. The location is per-fect for serving patients along the i-15 from mira mesa to rancho bernardo and reaches west with easy access to highway 56. suites are available from 1,000—11,000 sF and will be improved to meet exact requirements. Free renT incenTives and a generous improvement allowance is provided.

For information, contact ed muna at 619-702-5655, [email protected]

www.pinnaclemedicalplaza.com

MeDiCal DireCtOr: Licensed physi-cian for busy outpatient substance abuse program. Treatment for opiate/opioid ad-diction — maT format — methadone and su-boxone. 32 hours a week. san Diego and el cajon locations.

contact Dennis Whitmyer at [email protected]

or at (619) 718-9890

http://www.pinnaclemedicalplaza.com




Lydia Gormish at (619) 229-5055 and submit curricu-lum vitae to [email protected]. [853]

prOfil institute fOr CliniCal researCh seeKing COntraCt physiCian: At Profil, we combine the careful and critical attitude of academic science with the professionalism of the bio-phar-maceutical industry. Located in Chula Vista, Profil Institute for Clinical Research is currently accepting applications for a highly qualified contract physician. Reports to medical director. Main purpose of job: Ensure the safety and wellbeing of human subjects; ensure integrity of study data; provide medical lead-ership and supervision for human clinical trials within PICR. Work side by side with a highly committed team proud of its contribution to diabetes and obesity re-search. Profil offers a competitive salary, excellent benefits, and career opportunities in a dynamic, quali-ty-focused environment. For further information, visit SDCMS.org/classifieds/physician-positions-available. Forward resumes to [email protected]. No faxes or phone calls, please. [851]

physiCians neeDeD: Full-time, part-time, and per-diem opportunities available for family medicine, pedi-atric, and OB/GYN physicians. Vista Community Clinic is a private, nonprofit outpatient clinic serving the communities of North San Diego County. Must have current Calif. and DEA licenses. Malpractice coverage provided. Bilingual: English/Spanish preferred. For-ward resume to [email protected] or fax to (760) 414-3702. Visit our website at www.vistacom-munityclinic.org. EOE/M/F/D/V [846]

internal MeDiCine physiCians: SHARP Rees-Stealy Medical Group, a 350+ physician multi-specialty group in San Diego, is seeking full-time BC/BE internal medicine physicians to join our staff. We offer a first year competitive compensation guarantee, excellent benefits package, and shareholder opportunity after two years. Please send CV to SRSMG, Physician Ser-vices, 2001 Fourth Avenue, San Diego, CA 92101. Fax: (619) 233-4730. Email: [email protected]. [842]

OBstetriCians neeDeD: La Maestra Clinic is seek-ing to contract with obstetricians willing to do deliveries of our patients at Sharp Mary Birch, Scripps Mercy, or Grossmont Hospitals. We do all prenatal care, transfer to you at 36 weeks, then we resume care post-partum. No high-risk cases. Excellent opportunity! Interested? Contact David Priver, MD, OB/GYN Medical Director, at (619) 987-3092 or at [email protected]. [839]

lOOKing fOr 1–2 neurOlOgists tO JOin Our praCtiCe in la JOlla: We are located on the cam-pus of Scripps Memorial Hospital. This is a well-estab-lished (35+ years) practice. We have a strong referral base. Our practice treats neurodegenerative diseases with emphasis on dementias. We see a large number of movement disorder, stroke, and Botox treatment, as well as Parkinson’s disease. One of our physicians is the stroke director at Scripps Memorial Hospital, La Jolla. Outstanding earning potential and the option to expand into other areas is certainly a possibility. Email [email protected]. [837]

physiCian pOsitiOn WanteD

physiCian pOsitiOn WanteD: Female OB/GYN in solo practice for over 20 years in Southern California seeking part- or full-time position in San Diego area. Insured. Clean background. Please contact [email protected]. [833]

nOnphysiCian pOsitiOns aVailaBle

prOViDer praCtiCe Manager: About Us: San Diego Hospice and The Institute for Palliative Medi-cine (SDHIPM) is one of the 10 largest community-owned, not-for-profit hospice programs in the nation,

caring for the 1,000 patients daily in their homes or other facilities in San Diego County. Our mission is to prevent and relieve suffering and to promote quality of life, at every state of life, through patient and fam-ily care, education, research, and advocacy. Position Description: The provider practice manager oversees all medical staff support, including administration, planning, budgeting, financial management, provider scheduling, and credentialing. Working in conjunc-tion with the practice director, the provider practice manager ensures full and effective administrative and compliance support for the provider practice group. Works with IT, finance, and health information on documentation, billing, electronic medical record ac-tivities, and other activities of, and supports for, the provider practice group. Participates as appropriate in strategic and planning discussions related to provider and patient care services operating models and sup-ports integration of direction. Education: Requires a bachelor’s degree, preferably in health administration or business administration. Experience: Must have at least three years of experience in managing the op-erations a physician practice group. Prior experience in a home health or hospice setting is preferred. Ex-perience with electronic health records ideal. Must demonstrate ability to not only use computer systems effectively but also to employ them to improve pro-cesses. Familiarity with hospital and/or hospice regu-lations required. Position is full time, Monday through Friday. Shift is 8:00am to 5:00pm. sdhospice.org/careers [858]

lOOKing fOr a liCenseD pnpC: With two years experience for a pediatric office in Clairmont area. Part/full time. Call (858) 268-0702. Fax (858) 268-0374. [856]

WanteD CalifOrnia-liCenseD Cls gener-alist: For lead technologist for busy group practice. Must excel at multitasking and be able to supervise lab assistants and other CLS while performing patient testing. Will oversee day-to-day operations, including quality control, lab workflow, and troubleshooting. Instrumentation includes Dimension Expand and Cell-Dyn. Strong technical background required. Two years plus experience preferred. Reports to lab director and technical consultant. Excellent benefits package. Sal-ary commensurate with qualifications. Contact Lydia at (619) 229-5055. [845]

physiCian assistant Or nurse praCtitiO-ner: We have an opening for a licensed midlevel prac-titioner (physician assistant or nurse practitioner) in our specialty practice. The successful candidate must be able to make focused patient assessments and have experience in clinical decision-making appropri-ate to a midlevel provider. We provide an environment of strong clinical support and access to supervising physician. We’re willing to make an investment in train-ing the right candidate. The qualified candidate must be: graduate of an accredited program; current DEA certificate; Calif. license; Spanish speaking a plus; 2+ years of clinical experience. Please email cover letter, CV, and salary requirements to [email protected]. [844]

lOOKing fOr a Mature, eXperienCeD MeDi-Cal praCtiCe Manager: Twenty-hour-per-week position. Established nephrology practice with two physicians and a third physician in the office in another specialty. Duties: The manager must have computer practice management and EHR experience. The man-ager must be familiar with all state and federal regula-tions pertaining to medical office management. The manager has to be able to evaluate and direct the of-fice staff. The manager must be able to communicate and work with the four physicians in the office (there is a locum physician). The manager must be able to hire and fire people in a legal and professional way. The office is currently re-tooling with Allscripts; this is

our software company as we move toward meaning-ful use. Dr. Ramenofsky’s wife is his account manager and works remotely. She is in charge of working with Allscripts to evaluate and re-tool the office to quality for the stimulus. The office manager will have to in-teract with her on a limited basis and then direct the office staff. Mrs. Ramenofsky also manages the hard-ware in the office, so that is one less duty the office manager has to perform. The entire office will re-train with the Allscripts academy onsite, the new manager will participate in this training for practice manage-ment and EHR. The manager will need to hold weekly or bi-weekly meeting with the staff to communicate and maintain high quality moral and work in the of-fice. Contact Lauren Ramenofsky via her email: [email protected]. [843]

MeDiCal assistant: Full-time medical assistant position available for general practice office. Four, 10-hour day shifts: Monday, Tuesday, Thursday, Friday. Office closed on Wednesday. Experience required. Please fax resume with cover letter to (858) 756-5952. If you have any questions, please call (858) 756-2340. [831]

lOOKing fOr eXperienCeD / liCenseD nurse praCtitiOner: Part time / full time, for a busy pri-vate primary care practice. Spanish helpful. National certification required. Location: Oceanside/Tri-City area. Compensation: competitive. The nurse practitio-ner will provide general medical care and treatment to patients in the office. Under the direction of physi-cian: Performs physical examinations and preventive health measures within prescribed guidelines and in-structions of physician. The nurse practitioner orders, interprets, and evaluates diagnostic tests to identify and assess patient’s clinical problems and healthcare needs. Records physical findings, and formulates plan and prognosis, based on patient’s condition. Dis-cusses case with physician to prepare comprehensive patient care plan. Submits healthcare plan and goals of individual patients for periodic review and evalua-tion by physician. Prescribes or recommends drugs or other forms of treatment such as physical therapy, inhalation therapy, or related therapeutic procedures. May refer patients to physician for consultation or to specialized health resources for treatment. Call (760) 639-1204. Fax (760) 630-1252. Email [email protected]. [830]

praCtiCe fOr sale

MeDiCal eQuipMent

saCrifiCe sale: Slightly used, full-size hip and spine HOLOGIC Bone Densitometer. Price negotiable. Call (760) 703-0691. [755]

ranChO BernarDO MeDiCal Weight lOss praCtiCe fOr sale $75,000: practice uses OpTiFasT and counseling programs-can add other programs. bariatric specialty not required-OpTiFasT offers physician training. patients see doctor or ma once week, get product, do labs, and attend lifestyle modification with counselors. Take over with no start-up is-sues, payments are cash/credit card – no in-surance. Doctor’s other practice expanding, forcing sale. Great freeway access and park-ing. easy transition with fully equipped office space, low rent, expert staff, website, etc.

call Diane 760-580-4423 or [email protected]



themedicalstudentperspectiveBy Rachel Hogen, MS-II

With health reform passing at the end of my first year of medical school, I decided to spend my summer interning at Capitol Hill in a con-gressman’s office in hopes of determining a physician’s place in the politics of healthcare. While I certainly did not find politics to be the most beautiful of decision-making processes at times, I accepted it as our current reality in hopes of learning something from my sum-mer. In the end, I discovered a Capitol in need of the unified presence of physicians.

I learned early on that congressmen are ac-tually quite responsive to their constituents, as my fellow interns and I answered constitu-ent calls and logged the mail and faxes each day. There is a constant eye toward what the constituents want. In fact, the desires of constituents seem to be the decisive factor in how the congressman votes each day. In ad-dition, those constituents who make their interests readily apparent, or those constitu-ents that are doing something beneficial for the district, seem to bear greater influence. For example, I discovered during my stay that while the congressman has limited stance on agricultural issues because there are no farms in the district, he is a proud advocate for facili-

tating the important advancements being made by the biotech indus-tries in San Diego. Thus, I got to thinking how many doctors lived in the district, and, in combination with their patients, I envisioned their vast potential to positively influence the politics of each day. Their potential further amassed in my head when I realized that, whereas a district may lack farms or miners or fisherman, no district lacked doctors.

The second thing I found par-ticularly striking at the Capitol was

the overwhelming workload of the congress-men and staffers. This has direct implications on how they treat physicians. It means that they regard doctors as doctors, and care little for their specialty of choice. They do not have the time to learn and track the needs of each specialty. Thus, I came to believe that the differences between specialties need to be worked out among doctors before they talk with the people in political power if doctors want to wield any power themselves. This ap-plies to the physician research community as well. During a committee hearing regarding the best PTSD treatments to be adopted by the VA, I watched the committee chairman ask a discordant Duke neurosurgeon and physician specializing in hyperbaric oxygen therapy why they couldn’t talk to each other a bit before coming to talk to him.

The last and most influential lesson that I took from my summer is the huge potential for physicians to become involved as educa-tors in the formation of health policy. Physi-cians are seen by politicians as experts in the provision of healthcare. From my first day in the office, I was respected and utilized as a source of specialized knowledge in science and healthcare for merely deciding to em-

bark on the path to becoming a physician. As I said, congressmen and their staff are highly overworked. They are not capable of becom-ing experts on every issue, especially an issue as complicated as healthcare. The vast major-ity of their day is spent seeking guidance as to the best course of action to take — whether through lunch talks on healthcare reform, sharing information with other offices, or calling Health and Human Services. As recog-nized experts in their field, doctors need to be more available as a source of this guidance.

Furthermore, the debates surrounding the Sustainable Growth Rate (SGR) in June led me to understand that guidance from physicians should be as productive as possible. As experts in their field, physicians should be a source of knowledge not only about the problems that physicians face, but also the problems that the provision of healthcare in the United States faces. For politicians, SGR is a budget-ary issue. Most politicians agree that it’s im-portant to adequately reimburse physicians, but when faced with reforming and fixing SGR, politicians are worried about the deficit. Their underlying concern is how healthcare spending is going to be limited in the future. As highly knowledgeable, educated, and practiced as they are, physicians should have an answer to this question, and they need to have an answer if they want to be effective in protecting their own interests.

My summer in a congressman’s office gave me a brief insider’s view into the daily ac-tivities of running our country, and I found a much-needed place for physicians in the process. I met a Capitol that had not yet come to terms with the health reform legisla-tion passed more than five months ago. I ate countless free sandwiches at lunch talks dedi-cated to deciphering the Patient Protection and Affordable Care Act (PPACA) and sway-ing congressmen and their staff on its impli-cations. I experienced a Capitol asking, what did we pass? What does it mean? What do we do next? A Capitol yearning for a unified body of physicians with a clear and strong voice to help them find the answers.

{ABOuT THE AuTHOR} Ms. Hogen, SDCMS-CMA member since 2009, is a second-year medical student at the UC San Diego School of Medicine.

A Summer at the CapitolAn Insider’s View Into the Daily Activities of Running Our Country


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