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November 2011 • Vol. o 33 No. 11

Official Magazine of FRESNO COUNTY Fresno-Madera Medical Society KERN COUNTY Kern County Medical Society KINGS COUNTY Kings County Medical Society MADERA COUNTY Fresno-Madera Medical Society TULARE COUNTY Tulare County Medical Society

Vital Signs

See Inside: Is Your Practice Ready for 5010? Air Quality CALPAC: Fighting for You


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Vital Signs Official Publication of Fresno-Madera Medical Society Kings County Medical Society Kern County Medical Society Tulare County Medical Society

Contents CMA NEWS ................................................................................................................................5 iHEALTH NEWS.........................................................................................................................14 NEWS CMA 5010: Is Your Practice Ready for 5010? .........................................................................11 CALPAC: Fighting for You; and Membership Form ....................................................................12

November 2011 Vol. 33 – Number 11 Editor, Prahalad Jajodia, MD Managing Editor, Carol Rau Fresno-Madera Medical Society Editorial Committee Virgil M. Airola, MD John T. Bonner, MD Hemant Dhingra, MD David N. Hadden, MD Roydon Steinke, MD Kings Representative TBD Kern Representative John L. Digges, MD

AIR QUALITY: Breathing in America.........................................................................................15 CLASSIFIEDS ...........................................................................................................................19 TULARE COUNTY MEDICAL SOCIETY.........................................................................................16 • Gemstone Primer • CPT and ICD9 Requirements • TCMS Holiday Dinner: Save the Date December 1 KERN COUNTY MEDICAL SOCIETY ............................................................................................17 • President’s Message FRESNO-MADERA MEDICAL SOCIETY .......................................................................................18 • Membership Meeting Scheduled November 9 • Fresno County Regional Forensic Science Center Open House December 7

Tulare Representative Gail Locke

Vital Signs Subscriptions Subscriptions to Vital Signs are $24 per year. Payment is due in advance. Make checks payable to the Fresno-Madera Medical Society. To subscribe, mail your check and subscription request to: Vital Signs, Fresno-Madera Medical Society, PO Box 28337, Fresno, CA 93729-8337.

Cover photography: “Fall Colors”, Arcadia National Park, Maine by Joseph Hawkins, MD

Advertising Contact: Display: Annette Paxton, 559-454-9331

Calling all photographers: Please consider submitting one of your photographs for publication in Vital Signs. – Editorial Committee

Classified: Carol Rau, 559-224-4224, ext. 118

Vital Signs is published monthly by Fresno-Madera Medical Society. Editorials and opinion pieces accepted for publication do not necessarily reflect the opinion of the Medical Society. All medical societies require authors to disclose any significant conflicts of interest in the text and/or footnotes of submitted materials. Questions regarding content should be directed to 559-224-4224, ext. 118. V I TA L S I G N S / N OV E M B E R 2 0 1 1



The Pursuit of Excellence



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TOPICS: Excellence or Else! Safety in Space: What We Learned from the Challenger & Columbia Tragedies; Technology Revolution Inspired by the Space Program; and America’s Future in Space Glenn D. Steele Jr. MD, PhD, President & CEO, Geisinger Health System

TOPIC: Excellence in an Integrated Health System: Looking Ahead to HealthCare Reform

John Popovich Jr. MD President & Chief Executive Officer, Henry Ford Hospital

TOPIC: Medical Professionalism in Today’s Healthcare World

Mark Morgan Vice President, General Manager, Anthem Blue Cross – California Small Group Business

TOPIC: ACO: Impact on Physicians Aldo De La Torre (not pictured) Vice President, Contracting, Anthem Blue Cross

TOPIC: Insurance Exchange: What Does That Mean To Physicians, Insurance Companies & Patients? Joanne M. Conroy MD Chief Health Care Officer, Association of American Medical Colleges

TOPIC: Update: Impact of Health Care Reform on Academic Medical Centers

Doris Kearns-Goodwin Acclaimed American Historian, Best-Selling Author, Pulitzer Prize Winner, Popular Network Panelist

TOPIC: A Moment in Time – A Historical Perspective

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CMA NEWS CMA Sends Letter to Congressional “Super Committee” on Deficit Reduction and to Chairman Wally Herger (R-CA) TRUE DEFICIT REDUCTION MUST ADDRESS THE MEDICARE SGR END THE MEDICARE MADNESS Dear Honorable Members of the Joint Select Committee on Deficit Reduction: The California Medical Association urges the Committee to end the Medicare madness and repeal the physician SGR payment formula once and for all in your final legislation. Deficit reduction cannot be honestly achieved until Congress eliminates the Medicare SGR and adopts an alternative payment system that promotes access to appropriate, efficient, high quality care. We are also urging the Committee to resist additional cuts to California’s Medi-Cal (Medicaid) program that will create barriers to obtaining a physician’s care. Stable reimbursement in the Medicare and Medicaid programs not only protects access to care but it makes economic sense as well. Repealing the Medicare SGR Now Reduces the Debt It is time for Congress to make a fiscally responsible choice. Five years ago the cost to repeal the SGR was $48 billion. Today it is $300 billion and in a few years it will be nearly $600 billion. Congress needs to stop digging the hole and pay the bill. Physicians Contribute to the Economic Well-Being of California and our Nation Physicians are facing a 30% Medicare SGR cut on January 1, 2012 and a 10% cut in the Medi-Cal program. There is wide bipartisan agreement in Congress that physicians cannot sustain such cuts and continue to practice medicine. Physicians are vital to the health and economic well-being of California. Physicians employ more than 500,000 Californians and are substantial contributors to the state and federal tax base. A recent report by the Lewin Group states, “…strong physician practices not only ensure the health and well-being of communities but also critically support local economies and enable jobs, growth and prosperity.” The attached report shows the contribution by community. Providing stable reimbursement will keep physicians in practice and prevent further unemployment and economic erosion. The MedPAC Proposal and Other Cuts Will Harm Access to Care for California’s Patients We also urge you to resist adopting the Medicare Payment Advisory Commission (MedPAC) proposal that would repeal the SGR but pay for it by imposing an 18% payment cut on specialist physicians followed by a 7 year freeze and a 10 year payment freeze on primary care physicians. A freeze equates to an actual 3-6% reduction every year. It is preposterous to think that physicians and patients should bear the brunt of Congress’ inability to address the flawed formula.

There is no question that the MedPAC proposal will exacerbate the already serious access to care problems in California. For instance, • California has some of the lowest patient to primary care physician ratios in the country. • More than half of California physicians are over the age of 55. This proposal will force many of these late career physicians out of practice. • Prior to the passage of health care reform, the University of California projected that the growth in physician demand would outpace physician supply by 20% in a few years. • A recent survey shows that if the Medicare SGR cuts occur 72% of California physicians would reduce the number or stop accepting new Medicare patients and 55% would reduce the number or stop seeing Medicare patients altogether. • California’s private insurer payment rates are influenced by Medicare so cuts to Medicare rates have an added negative impact on physician practices. To protect access to health care, Congress must promote policies that sustain physician practices. Protect California’s Medicaid (Medi-Cal) Program from Further Cuts Finally, California’s Medicaid (Medi-Cal) program is already one of the most efficient in the country. Our reimbursement rates rank 47th nationally. The state has recently proposed to reduce physician reimbursement rates by 10%, which would place MediCal rates 60% BELOW MEDICARE. A physician would receive $11 for an office visit – hardly adequate to cover a physician’s office overhead and staff. Due to these extremely low rates, 2/3 of the state’s physicians already can’t afford to take Medi-Cal patients and thus, half of Medi-Cal patients report they cannot find a doctor to care for them. Medi-Cal patients are by far the highest users of California’s emergency departments. CMA urges the Committee to resist short-sighted proposals to cut funding. Paying appropriate rates ensures that physicians can participate in the program and provide efficient primary care that prevents unnecessary ER visits and hospitalizations, which saves taxpayer dollars and patient’s lives. Please repeal the Medicare SGR and resist further cuts to California’s Medi-Cal program. Such action is fiscally sound and will prevent irreparable harm to California’s seniors, disabled patients, pregnant women and children. We pledge to work with you to develop alternatives based on innovative models being adopted in California today. Sincerely,

James G. Hinsdale, MD, FACS CMA President Congressman Wally Herer Continued on page 7 V I TA L S I G N S / N OV E M B E R 2 0 1 1




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CMA NEWS Continued from page 5 Chairman Subcommittee on Health Ways and Means Committee U.S. House of Representatives Washington, DC 20515 Dear Chairman Herger: As the Ways and Means Subcommittee on Health develops Medicare recommendations for the Joint Select Committee on Deficit Reduction, the California Medical Association urges you to include authorization for a Medicare private contracting pilot program. The CMA supports the “Medicare Patient Empowerment Act” (H.R. 1700) introduced by Representative Tom Price, MD (RGA) which would fully authorize private contracting in the Medicare program. We believe the legislation would help to preserve the physician-patient relationship by allowing seniors to continue to use their Medicare benefit, even with physicians who do not accept Medicare patients. As physicians face an enormous 30% Medicare SGR payment cut on January 1, 2012 that was preceeded by a decade of instability and failed attempts by Congress to fix the SGR, it is clear that Congress needs to immediately test and adopt alternatives payment reforms. Otherwise, access to care for California’s seniors will continue to erode. The Medicare private contracting approach would expand access to care without costing the federal government additional resources. While we support full authorization, we believe that voluntarily testing this approach in certain regions of the country with Medicare’s oversight would provide important information and lay the foundation for more widespread adoption. Thank you for your consideration. Sincerely,

James G. Hinsdale, MD, FACS President cc: The Honorable Kevin McCarthy



previously reported, the California Medical Association (CMA) has received a number of complaints from physicians that the Anthem Blue Cross Special Investigations Unit (SIU) is requesting refunds outside of the 365-day period allowed by California law. State law allows health plans to pursue recovery of any type of overpayment made to providers within 365 days of the date the claim was paid. For claims older than 365 days, plans can seek to recover overpayments only if the alleged overpayment was “caused in whole or in part by fraud or misrepresentation on the part of the provider.” CMA believes that Blue Cross is using an

overly broad definition of “misrepresentation” to seek recoupment on claims older than one year. In June, CMA filed a formal complaint with the Department of Managed Health Care (DMHC) asking that it investigate these potential violations. DMHC subsequently referred CMA’s complaint to its Enforcement Division. CMA has received calls from physicians who report that they have been contacted by Blue Cross SIU, offering to reduce overpayment amounts due if they agree to sign settlement agreements. CMA believes some of the recoupment requests that the SIU is trying to settle may be the same requests that are the subject of our complaint filed with DMHC. Physicians who are approached to sign any type of settlement agreement are strongly encouraged to ask for the offer in writing and to have an attorney review the settlement before signing. Often, these types of settlement agreements require that physicians waive and abandon their legal rights over the moneys at issue. To help physicians understand their rights and options when it comes to health plan refund requests, CMA has published a “Special Investigations Unit Audit Guide.” This document is available free to members in CMA’s online resource library. Contact: CMA’s reimbursement helpline, 888-401-5911 or



California Medical Association (CMA) often receives questions from members as to appropriate billing policy when a patient repeatedly “no-shows” or misses a scheduled appointment. What you may not know is that unless a physician has entered into a contract with a payor that prohibits such charges, a physician may charge a patient when he or she misses an appointment or does not cancel in adequate time to allow another patient to fill the appointment slot – if advance notice of such a billing policy is given. Specific billing rules may also apply with regard to certain payors (e.g., Medi-Cal and Medicare). For more information about your rights when it comes to billing patients for missed appointments, see CMA medical-legal document #0110, “Billing Patients.” This document includes a detailed discussion about noncovered services, discounts for the uninsured, and discounts for prompt payment and stresses the importance of receiving and maintaining accurate patient financial information. It also contains a sample patient financial responsibility form. Medical-legal document #0110, “Billing Patients,” as well as the rest of the CMA medical-legal library (formerly CMA OnCall), is available free to members at CMA’s online resource library. Nonmembers can purchase medical-legal documents for $2 per page. Contact: Samantha Pellon, 916-551-2872 or


Medical record retention is an issue that routinely arises in a physician’s medical practice and one that should be evaluated when you are developing appropriate office policies and Continued on next page V I TA L S I G N S / N OV E M B E R 2 0 1 1


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CMA NEWS Continued from page 7 procedures. In California, there are several statutory authorities that specifically regulate the retention of medical records. For instance, a physician who treats Medi-Cal patients must retain the records of Medi-Cal patients for three years after the date that the last service was rendered under the Medi-Cal program, while physicians who are Qualified Medical Examiners in Workers’ Compensation cases must retain all medical-legal reports for five years from the date of the employee’s evaluation. As there are differing statutory requirements, potential contractual obligations, and the California statute of limitations on when a suit may be filed for professional negligence, CMA offers several recommendations for possible retention periods in its medical-legal document #1160, “Retention of Medical Records.” Document #1160 also includes recommendations for physicians who may be retiring or closing their practice, appropriate protocols to follow when destroying medical records, and the proper safeguards that should be implemented to comply with HIPAA and California law. Medical-legal document #1160, “Retention of Medical Records,” as well as the rest of the CMA medical-legal library (formerly CMA On-Call), is available free to members in CMA’s online resource library. Nonmembers can purchase medical-legal documents for $2 per page. Contact: Samantha Pellon, 916-551-2872 or


The California Department of Health Care Services has begun accepting enrollments for the Medi-Cal EHR Incentive Program. Enrollment began on October 3 for hospitals, November 15 for groups and clinics, and December 15 for individual providers. Under the American Recovery and Reinvestment Act of 2009 (ARRA, or the “Stimulus Act”), physicians are eligible for financial incentives for demonstrating “meaningful use” of an electronic health record (EHR) system. Medi-Cal providers who meet certain patient volume thresholds will qualify for up to $63,750 paid out over six years, beginning as early as 2011 or as late as 2016. In the first year that a physician is enrolled in the incentive program, he or she can receive up to $21,250 for purchasing, implementing or upgrading an EHR system. Physicians will not have to demonstrate “meaningful use” until their second year in the program. Accessing these incentives will require a two-part enrollment. Physicians must first register with the Centers for Medicare & Medicaid Services (CMS) at They must then enroll in the Medi-Cal Incentive Program at Physicians qualify for incentives if: • Medi-Cal patients make up at least 30 percent of their patient volume. • They are a pediatrician with at least a 20 percent Medi-Cal patient volume. (However, pediatricians with 20 to 30 percent Medi-Cal patient volume only qualify for two thirds of the total incentive.)

• They practice in a federally qualified health center, rural health center, or Indian health clinic and at least 30 percent of their patient volume is “needy individuals,” such as Medi-Cal, Healthy Families, sliding scale, or uncompensated care. For more information on the Medi-Cal EHR Incentive Program, see Additional information on the Medi-Cal and Medicare EHR incentive programs, and other CMA HIT resources, is available at /hit. Contact: David Ford, 916-551-2554 or


The Department of Health Care Services (DHCS) recently awarded a 10-year contract to Affiliated Computer Services (ACS), which will serve as the new fiscal intermediary for MediCal. ACS will manage claims processing for health care providers in the Medi-Cal fee-for-service program, including physicians, pharmacies, hospitals and others. ACS assumed full responsibility for Medi-Cal claims processing and related services on October 3, 2011. All claim forms and submission processes will remain the same. Physicians should continue to submit claims as usual. If you have any questions regarding this transition, please contact Medi-Cal at 800-541-5555. CALIFORNIA MEDICAL ASSOCIATION’S MEDICAL-LEGAL LIBRARY (AVAILABLE ONLINE AT WWW.CMANET.ORG)

The California Medical Association’s 24-hour online medicallegal library is the most comprehensive health law and medical practice resource for California physicians. The medical-legal library’s documents include most of the Center for Legal Affairs’ California Physician’s Legal Handbook (CPLH), as well as more specialized information on peer review and other subjects. These documents are available free to members at or by calling the member help center at 800-786-4262. Nonmembers can purchase CMA ON-CALL documents for $2 per page at www.cmanet. CMA HOTLINES AND MEMBERSHIP BENEFITS • Membership Help Line: 800-786-4262 • Legal Information Line: 415-882-5144 • Reimbursement Help Line: 888-401-5911 • Contract Analysis: 415-882-3361 • Legislative Hotline: 866-462-2819 • Medical-Legal Documents: On-Call at

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CMA: 5010

Is Your Practice Ready for 5010? On January 1, 2012, physicians and others in the health care industry will be required to use the updated 5010 version of the Health Insurance Portability and Accountability Act (HIPAA) transactions standards to conduct electronic transactions such as claims submissions, eligibility verification, claims status, remittance advice, and referral authorizations. To avoid rejected claims and cash flow interruptions, physicians should prepare for the transition by working with their vendors, clearinghouses, billing services, and payors to upgrade and test their systems to ensure that they are able to successfully implement the new standards prior to the compliance date. To assist physicians in this transition, CMA has published the resource sheet, “Are you ready for the Transition to HIPAA Version 5010?” The sheet, which includes practice tips for implementation from the American Medical Association and a list of additional resources for physicians, is available free to members in CMA’s resource library. For more information, see CMA medical-legal document #1606, “HIPAA Electronic Transaction Rule,” also in the resource library. Medical-legal documents are free to members. Nonmembers can purchase documents for $2 per page. Contact: CMA reimbursement helpline, 888-401-5911 or


The following are five simple actions you can take now to start getting ready for the 5010 conversion. Please note: These are not all of the 5010 data reporting changes; you should check with your clearinghouses and billing vendors to determine the full scope of changes that apply to your practice. Action 1: Is your practice reporting the appropriate Type 2 (organizational) National Provider Identifier (NPI) number for the Billing Provider on all electronic claim submissions? In 5010, you must bill all payers the same way using your lowest “level” Type 2 NPI for the Billing Provider. (For example, if your practice has an NPI at the practice level and you have a lab facility under the practice that received a separate NPI, then when billing for the lab services, you will be required to report the lab’s NPI. The lab’s NPI will need to be reported the same way to all of your payers.) If you are not doing this today, work with your payers now on making the changes to report your Billing Provider NPI correctly for 5010. Action 2: Is your practice using the 9-digit ZIP code in the Billing Provider and Service Facility Location address fields in your electronic claim submissions? In 5010, the 9-digit ZIP code is required in these two address fields. Begin using the 9-digit ZIP code today in these locations in preparation for the 5010 requirements. Action 3: Is your practice currently reporting a PO Box in the Billing Provider address field of electronic claim submissions? PO Boxes are not permitted in the Billing Provider Address field in the 5010 claim transaction. The Billing Provider Address must be the street address or physical location of the Billing Provider. If you wish to have payments delivered to a PO Box or different address from the Billing Provider street address, report this address in the Pay-to Address field. If you will be changing the address you report today in the Billing Provider Address field, you should contact your payers about updating your enrollment information. Many payers use the address in their provider files to validate the physician, so they may pend or reject your claims if you begin submitting a different address in your claim. You may also need to update your information in the National Plan & Provider Enumeration System (NPPES) ( Action 4: Is your practice currently submitting electronic claim submissions that accurately balance at the line level? This will be a requirement in 5010, so begin making the claim balance at the line level. Payers will also be required to ensure the electronic remittance advice accurately balances at the line level. Action 5: Do you receive paper explanations of benefits? If not, now is the time to consider moving to electronic remittance advices. Use of the electronic transaction is more efficient and cost-effective for physician practices. In preparation for the electronic remittance advice transaction, become acquainted with the HIPAA mandated Claim Adjustment Reason Codes (CARCs) and Remittance Advice Remark Codes (RARCs) that are used in the transactions. To access the current HIPAA CARC and RARCs, visit to access a complimentary look-up tool or visit and select “Code Lists.”

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California Medical Association Political Action Committee

Participation Level:

2011 MEMBERSHIP FORM Fighting For You!

❏ $6500 - Diamond CALPAC, the California Medical Association Political Action Committee, supports candidates and legislators who understand and embrace medicine’s agenda. Health care in California ❏ $2500 - Platinum

is highly regulated and legislated. As government and the insurance industry continue their quest to control health care, your clinical autonomy is in great jeopardy. Now more than

❏ $1000 - President’s Circle

ever, you need to fight to keep medical decisions in your well-trained hands.

Fortunately, you do not have to wage the fight alone. ❏ $500 - Congressional Club

Successful legislative advocacy depends upon an integrated approach, consisting of lobbying, continuing grassroots activity and political action through CALPAC. CALPAC

❏ $300 - 300 Club

is operated by physicians for physicians. By focusing physician resources, CALPAC supports hundreds of candidates for state and federal office who share our philosophy and vision of the future of health care and medical practice.

❏ $150 - Sustainer

CALPAC is a voluntary political organization that contributes to physician-friendly candidates for state and federal office. Political law and CALPAC policy determines how your contribution to CALPAC is allocated. CMA will not favor or disadvantage anyone based

❏ $25 - Alliance

on the amounts of or failure to make PAC contributions, nor will it affect your membership status with the CMA. Contributions to PACs are voluntary and not limited to the suggested ❏ $10 - Student/Resident

amounts. Contributions are not deductible for state or federal income tax purposes.

Name: _____________________________________________________________________________________ Billing Address: _______________________________________________________________________________ City: ______________________________________________________ Zip:_____________________________ Phone: ___________________________________

Email: ____________________________________________

Amex/MstrCard/Visa #: _______________________________________________ Expiration Date: ______________ Signature: ________________________________ _______________ Security Code:________________________

❏ Self-Employed / Employer: ____________________________________________________________________ ❏ Physician

❏ Alliance

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1201 J Street, Suite 275, Sacramento, CA 95814 • Fax (916) 551-2549 • Phone (916) 444-5532


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CALPAC: Fighting for You! Richard Thorp, MD Chair, CALPAC Internist, Paradise, CA

As Chair of CALPAC (California Medical Association Political Action Committee), I wanted to give you an update on how CALPAC has been fighting for you in the political arena. CALPAC supports candidates and elected officials that are friendly to the House of Medicine. I can say that these members will now be strong advocates on our behalf. Despite our successes, we still face many challenges. Trial attorneys have already started a fight to overturn MICRA, California’s landmark Medical Injury Compensation Reform Act, there are ongoing efforts to erode the prohibition on the corporate practice of medicine, and there are continuous efforts to challenge your scope of practice. Your support is needed to build on our successes and ensure that we have the necessary resources to prepare for the 2011–2012 election cycle. These elections are going to be transformational for the California Legislative. The Citizen’s Redistricting Commission has finalized Congressional, State Senate, State Assembly and Board of Equalization districts. The perceptions of the commission’s decisions, good and bad, are likely to shape a national trend. These newly drawn districts, coupled with California’s open primary system, will result in a number of very contentious races. CALPAC has extensively studied the new districts and is preparing for these high profile races on your behalf. The bottom line is this: we must be stronger than ever to defend against increased challenges to physicians, both in the legislature and in the upcoming elections. That is why I am asking for your support. I have believed for some time that donating to CALPAC is one of the most important contributions that I make because it ensures Medicine has direct access to the policy makers that have the potential to come between me and my patients. Personally I have been a President’s Circle member for 9 years by donating $1,000 every year. By making a contribution today, you will ensure we continue to have the most active political affairs operation in California. 2012 is going to be a very challenging year with many more high profile elections for us to be involved in than ever before. Please visit to donate today! I look forward to working with all of you on behalf of our patients and our profession.

FOUR SPECIAL ELECTIONS THROUGHOUT THE STATE THIS YEAR HAVE YIELDED FRIENDS TO THE HOUSE OF MEDICINE Assembly District 4 (North of Sacramento) – CALPAC supported Beth Gaines, a republican businesswoman from Roseville. Mrs. Gaines handily won the election over democrat Dennis Campanale. Senate District 17 (Antelope Valley) – CALPAC supported former Assembly Member Sharon Runner, a republican businesswoman from Antelope Valley. Mrs. Runner also handily won the election over Darren Parker. Senate District 28 (Los Angeles) – CALPAC supported former democratic Assembly Member Ted Lieu. Assembly Member Lieu defeated republican James Thompson and moved to the upper house. Congressional District 36 (Los Angeles) – CALPAC was instrumental in AMA’s Political Action Committee supporting democratic Los Angeles Council Member Janice Hahn. Council Member Hahn defeated republican Craig Huey in the high profile race.

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iHEALTH NEWS Reprinted with permission from iHEALTHBeat



Optical Society of America recently announced that University of California-Davis researchers have modified Apple’s iPhone and transformed it into a low-cost, high-quality medical imaging device for analyzing blood samples, United Press International reports. To develop the device, Kaiqin Chu – a postdoctoral optics researcher at UC-Davis – inserted a $40 ball lens into a hole in a rubber sheet to create a low-powered magnifying glass. He then taped the rubber sheet onto the camera of an iPhone. When attached to the iPhone’s camera, the ball lens can examine features that are 1.5 microns in size, allowing users to identify various types of blood cells (United Press International, 10/3). Although the ball lens creates a distorted image, researchers developed a software program that takes multiple pictures of a blood sample as the camera or the sample moves. The software then combines the pictures into a large, undistorted image (Cass, Technology Review, 10/5). According to researchers, the modified smartphone could help health care providers diagnose blood diseases in developing countries and in rural clinics that lack access to laboratory equipment. In addition, the technology could send real-time data to health care professionals across the world for additional analysis (United Press International, 10/3). Researchers will present the iPhone attachment at OSA’s annual meeting in October. (Godt, CMIO, 10/5) Read more:


The American Board of Medical Specialties has formally recognized clinical informatics as a medical subspecialty, MedPage Today reports (Frieden, MedPage Today, 9/23). The formal recognition comes after a six-year push by advocates of clinical informatics. Physicians who are board-certified in any of the 24 primary medical specialties will be able to gain additional certification as medical informaticians (Versel, InformationWeek, 9/23). ABMS will administer the examination for physicians seeking certification as informaticians. According to a release from the American Medical Informatics Association, the first clinical informatics exam will be available next fall, and the first certificates will be awarded in early 2013 (Conn, Modern Healthcare, 9/23). AMIA is preparing materials for online and in-person courses for physicians who wish to take the exam. AMIA said the materials will be ready by spring 2012 (Manos, Healthcare IT News, 9/23). AMIA President and CEO Edward Shortliffe said clinical informatics is the first subspecialty certification available to any physician who already has received board certification in any primary medical specialty. The American Board of Preventive Medicine and the American Board of Pathology are joining ABMS as co-sponsors of the subspecialty. Other organizations also could sign on as co-sponsors. 14

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Sponsoring organizations will call on the Accreditation Council for Graduate Medical Education to approve a fellowship program for the subspecialty, according to InformationWeek (InformationWeek, 9/23). According to AMIA, the role of clinical informaticians is to combine knowledge of informatics tools and patient care to: • Assess and enhance clinical processes; • Determine the information needs of health care providers and patients; and • Continually work to improve clinical information systems, such as electronic health records and provider order entry systems (Healthcare IT News, 9/23). Read more: clinical-informatics-is-recognized-as-certified-medicalsubspecialty.aspx#ixzz1aaqW8Ci8


Government officials in the United Kingdom have announced that they are scrapping a £11 billion [about $17 billion] national health IT project, the Wall Street Journal reports. Officials said that some of the £6.4 billion [about $9.9 billion] spent on the health IT project so far has been wasted and that the program “is not fit to provide the modern IT services,” that the National Health Service needs (Whalen, Wall Street Journal, 9/23). Health Secretary Andrew Lansley said that the National Programme for Health IT, which launched in 2002, “let down the NHS and wasted taxpayers’ money” (Press Association, 9/22). The move comes after the House of Commons’ Public Accounts Committee published a report stating that the health IT project is “beyond the capacity of the Department of Health to deliver” (iHealthBeat, 8/5). The report particularly criticized the implementation of a system that aimed to help doctors and nurses track patients as they moved through the hospital. According to the report, there were “major delays” in the development and rollout of the system. The U.K. Department of Health said that future IT decisions will be made at the regional level and that more vendors will be allowed to compete for health IT contracts (Wall Street Journal, 9/23). In addition, the U.K. government is establishing a new cabinet-level oversight committee that will monitor future health IT investments to ensure funds are not wasted. Read more: REPORT: HEALTH CARE INDUSTRY UNPREPARED FOR DATA BREACHES


health care organizations are eager to embrace new technology, the industry is not adequately prepared to address potential data breaches, according to a report by PricewaterhouseCoopers, Reuters reports. For the report, PwC’s Health Research Institute conducted 600 interviews with health care executives in the spring of 2011. Researchers found that about 74% of health care organizations plan to expand their use of electronic health data. However, the report also found that: Please see iHealth News on page 15


Breathing in America Robert W. Watson III, MD Pediatrician, Modesto, CA

Two recent articles, one in the lay press and the other in a medical book, give further evidence that air quality is poor and dangerous to our health. Fortunately, we can and must do something about the challenge of bad air. WE ARE There is a recent book put out LOOKING FOR by the American Thoracic EVIDENCESociety titled “Breathing in BASED America.” In it, there is a study by INFORMATION TO Michael J. Lipsett et al. “LongFIND THE BEST Term Exposure to Air Pollution and Cardiorespiratory Disease in COURSE OF the California Teachers Study ACTION TO Cohort”. This study was longSOLVE THE term and had 100,000 women CHALLENGES teachers in it. THAT FACE US To quote the conclusions: NOW. “This study provides evidence linking long-term exposure to PM2.5 and PM10 with increased risks of incident stroke as well as IHD mortality; exposure to nitrogen oxides was also related to death from cardiovascular diseases.” We may think that air pollution affects only the respiratory system, when this article describes circulatory damages as well. So there’s the evidence-based information that we all long for. Scientific. Does that get you up and motivated to do something? The article in O, The Oprah Magazine in the October issue on page 50 describes an Oakland woman who was a housekeeper and a single mom. While cleaning an eco activist’s home, she came upon a stack of environmental magazines that changed the way she thought about the environment, especially dirty air.

iHealth News Continued from page 14 • Less than 50% of health care organizations have addressed issues related to the use of mobile devices; • About 47% of organizations have addressed issues related to health data privacy and security; and • Less than 25% of organizations have addressed issues related to the use of social media (Selyukh, Reuters, 9/22). James Koenig – co-lead of PwC’s Health Information Privacy and Security Practice – said the survey found that health data breaches often are carried out by “knowledgeable insiders – such as people in admissions, billing, computer programmers, the janitorial staff, even in security – who get access either to

At first she, like us, thought that these pollution problems are for someone else. She realized that not only did a polluted environment kill animals, it also damaged and killed people, including children. Her personal interest became acute when she connected the factors that pollute the air, like diesel truck exhaust, to the asthma that Robert L she and her grandchildren suffered from. She Watson III, MD noted that the hospitalization rate was seven times as high as other areas in California. Also noted was the black residue on the cars related to the air pollution. While working, she spent thousands of hours testifying before committees regarding the pollution and its damaging effects on people. She fought for cleaner air by rerouting the trucks away from residential areas. Her comment “If you’re not at the table, you’ll end up on the menu” is a pithy motivation for us to get out of the easy chair and into the government testimony rooms. Margaret Gordon, 64 years of age, changed careers from cleaning houses to cleaning the big house we all live in. We are looking for evidence-based information to find the best course of action to solve the challenges that face us now. Here we have further specific information regarding the effects of air pollution on the organs and the lives of people. What are we going to do about it? Are there other Margaret Gordons out there to take up the flag of cleaning the air so that all may breathe easier and wave it so that others may follow? If you are interested in helping this challenging cause, contact Michelle Garcia, air quality director at the Fresno-Madera Medical Society, 559-224-4224, ext. 119 or

building facilities or to computer systems for information” (Eisenberg, Bloomberg Businessweek, 9/22). Researchers found that: • More than 50% of surveyed executives said they were aware of a privacy or security breach at their organization during the past two years (Reuters, 9/22); and • 40% of survey respondents said they were aware of improper internal use of protected health data during the past two years. According to the report, theft accounted for about 66% of publicly reported health data breaches (Bloomberg Businessweek, 9/22). Read more: articles/2011/ 9/22/report-health-care-industry-unprepared-for-databreaches.aspx#ixzz 1aarzJ1UQ

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Tulare Gemstone Primer: In Time for Holiday Gift Giving Steven Cantrell, MD 3333 S. Fairway Visalia, CA 93277 559-627-2262 Fax 559-734-0431 website:

TCMS Officers Steve Carstens, DO President Gaurang Pandya, MD President-elect Mark Reader, DO Secretary/Treasurer Ralph Kingsford, MD Immediate Past President Board of Directors Steve Cantrell, MD Karen Haught, MD Thomas Gray, MD Parul Gupta, MD Monica Manga, MD H. Charles Wolf, MD CMA Delegates: Thomas Daglish, MD Roger Haley, MD John Hipskind, MD CMA Alternate Delegates: Robert Allen, MD Ralph Kingsford, MD Mark Tetz, MD Sixth District CMA Trustee James Foxe, MD Staff: Steve M. Beargeon, Executive Director Francine Hipskind Provider Relations Gail Locke Physician Advocate Thelma Yeary Executive Assistant

Gems, also known as gemstones or jewels, are usually minerals that for centuries have been used in jewelry, crowns, robes and other items of wealth. Non-minerals such as amber, coral and pearls are also considered gems. Gems can be displayed in any fashion, but are usually cut and polished. Often gems worn as jewels are cut into shapes and are faceted (see right). Facets are the angled cuts on the surface of a gem. There are over 130 recognized gems, but I will discuss only four: diamond, ruby, sapphire and emerald. These four are considered to be the precious gem stones. As an ophthalmologist, I have the luxury of having a slit lamp that provides magnified, stereo views of gemstones. Diamonds: The hardest mineral on Earth, Diamond is considered by many the most prized of all gemstones. The birthstone of April, diamonds are often used in jewelry, especially engagement rings. Due to their hardness, diamonds have many industrial uses. Diamonds are assessed base on four GEMSTONE CUTS qualities (often referred to as the Four Cs: cut, carat, color and clarity. Carat is the unit used to measure the weight of a Round Oval Pear Heart Marquise diamond and is broken down into 100 points. Five carats is equal to one gram. The term carat derived from the seeds found in carob tree pods which were historically used to measure diamond weight. Color of diamonds is classified using a scale Radiant Emerald Princess Baguette Trillion ranging from D (coloress) to Z (yellow). Clarity, the measurement of how visibly flawed a diamond is, ranges from Flawless (F) with no GIA COLOR CHART inclusions to I3 where inclusions are easily seen DEF Colorless with the naked eye. GHIJ Near Colorless Sapphires & Rubies: Sapphires and Rubies are KLM Faint Yellow gem quality Corundums. The distinguishing feature is that Rubies are red and Sapphires come in all NOPQR Very Fait Yellow other colors. Both are durable stones, just under STUVWXYZ Light Yellow diamonds in terms of hardness. Like diamonds, sapphires and rubies have industrial uses. While rubies are always red, sapphires are mostly associated with the color blue. When sapphires come in colors other t-han blue such as yellow, pink or green, they are often referred to as fancy sapphires. The color of sapphires used in jewelry is often enhanced by heating. The grading of colored Please see Gemstones on page 19


2011 is passing us by quickly and updated 2012 CPT and ICD-9 will be required for correct billing. Order now and we will have books shipped free directly to your office as soon as they become available. Please call us if you are interested in taking advantage of extraordinarily discounted rates for: CPT and ICD-9 for 2012 Please contact Dana Ramos, provider relations, to order or obtain information559-7340393, 16

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TCMS Holiday Dinner Event Thursday, December 1. Visalia Convention Center


Kings PORTIA CHOI, MD, MPH PO Box 1029 Hanford, CA 93230 559-582-0310 Fax 559-582-3581

2229 Q Street Bakersfield, CA 93301-2900 661-325-9025 Fax 661-328-9372 website:



KCMS Officers Portia S. Choi, MD President Joel R. Cohen, MD President-elect Calvin J. Kubo, MD Secretary Ronald L. Morton, MD Treasurer Mark L. Nystrom, MD Immediate Past President Board of Directors Alpha Anders, MD Brad Anderson, MD Eric Boren, MD Lawrence Cosner, MD Noel Del Mundo, MD John Digges, MD J. Michael Hewitt, MD Wilbur Suesberry, MD Tonny Tanus, MD Edward Taylor, MD CMA Delegates: Jennifer Abraham, MD Eric Boren, MD John Digges, MD Ronald Morton, MD CMA Alternate Delegates: Lawrence Cosner, Jr., MD Patrick Leung, MD Michelle Quiogue, MD Staff: Sandi Palumbo, Executive Director Kathy L. Hughes Membership Secretary

a friend and a veteran teacher named Bruce Caukin welcomed the arrival of a young colleague, Maria Chan, to his first period history class. She was to teach first period for a month, while Mr. Caukin observed, to learn important concepts of pedagogy. Said Mr. Caukin: “She presented many new ideas in teaching that I was not aware of,” noting that after thirty years in the classroom he was still open to the assistance of a coach. Experienced physicians may also benefit from coaching, according to 45-year old surgeon Atul Gawande in his excellent article in the October third issue of The New Yorker. After eight years he has performed more than two thousand operations, 75% in his specialty, endocrine surgery, and the rest including everything from simple biopsies to colon cancer. He felt that after six years he had reached a plateau in his skill levels, and decided to use his former mentor, Dr. Robert Osteen, as a coach. Dr. Gawande firmly believes that “no matter how well trained people are, few can sustain their best performance on their own. That’s where coaching comes in.” What is a coach? “The concept of a coach is slippery. Coaches are not teachers, but they teach. They’re not your boss. Mainly, they observe, they judge, and they guide.” “Outside eyes and ears” can notice the little things which can be improved. Dr. Osteen, a retired general surgeon, silently observed while Dr. Gawande performed a thyroidectomy for a patient with a cancerous nodule, for perhaps the 1000th time in his career. This had not been a specialty of Dr. Osteen’s, yet he had a whole list of useful observations: the draping restricted the usefulness of the surgical assistant; Dr. Gawande’s elbows should remain loose and down by his sides (not raised); the magnifying loupes restricted his peripheral vision which caused him to miss blood pressure problems; for thirty minutes the operating light had drifted out of the wound, leaving only reflected light for the procedure; the instruments chosen for holding the incision open got tangled up. Since taking on a coach, Dr. Gawande has noticed that his complication rate has gone down. He advocates that coaching programs be made available for doctors other than surgeons. Internists can sharpen their diagnostic skills; cardiologists can improve their heart-attack outcomes; all physicians can use their resources more efficiently in an age of health care reform. Incidentally, Dr. Gawande personally interviewed prominent musicians Itzhak Perlman and Renee Fleming. They both, to this day, believe that their coaches are essential to top-notch performance.

KCMS Officers Mario Deguchi, MD President Daria Majzoubi, MD President-elect Theresa P. Poindexter, MD Secretary Treasurer Jeffrey W. Csiszar, MD Past President Board of Directors Bradley Beard, MD Bhupinder Chatrath, MD James E. Dean, MD Laura Howard, MD H. James Jones, MD Ying-Chien Lee, MD Bo Lundy, MD Kenny Mai, MD CMA Delegates: James E. Dean, MD Jeffrey W. Csiszar, MD CMA Alternate Delegates: Mario Deguchi, MD Staff: Marilyn Rush Executive Secretary

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Post Office Box 28337 Fresno, CA 93729-8337 1040 E. Herndon Ave #101 Fresno, CA 93720

General Membership Meeting 2011 Annual Installation & Awards Dinner

559-224-4224 Fax 559-224-0276 website: FMMS Officers Oscar Sablan, MD President Sergio Ilic, MD President Elect Krista Kaups, MD Vice President Prahalad Jajodia, MD Secretary/Treasurer Harcharn Chann, MD Past President Board of Governors A.M. Aminian, MD Hemant Dhingra, MD Ujagger-Singh Dhillon, MD William Ebbeling, MD Terril Efrid, MD Ahmad Emami, MD David Hadden, MD S. Nam Kim, MD Stewart Mason, MD Ranjit Rajpal, MD Rohit Sundrani, MD Mohammad Sheikh, MD CMA Delegates FMMS President John Bonner, MD Adam Brant, MD Michael Gen, MD Sergio Ilic, MD Brent Kane, MD Kevin Luu, MD Andre Minuth, MD Shazia Mughal, MC Roydon Steinke, MD Toussaint Streat, MD CMA Alternate Delegates FMMS President-elect Prahalad Jajodia, MD Toby Johnson, MD Peter T. Nassar, MD Trilok Puniani, MD Dalpinder Sandu, MD Salma Simjee, MD Steven Stoltz, MD Rajeev Verma, MD

Wednesday, November 9, 2011 Roger Rocka’s Dinner Theater • 6:00pm featuring:

Installation of 2012 President Sergio Ilic, MD Honoring 2011 Physician Community Service Award recipients: Lifetime Achievement Special Project Malcolm Masten, MD John Telles, MD benefitting the FMMS Foundation Includes dinner and show: Dinner and show: $60/person Sponsorships Available: Table of 10, $750; Table of 8, $600; Tables of 4, $300 For information on event sponsorship or advertising opportunities contact:

Fresno County Regional Forensic Science Center OPEN HOUSE Fresno County Coroner David Hadden, MD will host specifically for Fresno-Madera Medical Society members and guests, a tour of the new, state-of-the-art Fresno County Morgue.

CMA YPS Delegate Paul J. Grewall, MD CMA YPS Alternate Yuk-Yuen Leung, MD CMA Trustee District VI Virgil Airola, MD Staff: Sandi Palumbo Executive Director 18

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Wednesday, December 7, 2011 • 5:00-7:00pm Light refreshments 3150 E. Jefferson Ave, Fresno (Corner of Jefferson and Chestnut Avenues)

CME Activities


Perinatal Mental Health: An Integrated Approach – November 8 Fort Washington Country Club; 6-8:15pm; dinner lecture N/C; CME approval pending; Contact: 559-459-1639. Diabetes Symposium 2011– November 19 Saint Agnes Medical Center; 8am-1:30pm; Credit: 4 hours CME; Fee: N/C; Contact: 559-450-7566.

MEMBERS: 3 months/3 lines* free; thereafter $20 for 30 words. NON-MEMBERS: First month/3 lines* $50; Second month/3 lines* $40; Third month/3 lines* $30. *Three lines are approximately 40 to 45 characters per line. Additional words are $1 per word. Contact the Society’s Public Affairs Department, 559-224-4224, Ext. 118.


Gemstones Continued from page 16 gemstones is more complex and variable than that of diamonds. This will be discussed in the section following emeralds. Emeralds: Emeralds are the least durable of the precious gemstones. Because they lack the hardness of diamonds, rubies or sapphires, they have no significant industrial use. Unlike the harder gemstones, special consideration is given when faceting emeralds to avoid corners as they are prone to chipping. Some of the most desirable emeralds are clear with a vibrant green color. Most emeralds are treated with oil to fill cracks and improve overall color. Grading of Colored Gem Stones: Like diamonds, grading the other precious gemstones uses the four C’s: Cut, Carat, Color and Clarity. Generally speaking, Color is given more weight in determining value than it is with diamonds. Certain vibrant blues of sapphires, reds of rubies and greens of emeralds command prices at or above equal sized diamonds. On the other hand, similar sized, less desirable gemstones may be worth very little. Whether or not a stone has been enhanced or treated will also affect a gems value.








Gem Stone Treatments: Gem stones have been treated with various methods for centuries. All treatments are aimed at increasing the clarity, color or size of the stone. Some treatments have a greater impact on a stones value than others. Heating, for example, has been used for since ancient times to enhance the color and clarity of sapphires and rubies. Heating is a permanent treatment and many valuable stones have undergone heat treatment. Fracture filling, the filling of imperfections in gems with glass or other substances, is not considered permanent and tends to have a more significant impact of the stones value. Emeralds are often oiled to fill cracks and improve luster. While far from a comprehensive guide to the precious gemstones, my hope is that this primer will make you a better shopper for you next gemstone.

University Psychiatry Clinic: A sliding fee scale clinic operated by the UCSF Fresno Dept. of Psychiatry at CRMC M-F 8am-5pm. Call 320-0580.

FOR LEASE OR SALE Free standing medical office, 10 exam rms., 4 bthrms, 2 exec. Suites. Lab, X-ray. See: 805-796-0030 General medical practice for sale in Madera. Call 559-661-1100 Medical office space, 3,000-7,000 sf in prime location near Fresno Surgical Hospital. Negotiable rates. Call 559-273-0600.

Gar McIndoe (661) 631-3808 David Williams (661) 631-3816 Jason Alexander (661) 631-3818

MEDICAL OFFICES FOR LEASE 1902 B Street – 1,695 sf. 2701 16th St. – 2,400 2007 17th Street – 5,090 rsf. 2031 17th Street – 1,776 rsf. 608 34th St. – 1,935 rsf. Crown Pointe Phase II – 2,000-9,277 rsf. 500 Old River Road – 3,071 rsf. Meridian Professional Center – 1,740-9,260 rsf. 2204 “Q” Street – 2,894 rsf. 4040 San Dimas St. – 2,035 rsf. 9300 Stockdale Hwy. – 3,743 - 5,378 rsf. 9330 Stockdale Hwy. – 1,500-7,700 rsf. 3115 Latte Lane – 5,637 rsf. 2731 H Street – 1,400 sf. 3941 San Dimas Street – 3,959 rsf. SUB-LEASE 4100 Truxtun Ave. – 11,424 rsf. Medical Admin and Chart Storage DENTAL OFFICE FOR LEASE OR SALE 3115 Latte Lane – 5,697 rsf. 2023 Brundage Lane – 3,500 sf. FOR SALE Crown Pointe Phase II – 2,000-9,277 rsf. Meridian Professional Center – 1,740-9,260 rsf. 2000 Physicians Plaza – 17,939 sf. gross 9900 Stockdale Hwy. – 2,000-6,000 rsf.

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PRSRT STD U.S. Postage PAID Fresno, CA Permit No. 30

VITAL SIGNS Post Office Box 28337 Fresno, California 93729-8337








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HAVE YOU MOVED? Please notify your medical society of your new address and phone number.




To make a calculated decision on medical liability insurance, you need to see how the numbers stack up—and there’s nothing average about NORCAL Mutual’s recent numbers above. We could go on: NORCAL Mutual won 86% of its trials in 2010, compared to an industry average of about 80%; and we paid settlements or jury awards on only 12% of the claims we closed, compared to an industry average of about 30%.* Bottom line? You can count on us. *Source: Physician Insurers Association of America Claim Trend Analysis: 2010 Edition.

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