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We Celebrate Excellence – James Strebig, MD CAP member, internal medicine physician, and former President of the Orange County Medical Association.



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

Contents EDITORIAL..................................................................................................................................5 CMA NEWS ................................................................................................................................7 NEWS iHEALTH NEWS .....................................................................................................................10 INSRURANCE: See What You Could Be Saving! .......................................................................11

July 2012 Vol. 34 – Number 7 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

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. Advertising Contact: Display: Annette Paxton, 559-454-9331 Classified: Carol Rau, 559-224-4224, ext. 118

BLOOD BANK: AABB Publishes Clinical Pracitice Guideline for RBC Transfusion.........................12 AIR QUALITY: Go Electric .......................................................................................................13 CLASSIFIEDS ...........................................................................................................................18 CME ACTIVITIES .......................................................................................................................18 FRESNO-MADERA MEDICAL SOCIETY .......................................................................................14 • An Evening with Ray Kurzweil TULARE COUNTY MEDICAL SOCIETY.........................................................................................16 • Save the Date September 13: Meet 2013 California Medical Association (CMA) Incoming President, Paul Phinney, MD • 2013 Coding Book News KERN COUNTY MEDICAL SOCIETY ............................................................................................17 • President’s Message • Take Away Tattoos Program

Cover photography: “Lazy Day on Huntington Lake” by David Slater, 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 / J U LY 2 0 1 2



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Lies and Damn Lies, Truth Trumps Fiction – A Few Examples Lyle B. Stillwater, MD, FACS, Otolaryngology, Visalia Past President Tulare County Medical Society

It is so regrettable that the California State Government is basing its job killing “cap and trade” law on junk science. Why biased and scientifically ignorant ideologues are free in our state to pass foolish laws that will continue to hurt an already ailing economy, is beyond me. Man-made global warming is a total hoax and has no basis in fact. CO2 is not a pollutant – it is a plant food, and the Green Lyle B. Stillwater, House effect is complete fiction. In 2007 we MD, FACS saw a large one-year temperature change, but cooling, not warming. All four major global temperature tracking outlets have data showing that global temps have been dropping, and recent drops in global temps have wiped out a century of mild warming. Multiple researchers have linked global temps to levels of solar activity i.e. a changing solar cycle, not any effects due to man-made pollution. Next fallacy, cigar smoking is harmful to one’s health. Occasional cigar smoking is defined as less than one cigar per day. The heath risks linked to occasional cigar smoking (less than daily) are not known. Most occasional cigar smokers do relax, lower their blood pressure and receive a mental health benefit and may be aided in controlling their weight. Also cigar smoke does repel flying insects. Nicotine is the alkaloid in tobacco. It helps patients with schizophrenia, depression and anxiety disorders function better. It generally increases alertness, and for someone who is agitated, nicotine has a calming effect. There is a lower incidence of Alzheimer’s disease in smokers. It may boost cognitive abilities in elderly people who are experiencing the typical mental decline associated with old age. There is a direct link between nicotine and an increase in the release of dopamine and serotonin, two vital neurotransmitters. A variety of conditions are being studied for the potential uses of nicotine; anxiety, depression, Tourette syndrome, ADHD, Parkinson’s disease, Diabetes and schizophrenia. An occasional cigar could be legitimately viewed as an occasional mental “tonic.” Some of my more liberal friends and family members were horrified to read the front page of the May 6, 2012 Fresno Bee, which revealed the current booming sales of all types of firearms in California especially the Central Valley. Every type of firearm is in high demand, and the major American gun makers can not keep up with the demand. This situation could make non-gun owning citizens quite nervous, but it should not. The facts should put their minds at ease. States with the largest increases in gun ownership also have the largest drops in violent crime. Thirty one states now have laws called “shall issue” laws. These laws allow adults the right to carry concealed handguns if they do no not have a criminal record or a history of significant mental illness.

Just as higher arrests and conviction rates deter crimes, so does the risk that someone committing a crime will confront someone able to defend him or herself. There is a strong negative relationship between the number of law abiding citizens with permits and the crime rate. As more people obtain permits, there is a greater decline in violent crime rates. For each additional year that a concealed handgun law is in effect, the murder rate declines by three percent, rape by two percent and robberies by over two percent. Concealed handgun laws reduce violent crime for two reasons. First, they reduce the number of attempted crimes, because STATES WITH criminals are uncertain which THE LARGEST potential victims can defend INCREASES IN themselves. Second, victims who GUN OWNERSHIP have a gun are in a much better ALSO HAVE THE position to defend themselves. LARGEST DROPS Restrictive gun laws risk creating situations in which the IN VIOLENT good guys cannot defend CRIME. themselves from the bad guys. The effect of “shall issue” laws on those violent crimes has been dramatic. When states passed those laws, the number of multiple victim shootings declined by 84%. Deaths from those shootings plummeted on average by 90% and injuries by 82%. Both children as well as adults are protected when law abiding adults are allowed to carry concealed handguns. There is no evidence that increasing the number of concealed handguns increases accidental shootings. The type of person who obtains a permit is extremely law abiding, and they are extremely careful in how they take care of their guns. Despite over two hundred million guns owned by between 76-85 million people, the children killed is much smaller than the number lost through bicycle accidents, drowning and fires. Children are 145 times more likely to die from car accidents than from accidents involving guns. Despite millions of people licensed to carry and many states having their laws for decades, there has only been one case where a person with a permit used a gun after a traffic accident and even in that one case, it was in self defense. Murder rates decline when either more women or more men carry concealed, but a gun represents a much larger change in a woman’s ability to defend herself than it does for a man. An additional woman carrying concealed reduces the murder rate for women by about 3-4 times more than an additional man reduces the murder rate for men. Please see Editorial on page 12 V I TA L S I G N S / J U LY 2 0 1 2



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Pending or denied claims can be devastating to any practice’s finances, but if some recent revisions to the final federal health insurance exchange rule aren’t sorted out, unpaid claims could soon become a regular occurrence for physicians who treat patients covered by one of the state’s exchange plans. The final rule allows plans operating under the exchange to suspend payment for services rendered if an enrollee is more than one month delinquent on his or her premium. If the patient fails to settle up with the plan within the statutory three-month grace period, the plan can then terminate coverage for nonpayment and deny all pending claims for services that were provided by physicians in good faith during the second and third months of the grace period. THE EXCHANGE’S 3-MONTH GRACE PERIOD FOR NON-PAYMENT OF PREMIUMS First month of delinquency • Normal payment claims • Plan effectively treats this month as paid even if enrollee is eventually terminated for non-payment • No provider notification of the patient’s delinquency Second & third months of delinquency • Plan has the option to pend claims for services performed until the enrollee pays the outstanding premium balance • Providers submitting claims during these two months are notified of the potential for a denied claim • If enrollee pays off the premium balance, providers’ claims are paid at that time Terminated after three months of delinquency • Plan has the option to deny all claims for services performed in the 2nd and 3rd months of delinquency • Providers may seek payment for denied claims from the patient • Patient may then enroll in a different Exchange plan during the next open enrollment period regardless of whether they pay off premium balances with previous insurers

This provision shifts most of the burden of covering claims submitted for delinquent enrollees from the plans to the providers. This would apply to all enrollees receiving tax subsidies for coverage. Recognizing the financial risks it places on providers, the revision requires that physicians who submit claims for services rendered during the second or third months of grace period be “notified of the possibility for denied claims.” Unfortunately, this implies that notice is required only after submission of a claim in the months when a plan has already stopped paying claims for the enrollee. While this revision could pose a huge financial threat to physicians, the damage would not stop there. Because this provision would no doubt hit physicians depending on fee-forservice payments the hardest, enrollees in need of specialists’ services and those in rural areas, among many others, would suffer difficulties in access. This fee-for-service impact would also likely drive sicker patients in the exchange toward the networks of capitated products, creating adverse selection. The problem of medical bankruptcy among Californians would also worsen, as they remain on the hook for any unpaid claims submitted on their

behalf during the final two months of the grace period. While exchange staff has said that the grace period provision likely would not be up for public discussion until July and August, Reform Essentials will continue to update our readers as developments occur. In the meantime, the exchange will need to determine whether and to what extent this policy preempts state law, such as prohibitions on plans’ rescission or modification of authorized payments after a physician renders services in good faith. For the latest information on California’s ongoing implementation of federal health care reform, see CMA Reform Essentials ( Contact: Brett Johnson, 916-551-2552 or


You have less than a month to convert your electronic transactions to the new HIPAA 5010 transaction standards. If you have not yet finalized your version 5010 upgrade, you should be working to complete this step as soon as possible. The Centers for Medicare & Medicaid Services (CMS) requires all Medicare electronic claims be transmitted in the new format effective July 1, 2012. As of that date, claims transmitted in the 4010 transaction format will be rejected. Practices that are required to transmit claims electronically will not be able to drop their claims to paper. Additionally, Medi-Cal has announced that beginning June 25, submitters will be able to send either 4010 or 5010 transactions. While Medi-Cal will continue to accept 4010 transactions after June 25, once you switch to the new 5010 format, you will no longer be able to submit in the 4010 format. Most of the major private payors in California have already required electronic claims to be transmitted in the new standard format, however, some have allowed for contingencies through June 30. The California Medical Association (CMA) surveyed the major payors in California to learn about each payor’s requirement for submitting electronic claims and has created a 5010 Quick Reference Guide, available on our website at If you are not yet ready to transmit in the new format, many payors will still accept paper claims. However, practices should contact their payors prior to submitting paper claims to avoid delays or denials. Questions: CMA’s Reimbursement Helpline: 888-401-5911 or ARE YOUR CONTROLLED SUBSTANCE PRESCRIPTION PADS UP-TO-DATE? On January 1, 2012, a new law took effect that requires changes to controlled substance prescription forms. Please see CMA News on page 8 V I TA L S I G N S / J U LY 2 0 1 2


CMA News Continued from page 7 Unless a physician is a designated prescriber from a licensed health care facility, prescription forms for controlled substances are now required to include the preprinted address of the prescribing practitioner. Previously, prescription forms were only required to include the preprinted name, category of licensure, license number and federal controlled substance registration number of the prescribing practitioner. Physicians must also now ensure their controlled substance prescription pads contain a statement printed on the bottom of the prescription form that the “prescription is void if the number of drugs prescribed is not noted.” Any controlled substance prescription form that is not in compliance with these requirements won’t be valid or accepted after July 1, 2012. For more details, see California Health & Safety Code §11162.1 ( Physicians are urged to check that their prescription pads are up-to-date and were obtained from an approved security printer – you can check approved printers at the Office of the attorney general’s website ( CMA has partnered with RxSecurity, a state-approved printer, to provide tamperresistant prescription pads to CMA members at a significant discount. Using the 15 percent CMA member-discount, physicians will pay as low as $2.68 per pad for one-part pads or $4.46 for two-part pads. Special pricing is available for hospitals, clinics, and other high-volume purchasers. To place an order with RxSecurity, visit or call 800-66-RX-PAD. Contact: Member Service Center, 800-786-4262 or member


To make sure that you are aware of important news from your contracting health plans, we encourage you to regularly read plans’ provider newsletters and bulletins. Follow the links below to access the current issues. AETNA: Click on “Health Care Professionals” in the main menu, then on “News for Providers” in the left sidebar. CIGNA: Click on “Health Professionals” under “Customer Care” in the main menu. Then, scroll down and click on “Newsletters.” ANTHEM BLUE CROSS: Click on “Providers” in the main menu, then on “Professional Network Update” under “Spotlight.” BLUE SHIELD: Click on “I’m a Provider,” then on “Announcements” under “News and Features.” HEALTH NET: Click on “I’m a Provider” and then “California.” Enter username and password, and then click “Online News.” MEDI-CAL: Click on “Publications” in the main menu, then on “Provider Bulletins.” MEDICARE/PALMETTO GBA: Click on “Publications” in the left sidebar, then on “Medicare Advisory.” UNITED HEALTHCARE: www.unitedhealthcareonline. com. Click on “Tools & Resources” in the main menu, then on “Network Bulletin.” CMA RESOURCE: Find up-to-date profiles on each of the major payors in California. PROBLEMS GETTING PAID?


California Medical Association’s Center for Economic Services provides direct reimbursement assistance to CMA physician members and their office staff. Reimbursement Help Line 888-401-5911 • One-on-one educational and reimbursement assistance to physician members and their staff Practice Empowerment • Tools and resources to empower physician practices • Seminars and toolkits for physicians and their staff Please see CMA News on page 11 8

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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. July 11: 2012 Legislative Update Carolyn Ginno • 12:15-1:15 p.m. July 18: Preparing for a Medicare/Medi-Cal Audit Mary Jean Sage • 12:15-1:15 p.m. Aug. 1: Coding for Medical Necessity Arthur Lurvey, M.D. • 12:15-1:15 p.m. Aug. 15: Program Integrity in Medicare & Medi-Cal Bruce Tarzy, M.D. • 12:15-1:15 p.m. Aug. 16: California Workers' Comp eBill Part 1: Are You Ready? Jopari Solutions/CA Workers’ Comp • 12:15-1:45 p.m. Aug. 23: California Workers' Comp eBill Part 2: Implementation Jopari Solutions/CA Workers’ Comp • 12:15=1:45 p.m. Aug. 30: California Workers' Comp eBill Part 3: Understanding Remittance Advice Rules Jopari Solutions/CA Workers’ Comp • 12:15=1:45 p.m. Sept. 5: A Guide to Reviewing Payor Contracts Kris Marck • 12:15=1:15 p.m. Sept. 6: California Workers' Comp eBill Part 4: First-Time Submission Jopari Solutions/CA Workers’ Comp • 12:15-1:45 p.m. Sept. 19: Creating and Implementing Financial and Office Policies Debra Phairas • 12:15-1:15 p.m. Oct. 3: Protect Your Practice From Payor Abuse Mark Lane • 12:15-1:15 p.m. Oct. 17: Establishing Expectations for High Performance from Medical Staff Debra Phairas • 12:15-1:15 p.m. Nov. 7: Understanding ARC and CARC Revenue Codes David Ginsberg • 12:15-1:15 p.m.

2012 Education Series A Webinar Invitaon for All Physicians and Their Staff

Preparing for a Medicare and/or Medi-Cal Audit With Mary Jean Sage, founder of

Wednesday, July 18 12:15 – 1:15 p.m. CMA hosted webinars are FREE as a benefit of your CMA Membership. *Nonmembers are invited to join this webinar for $99*

What A!endees Can Expect to Learn: All third-party payers, including government health plans, have stepped up their audit ac vity. It is no longer a ma!er of “if” you go through an audit, but “when” you are selected for an audit. It is always preferen al to be prepared. This webinar will discuss: • Recognizing those things that put your prac ce at risk for an audit • How you know you are being audited • Handling a request for records • What do you do with your results To register for this or any CMA webinar, please visit **CMA is pleased to provide 1 PMI CEU credit for medical office staff.** This webinar is being hosted by the California Medical Associaon. You must register at least one hour prior to the event. Once your registraon has been approved, you will be sent an email confirmaon with details on how to join the webinar. Quesons? Call the CMA Member Help Line at (800) 786-4262.

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iHEALTH NEWS Reprinted with permission from iHEALTHBeat





U.S. Olympic Committee announced that it will use an electronic health record system to manage care for athletes, staff and volunteers, eWeek reports. The announcement marks the first time that USOC has used an EHR system to manage care. Bill Moreau, USOC managing director of sports medicine, said, “We previously had to ship, sort and store palettes of paper records for each [Olympic] Games – those days are gone” (Horowitz, eWeek, 5/24). USOC will deploy GE’s EHR system and its medical record image viewing software (Walsh, CMIO, 5/24). The system will contain medical data on 700 athletes competing in the Summer 2012 London Olympic and Paralympic Games, as well as almost 3,000 USOC staff members and volunteers (Miliard, Healthcare IT News, 5/24). Physicians will be able to access the health records via tablet computers. USOC said the health IT tools will allow physicians to quickly access information about allergies and medications while treating athletes’ injuries (eWeek, 5/24). USOC said it plans to continue its partnership with GE for several future Olympic Games, including the 2014 winter games in Russia and the 2016 summer games in Brazil. Jan De Witte – CEO of GE’s health IT and performance solutions divisions – said the EHR system “is a platform that will stay with the USOC for the years to come” (Healthcare IT News, 5/24). Read more:

of electronic 2002 2011 health record adoption 19.9% among physicians in the Northeast U.S. grew from Northeast 52.1% 19.9% in 2002 to 52.1% in 2011, according to a 19% recent Health Affairs Midwest 55.5% study. The study found that EHR adoption rates 16.5% among physicians in the South 50.9% Midwest grew from 19% in 2002 to 55.5% in 2011, 19.5% while EHR adoption rates West among physicians in the 60.8% South grew from 16.5% in HEALTH AFFAIRS 2002 to 50.9% in 2011. In the Western U.S., EHR adoption rates increased from 19.5% in 2002 to 60.8% in 2011. The study is based on data from CDC’s National Ambulatory Medical Care Survey from between 2002 and 2011. Source: Health Affairs, “Physicians in Nonprimary Care and Small Practices and Those age 55 and Older Lag in Adopting Electronic Health Record Systems” Read more: what-percentage-of-physicians-from-various-us-regions-haveadopted-an-ehr-system.aspx#ixzz1xVciwBTC


The health care industry’s adoption of mobile technology poses U.S., MEXICO TO ADOPT GUIDELINES FOR SHARING PUBLIC HEALTH DATA

HHS officials announced that the U.S. and Mexico have reached an agreement to adopt a set of technical guidelines outlining how information will be shared during public health events and emergencies, Modern Healthcare reports (Barr, Modern Healthcare, 5/22). The new guidelines aim to help the countries exchange information for various public health activities, such as: • Tracking patients with HIV/AIDS or hepatitis to ensure that they receive proper care; and • Coordinating efforts to decrease the spread of epidemics or outbreaks like influenza and pertussis. Officials also announced that Mexico has joined CDC’s Laboratory Response Network, which links national and international laboratories to better respond to public health emergencies. Mexico is the fourth country to join the network after Australia, Canada and the United Kingdom (Monti, Examiner, 5/22). Read more:

certain security risks to health data, according to a report by the Department of Homeland Security, Government Computer News reports (McCaney, Government Computer News, 5/16). DHS’ National Cybersecurity and Communications Integration Center issued the report, titled, “Attack Surface: Healthcare and Public Health Sector” (Horowitz, eWeek, 5/16). The report stated, “Since wireless medical devices are now connected to medical IT networks, IT networks are now remotely accessible through the medical device.” It added that “communications security of medical devices to protect against theft of medical information and malicious intrusion is now becoming a major concern” (Kurtz, Becker’s Hospital Review, 5/17). The report noted that security threats against mobile devices – such as smartphones and tablet computers – include: • Introduction of spyware and other malicious software; • Loss of treatment records or test results; and • Theft of patient data. In the report, DHS recommended that health care organizations: • Purchase only devices that have well-documented security features and can be configured safely to the organization’s IT network; • Require vendor support for firmware, software patches and antivirus updates; Please see iHealth News on next page


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Continued from page 10 • Operate well-maintained firewalls; • Create and enforce password policies to protect patient data; and • Protect communication channels – particularly wireless channels – by using authentication and encryption (Government Computer News, 5/16). Read more: dhs-mobile-technology-poses-security-risks-to-healthdata.aspx#ixzz1xVd3TPiv


The American Medical Association sent a letter to acting CMS Administrator Marilyn Tavenner asking the federal government to further delay the compliance date for the transition to ICD-10 code sets to Oct. 1, 2015, Modern Healthcare reports (Conn, Modern Healthcare, 5/11). U.S. health care organizations are working to transition from ICD-9 to ICD-10 code sets to accommodate codes for new diseases and procedures. The switch from ICD-9 to ICD-10 code sets means that health care providers and insurers will have to change out about 14,000 codes for about 69,000 codes. In April, HHS announced that it would delay the deadline for complying with ICD-10 standards by one year, to Oct. 1, 2014. HHS said it decided to push back the compliance date partly in response to health care providers’ concerns that they would not be able to meet the initial deadline (iHealthBeat, 5/10). The comment period on the new ICD-10 compliance date ended May 17. Read more: a m a - c a l l s - f o r- f u r t h e r- d e l a y - t o - i c d 1 0 - c o m p l i a n c e deadline.aspx#ixzz1xVdkpUlG

CMA News Continued from page 8 Experienced Staff • Staffed by practice management experts with a combined experience of over 125 years in medical practice operations Need help? Contact CMA’s reimbursement experts at 888401-5911 or

See What You Could Be Saving! “My premium savings was over $1,900! What a great member benefit. All Society members with employees should get a quote. It was so easy to do.” – Philip R. Delio, MD Neurology Associates of Santa Barbara

Did you know that CMA/Society members can save 5% on their workers’ compensation insurance? And, they may save even more than that, up to 15%, depending upon their group medical carrier. It’s true. CMA/FMMS/KCMS/TCMS members receive a 5% discount on workers’ compensation insurance policies provided through Employers Compensation Insurance Company. This discount is available exclusively through Marsh/Seabury & Smith Insurance Program Management, the CMA/FMMS/ KCMS/TCMS sponsored broker and administrator. And, EMPLOYERS provides you with the loss control tools, such as Loss Control ConnectionSM, that can help you manage the long-term costs associated with workers’ compensation. Because safer workplaces contribute to lower workers’ compensation premiums and less lost time for employees, the importance of effectively preventing injuries and managing claim costs is clear. EMPLOYERS Loss Control ConnectionSM is an easy-to-use, online risk management database that provides policyholders with unlimited access to a comprehensive library of loss prevention tools, OSHA log software, safety posters and other valuable resources – at no charge. Should you have a claim, experienced professionals at EMPLOYERS work to deliver prompt, efficient, knowledgeable service to resolve claims quickly and fairly while helping employees get back to work. Don’t wait until the last minute. Contact Marsh today to get a workers’ compensation premium quote so you’ll be prepared in the event your rate increases on renewal. If you have any questions, or would like to get an immediate indication of your potential savings, please call a Marsh Client Service Representative at 800-842-3761 or email CMACounty. d/b/a in CA Seabury & Smith Insurance Program Management • CA Ins. Lic. #0633005 • AR Ins. Lic. #245544, 56830 (7/12) ©Seabury & Smith, Inc. 2012 • 777 South Figueroa Street, Los Angeles, CA 90017 • 800-842-3761 • •


The California Medical Association’s 24-hour online medical-legal library is the most comprehensive health law and medical practice resource for California physicians. These documents are available free to members at or by calling the member help center at 800-786-4262. Nonmembers can purchase CMA ON-CALL documents for $2 per page at www.cmanet. V I TA L S I G N S / J U LY 2 0 1 2



AABB Publishes Clinical Practice Guideline for RBC Transfusion More than 15 million units of whole blood and red cells (RBCs) are transfused annually in the US, but there is much variation among physicians in when they decide to transfuse patients. AABB (formerly the American Association of Blood Banks) recently published a clinical practice guideline providing recommended transfusion triggers to help facilitate the appropriate use of RBC transfusions when treating stable adults and children. Members of AABB’s Clinical Transfusion Medicine Committee, along with representatives from the following major stakeholders in transfusion practice developed this guideline: American Association for the Surgery of Trauma, American College of Cardiology, American Society of Anesthesiologists, American Society of Hematology, and the Society for Critical Care Medicine. Jeffrey L. Carson, of the Robert Wood Johnson Medical School at the University of Medicine and Dentistry of New Jersey, was the lead author of the guideline. It was published online in the Annals of Internal Medicine on March 26 and is available at as well as on the AABB website ( “In order to avoid unnecessary transfusions, AABB developed this guideline to provide clinicians with evidence-based recommendations about when it is appropriate to transfuse,” said Dr. Carson in an AABB press release. “Optimal patient care should involve administering enough red blood cells to maximize clinical outcomes while avoiding transfusions that expose patients to potential infectious or noninfectious risks and increase medical costs.” In general, the guideline makes three recommendations: 1) Adhering to a restrictive transfusion strategy (Hgb 7 to 8 g/dl) in hospitalized, stable patients • transfusion should be considered at a hemoglobin concentration of 7 g/dl or less in adult and pediatric ICU patients • transfusion should be considered at a hemoglobin concentration of 8 g/dl or less in postoperative surgical patients, or for post-op surgical patients with symptoms (chest pain believed to be cardiac in origin, orthostatic hypotension or tachycardia unresponsive to fluid resuscitation, or symptoms of congestive heart failure)

Editorial Continued from page 5 High crime urban areas with large minority populations have the greatest reduction in violent crimes when citizens are legally allowed to carry concealed. People may use guns to prevent horrible things from happening to them. Allowing law abiding citizens to own guns does save lives. In summary, we should always desire clean air and clean water, 12

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2) Adhering to a restrictive strategy (Hgb 8 g/dl or less) in hospitalized hemodynamically stable patients with preexisting cardiovascular disease, and likewise (8 g/dl or less) when symptoms as described above are present in these patients 3) Transfusion decisions should be influenced by considering patient symptoms as well as hemoglobin concentration The AABB guideline could not recommend for or against a liberal or restrictive transfusion threshold for hospitalized, hemodynamically stable patients with acute coronary syndrome; further research is needed to determine the optimal threshold. If the restrictive strategy is implemented widely, exposure of patients to RBC transfusions would decrease by an average of 40 percent, which would have a large effect on blood use and the risks for infectious and non-infectious complications of transfusion. Although the blood supply is very safe now, with extremely low risks of getting an infectious disease from transfusion, decreasing unnecessary transfusions can improve patient care. Blood management and appropriate use of blood and blood products has been a central theme in the transfusion medicine world recently, especially since a June 2011 meeting of the Health and Human Services’ Advisory Committee on Blood Safety and Availability. At the meeting, experts emphasized that there is excessive and inappropriate use of blood, and that developing appropriate transfusion triggers and blood management systems is vital to improving patient care. Citation: Carson JL, et al. Red Blood Cell Transfusion: A Clinical Practice Guideline from the AABB.Ann Intern Med 2012 March 26. [Epub ahead of print] (Aadapted from ABC Newsletter April 6, 2006)

but not accept the junk science and socialist propaganda involved in the false theories of a Green House effect due to CO2 or manmade global warming. It is ok to enjoy an occasional good cigar (no inhaling) and not worry about any negative health effects when used in moderation. Soaring Central Valley gun sales to legal/legitimate mentally healthy citizens makes us more rather than less safe, in our communities. Armed women who have trained properly with their legal concealed handgun, derive a significant increase in there personal safety as they live their busy lives.


Go Electric! Joan Rubinstein, MD and Alex Sherriffs, MD

Undoubtably the biggest single action you can take to cut your contribution to Valley air pollution and green house gas emissions is to buy an all-electric vehicle. It’s fun. And you will probably save some money too! We attended a workshop at the local San Joaquin Valley Air Pollution Control District a couple months ago and heard from happy Joan drivers of Teslas, Leafs, Mitsubishis, plug-in Rubinstein, MD bikes, all-electric school buses, and hybids including the Prius. “Over 4 million Prius’ sold!” by the way, to paraphrase mighty McDs. This is not really new and unproven technology after all. None-the-less, buying an all-electric plug-in car (“ZEV”) felt like stepping over a precipice. We had done enough home-work that our first couple weeks of ownership have far exceeded expectations. Current vehicles available in the Valley seem to be limited to the Nissan Leaf, a roomy 5-seater, and the Mitsubishi i-MEV, a less expensive smaller easy urban parker. Ford is supposed to hit the market in a couple months. We are not talking hybrids. There is NO gas driven internal combustion in these gems. Our decision to buy an all electric vehicle was based on common-sense calculations. We thought about our daily commutes and found an 80-100 mile range would satisfy one of us every working day. Every one wants to know what we will do when we run out of charge. How many times have you run out of gas? The learning curve is not complicated. When you know your return trip is 15 miles, there is no cause for concern at having “only” 34 miles of charge. And I do not expect to suddenly go on a 50-mile whim when the battery says it has 48 miles of charge. How long does it take to charge? We expected to pay several hundred to a couple thousand dollars to install a “high speed” charger in our garage. We may never bother. Our standard household 110 plug is doing the job nicely by plugging in overnight when we get home after work. Weak performance? The electric engine develops full torque instantly. Corvettes and Mustangs beware. We have no problems zipping around slower traffic at freeway speeds. Yes, we do have air conditioning in our car!

Will repairs be more expensive? With an eight-year/100,000 mile warranty on the battery (the scary part of all this, right?) let’s just talk about usual maintenance costs. First standard maintenance at 7,500 miles is to rotate the tires and inspect the engine, period. We’re laughing as we bid farewell to three or four oil changes per year at over $50 Alex Sherriffs, MD each. No more smog checks! Twelve month maintenance? Free dealer battery check, repeated at annual intervals for three years. (But don’t forget to keep rotating the tires.) Comparing the electricity to gas cost, it is as if we are paying $1/gallon for gas. At our estimated annual mileage we OUR DECISION anticipate saving close to $2,000 TO BUY AN per year for energy. A Tesla ALL ELECTRIC roadster is pricey, but after tax VEHICLE WAS incentives and rebates a Mitsubishi can be had for less BASED ON than $20,000. COMMON-SENSE Did buying an all-electric CALCULATIONS. mean getting rid of our 4-cylinder sedan? Of course not. Much as we dislike the consequences of consuming petroleum, including messy Middle-Eastern politics, CO2 emissions, air pollution and the billions of dollars in negative health consequences that follow in the absence of adequate public transportation, we still anticipate driving our internal combustion vehicle to Southern California to visit friends and family. However, with a little attention to our driving habits and planning the day’s travel needs, we are on track to eliminating over 60 percent of the gasoline-fueled miles we drove last year. Bingo! The parallels to thinking about how we eat and the obesity epidemic are many. The car’s meters show energy use and regeneration, and we know we are more thoughtful drivers now. Why are all these people racing up to the stop-light? Is it any wonder we’re smiling as we pull into the garage each night and plug in?

V I TA L S I G N S / J U LY 2 0 1 2



An Evening with RAY KURZWEIL “2045: The Year Man Becomes Immortal” Post Office Box 28337 Fresno, CA 93729-8337

as presented by the Fresno-Madera Medical Society

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


J U LY 2 0 1 2 / V I TA L S I G N S

“The Central Valley had a rare and enlightening visit from one of this era’s deepest thinkers, Dr. Ray Kurzweil. His visit and lecture, sponsored by the Fresno-Madera Medical Society, touched on the huge chances we might expect in the next 20-30 years. Dr. Kurzweil, credited with numerous computer and technical patents, talked about advances in medicine, in planetary energy management and even the advancement of the human species. All who attended came away with a new appreciation for the technology that exists in our world today, how we got here, and where we might be going. What a wonderful evening!” – Larry Cosner, MD Kern County Medical Society • • •

“The evening was a great success, and the speaker was excellent. Thank you for allowing us (Premier Valley Bank) the opportunity to be a Gold Sponsor.” – Marvell French, Senior Vice President, Premier Valley Bank • • •

We express our gratitude to you (Fresno-Madera Medical Society) for organizing one of the most intellectually stimulating evenings possible. I learned so much and found it all fascinating and interesting to see the predictions he (Dr. Kurzweil) made in the 1980s. Despite recessions, wars and other calamities – they seemed to have had no effect on the accuracies of the predictions today – and the evolving exponentially intellectual information. – Judith Kuipers, Former Fresno State provost and university president


Thank You to our Sponsors TITLE SPONSOR Central Valley Physician Benefits

GOLD SPONSORS Cooperative of American Physicians Fitness Social Hadden Pathology MRI Imaging & NorthWest Imaging NORCAL Mutual Insurance Co Premier Valley Bank

SILVER SPONSORS avecinia wellness center Darden Architects Hedrick’s Chevrolet Medical Protective Optimal Rehab Physical Therapy Phys Med Inc. Physical Therapy Valley Metabolic Imaging, LLC V I TA L S I G N S / J U LY 2 0 1 2




PO Box 1029 Hanford, CA 93230 559-582-0310 Fax 559-582-3581

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

Please Save the Date Tulare County Medical Society Physician Members (and guests)

Thursday, September 13 6:30PM-8:30PM Visalia County Club Please plan to join us as we welcome 2013 California Medical Association (CMA) Incoming President, Paul Phinney, 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

Contact Gail at 559-734-0393 or

2013 Coding Book News It is that time again to start purchasing coding books.

Order your 2013 editions of CPT, ICD-9, ICD-10, and HCPCS thru us. We are offering extraordinarily discounted rates and free shipping directly to your office. Please contact Dana Ramos, Provider Relations to order or obtain more information. 559-734-0393 or


J U LY 2 0 1 2 / V I TA L S I G N S

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


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

President’s Message


“I will be fatter, balder and more bitter.....”

There were many lessons to be learned at the recent CMA Leadership Conference in Anaheim, but one of the highlights was from a management consultant who asked us to predict what life will be like in the future, if the current trends in medicine continue as they are. There was a consensus that unfettered. We would all end up “fatter, balder and more bitter.” Attendees predicted that there would be ongoing pressures on reimbursements, work loads would increase, regulations would make life more difficult, there would be less leisure time in our lives, and the practice of medicine would not be very enjoyable. This is not something to look forward to. The real question then, is why would we continue like this? Is there an alternative where life is different? It turns out, when you think of how you would really like life to be, especially when you’re already in the happiest place on earth, there are many better scenarios. When we drew a brighter picture of the future, it became easier to imagine life ending up differently. Medicine could remain an enjoyable life with controllable workloads, improving incomes, less burdensome regulations, etc. Getting to this brighter future can be accomplished one step at a time. The trick is to define these steps, one small bite at a time, and then to live each day of our lives, taking one small, incremental step closer to this brighter future. For this discussion, let’s start small by first thinking about the future of the local medical society. For example, some might paint the future of local medical society chapters as one where membership is flagging, meetings are boring and a waste of time and no one wants to attend our events due to apathy. Or one can see a future where the medical society is a vibrant and growing tradition locally, where the meetings are useful and targeted, where we all look forward to the next issue of Vital Signs to see what exciting events are planned so that we can get more involved in the local medical society.... but how do we get there? Please see Kern President on page 18

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

Probation Auxiliary County of Kern (P.A.C.K.)


The Take Away Tattoos Program was first implemented in June of 1998 by the Probation Auxiliary County of Kern, a non-profit organization. Volunteer medical providers have maintained its success ever since. The program is actively seeking doctors, nurse practitioners, and physicians’ assistants who would be willing to volunteer their time to this much needed service in Kern County. Training will be provided. Clinics are scheduled twice monthly on Saturday mornings, from 8 a.m. until noon. Clinica Sierra Vista generously donates office space. As the good reputation of the program continues to expand and referrals increase, there is great need for additional medical providers. Our program is voluntary and our participants are comprised of Kern County youth and adults who are on probation. Prison Realignment has greatly increased the number of referrals. Our program serves those at-risk who have expressed concern about their future with regard to having visible gang-related tattoos on their hands, necks, forearms and/or faces and who are choosing to make a positive lifestyle change. These individuals realize how they may be perceived by potential employers, educational institutions, the military, as well as by members of the community. For visual understanding of the process and to see and hear from a client during treatment, visit the P.A.C.K. webpage at, where you will find two short, informative videos. If you are an MD, NP or PA interested in donating your time and services, please contact Inger Summers, Probation Volunteer Services Coordinator, P.A.C.K. Executive Director, at 868-4103 or, for more details.

Staff: Sandi Palumbo, Executive Director Kathy L. Hughes Membership Secretary

V I TA L S I G N S / J U LY 2 0 1 2


Professional/Medical Office for Lease Cambridge Court 6335 N. Fresno Street, Fresno

NEWLY REMODELED 1,200 sq.ft. office

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.

Excellent parking and close to St. Agnes Medical Center

Carl Abercrombie 559-227-4658 c: 559-970-9035 Jim Abercrombie 530-626-0321 Gar McIndoe (661) 631-3808 David Williams (661) 631-3816 Jason Alexander (661) 631-3818

MEDICAL OFFICES FOR LEASE 2701 16th St. – 2,400 2031 17th Street – 1,776 sf. 4817 Centennial Plaza Way – 2,370 rsf. Crown Pointe Phase II – 2,000-9,277 rsf. 3115 Latte Lane – 5,637 rsf. 3115 Latte Lane – 2,660-2,925 sf. Meridian Professional Center – 1,740-9,260 rsf. 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. FOR SALE 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.

J U LY 2 0 1 2 / V I TA L S I G N S


1,800 sf medical space in Porterville in prime location w/ ample parking. Available FT or PT, brand new, 5 private exam rms. Contact Casey, 559-784-4925.



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 or call Cathy at 225-6100 ext. 6339.

1,650 sf medical office space in Madera on Yosemite Ave. Call Dr. T. Nassar at 559674-0917 Medical office space 1,000 sf up to 2500 sf at First & Herndon and First & Bullard, starting at $1psf++ by owner. Call 559-4497668 or 559-284-2625. Medical space, 850-3,500 sf. at Valley Medical Plaza on Herndon near SAMC. Rates starting at $1/sf. No triple net. Tenant improvements available. Call Brian at 559-281-1500.


3,400 sq.ft. space Suitable for a Physical Therapy or Individual practice; may be divided & remodeled to suit


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 320-0580.


with five exam rooms




FOR RENT / LEASE 5 rm. office space, 1 mile off Hwy 99 in SW Bakersfield, in 112,000 sf. neighborhood center anchored by InShape City Fitness. Underserved area in need of healthcare professionals. Retail spaces also available. Call Balmeet at 661-717-8383.

Kern President Continued from page 17 One small step at a time... I hope that we are on the right path. We start by making the meetings a social event and try better to appeal to the Alliance members as well. I hope that we were on target with our recent membership meeting speaker who was discussing the impact of litigation on the entire family (and this ended up being a really terrific group event about managing life stress in medicine in general – if you missed it, please check with your colleagues about the event and look for some pearls). We create social events (we had this meeting recently in the Bell Tower Club – a terrific venue where we could socialize, meet this year’s scholarship recipients and get excited about the future of our profession). When we get more fun and involved, we become more excited about the future. (We have an upcoming picnic with the new residents and student physicians in town – keep your eyes peeled for announcements; you’d really hate to miss out).

We show the value in becoming a KCMS member and once again establish and grow our presence in the local medical community. (By the way, there are 200 of your local colleagues who are insured by NORCAL but not members of the KCMS and are missing the opportunity to save up to 7% on their NORCAL premiums... That is real value. You really should talk with them about joining the KCMS and pocketing a fair savings... How’s that for value?) So there really is an alternative to just becoming “balder, fatter and more bitter.” It does require a little imagination and keeping the goal in mind. This is not only true for the KCMS, but it is also true for our futures in medicine. Imagine where you want to be in the future, even with healthcare reform, pressure on reimbursements, litigation stress, and the like, and develop a few steps to get closer to a brighter future. Every day take a small step closer to that brighter future and one step away from being “balder, fatter and more bitter.”

“My premium savings was over $1,900! What a great member benefit. All Society members with employees should get a quote. It was so easy to do.”

Philip R. Delio, M.D. Neurology Associates of Santa Barbara


Please call a Client Service Representative at 800-842-3761 today.

than that, up to 15%, depending upon their group medical carrier.

The process is simple and fast.

It’s true. CMA/FMMS/KCMS/TCMS members receive a 5% discount on workers’ compensation insurance policies provided

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Rather than guess what your savings can be, take a moment to contact Marsh and let us show you how we can deliver a quality

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insurance program and exceptional savings to you. Marsh is sponsored by:

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56392 (7/12) ©Seabury & Smith, Inc. 2012

AR Ins. Lic. #245544 • CA Ins. Lic. #0633005 • d/b/a in CA Seabury & Smith Insurance Program Management 777 South Figueroa Street, Los Angeles, CA 90017 • 800-842-3761 • •

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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.

At NORCAL Mutual, our numbers testify to great claims support for you. Of the claims we closed in 2011, 88% were closed without settlements or jury awards, compared to an industry average of 71%.* We won 86% of our trials, compared to 80% industry-wide.** You’re prepared for each stage of litigation and kept fully informed — and we don’t settle without your consent. We help you manage events so they don’t become claims, and, to back up our promise to stand by you, we remain financially stable, as evidenced by 29 consecutive years of “A” ratings by A.M. Best.

Our numbers add up to gr great eat claims support for your practice. * Physicians Insurers Association of America Risk Management Review: 2011 Edition. **Jena et al. Research Letter Letter,, Online First: Outcomes of Medical Malpractice Litigation Against U.S. Physicians. Archives of Internal Interrnal nal Medicine Medicine.. May 14, 2012.

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