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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 CMA NEWS ................................................................................................................................5 NEWS CMA: Docs Who Feel They’re Always Pushing Rocks Up The Hill .................................................7 EMERGENCY CARE: Emergency Rooms Crisis – Solutions..........................................................8 PRACTICE MANAGEMENT: What to Know Before You Store Patient Credit Card Numbers ...........12

December 2012 Vol. 34 – Number 12

2013 Yosemite Postgraduate Institute ...................................................................................14 CLASSIFIEDS ...........................................................................................................................18

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 Thelma Yeary

FRESNO-MADERA MEDICAL SOCIETY .......................................................................................13 • President’s Message • Walk With A Doctor Program • Season of Light: FMMS Member Event Wednesday, December 5 KERN COUNTY MEDICAL SOCIETY ............................................................................................15 • Pediatric Consultant Position, Kern County CCS • Introducing the Upright MRI • Membership News TULARE COUNTY MEDICAL SOCIETY.........................................................................................16 • President’s Message • Kaweah Delta Health Care District Receives Accreditation for Residency Programs • Information Regarding Palmetto to Noridian Transition

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 apaxton@cvip.net Classified: Carol Rau, 559-224-4224, ext. 118 csrau@fmms.org

Cover photography: “Winter Holiday” by Cynthia Ginn, RN 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 / D E C E M B E R 2 0 1 2

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You said what to the Medical Board’s investigator? Physicians often come to us after they have been interviewed by a Medical Board investigator or after they have already provided a written description of their care. Did you know that a Medical Board investigator is a sworn peace officer, with a gun, and a badge, and the power to arrest you? When the Medical Board demands an explanation, seek help immediately. The attorneys at Baker, Manock & Jensen have helped many physicians through the maze that is a Medical Board investigation. We would be honored to help you.

George L. Strasser 5260 North Palm Avenue Fresno, CA 93704 559 432-5400 gstrasser@bakermanock.com www.bakermanock.com

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CMA NEWS ANTHEM BLUE CROSS AMENDING SOME PHYSICIAN CONTRACTS TO INCLUDE INDIVIDUAL/EXCHANGE PRODUCT

On

October 24, Anthem Blue Cross sent a notice to 8,345 physicians who are part of the Blue Cross Select PPO network announcing its intent to participate in the California Health Benefit Exchange, the state’s new insurance marketplace called for under the Affordable Care Act. Beginning in 2014, individuals and small business will be able to purchase health insurance using tax subsidies and credits from the exchange. According to the notice, Blue Cross will be creating a new provider network called the “Anthem Individual/Exchange Network,” which will serve both individuals who purchase coverage through the exchange and individuals who purchase coverage from Anthem Blue Cross in the individual market outside of the exchange. In other words, the fee schedule would apply to all individual business, whether bought on or off of the exchange. Blue Cross has clarified for the California Medical Association (CMA) that this fee schedule change will not apply to Small Business Health Options Program (SHOP) business purchased through the exchange. It’s important to note that the letter also states that Blue Cross is amending the physician’s Blue Cross Prudent Buyer Agreement to automatically include the new individual/ exchange network, effective January 1, 2014. The new fee schedule associated with this product was included with the notice. CMA has been actively working with exchange stakeholders to address significant concerns regarding the exchange grace period, monitoring of network adequacy and clinician-level performance measurement in qualified health plans offered in the exchange (http://www.cmanet.org/news/detail/?article=physicians-mayalready-be-contracted-with). Though not mentioned in the Blue Cross cover letter, Sections VI and VIII of the enclosed amendment provide instructions for physicians who wish to opt out of the individual/exchange network. Physicians who do not wish to participate in this network must notify Blue Cross of their intent to opt out by December 31, 2012. Opt out notices should be in writing and sent via certified mail, return receipt to the address specified in Section VI of the amendment. CMA is working with Blue Cross to obtain additional clarification on the amendment and will provide updates as they are received. Please note that a small subset of Select PPO Network physicians did not receive the October 24 notice automatically opting them into the individual/exchange network. This subset of physicians received a notice from Blue Cross dated October 9 regarding fee schedule reductions. Physicians who choose to discontinue participation in the Select PPO network at the reduced rates have until December 14 to notify Blue Cross in writing. As always, physicians are encouraged to carefully review all proposed amendments to payor contracts. You do not have to accept substandard contracts that are not beneficial to your practice. Physicians who did not receive a letter and are unsure whether they are affected by this change or those who have general

questions about the amendment can contact Blue Cross’s Network Relations Department at 855-238-0095 or networkrelations@ wellpoint.com. Contact: CMA reimbursement helpline 888-401-5911 or economicservices@cmanet.org.

UNSURE WHETHER YOU SHOULD SIGN THE NEW BLUE SHIELD AGREEMENT?

The California Medical Association (CMA) continues to receive a high volume of calls from physicians and their staff regarding the new Blue Shield contracts. However, more recent reports from physicians indicate Blue Shield representatives have become more aggressive in their attempts to get physicians to sign the new contracts. To assist physicians, CMA has published an updated analysis of the new Blue Shield contract, which is available to members in CMA’s online resource library at www.cmanet.org/resource-library. CMA has also prepared answers to the most common questions received: Why is Blue Shield asking me to sign a new agreement? According to Blue Shield, the reason for the recontracting initiative is twofold: 1) Blue Shield has not done a large scale recontracting with physicians in over a decade, so the new contracts will ensure consistency and compliance with new laws and regulations; and 2) Blue Shield is offering various tiered networks based on price point in anticipation of possible participation in California’s Health Benefit Exchange and other new delivery models. The new contract includes three new product types (Networks A, B and C). What types of products are these? Exhibit B in the Blue Shield contract identifies these networks as Commercial PPO/EPO (Blue Shield Networks A, B and C), respectively reimbursing at staggered percentages of the rates set forth in the Blue Shield Provider Allowances. Blue Shield has advised CMA that these three tiered networks are being offered in anticipation of possible participation in the state’s health benefit exchange. CMA has been actively working with exchange stakeholders to address significant concerns regarding the proposed grace period regulations, monitoring of network adequacy and clinician-level performance measurement in qualified health plans offered in the exchange. More information on contracting with exchange plans can be found in the “Reform Essentials” section of the CMA’s website, www.cmanet.org/cma-reform-essentials. Can I designate which products I am willing to participate in? Yes. Exhibit A of the new Blue Shield contract allows physicians to designate which products they are willing to participate in by product type. Additionally, a section of Blue Shield’s frequently asked questions (FAQ) encourages physicians to read Exhibit A carefully to ensure you clearly understand your participation choices. What happens if I do not sign and return the agreement by the date requested? Blue Shield has assured CMA that if a physician chooses not to sign the new agreement, his or her current participation status with Blue Shield will not be affected. Blue Shield had advised CMA, however, that physicians who do not sign and return the new agreement will receive follow-up calls and letters from Blue Shield representatives encouraging them to sign Please see CMA News on page 6 V I TA L S I G N S / D E C E M B E R 2 0 1 2

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CMA NEWS Continued from page 5 the agreement and return to Blue Shield. It’s important that physicians understand if they do not wish to participate in the new tiered networks offered in anticipation of the Exchange or any other product types offered, they are not required to sign and return the new agreements. Their current participation status will not change. Physicians who want to participate in the new tiered networks will need to decide whether they wish to opt out of any product types and affirmatively do so by checking those product type boxes in Exhibit A number 2, then sign and return the agreement to Blue Shield. As indicated in Exhibit A number 2, by checking the box the physicians is stating he/she does not agree to participate in that product. A box left blank indicates the physician agrees to participate in that product. Questions: CMA’s reimbursement helpline 888-401-5911 or economicservices@cmanet.org.

PALMETTO PROTESTS MEDICARE CONTRACT AWARD

Palmetto GBA has officially protested the Centers for Medicare & Medicare Services (CMS) awarding of the Medicare Administrative Contractor (MAC) contract for Jurisdiction E to Noridian Administrative Services. CMS previously announced that Noridian would assume the MAC duties for the new Jurisdiction E, which includes California, Nevada, and Hawaii, as well as the U.S. territories of American Samoa, Guam and the Northern Mariana Islands, following a competitive bidding process. Palmetto had previously held that contract and is now protesting the decision. Notice of the protest can be found on the GAO Bid Protest Docket under File Number B-407668.2. The due date for a decision is January 23, 2013. This protest means that the earliest a handover from Palmetto to Noridian could take place would be mid-to-late 2013. Palmetto has assured CMA that while the protest is being considered by the GAO, business will continue as usual. Once a final decision has been made, CMA will notify members and work with CMS and the contractors to develop any necessary transition plans. Please see CMA News on page 6 6

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CMA NEWS Continued from page 6

CMS ANNOUNCES EXTENSION OF 2013 ELECTRONIC PRESCRIBING HARDSHIP EXEMPTION REQUEST

The Centers for Medicare and Medicaid Services has reopened the hardship reporting period to request an exemption from the 2013 e-prescribing payment adjustment. Requests can be submitted until January 31, 2013, and must be submitted via the CMS Quality Reporting Communication Support Page at www.quality net.org (https://www.qualitynet.org/portal/server.pt/community/ communications_support_system/234). If you have questions or needs assistance submitting a hardship exemption request, please contact the QualityNet Help Desk at 866-288-8912 or qnetsupport@sdps.org. They are available Monday through Friday from 7:00 a.m. to 7:00 p.m. CST. NEW MEDICARE PRIVATE CONTRACTING ADVOCACY MATERIALS AVAILABLE

The California Medical Association (CMA) and the American Medical Association (AMA) continue to push Congress to pass legislation to allow a private contracting option for Medicare patients. There are two bills, jointly known as the Medicare Patient Empowerment Act, currently making their way through the legislative process that would allow Medicare patients to enter into private contracting arrangements with physicians without penalties for either party. CMA and AMA have launched a grassroots campaign to secure cosponsors for the bills – HB 1700, introduced by Rep. Tom Price (R-GA), and SB 1042, introduced by Sen. Lisa Murkowski (RAK). A range of resource materials has been developed to support the campaign, including a downloadable patient flyer for physician offices and a web-based petition for patients and physicians. Physicians who sign the petition may also order patient brochures for their offices at no cost. These materials and more are available at www.ama-assn.org/go/ privatecontracting. CMA has long sought a private contracting option for Medicare patients. Currently, seniors who wish to see a doctor who does not accept Medicare must pay for all services by that physician out of their own pocket. The physician may not seek reimbursement from Medicare for the care provided, nor will Medicare reimburse the beneficiary – despite the fact that seniors have paid into the program in the form of payroll taxes throughout their working lives. Medicare private contracting approach would expand access to care without costing the federal government additional resources. It would allow seniors to continue to use their Medicare benefits, even if the physician they choose does not see them through the Medicare program. In such a scenario, the patient would only be responsible for the difference between what Medicare typically covers and what the physician charges. For additional information on Medicare contracting options, see CMA On-Call document #0151, “Medicare Participation (and Non-Participation)”. The document is free to members in the resource library at www.cmanet.org/resource-library. Contact: Elizabeth McNeil, 415-882-3376 or emcneil@cmanet.org.

CMA

Docs Who Feel They’re Always Pushing Rocks Up The Hill Virgil Airola, MD

Did you hear that you already saved more than 50 percent on your medical malpractice insurance premium for next year? Two legislators in Sacramento, Steinberg in the Senate and Dickenson in the Assembly, tried in the final week of the 2012 legislative session to raise your cost of doing business by weakening MICRA, but the California Virgil Airola, MD Medical Association fought for you and WON! Your premiums won’t change as a result! This kind of last minute stuff happens every year in Sacramento as the crush of bills peaks in the California Legislature at the final bell. What would happen if nobody was watching? It’s like Sisyphus pushing his rock up the hill. Check it out: http://www.cmanet.org/resource-library/list?filter& keyword=148. When I know CMA’s watching, I feel every doctor member of CMA is a brick in a wall around our patients and our medical practice – a wall that protects us all and is stronger with more “bricks” as members. The Dickenson bill, AB 1062, was changed (“gutted and amended”) to lower the standard of evidence in elder abuse cases, so trial attorneys could more easily sue physicians and more easily win cases under the Elder and Dependent Abuse Act. The “end run” around MICRA in the bill made all attorney fees exempt from the limitations provided under MICRA, so patient plaintiffs would be paying successful attorneys higher fees. The Steinberg bill, SB 1528, would provide that in a successful malpractice lawsuit a Medi-Cal beneficiary, treated under a managed care arrangement or contract, would recover from a defendant physician the “reasonable value of benefits” which is defined in the bill as “the usual customary and reasonable charge made to the general public by the provider for similar services,” not what Medi-Cal pays for those services. These are just two of the too-numerous-to-count examples of how CMA fights daily battles all year round in Sacramento and Washington to help keep your practice stable. So when I think of REAL VALUE for my DOLLAR, I think I get the combined value of every CMA and local Medical Society members’ dues dollar from the cost of my membership in these organizations just from stuff like the examples I listed above. And CMA and the Fresno Madera Medical Society provide lots of other benefits to my practice, my colleagues, and my patients – help with fighting billing issues with insurance companies, medical school scholarships, educational loan repayment program information and advocacy, practice management materials and seminars, educational meetings, social events, web based info on all kinds of issues affecting medicine, and ADVOCACY, ADVOCACY, ADVOCACY in Sacramento and Washington! Check it out on the web at: http://www.cmanet.org/ and http://www.fmms.org. V I TA L S I G N S / D E C E M B E R 2 0 1 2

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EMERGENCY CARE

Emergency Rooms Crisis – Solutions John Maa, MD

Combining music with surgery is what many surgeons do routinely. In a concert lecture I attended years ago, San Francisco Symphony conductor Michael Tilson Thomas shared his strategy to draw out the best performance from the orchestra. He challenges each member with three questions as they prepare for a new composition. First, what was the political and social historic context that was the inspiration for the music’s creation? Second, what was the composer trying to communicate? But these questions only serve as the foundation for the third most important question: what does the music mean to you? Perhaps we should all carefully reflect what strengthening the emergency care system means to us individually before we collectively attempt to define its future. A PATIENT’S STORY My personal answer to Michael Tilson Thomas is revealed through the story of a patient. This particular patient was 69-yearsold, who awoke one day with an irregular heart beat and mild shortness of breath. Her heart rate accelerated to 130 on a home blood pressure cuff, but her blood pressure was stable later that day when she was seen in the Emergency Department (ED). She was diagnosed with rapid atrial fibrillation and admitted around 8 pm. on a Thursday evening for anticoagulation therapy with heparin, and a plan for electrical cardioversion the next day after a transesophageal echocardiogram. Because an inpatient bed was unavailable, she spent the entire night in the ED. She was not admitted to a hospital bed until late Friday morning, after other patients had been discharged. She had slept poorly in the ED hallways, and was hungry after having fasted for the procedures that day. The cardiologist spoke with the patient and her family that Friday afternoon, and explained that because of the delays in her admission, the planned procedures had been cancelled, and she would remain on blood thinners over the weekend until the echocardiogram and cardioversion could be performed on Monday. Unexpectedly, on Saturday afternoon, the patient suffered a sudden and massive stroke with complete occlusion of the carotid artery from the arch of the aorta to the intracranial branches of the middle cerebral artery. She was rushed to the OR where a neurosurgeon attempted to remove the blood clot, but the carotid artery tore, leading to massive intracranial bleeding and brain death. She was kept alive in the ICU until funeral preparations could be completed. She died at noon on the following Tuesday, 112 hours after she first stepped into the hospital. The patient was my mother. Some may recognize this story from an article in the New England Journal of Medicine that was published on the 2½-year anniversary of my mother’s passing “The Waits that Matter.” I was amazed by the response from around the nation, and even the world, to the coverage the story received in The New York Times and The Wall Street Journal. Four months after the article was published, I received a surprise in the mail, an honoraria granted to Perspectives authors by the Massachusetts Medical Society. I used the money to obtain a copy of my mother’s medical record. It was 8

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difficult to relive the final hours before my mother’s devastating stroke, to hear her final words as recorded in the nurse’s notes. After reviewing the 811 pages, it became clear that there was more to the story of my mother’s death. The admission notes documented that she was to be started on heparin shortly after being admitted with a HR of 160. However, the heparin was not started until 11 am the next day, almost 15 hours later. It is unclear whether the medication was unavailable from the pharmacy, an order was missed, or there was difficulty prescribing the anticoagulation. A transthoracic echocardiogram was normal the evening of admission, and the lethal thrombus likely propagated during the prolonged period without anticoagulation.

A NATIONAL CRISIS Tragedies like this are not uncommon in the U.S. An Institute of Medicine report detailed a national crisis in emergency care in 2006; six years later, many of the challenges of overcrowding, ambulance diversion, and the boarding of admitted patients (like my mother) in the ED have only become more dire. In a landmark study in JAMA, Dr. Renee Hsia plotted the survival of hospital EDs on Kaplan-Meier curves, identifying the characteristics predictive of the closure of an ED, including for-profit or safety-net status. At UCSF, my career has focused on strengthening emergency surgical care through the dedicated availability of a surgeon to see patients needing surgery in the ED and hospital. This surgical hospitalist model has been implemented at over 400 hospitals across the country since my colleagues and I introduced the program in 2005. However, I was still unable to change the lethal outcome of delays in treatment as my mother received care at a different institution. Unfortunately, the passage of the Affordable Care Act (ACA) may only make stories like my mother’s more common, if lack of access to primary care results in increased numbers of Americans seeking access to an overwhelmed emergency system. The American College of Emergency Physicians (ACEP) has identified the passage of a law in 1986 – Emergency Medical Treatment and Active Labor Act (EMTALA) as a key driver of this crisis as it mandates public access to emergency care regardless of one’s ability to pay. ACEP has tirelessly worked to reform this well-intended but underfunded mandate that has forced some EDs to close, and negatively impacted quality of care. Maybe there is some comfort that similar challenges in emergency care are being reported worldwide.

A JOURNEY TO AMERICAN EMERGENCY DEPARTMENTS The untimely death of my mother inspired me to take almost a year off to work on Capitol Hill with our elected officials, the media, and leading medical organizations to better understand the challenges in emergency care. I was inspired by Abraham Flexner, the champion of medical education reform, to visit over 50 EDs to take inventory and search for new solutions. I rode on planes and trains and drove over 7000 miles in the summer of 2011 to meet with and to hear the personal stories of the people who had written Please see Emergency Care on next page


EMERGENCY CARE

Continued from page 8 to me after the publication of my article in the New England Journal of Medicine. What struck me was the recurring theme of personal loss they too had suffered from an overwhelmed emergency system. Yet we should also not forget the successful outcome for Congresswoman Gabrielle Giffords after the deadly rampage in Arizona in 2011; the story of her amazing recovery catalyzed a positive change in perception in Washington, DC, about the heroism and courage of emergency physicians and trauma surgeons. Indeed it is a privilege and an honor to take emergency call, and the need for emergency care reflects the trust that society places in its emergency workforce. Ultimately, identifying ways to support those courageous physicians willing to place themselves on the front lines of clinical care will be key to solving the emergency care crisis. As I traveled across our amazingly beautiful country, I noted several recurring themes. In some parts, one can drive through deserts for hundreds of miles and not see an ED, whereas in some cities one can walk out of one Level 1 Trauma center right into another one a few blocks away. I was amazed by the billboards advertising how short waiting times to be seen were in certain EDs, suggesting the delivery of ED care is becoming competitive. I noted a wide variability and lack of standardization not only in care, but also in organization. In some hospitals, the ED is part of the Department of Medicine, in others it is part of the Department of Surgery, and in yet others, it is its own stand-alone department, which I believe is superior. As a mystery shopper, I often visited EDs unannounced through the front door, to witness care delivery through the eyes of the patient. In some EDs I was greeted by a valet for parking or by a nurse with a cup of coffee, and at others by ominous and foreboding security personnel seated behind bulletproof glass and metal detectors. I marveled that the most glistening and magnificent parts of hospitals were the cancer centers, and hope one day that towers dedicated to emergency care will also arise. I was pleased to see the emergence of dedicated children’s EDs, highlighting that children are not simply small adults. One of the most impressive EDs was Please see Emergency Care on page 11

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EMERGENCY CARE

Emergency Care Continued from page 9 at UCSF Fresno, which I regard as a premier ED nationally. I would like to thank Greg Hendey, MD, for his enlightening tour of this 70bed, Level-1 Trauma ED, with state-of-the-art trauma resuscitation bays, a burn unit, and precise attention to efficiency and economy in patient flow as it serves an annual ED census of over 110,000 patients.

THREE-PART SOLUTION On the basis of my experiences around the country, I’ve reached the conclusion that the emergency care crisis is entirely solvable, through better distribution and prioritization of resources and incentives, and by standardizing and coordinating care nationally. I believe the solution involves three things: 1) we must inspire young people to work in emergency care; 2) we need to rewrite the laws, the ACA, and EMTALA; and 3) we must tell powerful stories to attract the attention of the media and of Capitol Hill, as the pathway forward to changing the law. Regarding inspiring more young physicians to work in emergency care, Thomas C Ricketts, MD, and George F Sheldon, MD, at University of North Carolina Chapel Hill have prepared excellent maps highlighting areas with shortages of surgeons, documenting nearly 1,200 counties in America without a general surgeon available. A remarkable solution proposed in Washington, DC, is to create a General Surgery National Health Service Corps to deploy board-certified surgeons for 3- to 6-month rotations across rural America. A visionary federal approach could be similarly applied to all specialties, and would require the creation of new maps for Capitol Hill and U.S. Department of Health and Human Services to determine where which specialties are needed most. A starting point could be the current distribution of criticalaccess hospitals nationally, or alternatively, the distribution of post offices. Equally important is to identify where to recruit physicians willing to relocate temporarily. I believe we have an opportunity to harness the altruism of American physicians who seek to address global disparities in health care, and to persuade them to travel to hospitals in our own beautiful country. More than 25 years ago, a young surgeon arrived in Tucson, AZ, to solve the challenges of Arizona’s emergency care system. The surgeon dedicated his career to implementing a trauma system in southern Arizona grounded in the concept of regionalization. The successful outcome for Congresswoman Giffords is a testament to the efforts of that surgeon – Richard Carmona, MD – who would later become the 17th U.S. Surgeon General. Our nation can and must do better to improve our emergency care delivery system, by focusing time and energy to solve the challenges facing emergency rooms nationwide. I do believe that within the field of medicine, we have the special

opportunity to redefine and transform emergency care nationally, by thinking differently. Perhaps further answers will come from one of the medical students or residents in training today, who will follow Dr. Carmona’s inspirational path and define their own personal answer to Michael Tilson Thomas’s question. Turning to the second proposed solution of rewriting the law, this is at the heart of activity in Washington, DC. Capitol Hill writes the laws, the Supreme Court reviews these laws and determines their constitutionality, and the President (often an attorney) prepares Executive Orders that carry the force of the law. A Congressional staffer once shared with me the following: “On the game show Jeopardy, one must phrase the answer in the form of a question. In Washington, one must phrase the proposed solution in the language of a law that can be presented to Congress for a vote.” We must recognize that market forces have led to the closure of EDs all across America in the past decade; leaving this problem to the business sector will not be the final answer. A single institution will be unable to solve this crisis on a larger scale, and hospitals will need to work together rather than compete against one another. Accountable care organizations should be charged to solve overcrowding and boarding. Dr. Ellen Weber from UCSF wrote about the positive long-term results of a new policy in England mandating either patient admission or discharge home within four hours of arrival at an ED. It may take rewriting the ACA and EMTALA to use the “law” to instill “order” in the ED. If this is unsuccessful, reforming Medicare Part A reimbursement to hospitals for boarded patients may become necessary. Reforming patient expectations is also essential. The ED has been described by Kate Heilpern, MD, the Chair of Emergency Medicine at Emory, as a mirror for society’s problems – the overuse of guns, underuse of seatbelts, and drinking and driving. Perhaps the time has arrived to consider a 28th Amendment to decide whether access to basic medical care and emergency treatment is a constitutionally guaranteed right? Only after reaching agreement here can our nation then move to the equally important discussion of the responsibilities and expectations inherent in that right. In Washington, DC, two of the profound lessons I learned from attending Capitol Hill hearings are the power of the law, and the power of storytelling as the gateway to the media and television to convince Congress and State legislatures to enact new laws. I visited the R. Adams Cowley Shock Trauma Center in Maryland and learned of R. Adams Cowley, MD, who coined the term “the golden hour,” and pioneered the concepts of advanced trauma life support and regionalized care to dedicated trauma facilities. The tipping point came in 1975, when attorney Dutch Ruppersberger was involved in a near fatal automobile accident and survived after being transported directly to Shock Trauma, bypassing other nontrauma EDs en route. Mr. Ruppersberger later ran for public Please see Emergency on page 17 V I TA L S I G N S / D E C E M B E R 2 0 1 2

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PRACTICE MANAGEMENT

What to Know Before You Store Patient Credit Card Numbers Fran Cain Information Technology Department, NORCAL Mutual Insurance Company

Everyone uses credit cards. Patients love to rack up points for travel and cash-back rewards. But before you store a credit card number in your practice database, be aware of the consequences if your patient records ever become compromised. Credit card companies can impose huge fines if your office system is not securing patient credit card information adequately and it becomes compromised – to the tune of up to $100,000 per incident. After reviewing this article and weighing the risks, ask yourself, “Does my practice really need to store credit card information on file?” I have a small practice. How does this apply to me? All credit card companies belong to the Payment Card Industry (PCI). PCI has established a Security Standards Council to set and manage standards known as the Data Security Standard, or PCI DSS. If your practice accepts or processes payment cards, you must comply with the PCI DSS. Patients prefer that I keep their credit card numbers on file. What if I want to store credit card numbers? There are many rules to follow to be in compliance. You will be required to build and maintain a strong network; protect cardholder data; maintain a vulnerability management program; implement strong access control measures; regularly monitor and test networks; and maintain an information security policy. Here are some tips from the Payment Card Industry website: • Encrypt all credit card numbers if stored in any system or database, including but not limited to logs and backups. • Ensure the network has adequate firewall and up-to-date antivirus software. • Use strong encryption for transmission of cardholder date over the Internet. • Regularly apply all systems and software security patches. • Quarterly, run external vulnerability scans or penetration tests on the network. • Limit access to cardholder information to staff with a legitimate business need. • Enforce strong passwords. • Avoid printing any card data on paper. If any exists, it must be carefully secured and destroyed when no longer needed. • Maintain data security policies that provide clear guidance to staff about handling of sensitive data (e.g., never e-mail Primary Account Numbers or PANs) and how to respond in case they discover data is compromised. You must assess your business systems and processes annually to ensure you are in compliance. The PCI website can help you to assess your environment. You may be able to use a Self-Assessment Questionnaire, which must be completed annually, depending on the bank card. For example Master Card allows you to self-assess if you process less than 50,000 transactions annually, while JCB International allows you up to 1 million transactions. Check with each credit card company or look on its website to determine your merchant level and the requirements for your business. If you are allowed to self-assess, it is not necessary to submit a report to the credit card companies or PCI, but compliance is still 12

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required at all times. There are several different self-assessment questionnaires, and it may be confusing to decide which one to use. Use the chart on the website to choose the questionnaire that most closely fits with your credit card collection practices. If you are not allowed to self-assess, you will need to use a Qualified Security Assessor (QSA) to conduct annual assessments. What happens if I store credit card numbers and a practice computer is lost, stolen, or some other breach occurs? You must be able to demonstrate that you have been in compliance with PCI DSS. If your practice computers, network and/or database are compromised in any way, you must notify the credit card companies. If you cannot demonstrate that the data was completely protected and that you have been in compliance with PCI DSS, you will be subject to significant fines and lawsuits. If the credit card company does not terminate the contract, you may be treated the same as a higher level merchant and be required to conduct annual on-site assessments and validation by a Qualified Security Assessor. Expect the annual on-site assessments to cost in the $10,00-20,000 range or more. You will be required to remediate any inadequacies discovered during the annual assessments at your own expense. Who enforces compliance of the PCI DSS? American Express, Discover Financial Services, JCB International, MasterCard Worldwide, and Visa Inc. Each of these institutions posts compliance guidance which may be slightly different from the others. Before going to each credit card company website, read, understand, and follow all guidelines provided by PCI. Why aren’t card readers or software safe enough from hackers? According to the PCI, there are many reasons credit card readers or applications may not be secure. Card readers may inadvertently store magnetic stripe data which contains Sensitive Authentication Data or card verification codes; they may not be installed properly or securely and might be easily compromised; default settings or passwords may not have been changed on readers or in applications; security patches were not kept updated; the credit card data on the network is not properly segregated to be secure; data may not be properly encrypted; web applications may not be hardened against vulnerabilities. What if I complete a self-assessment and uncover deficiencies? If the self-assessment uncovers deficiencies, remediation is necessary. A remediation plan, known as an Action Plan for NonCompliant Status, should be completed. PCI allows 12 months to remediate, but progress must be demonstrable. All remediation is at the expense of the merchant. If your practice is very large and you process many transactions, you will need to work with a data security firm. PCI provides a list of qualified assessors on its website. How do I avoid the need for assessments altogether? If you accept credit cards for payment, an annual assessment is required. But if you successfully follow these guidelines, the selfassessment questionnaire is short and painless: Please see Credit Cards on page 18


Fresno-Madera SERGIO D. ILIC, MD Post Office Box 28337 Fresno, CA 93729-8337

President’s Message

1040 E. Herndon Ave #101 Fresno, CA 93720

DIFFICULT TO BELIEVE A YEAR HAS GONE BY ALREADY

This was an eventful year for the FMMS. When I was installed as president last year, I had several goals in mind, and I feel we have been successful in several of them. The first goal was to increase the membership, and we did this by enrolling the totality of the Kaiser members, an addition of ninety six. But there is still recruitment to be done. We need to convince all CCFMG members and the radiology and anesthesiology groups to stay in the Society as well as recruiting the hospitalists and ethnic societies’ members, such as the Indian, Pakistani and Latino groups. That will probably be the number one task of my successor Dr. Rajpal. My second goal was to bring financial information to the members in the form of seminars to be given at the Society office – not only for the practicing physician but also to the residents at the UCSF Fresno campus. Amy Nuttal Zwaan and Eric Van Valkenburg from Central Valley Physician Benefits and LPL Financial are doing a great THE SOCIETY IS job in providing these seminars. The classes have been very well OF TREMENDOUS received and successful. I feel that as doctors we do not know enough about finances, and we make too many costly mistakes that can very VALUE TO ALL easily be avoided with some knowledge and help from well qualified OF US, advisors. My third goal was to make the general membership meetings more MEMBERS AND social. In February, we had a comedian, in May Dr. Ray Kurzweil gave NON MEMBERS a very exciting talk to almost 700 people , in September we had a wine tasting dinner at APCAL winery and in November we had the installation at Roger Rockas for the third year followed by the wonderful show “Singin In The Rain.” My fourth goal was to make the FMMS more relevant. This has to be an ongoing effort, and in order to do this we have upgraded our computer system so we can be more responsive to the new generation of doctors. We have a new web page that should be fully functioning by the first of the new year, and we are on Facebook. This also gives us the capability of being in contact with members and non members easier. We have gone to the UCSF campus to give talks to the residents and interns, so they get to know us and can participate in the Society’s activities and know what we have to offer. We have also started a number of programs and events including “Walk with a Doc.” The Society is of tremendous value to all of us, members and non members. To give an example, through our efforts and CMA’s we have defeated a proposed law change to MICRA that would have increased the non-economic damages in a malpractice case to $500,000 or more. That would have meant, if successful, an immediate increase in the malpractice premiums of about 50 percent or more. This would have been in dollars terms, a lot more than the dues we pay for the FMMS and CMA! It has been an interesting year for me, and I want to thank the staff – Sandi, Carol, Sheryl and Rashad for their help and the Board members and delegates as well. These accomplishments could not have been done without the support of all of you. I thank the FMMS for having entrusted me to lead the organization as its 129th President for the year 2012. I truly enjoyed the year, and I hope the same support that was given to me will be available to Dr. Rajpal for the 2013 term.

559-224-4224 Fax 559-224-0276 website: www.fmms.org FMMS Officers Sergio Ilic, MD President Ranjit Rajpal, MD President Elect Prahalad Jajodia, MD Vice President Stewart Mason, MD Secretary/Treasurer Oscar Sablan, MD Past President Board of Governors A.M. Aminian, MD Hemant Dhingra, MD Ujagger-Singh Dhillon, MD William Ebbeling, MD Babak Eghbalieh, MD Ahmad Emami, MD David Hadden, MD S. Nam Kim, MD Constantine Michas, MD Khalid Rauf, MD Rohit Sundrani, MD Mohammad Sheikh, MD CMA Delegates FMMS President A.M. Aminian, MD John Bonner, MD Adam Brant, MD Michael Gen, MD Brent Kane, MD Kevin Luu, MD Andre Minuth, MD Roydon Steinke, MD Toussaint Streat, MD CMA Alternate Delegates FMMS President-elect Don H. Gaede, MD Prahalad Jajodia, MD Peter T. Nassar, MD Trilok Puniani, MD Dalpinder Sandu, MD Salma Simjee, MD Steven Stoltz, MD Rajeev Verma, MD CMA YPS Delegate Paul J. Grewall, MD CMA YPS Alternate Yuk-Yuen Leung, MD CMA Trustee District VI Virgil Airola, MD Staff: Sandi Palumbo Executive Director

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Fresno-Madera FREE HEALTHY LIFESTYLE TALKS & WALKS WITH A DOC

SAVE THE DATE: April 12-14, 2013

2013 Yosemite Postgraduate Institute Yosemite National Park Information: csrau@fmms.org or 559-224-4224x 118

Walking for as little as 30 minutes a day can reduce your risk of coronary heart disease, improve your blood pressure and blood sugar levels, elevate your mood, and reduce your risk of osteoporosis, cancer and diabetes. Attedn a free walk and take steps toward a healthier you! Walk With A Doc is a free walking program for anyone who is interested in taking steps to improve their health. Each walk is lead by friendly, local physicians. In addition to the numerous health benefits you’ll enjoy just by walking, you’ll also get: • Healthy snacks • Healthy lifestyle tips/resources • Chance to talk with the doc while you walk

NEXT WALK: DECEMBER 15 WOODWARD REGIONAL PARK SUNSET VIEW SHELTER Everyone is welcome Registration 8:45am • Event 9am Information: Call FMMS 559-224-4224 or email: receptionist@fmms.org

Holiday Traditions: Their Connections to the Sky Downing Planetarium • Wednesday, December 5, 2012 This family-oriented program focuses on winter holiday traditions from many cultures and how they have been used for millennia to light up this darkest and coldest of seasons. It showcases customs, highlights some of the winter constellations, demonstrates the cause of the four seasons and the meaning of the winter solstice. This exclusive FMMS showing is at the Downing Planetarium, a 74-seat Star Theater under a 30-foot hemispherical dome located on the CSU Fresno campus. Celebrate the holidays by spending a relaxing and educationalfilled evening learning the history and development of many of the world’s December holiday customs. This show is designed for audiences grade K to adult.

Doors Open: 6:30 pm Show time: 7:00 pm Star Gazing: 8:15 pm (weather permitting) Cost: No Charge FMMS member • $6 non-FMMS member Tickets & parking passes held at door • Confirmation & directions will be emailed No food or drinks allowed in theater • Information: 224-4224 x 118/csrau@fmms.org ***Limited Seating = must RSVP to attend

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Kern

Kings Pediatric Consultant Position, Kern County CCS

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

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

A part time or full time position for a Pediatric Consultant with Kern CCS available in July 2013. This position will be open to negotiation and consists of the Pediatrician serving as an advisor or consultant on a case by case basis to the California Children’s Services program. All interested parties should contact T. Pallitto, Kern CCS Administrator at 1800 Mt. Vernon Avenue, Flr 2, Bakersfield, CA 93306, 661-321-3000.

Introducing the Upright MRI There is a new option for MRI scanning in Bakersfield. Claustrophobic, obese and children do not need to suffer the anxiety that a traditional “coffin” MRI brings about. The Upright MRI is covered by insurances covered similar for a traditional MRI and the cost is the same across the board. The scanning on this technology is first rate. This is the fourth Upright MRI in California (www.bakuprightmri.com) – two in Los Angeles and one in San Jose, so to have one in Bakersfield/Central Valley is great! Please help spread the word. Drs. Arturo Palencia and Brad Anderson, as well as a Neuro Spine Surgeon are owners of this new amazing technology. Our community, patients and doctors will benefit from knowing that it is here in Bakersfield!

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

MEMBERSHIP NEWS Membership Recap OCTOBER 2012 Active.............................................................................................250 Resident Active Members .................................................................2 Active/65+/1-20hr .............................................................................5 Active/Hship/1/2 Hship.....................................................................0 Government Employed......................................................................7 Multiple memberships........................................................................1 Retired..............................................................................................58 Total ..............................................................................................323 New members, pending dues .............................................................0 New members, pending application ..................................................0 Total Members..............................................................................323

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Tulare GAURANG PANDYA, MD

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

President’s Message IT IS MY HONOR TO SERVE AS PRESIDENT OF TULARE COUNTY MEDICAL SOCIETY

website: www.tcmsonline.org

TCMS Officers Gaurang Pandya, MD President Steve Cantrell, MD President-elect Thomas Gray, MD Secretary/Treasurer Steve Carstens, DO Immediate Past President Board of Directors Virinder Bhardwaj, MD Carlos Dominguez, MD Parul Gupta, MD Monica Manga, MD Christopher Rodarte, MD H. Charles Wolf, MD CMA Delegates: Thomas Daglish, MD Roger Haley, MD John Hipskind, MD CMA Alternate Delegates: Robert Allen, MD Ralph Kingsford, MD Mark Tetz, MD Sixth District CMA Trustee James Foxe, MD Sixth District CMA Alternate Thomas Daglish, MD Staff: Steve M. Beargeon Executive Director Francine Hipskind Provider Relations Thelma Yeary Executive Assistant Dana Ramos Administrative Assistant

Thelma asked me to write a last communication as president then I realized that this year has gone by very fast. I must say that in many ways, this past year has been a transformational year, both personally and professionally. Global economy is sputtering. Who knew that what the Greeks do would impact practice of medicine in Tulare County? In an effort to bring vigor in U.S. economy Government injected borrowed money in our economy. That kept the economy alive, but is still on life support. We still face fiscal cliff in January. Nationally the Supreme Court did not repeal ACA and President Obama won the reelection. Reportedly the Affordable Care Act will LOOK TO THE soon be fully implemented. The White house will release a truckload COUNTY SOCIETY of regulations. However our country has no identified resources to pay AND CMA FOR for full implementation of ACA. The providers like us will be asked to HELP ABOUT do more for less. Some of us will pursue other goals in life and will retire. Others may find a way to continue practicing after taking pay WHAT CHOICES cuts. Please look to the county society and CMA for help about what WE HAVE. ALSO choices we have. Also ask your colleagues to join Medical Society and ASK YOUR CMA for their benefit. COLLEAGUES TO In California the insurance Exchange will sell plans by October JOIN MEDICAL 2013. Many employers will realign their employment practices and SOCIETY AND benefits to qualify many employees for a federal subsidy to pay for exchange premiums. Health plans have to show an adequate Exchange CMA FOR network of contracted providers. Blue Shield of California has THEIR BENEFIT maintained that you are contracted to exchange plan enrollees. The Blue Cross of California sent a contract amendment that says you are on panel for exchange but could opt out. Again please look to see what is best for you and your patients. When in doubt please look to medical society and CMA for help consider options. In Tulare County we have been proactive. We have partnered with Tulare Medical Reserve Corps. We have done one training exercise in Porterville Sikh Center for mass vaccination. The St. Anne’s Parish is interested in partnering with us for development of their disaster preparedness plan and will hold an event in Holy Cross Church in Porterville on December 2. Apparently the parish is not currently articulated with Red Cross and the California emergency management service. This relationship for the church was made possible because of the leadership of our medical society. The church can become an official shelter for local disasters such as hurricane Sandy. Please consider joining Tulare Medical Reserve Corps. It is voluntary participation that allows you to bring disaster preparedness resources to your family, friends, patients, church and community. If any one has any question please contact me at my office. I along with the dedicated staff of Tulare County Medical Society wish you very happy holidays and successful and prosperous new year! Thank you again and God bless all of you! You may reach Gaurang Pandya, MD, by calling 559-782-8533, or email: gpandyamd@gmail.com.

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Tulare Kaweah Delta Health Care District Receives Accreditation for Residency Programs

Emergency

Kaweah Delta Health Care District has received accreditation to offer residency-training programs in Family Medicine and Emergency Medicine. The first group of residents will begin their training on July 1, 2013. Kaweah Delta plans to start additional residencies in General Surgery and Psychiatry, as well as sponsoring a Transitional Year Program. The Emergency Medicine Residency Program, led by Dr. Michael Burg, will enroll six residents per year, for a three-year training program. The KDHCD program is one of only 160 emergency medicine programs in the U.S. There is a great need for emergency medicine residency programs across the country, and Kaweah Delta’s record emergency department volume should attract high-quality applicants, Dr. Burg said. In general, emergency medicine residencies are very competitive. “There are more applicants than available training positions across the country, so there’s definitely a need for more providers,” said Burg, noting that Kaweah Delta’s program was only the 14th new emergency medicine program accredited by the ACGME in the last 10 years. The Family Medicine Residency Program, led by Dr. Robert Allen, will include six residents per year, for a three-year training program. “This program is really important to the community because our desire is that it will grow physicians who will become the family physicians of the future for Tulare County, Visalia and the Central Valley,” said Dr. Robert Allen, Program Director of Kaweah Delta’s family medicine program. “Because of the aging physician population, there is a need for primary care physicians in our community.” It is estimated that between 40-50% of the physicians that train in Tulare County through the GME programs will remain and practice in the Visalia area. “This program is going to change the face of medical care in Visalia and the Central Valley,” Burg said. “These young doctors are going to come here with very high standards and want to practice great medicine.” For more information about Kaweah Delta’s Graduate Medical Education Program and its faculty, please visit www.kdgme.org.

Continued from page 11

Information Regarding Palmetto to Noridian Transition When our Provider Relations department asked a Noridian representative for information as to when Noridian Administrative Services (NAS) will be taking the Medicare Part A & B from Palmetto GBA, the following response was received: As of October 16, 2012, two protests have been filed against the Jurisdiction E A/B MAC contract that was awarded to Noridian Administrative Services on September 20. CMS has issued a stop work order for the Jurisdiction E contract, while the Government Accountability Office (GAO) reviews the procurement record. During the GAO review period, which is expected to be completed by the end of January 2013, Medicare providers in California, Hawaii, Nevada, and the Pacific territories will continue to file their Medicare claims with the incumbent A/B MAC (Palmetto GBA). Because of the JE stop work order NAS may not do any work related to the JE award. Implementation activity may not take place until the stop work order is revoked. Tulare County Medical Society’s Provider Relations will continue to monitor this transition and keep our members as up to date as possible. Should you have any questions or concerns please feel free to call or e-mail Fran Hipskind at 559-734-0393 or fran@tkfmc.org.

office and championed both Shock Trauma and regionalized care by sharing his personal story. Many of you are likely aware that Parkinson’s disease was one of the highest-funded diseases by Congress for a number of years, as a result of the passionate testimony and eloquence of Michael J. Fox on Capitol Hill. On hearing the words “Once upon a time …” a child instantly recognizes that a story will follow, perhaps the fairy tale of a courageous hero that will capture their imagination and simultaneously enlighten, empower, and inspire hope in the young mind. The art of storytelling to educate continues throughout our lifetimes, as we share stories that reveal the valuable lessons we have learned from our successes and failures to create a deeper bond with others. Regardless of one’s profession, the better a storyteller you are, the greater your chances of succeeding by fully engaging and inspiring your listeners. In a 2010 article in the Journal of Patient Safety, actor Dennis Quaid highlighted a secret weapon in the national patient safety efforts – of the potential of “story power as an untapped vehicle to inform, equip, and challenge leaders to drive change that can save lives, save money, and build value in communities.” He defined “story power” as the ability to change or reinforce the behavior of others by telling a story, as a call to action that harnesses the power of full engagement. Quaid highlighted the story of Josie King, an 18-month-old infant who died at one of America’s most famous hospitals as a result of missed orders to start oral fluids, followed by a medication error. A 10-minute videotaped interview with her mother, Sorrel King, recounting the tragic story has now been used in over 2,000 hospitals through the Josie King Patient Safety Initiative to transform the delivery of health care worldwide. The power of storytelling is repeated in recounting the near death experience of Quaid’s newborn twins Zoe Grace and Thomas Boone Quaid, who received 1,000 times the intended dosage of the blood thinner heparin, leading to a two-day battle between life and death. The larger tragedy for our nation is that the same medication error occurred 11 months earlier elsewhere, killing other children, and has also happened since, because of the look-alike packaging of two different concentrations of heparin. Quaid has shared his story publicly to become a champion for highquality care. Please see Emergency on page 18

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

NEWLY REMODELED 1,200 sq.ft. office

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.

FRESNO/MADERA

with five exam rooms

ANNOUNCEMENT

3,400 sq.ft. space Suitable for a Physical Therapy or Individual practice; may be divided & remodeled to suit Excellent parking and close to St. Agnes Medical Center

Carl Abercrombie 559-227-4658 c: 559-970-9035 Jim Abercrombie 530-626-0321

University Psychiatry Clinic: A sliding fee scale clinic operated by the UCSF Fresno Dept. of Psychiatry at CRMC M-F 8am-5pm. Call 559-3200580.

FOR RENT / LEASE 1,250sf medical office, 950 E. Almond Ave. Madera. $1,000 per month. Contact Martinelli Properties 559-673-2166 or martinelliproperties@gmail.com. Medical office spaces: 1,000sf up to 2,500sf at NE. corner First/Herndon and NW corner First & Bullard starting at $1 psf++ by owner. Call 559449-7668 or 559-284-2625. FresnoTimeshare. Newly renovated furnished office in medical complex. Includes internet. No minimum. Reasonable rate. info@fresnomedicalspecialists.com

FOR SALE 2,466sf medical/dental office at 924 Emily Way, Madera. $400,000 or for lease at 50¢ sf. Contact Brett Visintainer at 559-447-6265 or bv i s i n t a i n e r @pearson realty.com.

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

MEDICAL OFFICES FOR LEASE 2701 16th St. – 2,400 2005 17th St. – 2,955 sf. 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 – 3,200 rsf. 4040 San Dimas St. – 2,035 rsf. 9300 Stockdale Hwy. – 3,743 - 5,378 rsf. 9330 Stockdale Hwy. – 1,500-7,700 rsf. 1919 Truxtun Ave. – 2,080 sf. 2323 16th St. – 1,194 rsf. 2323 16th St. – 1,712 rsf. 2323 16th St. – 2,050 rsf. 2323 16th St. – 2,568 rsf. SUB-LEASE 4100 Truxtun Ave. – Can Be Split Medical Records & Offices Sprinklered – 4,764 usf. Adm. & Billing – 6,613 rsf. 2323 16th St. – 2,884 rsf. FOR SALE 1911 17th Street – 2,376 sf. Crown Pointe Phase II – 2,000-9,277 rsf. Meridian Professional Center – 1,740-9,260 rsf. 9900 Stockdale Hwy. – 4,000 rsf.

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FT or PT opening for physician in a busy practice in Visalia. Offering full benefit pkg and more. Contact Nicole at 559-627-3222 or Nicole@valley industrialmed.com.

Emergency Continued from page 17 “A slow cultural shift over the past 20 years, led by television (from St. Elsewhere to ER) has been humanizing society’s view of the practice of medicine.” This comment was an accolade to Atul Gawande, MD, MacArthur Genius award recipient and noted author. His writings in the New Yorker have influenced the political debate about health reform. But whereas singular medical voices like his are having an impact, overall the profession of medicine is failing to have an effect in Washington, DC. The impact of the Supreme Court decision in 2012 upholding the Affordable Care Act has been felt worldwide. As physicians, we must now harness the power of storytelling to enlighten Capitol Hill to enact new laws to strengthen EMTALA and the ACA to support emergency health

Credit Cards Continued from page 12 • Secure your credit card readers. • Use a virtual terminal solution provider validated by the PCI. • Do not store credit card numbers, or any of the information from the credit card on any computer or system. Never store sensitive authentication data, this includes: Primary Account Number (PAN) commonly known as the credit card number; the Personal Identification Number (PIN); the data from the magnetic stripe or, if present, the chip; the card security code, the 3-digit number on the back of most credit cards or the 4-digit code on the front of American Express cards • If the PAN is displayed, it must be masked. Only the first six and last four digits may be displayed. Now that you know some of the risks and requirements of storing credit card information, do you really need them on file? For information, visit Payment Card Industry at www.pcisecurity standards.org. Fran Cain is the Network Systems Manager for NORCAL Mutual Insurance Company. Copyright 2012 NORCAL Mutual Insurance Company. All rights reserved.

care personnel, who struggle courageously each day to meet the needs of society. As the debate moves forward again, perhaps patients and physicians across America will succeed in infusing the discussion with the hopes, failures, and triumphs from their personal stories. Harold Goddard once said: “The destiny of the world is determined less by the battles that are lost and won than by the stories it loves and believes in.” Whether one chooses to apply the power of storytelling to become a better patient, physician, health care advocate, or health policy leader, the time has clearly arrived to enlighten Capitol Hill to enact new laws grounded in the principles of fairness, equality, and justice to fulfill the overarching intent of quality, efficiency, and safety in health care in America. Reprinted from The Permanente Journal 2012 Summer; 16(3): John Maa, MD “Solving the Emergency Care crisis in America; the power of the law and storytelling” 71-4. ©2012 with permission from The Permanente Press.


“When I found out how much money I could save ($1,650) on the sponsored workers’ compensation program, I joined CMA. The savings paid for my membership and then some. Now I have access to everything CMA offers.” Nicholas Thanos, M.D. CMA Member

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