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Spring 2018

VALLEY CHILDREN’S

Strategy for providing High Quality, Comprehensive Pediatric Care

Physician Wellness It is a Matter of the Heart If We Can’t Breathe The Value of Advocacy Spring 2018

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VOLUME 3, NUMBER 1 • SPRING 2018

{FEATURES}

8 14 18 22 26 42 48 Spring 2018

DISASTER PREPARDNESS PHYSICIAN WELLNESS IT’S A MATTER OF THE HEART IF WE CAN’T BREATHE 30 MILES OR 30 MINUTES THE VALUE OF ADVOCACY

{DEPARTMENTS} 6

MESSAGE FROM THE EDITOR

12 PRESIDENT’S REPORT 24 MEMBER BENEFITS 32 FIRE FALLS IN YOSEMITE 34 CLOVIS COMMUNITY MEDICAL CENTER 36 TOP 10 REASONS TO BE A MEMBER 40 CLASSIFIEDS 46 PUBLIC HEALTH

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From The Executive Director

NEW ADDITIONS!

Wow, I cannot believe it is already April. There are many changes at the medical society, and they are all GREAT! First, Membership is going well this year, we have over 90% in renewals for 2018 and that is better than this time last year. We only have a couple dozen doctors that we are following up with and I am sure we will reach our goals before the end of the month. New member growth has been NICOLE BUTLER good too. So far this year we have over 50 new doctors that have joined and the number keeps growing. Fresno Madera Medical Society also has two new employees, and I am thrilled to have them onboard. Stacy Woods joined the medical society in March as the Membership and Events Manager. Stacy comes to us from the Fresno Philharmonic where she spent the past five years as the Marketing Director. She is a valley native who attended the University of the Pacific in Stockton, CA and has spent most of her career in marketing, communications and event promotion. Stacy currently resides in Madera with her husband and two children. She is a great addition to the team and has already been a great help with marketing. Kailey Fontes joined in January and is our Marketing and Events coordinator. She will be working on our social media, website and our new PodCast channel, Central Valley Physicians. Kailey has a Health Science degree with an emphasis in Community Health from California State University of Fresno. She is passionate about assisting others through the medical field and building quality, customer relationships. If you have not met her yet you will, she will be visiting FMMS members regularly. With the growth of FMMS team, we are working on developing more services and benefits for our members, so please stay tuned for some new announcements. For those of you that are not members, we hope that you will take the time to attend one of our events or stop by and meet our team.

PRESIDENT Trilok Puniani, MD PRESIDENT-ELECT Cesar A. Vazquez, MD VICE PRESIDENT Alan Birnbaum, MD TREASURER Don Gaede, MD PAST-PRESIDENT Alan Kelton, MD BOARD OF GOVERNORS Christine Almon, MD, Andres Anaya, MD (Resident Board Member) Janae Barker, DO, Jennifer Davies, MD Joseph Duflot, MD, Patrick Golden, MD David Hadden, MD, Prahalad Jajodia, MD Brent Kane, MD, Shamsuddin Khwaja, MD Christine Maser, MD, Katayoon Shahinfar, MD Nadarasa Visveshwara, MD CMA Trustee; Ranjit Rajpal, MD CENTRAL VALLEY PHYSICIANS EDITOR Don Gaede, MD MANAGING EDITOR Nicole Butler EDITORIAL COMMITTEE Don Gaede, MD - Chair, Alan Birnbaum, MD - Associate Editor, Roydon Steinke, MD, Cesar Vazquez, MD, Nicole Butler, Trilok Puniani, MD CREATIVE DIRECTOR www.sherrylavonedesign.com CONTRIBUTING WRITERS Don Gaede, MD, Jennifer Seita, Trish Brall, Trilok Punani, MD, Julie Brightwell, JD, RN, Praveen Buddiga, MD and Nicole Butler CONTRIBUTING PHOTOGRAPHERS James Ramirez, Don Gaede, Royden Steinke, Kailey Fontes and Nicole Butler CENTRAL VALLEY PHYSICIANS is produced by Fresno Madera Medical Society PLEASE DIRECT ALL INQUIRIES AND SUBMISSIONS TO: Central Valley Physicians 255 W. Fallbrook, Suite 104 Fresno CA 93711

On a personal note, I wanted to let everyone know that my husband and I are in the process of adopting a baby girl. She was born, February 20, 2018 and her name is Chandler Monroe. She has been with our family since March 5 and if all goes well the adoption will be final later this year. Sincerely,

Phone: 559-224-4224 • Fax: 559-224-0276 Email Address: nbutler@fmms.org MEDICAL SOCIETY STAFF Executive Director, Nicole Butler Marketing and Events Coordinator, Kailey Fontes Membership and Events Manager, Stacy Woods Receptionist, Becky Gentry

Nicole Butler

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Spring 2018


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A message from our Editor > Don H.Gaede, MD

Physician Empathy I’d like to thank all the physicians who submitted articles for our first writing contest. The articles were all a pleasure to read, and choosing the winner was not an easy task. I’ve sometimes heard it said that while we physicians may be intelligent and educated, we also tend to be a bit cold, lacking in empathy, and perhaps focused too much on making money. But the submissions argue against that perception. Almost all of the articles seemed to come from deep in the emotional cores of these doctors, who spoke about patients and loved ones that moved them, often in unexpected ways. Here a are a few quotes that I found particularly intriguing: ABOUT THE AUTHOR ­ Dr. Gaede, a Fresno native, is board-certified in Internal Medicine and specializes in Vascular Medicine, with an expertise in the treatment of varicose veins, circulation problems, blood clots, and advanced techniques using ultrasound and sclerotherapy.

“My father’s hands. Big, gentle, gracious, useful. Just like the person.”

“His left elbow was limp, so he’d use his shoulder to swing his left hand up to the table where he could finger-walk his hand around to maneuver his cards.”

“He is a homeless alcoholic with an equal amount of ascites and denial.”

“There is something about a patient dying that makes you rethink every step you took in their care. Did I try hard enough? Did I do enough? Did I make a difference?”’ “In that moment, Roy transformed in my eyes from an old man on the street to some kind of selfless hero.” After careful review, our panel of judges decided that the winning author would be Dr. Farah Karipineni. Congratulations! Her moving and timely article is featured on page 18. The other submissions were also excellent, so I hope to run some of the them in subsequent editions of Central Valley Physician.

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Spring 2018


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R E T S A S DI e ic t c a r P l a ic d e M r u o Y r fo s s e n d Prepare JULIE BRIGHTWELL, JD, RN, DIRECTOR, HEALTHCARE SYSTEM PATIENT SAFETY, THE DOCTORS COMPANY

Recent fires, hurricanes, and floods nationwide have highlighted the importance of planning for disasters. Wildfires in California forced several physicians to quickly relocate their practices some permanently and to move scheduled procedures to different facilities. Hurricane and flood damage in Texas and Florida left practices without power for days or even weeks. Is your practice prepared for this type of situation? A disaster can overwhelm a medical practice, with damage that can include shattered windows, flood debris, power outages, disrupted telephone systems, computer

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and system outages, unsafe drinking water, destroyed medical records, medication exposure to temperature and humidity extremes, contaminated instruments, and building structure failure. Disaster preparedness requires a continuous cycle of planning, organizing, training, equipping, rehearsing, and evaluating. Physicians are critical participants in disaster preparedness, ensuring that patient care and critical services are not interrupted—especially for at-risk individuals who may have special medical needs.

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Plan Ahead Now Before the next disaster strikes, make sure your practice has a plan in place. A checklist, ordered by priority and customized to specific types of disasters, can provide the framework for a comprehensive plan. The checklist should include these elements:

• A full-circle call tree that outlines who contacts whom. • Instructions for setting up instant messaging technology that enables staff to communicate without a wireless network or cellular data connection • Instructions for securing records of patients undergoing diagnostic testing and a list of outstanding diagnostic studies • Guidelines for maintaining Health Insurance Portability and Accountability Act (HIPAA) compliance. Although the HIPAA Privacy Rule is not suspended during a natural disaster or other emergency, the Secretary of Health and

Human Services may waive certain provisions of the Privacy Rule • A Certificate of Insurance for your medical malpractice coverage, or instructions for contacting your agent or insurer directly to obtain proof of coverage. This document will be necessary if you are forced to temporarily relocate your practice or procedures • Verification that home health agencies caring for your patients have plans in place to provide adequate services in a disaster • Steps to follow upon returning from evacuation

When Disaster Strikes Planning today makes accomplishing the following tasks more feasible during a disaster:

Communication

Computers and systems

• Contact staff immediately to determine realistic return-to-work time frames.

• Contact computer service vendors to ensure integrity and recovery.

• Notify external vendors and business associates of your practice interruption and targeted resumption of operation.

• Verify insurance coverage for repair or replacement costs and losses.

• Implement staff briefings at the beginning and end of each day.

• Evaluate applicable warranties and consider an information technology restoration service contract. • Inventory and document hardware and software.

• Create temporary phone, fax, and answering services.

• Document the type and extent of both lost electronic and paper data.

• Establish patient telephone triage. • Implement temporary controls to ensure HIPAA compliance.

• Ensure data back-up and periodically test compliance. • Reestablish filing systems and internal programs.

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Medical records

• Determine the extent of damage to, or loss of, patient records and filing systems. • Attempt to restore all damaged charts and document inventory findings. • Notify the state medical board for specific guidance pertaining to lost or damaged records. • Document all efforts to restore and protect existing records. • Reconstruct lost charts at the next patient encounter. • Contact your insurance carrier for restorative services and/ or claim procedures. • Reestablish a filing system and temporary storage if necessary. • Obtain legal guidance for patient notification during recovery efforts. • Contemporaneously date and initial all late entries and duplicate information in context of recovery efforts.

Physicians are critical participants in disaster preparedness, ensuring that patient care and critical services are not interrupted. In addition, create an inventory of all equipment and medications that may have been exposed to water or extremes in temperature. Repair, replace, or discard damaged items appropriately. Once your plan is in place, regularly reevaluate its steps and update all contact information. Practice and rehearse the plan’s protocols. An effective disaster preparedness plan will help keep your practice focused on delivering care during an emergency.

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Spring 2018


Secured over $1 billion annually to improve provider payments and graduate medical education funding.

ONEBILLION

Defended medical staff independence in “existential threat” lawsuit against the Tulare Regional Medical Center.

ONEMILLION Recouped nearly $1 million from payors on behalf of physician members.

Expanded member insurance program with state-approved workers comp coverage, new cyber liability program and personal insurance products.

CMA executive awarded “CFO of the Year” for fiscal responsibility and innovative strategic investments.

Defeated irresponsible federal legislation that would have harmed patient access to physicians and decreased health care coverage.

Stood in solidarity with California’s “Dreamers” and in support of diversity and inclusion.

Reaffirmed staff commitment to CMA’s mission by developing a credo.

Developed AB 72 and MACRA resource centers to educate members on rights and responsibilities.

Debuted a Mother’s Room at CMA headquarters for breastfeeding staff and members.

Convinced CMS to further reduce 2018 MACRA reporting burdens.

Declared firearm violence “violates the fundamental human right” to “live safely without fear in a free society.”

@cmaphysicians www.cmanet.org Spring 2018

Headquarters 1201 J Street, Suite 200 Sacramento, CA 95814 (916) 444-5532

CMA Member Service Center Just one number to call for all your CMA needs! (800) 786-4CMA (4262)

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President Report > Trilok Puniani, MD

Gun Violence and Mental Illness

ABOUT THE AUTHOR ­ Dr. Trilok Puniani is a board certified in Neurology and Vascular Neurology, he completed is residency training at New York Medical College and Westchester County Medical Center, in Valhalla, NY and his fellowship training at Methodist Hospital and Baptist Memorial Hospital in Memphis, TN. Upon completion of residency and fellowship in Neurology, Puniani moved to Fresno in 1989 and started a private practice later joining Kaiser Permanente in 1997 where he is currently Chief of the Neurology Department.

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Every time the country is shaken by a tragic mass shooting and the loss of innocent lives, the same debate is repeated. Besides sending thoughts and prayers for the victims, a common theme is talking about the warning signs of mental illness and their role in the actions of the perpetrator. The term mental illness covers a wide range of psychiatric conditions, including anxiety disorders, post-traumatic stress disorder, schizophrenia, dementia, different forms of depression and personality disorders /antisocial personality disorder, autistic spectrum disorder. Substance abuse conditions--alcohol abuse is the most common—may also contribute. How many times have Americans turned on their television sets to see these words filling up the screen? BREAKING NEWS. If one follows the pattern of recent events, “breaking news” has either to do something with the current President and his administration, or school shootings. These shootings are happening across school campuses, at educational institutions that are supposed to be safe zones, zones where children come from all walks of life to assemble and learn. There was a time when schools were considered a sanctuary. Whenever there was an emergency, displaced residents were gathered in school campuses until a plan of action was set forth. Now, those same schools have become places of crime, a zone of bloodied bodies, and are no longer considered the safe havens. The nation was horrified when two teenage students went on a shooting spree at Columbine High School in Littleton, Colorado, almost twenty years ago. They managed to kill thirteen individuals and wounded dozens of others before committing suicide by shooting themselves. The National Rifle Association was taken to task, and people demanded firearm regulation. The NRA called this a hasty generalization and said that guns did not kill the students, but two troubled teenagers did. Their statement was supported by evidence that the two teenagers were influenced by violence-filled video games and music. Some said the shooters were bullied in school, and therefore, they were filled with rage and wanted to punish others. Thirteen years after Columbine High School, another student went on a shooting rampage at Sandy Hook Elementary School in Newtown, Connecticut. He killed twenty-six people and shot himself. The shooter was obsessed with mass

Spring 2018


The AMA has supported efforts to boost gun violence research, ban assault weapons and to restrict access to automatic weapons. murders and school shootings. He was described as an odd and reclusive person who suffered from mental illness. February 14, 2018, on a day that was supposed to be a day of love and friendship for the students of Stoneman Douglas High School in Florida, a 19-year old killed seventeen people and injured seventeen others. Armed with a semi-automatic rifle and multiple magazines, he began firing indiscriminately at students and teachers. The shooter was arrested shortly afterward and he confessed to the crime. These three massacres happened years apart, but share two common factors. The shooters were troubled teenage boys who had somehow been able to get access to enough guns and ammunition to carry out mass shootings. The shooters were struggling in school for various reasons: mental health, disciplinary issues, and bullying. Frustration is mounting in the medical community as the current administration again points to mental illness in response to the latest mass shooting. “The concept that mental illness is a precursor to violent behavior is nonsense,” said Dr. Louis Kraus, forensic psychiatry chief at Chicago’s Rush University Medical College. “The vast majority of gun violence is not attributable to mental illness.” Mental health professionals welcome more resources and attention, but they say the Trump administration is ignoring the real problem — easy access to guns, particularly the kind of high-powered highly lethal assault weapons used in many of the most recent mass shootings. The AMA has supported efforts to boost gun violence research, ban assault weapons and to restrict access to automatic weapons. But under gun industry pressure, CDC research on firearm violence has been limited for decades. AMA President David Barbe wrote in an online column after the latest shooting: “We are not talking about Second Amendment rights or restricting your ability to own a firearm. We are talking about a public health crisis that our Congress has failed to address. This must end. Better access to mental health care, including for those who might be prone to violence, is important, but to blame this all just on mental illness is not sufficient.” The American Psychiatric Association, the American Academy of Pediatrics and four other medical associations issued a joint statement, urging comprehensive action by

Spring 2018

Trump and Congress, including labeling gun violence as a national public health epidemic. The groups’ recommendations include limits on highpowered, rapid-fire weapons designed to kill, and funding gun violence research at the CDC. Appealing to lawmakers to revise the gun laws has always been received with mixed emotions and counterattacks. But increasing the age limit on the ability to buy firearms is a step in the right direction. There must be sufficient background checks before anyone is sold a firearm. Mental issues amongst teens cannot be ignored. Early detection and treatment is the key. How can we help these troubled children and teens who are struggling with mental health issues? Some answers can be achieved by implementing the process of screening. The screening process must be conducted in elementary, middle, and high schools across the nation. • Instead of just focusing on arming the school teachers, so that they are ready to fire back at the shooter, schools must hire more staff who are trained psychologists. • Teachers must be trained to look for the warning signs or peculiar behavior such as the underlying causes that coerce these youngsters to retaliate so violently. • There must be zero tolerance for bullying on school campuses. • The current health care system needs an overhaul to be better equipped to recognize mental health issues and offer treatment. • Work with families and parents whose teens are struggling with mental health issues. Most of the times, parents feel helpless and isolated. Their love for their children prevents them from coming out and talking about it openly. They fear being judged, hence bear this pain alone. They do not have to feel alone, if schools, health professionals, and volunteers come together to help them. • Local communities need big brother, big sister-like mentors, who are willing to spend time with the teens to decipher what is going on in their lives. Trilok S Puniani, MD President FMMS Special thanks to my wife, Navjit for her contribution to this article.

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In 2014, as the national epidemic of physician burnout continued to spread and more and more physicians were leaving the profession, many physician leaders determined that burnout might well make the Triple Aim untenable.

A CULTURE OF HEALTH: MAKING WELLNESS A PRIORITY FOR PHYSICIANS Southern California Permanente Medical Group’s “Five Pillars” fosters a culture of wellness that is helping turn the tide of physician burnout. By Trish Beall

Enhancing patient experience, improving population health and reducing costs are the central tenets of medical practice that the Cambridge, MA-based Institute for Healthcare Improvement Promulgated in 2007. It’s known as the “Triple Aim,” and healthcare organizations nationwide, including the 9,000-physician/4.3-million patient Southern California Permanente Medical Group (SCPMG), have implanted it in their systems. In 2014, as the national epidemic of physician burnout continued to spread and more and more physicians were leaving the profession, many physician leaders determined that burnout might well make the Triple Aim untenable. They proposed, in the Annals of Family Medicine, adding another aim, which was “the

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goal of improving the work life of health care providers, including clinicians and staff.” This was just about the time that SCPMG was rolling out its Physician Wellness Program, which received the California Medical Association (CMA) 2017 Gary S. Nye, M.D., Award for Physician Health and Well‐Being. What is now called the “Quadruple Aim” is the overriding mantra of the organization, its wellness endeavors, and its commitment to fostering a culture of wellness. CMA recently interviewed Edward Ellison, M.D., who is SCPMG’s Executive Medical Director and Chairman of the Board; ob-gyn Dawn Clark, M.D., who is the group’s Chief Wellness Officer and the creator of SCPMG’s three-year-old

Spring 2018


THE FIVE PILLARS 1) PREVENTION—emphasizing to physicians the importance of taking care of their own health 2) PROFESSIONALISM AND CONTINUING MEDICAL EDUCATION, so physicians can learn to see their personal wellness as a critical component of providing quality patient care 3) PRACTICE MANAGEMENT, which Dr. Clark summarizes as “backoffice efficiencies—how to get through our days in an easier, healthier, more productive way” 4) COLLEGIALITY AND COMMUNITY SERVICE 5) HEALTHY EATING, HEALTHY EXERCISING AND HEALTHY WEIGHT

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Physician Wellness Program; and Frank Flowers, M.D., medical director of SCPMG’s Riverside region. All three noted how crucial that fourth aim is. As Dr. Clark explained, “My message to our senior leadership has been: every time you make a decision about patient experience or quality or reduction of cost, make sure that you add this fourth aim and think about how your decision and every aspect of our organization affects the health and wellness of the physicians and the staff.” Dr. Ellison hardly needed convincing. When he took on the position of Executive Medical Director/Chairman of the SCPMG board in 2012, he was well aware that survey after survey around the country showed more and more physicians reporting symptoms of burnout and an intention to leave the profession. He very quickly began soliciting Permanente physicians to tell him what their concerns were. In April 2013, he posted a job listing for a brand new post within Southern California Permanente— Chief Wellness Officer. Dr. Clark said, “When I saw the posting I saw my opportunity to align my own personal journey of work life integration with our organizational needs.” And she got the job. She didn’t start out by simply creating feel-good programs. She began by researching wellness programs at other medical organizations. There were the physician-well-being programs that hospitals are required to have to address individual physicians’ substance abuse and mental health problems. Additionally, some academic centers were beginning to address wellness among their trainees, but “there weren’t really any wonderful examples out there,” she said. And so she and Dr. Ellison researched SCPMG physicians’ needs by sending out a survey asking them what they wanted to see in a wellness program. That survey included questions about how they rated their medical environment as a “culture of health.” Dr. Clark said, “Our program was based on their feedback and external benchmarking.” The wellness program that she and Dr. Ellison presented to its physicians a year later is a “five-pillar model” that helps physicians maintain or regain their resilience. The five pillars include 1) prevention—emphasizing to physicians the importance of taking care of their own health; 2) professionalism and continuing medical education, so physicians can learn to see their personal wellness as a critical component of providing quality patient care; 3) practice management, which Dr. Clark summarizes as “back-office efficiencies—how to get through our days in an easier, healthier, more productive way”; 4) collegiality and community service; and 5) healthy eating, healthy exercising and healthy weight. Regarding collegiality, both Drs. Clark and Ellison noted that their physicians had stopped eating lunch together because of such demands on their time as the morass of emails and reporting requirements. Using these five pillars, SCPMG has shifted its culture in a

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meaningful way that makes wellness a priority for physicians. The program has been nationally recognized for its effective and innovative work in physician wellness. On the Physician Wellness Program website, the five pillars appear as: My Health, My Education, My Practice, My Community, and Food and Fitness, with each pillar’s section offering, among many other things, a portal to a “total health assessment,” helpful articles to read, and schedules of upcoming events and of non practice getaways that may focus on meditation and mindfulness or golf and tennis tournaments. The website is just one component, however. SCPMG’s regional medical directors and their appointed “wellness champions” encourage their physicians to attend “Health Connect Essentials,” which are how-to lessons in practice efficiencies, such as electronic health record entry shortcuts. In the Riverside region, Dr. Flowers said attending such programs is not mandatory, but at meetings of his 680 physicians he “invites and reinvites” such engagement – receiving very positive feedback from many who have attended. Don Yoshimura, M.D., sits on the Fresno Health and Wellness Committee and serves as a member of the Permanente Medical Group (TPMG) Wellness Task Force for Northern California, serving a group of 9,000 physicians. He, along with his team, are tasked with developing and implementing their wellness strategy which includes: workflow optimization for making physician’s lives easier at work, weaving wellness awareness into operational decision making, providing resources and skills to improve physician resilience, promoting personal health and wellness through exercise, healthy eating, social interaction and community involvement, leadership education, and developing means to measure their organization’s progress. “Physician burnout is a reality for our medical group and for the medical profession as a whole. Leadership and organizational commitment in identifying and tackling the problem is an agenda that I am devoted to promoting,” said Dr. Yoshimura. Early changes to Fresno’s Health and Wellness Committee include improvements to their electronic medical record data entry with use of an upgraded voice recognition system and the development of a virtual call center to handle the ever-increasing burden of electronic messaging. Their internal surveys have indicated an overall increase in physicians’ trust in leadership since new developments have been implemented. In comparison to the annual Medscape survey of all US physicians, TPMG ranks higher than their non-TPMG physician colleagues in terms of professional satisfaction—86 percent of TPMG physicians feel they made the right decision when choosing medicine as a career, as opposed to 77 percent of nonTPMG physicians. Dr. Yoshimura and his colleagues have been working tirelessly towards the ultimate goal of developing a group culture of

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On the Physician Wellness Program website, the five pillars appear as: My Health, My Education, My Practice, My Community, and Food and Fitness, with each pillar’s section offering, among many other things, a portal to a “total health assessment,” helpful articles to read, and schedules of upcoming events and of non practice getaways that may focus on meditation and

engagement, collaboration and excellence, which values the health and wellness of their physicians and employees, as well as their patients. He reminds the next generation of physicians to start taking care of themselves from a young age and to stay engaged in the process. “Don’t be afraid to speak up and contribute to process improvement at every level. Be mindful of your own health and wellness, as well as that of your family and your community.” SCPMG leaders are also instituting other significant wellness and anti-burnout measures across the region. For example, physicians have new flexible-work-hour possibilities, and Dr. Ellison described a new “concierge” office to help physicians manage their non practice lives. The concierges do such things as help physicians plan trips and find someone to look after their house when they are away. There is also a major initiative to address “second victim syndrome,” the emotional toll that can overwhelm a physician when a patient dies unexpectedly. “Compassion fatigue,” another common burnout factor the organization is addressing, seems to hit mostly women physicians, and there are gatherings and retreats just for those doctors. Is SCPMG’s wellness program working? A second survey of SCPMG physicians in 2016 determined that physician ratings of

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mindfulness or golf and tennis tournaments.

key workplace “culture of health” measures improved by a range of 11-23 percent. However, “although we are making progress, there is more work to be done,” said Dr. Ellison. “More work” may well require a sea change in medical education, medical training and medical practices, he proposes. SCPMG’s approach to fostering a culture of wellness is hardly proprietary, and they are willing to share and learn, he said. Many organizations are tracking each other, continually adopting new ideas. State and county medical associations are drawing physicians together to discuss what works. Leaders of major medical organizations and the American Medical Association have meetings to brainstorm the solutions to the burnout epidemic and the looming possible shortfall of physicians nationwide. The beginnings of that sea change are happening. Trish Beall is a freelance writer and editor in Berkley. Michelle Mott, a communications intern at the California Medical Association, also contributed to this story.

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AMATTEROFTHEHEART I believe without a doubt that we all have a path in life. In that respect, my career as a surgeon was inevitable. But as far as this worldly life is concerned, it’s fair to say that I chose the field of surgery in large part because of my father’s hands.

My father’s hands. Big, gentle, gracious, useful. Just like the person. Problem-solver, answer-giver, plumber, doctor, builder, you name it, my dad will do it. He can fix a car, a toilet, a TV, a table. He can build a fountain, pave a road. He can coax a lamb out of a sheep’s womb, cajole peppers out of well-toiled soil. He diffuses tense situation with thoughtfully placed words, makes you feel at home whether you have business here or not, and treats you like you’re human according to your humanity, not your wealth. My father is a surgeon. A vascular surgeon, which I never thought made much of a difference until surgery residency. Until then, I thought the specialty was all about old people who smoke and have bad arteries or varicose veins and every medical problem in the book. And much of it, to be honest, is about that. But there is also a terribly elegant art to it.

By Farah Karipineni, MD, MPH Endocrine Surgery and General Surgery

In its simplest description, the human body is a 5-liter bag of pipes filled with blood. Of course, there are also the airway apparatus and the plumbing systems, but without the sheer volume of liquid pumping through this bag of skin, the rest would be functionally nonexistent. So when we talk about giving someone blood thinners for peripheral arterial disease, or obliterating someone’s veins for varicosities, or, more dramatically, reinforcing an aneurysmal aorta, it is no trivial matter. Growing up on a farm in California, the fact that my dad did surgeries that tinker with this lifeblood in astonishing ways never mattered to me. He was just my dad. For me, he’s never been a hero for repairing an aorta or saving a limb. He was special for many other reasons. It was not until my vascular rotations that I realized those qualities I so admired had much to do with an equally striking profession. A picture tells a thousand words, but I’m not a photographer—paragraphs are my snapshots. The following are a few:

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I learned this from my father’s hands. Not in the operating room, but in the garden; not as a surgeon, but as a veterinarian; not by his lectures, but by his living example.

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One: I’m standing outside the house near our makeshift barn

Three: I’m five years old hiding under a dressing table. A few

in the freezing cold at 5:30 am. My dad is with me, kneeling to minutes earlier, my father had gone downstairs in our newly inspect Catarina’s mangled foot. She is shifting her hind legs, built house to investigate an odd noise, only to be shot through unable to bear weight after a run-in with some barbed-wire the bare glass windows by an armed intruder. Blood dripping, fencing. It’s a bad sign. My dad cleans up the wound with a garden my father then gathered my sister and I into a hiding place before hose, putting his thumb over the spout to deflect the force. He calling the police. We then exit the house in a human chain, pulls out a tube of betadine he keeps in the house in case anyone where he stands outside the ambulance, hands compressing his gets hurt. While he cleans, eye wound, refusing to enter he teaches. “You see, horses until the police have safely are very sensitive animals.” retrieved our nanny. Over Catarina shuffles her feet the next several years, as I in discomfort, lending develop my own surgical It was not until after completing quiet agreement. He waits career, I will contemplate in residency that I realized how far from my patiently, then wraps awe over how he continued own humanity I had strayed. In training, the foot up in gauze and as a surgeon for decades I believed the best surgeon was simply goes back to stroking her, with a piece of shrapnel the most technically excellent one. In continuing his lecture on wedged in his cornea. It is practice, I am no less concerned with the horse psychology. We do that combination of grit, skill of my hands, but far more in tune this daily until the wound humility, and precision that with the skill of my heart. heals. I love about my father and surgery. Two: It’s the first week of my vascular rotation as It was not until after a resident. I’m bent over completing residency a hospital bed, cutting that I realized how far out devitalized tissue from a veteran’s gangrenous foot as he from my own humanity I had strayed. In training, I believed watches Maury Povich. He’s almost deaf, so when I enter the the best surgeon was simply the most technically excellent room, I yell into his ear, “It’s time for our date, Mr. Miller! We one. In practice, I am no less concerned with the skill of my gotta stop meeting like this!” He smiles vacantly in my general hands, but far more in tune with the skill of my heart. Surgeon direction. I tell myself we have a special relationship, though I’m or not, the rules of engagement are the same no matter what not sure how much he comprehends. I take off his protective endeavor we choose to pursue. An unwavering commitment to boot and unwrap the dressing to expose our putrid villain. I take the preservation of hope and dignity is required, whether the my scissors and forceps and slice away. Something makes me subject is a horse, a rosebush or a human being. remember my dad, perhaps Catarina’s injury or a more distant memory. I kneel next to the malodorous wound, thinking of my I learned this from my father’s hands. Not in the operating dad nudging his glasses up the bridge of his nose to examine the room, but in the garden; not as a surgeon, but as a veterinarian; health of a rosebush. “You have to remove all the dead leaves,” not by his lectures, but by his living example. It is not he’d tell me as I watched him purposefully snip away hardsomething one can learn from reading a book or hearing a earned branches. “It will grow better this way.” I return to the lecture. It is a matter of the heart. task at hand, thinking of the fresh pink tissue that will appear if I do my job well.

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CENTRAL VALLEY PHYSICIANS

Spring 2018


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If we cannot breathe, nothing else matters

By Praveen Buddiga, MD

As a physician, I see many patients every day. Whether it is asthma, COPD, or other chronic respiratory diseases, it is evident that poor air quality is having an impact on our community’s health. Unfortunately, I see these impacts far too often in Fresno.

The Fresno region, and much of the Valley, ranks among the worst air quality in the nation. In the most recent State of the Air report from the American Lung Association, Fresno ranked third worst for ozone, or smog pollution, and particle pollution, largely caused by vehicle traffic and freight. California has some of the strongest policies in the country to reduce vehicle emissions through both zero-emission vehicles and clean fuels. Those policies are an important tool to decrease vehicle emissions, but we need more tools to solve the problem. We must address the fundamental changes that need to happen in our state’s land use planning and transportation system decisions.

To clean the air and improve health we must change the way we have designed our neighborhoods for decades. We have placed the focus on sprawl that leads to increased traffic and air pollution while reducing the ability for residents to walk, bike or share a ride for even the simplest of errands. It is time we make regional planning decisions based on public health and reduced air pollution. Last week the California Air Resources Board started the process to update regional climate targets for 2020 and 2035, focused on reducing emissions through landuse and transportation decisions.

We have placed the focus on sprawl that leads to increased traffic and air pollution while reducing the ability for residents to walk, bike or share a ride for even the simplest of errands.

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Spring 2018


These targets, originally established by state legislation in 2008, will guide community-planning decisions in Fresno and beyond to limit air pollution from vehicles. For public health, it is critical the Air Board pass the strongest targets to continue efforts to reduce air pollution. Breathing unhealthy air can affect everything from birth weight to school performance, and it can lead to an increased risk for a lifetime of lung disease. Air pollution is connected to increased asthma rates, emergency room visits and hospitalizations, and even premature death. The San Joaquin Valley is one giant basin, which naturally traps air pollution. We can't change our geography, but we can urge regional planners to consider public health when designing neighborhoods and transportation systems for easy access to schools, work, entertainment and shopping. The regional climate targets set by Senate Bill 375 in 2008 are already working to better align community planning with state goals to reduce greenhouse-gas emissions. Our state and local leaders must now accelerate the progress to achieve California’s bold vision for climate action and healthier communities.

Spring 2018

“Breathing unhealthy air can affect everything from birth weight to school performance, and it can lead to an increased risk for a lifetime of lung disease.”

Local governments especially should take advantage of state financial resources now available to them to build healthier communities. California’s Climate Investment Program, funded through cap and trade funds, combined with other state funding, is available to support sustainable, healthy community planning, transit, active transportation and more. One key example of this is the Transformative Climate Communities grant program that will invest $70 million into Fresno communities in the next year, with pending proposals for energy efficiency, solar and urban greening projects in Southwest Fresno worthy of state funding. We can build on the success of our community voices and build a healthier Fresno for everyone. I join with physicians from around the state to urge the California Air Resources Board to make health improvement the top priority and adopt the strongest possible regional climate targets together with other strategies to reduce vehicle dependence. I call on our local government officials to take advantage of those climate funds now available to make our communities healthier and reduce air pollution. We must continue to do everything we can to fight for clean air in our region. Because if we can’t breathe, nothing else matters. Dr. Praveen Buddiga is a specialist at Family Allergy Asthma Clinic in Fresno and a volunteer with the American Lung Association in California.

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PUT YOUR MEMBERSHIP TO WORK! When you join the Fresno Madera Medical Society, you join the California Medical Association as well. Together FMMS-CMA can help with the success of your practice. Your annual dues can be more than offset when using membership services and discounts, and you get personal assistance with practice management and payment recovery issues to improve your bottom line. Join the FMMS to be a better leader for your staff and patients, and to amplify your voice to influence policy and legislation. The FMMS brings together an active community of physicians in order to improve the larger community. Our mission is physician-driven, and we want to help you solve your biggest practice management issue. Join the FMMS today!

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Free tool kit on quality measures & online tool to create custom MIPS plan.

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CENTRAL VALLEY PHYSICIANS

Spring 2018


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Up to 89% off the cover price of hundreds of magazines for your home, office, and waiting and patient rooms.

Consumer Subscription Services (800) 289-6247 www.cmanet.org/magazines

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Discounts on 24-hour emergency identification and family notification services.

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FMMS 255 W Fallbrook Ave Suite 104 (559) 224-4224

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Trained economic advocates with expertise in physician reimbursement and medical practice issues.

FMMS: (559) 224-4224 CMA: (888) 401-5911

Help for practices of all sizes: legal handbooks, practice mgmt. guides, patient education materials, etc.

CMA Resource Library www.cmanet.org/resource-library

Premier Valley Bank

Local bank offering comprehensive banking solutions that help make the job of managing finances easier

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Financial professionals helping clients establish priorities and develop strategies to acheive financial success.

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Financial advisors offering services in investment management, financial planning and retirement plans.

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Get paid: members receive one-on-one assistance. We have recouped $16 million from payors in the last 10 years.

FMMS: (559) 224-4224 CMA: (888) 401-5911

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CENTRAL VALLEY PHYSICIANS

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Radiology Tech, James Frias scans 11 year old, Celine Herrera from Porterville, CA 26

CENTRAL VALLEY PHYSICIANS

Spring 2018


Valley Children’s Strategy for providing High Quality, Comprehensive Pediatric Care By Jennifer Setia • Photography By James Ramirez

The mission of Valley Children’s Healthcare is simple – to keep Valley kids healthy more of the time. But with more than 1.3 million children living in Valley Children’s 12-county footprint, achieving that goal isn’t short of obstacles. The healthcare group is faced with the unique task of providing the highest quality of care to a vast geographic region that is made up of one of the most socioeconomically and culturally diverse populations in the country. >> Cover Photo - Kambria Rohrbach, age 12 Porterville, CA Spring 2018

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Despite these challenges, Valley Children’s is committed to providing the nation’s best healthcare for kids. This is accomplished through the network’s ambitious pursuit to provide improved access, commitment to quality of care, collaborative trainings and partnerships, enhanced safety, and innovative technology solutions. A key driver in Valley Children’s ability to be a leader in pediatric care is its quick adoption of cutting-edge technology. Whether it’s improving patient satisfaction through the addition of new NICView cameras that allow parents and families to remotely view their baby in the NICU through any internet device at any time, utilizing telemedicine to improve efficiencies and access in rural areas, or identifying procedures and equipment to improve patient outcomes, Valley Children’s is forging a bold path to the future of healthcare. For example, Valley Children’s Orthopaedics Department recently acquired a new EOS Imaging System, which is a 3-D imaging tool that drastically reduces the amount of radiation emitted during an X-ray. In fact, studies show that use of a low dose EOS exam can reduce the radiation dose by 50-85% as compared to standard X-ray technologies, all without compromising image quality. “This type of imaging is particularly beneficial to our pediatric patients with spinal deformities or scoliosis that might require X-rays every few months over the course of several years,” said Valley Children’s Medical Director of Orthopaedics Dr. Joseph Gerardi, DO. The EOS Imaging System provides a safer, faster and higher quality imaging solution for its pediatric orthopedic patients. And

Spring 2018

Pelandale Specialty Care Center, Valley Children's second outpatient center in Stanislaus County. Photo credit: Joan Lee/Modesto Bee because the EOS images are true to size without any vertical distortion, it provides physicians with more precise information, allowing them to make more informed diagnosis and treatment plans. Valley Children’s Orthopedic Department, which was recognized this year by U.S. News & World Report as one of the nation’s best children’s hospital specialties, is the first in the Central Valley and one of a handful in California to offer this technology. The EOS Imaging System is housed at Valley Children’s Spruce Specialty Care Center in Fresno, Ca. The center opened in Summer 2017 with services in Pediatric Orthopaedics, Child Advocacy and Otolaryngology (Ear, Nose & Throat) services, and is part of a larger network of specialty care centers opening throughout the medical group’s 12-county footprint, stretching from Sacramento to Bakersfield.

Care Closer to Home Valley Children’s Healthcare specialty care centers have been popping up all over the place. It’s part of their “30-miles or 30-minutes” strategy, meaning that every family in the Valley Children’s footprint should be within 30-miles or 30-minutes of high quality, comprehensive pediatric care.

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“We know that one way we have to stay true to the objective to keep kids well more of the time, we have to be within 30 minutes or 30 miles of every family in the Valley,” said Valley Children’s Healthcare President and CEO Todd Suntrapak. “Because the closer we are to where these families live, the quicker they can get their child in front of one of our clinicians, and everyone knows in the pediatric sector, the sooner you get a child in front of a clinician, the better chance you have of getting them on the path to having a healthy and productive life. And frankly, the better chance you have to make a difference immediately in the health status of that child.” Valley Children’s Healthcare currently operates specialty care centers in Modesto, Merced, Visalia, and Bakersfield, with construction underway on second locations in Modesto and Bakersfield and on new centers in Fowler and Clovis. In other areas, clinical hospital partnerships are the answer. These different approaches to care help to make their 30-mile strategy a reality. And, there’s a huge emphasis on getting care closer to home for other reasons like being closer to family, work and other personal commitments.

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“We want kids to get quality care that Valley Children’s is known for, but as close to home as possible,” said Gerardi. “So even if a child gets in an accident in their hometown of Bakersfield and we have to perform surgery at our hospital in Madera, we want that family to get all of their follow-up appointments in their hometown.” In addition to the growth of their specialty care centers, Valley Children’s Healthcare is finding other unique ways to serve the Valley, through primary care physician (PCP) offices, urgent care locations, and clinical partnerships with regional hospitals and outpatient facilities throughout the Valley. In fact, Valley Children’s Healthcare is partnered with every healthcare organization in the Valley but a few. “It’s a combination of bringing assets together in a way that is market specific, and is consistent with what that community needs to make sure that kids benefit and have access,” Suntrapak added.

Spring 2018


And there are even more new projects on the horizon including a future 6-acre outpatient campus in Visalia that is in the land acquisition phase. The Eagle Oaks Pediatric Specialty Center’s 10-acre campus will open in Bakersfield this year, with Phase I boasting a 55,000 square-foot building and Phase II allowing for another 75,000 square feet of room to grow. The facility will nearly quadruple the amount of pediatric sub-specialists that live and work in Bakersfield. Additionally, Valley Children’s Healthcare will continue to develop their school-based clinic strategy into other school districts throughout the Valley, outside of Fresno and Clovis. “We spend a lot of time listening to the communities we serve to hear what they really need, and then we match that up to our own assessment and it helps us prioritize which services we bring and when,” said Suntrapak.

Going Beyond Access Having access to pediatric healthcare is critical for the future of a healthy community. But just as important is the quality of healthcare, and that’s something Valley Children’s takes very seriously – and it shows.

Spring 2018

The hospital’s quality and safety outcomes are ranked among the highest in the country in critical areas like central line-associated blood stream infections and catheter-associated urinary tract infections. “Our goal for central line infections, urinary tract infections, all of the serious safety events that are preventable is zero,” said Suntrapak. “We are not focused on a rate per thousand days. We are focused on driving to zero.”

Valley Children’s commitment to patient safety is part of the hospital’s culture and dedication to being a High Reliability Organization (HRO). “It’s a great honor for all of us no matter if they are in Bakersfield, up north in Sacramento or here on the main campus, to realize that that these families of this Valley are entrusting what’s most precious in their lives to us, which are their children.”

Valley Children’s Hospital was recognized as one of the nation’s best children’s hospitals in three different specialties by U.S. News & World Report in its “2017-18 Best Children’s Hospitals” rankings. Those specialties are: Pediatric Orthopedics, Pediatric Diabetes & Endocrinology and Pediatric Gastrointestinal Surgery. Rankings are determined by three areas: outcomes, process and structure. “The U.S. News & World Report rankings are truly a recognition of the trust and investment that the community and the Valley has placed in us,” said Suntrapak. “We would not have progressed as an organization to the place where we are today without the support of the communities we serve.”

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IN YOSEMITE This year’s Yosemite Conference provided another first for the Medical Society. We hosted the 67th Annual Postgraduate Institute event a month earlier than usual and it provided a few challenges, but a new perspective on what Yosemite National Park has to offer. The event itself continues to be a success with attendance, and speakers and for those physicians who get their Continuing Medical Education credits online, from hospital programs, or medical journals, you really missed out! Most arrived to a blanket of snow from the top of Half Dome all the way to the hotel in the valley. We all watched as the snow melted off over the next two days, but what it did provide was amazing views. And since this year event was held in late February, most of the group hiked up Bridal Veil Falls to view the spectacular “Fire Falls”. Next year’s event will be held February 21-23, 2019 during the same time of year as the Fire Falls, so please mark your calendar now, and join us for another adventure.

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Spring 2018

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A rendering of Clovis Community Medical Center’s 190,000-square-foot expansion project. (Community Medical Centers)

The perfect blend of exceptional care and comfortable accommodations, Clovis Community Medical Center remains a top choice for women’s services, labor and delivery, minimally invasive

CLOVIS COMMUNITY MEDICAL CENTER MOVES FORWARD WITH

surgeries, sports medicine and weightloss surgery.

$390 MILLION EXPANSION By Clovis Roundup Staff - April 3, 2018

The Board of Trustees at Community Medical Centers approved a four-year, $390 million project Tuesday that will add 144 private beds and expand several services at Clovis Community Medical Center. >>

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Spring 2018


CCMC’s 190,000-square-foot expansion project will feature a five-story bed tower and will add 15,000 square feet to the hospital’s emergency room, create six additional operating rooms, 24 additional ICU beds, and expand the hospital’s radiology, pharmacy and laboratory services along with the kitchen and dining areas.

all-private inpatient beds while providing jobs for an additional 420 nurses, therapists, technicians and support staff. “We need to significantly expand inpatient capacity in our hospital system, and this Clovis project is the quickest and most cost-effective way to do it,” said Tim Joslin, Community Medical Centers President and CEO.

The project, which breaks ground next month, will include an additional parking structure and a two-story, 60,000-squarefoot clinical and administrative support building. When the project is completed in 2022, Clovis Community will have 352

Another project in the works at Clovis Community is a 100,000-square-foot cancer center, which is expected to open in August.

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MEMBERSHIP

Becoming a Member Top 10 reasons why you should join today.

When you become a member, you support your local medical society and hire CMA, a powerful professional staff to protect your profession from legal, legislative, and regulatory intrusions. Below are the top 10 reasons to be a member of Fresno Madera Medical Society (FMMS) and the California Medical Association (CMA).

1. Protect MICRA

3. Stay in the Know

CMA staunchly defends the landmark Medical Injury Compensation Reform Act (MICRA) year after year, saving each California physician an average of $75,000 per year in professional liability insurance premiums.

FMMS publishes the quarterly magazine, Central Valley Physicians, as well as CVP Podcasts for physicians, as a way to stay up-to-date with current events that affect medicine in the Valley. In addition, CMA produce publications to keep you up-to-date on the latest health care news and information affecting the practice of medicine in California.

2. Collaborate with Colleagues FMMS bring together physicians from all over the Valley, from different specialties and modes of practice to develop strong unity through leadership, collaboration, socials, educational events, and community service.

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4. Shape the Future of Medicine Through aggressive political and regulatory advocacy, CMA and its county medical societies

CENTRAL VALLEY PHYSICIANS

Spring 2018


MEMBERSHIP

CMA was founded in 1856 by a small group of physicians who knew it was their duty to fight for their patients and for their profession.

are positioned among the most influential stakeholders in the development and implementation of health policy. In addition, members receive direct access to our state and national legislative leaders to influence how medical care is provide today and in the future.

5. Save Money There are several ways to save money when you are a member. Discounted health insurance for you and your staff, automatic 5% savings on workers’ comp insurance, CME and Online educational courses, auto and home insurance, car rental, office supplies and much more. >>

NEW! New Monthly Membership! Fresno Madera Medical Society and California Medical Association membership is easy to maintain and hassle-free with automatically recurring monthly payments at an affordable price. If you are not a member, enroll today at www.cmanet.org/monthly to start receiving your benefits! If you’re a current member, and would like to switch to monthly payments keep an eye out for your renewal invoices and choose the monthly payments.

QUESTIONS? Contact CMA’s Member Service Center at (800) 786-4262 or memberservice@cmanet.org.

Spring 2018

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MEMBERSHIP

Ask yourself who will have the most impact on the way you practice “medicine - the government, or physicians in organized medicine through CMA? Be involved or be left behind. ” - J. Brennan Cassidy, M.D.

6. Get Paid Members receive one-on-one assistance from CMA’s reimbursement experts, who have recouped $15.5 million from payors on behalf of CMA physicians in the past nine years.

7. Continue Medical Education FMMS provides opportunities to further your knowledge with Continuing Medical Education. CME symposiums and dinner events are provided throughout the year with current topics that relate directly to your patient care. Learn from the experts and hear from recognized speakers.

8. Education and Training for Your Practice FMMS provides monthly Medical Managers Forum to arm your office staff with practical information and tools to overcome new challenges in

healthcare, run the office successfully and move your practice forward.

9. Lead by Example FMMS and CMA provide many opportunities to get involved, including opportunities to volunteer; serve on a committee, council or board; and shape the future of the medical profession and giving back.

10. Together We Are Stronger Together we stand taller and stronger as we fight to protect patients and improve the health of our communities. We are a dominant force in health care – but all the great work we do wouldn’t be possible without the support of members like you. Fresno Madera Medical Society was founded in 1883, as the first professional organization in Fresno County. Chester Rowell, MD, and a small group of physicians created the organization two years before the city of Fresno was incorporated, and formed the cornerstone of organized medicine in the area. Today, Fresno Madera Medical Society has over 1200 physician members working together to provide care to Valley residents.

Christina Maser, MD, FACS Associate Clinical Professor, UCSF Medical Director, University Surgical Associates • Member since 2006

QUESTIONS? Contact FMMS at (559) 224-4224 ext 118 or CMA’s Member Service Center at (800) 786-4262. 38

CENTRAL VALLEY PHYSICIANS

Spring 2018


CALIFORNIA MEDICAL ASSOCIATION

SEE JANE SAVE WITH CMA Purchased health insurance for her

Purchased workers’ comp insurance

8-person staff through Mercer.

through the Mercer/Preferred

SAVED: $12,120

Employers program.

SAVE: $750

Called CMA’s legal information line and accessed documents from CMA’s online

Earned 16.75 CME by attending

health law library, instead of calling an

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attorney for that same information.

Leadership Academy.

SAVED: $2,660

SAVED: $400

Used EnviroMerica to manage

Participated in 3 online webinars.

her practice’s medical waste and

SAVED: $297

regulatory compliance.

SAVED: $1,200

Used CMA’s magazine discount program to subscribe to 10 magazines

Hired CMA partner Mayaco Internet

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SAVED: $250

mobile-friendly website.

SAVED: $1,000

Bundled her auto and home insurance through Mercury Insurance.

Called CMA’s reimbursement helpline.

RECOVERED: $800

SAVED: $230 Kept track of her CME credits through

Sent her billing staff to CMA’s

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ICD-10 boot camp.

SAVED: $24

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Bought security prescription EMR Purchased office supplies through

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CMA’s Staples Advantage program.

SAVED: $10

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TOTAL SAVINGS: $21,291 Saving money, having access to unique services, knowing her dues support the California Medical Association’s efforts to Spring 2018 CENTRAL VALLEY PHYSICIANS 39 protect the viability of her practice, so she can focus on providing her patients with excellent care: PRICELESS


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POSITIONS AVAILABLE Chief Residents Needed for SAMC GME Program Leaders wanted! The newly accredited Internal Medicine Physician Residency Program at Saint Agnes Medical Center is seeing well-qualified PGY3s to serve as Chief Residents.  This is an excellent opportunity to grow your leadership skills and be a member of a vibrant and transformational team.  Interested individuals should contact GME@samc.com or visit http://www.samc.com/ physician-residency-programs for more details and application instructions.

Veteran State Home Fresno (CalVet) Has openings for a full-time and part-time physicians. This is a State position with State benefits. For more information or if you are interested please email asha.sidhu@calVet.ca.gov or call 559-681-7800 or apply online at calhr.ca.gov.

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CENTRAL VALLEY PHYSICIANS

Medical Consultants Needed for Fresno Field Office This is an excellent opportunity to help your community and to obtain valuable experience. The Department of Consumer Affairs, Division of Investigation, and Health Quality Investigation Unit is seeking well-qualified individuals to be a Medical Consultant for the Fresno Field Office. Are you interested in being an integral part of the Medical Board of California enforcement process? Do you have the ability to conduct interviews, exercise sound judgment in reviewing conflicting medical reports and preparing opinions, analyzing problems, and taking appropriate action? Interested individuals must submit an application for examination. Visit jobs.ca.gov/JOBSGEN/5CACC.PDF for additional information and instructions. If you have any questions please contact Herbert Boro, MD, F.A.C.P. with the Health Quality

Spring 2018


Investigation Unit in Fresno at (559) 447-3045 or by email at herbert.boro@mbc.ca.gov.

Family/ General Practice Physician Needed A multi-disciplinary organization is looking for a FP/ GP/DO/Medical Director for our Fresno medical office. Candidates must have an active CA license. As a member of our team you will enjoy a Monday-Friday workweek, no weekends, late nights, or hospital calls. Part time and full time available!! Benefits include 401K, health, dental and vision insurance. Great-pay, potentialto bonus by performance criteria and protocol. 100% employer paid malpractice. For immediate consideration please submit your CV by email to matt@firsthealthmedical.com or by fax to (559) 435-3462.

California Correctional Health Care Services is seeking 2-3 IM/FP Primary Care Physicians. Up to $327,540 annually plus $50-$60K w/OnCall - can be $380-$390K! Benefits include: 4-day workweek; 10 patients per day; generous paid time off; State of CA Pension that vests in 5 years; plus 401(K) and 457 retirement options – tax defer up to $48K; and much more! Contact Danny Richardson, Hiring Analyst, at (916) 691-3155 or danny.richardson@cdcr.ca.gov. EOE.

Physician Job Description - Specialty: Internal Medicine / Family Medicine- NonOB, Out-patient only - Active CA license, Active DEA, American Board Certified, Current ACLS - Schedule: Mon-Fri (8am-4pm), 10-15 scheduled daily appointments - Compensation: $16,000/mo., Must pass credentialing process - Central California (near Bakersfield, CA) CONTACT: Patricia Spiro, CEO Forensic Expert Services 559-904-5522

Spring 2018

FOR SUBLEASE

Class A Medical Office Space, approximately 1500 square feet. 1781 East Fir Avenue, Suite 102, available 7/1. Rent: $2250 plus security deposit. Contact Robert at (559) 800-7476 or administration@cvphysiatry.com.

Premiere medical office space for sublet.

The entire facility is 5000 square feet with modern aesthetic furnishings. Can include access to accredited ambulatory surgical facility with ability to perform procedures under general anesthesia or sedation as part of an office-based procedure. There are 4 exam rooms and nursing station, well suited for ophthalmology, gynecology, dermatology, plastic surgery or ENT practices. Support staff can be provided on request. Please inquire at 559 797-9000 or email hedi@wpsfresno.com.

If you would like to submit a listing to our Classifieds, contact swoods@fmms.org. Listings are free for members with reasonable rates for nonmembers.

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The Value

of

ADVOCACY Dear Health Care Professional,

This report details the California Medical Association’s (CMA) efforts, on your behalf, to increase practice profitability and save physician practices from bad bills. This year CMA has successfully:

PREVENTED RAISES IN YOUR OPERATIONAL COSTS DECREASED YOUR PROFESSIONAL LIABILITY BLOCKED ATTEMPTS TO SADDLE YOU WITH MORE ADMINISTRATIVE BURDENS INCREASED ACCESS TO CARE FOR YOUR PATIENTS

CMA is one of the most influential stakeholders in the development and implementation of health policy. Our past, present and future success is rooted in one principle: California’s physicians are stronger when we stand together. With over 80 years of combined experience in Sacramento politics, our team is constantly monitoring legislative threats to the practice of medicine, and working to ensure that bad bills don’t become bad medicine. The bills in this report were introduced last year, the first of a two-year legislative session. This means they could possibly move forward or get re-introduced this year. CMA will continue to keep you engaged and informed on these important matters that could have a profound impact on your practice.

To join this fight and stay informed on issues critical to the practice of medicine, please contact us at (800) 786-4262. You can also receive regular updates by subscribing to our free biweekly Newswire at www.cmanet.org/newsletters. 42

CENTRAL VALLEY PHYSICIANS

Spring 2018


ADVOCACY

Prevented Administrative Burdens, Lowered Operational Costs and Increased Profitability

Recent studies have suggested that physicians spend twice as much time completing administrative tasks as they do seeing patients. This is unacceptable and negatively affects delivery of care. CMA aims to

lessen or streamline the administrative requirements placed on physicians so they can spend more time with patients, which improves health outcomes, increases access and increases practice profitability.

AB 40 (Santiago): CURES database: health information technology system Obtained amendments to remove the Department of Justice’s ability to influence the electronic health record (EHR) vendor market by establishing a narrow vendor list of EHRs allowed to interface with the Controlled Substance Utilization Review and Evaluation System (CURES), and unilaterality dictating the terms of being able to interface. AB 120 (Ting): Proposition 56 tobacco tax funds Appropriates Proposition 56 funds to the Department of Health Care Services (DHCS) and contains language allocating over $700 million ($325 million plus the federal match) in funding to physicians. Additional provisional language states that provider payments may be adjusted up to $800 million in the 2018-19 fiscal year. The bill was signed by the Governor in June as part of the Budget Act of 2017. AB 221 (Gray): Workers’ compensation Defeated this workers’ compensation legislation that would have broadly limited payments to physicians for treatment provided to workers suffering from occupational cumulative trauma injuries. AB 387 (Thurmond): Minimum wage: health professionals: interns For the purposes of paying minimum wage, AB 387 expanded the definition of employer. CMA obtained amendments to mitigate the impact of the bill on physician practices by excluding all practices. The bill was ultimately defeated in the Assembly. AB 700 (Jones-Sawyer): Public health: alcoholism or drug abuse recovery Stopped this measure that would have required physicians

Spring 2018

who provide substance use disorder services to get certified by DHCS, in addition to their medical license, to provide these services in programs authorized by DHCS.

AB 715 (Wood): Workgroup review of opioid pain reliever use and abuse Worked with the author to avoid the creation of duplicative opioid prescribing guidelines, which could have created further confusion and complication around prescribing for chronic pain, narrowing the bill to create a guideline focused exclusively on acute prescribing. AB 1250 (Jones-Sawyer): Counties: contracts for personal services Obtained amendments that exempt physician services from newly proposed stringent requirements for a county and a third party to enter into a contract to provide government services. AB 1250 was defeated in the Senate. AB 1312 (Gonzalez Fletcher): Sexual assault victims: rights Obtained amendments to remove a requirement that physicians provide sexual assault victims information about the investigation process, evidentiary process and the rights of victims under criminal laws. AB 1316 (Quirk): Public health: childhood lead poisoning: prevention Obtained amendments to remove mandatory universal lead screening for all young children.

SB 43 (Hill): Antimicrobial-resistant infection: reporting Obtained amendments to remove a proposed new requirement to list antimicrobial-resistant infections as a cause of death on a person’s death certificate.

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SB 189 (Bradford): Workers’ compensation fix Effective July 1, 2018, all owners of medical corporations will be able to exempt themselves from workers’ compensation coverage, regardless of percentage ownership, as long as they submit a waiver and have health insurance coverage. This will result in thousands of dollars in premium savings for physician practices. SB 199 (Hernandez): The California Health Care Cost, Quality and Equity Atlas Defeated this measure that would have created additional administrative reporting requirements on physician practices. SB 419 (Portantino): Medical practice: pain management Defeated this measure that would have legislated the practice of medicine by preventing physicians’ ability to appropriately prescribe pain relief medications.

SB 636 (Bradford): Addiction treatment: advertising: payment Stopped this measure that would have created an additional disciplinary process for physicians providing substance use disorder treatment in DHCS-certified programs. SB 640 (Hertzberg): Sales tax on services Obtained an exemption for health care services in this proposed services tax legislation. SB 790 (McGuire): Health care providers: gifts and benefits Defeated this measure that would have unfairly curtailed what expenses a pharmaceutical company could provide a physician, including all those expenses connected to educational seminars, research and events.

Decreased Liability Allowing physicians to practice without worrying about the threat of a frivolous lawsuit is one of CMA’s core tenets. We work to ensure that the trial lawyers’ efforts to increase malpractice liability are beaten back, and we oppose any effort to increase malpractice premiums. Additionally, we advocate to protect physicians from exposure to new areas of liability.

AB 334 (Cooper): Sexual assault/forensic medical exams Obtained amendments to remove provisions that would have increased physician liability by allowing forensic medical exams on unconscious patients without the patient’s consent. AB 859 (Eggman): Elders and dependent adults: abuse or neglect Obtained amendments that exempt physicians from a proposed lowering of the standard of review in elder abuse cases from “clear and convincing” to a “preponderance of the evidence” if the court found that a defendant intentionally destroyed evidence. The bill was vetoed by the Governor.

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CENTRAL VALLEY PHYSICIANS

AB 889 (Stone): Secrecy agreements Defeated this measure that would have prevented certain confidentiality agreements from being enforced if keeping the information secret presented a “public health hazard” or “environmental danger.” CMA was concerned about how this law would affect medical malpractice settlement agreements. AB 1422 (Daly): Workers’ compensation insurance: fraud Obtained amendments to ensure due process protections for workers’ compensation physicians facing certain types of fraud accusations.

Spring 2018


ADVOCACY

SB 33 (Dodd): Arbitration agreements Obtained amendments to exempt physician arbitration agreements from a new consumer protection that invalidates arbitration clauses in contracts upon a showing of fraud.

SB 349 (Lara): Chronic dialysis clinics: staffing requirements Obtained amendments to remove liability for medical directors of chronic dialysis clinics related to the proposed staffing requirements.

SB 219 (Wiener): Long-term care facilities: right of residents Obtained amendments to ensure that physician liability would not be increased for those practicing in long-term care facility settings acting in the best medical interests of their patients.

SB 617 (Bradford): Workers’ compensation Stopped workers’ compensation legislation that would have required outreach reports to physicians without sufficient privacy protections.

Access to Care and the Physician-Patient Relationship

CMA defends and advocates to improve physicians’ ability to negotiate fair contracts with payors. Protecting the economic viability of physician practices ensures that physicians are financially

capable of providing service for patients and protects access to care. Additionally, CMA advocates to protect patient privacy, recognizing that it is an essential component of quality medical care and the patient-physician relationship.

AB 595 (Wood): Health care service plans: mergers and acquisitions Obtained amendments to ensure that the Department of Managed Health Care and the Department of Insurance, for any health care service plan merger, consider the impact on physicians’ ability to secure competitive contracts and patient access to care prior to approving the mergers. SB 350 (Galgiani): Incarcerated persons: health records Obtained amendments ensuring consistency in medical information privacy laws to limit confusion on when medical information and records can be disclosed. The bill was ultimately defeated in the Senate.

Spring 2018

SB 538 (Monning): Hospital contracts Defeated this measure that allowed health plans and health insurers to eliminate the Provider’s Bill of Rights, which helps guard a physician’s ability to negotiate fair and reasonable contracts and break up integrated health care systems.

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Public Health

Update

The WIC Public Health Model: Low-Income Women, Infants, and Children

Public Health Problem • Higher rates of low and very low birthweight babies • Higher rates of stunted growth and development of children •Higher rates of infant mortality • Lower breastfeeding rates

Behavioral and Environmental Risk Factors

Public Health Program • Nutrition education

• Inadequate intake of nutritious food • Inability to afford nutritionally adequate food • L ack of nutrition and health education and support

• Breastfeeding education and support • Health care and social services referral services • Nutritious food prescription (package)

Short-term Outcomes

Long-term Outcomes

• Improved nutritional intake/diets

• Decreased rates of anemia

• Increased health knowledge, especially about nutrition and breastfeeding

• Reduced risk for pre-term, low birthweight, and very low birth-weight babies

• Increased use of health care and social services

• Reduced infant mortality rates

• L ack of regular access to health care and social services

• Adequate physical growth and cognitive development • Increased breastfeeding rates • Reduced risk for child abuse and neglect • Reduced long-term health care costs

WIC Nutrition Program Contributes to a Healthy Start Kimberly Smith, RD, CLE, WIC Program Coordinator Karen Furst, MD, MPH, Interim Health Officer San Joaquin County Public Health Services The human cost and financial burden resulting from poor birth outcomes begins at delivery and often carries over into adulthood. According to the San Joaquin County 2016 Community Health Needs Assessment (CHNA) Data Book 1, the incidence of preterm births, low and very low birth weights, as well as infant mortality exceeded the state benchmark. Data revealed 10% of infants born in the County in 2011 were preterm (<37 weeks gestation), 7% low birth weight, 1.3% very low birth weight, and 5.8 infants per 1,000 births did not reach their first birthday. Infants born early or low birth weight are more likely to experience cognitive and developmental delays as well as struggle with disabilities during childhood in addition to facing higher risks of chronic disease as adults.

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CENTRAL VALLEY PHYSICIANS

Spring 2018


Causes of preterm birth may be multi-factorial making prevention challenging. According to the Centers for Disease Control and Prevention, factors may include being a teen or woman over age 35, of the black race, low income, under stress, and a smoker or substance user. Though pregnancy is often anticipated as a joyous time in life, any one or more of these factors can affect the outcome. Women may therefore require additional support beyond their trusted and valued physician, family, and friends to assist in mitigating the possibility of poor birth outcomes. The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) provides targeted support for moderate to low income women who are pregnant or recently had a baby, in addition to infants and children up to age five who are at nutritional risk. The effectiveness of WIC in improving birth outcomes is well documented. In a recent study conducted by the California Department of Public Health (CDPH)1, scientists found WIC participation was associated with reductions in the risk of premature birth by 29 to 48%, low birth weight by 23 to 36%, and perinatal death by 22 to 31%. Women were less likely to experience adverse birth outcomes specifically beginning in the third trimester compared to women eligible but not on the program. The impact of WIC participation was significant and greater near delivery suggesting a cumulative effect. WIC Services The WIC program provides screening for a variety of risk factors such as inadequate growth, excessive weight gain, iron deficiency anemia, and high lead levels. The program promotes regular medical care including immunizations and links participants with community resources, and encourages utilization of adjunct services like CalFresh to help stretch food dollars and reduce the risk of food insecurity. WIC also works with retailers in low-income neighborhoods towards becoming WIC authorized vendors by stocking more fruits, vegetables, and whole grains.

Program where moms receive support via phone or in-person. To ease access, WIC clinics are available throughout the county. WIC eligibility is based on California residency and income according to family size. For example, families with two individuals (including unborn baby) qualify with an annual income of $30,044. California applicants automatically qualify if they receive Medi-Cal, CalFresh or Temporary Aid to Needy Families (TANF). San Joaquin County provides WIC services to approximately 26,000 residents; however, many more qualify who are not being identified and referred. Data collected by CDPH in March 2016 revealed over 6,000 infants and children were WIC eligible in our County, yet not on the program. This is a statewide issue. Data from the CDPH 2010-2012 California Maternal and Infant Health Assessment Survey2 found that many women did not apply during pregnancy because 40% assumed they would not qualify and 35% did not think they needed WIC. The Physician’s Role A woman’s trusted practitioner learning of her pregnancy or when caring for her infant or children presents an excellent opportunity to provide information about WIC, either directly or through an office staff member knowledgeable of our services. Fathers, grandparents, legal guardians, and foster parents are also welcome to apply on behalf of an infant or child under age five. A referral is not necessary. Physicians need only to encourage their patients to call (209) 468-3280 for an appointment. At that first appointment, WIC staff will help to determine eligibility and enroll patients so they can start taking advantage of the benefits of this cost-effective, family-centered program designed to help families thrive. For more information on the WIC program, please call: (209) 468-3280. Harder + Company Community Research. (2016). San Joaquin County 2016 Community Health Needs Assessment, Data Book, published online November 4, 2016. Available from: www.sjcphs.org/Disease/Epidemiology.aspx. 1

Nutrition education is central to the program. Registered Dietitians work with participants at higher risk such as women with gestational diabetes, preterm and low birth weight infants, and overweight children. Nutrition Assistants encourage and support healthy habits of lower risk participants. WIC promotes breastfeeding, and their International Board Certified Lactation Consultants provide hands-on breastfeeding assistance. WIC agencies may also offer a Breastfeeding Peer Counseling

Spring 2018

Carlson, Steven, Neuberger, Zoe. WIC Works: Addressing the Nutrition and Health Needs of LowIncome Families for 40 Years. Center on Budget and Policy Priorities, published online March 29, 2017. Available from:www.cbpp.org/research/food-assistance/wic-works-addressing-the-nutrition-and-healthneeds-of-low-income-families 2

Making Connections: Understanding Women’s Reasons for Not Enrolling in WIC during Pregnancy, California 2010-2012. Sacramento: California Department of Public Health, Center for Family Health; 2016. Available from: www.cdph.ca.gov/Programs/CFH/DMCAH/MIHA/CDPH Document Library/MIHA-MakingConnections-2010-2012.pdf.1 3

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47


AB2640:

California healthcare providers need to be aware of and fully compliant with the legal requirements of Californiaâ&#x20AC;&#x2122;s AB2640, signed into law in September,

Are You Prepared for

2016. I had no idea that I was required

Compliant HIV Testing?

their HIV tests came back negative.

After the results of a test performed pursuant to this section have been received, the medical care provider or the person who administers the test shall ensure that the patient receives timely information and counseling, as appropriate, to explain the results and the implications for the patientâ&#x20AC;&#x2122;s health. If the patient tests positive for HIV infection, the medical provider or the person who administers the test shall inform the patient that there are numerous treatment options available and identify follow-up testing and care that may be recommended, including contact information for medical and psychological services. If the patient tests negative for HIV infection and is determined to be at high risk for HIV infection by the medical provider or person administering the test, the medical provider or the person who administers the test shall advise the patient of the need for periodic retesting, explain the limitations of current testing

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CENTRAL VALLEY PHYSICIANS

to further educate my patients when

technology and the current window period for verification of results, and provide information about methods that prevent or reduce the risk of contracting HIV, including, but not limited to, preexposure prophylaxis and postexposure prophylaxis, consistent with guidance of the federal Centers for Disease Control and Prevention, and may offer prevention counseling or a referral to prevention counseling. These requirements are intended to reduce the incidence of HIV positivity by ensuring that all HIV positive patients have access to treatment, and that HIV negative patients are educated on prevention options. Advances in treatment of HIV have made it possible to prevent transmission. The Center for Disease Control (CDC) recently recognized that a person living with HIV who is on antiretroviral therapy and has an undetectable viral load has essentially no risk of transmission of HIV with sexual activity. That makes it vital that patients have

Spring 2018


These requirements are intended to reduce the incidence of HIV positivity by ensuring that all HIV positive patients have access to treatment, and that HIV negative patients are educated on prevention options. access to testing, education, and medications in order Pediatrics, Visalia Medical Clinic to achieve maximal medication compliance. Healthcare President, PFLAG Tulare & Kings Counties providers need to be able to knowledgeably discuss Board Member, The Source LGBT+ Center harm reduction in sexual activity and be able to prescribe medications for post-exposure prophylaxis (PEP) and pre-exposure prophylaxis (PrEP). Not all patients are candidate for PEP or PrEP. To learn more, check out the excellent free CME archived webinars on HIV, AIDS, PEP and PrEP available to all healthcare to build a providers at the National LGBT powerful business Health Education Center at the Fenway Institute in Boston at www. lgbthealtheducation.org or go to www.pleaseprepme.org, which has provider and patient information Considering a commercial loan? as well as a PrEP finder to locate Choose the right bank to join your team. At Central Valley providers who will prescribe PrEP. Community Bank, we’re just the right amount of both big and small – the strong lending power of a big bank together with the There is no one in Tulare County values and relationships of a community bank. We’re local too – signed up to prescribe PrEP! and know the marketplace and what is right for you and your medical practice. Further information on prevention of HIV and AIDS is Whether you want to expand, start a new product line, modernize or hire new employees, sit down with our expert lenders today and available online from the CDC, find out why so many of our satisfied customers refer us to friends Planned Parenthood, and at https:// and colleagues. www.womenshealth.gov/hiv-andGet to know the most trusted, safe and secure business partners in aids/hiv-prevention. The Source the region. LGBT+ Center in Visalia also has information for patients and providers on HIV prevention and is able to provide trainings. The Source is located at 208 W. Main St. in Visalia, downstairs in Suite B, open from 3 to 6 pm Tuesday through Friday, also online at Investing In Business Relationships. www.thesourcelgbt.org, and by phone at 559-429-4277. www.cvcb.com • (559) 298-1775 Proudly serving the San Joaquin Valley and Greater Sacramento Kathryn Hall, M.D., F.A.A.P.

BORROW OUR

STRENGTH

Spring 2018

CENTRAL VALLEY PHYSICIANS

49


The California Medical Association and the Fresno Madera Medical Society

MONTHLY PAYMENT PLAN

TOGETHER, WE ARE STRONGER. Itâ&#x20AC;&#x2122;s through a strong membership foundation that CMA remains a dominant force in health care, leading the charge on several fronts, including the following: Continuously defending the Medical Injury Compensation Reform Act (MICRA) Advocating for specialty scope of practice that protects patients Leading public health efforts, including decreasing youth smoking and passing a landmark immunization law Other benefits of membership include professional, personal and practice resources, which commonly offset the price of dues. Learn more at www.cmanet.org/groupdiscounts.

90

JOIN TODAY FOR ONLY

$

/ MONTH

When you join the California Medical Association and your local county medical society, you join more than 43,000 members statewide who are actively protecting the practice of medicine and defending public health. Together, we are stronger.

JOIN TODAY TO START RECEIVING YOUR BENEFITS! COMPLETE THE APPLICATION ON THE BACK AND FAX OR MAIL TO: FAX:

(916) 596-1128

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California Medical Association, 1201 J Street, Suite 275, Sacramento, CA 95814

OR SIGN UP AT: WEB:

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PHONE: (800) 786-4262 This payment plan is available for individual, full dues membership. 50

CENTRAL VALLEY PHYSICIANS

Spring 2018


Funding For

medical

professionals

by those who understand

the industry Credit lines and loans, tailored to the medical industry, with rates starting as low as *6% and 24-hour underwriting. Need funding? Ask us about our options and services by contacting Dr. Mark Scoffield: mark@vettedfunding.com | 559-281-4699 | WWW.VETTEDFUNDING.COM Vetted Partners is a nontraditional consulting company focused on the funding and strategic growth of businesses. *for eligible applicants Spring 2018

CENTRAL VALLEY PHYSICIANS

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Good news for anyone who can’t stand waiting When you’re injured or ill, a month can seem like an eternity to wait for an appointment. Fortunately, we offer same- or next-day appointments, extended hours and a range of services to address your needs. Need a physical? We’ll get you one within the week. It’s primary care on your schedule – available right here in Fresno and Clovis. Call (559) 450-7267 to schedule an appointment with a physician at one of our Saint Agnes Care sites.

And for those unexpected illnesses and accidents that happen after-hours and on weekends, we offer urgent care When you’re confident you’ve chosen the right at two convenient locations. hospital for your maternity care, you’re free to think of just For about anything. It’s why so many more information, visit samc.com/urgent-care. women choose Saint Agnes Medical Center. Along with all-private rooms, we partner with more convenient. Medical care has never been Valley Children’s Healthcare to give you and your baby access to a Level III NICU and one of the top maternal fetal medicine programs around. ®

Visit www.samc.com to learn how peace of mind is just one of the many things we deliver.

Saint Agnes Care

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CENTRAL VALLEY PHYSICIANS

Saint Agnes Care locations to meet your primary care needs: Avecinia 2006 Shaw Ave., Clovis 93611 LQMG 1221 E. Spruce Ave., Fresno 93720 Northwest 4770 W. Herndon Ave., Fresno 93722 Surinder P. Dhillon Internal Medicine 6079 N. Fresno Street, Ste. 101, Fresno 93710

Saint Agnes Urgent Care (559) 450-CARE (2273) Northwest 4770 W. Herndon Ave., Fresno 93722 Main Campus 1245 E. Herndon Ave., Fresno 93720 Most insurance plans accepted

Spring 2018

Central Valley Physicians Spring 2018  
Central Valley Physicians Spring 2018  
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