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Official Magazine of FRESNO COUNTY Fresno-Madera Medical Society KERN COUNTY Kern County Medical Society KINGS COUNTY Kings County Medical Society MADERA COUNTY Fresno-Madera Medical Society TULARE COUNTY Tulare County Medical Society

See Inside: Letters to the Editor CMA: Exchange Plans Now Riskier Health Reform

August 2012sVol. 34 No. 8

Vital Signs

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



For 35 years, the Cooperative of American Physicians, Inc. (CAP) has provided California’s finest physicians, like internal medicine specialist James Strebig, MD, with superior medical professional liability protection through its Mutual Protection Trust (MPT). Physician owned and physician governed, CAP rewards excellence with remarkably low rates on medical professional liability coverage – up to 40 percent less than our competitors.


CAP members also enjoy a number of other valuable benefits, including comprehensive risk management programs, best-in-class legal defense, and a 24-hour CAP Cares physician hotline. And MPT is the nation’s only physician-owned medical professional liability provider rated A+ (Superior) by A.M. Best. We invite you to join the nearly 12,000 preferred California physicians already enjoying the benefits of CAP membership.

Superior Physicians. Superior Protection.


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

Contents CMA NEWS Exchange Plans Now Riskier Propositions for Physicians ...........................................................7 CMA Economic Services Webinars ...........................................................................................8 CMA 2012 Education Series: Coding for Medical Necessity .......................................................9 NEWS

August 2012 Vol. 34 – Number 8

LETTERS TO THE EDITOR.........................................................................................................5

Editor, Prahalad Jajodia, MD Managing Editor, Carol Rau

AIR QUALITY: Support for Clean Energy: Solar.........................................................................13

HEALTH REFORM: California to Continue Reform Efforts Following Ruling..................................11

Fresno-Madera Medical Society Editorial Committee Virgil M. Airola, MD John T. Bonner, MD Hemant Dhingra, MD David N. Hadden, MD Roydon Steinke, MD Kings Representative TBD Kern Representative John L. Digges, MD Tulare Representative Gail Locke

CLASSIFIEDS ...........................................................................................................................18 FRESNO-MADERA MEDICAL SOCIETY .......................................................................................13 • President’s Message • Medical Managers Forum • Educational Program Offered: Differential Diagnosis of Pulmonary Nodules, August 22 • In Memoriam: Cooper Collins, MD • 2012 Educatdional Series for FMMS members KERN COUNTY MEDICAL SOCIETY ............................................................................................15 • Nominations Now Being Accepted for KCMS Outstanding Contribution Awards • Membership Recap TULARE COUNTY MEDICAL SOCIETY.........................................................................................16 • Executive Director’s Message • Save the Date September 23: Tulare County Medical Society 2012 Family Day

Vital Signs Subscriptions Subscriptions to Vital Signs are $24 per year. Payment is due in advance. Make checks payable to the Fresno-Madera Medical Society. To subscribe, mail your check and subscription request to: Vital Signs, Fresno-Madera Medical Society, PO Box 28337, Fresno, CA 937298337.

Cover photography: “Sunflowers” by Newton Seiden, MD

Advertising Contact: Display: Annette Paxton, 559-454-9331

Calling all photographers: Please consider submitting one of your photographs for publication in Vital Signs. – Editorial Committee

Classified: Carol Rau, 559-224-4224, ext. 118

Vital Signs is published monthly by Fresno-Madera Medical Society. Editorials and opinion pieces accepted for publication do not necessarily reflect the opinion of the Medical Society. All medical societies require authors to disclose any significant conflicts of interest in the text and/or footnotes of submitted materials. Questions regarding content should be directed to 559-224-4224, ext. 118. V I TA L S I G N S / A U G U S T 2 0 1 2



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Dear Editor: This letter is in response to Dr. Stillwater’s editorial in July’s edition of Vital Signs. I strongly object to the negative tone of the article, and to its one-sided arguments. I am pleased Dr. Stillwater is in favor of clean air and clean water. But when he goes Don H. on to characterize the greenhouse effect and Gaede, MD man-made global warming as “junk science and socialist propaganda,” he only serves to anger and alienate physicians (like myself) who are convinced otherwise. His arguments in favor of other issues regarding the carrying of concealed handguns and cigar smoking are also unbalanced. These issues may all be all good topics for discussion, but the first page of our medical societies’ newsletter is not the place. To promote better health for our patients, we physicians need to work together as much as possible. Let’s remember to show respect for those of differing opinions. – Don H. Gaede MD ••• Dear Editor: The July lead editorial in Vital Signs implied global warming and the contribution of human activity are a hoax, there is a safe level of tobacco use, and wider public possession of firearms will increase public security. There is a fine print disclaimer (page 3) that editorials Alex are not necessarily the opinion of the Sherriffs, MD component medical societies. Understanding that Vital Signs is how members of the public may first come to know us and how potential members of our component societies may come to understand us, I think much bolder disclaimers are called for. We use the best available science in the interest of our patients and the public’s health. My experience with patients suggests they expect us to be proactive on their behalf. The data supporting the concept of global climate change driven by human activity becomes only stronger and stronger, and the data which suggest adverse health consequences also grows. Of course there are some who believe otherwise, and of course no modeling is exact. But the preponderance of evidence pushes in one direction. If you doubt the science, follow the money: a July 7 Bakersfield Californian editorial reminds us the reinsurers are convinced, and scrambling to deal with the predicted adverse and extreme weather events. The preponderance of evidence for the adverse effects of tobacco use has no counter-balancing body of evidence for a safe level of use. The data on adverse effects of second-hand smoke grows, as does evidence for adverse consequences even when smokers conscientiously smoke outdoors. I heartily congratulate my 2 pack per day patient who is down to 1-2 cigarettes per day, but I continue to encourage complete abstinence. I anxiously read about criminal violence, but I also have seen the statistics suggesting as a gun owner, I am far more likely to harm myself or a loved one with that firearm than I am to thwart a violent criminal. These three topics are important issues in our patients’ lives and in the public health arena. There is much to discuss and learn.

JAMA has devoted whole issues to the latter two. The lead editorial of our house organ should represent our best selves: scientific, proactive, and engaged in the challenging realities of our times. – Alex Sherriffs, MD Past President, FMMS ••• Dear Editor: The editorial by Dr. Stillwater (July 2012) has disturbed me on several fronts, especially in regards to global warming. I disagree with his assessment that man-made global warming is a “hoax.” Ninety-seven percent of climate Sergio D. scientists agree that global warming does exist, Ilic, MD is unequivocal, continues to increase and is due primarily to human activity such as the use of fossil fuels, deforestation and others. From 1906 to 2005 the average temperature on earth rose 0.74 degrees C. The main culprit is not CO2, which accounts for 9% to 26% of it, but water vapor accumulation, 30% to 70%, by methane 4% to 9% and by others. Since 1750, the concentrations of CO2 have increased 36% and of methane 148% and 75% of the CO2 increase is due to the use of fossil fuels by human activity and 25% by mostly deforestation. Since 1880, the 11 warmest years have been between 2001 and 2011. The trend is clearly on the upswing, but short term fluctuations can mask the trend (2007 for example, according to the author). Ice cores studies show that these levels are the highest in the last 800,000 years. This is not difficult to understand since the earth’s population has been increasing steadily and is now over 6 billion people. The economic improvement of large numbers of this population over the last 25 to 50 years (the fall of the Soviet Empire, the opening of China, India, etc.) makes this easily understandable, as they are using more fossil fuels as a result. The sun is believed not to have a very important effect on global warming as its activity has been steady during the years 2005 to 2010, while warming has continued. This has produced the permafrost to thaw, the ice polar caps to decrease, the level of the seas to increase, storms to become more violent and destructive, areas of drought more extensive and more importantly, an accelerated rate of ocean acidification, which in turn will lead to the extinction of many species. Studies show the rate of acidification is greater than in the last 300 million years, etc. There is a tremendous amount of bibliography that supports global warming, and I can make it available upon request. It is not too late to try to curb gas emissions. I don’t have to convince many of you, but to the ones that don’t believe in global warming, I ask you to think about if you are wrong, and 30 or 50 years from now we have environmental problems that are not solvable, and civilizations on earth ceases to exist as we know them today. I believe it is better to make some adjustments now when we can, and prevent nightmarish scenarios that can happen in the future. Global warming doesn’t have physical limits, doesn’t have boundaries; it will affect all of us whether we like it or not. We are starting to see the effects. Think about it. – Sergio D. Ilic, MD V I TA L S I G N S / A U G U S T 2 0 1 2



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CMA NEWS Exchange Plans Now Riskier Propositions for Physicians James T. Hay, MD President, California Medical Association


Following the U.S. Supreme Court ruling, it is clear that Californians can still expect many changes in health care delivery and insurance coverage. The ruling to uphold the Affordable Care Act (ACA), specifically the individual mandate provision, guarantees insurance coverage for most of the uninsured patients in California. It has been the California Medical Association’s goal for decades to achieve universal health insurance coverage. Despite this monumental step forward, there is tremendous work to be done to ensure appropriate implementation here in California. Moreover, there are many problems with the law that need to be fixed to make the ACA work. CMA has long advocated for affordable access to care for California’s uninsured and for an expansion of health insurance coverage. However, as physicians, we know that insurance coverage alone does not mean access to doctors. Throughout the federal health care reform debate, your CMA advocated for meaningful changes to the health care delivery system that build on what works, while fixing only what is broken. In addition to supporting the individual mandate, CMA has also fought for the protection of the physician-patient relationship from third-party interference, for meaningful reforms to the for-profit health insurance industry, and for sufficient resources to deliver on the promise of improved access to doctors. CMA has also supported eliminating egregious health insurance cancellation practices, pre-existing condition exclusions from coverage, lifetime or annual limits on benefits, and excessive insurer profit and administrative costs. These reforms will ensure that patients are not denied health insurance based on what illnesses they have, but rather will help to guarantee coverage for all. While the individual mandate is essential to making coverage affordable for all, these insurance industry reforms are also critical to making the ACA work. The ACA also made important investments in primary care, primary care training, rural health care, medical homes, public health and prevention, funding research on the effectiveness of different treatments, and increased payment rates, albeit temporary for primary care physicians and related subspecialties in Medicare and Medi-Cal. However, the legislation has left several serious problems unresolved, most specifically the underfunding of Medicare and Medicaid. For a decade, California physicians have been calling on Congress to eliminate the flawed Medicare Sustainable Growth Rate (SGR) fee-for-service payment formula and adopt a long-term path to an alternative payment system that recognizes the real drivers of health care costs. That issue was not addressed in the ACA, and physicians are now facing a 32 percent cut in payment rates for Medicare patients at the end of this year. The Medicare Advantage rates are being cut as well.

Many physicians will not be able to sustain such cuts and remain in the Medicare program, which would have grave negative impacts on Medicare seniors as well as private patients. CMA and our partners in this fight will continue to work with Congress to find a long-term solution that addresses this serious threat. CMA worked to eliminate the SGR and increase Medicaid reimbursement rates, but unfortunately nothing was done in the final bill to fix the grossly inadequate Medi-Cal (California’s Medicaid program) payment rates that leave many patients without physicians. This severe underfunding must be addressed, as nearly three million new patients will enroll in Medi-Cal under the ACA. California is leading the way for the Medicaid expansion across the country, but in order to succeed, we must look at the reimbursement structure of the program here in our home state. The ACA does increase reimbursement rates for primary care physicians (and related subspecialties) who see Medi-Cal up to Medicare payment levels, but only through 2014. While this is a significant step in the right direction, CMA will be advocating to extend the increase well beyond 2014. CMA was also strongly opposed to the ACA’s creation of an unaccountable Independent Medicare Payment Advisory Board (IPAB), which will mandate arbitrary spending cuts, force more physicians out of the program and limit seniors’ treatment options even further. The IPAB removes Congress’s accountability to voters, including to physicians and seniors, for the Medicare program by simply mandating physician payment cuts if Medicare spending exceeds congressionally set health care spending limits. There have been a number of questions about the Medicaid expansion part of the court’s ruling. The ACA allows an expansion of Medicaid and would make additional Medicaid funds available to states that comply with the expansion. For states that do not comply with the expansion requirement, the ACA intended to impose the penalty of withdrawing all Medicaid matching funds, including funding for current participation levels. The court found that the penalty portion of the Medicaid expansion provision is unconstitutional, but that the provisions of the ACA that expand Medicaid are otherwise valid. Therefore, it is up to the states to decide whether to expand Medicaid – the federal government cannot withhold federal matching funds if states do not comply. This Medicaid ruling will not affect California, because the state has said they will continue to move full steam ahead in implementing the ACA. As your CMA President, I understand that the ACA and the Supreme Court ruling are controversial among California physicians. However, there is deep support among the large majority of you for the individual mandate and universal health insurance coverage. I want to assure you that CMA is firmly committed to advocating for improvements and reforms to the ACA that will ensure everyone can actually see a doctor when Please see CMA News on page 18 V I TA L S I G N S / A U G U S T 2 0 1 2



Economic Services Webinars Aug. 8: CMA and the Courts/ Accessing CMA’s Legal Library – 12:15-1:15 pm Learn about CMA’s role in important litigation in California and nationwide, and learn how to navigate CMA’s health law library. The Legal hotline staff will provide an overview of the wide array of topics covered CMA’s online library. Aug. 15: Program Integrity in Medicare and Medi-Cal – The Physician’s Role – 12:15-1:15 pm This session provides physicians with information about the risks of becoming a victim of fraud and how to take preventive action. It also covers compliance with Medicare and MediCal documentation requirements. Aug. 16: California Workers’ Comp eBill Part 1: Are You Ready? – 12:15-1:30 pm Part 1 of an extended three-part California eBill Webinar Educational Series. This webinar will provide you with an overview of what eBill is, how it works, and the benefits and tools to help you evaluate your practice’s eBill readiness. Aug. 23: California Workers’ Comp eBill Part 2: Implementation – 12:15-1:30 pm Part 2 of an extended three-part California eBill Webinar Educational Series. This webinar will provide an overview of the eBill compliance requirements and focus on electronic claims and attachment submission requirements including acknowledgement transactions. Aug. 30: California Workers’ Comp eBill Part 3: Understanding Remittance Advice Rules – 12:15-1:30 pm Part 3 of an extended three-part California eBill Webinar Educational Series. This session will provide an overview of the eBill electronic remittance advice rules and how to use these rule as a tool to help automate your back office workflow processes. UPCOMING: Sept. 5: A Guide to Reviewing Payor Contracts – Kris Marck – 12:15-1:15 pm Sept. 6: California Workers' Comp eBill Part 4: First-Time Submission Jopari Solutions/CA Workers’ Comp • 12:15-1:45 p.m.

Sept. 19: Creating and Implementing Financial and Office Policies Debra Phairas • 12:15-1:15 p.m.

Oct. 3: Protect Your Practice From Payor Abuse Mark Lane • 12:15-1:15 p.m.


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

Coding for Medical Necessity With Arthur Lurvey, MD, Palme!o GBA

Palmetto GBA®



Wednesday, August 1 12:15-1:15 pm CMA hosted webinars are FREE as a benefit of your CMA Membership. *Nonmembers are invited to join this webinar for $99*

What A!endees Can Expect to Learn: Medicare and private payers all recognize medical necessity as a deciding factor for claims payment and it is important that all prac"ces know the rules. We will discuss applying the rules to your pa"ent encounters, medical decision making and medical necessity, the importance of diagnosis coding, coverage determina"on policies, using an electronic health record, how to respond to requests for records, and how to appeal if you disagree with decisions from outside reviewers. To register for this or any CMA webinar, please visit **CMA is pleased to provide 1 PMI CEU credit for medical office staff.** This webinar is being hosted by the California Medical Associaon. You must register at least one hour prior to the event. Once your registraon has been approved, you will be sent an email confirmaon with details on how to join the webinar. Quesons? Call the CMA Member Help Line at (800) 786-4262.

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How Successful Is Your Practice? Let physician members know your practice is available for referrals Use Vital Signs to advertise your practice at special rates offered to member physicians. contact: Annette Paxton Vital Signs Advertising Representative (559) 454-9331


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California to Continue Reform Efforts Following Ruling Exchange, said the state is “moving fullspeed ahead” to establish the exchange and will launch a “major media and outreach campaign” in 2013 (“Capitol Alert,” Sacramento Bee, 6/28).

Reprinted with permission from California Healthline

Following the U.S. Supreme Court’s ruling to uphold the federal health reform law, California officials said the state will continue implementing the law’s provisions, the Sacramento Bee’s “Capitol Alert” reports (Siders, “Capitol Alert,” Sacramento Bee, 6/28). Ruling Details In a 5-4 ruling the Supreme Court upheld the federal health reform law’s individual mandate, reaffirming the law’s requirement that most U.S. residents must purchase health insurance. The majority of the justices also affirmed the constitutionality of the Medicaid expansion provision in the law, which would require states to extend coverage to adults with incomes up to 133% of the federal poverty level beginning in 2014. However, the justices struck down the provision that would have allowed the federal government to withhold existing Medicaid funding if the states failed to comply with the expansion. Details of Reform Efforts in California Since President Obama signed the reform law two years ago, California lawmakers have passed several state laws related to the overhaul, including measures that: • Allow young adults to remain on their parents’ health insurance plans until age 26; • Block insurers from setting lifetime caps on health benefits; • Establish a state health insurance exchange, called the California Health Benefit Exchange; and • Prohibit insurers from denying health coverage to children with pre-existing conditions (California Healthline, 6/28). State officials estimate that about two million residents, many of whom are uninsured, will obtain insurance through the exchange beginning in 2014 (“Capitol Alert,” Sacramento Bee, 6/28). In addition, 47 California counties are participating in the “Bridge to Reform” program, which aims to implement the reform law’s Medicaid expansion ahead of schedule. The program provides low-income residents with health coverage that they can use for no-cost treatments at local hospitals and public clinics. More than 360,000 Californians already are receiving coverage through the program (California Healthline, 6/25). According to “Capitol Alert,” the state is expected to receive $45 billion to $55 billion from the federal government from 2014 to 2019 to expand Medi-Cal, California’s Medicaid program. Officials expect that an additional 1.2 million to 1.6 million state residents will gain health insurance coverage under the expansion. State Officials Expect More Progress on Health Reform Diana Dooley – California’s Health and Human Services Secretary – said, “California has been a leader in health care reform for a very long time. We’ve had many starts and stops, and we are now in the full go mode here” (“Capitol Alert,” Sacramento Bee, 6/28). Peter Lee, executive director of the California Health Benefit

Officials, Stakeholders Urge Caution However, some state officials believe California should be cautious with health reform efforts. Sen. Tom Harman (R-Huntington Beach) said that lawmakers should not enact any reforms that go beyond the federal overhaul because a recent budget plan signed by Brown reduces state spending by hundreds of millions of dollars (Santa Cruz Sentinel, 6/28). In addition, James Hay, president of the California Medical Association, said that while physicians support reform efforts, more must be done to address shortcomings in Medicare and Medi-Cal. He said that the reform law “builds... on the broken foundations of Medicare and Medicaid without addressing the underlying problems and inadequate funding.” Meanwhile, Patrick Johnston – president and CEO of the California Association of Health Plans – said the state must focus on addressing the “underlying cost drivers that are increasing the cost of care” (Herdt, Ventura County Star, 6/28). Read more: officials-california-to-continue-reform-efforts-followingruling.aspx#ixzz2092h4f00



tax measures have officially qualified for the November ballot, the Sacramento Bee reports. The tax ballot measures include: • A compromise tax hike plan – developed by Gov. Jerry Brown (D) and supporters of the “Millionaires Tax;” • A tax increase proposal by attorney Molly Munger; and • A tax initiative by hedge fund manager Tom Steyer (Yamamura, Sacramento Bee, 6/21). Details of Compromise Tax Hike Plan The compromise tax hike plan would: • Increase the personal income tax by one percentage point for individuals who earn $250,000 annually or couples who earn $500,000 annually and by two percentage points for individuals who earn $300,000 annually or couples who earn $600,000 annually; • Extend the income tax increases on wealthy residents from five to seven years; and • Increase the sales tax by a quarter of a cent. The sales tax hike would expire in four years and would raise an estimated $9 billion over the next fiscal year (California Healthline, 6/11). The compromise tax hike measure has been incorporated into a fiscal year 2012-2013 budget plan currently being negotiated by Brown and Democratic legislators (California Healthline, 6/19). Please see November Ballot on page 18 V I TA L S I G N S / A U G U S T 2 0 1 2



Support for Clean Energy: Solar Tom Cotter Regional Sales Manager, Real Goods Solar

Summertime is a great time to relish in the things that are OhSo-All-American. You know, like baseball, fireworks, picnics, celebrating our independence, waving the American flag and flocking to the beach. This summer in particular is a great time to be an American. Soon enough we’ll be rooting on our favorite American Olympic athletes. As Americans, we take pride in the great traditions that make us who we are. We care about our country and now more than ever, we seem to be caring more about our country’s resources. In true American form, most of us will be cranking our air conditioners this summer, especially here in the Central Valley. I’m guessing, though, that most of this energy will not be generated through a clean energy source.


Americans are quite concerned about energy and there are numbers to prove it, according to the recent results of a survey released June 7 by the Associated Press – NORC Center for Public Affairs Research. In fact, 78 percent of people surveyed, a majority of whom were homeowners, said that the issue of energy is important to them. Many believe that the nation’s energy problems are a result of Americans not supporting clean energy sources like wind and solar. This survey makes me wonder. Is there really not enough support for clean energy sources? I think when you get right down to it most people are in support of clean energy. I’ve never seen protestors with signs screaming “Dirty Energy Now” or “Down with a Clean Environment.” Perhaps the problem instead is that there simply are so many myths circulating about clean energy sources that your average American, my neighbor and yours, don’t even give them a second thought.


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I work in the energy industry – solar to be specific – so I’ve heard nearly every urban legend about clean energy that’s been passed along, kind of like a bad game of telephone. You’ve probably heard them, too. At the risk of perpetuating them, I’ll list a few myths about solar here: Solar is too expensive; You shouldn’t go solar if you’re planning to move; Solar panels will increase property taxes and home insurance rates. I could go on, but these myths are like nails on a chalkboard to me and they are all just that – myths. The fact of the matter is that a clean energy source like solar is within nearly every homeowner’s reach. There are many programs in the solar industry that help people install solar panels on their homes with next to nothing down. According to the Department of Energy, solar panels actually help homes sell faster – a good thing in today’s saturated real estate market if you ask me. In most states, solar panels also are exempt from property taxes, unlike other improvements like energy-draining pools. These myths must be contributing to our energy crisis. Seventy-seven percent of respondents said they believe doing more to save energy will help save money in the long run. What else would keep them from actually taking the steps necessary to save energy and to save money? Sixty-nine percent of respondents said they wanted to save money on energy costs, while 56 percent wanted to make sure their homes were energy efficient. So why aren’t they taking the steps to save energy? Misinformation is the answer. From purple mountains majesty to amber waves of grain, most Americans want to do what’s right for the environment. Even more so, they want to make ends meet for their families. Both causes are important and necessary, but they are not mutually exclusive of the other.

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

President’s Message

1040 E. Herndon Ave #101 Fresno, CA 93720


Well, we have a decision. The Affordable Care Act (ACA) was upheld by the Supreme Court on Thursday June 28, 2012. This decision has the country and the doctors divided. I also have mix feelings about the whole reform. Let’s examine what I see as positive and negative about the law. First of all, there’s the mandate for all of us to have insurance. I feel this is needed if reform is to work. Without it, there is not a large enough base to cover everyone. Remember, in the 90’s Washington state passed a law that required the insurance companies to insure everyone regardless of their health condition, along with a mandate for everyone to purchase insurance. A couple of years later, the mandate was repealed. A few years after the repeal, health insurance companies stopped selling policies in the state. So the mandate is absolutely necessary for reform to work. I believe it’s good that young people up to age 26 can stay on their parent’s policy, and insurance companies cannot deny coverage for preexisting conditions, cannot terminate your policy if you have a major or catastrophic event and limits increasing premiums due to age. It’s also good that the insured don’t have a co pay for preventive health care visits, and the doughnut hole payments that seniors frequently incur, will close. But most important, reform will provide a mechanism for up to 49 million uninsured Americans to get coverage through expansion of Medicaid to cover people up to 133% of the poverty line, amongst other things. Now, what I don’t like about the ACA. There are many things, but the most important is that there is no adequate funding to pay for all these people that will be seeking medical care. Medicaid payment rates are very low and do not cover the expenses of seeing that patient in a private office. The fees to the different providers need to go up. (In addition, don’t forget that because of the SGR system, we are due to have a 32% payment cut in Medicare the first of the year). Furthermore, will there be enough providers to take care of all these newly insured people? Especially here in the Valley, we already have a shortage of PCP’s and to a lesser extent of specialists. But this certainly is not an excuse to leave people without insurance. We are already hearing that the legislature wants to empower NPs and PAs to be able to do more by enlarging their scope of practice. And then we have the ACO’s (Accountable Care Organizations). Basically, these are large groups being formed that include hospitals, doctors, health insurance companies and patients. There are major problems I foresee with an ACO. Who is going to control it, and how will the pool of money be divided? Who or what group of doctors will be asked to join? How are the excluded doctors going to survive financially speaking, and what is going to happen to doctors that over utilize the system? Are they going to be penalized, kicked out or be obligated to practice medicine according to certain guidelines etc.? For example, we all know that a joint replacement ideally should be performed in patients that are over 65 years old. But what about the athlete or the trauma patient that develops severe OA at an earlier age? Will that patient have to wait 10 years to have it done? Remember the idea behind reform is to lower the cost of medical care, which overall is approaching 17% of the GNP and make it affordable for everyone. It seems to me that the two goals are incompatible unless we go into a national health care system in which all the doctors are on a salary, and there is no financial incentive to provide services. Medical care would be rationed, making patients wait an inordinate amount of time before they receive non-emergency care. Socialized medical care is not necessarily better. It has multiple inherent problems, and I personally do not agree that is the best approach or solution. The ACA provides no provisions to deal with the malpractice crisis affecting many states that have increased medical costs because of doctors practicing defensive medicine. I don’t like the creation of an Independent Medicare Payment Advisory Board (IPAB) which is unaccountable and will have the power to mandate spending cuts, limit treatment options and force physicians out of the program if they are noncompliant with guidelines. I feel the law intends well. There are good parts to it but it needs a lot of tweaking and improving. The American people should be explained to very clearly what the implications are and the unintended consequences of the law. Perhaps after that there should be a national dialog about how to proceed.

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

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COOPER COLLINS, MD 61-year member


Attention: FMMS PHYSICIANS Make sure your Medical Manager and/or Medical Office Staff is a part of the Medical Society’s

MEDICAL MANAGER’S FORUM NETWORK GROUP The FMMS Medical Managers Forum provides resources, education and networking opportunities designed to enhance the knowledge of office staff related to ever-changing issues impacting practice management, human resources, billing and coding, etc.

Collins, MD, a retired general surgeon, passed away May 22, 2012 at the age of 93. Dr. Collins was born in Long Beach in 1918. He received his medical degree from Stanford University School of Medicine in 1944, completed his internship at the U.S. Navy Veterans Hospital in San Francisco and residency at St. Francis Hospital in San Francisco. After WWII, Dr. Collins established his medical practice in Fresno. He served as president of the Fresno-Madera Medical Society in 1965 and retired in 2006. Dr. Collins is survived by three children, three grandchildren, six step children and ten step-grandchildren.

2012 Educational Series for FMMS Members As a member benefit, a series of Financial Education seminars

Office staff may register by providing: Name, Title/Position, Physician’s Office, Email Address, Telephone To sign them up, all it takes is a current and active email address! Contact SHERYL TATARIAN 559.224.4224x112

Educational Program Offered: Differential Diagnosis of Pulmonary Nodules Evaluate and order appropriate diagnostic work-ups for early detection and diagnosis of pulmonary nodules and know when to refer Michael Peterson, MD Chief of Medicine, UCSF Fresno Pulmonary Disease and Critical Care 1 hr, CME credit Wednesday, August 22, 2012 • 6-7:30 pm FMMS offices 1040 E. Herndon Ave. #101 RSVP to: 559-224-4224, ext. 118 or


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will be repeated to FMMS members and their guests during the months of August, September, October and November. In order to allow members attendance flexibility, the seminars will be repeated twice each month – the last Wednesday and Thursday evenings at 6 pm. August 29 & 30, 2012: “Investment Basics” presented by Eric Van Valkenburg, CLU, CHFC and Amy NuttallZwaan, CRPC, CSNA, Financial Consultants with Central Valley Physician Benefits. Presentation will include: • Investment fundamentals, effects of inflation and compounding • Understanding risk tolerance • The relationship between risk and reward • Understanding different types of investments and the advantages and disadvantages of each • Developing an investment strategy and allocation of investments in line with your objectives • Challenges facing investors today Seminars will be held at the Medical Society offices, 1040 E. Herndon Ave. #101. (NE corner of First/Herndon) Space is limited, so please reserve your spot as soon as possible by contacting the Medical Society at 559-224-4224, ext. 118 or at A light meal will be available. Future topics: • September 26 & 27, 2012: Estate Planning Basics • October 24 & 25, 2012: Financial Planning Basics • November 28 & 29, 2012: Understanding Society Security Benefits Eric Van Valkenburg and Amy Nuttall-Zwaan are Registered Representatives with and securities offered through LPL Financial. Member FINRA/SIPC.


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

KCMS Officers Joel R. Cohen, MD President Wilbur Suesberry, MD President-elect Noel Del Mundo, MD Secretary Ronald L. Morton, MD Treasurer Portia S. Choi, MD Immediate Past President Board of Directors Alpha Anders, MD Brad Anderson, MD Eric Boren, MD Lawrence Cosner, MD John Digges, MD J. Michael Hewitt, MD Calvin Kubo, MD Melissa Larsen, MD Mark Nystrom, MD Edward Taylor, MD CMA Delegates: Jennifer Abraham, MD Eric Boren, MD John Digges, MD Ronald Morton, MD

Kings Nominations Now Being Accepted for KCMS Outstanding Contribution Awards KCMS is seeking nominations for its Outstanding Contribution Award(s) to be presented at the Award’s Banquet Dinner this Fall. The Award categories are as follows: • Outstanding Contribution to the Medical Society – Presented to a KCMS Member who has exhibited tireless dedication and service to the Medical Society. • Outstanding Contribution to the Community – Presented to a KCMS Member who has participated in one or more community activities and/or whose work has benefited the community. • Outstanding Contribution to Medicine – Presented to a KCMS Member who has donated his/her services and efforts towards the advancement of medicine. When submitting your nomination, please attach a brief description for your selection. Nominations Are accepted via email at or by fax 661-3289372). Deadline for submission is Friday, August 10, 2012.

PO Box 1029 Hanford, CA 93230 559-582-0310 Fax 559-582-3581 KCMS Officers Theresa P. Poindexter, MD President Jeffrey W. Csiszar, MD President-elect Mario Deguchi, MD Secretary Treasurer Mario Deguchi, MD Past President Board of Directors Bradley Beard, MD James E. Dean, MD Laura Howard, MD Ying-Chien Lee, MD Bo Lundy, MD Michael MacLein, MD Kenny Mai, MD CMA Delegates: Jeffrey W. Csiszar, MD Thomas S. Enloe, Jr., MD Theresa P. Poindexter, MD CMA Alternate Delegates: Laura L. Howard, MD Staff: Marilyn Rush Executive Secretary

Membership Recap JUNE 2012

CMA Alternate Delegates: Lawrence Cosner, Jr., MD Patrick Leung, MD Michelle Quiogue, MD Staff: Sandi Palumbo, Executive Director Kathy L. Hughes Membership Secretary

Active ..........................................................................................246 Resident Active Members...............................................................2 Active/65+/1-20hr...........................................................................5 Active/Hship/1/2 Hship ..................................................................0 Government Employed ...................................................................7 Multiple memberships .....................................................................1 Retired ...........................................................................................61 Total............................................................................................322 New members, pending dues...........................................................0 New members, pending application................................................0 Total Members ...........................................................................322

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

Executive Director’s Message WE WILL MISS YOU GAIL


TCMS Officers Gaurang Pandya, MD President Steve Cantrell, MD President-elect Thomas Gray, MD Secretary/Treasurer Steve Carstens, DO Immediate Past President Board of Directors Virinder Bhardwaj, MD Carlos Dominguez, MD Parul Gupta, MD Monica Manga, MD Christopher Rodarte, MD H. Charles Wolf, MD CMA Delegates: Thomas Daglish, MD Roger Haley, MD John Hipskind, MD CMA Alternate Delegates: Robert Allen, MD Ralph Kingsford, MD Mark Tetz, MD

A little more than four years ago the Tulare County Medical Society and Foundation for Medical Care Boards of Directors decided to co-fund a position focused on helping physicians traverse the myriad of day-to-day operational issues they routinely faced. They believed that if there was a point person that was a single point of contact for physicians and their office staff to contact and have prompt and accurate response, hassle would be reduced. Gail Locke expressed interest in the concept and became our first Physician’s Advocate. Gail worked tirelessly to expand her knowledge and avail herself to the local physicians. Their problems became her concern and she reached out to experts at the California Medical Association, American Medical Association and educated herself on the issues and responded with accurate information in friendly and helpful manner. She quickly became a resource that countless physicians relied upon and accessed. Under Gail’s leadership, the educational seminars offered locally grew in attendance and relevance. Often it was necessary to offer multiple sessions of a seminar because the sign-ups exceeded the capacity of the meeting space. Our annual holiday event grew from 100 attendees to close to two hundred in recent years. Gail’s attention to detail and desire to the event memorable made it a night everyone appreciated. Unfortunately, Gail will be moving to Chicago with her spouse, Steve. Steve accepted a promotion from his employer. As CEO, I have been blessed with many talented staff members. Gail stands tall as one who excelled in their job. Her shoes will be hard to fill as she set the bar incredibly high. On behalf of local organized medicine, thank you Gail and good luck in your future endeavors.

Sixth District CMA Trustee James Foxe, MD Sixth District CMA Alternate Thomas Daglish, MD

SAVE THE DATE! Tulare County Medical Society

Staff: Steve M. Beargeon Executive Director

“Family Day 2012”

Francine Hipskind Provider Relations

at Adventure Park, Visalia

Gail Locke Physician Advocate

Sunday, September 23 11 am-3 pm

Thelma Yeary Executive Assistant

Buffet lunch Bumper Boats Miniature Golf Family Race Track Arcade Games and Laser Tag, too!

Please Plan to Join Us! (Invitations will be mailed soon)


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

MEDICAL OFFICES FOR LEASE 2701 16th St. – 2,400 2031 17th Street – 1,776 sf. 4817 Centennial Plaza Way – 2,370 rsf. Crown Pointe Phase II – 2,000-9,277 rsf. 3115 Latte Lane – 5,637 rsf. 3115 Latte Lane – 2,660-2,925 sf. Meridian Professional Center – 1,740-9,260 rsf. 2204 “Q” Street – 2,894 rsf. 3941 San Dimas Street – 3,959 rsf. 4040 San Dimas St. – 2,035 rsf. 9300 Stockdale Hwy. – 3,743 - 5,378 rsf. 9330 Stockdale Hwy. – 1,500-7,700 rsf. SUB-LEASE 4100 Truxtun Ave. – Can Be Split Medical Records & Offices Sprinklered – 4,764 usf. Adm. & Billing – 6,613 rsf. FOR SALE Crown Pointe Phase II – 2,000-9,277 rsf. Meridian Professional Center – 1,740-9,260 rsf. 9900 Stockdale Hwy. – 2,000-6,000 rsf.

Professional/Medical Office for Lease Cambridge Court

Classifieds MEMBERS: 3 months/3 lines* free; thereafter $20 for 30 words. NON-MEMBERS: First month/3 lines* $50; Second month/3 lines* $40; Third month/3 lines* $30. *Three lines are approximately 40 to 45 characters per line. Additional words are $1 per word. Contact the Society’s Public Affairs Department, 559-224-4224, Ext. 118.





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


Naeem Akhtar, MD, Ambreen Khurshid, MD and Mikhail Alper, PA-C at California Associates are Gastroenterology pleased to welcome Carlos C. Hernandez, MD to their practice. For appts. Call 559299-9395 Christine Lopopolo, MD announces her boutique obstetrics and gynecology practice in Fresno. Accepting new patients. Call 559-261-9320. University Psychiatry Clinic: A sliding fee scale clinic operated by the UCSF Fresno Dept. of Psychiatry at CRMC M-F 8am-5 pm. Call 559-320-0580.



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

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

FOR SALE Cardiology practice in Bakersfield closing Sept. 15. All office furnishing, supplies and equipment for sale. Call for specifics and arrangement: 661-323-5976.

PHYSICIAN/PROVIDED WANTED FT opening for MD in busy practice in Visalia. Offering full benefit package and more. Contact Rhonda: 559-627-2333 or

6335 N. Fresno Street, Fresno

NEWLY REMODELED 1,200 sq.ft. office with five exam rooms

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

Carl Abercrombie 559-227-4658 c: 559-970-9035 Jim Abercrombie 530-626-0321 18

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CMA News

November Ballot

Continued from page 7

Continued from page 11

they become ill or injured. We will be aggressive in pursuing appropriate payment reforms so that you can sustain your practice. We will continue to be vigilant in fighting to protect us and our patients from any government or private insurance intrusion into the doctorpatient relationship. CMA will keep you updated on ACA implementation issues, such as the state Health Benefit Exchange and health care delivery innovations, and their impact on our practices. Physician involvement in its implementation is crucial to a successful health care system.

Details of Munger’s Tax Hike Proposal Munger’s tax hike proposal, called “Our Children, Our Future,” aims to raise income tax for all residents, with highest earners seeing the largest hike. Most of the revenue would support education programs (California Healthline, 6/11). Details of Steyer’s Plan Steyer’s plan would raise about $1 billion annually by changing California’s corporate tax formula (Sacramento Bee, 6/21). About half of the funds would go to California’s general fund (Adler, “KXJZ News,” Capital Public Radio, 6/20). Read more: articles/2012/6/21/three-competing-taxm e a s u r e s - q u a l i f y - f o r- n o v e m b e rballot.aspx#ixzz2096QtWvP

Let us help find d the right Long-T Term er erm Care insuran plan for you, so you can spend time me on things that tha matter the most. People are living longer ger these daays, ys, but as life expectancies increase, so does the risk of serious health problems that could require re long-term care. In fact, at retirement age, g , 70% % of Americans will need long-term g g-term care and 40% w enter a nursing g homee.1 And with the avverage cost for or nursing home care in a ould literally

Long-Term Care Resources FMMS, KCMS and TCMS are pleased that members have access to an interactive and educational LongTerm Care evaluation tool to help you make the best decisions for your specific situation. To learn more, visit:

cost most or all of your life’s savings.2 Long-T Term Care insurance may not be for everyone. But with soaring healthcare costs, insurance restrictions and the need eed to stretch retirement savings through more years . . . it’s a good idea to seriously consider this valuable coverage while receiving a member premium discount.

To learn more about how FM M S, KC M S and TC M S members can help protect their assets from the rising cost of long-term care, call us or go online today.

Call 800.616.8759 800.616.8759 or visit 1

Department of Health and Human Services, National Clearinghouse for Long-T ng-TTerm erm Care Information, October 2008, www Genworth 2010 Cost of Care Survey urvey, April 2010, ent/genworth/us/en/products/lon The Long-TTerm erm Care Resources Network is only available for residents of thee United States. Coverage may vary v or may not be available in a 2

CA Ins. Lic. #0633005, AR Ins. Lic. #245544, 44, d/b/a in CA Seabury Sea & Smith Insurance Program Manage 58458 (8/12) ©Seabury & Smith, Inc. 2012 4PVUI'JHVFSPB4USFFU -PT"OHFMFT $"tt$."$PVOUZ*OTVSBODF!NBSTIDPNt

PRSRT STD U.S. Postage PAID Fresno, CA Permit No. 30

VITAL SIGNS Post Office Box 28337 Fresno, California 93729-8337






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

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

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

CALL 11-800-652-1051 -800-652-1051 OR OR VI VISIT SIT NORCALMUTUAL.COM NORCALMUTUAL.COM Pr oud to be endorsed by the Fr esno-Madera Medical Society and Proud Fresno-Madera the Kern, Kern, Kings and Tular Tulare County Medical Societies Tulare

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Vital Signs August 2012  

VS FINAL for August 2012 Vol.34 No.8

Vital Signs August 2012  

VS FINAL for August 2012 Vol.34 No.8