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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

May 2012 • Vol. o 34 No. 5

Vital Signs

May is Clean Air Month


M AY 2 0 1 2 / V I TA L S I G N S

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 NEWS HEALTHCARE REFORM: US Supreme Court: How is Health Insurance Different Than Broccoli?.....7 An Evening With Ray Kurzweil ..................................................................................................8 AIR QUALITY: Practical Information and Helpful Tips from Your Allergist ....................................10

May 2012 Vol. 34 – Number 5

AIR QUALITY: May is Asthma Awareness Month ......................................................................11 AIR QUALITY: A Year With My Chevy Volt .................................................................................12

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 Tulare Representative Gail Locke

CLASSIFIEDS ...........................................................................................................................18 CME ACTIVITIES .......................................................................................................................18 TULARE COUNTY MEDICAL SOCIETY.........................................................................................13 • President’s Message • Predictive Modeling Analysis of Medicare Claims KERN COUNTY MEDICAL SOCIETY ............................................................................................15 • President’s Message • Membership News FRESNO-MADERA MEDICAL SOCIETY .......................................................................................16 • President’s Message • Medical Society Presents Awards at Regional Science Fair • Educational Series for FMMS Members • Economic Forums for FMMS Members

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 937298337.

Cover photography: “Yokohl Valley near Exeter” by Justin Stoner

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 / M AY 2 0 1 2



M AY 2 0 1 2 / V I TA L S I G N S


California physicians are reporting that the Medicare payments they are receiving in 2012 have been reduced for a failure to prescribe enough electronically in 2011 – despite the fact that these physicians have filed hardship applications to the Centers for Medicare & Medicaid Services (CMS). CMS responded to California Medical Association (CMA) inquiries that it was not able to process all hardship applications prior to January 1, although the agency says it has since approved or denied all of those exemption requests. This means that CMS has levied a 1 percent penalty for what it considers “noncompliant physicians.” CMA is working with CMS to build clarity over whether penalties will apply to physician reimbursement rates going forward, and to ease confusion over the process in the future. CMA has urged CMS to re-evaluate the penalty timelines associated with the e-prescribing incentive program, as well as other health information technology incentive programs that are kicking in at the same time. For now, there is no official appeals process for the eprescribing penalty program. However, CMS has expressed a willingness to work with individual physicians on concerns with the payment adjustments. CMS encourages physicians who think they are receiving the e-prescribing penalty in error to contact its help desk. The QualityNet Help Desk can be reached by phone Monday through Friday, 7am to 7pm (CST) at 866-288-8912 or by email at Avoid the 2013 penalty On March 1, the agency reopened its hardship requests from physicians looking to avoid the 2013 e-prescribing penalty, which will grow to 1.5 percent. Physicians seeking waivers will have until June 30 to file exemption requests. A request for a feedback report, and an application for a hardship exemption, can be filed online by clicking on the Communications Support Page. CMA has published a guide to the e-prescribing process with pertinent deadlines and qualifications. Contact: Michelle Kelly, 213-226-0338 or


A state court of appeal has ruled that nothing in California law requires nurse anesthetists to be supervised by physicians when administering anesthesia to patients. The ruling came without regard for the numerous concerns and objections raised by the California Medical Association (CMA) and the California Society of Anesthesiologists (CSA). The court’s ruling lets stand a 2009 decision by former Governor Arnold Schwarzenegger to exempt California from federal rules requiring physician supervision of nurse anesthetists in Medicare participating hospitals. According to the court, any concerns “that a physician’s practical, ethical and legal responsibilities for his or her patient’s care will be jeopardized by the use of unsupervised certified registered nurse anesthetists to administer anesthesia” should be resolved “with the Legislature, not this court.”

CMA and CSA challenged Schwarzenegger’s decision in court because they believe it is inconsistent with California law, which requires that a physician always retain responsibility and control over the medical care of his or her patient. Physician supervision over nurse anesthetists is necessary within this framework, according to CMA, to ensure that the medical professional with the best training and the most clinical experience remain involved through all aspects of anesthesia care. Although nurse anesthetists can and do administer anesthesia, physicians are the most qualified to monitor the effects of the anesthesia, and to react immediately when medically necessary. Despite the recent court ruling and Schwarzenegger’s opt-out decision, hospitals in California still have the authority to require physician supervision of nurse anesthetists at their facilities. Furthermore, medical staffs at hospitals may also be able to implement a supervision requirement within the scope of their self-governance rights over the professional work in a hospital. While disappointed with the decision, CMA remains undeterred and committed to protecting the quality and safety of all medical care provided to Californians. CMA is analyzing the opinion and exploring all legal, regulatory and legislative options. Contact Samantha Pellon, 916-551-2872 or


Statutory authorities that specifically regulate the retention of medical records in a physician’s office are found broadly in California law. These include the Medi-Cal Act, the law governing the Emergency Medical Services Fund, the California Uniform Controlled Substances Act, the Knox-Keene Act, OSHA rules and the laws governing workers’ compensation. The California Medical Association’s (CMA) ON-CALL document #1160, “Retention of Medical Records,” discusses the major issues raised by the retention, abandonment, theft and destruction of medical or health insurance information and physician practice business records, including: statutory record retention requirements, the rules applicable to records abandoned in bankruptcy or otherwise, recommended retention periods, options for record management on the sale or closing of a medical practice, record destruction requirements, and obligations for safeguarding patients personal information and for responding when records containing identifying information are stolen or otherwise breached. This document, as well as the rest of CMA’s health law library, is available free to members in CMA’s online resource library. Nonmembers can purchase CMA ON-CALL documents for $2 per page. Contact Samantha Pellon, 916-551-2872 or


Two of the fastest-growing physician demographics – men near the end of their careers and women at the beginning or middle – are the most likely to demand part-time or flexible work Please see CMA News on next page V I TA L S I G N S / M AY 2 0 1 2



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Continued from CMA News page 5 schedules, according to experts in physician recruitment. This is according to a survey released March 12, 2012, by the American Medical Association and Cejka Search, a physician search firm based in St. Louis. The study found that male physicians headed toward retirement and young female physicians of child-bearing age are driving a change in medical practices across the nation. In 2011, 22 percent of male physicians and 44 percent of female physicians worked less than full time, up from 7 percent of men and 29 percent of women in a 2005 survey conducted by Cejka. The 2011 survey covered 14,366 physicians in 80 practices, which had from three to more than 500 doctors each. Larger practices offer more part-time work According to the survey, the shift is coming from within larger practices of 500 or more physicians as opposed to smaller practices. Twenty percent of male and 23 percent of female physicians in practices of 500 or more doctors worked part-time. Meanwhile, only 6 percent of male, and 4 percent of female physicians in practices of three to 50 physicians worked parttime. Total part-time work for in-hospitalbased practices was 5 percent of male and 7 percent of female physicians. Physician search firms said the increasing demand for part-time work – and large practices’ positive reaction to physicians’ part-time requests – is pressuring smaller groups to offer similar options. According to the survey, 75 percent of groups in 2011 offered a fourday workweek, and 30 percent allowed job-sharing. Some specialties, however, may find it more difficult than others to set up a parttime or flexible arrangement, physician recruitment experts and consultants said. Part-time practice is not uncommon in pediatrics and other nonsurgical specialties, but can be harder to set up for surgeons. Specialties that are more shiftoriented, such as hospitalists and urgent care and emergency department physicians, may find part-time easier to arrange.


U.S. Supreme Court: How is Health Insurance Different Than Broccoli? CMA, Reform Essentials

In March, attorneys representing the two sides in the debate around the federal Affordable Care Act (ACA) squared off in a round of oral arguments before the United States Supreme Court. While the arguments spanned a total of three days, much of the action was focused on the second day’s key question: Can the federal government require its citizens to purchase health insurance? In an effort to undermine the Administration’s call for an individual mandate, Chief Justice Roberts, as well as Justices Scalia and Alito, levied a series of hypothetical “slippery slope” arguments at the Administration. Through these arguments, opponents of the mandate attempted to highlight the key question of which market should be regulated by the mandate: the insurance market, all health services, or the portion of health services that uninsured people are likely to use. Justice Scalia challenged the Administration with broccoli. “Everybody has to buy food sooner or later, so you define the market as food, therefore, everybody is in the market; therefore, you can make people buy broccoli.” Chief Justice Roberts preferred comparing health insurance to cell phones on the basis that anyone might need to contact emergency services at some point, while Justice Alito likened it to burial insurance, saying, “I don’t see the difference... You can get burial insurance. You can get health insurance. Most people are going to need health care. Almost everybody. Everybody is going to be buried or cremated at some point. What’s the difference?” Speaking from a policy perspective – the legal perspective will be discussed in the next issue of Reform Essentials – the difference between health insurance and broccoli, cell phones or burial insurance can be boiled down to a basic question of cost. In one of the most reputed studies of its kind, Milliman, Inc. showed that uncompensated care cost the commercially insured an average of $1,017 per insured family and $368 per insured individual in 2008. By 2014, the first year of the mandate, this cost shift is likely to be even higher. Considering that health care spending made up nearly 18 percent of the gross domestic product (GDP) in 2011, these numbers take on even greater significance in the context of Supreme Court commerce clause precedent. In 2005, the Court found that in order to act under the

commerce clause, Congress must only have a rational basis for concluding that a target activity, taken in aggregated, would substantially affect interstate commerce. (Gonzales v. Raich) If the “target activity” is defined as receiving uncompensated health care, the effect on interstate commerce is clearly substantial, as data suggests it accounted for more than 10 percent of California’s premium costs in 2008. Regardless, the consensus among observers is that the Supreme Court appears likely to strike down the individual mandate, raising the issue of what in the ACA might fall with it.

WHERE DOES CALIFORNIA GO IF THE MANDATE IS STRUCK DOWN? Diana Dooley (Secretary of the California Health and Human Services Agency), Peter Lee (Executive Director of the California Health Benefit Exchange), Dave Jones (Insurance Commissioner), and William Monning (Chair of the Assembly Health Committtee), among others, have all implied California will continue forging ahead on health reform even if the entire ACA is struck down. Secretary Dooley has specifically suggested that the state may follow Massachusetts’ lead and institute an individual mandate at the state level if the ACA’s requirements that insurers accept all applicants without screenings and exclusions on account of preexisting conditions are permitted to stand. Dooley’s statement makes sense in light of a recent economic study from the Massachusetts Institute of Technology (MIT) that suggests, without the individual mandate, Exchanges eventually turn into nothing more than high risk pools. This is due to the ability of those with medical conditions to somewhat accurately project their health care costs for the next year. Even if the state is able to institute a mandate and dodge the high risk pool bullet, a lack of public funding could still doom California’s Exchange effort. A recent RAND Institute study estimated that without the individual mandate the amount of government spending per newly insured individual would more than double, from $3,659 to $7,468. Considering California’s growing budget struggles and the fact that even the lowest 2014 California Exchange enrollment estimates have exceeded 800,000, it is hard to imagine how the state could take on such potential costs without substantial federal assistance.

V I TA L S I G N S / M AY 2 0 1 2


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Practical Information and Helpful Tips from Your Allergist Regarding Allergies and Asthma Care Praveen Buddiga, MD, FAAAAI, Member FMMS Air Quality Committe Spring allergies – if the coming of spring fills you with dread, carries it for tens if not hundreds of miles. If you’re allergic to animals keep the pets out of the house and those that cannot be you’re probably among the 50 to 60 million left outside at least keep them out of the bedroom. Some studies Americans who suffer from seasonal allergic indicate that bathing your pet once a week can reduce the rhinitis more commonly known as hay fever. allergen load. Allergens themselves don’t make us sick, it’s Vacuum frequently and keep the house neat and simple. Limit our body’s over reaction to the substances the number of indoor plants that can produce mold spores from that produce the allergic reaction. The most the moisture in the soil. Keep the bathroom free of excessive common symptoms include sneezing, runny moisture to keep the mold to a minimum. The mold count can or congested nose, red, itchy, watery eyes, Praveen Buddiga, be very high in the soil outside especially if they’re old grass itchy skin, hives and in some people MD, FAAAAI clippings or old leaves in the soil. coughing, wheezing, tightness in the chest Medications – most people can get allergy relief from overand asthma. the-counter antihistamines, decongestants, or a combination of Common allergens include pollen, mold, animal dander and both. dust mites. Some people also have allergies to food, medications Although you can buy them without a prescription, you insect stings and skin products. These substances called antigens should note precautions with their use. For example alcohol and which are usually harmless react with allergy antibodies in the antihistamines don’t mix well, so avoid alcohol while treating allergic person to cause cells in the body to release histamine and allergy symptoms. These drugs can make you sleepy or dizzy and other chemical substances. Histamine and other mediators start impair your judgment so be very careful when driving or an inflammatory response which leads to allergy associated operating heavy machinery. Be sure to talk with your doctor if discomforts. you are already taking other medications for possible adverse interactions. I will generally recommend a combination antihistamine/ decongestant in the daytime or a straight antihistamine in the First Exposure IL-4 drives B cells to Pollen-specific IgE Second exposure Acute release of mast evening. There are also some to pollen produce IgE in response binds to mast cell to pollen cell contents causes to pollen antigens allergic rhinitis (hay fever) anti-inflammatory nasal corticosteroid sprays and antiCAN ALLERGIC REACTIONS BE AVOIDED? histamine nasal sprays that are very effective and these are Probably not altogether if you inherit an allergic tendency. usually obtained with a prescription from your primary care However, understanding more about what causes allergic doctor or your allergist. reactions and taking some precautions can make the hayfever Our understanding of the immune system and allergy season more bearable. Some general things you can do to antibodies has come a long way in recent years so there is a great minimize allergic problems is to take care of yourself. Get plenty chance that an effective treatment plan can be worked out for of rest, eat a well-balanced diet with plenty of fruits and you after appropriate allergic evaluation of exposures and skin vegetables. Exercise can be very helpful by improving your testing. circulation and opening up your nose and sinuses. Smoking and drinking will aggravate allergy symptoms. Allergy Shots – or desensitization injections are given on a There are three specific things you can do to minimize your weekly basis and administered subcutaneously. One develops allergic symptoms: protective antibodies to the antigens that they are allergic to. 1. Avoidance These type of injections are FDA approved for the following: 2. Medications 1. Allergic rhinitis 3. Allergy shots 2. Asthma Avoidance – the most important thing to do is to stay away 3. Allergic conjunctivitis from the allergens that gives you problems. 4. Atopic dermatitis or eczema Study the pollen patterns in your area and watch for pollen These injections do not contain steroids. The mechanism of indexes in your local newspaper. Avoid pollen by keeping indoors action is thought to be by an increase in immunoregulatory cells in an air-conditioned building when the pollen count is high. known as T regulatory cells that modulate and decrease the Keep the car windows closed. Try to limit your outdoor activity overall inflammatory mechanisms that result in allergic rhinitis, when the wind is blowing. The wind really stirs the pollen and asthma, allergic conjunctivitis and atopic dermatitis. V I TA L S I G N S / M AY 2 0 1 2



May is Asthma Awarenss Month What is asthma and what triggers it? Asthma is an abnormality of the bronchial tubes – airways that are reversible. The common feature of asthma is the hyperresponsiveness or “twitchiness “of the bronchial tubes to multiple stimuli. The most common triggers or stimuli of asthma are viral upper respiratory infections and allergy. Other triggers include exercise, temperature or barometric pressure change, sinus infections and medication such as aspirin. The common allergic triggers are tree pollen, grass pollen, weed pollen, dust mite, mold spores, cockroach and animal dander. Important Asthma facts: • Asthma is a chronic inflammation of the lung airways that causes coughing, chest tightness, wheezing or shortness of breath. • An estimated 22 million Americans have asthma; 6.5 million are under 18. • Asthma mortality is 4,000 deaths per year. • Asthma results in 497,000 hospitalizations and 1.8 million emergency room visits. • Asthma is the most common chronic illness in childhood, accounting for 12.8 million missed school days each year. It also accounts for 10.1 million lost work days for adults. • The estimated economic cost of asthma is $19.7 billion annually. • Asthma is often hereditary.

Asthma and allergies strike 1 out of 4 Americans

Million People

17 3


M AY 2 0 1 2 / V I TA L S I G N S





Heart Disease

million million Coronary million million Parkinson’s Alzheimer’s


Asthma & Allergies


million Cancer


• Direct medical expenditures associated with asthma, including hospital care, physicians’ services and medications, are estimated at $14.7 billion annually. • Indirect medical expenditures, including lost work days for adults suffering from asthma or caring for children with asthma and lost future earnings from premature deaths associated with asthma, total $5 billion annually. • Triggers that can initiate an asthma attack include allergens such as pollen, dust, animal dander, drugs and food additives, as well as viral respiratory infections and physical exertion. Obesity, use of acetaminophen and exposure to formaldehyde Please see Asthma on page 11




A Year With My Chevy Volt Sergio Ilic, MD FMMS President

In March of last year I traded my BMW for a Chevy Volt. That was the best decision I’ve made in years! I’m very worried about air pollution not only in our Valley but worldwide, and I felt this would be my contribution to clean air. I believe that motor vehicles pollute a great deal, and eventually we will have to do something about it. I felt I could start now. Let me remind you that the car is an ultra clean car. This is because when the battery goes dead there is a small generator that kicks in and charges the motor, allowing the car to continue to run on electricity. The generator produces a small amount of pollution. The nine-gallon gas tank uses premium gasoline, and I have filled it up only five times for an average of 155 miles per gallon!!! The highest mileage I have gone is 172 miles per gallon. If one uses the car on a long trip, the average goes down. One full battery charge plus a full tank of gasoline takes you about 350 miles! I have spent about $100 in gasoline this year. I have driven to Indian Wells, (the resort has chargers one can use), San Francisco twice and Bakersfield once. The transition to the generator is seamless. When I’m home in the evenings, I charge the car from a direct 110-volt outlet. It takes 8 hours to fully charge the car. If you plug the car into a 240-outlet, it charges the car in four hours. (I put in a 240 outlet, but haven’t used it). The battery lasts all day during a typical full day of driving – from my house in Clovis to CRMC downtown, back to Fresno Surgical Hospital, to

my office, to Summit Surgical, running a couple of errands and back to my home. During the summer months, the battery lasts the equivalent of 42 miles, but during the wintertime when it’s really cold, the charge goes for about 28 miles. Unfortunately the miles are not physical miles, but what would be the equivalent to them. This is because extra electricity is consumed if using the radio, the air conditioner, driving erratically, accelerating really hard etc. Owning this car has also had beneficial and unintended consequences. Since the car has a mechanism to measure the amount of electricity being spent, I’ve modified the way I drive. I now tend to have a more consistent speed driving between stop lights and I don’t accelerate or break really hard, becoming a less aggressive driver. I also don’t charge the battery during peak use time, saving money. It costs about $1 to $1.50 to charge the battery. What is the one thing I like best about the car? The quietness. It’s so quiet that sometimes I forget to turn the motor off, which has happened a couple of times. In summary, I really like the car, have not had any problems with it, it’s economic, comfortable, pleasant to drive, can go anywhere using the generator, and it has made me a more careful driver. Plus this year I am saving $10,000 in tax credits. I recommend it wholeheartedly to everyone.


asthma attacks. They relieve symptoms rapidly and are taken on an as-needed basis. • One of the most effective medications for controlling asthma is inhaled corticosteroids, which are anti-inflammatory medications. Taken early and as directed, these well-tolerated and safe medications can improve asthma control, normalize lung function, and possibly prevent irreversible injury to lung airways. • Combination therapy (inhaled corticosteroid plus a longacting beta2-agonist) is the preferred treatment for asthma when inhaled corticosteroids alone do not control the disease. • Immunotherapy or allergy vaccinations should be considered if asthma is triggered by exposure to unavoidable allergens, if symptoms occur year-round or during a majority of the year, or if it is difficult to control symptoms with medication.

Continued from page 10 and other volatile organic substances are identified as new risk factors for asthma. • Weather conditions such as extremely dry, wet or windy weather can worsen an asthma condition. • Effective asthma treatment includes monitoring the disease with a peak flow meter, identifying and avoiding allergen triggers, using drug therapies including bronchodilators and anti-inflammatory agents, and developing an emergency plan for severe attacks. • There are two types of asthma medications: long-term control and quick-relief medications. Long-term control medications are preventive, taken daily to achieve and maintain control of asthma symptoms. Quick-relief medications are used to treat

Sources: ACAAI website – American College of Allergy Asthma and Immunology; AAAAI website – American Academy of Allergy Asthma and Immunology; AAFA website – Allergy and Asthma Foundation of America V I TA L S I G N S / M AY 2 0 1 2


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Marsh is sponsored by:

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Fresno-Madera Medical Society Kern County Medical Society Tulare County Medical Society

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I am expected to communicate with our members as president of TCMS. Considering the task, it quickly dawned upon me that without members there is no president. All value of the Society is in our members and we on the TCMS Board have an assignment to make a difference to all the members. We all work for you. We are at your service. The next question I have is this, how good a job are we doing? Are we meeting your needs? Are we available to you when you need help? Are you proud and able to ask your friend or associate to join the Tulare County Medical Society? I need guidance from all of you. I want I would appreciate it if you let me know your to know your thoughts about the value of opinion and priority. Please remove this page, your membership in TCMS and CMA. Is complete the survery below and fax it to the Medical Society at 559-334-0090. Thank you for there anything that we can change, your time. improve or make available to you? Please let us know. Call us at 559-734-0393 and Name ask for Gail. FAX your hand written Contact Phone questions to: 559-334-0090 or email Address Or visit us in person at Email 3335 South Fairway, Visalia, CA 93277. I am available to you by cell phone 559-361Value Priority 1=highest 1=highest 2095 and by email: Goal 1,2,3,4,5 1,2,3,4,5 We have a dedicated physician advoImprove cate, Gail Locke. Gail is very personable, Practice economics knowledgeable and experienced. She is Improve Social opportunities able to activate help for the members and Disaster preparedness their staff. When needed members can Handle Medicare have access to CMA staff that can help in issues issues like nonpayment for services, unfair Increase our presence utilization review practices by health in community service plans, Medicare etc. In fact last year CMA Be able to teach staff was able to help members recover new residents several million dollars in reimbursement Leadership opportunities at CMA due to them from health plans. That Legislative and includes me also. political action Although it is not well publicized Discount CMA’s legal department is continuously purchasing group watching out for legislation and court Cost effective CME cases weakening MICRA. It is true that Other without MICRA protection, many of us will have to close our practices. Such is the case of Rahm vs. Kaiser Health plan. Although this is an ongoing case at this time and final case law has not been decided, it is very interesting to note that the trial lawyers want to have a trial by jury, in this case against Kaiser for determining punitive damages, for providing coercive inducements to physicians of Permanente group to deny an MRI examination for a 17-year-old patient. So does that mean that next time a health plan denies services for our patients, we will be dragged into a legal dispute? Probably not, but it could increase frequency of claims made against physicians, just in case, the trial attorney is hoping to drag health plans with deep pockets into the complaint. I am glad CMA staff is vigilant about protecting our flanks when we are busy taking care of our patients.

3333 S. Fairway Visalia, CA 93277 559-627-2262 Fax 559-734-0431 website:

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

Please see Pandya on page 17 V I TA L S I G N S / M AY 2 0 1 2




Predictive Modeling Analysis of Medicare Claims Provided by Judy Cotta, Compliance and Privacy Officer Kaweah Delta Health Care District

The Centers for Medicare & Medicaid Services (CMS), has implemented a predictive analytics system to analyze Medicare claims to detect potential fraudulent activity. The predictive analytics system uses algorithms and models to examine Medicare claims in real time to flag suspicious billing. This new process is similar to the pre-payment analysis already done by the financial and credit card industries. Medicare will incorporate this system into its claims payment process. As of June 30, 2011, CMS is streaming all Medicare FFS claims through its predictive modeling technology. As each claim moves through the predictive modeling system, the system builds profiles of providers, networks, billing patterns, and beneficiary utilization. These profiles enable CMS to create risk scores to estimate the likelihood of fraud and flag potentially fraudulent claims and billing patterns. Risk scores enable CMS to quickly identify unusual billing activity and flag claims for more thorough review prior to releasing payment. The system automatically prioritizes claims, providers, beneficiaries, and networks that are generating the most alerts and highest risk scores. CMS is leveraging the benefits of its new high-tech system to complement, not replace, the expertise of its experienced analysts: Analysts review prioritized cases by closely reviewing claims histories, interviews, and performing site visits as necessary. If an analyst finds only innocuous billing, the outcome is recorded directly into the predictive modeling system and the payment is released as usual. This feedback loop refines the predictive models and algorithms to better target truly fraudulent behavior. Analysts who find evidence or indicators of fraud will work with the CMS Center for Program Integrity, MACs, and Zone Program Integrity Contractors to enact targeted payment denials, and in cases of egregious fraud, revoke Medicare billing privileges. Program integrity entities may also, as appropriate, coordinate with law enforcement officials to investigate cases for criminal or civil penalties. Risk scores alone do not initiate administrative action and serve only to alert CMS to the necessity of more careful review of claims activity. While providers will be unable to appeal risk scores, CMS’s new technology will in no way alter a provider or supplier’s existing rights to appeal administrative actions or overpayment recovery efforts. Currently, CMS is not denying claims solely based on the alerts generated by predictive models. CMS is focused on developing and refining models that identify unusual behavior without disrupting its claims processing for Medicare providers. Working closely with clinical experts across the country and of every provider specialty, CMS is developing and refining algorithms that reflect the complexities of medical treatment and billing. The new technology will ultimately benefit the program’s many honest providers and suppliers by enabling the agency to prioritize the highest-risk cases for investigation and review. Prioritizing the alerts will minimize disruption to providers who may occasionally exhibit unusual but honest billing. Action Needed Hospitals and physician providers must make a point of planning for these analytics through clean charge capture processes and clean claim submission. While not directly a result of Medicare’s Recover Audit Contractor (RAC) and other audits taking place it provided Medicare with yet another tool to detect improper claims submission. The best defense is to ensure your processes are documented and working to ensure clean and accurate claims submission. This is just another step towards ensuring that Medicare only pays for medically necessary services. Reference:


M AY 2 0 1 2 / V I TA L S I G N S

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


President’s Message WE ARE THE 1%… AND WE ARE THE 99%

We are the 1%. We all share the same characteristics that made us doctors - hard work, dedication, unbending focus on a goal, the pursuit of perfection in our lives and in our practices, and a strong independent streak. We work hard, very hard and often to the point of fault. We sacrifice to serve others for a higher good. We are very diverse. But as far as I know, there is not one among us who is a Wall Street “Fat Cat.” Like me, many of us grew up on the bad side of the train tracks – absent a silver spoon. And like me, many of us worked hard to get through school and then have to pay for it for years. We are the 1% who then have suffered when these characteristics are taxed at an even higher rate. Yes, we suffer because we are the dedicated 1%. Yet, we are also the 99% who rely on the largesse of the government to supply our daily bread and who look to bureaucratic red tape as a way of life. We need the bureaucrats to tell us how to run our offices and practices, how to treat our patients and how to hire our staff. We have come to rely more and more on these bureaucrats. Whenever they visit, we end up with a raft of new regulations to determine how we dress, how we speak to patients, and even how much we sleep. We are the dependent 99%. All we need to do Please see Cohen on page 17 2012 Membership Directory Changes and Corrections ASTAKHOVA, Inga – 3700 Mall View Road, 93306 FAX: 334-2994 BELLA, George – Delete information (pg. 71) BLACK, Jennifer – 3733 San Dimas Street, 93301 FAX: 635-3430 CAMPOS, Marvin – 3501 Stockdale Hwy., 93309 FAX: 398-5057 DIGGES, John – DBP* HARMON, David – 3501 Stockdale Hwy., 93309 FAX: 398-5057 JAMALUDDIN, U. – Phone: 321-4310 LOOS, Donald – Move to Retired Section – 3821 Braeburn Dr., 93306-3607 MERCY HOSPITAL – Change name to Dignity Health (Hospital Index Tab – Back) MORTON, Ronald – Email: RAVI, Nandakumar – RISBUD, Madhavi – 3501 Stockdale Hwy., 93309 FAX: 398-5057 SMITH, Shannon – 3733 San Dimas Street, 93301 FAX: 635-3430 STAIGER, Pamela – 8800 Ming Avenue, 93311 FAX: 664-3729 KAISER PERMANENTE – Change the following addresses to 2531 Chester Avenue, 93301: AUNG, Kyi – FAX: 337-7271 BERTIZ, Augusto – FAX: 337-7271 CHRISTOPHER, Robert – FAX: 337-7096 DINH, Long – FAX: 337-7271 HOFFMAN, Douglas – OTO*/HNS FAX: 337-7258 HTOO, Aung – FAX: 337-7271 LEVINS, Anthony – FAX: 337-7096 MIRANDA, Elva – FAX: 337-7271 MIRANDA, Rodrigo – FAX: 337-7253 MISHKIND, Mark – FAX: 337-7253

NALESNIK, Jeffrey – FAX: 337-7258 NYSTROM, Mark – FAX: 337-7096 PATEL, Umesh – FAX: 337-7271 PENROSE, James – FAX: 337-7271 SALES, Jonathan – FAX: 337-7253 SELIGMAN, Jay – FAX: 337-7253 STONE, David – HNS/FPS* - FAX: 337-7258 TRAN, John – FAX: 337-7271 TRAN, Tan – FAX: 337-7271 VALOS, Nicholas – FAX: 337-7096 YEIN, Thu – FAX: 337-7271

Organizations of Interest Tab Changes, Corrections AMERICAN DIABETES ASSOCIATION – Remove P.O. Box Phone: 800/342-2383 BAKERSFIELD PREGNANCY CENTER – 326-1915 EMERGENCY MEDICAL SERVICES OF KERN – 1800 Mt. Vernon Ave., 93306 PH:321-3000 FAX: 868-0225 KERN AUTISM NETWORK – FAX: 588-4235 KERN COUNTY CORONER’S OFFICE – FAX: 868-0149 KERN COUNTY DENTAL SOCIETY – FAX: 327-1229 KERN COUNTY HEALTH DEPARTMENT – Phone: 321-3000 KERN COUNTY MENTAL HEALTH DEPARTMENT – Phone: 800/991-5272 KERN COUNTY VETERANS SERVICE DEPARTMENT – FAX: 868-7301 ODYSSEY HOSPICE – 5001 E. Commerce Dr. #140, 93309 Phone: 324-1232 FAX: 3240931 ONE LEGACY – Remove address; Phone: 800-786-4077 SOCIAL SECURITY ADMINISTRATION – Remove Haley St.; Phone: 866-476-1489

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

KCMS Officers 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

V I TA L S I G N S / M AY 2 0 1 2


Fresno-Madera SERGIO D. ILIC, MD Post Office Box 28337 Fresno, CA 93729-8337 1040 E. Herndon Ave #101 Fresno, CA 93720 559-224-4224 Fax 559-224-0276 website: 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


M AY 2 0 1 2 / V I TA L S I G N S

President’s Message FMMS HAS BEEN BUSY

Well, March came and went by very fast. The Medical Society’s annual Yosemite Postgraduate Institute CME conference was held March 23-25, and it was excellent. Thank you Drs. Aminian, Linder and Monteleone for the very good quality of speakers and interesting topics you brought to the conference. It was a pity that fewer doctors attended this year. As it has been said before, this is a jewel of a conference that is held in a beautiful environment, Yosemite National Park. We are hoping more doctors, especially our local doctors, will attend next year. A big thank you goes to Carol and staff for organizing it so well. Also in March we had the first in a series of Financial Education classes for our members. To allow for more scheduling flexibility, the classes are repeated the last Wednesday and Thursday evenings of the month. We had 17 people, most of them residents, which accomplishes one of our goals to teach the young doctors how to get savvy in this seemingly easy but really difficult area. Investing wisely is difficult, and many mistakes are made when we don’t have the knowledge on how to go about it. These mistakes are costly, and in this era of diminishing reimbursements, it is of paramount importance to invest wisely. See page 17 for this month’s topic. Great publicity has been given to the hearings of the Affordable Care Act by the Supreme Court. Depending on what you read, the justices are going to invalidate all or part of the law or uphold it. We don’t know how the Court is going to decide, but a great deal is at stake. If the court decides the law is constitutional, it will have great future repercussions. It will apparently expand the power of the executive branch over the States. On the other hand if it’s rejected, there will be 47 million Americans left without health insurance. I certainly do not envy the task of the Supreme Court. Finally, our biggest event ever is Friday, May 11. As most of you have already heard, Raymond Kurzweil is going to present a talk on a very interesting and controversial topic: “2045: The Year Man Becomes Immortal.” His theory is that scientific knowledge is growing at such an exponential rate that by 2045 we’ll have the technology to achieve this fete. Purchase your tickets or better yet a table of 10, and bring your family and friends to hear how Mr. Kurzweil believes how this can happen.

Medical Society Presents Awards at Regional Science Fair The 59th Annual Central California Regional Science, Mathematics & Engineering Fair was held in March at the Fresno County Fairgrounds. In addition to the regular panel of judges for the entire event, independent judges who represent government, professional and service organizations also judge and present awards within their specific areas. The FMMS sponsors awards related to medicine. The event provides an educational experience and stimulates young people’s interest in science, mathematics, computer, technology and engineering. It also provides for public recognition for their work. This year, Drs. Bonna Rogers-Neufeld and Joan Rubinstein served as the judges for the Medical Society. This year’s winners and their projects are: Junior Division • 1st place: Vinisha Prajapati, Alta Sierra Middle School, Clovis; “Bacteria vs. Turmeric” • 2nd place: Elizabeth Schulz, Granite Ridge; “Does the type of casting material and amount of cotton padding affect the peak temperature of a cast” Senior Division • 1st place: Michael Brooks, Clovis East High School; “Blood Proteins TRMPI and Clusterin at minimally invasive biomarkers of AR in renal and cardiac • 2nd place: Lindsey Greenwood, Sanger High School; “How child proof are child proof medicine bottles?” Air Quality Award • Yousef Joseph and Nick Mah, Clovis West High School; “The efficiency of the amount of light absorbed by chlorophyll under various color of light”

Fresno-Madera Financial Series for FMMS Members


As a member benefit, a series of Financial Education seminars will be offered to

Continued from page 13

FMMS members and their guests during the months of May and June – repeating in August, September, October and November. In order to allow members attendance flexibility, the seminars will be offered twice each month – the last Wednesday and Thursday evenings at 6pm.

At best these are changing times and by 2014 we all will see changes in the processes by which we manage our patients. CMA has redesigned the website and I recommend that if you have not signed up for the web site then please do as soon as possible. Get your login ID and password. If you need help, please let us know. We can help you get connected. It is important to be connected. This way we can get pertinent useful knowledge in timely manner in rapidly changing battlefield. There are also many other benefits. Please call Gail at 559-734-0393 to find out about many local benefits for TCMS members. I thank you for your membership and giving me an opportunity to be of service to the Tulare County Medical Society. Please ask your physician friends and associates to join our local medical society and California Medical Association.

MAY 30 & 31, 2012 “FINANCIAL PLANNING BASICS” Presented by Eric Van Valkenburg, CLU, CHFC®.and Amy Nuttall-Zwaan, CRPC, CSNA, Financial Consultants with Central Valley Physician Benefits. Presentation will include: • Setting financial goals, such as retirement, college and/or Estate Conservation • Building a plan around those goals • Investment Planning • Risk Management • Insurance Protection • Credit Fundamentals Seminars will be held at the Medical Society offices, 1040 E. Herndon Ave. #101. (NE corner of First/Herndon) Space is limited, so please reserve your spot as soon as possible by contacting the Medical Society at 559-224-4224, ext. 118 or at A light meal will be available. Future topics: Understanding Social Security and Medicare Eric Van Valkenburg and Amy Nuttall-Zwaan are Registered Representatives with and securities offered through LPL Financial. Member FINRA/SIPC.

Economic Forums for FMMS Members The month of May will mark the start of a series of quarterly “Economic Forum” events being offered as a benefit to FMMS members and their guests. The Forums are intended to be informative, as well as social, and each will incorporate a pertinent and timely topic of interest in today’s economy. The events will be hosted by Eric Van Valkenburg, CLU, ChFC® and Amy Nuttall-Zwaan, CRPC, CSNA, Financial Consultants with Central Valley Physician Benefits. Each Forum will host an industry expert as the featured Guest Speaker. The topic of May’s Economic Forum is “The State of the Health Care Real Estate Market”. • Opportunities & Risks in today’s market; • Current Health Care industry trends; • Factors Driving Supply & Demand today; Featuring Guest Speaker, Danny Prosky*, President & COO of GriffinAmerican Healthcare REIT II Wednesday, May 16, 2012 at 6 pm The Daily Grill (private room), Palm and Nees Avenues, Fresno Complimentary hors d’oeuvres and drinks will be served. Space is limited so please reserve your spot as soon as possible by contacting Central Valley Physician Benefits: 559-492-9592 or * Danny Prosky has spent the entirety of his 20-year career in the specialized field of healthcare real estate investment, where he has been responsible for more than 14 million square feet of acquisition transactions. Eric Van Valkenburg and Amy Nuttall-Zwaan are Registered Representatives with and securities offered through LPL Financial. Member FINRA/SIPC

Cohen Continued from page 15 is to look at the recent SGR “Doc” fix to understand that we are dependent on our bureaucrats to stay afloat. We are clearly the 99%. We cannot survive on our own. The upcoming elections in June and November are indeed critical ones. They will decide if we will nurture our 1% or choose to remain firmly entrenched among the 99%. Will we choose to cast our lot with the bureaucrats and tax our 1%, the hard working part of ourselves, in the hope (as long as we can trust politicians to remain true to their word) that they will preserve our dependent 99%? If we do so, can we indeed trust our elected politicians? (think SGR “Doc” fix) This is my final column before the next election. Please consider the ballot choices and decide whether we should encourage and nurture the 1% or the 99% inside of us that we all share. An old political saying is to “vote early and vote often.” I would recommend that we all vote – and vote wisely. V I TA L S I G N S / M AY 2 0 1 2


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.





California Gastroenterology Associates is announcing a change of their telephone number in their Fresno office. New number: 559-299-9395, fax: 559-299-0400 Christine Lopopolo, MD announces her boutique obstetrics and gynecology practice in Fresno. Accepting new patients. Call 559-261-9320. University Psychiatry Clinic: A sliding fee scale clinic operated by the UCSF Fresno Dept. of Psychiatry at CRMC M-F 8am-5pm. Call 559-320-0580.

ATL HDI 5000 Colorflow Doppler Digital Ultrasound Echo Machine with 3 Probes – L74, P4-2 and C5-2 – $7,500. Call 661-7030000 or email

FOR RENT / LEASE Medical office space 1,000sf up to 2,500sf at First & Herndon and First & Bullard, starting at $1psf++ by owner. Call 559-4497668 or 559-284-2625.


PHYSICIAN/PROVIDED WANTED IM/FP needed to join Tulare outpatient clinic practice. Friendly, collegial work environment. Part/full time. Competitive salary/ benefits – paid vacation, holidays, retirement, loan repayment. Send resume to Catherine.mcharry@ or call Cathy at 559-225-6100 ext. 6339.

PHYSICIAN/PROVIDED WANTED PA or NP wanted in busy primary care workers comp facility. Good social skills a must. Unlimited growth, no weekends, no call. Part or full time. Contact:

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

MEDICAL OFFICES FOR LEASE 2701 16th St. – 2,400 2007 17th Street – 5,090 rsf. 2031 17th Street – 1,776 sf. 4817 Centennial Plaza Way – 2,370 rsf. Crown Pointe Phase II – 2,000-9,277 rsf. 2525 Eye Street – 3,000 – 6,173 – 12,315 sf. 3115 Latte Lane – 5,637 rsf. 3115 Latte Lane – 2,660-2,925 sf. Meridian Professional Center – 1,740-9,260 rsf. 3815 Mt. Vernon – 1,000 sf [MD or DDS] 2204 “Q” Street – 2,894 rsf. 3941 San Dimas Street – 3,959 rsf. 4040 San Dimas St. – 2,035 rsf. 9300 Stockdale Hwy. – 3,743 - 5,378 rsf. 9330 Stockdale Hwy. – 1,500-7,700 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 2007 17th Street – 5,090 sf. Crown Pointe Phase II – 2,000-9,277 rsf. Meridian Professional Center – 1,740-9,260 rsf. 9900 Stockdale Hwy. – 2,000-6,000 rsf.


M AY 2 0 1 2 / V I TA L S I G N S

CME Activities 18th Annual Hispanic Medical Conference – May 5, 2012 Location: Fresno Art Museum; 7:30 am- 1:30 pm; Credit: 4 hours; Fee: $75; Contact: Yolanda at 559-266-8300 or 7th Annual Cardiology in the Valley Symposium – May 19, 2012 Location: UCSF Fresno Center; 8am–1:45 pm; Credit: 5 hours; Fee: N/C; Contact: Renee at 559-459-3872 or Natural Disasters & Terrorist Events – The Role of the Neurologist – May 24, 2012 Location: CRMC, Sequoia East; 12-1pm; Credit: 1 hour; Fee: N/C; Contact: Virginia at 559-459-6299 or Pulmonary Arterial Hypertension – State of the Art – June 20, 2012 Location: Medical Society offices; 6-7pm; Credit: 1 hour; Fee: No charge; FMMS member; Contact: 559-224-4224 x118 or

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











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