Page 1

Official Magazine of FRESNO COUNTY Fresno-Madera F resno-Madera Medical Society KERN COUNTY K ern County Medical Society Kern KINGS COUNTY Kings County Medical Society MADERA COUNTY F resno-Madera Medical Society Fresno-Madera TULARE COUNTY T ulare County Medical Society Tulare

June 2013 • Vol. 35 No. 6

Vital Signs

Se See ee e Inside: ns siide: de e:: He Health ealth alltth h Ca Care arre e Refor Re Reform effo orm rm Heats He ea ats ts s Up p Le Legal eg ga al TTips al iip ps s Ab About bo ou utt Patient P attiie a entt Di ent Dismissal is sm missal is ss sal all New ew HIPAA HIP IPA PAA P AA A Regulations Re eg gu ulations attiio on ns s Workshop W or ork rks sho sh op p Offered fffe erred ed d

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.


J U N E 2 0 1 3 / V I TA L S I G N S

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

Contents CMA NEWS ................................................................................................................................7 NEWS Health Reform Heats Up .........................................................................................................5 CHAT WITH THE EDITOR: Legal Tips About Patient Dismissal .....................................................9 WHAT’S NEW: Orthopedics ....................................................................................................11

May 2013 Vol. 35 – Number 5 Editor, Bonna Rogers-Neufeld, MD Managing Editor, Carol Rau Fresno-Madera Medical Society Editorial Committee Virgil M. Airola, MD John T. Bonner, MD Hemant Dhingra, MD David N. Hadden, MD Roydon Steinke, MD

BLOOD CENTER: Golf Tournament: September 9 .....................................................................11 AIR QUALITY: Growing Healthy in Fresno County ......................................................................12 CLASSIFIEDS ...........................................................................................................................18 FRESNO-MADERA MEDICAL SOCIETY .......................................................................................13 • President’s Message • New HIPAA Regulation Medical Manager Forum Network and Physician Presentation: June 13 • Walk With A Doc Dates Released • In Memoriam: L. Bruce Ellis, MD

Kings Representative TBD Kern Representative John L. Digges, MD Tulare Representative Thelma Yeary

• Save the Date: FMMS Family Picnic – June 29 KERN COUNTY MEDICAL SOCIETY ............................................................................................16 • President’s Message • KCMS Member Recognition: Michelle Quiogue, MD TULARE COUNTY MEDICAL SOCIETY.........................................................................................17 • 39th Annual Legislative Leadership Conference Review • Wine Social is a Hit • ICD-10 Workshop: September 19

Vital Signs Subscriptions Subscriptions to Vital Signs are $24 per year. Payment is due in advance. Make checks payable to the Fresno-Madera Medical Society. To subscribe, mail your check and subscription request to: Vital Signs, Fresno-Madera Medical Society, PO Box 28337, Fresno, CA 937298337. Advertising Contact: Display: Annette Paxton, 559-454-9331 Classified: Carol Rau, 559-224-4224, ext. 118

Cover photography: “Butterfly and Bee Sharing Nectar” by Michael DeLollis, MD Equipment used: Panasonic Lumix DMC-FZ40 at maximum zoom, automatic setting Calling all photographers: Please consider submitting one of your photographs for publication in Vital Signs. – Editorial Committee Vital Signs is published monthly by Fresno-Madera Medical Society. Editorials and opinion pieces accepted for publication do not necessarily reflect the opinion of the Medical Society. All medical societies require authors to disclose any significant conflicts of interest in the text and/or footnotes of submitted materials. Questions regarding content should be directed to 559-224-4224, ext. 118. V I TA L S I G N S / J U N E 2 0 1 3


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


J U N E 2 0 1 3 / V I TA L S I G N S


Health Reform Heats Up James Noonan, CMA Staff Writer

More than three years have passed since the Affordable Care Act (ACA) was voted into law, setting into motion some of the most dynamic and volatile years the nation’s health care industry has ever seen. Since its inception, the law has been a subject of controversy, inspiring hotly contested debates in Washington, D.C., Sacramento and across the entire nation. For some, this dramatic overhaul of the nation’s health care system represents our national leaders finally making good on the long-overdue promise of “health care for all.” Others claim that the law is a clear overreach of federal authority that threatens to overburden an already fragile economy. Although the law remains controversial, the United States Supreme Court has ruled that the law is constitutional, and active steps are being taken to move forward at the federal and state levels. With many of the provisions set to take effect on January 1, 2014, state officials across the nation are scrambling to make sure they’re ready to implement the law’s sweeping changes. The road has already been a somewhat rocky one. Throughout the implementation process, the U.S. Department of Health and Human Services has been narrowly meeting its own deadlines, often times leaving states waiting for federal guidance that could dramatically alter their own implementation plans. With several major deadlines coming in the next few months, many observers expect this problem to only get worse. Adding to the headache for the federal government is the fact that the ACA has received mixed support from the states, which has complicated implementation efforts nationwide. As of early February, only 19 states had elected to develop their own state-run “exchange,” an online marketplace where consumers can purchase subsidized coverage. An additional five states will form statefederal partnerships to operate their marketplaces, while the remaining states have declined to participate, meaning the federal government will be responsible for operating exchanges in those areas. Despite these problems, the march toward reform continues on. THE NEXT MAJOR MILESTONE The next major milestone toward full implementation is set to take place on October 1, 2013, when state exchanges are set to begin their pre-enrollment. In the first years following these marketplaces going live, more than 32 million currently uninsured Americans are expected to gain coverage, either through an exchange plan or the ACA’s massive expansion of the Medicaid program. Some analysts expect as many as 5 million of these newly insured to come from California. Three months after the pre-enrollment begins, January 1, 2014, exchanges are set to go live, meaning that millions of Americans will, for the first time, be able to purchase coverage using the federal subsidies promised in the ACA. In order to navigate this massive undertaking, states will need to decide which plans will be offered through their exchanges, construct the actual online marketplaces through which

consumers will purchase coverage and implement major public outreach campaigns to ensure that these citizens – many of whom have never had the benefit of “open enrollment” or a similar purchasing period – understand how and where they can sign up for coverage under the reform law.

CALIFORNIA LEADS THE WAY Despite the uncertainty swirling around the ACA’s implementation, California looks to be on track to meet the coming deadlines. In the days following the ACA’s passage, California was the first state to establish a health benefit exchange and has been working toward implementation ever since. That exchange, named Covered California, has already launched its online consumer marketplace, and is one of 25 states that have gained conditional approval from the federal government to operate its own insurance marketplace. There is, however, still much work to be done at the state level. Unlike most other states, California opted to adopt an “active purchaser” model when building its new exchange, meaning Covered California’s Board of Directors will be responsible for selecting which insurance providers will be allowed to offer products on the exchanges. The selected products, known as qualified health plans (QHPs), will be required to meet a set of benefit standards finalized by the Covered California board late last year. The QHPs will be selected through a competitive bidding process set to begin in the coming months, and it’s anticipated that somewhere between three to five QHPs will be selected for each one of California’s 19 geographical rating regions.

PROTECTING PHYSICIAN INTERESTS Unfortunately several recent decisions by the exchange board have placed California’s physician community on its heels. The California Medical Association (CMA) has been an active participant in stakeholder hearings and is working to ensure that the interests of physicians and their patients are taken into consideration as the exchange prepares to open for business. Several issues of concern arose when the board was working to finalize the benefit standards that interested payors will be required to meet in order to have their products considered for the QHP designation. One major concern for physicians is how the exchange plans to deal with monitoring and ensuring network adequacy among of QHPs. Throughout the benefit design conversation, exchange staff continued to favor the existing method of network monitoring, which calls for the Department of Managed Health Care (DMHC) and Department of Insurance (DOI) to be responsible for ensuring that plans offered to consumers have enough participating providers. In other words, the status quo. Several stakeholders, including CMA, have noted that those two entities are currently unable to ensure adequate networks among existing plans and would likely be overwhelmed by the added task of monitoring Please see Health Care Reform on page 6 V I TA L S I G N S / J U N E 2 0 1 3


HEALTH CARE REFORM Continued from page 5

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

George L. Strasser 5260 North Palm Avenue Fresno, CA 93704 559 432-5400


J U N E 2 0 1 3 / V I TA L S I G N S

additional exchange products. While CMA asked that the exchange take an active role in monitoring networks beginning in 2014, the DMHC/DOI method remained in the final benefit standards adopted by Covered California’s Board of Directors in August, meaning it could become the norm once the state’s marketplace goes live. CMA also voiced concern over the exchange’s handling of the “grace period” provision included in the ACA. Under current California law, patients who are delinquent on their premiums are allowed a full 90 days to settle up before their policy is terminated for nonpayment. However, under the ACA’s grace period provisions, exchange plans will be allowed to suspend payment for services rendered if an enrollee is more than one-month delinquent. If the patient fails to settle up within the threemonth grace period, the plan can then terminate coverage for nonpayment and deny all pending claims for services. In this scenario, physicians could potentially be on the hook for 60 days worth of services with no avenue for recourse. CMA has repeatedly asked Covered California’s board to reconcile the state and federal policy, but to date an adequate fix has not been presented. Given the exchange’s accelerated timeline, as well as the exchange board’s tendency to revisit issues that were previously thought to be decided, it remains possible that both of these matters, along with others that have caused concern to physicians, could see some sort of resolution before 2014. To be sure, the next few months will be some of the most important and tumultuous times the medical community has faced in recent memory, but as a CMA member you have the comfort of knowing that your interests are being advocated for in front of all the key players driving the nation’s reform efforts. For information on the implementation of health reform in California, subscribe to CMA Reform Essentials. This newsletter, available to both members and nonmembers, covers the activities of the state’s health benefit exchange board and legislation significant to California’s ongoing reform efforts. Subscribe today at


California’s trial attorneys have launched an all-out assault on California’s historic tort reform law, which since 1975 has helped keep malpractice premiums in-check and ensured that California’s patients have access to affordable health care. On Wednesday, May 2, 2013, a coalition – including the Consumer Attorneys of California and the trial lawyer-funded Consumer Watchdog group – announced intentions to seek to overturn California’s landmark Medical Injury Compensation Reform Act (MICRA) through a ballot initiative. The group has until September to submit a proposed initiative to qualify for the November 2014 general election ballot. If successful, the trial attorney’s efforts will cause malpractice rates to skyrocket, and recreate the same conditions that threatened to throw California’s health care system into crisis during the early 1970s. Prior to MICRA, out-of-control medical liability costs were forcing community clinics, health centers, physicians and other health care providers out of practice. California’s MICRA has been a national success story with broad public support and has safeguarded both patients and our health care delivery system for decades. Risky reforms like the ones being threatened by the trial lawyers would severely impede the state’s ability to provide health care to the poorest and most vulnerable patients. At a time when we are trying to implement federal health care reform and provide access to health care to all Californians, this is the worst possible overreach at the worst possible time. Physicians will be victorious in this fight, but in order to do so, CMA needs your help. DONATE: A fight of this magnitude will be extremely costly. The California Medical Association (CMA) is urging all physicians to consider a donation to CMA’s political action committee (CALPAC), which for the last 38 years has served as the first line of defense for California’s historic physician protections. JOIN: And if you are not already a member of CMA, consider joining today. By joining CMA, you will help to ensure that the voice of California physicians is heard loud and clear in the Capitol and beyond. Together, our unified voice can move mountains. SPEAK OUT: Sign-up to be a CMA Key Contact. As a Key Contact, we will provide you with all the tools you need to quickly and effectively deliver your message to legislators, from talking points to sample letters. CMA has some of the best lobbyists, lawyers and other advocates in the Capitol, but the most powerful weapon in advancing the cause of physicians and their patients is you. Hearing from a physician with experience from the frontlines of medicine can make all the difference for a legislator facing a complicated health care issue such as MICRA. DONATE, JOIN AND SIGN-UP TODAY For information on MICRA, visit PRESIDENT’S BUDGET ADDRESSES PHYSICIAN PAYMENT ISSUES

With the release of President Obama’s 2014 budget, the administration showed its support for repealing the Medicare sustainable growth rate (SGR). Not only does the budget build in the cost of repealing the SGR, it calls for “the continued development of scalable payment models” to promote affordable

quality care. The budget also eliminates the 2 percent Medicare sequestration cuts. Additionally, the budget gives the Independent Medicare Payment Advisory Board (IPAB) ability to trigger cuts sooner. IPAB, established by the Affordable Care Act (ACA), will mandate arbitrary spending cuts if Medicare spending exceeds certain targets. CMA has been lobbying long and hard for the board’s elimination and has offered other ways to control health care costs. This budget would allow the IPAB to make cuts to Medicare when spending hits GDP + 0.5 percent, versus the original ACA target of GDP + 1 percent. CMA sees this as a step backwards and supports bipartisan proposals to eliminate this unaccountable panel. However the congressional budget office estimates that the IPAB won’t likely be convened until 2020 because of the slower growth to Medicare spending in recent years. CMA also has concerns with other items in the budget including an $11 billion cut to indirect medical education payments to hospitals. Below is a summary of the proposed Medicare changes in the president’s budget: • Eliminates the 2 percent budget sequestration cuts to Medicare • Supports elimination of the SGR and development of a new payment system with a stable transition period. • Expands the data available to physicians to make medical decisions for patients • Requires wealthier Medicare beneficiaries to pay higher premiums, copayments and deductibles • Closes the Part D doughnut hole, and requires patients to pay more • Requires pharmaceutical manufacturers to pay higher rebates to low income beneficiaries • Establishes a 15 percent surcharge on MediGap supplemental insurance premiums to discourage overutilization • Cuts Indirect Medical Education payments to hospitals by $11 billion • Reduces Medicare payments to hospitals to cover bad debt • Allows IPAB cuts when Medicare spending hits GDP + 0.5 percent vs. the ACA target of GDP + 1 percent • Reduces reimbursement for physician-administered drugs from 106 percent to 103 percent of Average Sales Price • Allows physician self-referral if certain accountability standards are met



you haven’t started e-prescribing yet, the time is now. To avoid a 2 percent penalty on all Medicare Part B claims in 2014, physicians must by June 30, 2013, report e-prescribing activity using measure code G8553 with at least 10 fee schedule services between January 1 and June 30, 2013. This is true even for physicians who are already reporting through an electronic health record (EHR) system. Note: There is no incentive payment for eprescribing in 2014. June 30 is also the deadline to apply for an e-prescribing exemption for 2014, if you fall into one of the following hardship exemption categories: Please see CMA News on page 8 V I TA L S I G N S / J U N E 2 0 1 3


CMA NEWS Continued from page 7 • The physician is unable to electronically prescribe due to local, state or federal law or regulation; • The physician has or will prescribe fewer than 100 prescriptions for all patients during a 6-month reporting period (January 1-June 30, 2013) • The physician practices in a rural area without sufficient high-speed Internet access • The eligible professional practices in an area without sufficient available pharmacies for electronic prescribing CMA strongly recommends that physicians submit more than 10 claims during the reporting period to ensure the minimum threshold is met. Exemptions must be requested through the Quality Net Portal. Physicians may also avoid the penalty if they have demonstrated meaningful use of a certified EHR between January 1, 2012, and June 30, 2013, or have registered to participate in the EHR Incentive Program. For more information, see the CMA eprescribing guide, “Medicare Electronic Prescribing Overview: Payment Incentives and Payment Reductions.”


. . .

CRIMINAL DEFENSE PROFESSIONAL BOARD DISCIPLINE DEFENSE MEDICARE AND MEDI-CAL AUDIT AND FRAUD DEFENSE Former Deputy District Attorney Over 30 Years Experience Admitted in all California state and federal courts Telephone: (949) 336-2433; Cell: (949) 680-6332 4040 BARRANCA PARKWAY, SUITE 280 IRVINE, CALIFORNIA 92604


J U N E 2 0 1 3 / V I TA L S I G N S

CHAT WITH THE EDITOR The Editor of Vital Signs recently sat down with George Strasser, Esq. an experienced health care attorney who practices law at Baker, Manock, & Jensen. In an ongoing series, selected topics will be discussed. If you have a question that relates to health care law, please submit it to the Editor.

Legal Tips About Patient Dismissal Editor: What is the proper way to dismiss a patient from your practice? Mr Strasser: “Thou shalt not abandon thy patient.” It’s a commandment. We hear all the time about “firing” or “dismissing” or “getting rid of” or “terminating” a patient. But what a doctor must never do is “abandon” a patient. Abandonment happens when a patient does not receive necessary medical care from his or her doctor without an adequate justification. Even failing to arrange for adequate coverage when a doctor is out of town can be abandonment. Yes, there are legal ways to terminate (that is the preferred word) a patient, which I will describe. However, it is a mistake to ignore the human factor. Fortunately, patients are not as surprised as they once were at the idea of changing doctors. Many have had to change doctors before, perhaps when they switched jobs or HMO’s, or when their doctor retired or moved away. Some older patients will understand that it is time to switch to a geriatric specialist. On the other hand, some patients do not want to find the time to search for a new doctor, and some will be so overwhelmed by the idea that they won’t try, or they will give up after being put on hold over and over. These people will end up in the ER and they will give your name as their doctor. Some patients might see your effort to dismiss them as an act of discrimination, based on race, gender, sexual orientation, gender identity, color, religion, ancestry, national origin, disability, medical condition, genetic information, marital status, or some other type of invidious discrimination. Sometimes a physician will be designated as a patient’s primary care physician because of the way a managed care plan works. This topic can be quite complicated, and when a doctor wishes to terminate a patient who is part of a plan, the doctor should consult with the managed care company in question, as well as with his or her employer, malpractice carrier, and personal attorney. Broadly speaking, a doctor may terminate the physician/patient relationship by giving the patient written notice of the termination, including information about how to obtain the patient’s medical records, so long as the doctor gives the patient a reasonable amount of time for the patient to find substitute care. The peril lies in the individual circumstances, including the nature of the patient’s illnesses, the acuteness of a condition, the availability of substitute care, the status of the patient’s prescription medications, and the whether the patient can afford the care. Although form letters exist for terminating a physician/patient relationship, many organizations, including the California Medical Association, strongly advise that a physician consult with his or her malpractice carrier, because individual patient situations vary. No reason need be stated for terminating a patient. Yet often some problem has developed and the relationship is strained. A termination must be handled well, and the language of the written notice must be neutral in tone. If a physician has come to dislike a patient to the point of wishing to terminate the relationship, it can be difficult not only to exercise professional judgment when treating the patient, but when thinking through the best way to handle the termination. So get help. That is the bottom line. How much notice is adequate notice? There is no hard and fast answer. In a 2003 opinion (Scripps Clinic v. Superior Court), a court allowed a jury to consider whether a patient had been abandoned when there was a two-week period when the patient did not have access to any non-emergency care. That should tell you that the longer the notice, the better. Sometimes it is difficult to know if a patient has fired you. Just because a patient has not come to your office for a long time doesn’t mean that the patient doesn’t expect to receive care from you. Annual visits are far less common than they used to be. If a patient has explicitly discharged you, you should send a letter confirming that the patient has terminated the relationship. Again, you should get help with such a letter. Sometimes a letter confirming that the patient has discharged the doctor will result in the patient calling back. It is not unheard of for people to patch up their differences and continue the physician/patient relationship after a misunderstanding.

George Strasser, Esq.


Please see Legal Tip on page 15 V I TA L S I G N S / J U N E 2 0 1 3


A financial safety net for you—

AND THE ONES YOU LOVE 10- AND 20-YEAR LEVEL TERM LIFE Premiums reduced 5% from previous offer! No matter where you are in life, FMMS/KCMS/TCMS Group Level Term Life Insurance benefits can be an affordable solution to help meet your family’s financial protection needs. Marsh/Seabury & Smith Insurance Program Management and FMMS/KCMS/TCMS leveraged the buying power of your fellow members to secure dependable and affordable life insurance benefits at competitive premiums from ReliaStar Life Insurance Company, a member of the ING family of companies.

With first-class life insurance benefits extended at competitive rates, you’ll rest easy knowing you’ve provided coverage for your loved ones through the Group 10-Year and 20-Year Level Term Life Plan.

As a member, you can conveniently help protect your family’s financial future with the Group 10-Year and 20-Year Level Term Life Plan. It features: • Benefits up to $1,000,000 • Rates that are level for 10 or 20 full years* • Benefit amounts that never change provided premiums are paid when due

See For Yourself: Get more information about your Group 10-Year and 20-Year Level Term Life Plan including eligibility, benefits, premium rates, exclusions and limitations, and termination provisions by visiting or by calling 800-842-3761. Sponsored by:

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

Underwritten by:

Insurance is provided by ReliaStar Life Insurance Company, a member of the ING family of companies.

63169 (6/13) ©Seabury & Smith, Inc. 2013

AR Ins. Lic. #245544 • CA Ins. Lic. #0633005 • d/b/a in CA Seabury & Smith Insurance Program Management 777 South Figueroa Street, Los Angeles, CA 90017 • 800-842-3761 • • * The initial premium will not change for the first 10 or 20 years unless the insurance company exercises its right to change premium rates for all insureds covered under the group policy with 90 days’ advance written notice. The County Medical Associations and Societies/NORCAP/CMA receive sponsorship fees for insurance programs that offset the cost of program oversight and support member benefits and services.

WHAT’S NEW Dr. Sergio Ilic is the past president of the Fresno-Madera Medical Society and was very active in his tenure, most notable for the successful Ray Kurzweil lecture. The Editor had a chance to sit down with him in a recent interview and ask –

What’s New in Orthopedics? Dr. Ilic: There are several new treatments that are interesting in Orthopedic Surgery and one of the most intriguing is the Reverse Shoulder Arthroplasty. There have been numerous treatments for shoulder problems such as avascular necrosis of the humeral head, ORIF for fractures of the proximal humerus, osteoarthritis of the gleno-humeral joint. With an intact rotator cuff these can be treated with a regular REVERSE SHOULDER conventional prosthesis. But, until the last six to seven years, we did not have an effective treatment for irreparable rotator cuff tears. This problem has been treated in Europe for many years, but the implant was not approved in the U.S. by the FDA until 2004. If you remember your anatomy, the gleno-humeral joint is one of the 4 joints of the shoulder (the other three are the acromio-clavicular joint, the sterno-clavicular joint and the thoraco-scapular joint). The combination of these joints make “the shoulder joint”. The glenoid cavity is part of the scapula and the ball is the head of the humerus. When there is a severe rotator cuff tear, there is severe pain in the shoulder and inability to lift the arm fully. With arm forward flexion and abduction, the humeral head migrates superiorly and at the end makes contact with the inferior surface of the acromion, as there is no RC to separate the two. There is pseudoparalysis of the shoulder and inability to perform activities of daily living. This leads to arthritis of the gleno-humeral joint, which is called “Rotator Cuff Arthopathy.” One of the functions of the rotator cuff is to keep the humeral head down, while the deltoid elevates the arm. If we treat this condition with a conventional shoulder arthroplasty, the humeral head will migrate superiorly and the prosthesis will not work. So if the “ball” is on the glenoid and the cup is on the humerus, the problem is solved because the humeral cup can’t migrate superiorly. Hence the name, “Reverse Shoulder Arthroplasty.” I have done this procedure and it works really well. The ROM returns, except for internal rotation, and it is very stable. The best thing for the patient is that pain goes away!

Sergio Ilic MD

V I TA L S I G N S / J U N E 2 0 1 3


AIR QUALITY Growing Healthy in Fresno County Michelle Garcia Air Quality Director


On April 10, 2013 the American Lung Association in partnership with the Fresno-Madera Medical Society, the Fresno Council of Governments, the Fresno County Department of Public Health and Human Impact Partners held a health forum focused on creating greater awareness of the general plan process, smart growth, the Sustainable Communities Strategy outlined in SB375, and the undeniable connection to public health. The forum was aimed at bringing physicians, elected officials and key community leaders together to learn more about this important work. Participating on the panel of presenters were Drs. Don Gaede, Ed Moreno and Alex Sherriffs. The Fresno Council of Governments (FCOG) recently developed a set of scenarios to envision future planning of land use and transportation in Fresno County. This is an important step in the development of Fresno’s Sustainable Community Strategy (SCS) that will be adopted later this year to map out how the County will grow and develop over the next 25 years and which provides an opportunity to envision future transportation options like transit, walking and biking to reduce traffic pollution and promote healthier, more vibrant neighborhoods.

The performance indicators to help guide the scenario process are: • Criteria pollutant emission • Transit oriented development • Vehicle miles traveled • Greenhouse gas emission reduction • Land consumption • Compact development • Residential density • Important Farmland • Housing by types • Non-private auto transportation travel Outreach has and is currently being conducted in the form of community workshops in underserved communities, public hearings with final adoption anticipated in December 2013.


2020 Target -7% -7% -8% -7% -5%

2035 Target -13% -16% -13% -15% -10%

A general plan that encourages less urban sprawl, more walkable and bike-able communities, and access to public transportation will provide patients with a better quality of life through exercise and access to healthier foods and medical care.


J U N E 2 0 1 3 / V I TA L S I G N S

Ed Moreno, MD

Alex Sherriffs, MD

• Don H. Gaede, MD, Internal Medicine, provided a physician’s perspective on a community’s design and patient health • Ed Moreno, MD, former Director and Health Officer, Fresno County Department of Public Health, provided information on how the planning process can provide opportunities for prevention • Alex Sherriffs, MD, Family Practice, provided a brief description of SB 375 and the Valley’s charge with reducing air pollution by 5 percent in 2020 and by 10 percent in 2035. For more information contact: Michelle Garcia, Air Quality Director at or 224-4224 ext 119.


Post Office Box 28337 Fresno, CA 93729-8337

President’s Message

1040 E. Herndon Ave #101 Fresno, CA 93720


Recently, I had the opportunity to convene with various leaders and policy-makers in Sacramento to engage and discuss key legislative issues facing the medical community and the future of healthcare delivery in California, at CMA’s 39th Annual Legislative Leadership Conference. It was inspiring to be in the presence of such a talented and diverse gathering of leaders who were infused with so much passion and dedication to advancing the healthcare needs of the people of California. I had the good privilege and pleasure of meeting with our elected representatives – State Senators Anthony Cannella (12th District) and Tom Berryhill (14th District) and State Assemblyman Jim Patterson (23rd District), to highlight the interests and concerns of various stakeholders in the Central Valley’s medical community. Our conversations focused primarily around crafting tangible political solutions to meet the numerous challenges and opportunities, which will arise in the course of fully implementing the Patient Protection Affordable Care Act. Our FMMS delegation expressed concern over the public health ramifications of several particularly contentious bills, namely those outlined in Senator Hernandez’ Scope of Practice Expansion Bill Package and the proposed 10 percent Medi-Cal provider rate cuts adopted through AB 97 in the 2011-12 State Budget. CMA has sponsored Bill SB 640, which would eliminate these proposed Medi-Cal cuts. The series of legislative proposals outlined by Senator Hernandez were designed, ostensibly, to meet the demands of a burgeoning California by granting independent practice to various allied health professionals, including physical therapists, midwives, nurse practitioners, optometrists, pharmacists and physician assistants. This legislation, however well-intentioned it may be, is a misguided and inadequate patch to a complex problem. We can not compromise patient care and safety by attempting to circumvent standardized medical protocols and procedures. There are obvious concerns with the addition of 2.9 million newly insured Californians instituted through the ACA, but the demand and expectation for high quality health care must be met with responsible public policy that does not jeopardize patient safety. Emphasis should instead be placed on promoting collaborative programs and clinical integration initiatives between physicians and allied health professionals that would forge stronger relationships. At the heart of the matter lies a problem that impacts the entire nation as a whole – the acute shortage of physicians. Several pieces of legislation that our delegation endorses are oriented around educating the next generation of doctors by creating greater access to medical education including the CMA-sponsored UC Riverside Medical School Funding Bill Package. Two particularly salient proposals are outlined in CMA’s Physician Workforce Bill Package, AB 565 and AB 1176. Both of these proposals aim toward reducing the shortage of physicians by mitigating the socio-economic obstacles and barriers that have traditionally prevented new physicians from practicing in underserved areas. AB 565 would strengthen and complement the Steven M. Thompson Physician Corps Loan Repayment Program (STLRP), which enables recently licensed doctors to establish their practices in underserved areas in exchange for loan forgiveness – by ensuring that preference is given to applicants who agree to serve in medically underserved regions of the state. Similarly, AB 1176 will increase the allocation of priority funding for medical residency programs in medically underserved areas and for those programs that actively place graduates in underserved communities with the greatest medical need. All of the aforementioned issues and challenges underscore one core theme – we need to work together to galvanize the necessary political will from our leaders and their constituents in Sacramento and beyond to actively invest in education. To meet the healthcare needs of our communities now, we must invest in the long-term education of generations to come. I returned from Sacramento with a great sense of hope and optimism for CMA and FMMS, understanding the important role we assume in shaping the future of public health policy.

559-224-4224 Fax 559-224-0276 website: FMMS Officers Ranjit Rajpal, MD President Prahalad Jajodia, MD President Elect A.M. Aminian, MD Vice President Hemant Dhingra, MD Secretary/Treasurer Sergio Ilic, MD Past President Board of Governors S.P. Dhillon, MD Ujagger-Singh Dhillon, MD William Ebbeling, MD Babak Eghbalieh, MD Ahmad Emami, MD Anna Marie Gonzalez, MD David Hadden, MD S. Nam Kim, MD Constantine Michas, MD Trilok Puniani, MD Khalid Rauf, MD Mohammad Sheikh, MD CMA Delegates FMMS President A.M. Aminian, MD John Bonner, MD Michael Gen, MD Brent Kane, MD Kevin Luu, MD Andre Minuth, MD Shazia Maghal, MD Roydon Steinke, MD Toussaint Streat, MD CMA Alternate Delegates FMMS President-elect Praveen Buddiga, MD Surinder P. Dhillon, MD Don H. Gaede, MD Peter T. Nassar, MD Trilok Puniani, MD Oscar Sablan, MD Dalpinder Sandu, MD Mickey Sachdeva, 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

V I TA L S I G N S / J U N E 2 0 1 3



“The New HIPAA Regulations: Privacy, Security & Breach, Oh My!” The new regulations greatly enhances a patient’s privacy protection and provides individuals new rights to their health information. They also include direct liability for violations to business associates of HIPAA “covered entities” and strengthens the government’s ability to enforce the law. Compliance deadline is September 23, 2013 PRESENTED BY

William E Chaltraw, Jr, Esq.

Michael W Goldring, Esq.

Amanda S Patterson, Esq.

• Recent Changes to the HIPAA Regulations • How Best to Ensure Compliance • Recent Enforcement Efforts of the Federal and State Regulatory Agencies



CALL or EMAIL Sheryl Tatarian: 559.224.4224 x112 •


J U N E 2 0 1 3 / V I TA L S I G N S



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

L. BRUCE ELLIS, MD 51-year member

Bruce Ellis, MD, a retired radiologist, passed away April 30, 2013, at the age of 83. Dr. Ellis was born in St. Louis, IL, in 1929. He received his medical degree from Washington Univ. School of Medicine in St. Louis in 1955, did his internship at Presbyterian Hospital of Chicago and completed his residency at Mallinckrodt Institute of Radiology in St. Louis. After serving as Captain and Head of Radiology at U.S. Army Hospital at Fort Rucker in Alabama for two years, Dr. Ellis moved to Fresno in 1961 to begin his diagnostic radiology practice. He retired in 1995. Dr. Ellis is survived by his wife, four children and nine grandchildren.

Save the Date: Fresno-Madera Medical Society Family Picnic Saturday, June 29, 2013 11am-2pm Woodward Park

Legal Tip Continued from page 9 It would be impossible to list all the reasons that would justify terminating a patient. When problems arise be sure to document what happened, and how you tried to resolve the situation. Again, it is not necessary to have a reason for terminating a patient, but if a patient later says he was terminated for an improper reason, a record of past incidents can be very important. Finally, there can be ethical concerns that arise between a doctor and a patient or the patient’s family, which can result in a termination. Even the nicest people can vehemently disagree over when to switch from aggressive care to comfort care, the extent of life support for a patient, and related issues. These issues have a significant emotional component for everyone involved, including the physician. Again, the answer is to get help.

Fresno-Madera Medical Society to Host Free Community Health Walks

KCMS Officers Jeffrey W. Csiszar, MD President Vacant President-elect Mario Deguchi, MD Secretary Treasurer Theresa P. Poindexter, MD Past President Board of Directors Bradley Beard, MD James E. Dean, MD Thomas S. Enloe, Jr., MD Ying-Chien Lee, MD Uriel Limjoco, MD Michael MacLein, MD Kenny Mai, MD

WALK WITH A DOC COMMUNITY OUTREACH PROGRAM 'Walk with a Doc’ strives to encourage healthy physical activity in people of all ages and reverse the consequences of a sedentary lifestyle in order to improve their health and well-being.

CMA Delegates: Ying-Chien Lee, MD Staff Marilyn Rush Executive Secretary

ENCOURAGE YOUR PATIENTS TO PARTICIPATE! 2013 SATURDAY DATES: • June 29• July 27 • August 24 • September 28 7:30-8:30am Registration at 7:15am Woodward Regional Park WHO CAN ATTEND: Participation is open to anyone interested in taking steps to improve their health. EACH WALK IS LED BY LOCAL PHYSICIANS In addition to the health benefits of walking, you will receive: • Healthy Snacks • Healthy Lifestyle Tips/Resources • Chance to Talk with a Doc NOW RECRUTING PHYSICIAN VOLUNTEER WALKERS Contact the Medical Society at 559-224-4224, ext. 114 Find us on Facebook: Fresno-Madera Medical Society

V I TA L S I G N S / J U N E 2 0 1 3



President’s Message THREAT AND OPPORTUNITY 2229 Q Street Bakersfield, CA 93301-2900 661-325-9025 Fax 661-328-9372 website:

KCMS Officers Wilbur Suesberry, MD President Alpha J. Anders, MD President-elect Eric J. Boren, MD Secretary Ronald L. Morton, MD Treasurer Joel R. Cohen, MD Immediate Past President Board of Directors Bradford A. Anderson, MD Lawrence N. Cosner, MD John L. Digges, MD J. Michael Hewitt, MD Susan S. Hyun, MD Mark L. Nystrom, MD Sameer Gupta, MD Edward W. Taylor, MD CMA Delegates: Jennifer Abraham, MD John Digges, MD Ronald Morton, MD

Wilbur Suesberry, MD President, Kern County Medical Society

We are told that medical care is in a state of crisis. Part of the crisis is the result of the many uninsured and those who are insured but do not have knowledge of their medical home. The days when the family doctor can call at any time or make home visits is in the past. In the present, medical doctors continue to give knowledgeable, humane care. It is often seen in the eyes of surgeons who, with absolute compassion, give authoritative information to the patient that he or she does not have a diagnosis. And the patient has tears of relief. The medical care crisis has resulted in proposed threatening solutions with the expansion of the role of healthcare professionals to work without standardized procedures and the consultation of physicians. For example, currently there are Senate bills sponsored by Senator Ed Hernandez, an optometrist. SB 491 proposes eliminating the requirement for nurse practitioners to act within a standardized procedure or in consultation with a physician and surgeon. SB 492 would expand the practice of certified optometrists to include the ability to “immunize and treat certain diseases.” SB 493 pertains to expanding the function of pharmacists. Senator Hernandez is titled Dr. Ed Hernandez, OD. Using the title “doctor” becomes confusing to the public, wherein doctors are traditionally understood to be medical doctors. We do though, have medical doctors who are in the political arena in state legislatures and who even ran for the presidency, Jill Stein, MD and Congressman Ron Paul, MD. There can be opportunities during these times. For example, medical care is currently provided through a team approach with various health professionals, including nurse practitioners and physician assistants in consultation with physicians. The new opportunity is to expand the current model of healthcare delivery but with physicians in the lead. We also have the opportunity for medical doctors to express their opinions and come up with unified messages that are convincing to the public as well as to policy makers. Author can be reached at

CMA Alternate Delegates: Lawrence Cosner, Jr., MD Staff: Sandi Palumbo, Executive Director Kathy L. Hughes Administrative Assistant


KCMS Member Recognition: Michelle Quiogue, MD The California Academy of Family Physicians (CAFP) named Michelle Quiogue, MD as 2013 Family Physician of the Year. “Dr. Quiogue inspires us all with her tireless efforts to provide outstanding health care,” said CAFP President Mark Dressner, MD. “She leads initiatives to improve health by bringing care to underserved communities, cultural proficiency to medicine, and career dreams to underprivileged students and is an active spokesperson for the specialty of family medicine and family physicians’ roles in education and public health. She is wellloved by patients and respected by colleagues locally, state and nationwide.” said Dr. Dressner. Michelle Dr. Quiogue received her Medical Degree from Brown University, RI in 2000 Quiogue and completed her Family Medicine Internship/Residency from Kaiser LA Medical Center from July, 2000 – June, 2003. She is Board Certified in Family Medicine. She practices Family Medicine at Kaiser Permanente where she also serves as the Physician Champion of the Culturally Responsive Care and Diversity Council. In addition to her office-based practice, she was one of the first physicians to volunteer when Kaiser began sending a mobile health vehicle to serve patients in outlying areas of Kern County. She is president of the CAFP Kern County Chapter, a Delegate to the annual CAFP Congress of Delegates, and editor of the statewide California Family Physician magazine. She serves on the American Academy of Family Physicians (AAFP) Committee on the Health of the Public and Science and its Subcommittee for Health Equity, and has been a Delegate to the AAFP National Congress for Special Constituencies, representing both the minority and women’s delegations. Congratulations Dr. Quiogue!

J U N E 2 0 1 3 / V I TA L S I G N S

Tulare 39th Annual Legislative Leadership Conference Review Monica Manga, MD, Internal Medicine at Visalia Medical Clinic


April 16, World Voice Day was celebrated. The aim is to demonstrate the enormous importance of the voice in our daily life. In that setting, CMA held the annual Legislative Leadership Conference in Sacramento. A group of physicians from Tulare County Medical Society participated in this worthy event where the discussion centered on health care reform, medical liability and insurance regulations. The importance of advocacy was stressed, as well as the need to be vocal about the physician's needs and concerns. Once the conference ended, meetings with legislators were scheduled for each of the County Medical Societies. Tulare County Medical Society members met with Assemblywoman Connie Conway, Senator Jean Fuller and Assemblyman Jim Patterson. Key discussions were the Scope of Practice Expansion Bill Package from Senator Hernandez (AB 1000, AB 1308, SB 198, SB 491, SB 492, SB 493 & SB 494). This package proposes to expand the scope of practice of Physical Therapists, Midwives, Nurse Practitioners, Optometrists, Pharmacists, and Please see Tulare on page 18

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

From left: Drs. Steve Cantrell, Thomas Daglish, Monica Manga, John Hipskind, Assemblywoman Connie Conway, Drs. Ralph Kingsford, Raman Verma and Carlos Dominguez.

From left: Drs. Monica Manga, Steve Cantrell, Raman Verma (behind), Senator Jean Fuller (front), Drs. John Hipskind, Thomas Daglish, Carlos Dominguez and Ralph Kingsford.

TCMS Officers Steve Cantrell, MD President Thomas Gray, MD President-elect Monica Manga, MD Secretary/Treasurer Gaurang Pandya, MD Immediate Past President Board of Directors Virinder Bhardwaj, MD Carlos Dominguez, MD Pradeep Kamboj, MD Christopher Rodarte, MD Antonio Sanchez, MD Raman Verma, MD CMA Delegates: Thomas Daglish, MD Roger Haley, MD John Hipskind, MD CMA Alternate Delegates: Robert Allen, MD Ralph Kingsford, MD Mark Tetz, MD

From left: Drs. John Hipskind, Thomas Daglish, Ralph Kingsford, Raman Verma, Assemblyman Jim Patterson, Drs. Ranjit Rajpal (FMMS President), Steve Cantrell, Monica Manga and Carlos Dominguez.

Sixth District CMA Trustee James Foxe, MD Staff: Steve M. Beargeon Executive Director

Wine Social is a Hit

Francine Hipskind Provider Relations


Thelma Yeary Executive Assistant

May 3, one of our most popular events, the annual wine social attracted about 100 members and guest at the Chinese Cultural Center. The wines, selected by Chris Villard, M.D., are always a treat for those who attend and everyone agreed that this year’s selection was outstanding. The region selected as this year’s theme was the Central Coast. This year the wine maker for MCV syrah, Matt Villard, was in attendance. Matt was able to provide a lot of information regarding his wine and many of the other wines that were poured. Brenda Isaac catered the food for the event and it was a perfect match for the evening and very delightful.

Dana Ramos Administrative Assistant

V I TA L S I G N S / J U N E 2 0 1 3


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, 559224-4224, Ext. 118. FRESNO/MADERA



Dr. Ahmad Emami announces his Man of the Year campaign benefiting the Leukemia & Lymphoma Society. Tax-deductible donations to his campaign can be made at: ami. University Psychiatry Clinic: A sliding fee scale clinic operated by the UCSF Fresno Dept. of Psychiatry at CRMC M-F 8am-5 pm. Call 320-0580.

Complete suite of office furn. 1 desk w/return & file draws; 2 guest chairs; 10 exam rm chairs; 9 rolling stools for exam rms; 6 footstools; 8 desk chairs; 4 exam rm tables. Call 559-432-7700.

PHYSICIAN WANTED LQMG Medical Group is seeking Board Certified, Internal Medicine physicians to join its group. Call 559-450-5703.

FOR LEASE OR RENT Medical office space; 1476 W. Shaw Ave. between Fruit & West. 1200sf, great location. Call Shannon Mar, Guarantee Real Estate, 999-6165, Medical office; 1046 E. Shields, 1331 sf, close to Fwy 41 & Manchester Mall. Call Shannon Mar, Guarantee Real Estate, 9996165, Brand new (model) home near Willow Intl. campus. 2760 sf, numerous upgrades, 5 bdrms/3bths. Available early to mid August. Call: 559-273-5336.

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

MEDICAL OFFICES FOR LEASE Crown Pointe Phase II – 2,000-9,277 rsf. 3115 Latte Lane – 5,637 rsf. 3115 Latte Lane – 2,660-2,925 rsf. Meridian Professional Center – 1,740-9,260 rsf. 9300 Stockdale Hwy. – 3,743 - 5,378 rsf. 9330 Stockdale Hwy. – 1,500-7,700 rsf. 2323 16th St. – 1,194 rsf. 2323 16th St. – 1,712 rsf. 2323 16th St. – 2,050 rsf. 2323 16th St. – 2,568 rsf. 4939 Calloway Dr. – 1,795 sf. 3941 San Dimas St. – 9,000 rsf. SUB-LEASE 4100 Truxtun Ave. – Can Be Split Medical Records & Offices Sprinklered – 4,764 rsf. Adm. & Billing – 6,613 rsf. 2323 16th St. – 2,884 rsf. FOR SALE 1911 17th Street – 2,376 sf. 2019 21st Street – 2,856 sf. Crown Pointe Phase II – 2,000-9,277 rsf. Meridian Professional Center – 1,740-9,260 rsf. 9900 Stockdale Hwy. – SOLD OUT! 3941 San Dimas St. – 9,000 rsf.


J U N E 2 0 1 3 / V I TA L S I G N S

Tulare Continued from page 17 Physician Assistants; as well as to diminish the supervision required. CMA as well as TCMS emphasized the benefit of working collaboratively with other health care professionals to meet patient care demand; but within the scope of practice that each health care professional is qualified to perform; and hence ensuring quality of care and patient safety. UC Riverside Medical School Funding Bill Package (AB 27 and SB 21) and the Physician Workforce bill Package (AB 565 & AB 1176) were discussed, as ways to help increase access to physicians in underserved areas, and at the same time attract physicians to work there. Other topics included the planned 10% reduction in Medi-Cal Provider Payments (AB 97 of 2011/2012 State Budget). It was advocated the elimination of these cuts (SB 640), as they will have a disastrous impact on access to care, will more so impart the already underserved in our area.


AVAILABLE Nanny available for your children. Dr. Stanic’s wife, Katarina, knows a right person for your home. Contact: Call Sequoia Dental Office; 559-635-7186, ask for Katrina or (indicate NANNY) under subject).

During meetings like this one, is when the effect of advocacy is fully observed. No one better than a physician to see, feel and understand the health needs that the community he/she works for have. April 16 was a day to remind everyone of the importance of our voices as communication tools. TCMS members and advocates used, and will keep using, our voices to benefit the community we serve.



class addresses the transition and all of the components of ICD10. Get a comprehensive look at both the staged transition and hands-on coding practice. This is a full day workshop, open to TCMS members and their staff, and will be held at Visalia Convention Center. Space is limited. For more information, contact Dana Ramos, Tulare County Medical Society, at 559-734-0393 or

“When it comes to Meaningful Use, athenahealth did all the legwork… and then they made it easy for me to do.” –Dr. Reavis Eubanks

This is how Dr. Eubanks got paid for Meaningful Use.


fter practicing medicine 35 years, Dr. Reavis Eubanks knew it was time for an EHR. As a solo physician, he needed an easy transition and an effective way to begin earning up to $44,000 in Medicare incentive payments. athenahealth helped Dr. Eubanks go from paper to payment in just six months. With guidance every step of the way and proven, cloud-based services.  f Best in KLAS EHR*  f Free coaching and attestation

f 4FBNMFTTDMJOJDBMXPSLnPX f Guaranteed Medicare payments**

85% of eligible athenhealth providers attested to Stage 1 Meaningful Use. And we’re ready for Stage 2.

Visit or call 800.981.5085 *ambulatory segment for practices with 11-75 physicians *GZPVEPOUSFDFJWFUIF'FEFSBM4UJNVMVTSFJNCVSTFNFOUEPMMBSTGPSUIFmSTUZFBSZPVRVBMJGZ XFXJMM credit you 100% of your EHR service fees for up to six months until you do. This offer applies to HITECH Act Medicare reimbursement payments only. Additional terms, conditions, and limitations apply.

Cloud-based practice management, EHR and care coordination services

V I TA L S I G N S / J U N E 2 0 1 3


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.

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

22,689 To improve patient safety, you need to stay on top of best practices. That’s why, as shown by the 2011 numbers above, we provide you the risk management advice you need, when and how you want it. It’s why we provide industry-leading CME online and through Claims Rx, our monthly publication based on closed claims. And why we tailor solutions to help with your specific risk issues. The results include 98% policyholder retention, the highest-level CME accreditation and reduced risk for you.

CALL 877-453-4486 OR VISIT NORCALMUTUAL.COM Proud to be endorsed by the Fresno-Madera Medical Society and the Kern, Kings and Tulare County Medical Societies

Our passion protects your practice

Vital Signs June 2013  
Vital Signs June 2013  

June 2013 Vol. 35 No. 6