Official Magazine of FRESNO COUNTY Fresno-Madera Medical Society Fresno-Madera KERN COUNTY Kern County Medical Society Kern KINGS COUNTY Kings County Medical Society MADERA COUNTY Fresno-Madera Medical Society Fresno-Madera TULARE COUNTY T ulare County Medical Society Tulare
See Se ee IInside: e ns n sid de e: CMA CMA’s A’s ’s Practice Pra P rac act cttic ce Resources: Re eso so ourc ce es s: C CPR PR Regional Re eg gio on na al TTransportation Tra Tr ra anspo orta tattio tat ion Plans Pla la ans Ce Central ent e nttra ra al V Valle Valley alle le ey Ca ardio rd olog ogy gy Cardiology Symposium Sy ympo po osium
October 2012 s Vol. 34 No. 10
We Celebrate Excellence – James Strebig, MD CAP member, internal medicine physician, and former President of the Orange County Medical Association.
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O C T O B E R 2 0 1 2 / 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 ................................................................................................................................5 MEDICARE NEWS .......................................................................................................................9 NEWS PRACTICE MANAGEMENT: CMA’s Practice Resources: CPR.........................................................7 AIR QUALITY: Regional Transportation Plans: What You Need to Know ......................................10
October 2012 Vol. 34 – Number 10
BLOOD BANK: Comparative Effectiveness Research in Transfusion Medicine ............................11 32nd Annual Central Valley Cardiology Symposium..................................................................12
Editor, Prahalad Jajodia, MD Managing Editor, Carol Rau Fresno-Madera Medical Society Editorial Committee Virgil M. Airola, MD John T. Bonner, MD Hemant Dhingra, MD David N. Hadden, MD Roydon Steinke, MD Kings Representative TBD Kern Representative John L. Digges, MD Tulare Representative Thelma Yeary
CLASSIFIEDS ...........................................................................................................................18 FRESNO-MADERA MEDICAL SOCIETY .......................................................................................13 • President’s Message • General Meeting Save the Date: November 7 • Skywatchers of Ancient Mexico: FMMS members only event October 17 • In Memoriam: Charles W. Beam, MD, and Thomas G. Sayeg, MD • Educational Series and Economic Forum for FMMS members KERN COUNTY MEDICAL SOCIETY ............................................................................................16 • In Memoriam: Hans Einstein, MD TULARE COUNTY MEDICAL SOCIETY.........................................................................................17 • Executive Director’s Message • DumpOnUs.org
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: “Chapel Bridge" Lucerne, Switzerland by Cynthia Ginn, RN, CGCS
Advertising Contact: Display: Annette Paxton, 559-454-9331 firstname.lastname@example.org
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 email@example.com
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 / O C T O B E R 2 0 1 2
Transcranial Magnetic Stimulation (TMS) is a Safe, Proven Treatment for Depression • FDA Cleared • Non-Invasive, Non-Drug Treatment Without Side Effects • No Sedation; Patient Fully Awake • Performed in the Comfort of Our Private Office Our Clinical Results: 90% Response Rate 75% Remission Rate For more information about TMS Therapy call us at: Edgar Castillo-Armas, MD Fresno Office Medical Director 30 River Park Place West, Suite 310 Fresno, CA 93720 Visalia Office 220 S. Akers Street, Suite B (1867) (559) Visalia, CA 93291
O C T O B E R 2 0 1 2 / V I TA L S I G N S
CMA NEWS LAST MINUTE MOVE BY TRIAL LAWYERS TO SCUTTLE MICRA IS THWARTED
In the last days of the 2012 legislative session, a shell bill (SB 1528) was gutted and amended in an attempt by trial lawyers to undermine California’s Medical Injury Compensation Reform Act (MICRA). The California Medical Association (CMA) was able to thwart this move and the bill is dead for this legislative season. The bill would have artificially inflated medical expense damages by valuing them on the basis of the retail price of medical services provided, not the actual expense to the injured party. Simply put, this would allow trial lawyers to value medical expenses at rates much higher than what the physician who provided the service is actually paid. The legislation would have scrapped longstanding principles of law that allow an injured person to recover as economic medical expense damages only amounts actually paid or incurred for medical care and services. SB 1528 would have artificially inflated economic medical expense damage awards and undermined MICRA’s intent to prevent double recovery of these damages. This, in turn, would have increased medical malpractice premiums for physicians, many of whom would be forced to close shop thereby further limiting access to care for all Californians. Had this bill passed, it would have undermined the state’s landmark MICRA law, which is comprised of a number of different statutory provisions all designed to contain costs in medical professional negligence cases while ensuring adequate compensation for injured persons. MICRA was signed by Gov. Brown in 1975 during his first term as governor. The next legislative year CMA expects another challenge from the same lawyers and we will fight to the end to preserve the MICRA laws. Contact: Nikki Ragsac, 916-551-2045 or firstname.lastname@example.org. AETNA TERMINATING PHYSICIAN CONTRACTS FOR REFERRING PPO PATIENTS TO OUT-OF-NETWORK FACILITIES
Many physicians have notified the California Medical Association (CMA) that they have received notices from Aetna purporting to terminate their provider contracts. Aetna claims in these notices that the physician breached the provider contract by referring PPO beneficiaries to out-of-network facilities for covered medical services. CMA, along with a coalition of patients, individual physicians, ambulatory surgical centers and local county medical associations, is in active litigation in Los Angeles County Superior Court against Aetna over this exact practice. The lawsuit alleges that, while Aetna is marketing and selling PPO products featuring outof-network benefits, Aetna is unlawfully retaliating against patients who attempt to use their out-of-network benefits and contracted physicians who refer their patients to out-of-network providers and facilities. In response to the apparent increase in Aetna’s challenged practices, CMA has developed information and resources to help individual CMA members who have received termination notices from Aetna over out-of-network referrals. Affected physicians are encouraged to call CMA’s legal help line for assistance.
Contact: CMA legal help line, 800-786-4262 or memberservice@ cmanet.org.
CMS RELEASES STAGE 2 REQUIREMENTS FOR MEANINGFUL USE
The Centers for Medicare & Medicaid Services (CMS) released the final requirements for stage 2 “meaningful use.” The rule is part of a federal incentive program for Medicare and Medicaid physicians who adopt and achieve “meaningful use” of electronic health records (EHR), as authorized by the Health Information Technology for Economic and Clinical Health (HITECH) Act. Stage 2 (which will begin as early as 2014) requires physicians to use secure electronic messaging to communicate health information to patients, as well as to allow patients to view health records online. The final rule modifies the definition of “hospital-based” physicians to create an application process for physicians to demonstrate that they alone fund their EHR systems and are eligible to receive the incentive payments directly. The new rule also provides a flexible reporting period for 2014 to give providers sufficient time to adopt or upgrade to the latest EHR technology certified for 2014. The final rule lays out the timelines physicians will have to follow in order to avoid payment reductions in 2015. Under the provisions of the HITECH Act and the final rule, physicians who do not demonstrate meaningful use for 90 consecutive days beginning July 1, 2014, will see a 1 percent reduction in Medicare payments beginning in 2015. CMA is currently reviewing the final rule and will provide additional information as it becomes available.
FAQ: HOW FAR BACK CAN PAYORS SEEK REFUNDS OF OVERPAYMENTS?
The California Medical Association (CMA) frequently receives calls from physicians who are approached by payors to return monies allegedly overpaid on claims. Some of the reasons cited by the payors include changes in eligibility, manual processing errors or codes/services the payor considers bundled. The frequent question is whether there is a statute of limitations on how far back payors can go. The good news is that, in most cases, there are limits on how far back a payor can request a refund and there are requirements the payor must abide by when they believe a refund is due. One such requirements is that an overpayment refund request must be made in writing no more than 365 days after the original payment. This applies to payors regulated by both the Department of Managed Health Care and the Department of Insurance. If you believe you have received refund requests outside the 365-day period allowed by California law, contact CMA’s member help center for assistance at 800-786-4262 or memberservice@ cmanet.org. HHS DELAYS ICD-10 IMPLEMENTATION TO 2014
The U.S. Department of Health and Human Services (HHS) officially delayed ICD-10 implementation by one year, in a final Please see CMA News on page 6 V I TA L S I G N S / O C T O B E R 2 0 1 2
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Continued from page 5 rule published last week. The delay, first proposed in April, changes the date of compliance for ICD-10 from October 1, 2013, to October 1, 2014. The International Classification of Disease tenth revision (ICD-10) is a system of coding created in 1992 as the successor to the previous ICD-9 system. ICD-10 will include new procedures and diagnoses, which HHS hopes will improve the quality of information available for quality improvement and payment purposes.
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O C T O B E R 2 0 1 2 / V I TA L S I G N S
After the presidential election in November, Congress will be back in Washington, D.C., to take up some of the most complex and divisive issues of the day. Included in this will be the 27 percent sustainable growth rate (SGR) cut to Medicare, plus a potential two percent sequestration cut. Medicine will be competing with a glut of issues that must be addressed by Congress before the end of the year, such as whether to extend a number of expiring programs, including the Bush tax cuts, the Social Security payroll tax cut, and federal unemployment benefit extensions. Congress will also be faced with $1 trillion in government sequestration cuts, set to take effect on January 1, 2013, because of the Super Committee’s failure to agree on alternative budget solutions. Although Medicaid is exempt from the sequestration cuts, Medicare is facing an additional 2 percent cut, on top of the 27 percent SGR cut. California Medical Association (CMA) leaders will meet with congressional members during the August 2012 summer recess to lay the groundwork for the upcoming lame duck session, which could be contentious. Regardless of who wins the election, 2013 will be an important year for both Medicare and Medicaid reform issues. It is highly likely that the NovemberDecember congressional session will produce another short-term SGR fix and a new set of politicians will be faced with SGR reform. Please see CMA News on page 7
Continued from page 6
CMA’s Practice Resources: CPR
CMA JOINS EFFORT TO MONITOR CALIFORNIA HEALTH BENEFIT EXCHANGE
The California Medical Association and the Food & Drug Council have joined a statewide alliance that seeks to monitor developments in the California Health Benefit Exchange. The federal health reform law requires states to launch online insurance marketplaces by 2014.The California Health Benefit Exchange primarily will serve individuals and small businesses. Supporters hope that the exchange will function similar to websites like Amazon.com and Expedia.com so that users will be able to choose between various health plans through an easily navigable online store. Officials plan to open registration for the exchange in October 2013. An estimated 4.4 million Californians are expected to use the exchange by the end of 2016. The alliance – called the Healthcare Exchange Advocacy and Responsibility Team (HEART) – seeks to ensure that the exchange will lower costs, improve quality and expand health care access for residents and supports health plans that offer coordinated, team-based care. Members of the alliance include: • Businesses and unions; • Health care providers, such as Dignity Health; • Health insurers, such as Kaiser Permanente and Blue Shield of California; and • Patient advocates. Lisa Folberg, CMA vice president for medical and regulatory policy, said that family physicians belonging to CMA who support the concept of medical homes as a way to maximize the use of various health care workers and “bend the cost curve” encouraged the group to join HEART (Sacramento Business Journal, 8/29). Read more: http://www.californiahealthline.org/articles/2012/ 8/30/two-groups-join-effort-to-monitor-california-health-benefitexchange.aspx#ixzz266Sek1Ei PROBLEMS GETTING PAID?
The California Medical Association’s Center for Economic Services provides direct reimbursement assistance to CMA physician members and their office staff. Reimbursement Help Line 888-401-5911 – One-on-one educational and reimbursement assistance to physician members and their staff Practice Empowerment – Tools and resources to empower physician practices; seminars and toolkits for physicians and their staff Experienced Staff – Staffed by practice management experts with a combined experience of over 125 years in medical practice operations Need help? Contact CMA’s reimbursement experts at 888-4015911 or email@example.com
physicians contract with exchange plans without knowing? Beginning in 2014, California will begin offering subsidized health care coverage through the state’s Health Benefit Exchange as required by the Patient Protection and Affordable Care Act. Contracting with plans offered through the state’s Health Benefit Exchange likely brings a host of new obligations for physicians, and whether or not to do business with exchange plans is a decision that shouldn’t be taken lightly. Knowing this, it may be unsettling to learn that many California physicians could already be signed onto an exchange plan network due to the way that major insurance plans have structured their provider agreements. Many plans’ provider agreements give the provider the opportunity to opt in to all of the plan’s product networks or selectively opt out of those networks they would rather not take part in. This is where the contracting can get tricky. Because plans don’t know whether they will have a product on the exchange or what they will call those products, they are being identified in contract addenda under ambiguous names. For instance, in an addendum – titled Exhibit B – Blue Shield identifies its intended exchange provider networks as Commercial PPO/EPO Networks A, B and C, respectively reimbursing at staggered percentages of the rates set forward in Blue Shield’s provider manual. The word “exchange,” however, appears nowhere in the contract. In the above example, the tiered reimbursement approach reflects what is seen in the “metal tiers” for qualified health plans (QHPs) offered under the exchange, meaning plans are setting physicians up for exchange contracts without explicitly saying so. With plans’ ability to amend provisions of the contract and provider manual with relative ease, it’s likely that providers who opt in to the “all products” clause will soon find themselves represented as part of an exchange provider network, despite the absence of any discussion of such networks in the contract. In fact, Blue Shield’s current recontracting effort was launched, in part, to insert language in anticipation of participating in the state’s exchange. To later effectuate any new exchange requirements, the plan would only need to send them along as a state-mandated amendment. Generally, unless providers object in writing within 60 days of release, the amendment becomes part of the original contract. For this and many other reasons, practices need to ensure all new and revised contracts are thoroughly reviewed and that all products being signed onto are fully understood. CMA continues to work with exchange stakeholders to address significant concerns regarding the exchange grace period, monitoring of network adequacy and clinician-level performance measurement in qualified health plans offered in the exchange. V I TA L S I G N S / O C T O B E R 2 0 1 2
N ED. T I IM IS L
F ION T I U OT
Community MEDICAL CENTERS
Winter CME Symposium 2013 “The Pursuit of Excellence” February 6-10, 2013
at the LAS VEGAS
2013 Winter Symposium Speakers Scheduled to Appear Paul B. Ginsburg PhD President, Center for Studying Health System Change TOPIC: “Healthcare 2013: Report from National Center for Studying Health System Change"
Thomas J. Graham MD Chief Innovation Officer, Justice Family Chair in Medical Innovations; Vice Chair, Department of Orthopaedic Surgery, Cleveland Clinic TOPIC: “Great Expectations – Medical Innovation at Cleveland Clinic"
Eric Coleman MD, MPH Professor of Medicine, Head of Division of Health Care, Policy & Research; Director Care Transitions Program, University of Colorado TOPIC: “Innovative Models: What Will It Take to Ensure High Quality for Patients' Transitions of Care"
Paul Grundy MD, MPH, FACOEM, FACPM Global Director, IBM Healthcare Transformation His work has been reported widely in the New York Times, BusinessWeek, The Economist, New England Journal of Medicine and newspapers and television around the country. TOPIC: “Transforming Health Care Delivery: Creating the Patient-Centered Medical Model”
Joanne M. Conroy MD Chief Health Care Officer, Association of American Medical Colleges TOPIC: “Academic Hospitals and Physician Training in the World of Health Care Reform: An Update"
Richard “Chip" Davis PhD President, Sibley Memorial Hospital Johns Hopkins Medicine TOPIC: “Johns Hopkins: Changing the Way we Care (the Johns Hopkins Journey of Achieving Unprecedented Levels of Quality & Safety)”
W. Gregory Feero MD, PhD Former Senior Advisor to the Director, National Human Genome Research Institute, National Institutes of Health; Contributing Editor, Journal of the American Medical Association; Faculty for Dartmouth-Maine TOPIC: “Moving Genomic Medicine into the Doctor’s Office”
Donald Goldmann MD Senior Vice President, Institute for Healthcare Improvement TOPIC: “The Science of Quality Improvement: Developing Evidence for What Really Works”
Brent C. James MD, MStat Chief Quality Officer and Executive Director, Institute for Health Care Delivery Research Intermountain Healthcare TOPIC: “The Health Reform Debate Has Overlooked the Physician-Patient Dynamic”
Steven T. Valentine MPA President, The Camden Group (a national healthcare management consulting company) and a nationally recognized author and speaker on healthcare issues. TOPIC: “10 Healthcare Trends for 2013"
HISTORICAL SPOTLIGHT Chesley B. (Sully) Sullenberger, III “Miracle on the Hudson”
D For information/details, please contact: TEN Laurie Smith, Manager Physician Education T A firstname.lastname@example.org T O We encourage 559-459-1777 or 1775 O W you to learn more Group-discount N hotel rooms are and register online at: AN PL available. www.wintersymposium.com.
MEDICARE NEWS CMA URGES CHANGES TO THE 2013 MEDICARE PAYMENT RULE
California Medical Association (CMA) has submitted comments to the Centers for Medicare & Medicaid Services (CMS) on the proposed Medicare Physician Payment Rule for 2013.
Geographic Payments In the letter, CMA expressed extreme disappointment that the payment rule does not include the geographic practice cost index (GPCI) payment locality update that was recently recommended by the Institute of Medicine (IOM). “The overall goal for Medicare payment must be payment accuracy,” CMA wrote in its letter. “CMS is simply not paying physicians accurately and is severely underpaying thousands of physicians in California each year, which negatively impacts access to care in these regions.” CMA has been working for a decade to convince Congress and CMS to update the payment localities. The IOM report urged CMS to address the system’s acute payment inaccuracies in part by updating the physician payment localities and moving to Metropolitan Statistical Area boundaries – the same system Medicare uses to calculate payments to hospitals. According to CMS, creating additional payment localities will be administratively burdensome for the agency. CMA strongly disagrees with this conclusion, as does the IOM. Value-Based Payment Modifier While CMA supports efforts to improve quality and efficiency, the association strongly opposes the proposed Value Based Payment Modifier when applied to individual physicians. The value modifier takes effect in 2015, but will be based on 2013 data for groups of 25 or more physicians. The value modifier payment methodology was mandated in the Affordable Care Act (ACA). While CMA opposed the value modifier in the ACA, CMA amendments ensured that the payments would be risk and cost-adjusted for California’s higher costs. In a nutshell, the rule proposes a system whereby physicians who successfully report on quality measures and spend less than the national average per Medicare patient would be paid more, and physicians with lower quality and higher costs would be paid less. CMA strongly opposes the proposed value modifier payment formula unless the current attribution methodology, riskadjustment methodology and reporting mechanisms for individual physicians are vastly improved. The data must be accurate and statistically valid. CMA supports the value modifier when applied to physician groups of 25 or more, but only if they are multi-specialty groups that have already successfully participated in the Group Practice Reporting Program. CMA also opposes the proposed public disclosure of physician information until it is more accurate and physicians are given the opportunity to review the data before it is published, and to appeal and have the data corrected if found to be inaccurate. “Inaccurate information can mislead patients and physicians without improving the quality of care or reducing costs,” CMA wrote in its comments.
Nurse anesthetists scope of practice The proposed payment rule includes new language that would permit certified registered nurse anesthetists to furnish and bill for chronic pain management in states where it is within their scope of practice to do so. “[Nurse anesthetists] lack the training, education and clinical experience to provide chronic pain management care without physician supervision and direction,” CMA wrote in the letter. Although states have the ability to determine the scope of practice of nurse anesthetists and other non-physician practitioners, CMA urged CMS to lead and maintain a national standard to protect all Medicare beneficiaries who require chronic pain management. Contact: Elizabeth McNeil, 415-882-3376 or email@example.com.
MEDICARE TO REQUIRE PRIOR AUTHORIZATION OF POWER MOBILITY DEVICES
The Centers for Medicare & Medicaid Services (CMS) will require physicians in seven states, including California, to obtain prior authorization for motorized wheelchairs and other power mobility devices for Medicare fee-for-service beneficiaries. While it is being calling a demonstration project, CMS said prior authorization will ensure the delivery of necessary medical equipment and should reduce the number of high dollar fraud investigations. The demonstration is directed at beneficiaries who reside in seven states with high populations of fraud- and error-prone providers: California, Florida, Illinois, Michigan, New York, North Carolina and Texas. According to CMS, physicians will be required to conduct face-to-face examinations of Medicare patients prior to prescribing power mobility devices. Physicians will then be required to send authorization requests and supporting documentation that addresses specific coverage criteria directly to the durable medical equipment contractor (DMERC), or work with the durable medical equipment supplier who may submit the information for pre authorization. The DMERC will review the request to ensure that it meets national and local coverage requirements and, if approved, provide an authorization number that the supplier needs to fulfill the order. There are a few statutory requirements that must be met before the prescription is written. Details of the requirements and a sample checklist are available on the CMS Prior Authorization of Power Mobility Devices Demonstration web page, http://cal.md/pmd-demo. The checklist and other resources are located at the bottom of the page, under downloads. Contact: Michele Kelly, 213-226-0338 or firstname.lastname@example.org.
V I TA L S I G N S / O C T O B E R 2 0 1 2
Regional Transportation Plans: What You Need to Know Michelle Garcia, Air Quality Director
Transportation Plans (RTPs) are planning documents developed by Metropolitan Planning Organizations (MPOs) and Regional Transportation Planning Agencies (RTPAs) in cooperation with Caltrans and other stakeholders. They are required to be developed by MPOs and RTPAâ€™s per State legislation, (Government Code Section 65080 et seq.) and Federal regulation (Title 23 USC Section 134). The purpose of the RTP is to establish regional goals, identify present and future needs, deficiencies, and constraints, analyze potential solutions, estimate available funding and propose investments. A comprehensive public involvement program is an important component for developing a RTP. As Fresno COG undertakes the development of the 2014 RTP a major goal of the public outreach effort is to reach out to nontraditional as well as traditional audiences to include them in the transportation planning process. This program will help ensure that environmental justice issues such as air pollution are addressed and that interested members of the public have ample opportunity to understand and provide meaningful input while the RTP is in its early stages and throughout the planning process. The Fresno Council of Governments has developed a Public Outreach Strategy for the 2014 RTP/SCS process they will be using to enlisted public participation and involvement. The plan is available on their website at www.fresnocog.org under the Planning/Regional Transportation Plan pages. RTPâ€™s are updated every four years, so this is your opportunity to shape transportation in Fresno. For more information or to get involved contact Michelle Garcia at email@example.com or 559-224-4224 ext 119.
O C T O B E R 2 0 1 2 / V I TA L S I G N S
Comparative Effectiveness Research in Transfusion Medicine from ‘Comparative Effectiveness Research-Finding Answers in a Sea of Science’, by Dana Trevas, AABB News, July 2012
Taking statins with or without the organic compound niacin are two frequently prescribed regimens for cardiovascular disease patients. But is one protocol better than the other? National Heart, Lung, and Blood Institute, or NHLBI, researchers were particularly interested in knowing whether adding niacin helped these patients, and so they randomly assigned more than 3,000 patients to receive either the compound or a placebo with their statin therapy. Then, they examined the results. By examining the results of the comparison study, the NHLBI investigators learned that adding niacin to the statin therapy did not reduce the risk of heart attacks and stroke. This NHLBI study is an example of comparative effectiveness research, or CER, defined as the direct comparison of health care interventions to determine which work best for what groups of patients. All clinical research aims to gather evidence that ultimately will apply to practice, but CER is distinct, said Harold Sox, MD, a professor of medicine at Geisel School of Medicine at Dartmouth in Hanover, N.H. He co-chaired the Institute of Medicine’s, or IOM, Committee on Comparative Effectiveness Research Prioritization. First, CER compares two or more treatments or tests that are being implemented regularly in medical practice (as opposed to experimental drugs only available through clinical trials). Plus, research is conducted in community settings, not only academic research centers. “Frequently, studies are done in patients who are not typical of those seen in daily practice or the studies compare treatment with a placebo and not with another treatment,” Sox said. CER allows the research community “to be systematic about approaching key testing and treatment questions,” he noted. It is “a user-driven science that seeks to answer questions that make a difference in care,” added Jean Slutsky, PA, MSPH, the director of the Center for Outcomes and Evidence at the Agency for Healthcare Research and Quality, or AHRQ. CER is not new, but the significant federal investments over the past few years signal how important it is for health care. The American Recovery and Reinvestment Act and the Patient Protection and Affordable Care Act together committed billions of dollars to CER. In addition, the government established the Patient-Centered Outcomes Research Institute, or PCORI, an independent, nonprofit, private entity, to set the CER research agenda. PCORI finalized its research priorities and released its first round of funding announcements in May 2012. How CER Works: As Sox pointed out, CER seeks to provide meaningful answers to questions about commonly used approaches in real-world settings. To achieve results, this methodology involves different types of studies. Barbara Tilley, PhD, the Lorne Bain professor and director in the division of biostatistics at the University of Texas School of Public Health, explained that researchers could explore questions by looking at databases and medical records and reviewing and combining results of existing studies or conducting clinical trials. Pragmatic trials, in which researchers enroll a broad sampling of patients and look at easy-tomeasure outcomes, are another good option for CER, Tilley said. Barriers to CER Unique to Transfusion Medicine: Transfusion medicine lacks a strong body of high quality evidence on which to
base CER. The field involves not only transfusion specialists but also numerous clinicians from other disciplines, so there has not been a strong network of investigators focused on the same topics. “Transfusion transcends so many diseases” that it may be overlooked as a subject for study in itself, said W. Keith Hoots, MD, director of the division of blood diseases and resources at NHLBI. Transfusion medicine research is complicated by “confirmation bias,” said John Roback, MD, PhD, associate professor of pathology and laboratory medicine at Emory University School of Medicine. Because transfusions usually are given to very sick people, “when the patient does poorly or dies after transfusion, we blame their underlying condition, and when they improve, we credit transfusion,” he noted. “But we don’t typically ask whether the transfusion could have contributed to their death in the first case, or delayed their recovery in the second scenario.” As another example, Tilley said a patient can be enrolled in a study but not survive long enough to receive a transfusion. This survival bias complicates research findings. Improving CER: As CER gains traction, more resources are available for investigators. Networks such as the NHLBI’s Transfusion Medicine Hemostasis Clinical Trials Network and Bone Marrow Transplant Clinical Trials Network and the Center for International Blood and Marrow Transplant Research facilitate broad research. Improving Care: With health care costs rising, we cannot afford treatments and tests that do not work. . “CER allows you to do large trials with less funding, and the economic situation is going to help force that issue. “[CER] is the kind of research that most directly affects patient care and public policy. Researchers appreciate that CER offers them “the ability to use their methods to improve clinical care and public health,” he added. Sox summed up the need for CER this way: “CER is very much focused on the doctor and the patient in the office making a better decision – one that is right for the patient.” Reference: Boden WE, Probstfield JL, Anderson T et al. Niacin in patients with low HDL cholesterol levels receiving intensive statin therapy. N Engl J Med 2011: Dec 15;365(24):2255-67.
CER EFFORTS UNDERWAY IN TRANSFUSION MEDICINE • Red Cell Storage Duration Study (RECESS): Prospective, multicenter NHLBI randomized controlled trial looking at the effect of duration of red blood cell (RBC) storage on clinical outcomes for cardiac surgery patients. • Informing Fresh versus Old Red Cell Management (INFORM) study: International, multicenter study of 25,000 patients evaluating the effect of RBC age on mortality following transfusion. • Age of Blood Evaluation (ABLE) trial: Pragmatic, multicenter Canadian trial assessing whether transfusion with fresh RBCs improves mortality among critically ill adults. • Pragmatic, Randomized Optimal Platelets and Plasma Ratios (PROPPR) trial: Randomized trial, jointly supported by NHLBI and the U.S. Department of Defense, comparing mortality rates between two standard ratios of plasma, platelets and RBCs among patients receiving massive transfusions. V I TA L S I G N S / O C T O B E R 2 0 1 2
32nd Annual Central Valley Cardiology Symposium November 10, 2012 Madera Municipal Golf Center 8:00am-3:30 pm FEATURED TOPICS AND SPEAKERS • Endovascular Treatment of Thoracic and Abdominal Aortic Aneurysms • Ischemic Heart Disease in Women: Diagnostic Approaches and Management • (TAVR) Percutaneous Aortic Valve Replacement in High Risk Patients with Aortic Stenosis • Current, Evolving and Futuristic Therapies for Management of Atrial Fibrillation • Management of Ventricular Arrhythmias, including breakthrough Vent Arrhythmias in patients with ICD • Appropriate Triage of Chest Pain in the ED: who to refer for workup, testing and who can be sent home Gabriel S. Aldea, MD, FAHA, Section Chief, Univ. of Washington Ezra A. Amsterdam, MD, FACC, Professor, Univ. of Calif., Davis Roger A. Winkle, MD, FACC, Silicon Valley Cardiology Medical Group INFORMATION: 559-224-4224 x 118 or firstname.lastname@example.org
O C T O B E R 2 0 1 2 / V I TA L S I G N S
Fresno-Madera SERGIO D. ILIC, MD Post Office Box 28337 Fresno, CA 93729-8337
1040 E. Herndon Ave #101 Fresno, CA 93720
WE WEAR DIFFERENT HATS
559-224-4224 Fax 559-224-0276
Medical Societies have the difficult task to represent all their members, and as you know, physicians come in all shades of opinions and have strong beliefs, and we are never wrong. The Society has to somehow provide an unified opinion on issues that may profoundly divide the members and other segments of society at large. Take Health Care Reform (ACA). Some members are for a completely socialized way of delivering medical care and feel the law doesn’t go far enough to accomplish this, while others are for a completely different form of delivery and preserving private practice as we know it. I strongly believe that the FMMS should be more active in presenting positions on issues like these in a public way through the local media, like The Fresno Bee or through interviews on radio and TV. Health Care Reform is an issue that will affect the health care delivery for years to come, and we need to be more forthcoming with our point of view. We need to make sure the issues are presented in a nonpartisan or biased way. If we are going to be relevant, we need to make our opinions known to the public. I hope The Fresno Bee prints the article I sent to them on trying to educate the public about the ACA. As Dr. Basil R. Besh, MD, Chairman of Orthopedics at Washington Hospital puts it, there are two things that are driving up medical costs in this country. The first is that there is a disconnect between consumers and payors. Patients demand services and don’t care what the actual costs are because they are “free.” MRI’s for example. Their insurance pays. The second is a disconnect between the doctor who prescribes and the payor (hospital or insurance). We prescribe new, very costly medications when older ones are cheaper and just as effective, and we don’t question the price of a prosthesis etc. I agree with these facts. Having immigrated from a country that had mostly socialize medicine, I can tell you I didn’t like it then, and I don’t like it now. There are better ways to reform health care delivery. One way that should be given more consideration is with Health Savings Accounts (HSA). Everyone should have a mandate to have one of them, starting at age 21 or so. That takes care of the above problems and gives the responsibility to the patient who pays the doctor, the hospital, the medications etc. It is the patient’s money, so they will spend it wisely. We wear different hats at different times. Sometimes we are serious; sometimes we are not. One of our members did not like the wine tasting and dinner social that we had in September because of the difficult times and the serious issues we are facing that could wipe out private practice as we know it. While this member is right, I feel that life continues, and we can’t stop having an enjoyable evening and some fun now and then. We are wearing a different hat. SAVE THE DATE General Membership Meeting 2012 INSTALLATION & AWARDS BANQUET Wednesday, November 7, 2012 • 6pm Roger Rocka’s Dinner Theater Featuring: • Installation: 2013 FMMS President Ranjit Rajpal, MD • Honoring: 2012 Physician Lifetime Community Service Award recipients John Bonner, MD and Joan Voris, MD • Benefitting: FMMS Foundation Includes dinner and show: “Singin’ in the Rain” Sponsorship opportunities: Contact email@example.com
website: www.fmms.org FMMS Officers Sergio Ilic, MD President Ranjit Rajpal, MD President Elect Prahalad Jajodia, MD Vice President Stewart Mason, MD Secretary/Treasurer Oscar Sablan, MD Past President Board of Governors A.M. Aminian, MD Hemant Dhingra, MD Ujagger-Singh Dhillon, MD William Ebbeling, MD Babak Eghbalieh, MD Ahmad Emami, MD David Hadden, MD S. Nam Kim, MD Constantine Michas, MD Khalid Rauf, MD Rohit Sundrani, MD Mohammad Sheikh, MD CMA Delegates FMMS President A.M. Aminian, MD John Bonner, MD Adam Brant, MD Michael Gen, MD Brent Kane, MD Kevin Luu, MD Andre Minuth, MD Roydon Steinke, MD Toussaint Streat, MD CMA Alternate Delegates FMMS President-elect Don H. Gaede, MD Prahalad Jajodia, MD Peter T. Nassar, MD Trilok Puniani, MD Dalpinder Sandu, MD Salma Simjee, MD Steven Stoltz, MD Rajeev Verma, MD CMA YPS Delegate Paul J. Grewall, MD CMA YPS Alternate Yuk-Yuen Leung, MD CMA Trustee District VI Virgil Airola, MD Staff: Sandi Palumbo Executive Director
V I TA L S I G N S / O C T O B E R 2 0 1 2
S K Y WAT C H E R S O F ANCIENT MEXICO Downing Planetarium October 17, 2012 This show examines the early culture and history of what is now called Mexico and Central America and their astronomical accomplishments. Skywatchers will take you to colorful cities with their large observatories and elaborate temples when they were the ruling centers of great civilizations. This exclusive FMMS showing is at the Downing Planetarium, a 74-seat Star Theater under a 30-foot hemispherical dome located on the CSU Fresno campus. Spend a fun and educational-filled evening with your family and guests learning about the importance of astronomical observations to these cultures. This show is designed for audiences grade six to adult.
Doors Open: 6:30 pm • Show time: 7:00 pm • Star Gazing: 8:15 pm (weather permitting) Cost: No Charge FMMS member • $6 non-FMMS member Tickets & parking passes held at door Confirmation & directions will be emailed No food or drinks allowed in theater Information: 224-4224 x firstname.lastname@example.org ***Limited Seating = must RSVP to attend
O C T O B E R 2 0 1 2 / V I TA L S I G N S
Fresno-Madera Educational Series and Economic Forum for FMMS Members OCTOBER 23, 6-7:30PM: “ECONOMIC UPDATE: ELECTION EDITION” Speaker: Neil Leahey, CIMA®, Regional Vice President Pioneer Investments Educational objectives: • Economic market outlook with focus on 2012 presidential election • Market sector implications for each potential election outcome The Economic Forum is held at The Daily Grill, Palm & Nees avenues, Fresno. Complimentary hors d’oeuvres and beverages will be served. Space is limited; RSVP as soon as possible to: Central Valley Physician Benefits: 559-492-9592 or info@medicalsocietybenefits. com.
CHARLES W. BEAM, MD 55-year member
Charles Beam, MD, a retired radiologist, passed away July 16, 2012, one month shy of his 91st birthday. Dr. Beam was born in Montana in 1921. After serving for six years in the US Navy, he received his medical degree from the University of Oregon in 1952 and completed his internship and residency training at Santa Barbara Cottage Hospital. Dr. Beam began his practice in Fresno in 1956 and retired in 1984.
THOMAS G. SAYEG, MD 54-year member
Thomas G. Sayeg, MD, a retired general surgeon, passed away June 4, 2012, at the age of 90. Dr. Sayeg was born in Fresno in 1922. He received his medical degree from the University of California in 1950 and internship and residency training at Fresno General Hospital. During his residency, Dr. Sayeg served from 1951-1953 in the US. Army. He began his general surgical practice in Fresno in 1957 and retired in 1992.
OCTOBER 25, 6-7:30PM: “FINANCIAL PLANNING BASICS” presented by Eric Van Valkenburg, CLU, CHFC and Amy Nuttall-Zwaan, CRPC, CSNA, Financial Consultants with Central Valley Physician Benefits This presentation will include: • Setting financial goals, such as retirement, college and/or estate conservation • Building a plan around those goals
Bringing business banking solutions to your community
• Investment Planning • Risk Management • Insurance Protection
Come in today and let us get to know you so we can provide your business with the financial resources and tools to help you reach your business goals.
• Credit Fundamentals Seminars are held at the Medical Society offices, 1040 E. Herndon Ave. #101 (NE corner of First/Herndon). Space is limited; RSVP to the Medical Society, 559224-4224, ext. 118 or to: email@example.com. A light meal will be available. Future topics: Nov. 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.
From left to right: Gil Lara 437-3163, Tom Andersen 437-3147, Brian Donovan 437-7628, Frank Gallegos 437-7600
V I TA L S I G N S / O C T O B E R 2 0 1 2
Kern HANS EINSTEIN, MD February 1923-August 2012 2229 Q Street Bakersfield, CA 93301-2900 661-325-9025 Fax 661-328-9372 website: www.kms.org
KCMS Officers Joel R. Cohen, MD President Wilbur Suesberry, MD President-elect Noel Del Mundo, MD Secretary Ronald L. Morton, MD Treasurer Portia S. Choi, MD Immediate Past President Board of Directors Alpha Anders, MD Brad Anderson, MD Eric Boren, MD Lawrence Cosner, MD John Digges, MD J. Michael Hewitt, MD Calvin Kubo, MD Melissa Larsen, MD Mark Nystrom, MD Edward Taylor, MD CMA Delegates: Jennifer Abraham, MD Eric Boren, MD John Digges, MD Ronald Morton, MD CMA Alternate Delegates: Lawrence Cosner, Jr., MD Patrick Leung, MD Michelle Quiogue, MD Staff: Sandi Palumbo, Executive Director Kathy L. Hughes Membership Secretary
A native of Berlin, Germany, Dr. Hans Einstein grew up in Holland and lived there until the age of 10. The Netherlands became his home for the next six years. He then traveled onto New York and onto Furman University in South Carolina. While living in Greenville, SC, Dr. Einstein met Albert Einstein’s son. The two struck up a friendly acquaintance and when Albert Einstein would come to visit his aon, Dr. Einstein would join them for dinner on numerous occasions. It turned out that their grandparents were first cousins. A graduate of New York Medical College, Dr. Einstein served a rotating Internship at Paterson General Hospital in New Jersey before moving to Bakersfield in 1951. He finished his Internal Medicine Residency at Kern County General Hospital (KMC). Dr. Einstein was Medical Director at the County Tuberculosis Hospital in Keene, CA for a year, followed by serving as the Tuberculosis Controller for the Kern County Health Department. After more than twenty-five years of practice, he left Bakersfield to join USC School of Medicine as a Barlow Professor of Respiratory Diseases. In 1988, Dr. Einstein returned to Bakersfield to serve as Director of Medical Education at Bakersfield Memorial Hospital. Shortly after, he was named Medical Director. In 1999, Dr. Einstein “Retired” from practice being known as the foremost authority on Valley Fever. Our medical community has truly lost a great man. As one KCMS member stated “Great physician – yet a very humble human being.” REMEMBERING HANS E. EINSTEIN, MD Portia Choi, MD Immediate Past-President, Kern County Medical Society
The last time I saw Dr. Hans Einstein, it was in the beginning of the summer 2012. He was at a community event promoting healthy living and the arts. He greeted those who came up to him and gave a warm hand shake, sometimes a kiss and conversation. He was in a wheelchair and with one of his daughters. About a month later, he was hospitalized and then, I understand, at home in hospice care. I first met Dr. Einstein in 1984 when he took care of my Father at the Barlow Respiratory Hospital, which was affiliated with University of Southern California Medical School. When my father did not improve he was referred for evaluation to Dr. Einstein. He looked at my father’s chest x-rays and immediately informed me that the films were typical for coccidioidomycosis pneumonia. My father improved and was cured of his disease under Dr. Einstein’s care. I met Dr. Einstein again at the Public Health Chest Clinic; and came to understand the enormity of his contribution to medical science. He has provided his expertise and energy in working toward developing a vaccine to prevent coccidoidomycosis (Valley Fever.) Dr. Einstein was very charming and engaging whenever he spoke about any topic and particularly about Valley Fever. He also understood the politics of achieving a vaccine, and had engaged the various sectors toward the development of it. He and others were involved in the effort that resulted in the formation of Valley Fever Vaccine Project, a consortium of six academic institutions and four research laboratories, with oversight provided by a committee composed of Kern County-based physicians plus public health and civic leaders. Dr. Einstein has been honored in numerous ways. The Kern County Department of Public Health, when they dedicated their new building, named their conference room Hans E. Einstein M.D. Education Center and the semicircular driveway in the front of the building is named Hans E. Einstein, MD Way.
O C T O B E R 2 0 1 2 / V I TA L S I G N S
Kings STEVE M. BEARGEON EXECUTIVE DIRECTOR
3333 S. Fairway Visalia, CA 93277 559-627-2262 Fax 559-734-0431 website: www.tcmsonline.org
TCMS Officers Gaurang Pandya, MD President Steve Cantrell, MD President-elect Thomas Gray, MD Secretary/Treasurer Steve Carstens, DO Immediate Past President Board of Directors Virinder Bhardwaj, MD Carlos Dominguez, MD Parul Gupta, MD Monica Manga, MD Christopher Rodarte, MD H. Charles Wolf, MD CMA Delegates: Thomas Daglish, MD Roger Haley, MD John Hipskind, MD CMA Alternate Delegates: Robert Allen, MD Ralph Kingsford, MD Mark Tetz, MD Sixth District CMA Trustee James Foxe, MD Sixth District CMA Alternate Thomas Daglish, MD Staff: Steve M. Beargeon Executive Director Francine Hipskind Provider Relations Thelma Yeary Executive Assistant Dana Ramos Administrative Assistant
PO Box 1029 Hanford, CA 93230 559-582-0310 Fax 559-582-3581
Executive Directorâ€™s Message 2012 CMA HOUSE OF DELEGATES
On Saturday, October 13 the CMA House of Delegates (HOD) will convene in Sacramento C.A. The Tulare County Medical Society (TCMS) has three delegates and three alternate delegates that participate in the democratic process of developing the medical policy of the California Medical Association. It is time to tip our hats to the local physicians who represent the TCMS as your representatives. Drs. Roger Haley, Thomas Daglish, John Hipskind, Mark Tetz, Robert Allen and Ralph Kingsford are our current representatives. They volunteer four days of their time to meet with their colleagues to discuss hundreds of resolutions. With that many resolutions, they spend a great deal of other time familiarizing themselves with the many debated issues. Our membership is very fortunate. Most medical societies cannot fill their slots for delegates and alternates who attend the HOD. Our delegation is present and participating and many times leading the discussion. When other societies have vacancies, our alternates are allowed to sit and vote in their absence. It is not uncommon for all six of our delegates and alternates to be seated the entire meeting. This allows the TCMS to have a strong voice. Representation at the HOD is divided into ten regional districts. Tulare County is included in the Sixth District, made up of Central Valley counties Kern through San Joaquin. Dr. Roger Haley is the Chairman of District VI and works with the Speaker of the House to run an efficient and productive meeting. District VI is fortunate to have Dr. Haleyâ€™s leadership skills. The HOD also allows participation by mode of practice. Dr. Gaurang Pandya has sat in the last two Houses as a representative of the Solo and Small Group Forum. This year Drs. Steven Porter, Andrea Espinosa and Pradeep Kamboj have also been named to the Solo and Small Group forum as delegates and alternate delegates. Dr. James Foxe has served on the Board of Trustees since the early 2000. It had been many years since the TCMS had a physician elected to the Board of Trustees. Dr. Foxe has served as Chairman of a number of committees of the Board, most recently the Nominations Committee. This is another example of the significance of the TCMS members and their contribution to organized medicine. Last but certainly not least, as we have previously announced, Dr. Ron Marconi has been selected as the recipient of the Fredrick K. M. Plessner award. This award is given annually to the physician who best exemplifies the ethics and practice of medicine in rural California. This will be done Saturday, October 13 in front of the House of Delegates. It is a proud moment when one of our members is honored for all he has given to our community. Many times I am asked; what does the Tulare County Medical Society do for me? It is with great pride I acknowledge those who serve on your behalf. Please see TCMS News on page 18
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
V I TA L S I G N S / O C T O B E R 2 0 1 2
Gar McIndoe (661) 631-3808 David Williams (661) 631-3816 Jason Alexander (661) 631-3818
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.
FOR LEASE 2701 16th St. – 2,400 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. 4000 Physicians Blvd – 5,883 rsf. 2204 “Q” Street – 3,200 rsf. 4040 San Dimas St. – 2,035 rsf. 9300 Stockdale Hwy. – 3,743 - 5,378 rsf. 9330 Stockdale Hwy. – 1,500-7,700 rsf.
Naeem Akhtar, MD, Ambreen Khurshid, MD and Mikhail Alper, PA-C at California Gastroenterology Associates are pleased to welcome Carlos C. Hernandez, MD to their practice. For appts. Call 559299-9395 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.
Cardiology practice in Bakersfield closing Sept. 15. All office furnishing, supplies and equipment for sale. Call for specifics and arrangement: 661-323-5976.
SUB-LEASE 4100 Truxtun Ave. – Can Be Split Medical Records & Offices Sprinklered – 4,764 usf. Adm. & Billing – 6,613 rsf. FOR SALE 1911 17th Street – 2,376 sf. Crown Pointe Phase II – 2,000-9,277 rsf. Meridian Professional Center – 1,740-9,260 rsf. 9900 Stockdale Hwy. – 2,000-6,000 rsf.
Professional/Medical Office for Lease Cambridge Court
FOR RENT / LEASE 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. FresnoTimeshare. Newly renovated furnished office in medical complex. Includes internet. No minimum. Reasonable rate. firstname.lastname@example.org
2,466 sf medical/dental office at 924 Emily Way, Madera. $400,000 or for lease at 50¢ sf. Contact Brett Visintainer at 559447-6265 or email@example.com
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
October 25, 2012 St. Paul Newman Center Providing support to local programs for the underserved $50 per person
Carl Abercrombie 559-227-4658 c: 559-970-9035 Jim Abercrombie 530-626-0321 18
O C T O B E R 2 0 1 2 / V I TA L S I G N S
1,800 sf. medical space in Porterville in prime location w/ ample parking. Available FT or PT, brand new, 5 private exam rms. Contact Casey, 559-784-4925.
PHYSICIAN/PROVIDED WANTED FT opening for MD in busy practice in Visalia. Offering full benefit package and more. Contact Rhonda: 559-627-2333 or firstname.lastname@example.org.
TCMS News Continued from page 17
Dr. John L. Maffeo Memorial Award & Fundraiser Dinner
with five exam rooms
FOR RENT / LEASE
6335 N. Fresno Street, Fresno
NEWLY REMODELED 1,200 sq.ft. office
Call Mary Renner 559-255-4300
HOME GENERATED MEDICAL SHARPS DROP OFF
will begin col lecting home-generated medical sharps at each of its quarterly Dump On Us events hosted at the City of Visalia Corporation yard (335 N. Cain St.). Dump On Us events are held each January, April, July and October. Medical sharps include needles, syringes and lancets. All sharps must be placed in an approved sharps container. Limit of 24, 1.4 liter sharps containers (or equivalent) per person. No drugs or medicines accepted. Service is limited to City of Visalia residents only. For additional information, please call the City of Visalia Solid Waste Department at 559-713-4500.
So what can you do? Ëž Ëž
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October 2012 Vol. 34 No. 10