February 2012 â€˘ Vol. o 34 No. 2
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
See Inside: Recap of NORCAP Annual Educational Forum Yosemite Postgraduate Institute An Evening With Ray Kurzweil
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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 February 2012 Vol. 34 – Number 2 Editor, Prahalad Jajodia, MD Managing Editor, Carol Rau
Contents EDITORIAL..................................................................................................................................5 CMA NEWS ................................................................................................................................7 NEWS TREATMENT RECOMMENDATION: Antifungal Medication Usually Not Indicated in the Treatment of Coccidioidomycosis ...................9 NORCAP: Recap of Annual Education Forum ...........................................................................10 AIR QUALITY: In The AIr .........................................................................................................11 Yosemite Postgraduate Institute ............................................................................................12 An Evening With Ray Kurzweil ................................................................................................12
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 Tulare Representative Gail Locke
CLASSIFIEDS ...........................................................................................................................18 FRESNO-MADERA MEDICAL SOCIETY .......................................................................................13 • President’s Message • In Memoriam • Medical Staff Office Classes • FMMS Evening at the Fresno Philharmonic KERN COUNTY MEDICAL SOCIETY ............................................................................................15 • President’s Message • Ravi Patel, MD Honored • Membership News TULARE COUNTY MEDICAL SOCIETY.........................................................................................17 • Certified Medical Coder Course and Forum
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. Advertising Contact: Display: Annette Paxton, 559-454-9331 firstname.lastname@example.org Classified: Carol Rau, 559-224-4224, ext. 118 email@example.com
Cover photography: Venetian Sunset Over the Grand Canal by Virgil Airola, MD Calling all photographers: Please consider submitting one of your photographs for publication in Vital Signs. – Editorial Committee
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 / F E B R U A R Y 2 0 1 2
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My Astonishing 2012 New Year’s Resolution! Prahalad B Jajodia, MD Editor, Vital Signs
This year I plan to become younger. That’s right. Younger. Along with other important initiatives, I plan to recapture the very best emotional qualities of my youth. The zest. The vigor. You see, young isn’t so much a physical state as it is a joyous emotional event. It’s that Friday night feeling, knowing the winds of change have arrived and everything good is coming your way. In truth, we’re all modern day Ponce de Leóns searching for the joy of youth. Fortunately, unlike the famed but rather foolish explorer, we don’t need to sail uncharted waters to find it. It’s right here. We can have it anytime we want, just by doing the things proven to create true and lasting happiness. Being physically active, and the vitality it provides, is a hallmark of youth. If you have it, keep it. If not, reclaim this vitality with daily exercise. Note to curmudgeons: Do it even if it requires having fun. That vat of cookie-dough ice cream in the freezer and the chicken-fried steak at La Ptomaine don’t love you and don’t care if you die of a heart attack. Let them go. Like unfaithful friends, they will not be missed. Eat right to feel young and healthy. Tip: The red, green, and yellow things in the supermarket are called fruits and vegetables. They’re edible. The greasy stuff is called fat. It clogs drains. Don’t eat it. Sleep at least six to seven hours a night (snoozing through commercials on American Idol doesn’t count), then wake up refreshed and ready for the challenges of the new day. Make a serious effort to communicate better with your family, colleagues, and patients for less stress and better results. Screaming “Just do it or I’ll flip out!” does not qualify as good communication. Lowering stress levels is an important part of feeling young. Show respect for others by always being on time; put your competence on display with good time management. You’re young but not undisciplined. Like all young people, you should continue your education, not only professionally but also about life, your relationships, and financial security for yourself and your family. Spend less and save more. Isn’t this the same advice you give to your children? The benefits are obvious: security and peace of mind. Work smart, earn more, and save more in your retirement plan. Enough said. Spend more time with your family and let them share in the joy of your youth. They matter more than anything else. Vacation with them at least twice a year. A real vacation, not just a few days at home. Travel to new places and experience new things. You will all gain perspective and become closer as a family.
For the peace that it brings, enhance the spiritual side of your life. Pray every day to the deity of your choice or, if none come to mind, meditate on the priceless gift of life that fate has given you. This simple act is both clarifying and purifying. It will keep you from doing wrong. You will make better decisions. You will be happier. You will be younger. Guaranteed. Help the poor and needy. Share your wealth and blessings with IN TRUTH, those less fortunate. Donate a WE’RE ALL portion of your time and resources MODERN DAY to improving the lot of those who PONCE DE will never have anything LEÓNS approximating the plush life that we in the medical field sometimes SEARCHING FOR take for granted. It will renew your THE JOY OF spirit. YOUTH. Negative sentiments suck the FORTUNATELY, marrow from your life and make UNLIKE THE you old before your time. Banish FAMED BUT them. Forgiveness is not tantamount to weakness or RATHER FOOLISH acquiescence; it simply means you EXPLORER, WE don’t have to think about it DON’T NEED anymore. TO SAIL Focus on the key elements of a UNCHARTED good and happy life, and do not WATERS TO FIND diffuse your energy. It’s a blessing to live in IT. IT’S RIGHT America. Enjoy the freedom and HERE. bounty of this great land. My dear friends, I hope you’ve come to the same conclusion I have: This year is a fine year to become younger. It can be the springtime of your life. Again. Believe it. Make it so. And feel the warm breezes buff your face as a new world filled with possibilities opens before you. Peace and prosperity to you and yours. Dr. Jajodia is a gastroenterologist in private practice in Fresno. You can reach him at firstname.lastname@example.org.
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CMA NEWS SAVE THE DATE Í Í Í Í Í CMA’s LEGISLATIVE DAY IN SACRAMENTO Tuesday, April 17, 2012 The FMMS will be chartering a bus for the trip to the Capitol. Information: 224-4224 x 118 or email@example.com.
SGR CUTS AVERTED UNTIL END OF FEBRUARY
On December 22, 2011, the House agreed to extend the budget bill for two months (including a middle class tax cut and extension on unemployment benefits) and prevent the 27.4 percent Medicare sustainable growth rate (SGR) cut to physician reimbursement from going into effect on January 1, 2012. A House-Senate conference committee will begin work in late January on a longer term agreement, including a permanent solution to SGR. California Congressman Henry Waxman (DLA), the ranking Democrat on the House Energy Commerce (ie, health) Committee, is one of the conferees. Several days before the House agreed to the Senate’s twomonth patch, California Medical Association (CMA) President James T. Hay, M.D., sent a letter to Congress voicing the concerns and frustrations of California physicians who have been seeking a solution to the flawed SGR for 10 years. Stating that CMA was “outraged” that there had been no resolution to the long-standing problem before Congress went home for the holidays, the letter said, “The inability of Congress to adopt a long-term plan to replace the formula will cause irreparable harm to physician practices and patients. The letter also reminds Congressional leaders that physicians, in addition to being healers, are also employers. “Stable Medicare rates help physicians remain in practice, care for patients and prevent further unemployment and economic erosion.” Contact: Elizabeth McNeil, 415-310-2877 or firstname.lastname@example.org. NEW 2012 MEDICARE FEE-FOR-SERVICE PAYMENT RATES TOOK EFFECT IN JANUARY Highlights: • 2012 Physician Payment Rule takes effect with a 0.18 percent increase in the conversion factor • Palmetto posted new fee schedule on website by January 11, 2012 • CMS/Palmetto won’t begin processing claims until January 18 Despite the fact that the payroll tax extension legislation passed by Congress in December (Public Law 112-078) delayed cuts to Medicare fee-for-service, the Centers for Medicare & Medicaid Services (CMS) has confirmed that all of the other
changes that were included in the Medicare physician payment final rule for 2012 will still take effect. What to expect Physicians should expect some changes in their payment rates. Numerous changes were made to the relative value units, geographic practice cost indexes, and multiple procedure payment rules for 2012. Changes to electronic prescribing reporting and quality reporting programs will also be implemented. All of these changes will take effect for dates of service beginning January 1, 2012. Please see the California Medical Association (CMA) resource Medicare Part B 2012 Important Changes: What They Mean to Your Practice. In addition, although P.L. 112-078 provided for a 0 percent update to the Medicare conversion factor for January and February 2012, the final CMS rule indicated that there would be a 0.18 percent increase in the conversion factor for budget neutrality, and that this change will also be effective January 1, 2012. The budget neutrality increase is due to CMS adoption of the relative value system (RVS) Update Committee recommendations for misvalued codes. The 2011 conversion factor was $33.9764. The 2012 conversion factor will be $34.0376. Contractors are expected to have the new rates posted to their web sites by January 11. On January 4, 2012, CMS published a correction notice in the Federal Register to the 2012 final rule that modifies the relative values for a number of services. The agency also posted a revised relative value file on its website reflecting both the corrections and the legislation that stopped the 27.4 percent cut. CMA will continue to provide updates as information becomes available. Contact: CMA reimbursement helpline, 888-401-5911 or email@example.com.
RESIDENCY ‘SCRAMBLE’ SWAPPED FOR SOAP
The National Resident Matching Program (NRMP) is revising its annual residency match to improve how vacant residency slots are filled after ”Match Day.” Starting in 2012, the NRMP will administer a new system to link unmatched students with unfilled residency positions. Called the Supplemental Offer and Acceptance Program (SOAP), the system is designed to create a formal process for applying for unfilled positions. SOAP replaces the previous residency “Scramble,” a highly competitive and disorganized process in which unlinked students contacted programs with unfilled positions in an effort to find a slot, often forcing students to accept the first offer they got on the spot. In 2011, most of the 1,060 available positions were filled within the first 24 hours. As a result of SOAP, Match Day will move from the third Thursday to the third Friday of March. In 2012, Match Day will be on March 16. On March 14, residency programs with unfilled positions will finalize their preference lists of applicants, and the NRMP will begin making offers to applicants. All NRMP applicants will be notified about their eligibility for SOAP the Friday before Match Week. Unlike the Scramble, Please see on next page V I TA L S I G N S / F E B R U A R Y 2 0 1 2
CMA NEWS Continued from CMA News page 7 SOAP applicants could receive multiple offers in each round and will be able to consider their options before making a decision. In 2013, the NRMP plans to implement a new All-In Policy, requiring residency programs to place all of their first- and second-year residency positions in the Main Residency Match. The NRMP is accepting comments on the change. According to NRMP, there were 5,627 unmatched applicants and 2,288 unfilled positions in 2001. By 2010, the gap had grown to 8,794 unmatched applicants competing for 1,060 unfilled positions. For more information, visit www.nrmp.org.
CMA HOTLINES • 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 www.cmanet.org/member
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CMA Center for Economic Services Webinars At-A-Glance Please note that this calendar does not include CMA’s ICD-10 training courses to be offered in 2012. Feb. 15: HIPAA Risk Analysis for Meaningful Use David Ginsberg • 12:15 – 1:15 pm March 7: Managing Difficult Employees and Reducing Conflict in the Practice Debra Phairas • 12:15 – 1:15 pm March 21: HIPAA Update 2012 David Ginsberg • 12:15 – 1:15 pm April 4: A Guide to Managing Upset and/or Difficult Patients Debra Phairas • 12:15 – 1:15 pm April 18: Best Practices for Managing Your Accounts Receivable Mary Jean Sage • 12:15 – 1:15 pm May 2: Medicare: Top 10 Claim and Documentation Errors That Cost Your Practice Money Kevin Garrick • 12:15 – 1:15 pm May 16: Telephone Etiquette for Medical Personnel Mary Jean Sage • 12:15 – 1:15 pm June 6: A Manager’s Guide to Lowering Practice Costs Debra Phairas • 12:15 – 1:15 pm
June 20: Writing Effective Appeals Mary Jean Sage • 12:15 – 1:15 pm July 18: Preparing for a Medicare and/or Medi-Cal Audit Mary Jean Sage • 12:15 – 1:15 pm Aug. 1: Coding for Medical Necessity Arthur Lurvey, MD • 12:15 – 1:15 pm Aug. 15: Program Integrity in Medicare and Medi-Cal – The Physician’s Role Bruce Tarzy, MD • 12:15 – 1:15 pm Sept. 5: A Guide to Reviewing Payor Contracts Kris Marck • 12:15 – 1:15 pm Sept. 19: Creating and Implementing Financial and Office Policies Debra Phairas • 12:15 – 1:15 pm Oct. 3: Protect Your Practice From Payor Abuse Mark Lane • 12:15 – 1:15 pm Oct. 17: Establishing Expectations for High Performance from Medical Staff Debra Phairas • 12:15 – 1:15 pm Nov. 7: Understanding ARC and CARC Revenue Codes David Ginsberg • 12:15 – 1:15 pm
T R E AT M E N T R E C O M M E N D AT I O N
Antifungal Medication Usually Not Indicated in the Treatment of Coccidioidomycosis by Michael Mac Lean, MD, MS Health Officer, Kings County California
The use of oral antifungal medication may provide no benefit in the treatment of three common forms of coccidioidomycosis: uncomplicated primary disease, residual asymptomatic pulmonary cavity and asymptomatic residual pulmonary nodule. Treatment may be both unnecessary and potentially harmful. Although generally well tolerated, fluconazole has been associated with rare but serious hepatotoxicity and exfolliative dermatitis. Fluconazole has many drug-drug interactions and is thought to be a teratogen. If treatment is undertaken, the recommended duration of treatment is prolonged. There are published 1,2 guidelines for the treatment of all forms of coccidioidomycosis. Medical providers in area endemic for coccidioidomycosis (CM) should be familiar with these guidelines. This paper addresses those situations where oral antifungal medications are not known to be beneficial. In the pre-azole era, the toxicity and intravenous administrations of amphotericin argued against the use of this medication in low risk, uncomplicated CM. We know from the pre-azole era that most patients will do well with no oral antifungal therapy. Likely because of the toxicity of amphotericin treatment, oral azole therapy was adopted without controlled trials. The use of oral azole therapy in the treatment of CM continues to be complicated by the lack of adequate controlled trials. Primary coccidioidomycosis most commonly presents as influenza-like illness usually associated with pulmonary infiltrate and less frequently with intrathoracic adenopathy or pulmonary effusion. Erythema nodosum or erythema multiforme occasionally precede or are concurrently present. There is no evidence that treatment improves the symptoms or shortens the duration of primary pulmonary CM.3 The noted rashes are likely immunologic and are not an indication for treatment. Rather marked fatigue is common after other symptoms of primary CM have resolved. This fatigue can last weeks to months. The use of oral antifungal to treat fatigue is not recommended. Per the ATS treatment guidelines, “Most cases of primary pulmonary coccidioidomycosis in individuals without identified risk factors are self limited and do not require treatment.”2 The treatment guidelines of both the Infectious Disease Society of America and the American Thoracic Society are based on a comprehensive assessment of the individual case. The decision to treat with oral antifungal medication is made after assessing the severity of the illness and the risk of progression to complicated coccidioical disease. While a routine CT examination of the chest probably isn’t indicated, at a minimum a two view plain film of the chest should be included in the assessment. CM patients co-infected with untreated HIV can be expected to do poorly, Consistent with current CDC guidelines all adults with CM should be screened for HIV. Disease severity isn’t explicitly defined in either guideline.
Presumably, the treating physician/provider would use clinical judgment to determine the disease severity. Suggested indices of severity include: acute symptom of > 6 weeks duration; intense night sweats of >3 weeks duration; weight loss of >10%; pulmonary infiltrate involving >50% of one lung or involving multiple areas of both lungs; prominent or persistent hilar adenopathy; anticoccidioidal complement fixation antibody titers in excess of 1:16. Treatment with antifungal medications is also indicated in the presence of risk factors for chronic progressive pulmonary disease or for dissemination. Risk factors include age>55; diabetes; chronic pulmonary disease; chronic renal disease; congestive heart failure; immune compromised patients due to HIV, alpha TNF inhibitors, corticosteroids and solid organ recipients. Women in the second or third trimester, African-Americans and Filipino-Americans are also at increased risk for dissemination, and treatment should be considered. This list of risk factors may not be exhaustive. Those patients who don’t have sever disease or risk factors for complicated CM and who are not treated with oral antifungal medications require follow up. “All patients with primary pulmonary coccidioidomycosis should be followed for at least one year to assure complete resolution and the absence of complications.” 2 Asymptomatic pulmonary nodule and asymptomatic pulmonary cavity can be residual conditions associated with previous CM. The recommended follow up of primary pulmonary disease may obviate the need for diagnostic workup of these findings, e.g., a fine needle biopsy of a pulmonary nodule. There is no evidence that in immune competent individuals’ treatment with oral antifungal medications has any effect and treatment is 1,2 not recommended. This paper addresses those situations where treatment may not be beneficial or indicated. If treatment is deemed indicated, inexperienced physicians/providers should review the published treatment guidelines or seek consultation with an experienced specialist. The choice of drug and the duration of treatment are variable depending on the clinical circumstances. The minimum duration of any treatment recommended is three months. Azoles may be teratogens, and the use in pregnant women is problematic.4 In Kings County the unplanned pregnancy rate far exceeds the state average. The use of fluconazole in any fertile woman may warrant a careful weighing of risk and benefit. References: 1 Galgiani JA, et.al: Treatment guidelines for coccidioidomycosis. CID 2005; 41:1217-23 2 Limper HA, et.al: Treatment of fungal infections in adult pulmonary and critical care patients. Am J Respir Crit. Care Med Vol 183. pp 96-128, 2011 3 Ampel NM, et.al: Factors and outcomes associated with the decision to treat primary pulmonary coccidioidomycosis. CID 2009;48:172-178 4 Bercovitch RS, et.al: Coccidioidomycosis during pregnancy: A review and recommendations for management. Clin Infect Dis 2011; 53(4):363-368. V I TA L S I G N S / F E B R U A R Y 2 0 1 2
Recap of Annual Educational Forum by Bonna Rogers-Neufeld, MD, FACR
On December 10, 2011, an all-day educational seminar was organized and sponsored by the Northern California Physicians Council (“NORCAP”) in San Francisco. In response to the California malpractice crisis of 1975, Bonna RogersNeufeld, MD, northern Cali for nia FACR physicians banned together at the county medical society level to form NORCAP. It is through this effort that NORCAL Mutual Insurance Company – a new kind of policyholderowned medical professional liability insurance company was formed and incorporated on September 18, 1975. In the same spirit of physician advocacy that led to the passage of MICRA and formation of NORCAL, NORCAP continues physician advocacy efforts, conducting the peer reviews when insured physicians seek to appeal insurer decisions related to imposition of a surcharge or cancellation of liability insurance. Annually NORCAP provides an all day program inviting attendance by endorsing Medical Society executives, presidents, president-elects, NORCAP representatives and MRAC chairs. This year, FMMS was represented by µSergio Ilic, MD, presidentelect; Cynthia Bergmann, MD, NORCAP representative; Oscar Sablan, MD, president; Sheryl R. Tatarian, staff FMMS; and Bonna Rogers-Neufeld, MD, FACR, MRAC chair. The topics for the weekend included Health Care Reform, Electronic Medical Records, New Physician Payment Models, and High Risk Issues Associated with Malpractice. A highlight was a multimedia presentation created by the Kaiser Family Foundation, which is a nine-minute cartoon-like presentation that explains the 1000 page Health Care Reform Act in simple terms. This is something I Please see NORCAP on page 17 10
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In The Air by Alexander Sherriffs, MD Edited by Michelle Garcia, Air Quality Director
connection between air pollution and health has never been obvious, even if your eyes were burning and your chest felt tight in smoggy 1950s Los Angeles. When the counties of California first took on air pollution several decades ago, each county was its own jurisdiction. Obviously bad air doesn’t respect political boundaries, and Alex Sherriffs, eventually regional air boards were formed. MD The San Joaquin Valley Air Pollution Control District governing board (formed in 1981) was initially a mix of a supervisor from each of the eight counties plus rotating large and small city council members. The driving mandate for Air Boards has always been public health, but it was only in the last four years that a health professional position was designated for the SJVAPCD Board. FMMS’ own Dr. John Telles was the first governor’s appointee. After serving three years, Dr Telles resigned last year to focus more fully on his cardiology practice. Last November, I was appointed by Governor Brown to the SJVAPCD Board and also to the California Air Resources Board as SJVAPCD member. Thanks to FMMS and other component society members who supported my application. I’ll be more careful what I ask for in the future! I attended my first local Board meeting last month, as well as a State Board meeting in Sacramento. As you might guess, it is a new skill set (several!), and a significant volume of material to become familiar with for each month’s meetings (and Dr. Telles set a very high bar for mastery of the material), plus time meeting and talking with people and organizations regarding upcoming agenda items. And it is a no-pay volunteer position. But obviously the work is important, and it certainly gets one out of the office routine! I have many items I could report as good news although none were major breakthroughs on the past six weeks of unrelenting unhealthy air quality we have been experiencing in the Valley since Thanksgiving. Thirty-seven consecutive days at this writing of air quality far below federal health standards. Many friends and patients, back to the Valley for the holidays, commented on the need to find and dust off their inhalers. Alas, cleaning the air is a Sisyphean task, but then none of us got into medicine expecting to eradicate all diseases, did we? 2012 will be a special challenge for the Valley Air Board as a revised cleanup plan for small particulates (pm2.5) is due. Yes La Nina has given us stagnant air, but it is our home grown pollution we are breathing that is making us sicker. The PM2.5s don’t just damage our lungs, but are small enough to pass through the alveoli and enter the blood stream. The evidence grows that their triggering of inflammation accounts for myriad-associated negative cardiovascular effects. The magnitude of the cleanup challenge is
SOURCES OF SMOG-FORMING EMISSIONS SAN JOAQUIN VALLEY, 2006 (Data Source: o3sip 1.04 RF 976)
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Fuel Combustion from Stationary Sources 10% Petroleum, 4% Industrict Processes, 4% Solvents/Consumer Products, 6% Farming Operations (non-mobile) 7% Other, 6% Autos and Light Trusts, 13% Heavy-Duty Trucks, 27% Other mobile, 23%
suggested by considering the sources of the smallest and nastiest particulates. NOX are a key precursor to particulates. Of some 470 tons of NOX we create each day, 40 percent comes from the heavy duty trucks on our roads. About 15 percent comes from off-road equipment. A smaller contribution comes from farm equipment. Our cars have gotten cleaner over the years, and small trucks and cars contribute perhaps 10 percent. Our Valley Air District does not have jurisdiction for on-road mobile sources. Why be optimistic? The staffs of both CARB and SJVAPCD have impressed me with their energy and enthusiasm for their work. Most of the businesses and organizations that testified in Sacramento embraced change and were full of innovation for lower carbon fuels. Technologies are available, being utilized, and ready to scale up. Veterans groups from Iraq spoke passionately about moving the US away from its dependence on oil for energy. One immediate step that was taken for our Valley involved CARB swapping out higher polluting drayage trucks from California ports for newer cleaner trucks. And instead of just junking those trucks, many can be retrofitted and will be swapped out for older higher polluting Valley farm trucks that otherwise would not be taken out of service for another decade. We have so much to do, and we are impatient for progress, but even small steps toward improved health matter. I look forward to more involvement from our component medical societies in the future.
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THE FRESNO-MADERA MEDICAL SOCIETY Inventor, Scientist and Futurist
May 11, 2012 Fresno Convention Center
An Evening with RAY KURZWEIL “2045: The Year Man Becomes Immortal”
RAY KURZWEIL has been described as “the restless genius” by the Wall Street Journal and “the ultimate thinking machine” by Forbes. The magazine Inc. ranked him #8 among entrepreneurs in the United States, calling him the “rightful heir to Thomas Edison.” As one of the leading inventors of our time, Ray was the principal developer of the first CCD flat-bed scanner, the first omni-font optical character recognition, the first print-to-speech reading machine for the blind, the first text-to-speech synthesizer, the first music synthesizer capable of recreating the grand piano and other orchestral instruments, and the first commercially marketed large-vocabulary speech recognition. Among Ray’s many honors, he is the recipient of the $500,000 MIT-Lemelson Prize, the world’s largest for innovation. In 1999, he received the National Medal of Technology, the nation’s highest honor in technology, from President Clinton. And in 2002, he was inducted into the National Inventor’s Hall of Fame, established by the US Patent Office. He has received nineteen honorary Doctorates and honors from three US presidents. Well known for predicting the future of artificial intelligence and the human race, Ray has been described as the prophet of the “Singularity” movement. “Ray Kurzweil is the best person I know at predicting the future of artificial intelligence.” – Bill Gates
TITLE SPONSOR Central Valley Physician Benefits GOLD SPONSORS Cooperative of American Physicians Hadden Pathology NORCAL Mutual Insurance Co. Premier Valley Bank Spencer Medical Group Single tickets and tables available. $60: FMMS member $550 table of 10 $75: FMMS non-member $650 table of 10 $45: Medical Resident For further information or to reserve a table: 559-224-4224 X 118 or firstname.lastname@example.org Sponsorships still available. PROGRAM INVITATIONS TO FOLLOW
Make plans to attend
Yosemite Postgraduate Institute MARCH 23-25, 2012 Topics include: Wilderness Medicine• Dermatology Gastroenterology • Cancer • Urogynocology Pulmonary • Dementia “The Yosemite Postgraduate Institute is at a perfect venue – Yosemite Valley. Physicians of every specialty will benefit from this diverse and high quality program, and they and their families will be in awe of this beautiful environment. This will be my fifth time to attend. I also look forward to the enjoyment this event brings with seeing other physicians of the Central Valley.” – Roydon Steinke, MD
For further information
(559) 224-4224 x118• e-mail: email@example.com • website: fmms.org
F E B R U A R Y 2 0 1 2 / V I TA L S I G N S
Fresno-Madera SERGIO D. ILIC, MD Post Office Box 28337 Fresno, CA 93729-8337
1040 E. Herndon Ave #101 Fresno, CA 93720
We have been looking at Congress to solve the 27.4% cut that the SGR demands this coming year. They delayed the final decision for two months until March 1. What is going to happen then? No one knows. Opting out of Medicare or not taking new Medicare patients are not good ideas, and I personally will not do either. We are smart, so surely we can find better solutions to our health care system. In my opinion, nationalizing the health Insurances is also a bad idea. We already have examples such as Medicaid/Medi-Cal and the VA systems. We know they do not work well. They are bureaucratic, and very few of us accept Medi-Cal.. Why then, make this a nationwide problem? If we look at the Canadian and UK systems, they work well for emergencies, but for elective cases they delay care (ration?) to the point where many patients come to the US for it. Many doctors also come to practice here because they are unhappy with their health care system. Perhaps making the health insurance companies NOT-for-profit will help. When I came to this country in 1972, the Blues were not- for-profit, and they worked very well. Then they separated and became for-profit I believe in the late 70s or early 80s. These for-profit health insurance companies need to be held accountable and show why they keep increasing their premiums. If they can’t justify the increases, they should be denied. Malpractice reform should also be tackled. Why haven’t we heard more about reform in this area? Basically because the trial lawyers’ lobby is very strong, and Congress is made up of 95 percent of lawyers. If they want to make a real difference in the nation’s economy, they should put the interest of the public ahead of their own. We are being told that the medical care we deliver is bad. I disagree with that assertion. The great majority of us are good doctors, and we do the best we can to get our patients better. I feel there is a very good tracking system here to identify our mistakes. Most countries don’t have such a system. Mistakes are buried or ignored, and there is no accountability or malpractice. A doctor can’t be sued, so adverse outcomes are not known. We are being told that we spend too much money for the care we give. The problem is that most people do not want to spend any money out of pocket. They spend a lot of money on their pets but on their selfs? For patients that do not have insurance, the delivery of care is excellent and available. They can go to any emergency room and are treated with the most advanced lab tests, MRI’s, surgeries etc. without regards to their insurance status. All these contribute to the increase in costs in medical care. It is also very important that we reach agreements on end-of-life care. We know that a large amount of resources are spent during the last two years of life. Many treatments do not help with the quality of life of the patient, but nonetheless, we provide treatments that prolong life and suffering. Can we do better? Yes, and we will to do better because the expenditures in medical care are growing at an unsustainable rate, and they have to decrease. We can improve on preventive care by curbing smoking, excessive drinking and drug abuse. Anything we do, though, needs to be complemented with mandatory insurance regardless of our age. Whether this will be deemed legal will be determined by the Supreme Court’s decision later this year. Other ideas would be to offer age-appropriate insurance. For example, 20 to 40 year olds can be covered for trauma and certain basic diseases at a lower premium, but not for most cancers (women should be covered for breast cancer and of course for pregnancy etc.), or heart attacks. As you get older, you get more comprehensive coverage. When you reach Medicare age, you are covered for everything. There will always be patients that get sick and develop diseases that are not in his or her plan, but that is the risk you are taking. You can always buy a more comprehensive plan if you wish. These are some of my thoughts. In the meanwhile we need to wait and see what happens. There are too many factors out there that will shape the future of medical practice in the US for better or for worse.
559-224-4224 Fax 559-224-0276 website: www.fmms.org FMMS Officers Sergio Ilic, MD President Ranjit Rajpal, MD President Elect Prahalad Jajodia, MD Vice President Stewart Mason, MD Secretary/Treasurer Oscar Sablan, MD Past President Board of Governors A.M. Aminian, MD Hemant Dhingra, MD Ujagger-Singh Dhillon, MD William Ebbeling, MD Babak Eghbalieh, MD Ahmad Emami, MD David Hadden, MD S. Nam Kim, MD Constantine Michas, MD Khalid Rauf, MD Rohit Sundrani, MD Mohammad Sheikh, MD CMA Delegates FMMS President A.M. Aminian, MD John Bonner, MD Adam Brant, MD Michael Gen, MD Brent Kane, MD Kevin Luu, MD Andre Minuth, MD Roydon Steinke, MD Toussaint Streat, MD CMA Alternate Delegates FMMS President-elect Don H. Gaede, MD Prahalad Jajodia, MD Peter T. Nassar, MD Trilok Puniani, MD Dalpinder Sandu, MD Salma Simjee, MD Steven Stoltz, MD Rajeev Verma, MD 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
V I TA L S I G N S / F E B R U A R Y 2 0 1 2
LEONARD THOMPSON, MD 45-year member
an Evening with the Fresno Philharmonic
Wicked Divas Saturday February 11, 2012 William Saroyan Theatre 6:00 p.m. Reception 8:00 p.m. Concert
Bewitching, Beguiling, Bedazzling. Wicked Divas is a concert of amazing voices, humor, energy and sass delivering diva showstoppers from Broadway, opera and popular music, highlighted by selections from the Tony-award winning Broadway musical, Wicked. Begin your evening enjoying hors d’oeuvers and beverages while socializing at an exclusive pre-concert reception for Fresno-Madera Medical Society members and guests.
For further information or tickets, call 224-4224, x118 or firstname.lastname@example.org With appreciation to our reception sponsor: Premier Valley Bank
Leonard Thompson, MD, a retired pediatrician, passed away December 24, 2011 at the age of 77 after a short battle of cancer. Dr. Thompson was born in Ohio in 1934. He received his medical degree from Ohio State Univ. in 1960 and completed his internship and residency at Fitzsimons General Hospital in Denver. After practicing at the Ireland Army Hospital in Kentucky for three years, Dr. Thompson opened his private pediatric practice in Fresno in 1966. He retired in 2009. Dr. Thompson is survived by his wife, six children and 10 grandchildren. 2012 FMMS Educational Series As a member benefit, a series of Financial Education classes will be offered to FMMS members beginning in March. Classes will be held on the last Wednesday and Thursday of March, April, May and June to be repeated August, September, October and November at 6 pm at the Medical Society offices. Topics to include (but not limited to and subject to change): • Introduction to Investing • Investment Fundamentals • Estate Planning/Conservation • Understanding Social Security and Medicare • Taxation Basics/Strategies Check future issues of Vital Signs, the FMMS website and your email for specific topics and dates. For more information, please email email@example.com.
Wicked Divas February 11, 2012 RECEPTION:
Medical Office Staff Classes
___ FMMS member at no charge ___ FMMS guest(s) at $10 each
Tuesday, February 28, 2012
CONCERT: ___ Orchestra Seats at $55 each Total Payment Enclosed: $
* Check (payable to FMMS)
Card #_________ | _________ | _________ | _________ Verification # Expiration Date Cardholder’s Name Billing Zip Code Cardholder’s Signature Phone Preferred mailing address for tickets
Mail payment and form to: FMMS, PO Box 28337, Fresno, CA 93729-8337 or FAX to: 559-224-0276
F E B R U A R Y 2 0 1 2 / V I TA L S I G N S
Coding and Medicare Update 2012: 9am-12pm • OIG Work Plan 2012 review • Preparing for Version 5010 testing standards • Latest updates on private payer policies and reimbursement Transitioning to ICD-10-CM: 1pm-4pm • Common concerns for ICD-10-CM conversion • Creating a timeline for conversion • Documentation requirements Location: Bella Pasta Restaurant Cost: $130 for one session $240 for two sessions Exclusive offering for FMMS members’ staff Information: 559-224-4224 X 112 or firstname.lastname@example.org
Kern JOEL R. COHEN, MD
2229 Q Street Bakersfield, CA 93301-2900 661-325-9025 Fax 661-328-9372
“We must hang together or assuredly we will all hang separately” – Ben Franklin
These immortal words ring as true today as they did 200 years ago, even more so now in medicine in the Golden State. In many ways, medicine is changing and we, as physicians, must close our ranks if we are to survive this transition intact, just as Ben Franklin and his compatriots did. Below are a number of simple steps that we can take to help do this, as an organization and as individuals. We should all commit to do these each day. We must support one another professionally... If you see a colleague in need, offer to help; it is always good to improve outcomes, for patients and for our colleagues. And under the rare circumstances of physician wellness, the Medical Society has resources and referrals to help, but it takes the care of a colleague to say something. We must support each other socially… I will commit now to sponsor an Alliance social event with each one of our general membership meetings; I will ask for an Alliance leader to attend our Board meetings. I will explore venues in which our local physician community can learn from experts in services that we all use routinely, information technology, insurance, banking and the like. We must grow our membership… Policy leaders will only listen to our voice if we speak for many. Each one of us should identify at least one new member this year and hand them an application. In this way, we all benefit, including the new member who benefits from reduced membership rates, all the CMA activities and perks, etc. Keep in mind that we all do share many least common denominators, such as the desire to practice the best quality medicine possible, to improve patient outcomes, to be surrounded by a plethora of services to offer our patients, to be able to pay off our massive student and practice debts, to be more free of payer over site, and to be less burdened by redundant regulations, etc. It is certain that all physicians in the community do benefit from a growing and robust medical society. These are tough times and the way to survive as a group and to prosper together, is to pull together. I look forward to seeing many new faces at each one of our meetings this year.
Ravi Patel, MD Named Recipient of Outstanding Contribution to the Community Award
Joel R. Cohen, MD President Wilbur Suesberry, MD President-elect Noel Del Mundo, MD Secretary Ronald L. Morton, MD Treasurer Portia S. Choi, MD Immediate Past President Board of Directors Alpha Anders, MD Brad Anderson, MD Eric Boren, MD Lawrence Cosner, MD John Digges, MD J. Michael Hewitt, MD Calvin Kubo, MD Melissa Larsen, MD Mark Nystrom, 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
by Portia Choi, MD
Ravindranath (Ravi) Patel M.D. received the Outstanding Contributions to the Community Award for Kern County Medical Society in 2011. The medical community and even a local television news station were there to honor him. Dr. Patel began his solo practice over 25 years ago with two employees, one nurse and one receptionist. His practice has grown to 220 staff with 15 physicians at the Comprehensive Blood and Cancer Center (CBCC), a center that he founded and where he is the current managing director. He has additional staff globally, particularly in India. Dr. Patel was born in Johannesburg, South Africa, the son of a homemaker and a gold mining equipment company department manager. He and his mother went to India to care for his elderly grandfather. There he went to college and medical school. Dr. Patel completed fellowship in Hematology/Oncology at Loyola University, Stritch School of Medicine; and board certified by the Please see Ravi Patel, MD on page 16 V I TA L S I G N S / F E B R U A R Y 2 0 1 2
Kern Ravi Patel, MD
Kings Membership Recap DECEMBER 2011
Continued from page 15 American Board of Internal Medicine and specialized in Hematology/On cology. In honoring Dr. Patel, a colleague stated “Dr. Patel has been an enormous asset to Bakersfield and Kern County. Not only is he an excellent, caring and compassionate physician, he is a true innovator. He has succeeded in developing the largest free standing, non-academic cancer facility on the West Coast.” Dr. Patel’s goal is to provide to each patient both established cancer treatment and more advanced treatments through clinical research trials. The center has many “firsts” in Kern County such as Intensity Modulated Radiation Therapy (IMRT), CT Positron Emitting Technology (PET), stem cell transplants, cutting edge clinical trials, plasmapheresis, outpatient prostate brachytherapy and most recently the Cyberknife. CBCC participated in clinical trials for many new and exciting drugs to treat cancer, medications that are now routinely used. One example was the Herceptin trials with Dr. Slamon at UCLA, a life-saving option for many with Her- 2 positive breast cancer, and is now used routinely. Another example was Erbitux that was first used in trials at CBCC in 2003 for colorectal cancer patients who had failed many therapies. Patients flew from other parts of USA to receive access to this trial in Bakersfield. CBCC has participated in research leading to the approval of such novel cancer drugs as Gleevec, Tykerb, Avastin, Vidaza, Afinitor, Tarceva, Faslodex, Trisenox, Procrit, Aranesp, Neupogen, Neulasta, Nexavar, and Xalkori. The center currently has trials for both chemotherapy and targeted-therapy in lymphoma, breast, colon, lung, esophageal, gastric, lung, ovarian, prostate and pancreatic cancer. Additionally, the Center offers modalities for healing the whole patient, including the spiritual and emotional aspect. It offers integrative health modalities such as meditation, relaxation techniques, and therapeutics modalities. It has programs into the community and hosts support groups for cancer patient and their families such as “Look Good Feel Better Program”, “Man to Man” and “Women to Women.” Dr. Patel is involved in training other physicians. He is an Assistant Clinical Professor of Medicine at the University of California at Los Angeles (UCLA); and involved with the residents at Kern Medical Center. He has received many awards including the HOPE (Hematology Oncology Practice Excellence) Award, and the Excalibur Award from the American Cancer Society. Additionally, his CBCC foundation supports community wellness projects.
F E B R U A R Y 2 0 1 2 / V I TA L S I G N S
Active.......................................250 Resident Active Members ...........1 Active/65+/1-20hr .......................5 Active/Hship/1/2 Hship...............0 Government Employed ................6 Multiple memberships..................1 Retired ........................................61 Total .........................................324 New members, pending dues .......8 New members, pending application .....................0 Total Members.........................332
New Members The following physicians’ names, etc. are being published in compliance with the KCMS Constitution & Bylaws. Board Certification will be listed only if the physician has been certified by a Specialty Board recognized by the American Board of Medical Specialists, as approved by the American Medical Association.
Linda P. Veneman, MD Pathology/Clinical/Anatomic Pathology Physicians Automated Lab 2801 H Street, 93301-1913 661-325-0744 / FAX: 832-8169 email@example.com Medical Degree: Loma Linda U 1975 IM Internship/Residency: Loma Linda U 1976-1979 Rheumatology Fellowship: Loma Linda U 1979-1981 Clinical/Anatomic Pathology Training: Loma Linda U 19831987 Cytopathology Training: Olive View Medical Center 19901991 Board Certified: Pathology/Internal Medicine
PO Box 1029 Hanford, CA 93230 559-582-0310 Fax 559-582-3581 KCMS Officers Theresa P. Poindexter, MD President Jeffrey W. Csiszar, MD President-elect Mario Deguchi, MD Secretary Treasurer Mario Deguchi, MD Past President Board of Directors Bradley Beard, MD James E. Dean, MD Laura Howard, MD Ying-Chien Lee, MD Bo Lundy, MD Michael MacLein, MD Kenny Mai, MD CMA Delegates: Jeffrey W. Csiszar, MD Thomas S. Enloe, Jr., MD Theresa P. Poindexter, MD CMA Alternate Delegates: Laura L. Howard, MD Staff: Marilyn Rush Executive Secretary
Certified Medical Coder Course and Exam The Tulare County Medical Society (TCMS) is pleased to announce a second 5-week/5 Fridays coding and certification course for qualified physician’s office staff. The Certified Medical Coder (CMC)® is a certification designed for physician-based coding intermediate level professionals with at least one-year coding and reimbursement experience. Experienced individuals, able to demonstrate by exam a superior level of physician-based coding knowledge, are awarded the CMC certification. The certification becomes a currency that validates personal achievement, demonstrates a person’s commitment to the profession, improves employer confidence, and can help guard the practice against fraud and abuse. This course is also the ideal preparation for 2013 ICD-10. Time: 8:30 a.m. 4:30 p.m. each Friday When & Where: 5 Fridays; March 2, 9, 16, 23 – March 30 (Exam) Sequoia Regional Cancer Center Curriculum Material: • Medical Terminology for Diagnostic/Procedural Coding; • ICD-9-CM Diagnostic Coding • CPT Procedural Coding; • Ancillary Services & Advanced Coding Course Cost: $750 for TCMS/CMA members/staff Contact: Gail Locke, TCMS to register or for more information on 2012 Certified Medical Coding Course, 734-0393, firstname.lastname@example.org. Hurry, seating is very limited!
NORCAP Continued from page 9 encourage you all to watch and I think you can recommend it to your staff and patients. Access it by going to the You Tube site and type the following into search – Health Reform Explained Video: “Health Reform Hits the Main Street.” There was a fascinating presentation on the new issues of discovery related to malpractice cases when the records are electronic. A lot of information is embedded in the systems, which is discoverable in lawsuits. These issues relate to times and dates when documents were created and reviewed – or altered. Plaintiffs’ attorneys are very savvy. There have already been lawsuits that relate to the mixing up of electronic medical records. One of the cases presented was an error that simply related to the fact that one physician had not signed off properly before another signed on!
Material was presented regarding causes for malpractice claims settlements and once again, one of the key issues noted was FAILURE of communication of information from doctor to doctor and failure to communicate results/information to the patient. This issue is highlighted in plaintiff attorneys’ educational material to other lawyers where they point out that although a jury may not understand technical and scientific information, they will understand a “failure to communicate.” In our coming future, we will have more electronic record keeping and this will give opportunity for more tracking of our results and outcomes. This will produce a lot of data that will likely lead to reimbursement guidelines. If you thought Big Brother hadn’t arrived – forget about that! Not only has he arrived — he has moved into your house. If you would like more information regarding the seminar, please contact me at email@example.com.
3333 S. Fairway Visalia, CA 93277 559-627-2262 Fax 559-734-0431 website: www.tcmsonline.org
TCMS Officers Gaurang Pandya, MD President Steve Cantrell, MD President-elect Thomas Gray, MD Secretary/Treasurer Steve Carstens, DO Immediate Past President Board of Directors Virinder Bhardwaj, MD Carlos Dominguez, MD Parul Gupta, MD Monica Manga, MD Christopher Rodarte, 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 Sixth District CMA Alternate Thomas Daglish, MD Staff: Steve M. Beargeon Executive Director Francine Hipskind Provider Relations Gail Locke Physician Advocate Thelma Yeary Executive Assistant
V I TA L S I G N S / F E B R U A R Y 2 0 1 2
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. 4817 Centennial Plaza Way – 2,370 rsf. 1311 Columbus St. – 4,400 sf. Crown Pointe Phase II – 2,000-9,277 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. 3115 Latte Lane – 2,660-2,925 sf. 2731 H Street – 1,400 sf. 3941 San Dimas Street – 3,959 rsf. SUB-LEASE 4100 Truxtun Ave. – Can Be Split Medical Records & Offices Sprinklered – 4,764 usf. • Adm. & Billing – 6,613 rsf.
DENTAL OFFICE FOR SALE 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.
F E B R U A R Y 2 0 1 2 / V I TA L S I G N S
Classifieds 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.
FOR LEASE OR SALE
Fresno Women’s Medical Group welcomes board certified OBG, Preti Srivatsa, MD and board certified FM, Robin Linscheid, MD. Accepting new patients & most insurance. Call 559-322-2900 for appointments. Rare opening for a new client. Medical Billing service. Professional, precise, collection experts. 559-499-1233, firstname.lastname@example.org University Psychiatry Clinic: A sliding fee scale clinic operated by the UCSF Fresno Dept. of Psychiatry at CRMC M-F 8am-5 pm. Call 3200580.
High quality medical suite on NE corner of Palm/Barstow. Approx. 2,030 sf, 4 exam rms. 2 offices, lg. reception area. Available Jan. 2012. Excellent move-in incentives. Call Justin or Garry at 559-449-2424. www.russellgsmithinc.com. Medical office space, 3,000-7,000 sf in prime location near Fresno Surgical Hospital. Negotiable rates. Call 559-273-0600.
PHYSICIAN/PROVIDED WANTED Established IM and CD group seeks F/T physician. Ancillary services on site. Located adjacent to SAMC. Excellent opportunity for new and established practices. Call Kim at 559-435-2633 or 559-289-5535.
CME Activities Guide to Breastfeeding Infants with Special Needs – February 2, 2012 11:30am-4pm; UCSF-Fresno Center; Credit: pending; Fee: N/C; Contact: 559-459-1777.
V I TA L S I G N S / F E B R U A R Y 2 0 1 2
PRSRT STD U.S. Postage PAID Fresno, CA Permit No. 30
VITAL SIGNS Post Office Box 28337 Fresno, California 93729-8337
OR VERY SATISFIED
IN A ROW OF A.M. BEST “A” (EXCELLENT) RATING
TOTAL YEARS DECLARED DIVIDEND
HAVE YOU MOVED? Please notify your medical society of your new address and phone number.
$425M TOTAL DIVIDENDS DECLARED
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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