Vital Signs March 2013

March 2013 • Vol. 35 No. 3Official Magazine of

FRESNO COUNTYFresno-Madera Medical Society

KERN COUNTYKern County Medical Society

KINGS COUNTYKings County Medical Society

MADERA COUNTYFresno-Madera Medical Society

TULARE COUNTYTulare County Medical SocietyTulare County Medical Society

March 2013 • Vool. 35 No. 3

Vital SignsSee Inside:

CMA Year in Review

CMS Releases Final Rule on Physician Payment Disclosure

Implementation of Several Affordable Care Act’s Provisions Delayed

Register Now forYosemite Postgraduate Institute

See Inside:

CMA Year in Review

CMS Releases Final Rule on Physician Payment Disclosure

Implementation of Several Affordable Care Act’s Provisions Delayed

Register Now forYosemite Postgraduate Institute

2 MARCH 2013 / V ITAL S IGNS

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VITAL S IGNS / MARCH 2013 3

Official Publication of

Fresno-Madera Medical Society

Kings County Medical Society

Kern County Medical Society

Tulare County Medical Society

March 2013Vol. 35 – Number 3

Editor, Bonna Rogers-Neufeld, MDManaging Editor, Carol Rau

Fresno-Madera Medical SocietyEditorial CommitteeVirgil M. Airola, MDJohn T. Bonner, MDHemant Dhingra, MDDavid N. Hadden, MDRoydon Steinke, MD

Kings RepresentativeTBD

Kern RepresentativeJohn L. Digges, MD

Tulare RepresentativeThelma Yeary

Vital Signs SubscriptionsSubscriptions to Vital Signs are$24 per year. Payment is due inadvance. Make checks payable tothe Fresno-Madera Medical Society.To subscribe, mail your check andsubscription request to: Vital Signs,Fresno-Madera Medi cal Society,PO Box 28337, Fresno, CA 93729-8337.

Advertising Contact:Display:

Annette Paxton,559-454-9331

[email protected]

Classified:Carol Rau,

559-224-4224, ext. [email protected]

ContentsVitalSigns

Vital Signs is published monthly by Fresno-Madera Medical Society. Editorials and opinion piecesaccepted for publication do not necessarily reflect the opinion of the Medical Society. All medicalsocieties require authors to disclose any significant conflicts of interest in the text and/or footnotes ofsubmitted materials. Questions regarding content should be directed to 559-224-4224, ext. 118.

NEW VITAL SIGNS EDITOR Vital Signs’ Editorial Board announces the election of Bonna Rogers-

Neufeld, MD, FACR as the new chair of the Editorial Board and Editor ofVital Signs. Dr. Rogers-Neufeld encourages all members of Fresno-Madera,Kern and Tulare counties’ medical societies to consider submitting articlesand opinion pieces that are of relevance to the medical community to thepublication. She can be reached at [email protected].

Cover photography: “Woodward Park Geese” by Don H. Gaede, MDEquipment used: Canon 60D, 18-135mm lens, ASO 100, 1/200, F/8

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

CMA NEWS ................................................................................................................................5

NEWS

CMA Year in Review ................................................................................................................9

2013 CMA Education Webinar Series.....................................................................................11

CMS Releases Final Rule on Physician Payment Disclosure .....................................................11

HEALTHCARE REFORM: Implementation of Several Affordable Care Act’s Provisions Delayed......12

2013 Yosemite Postgraduate Institute ...................................................................................13

AIR QUALITY: Proposed Medical University at Mllerton Lake: Good or Bad Idea? .......................13

CLASSIFIEDS ...........................................................................................................................18

TULARE COUNTY MEDICAL SOCIETY.........................................................................................14

• GME at KDMC: What It Means to Me

• Save the Date: TCMS Annual Wine Social, May 3

• Selfless Service in Tulare County Honored

KERN COUNTY MEDICAL SOCIETY ............................................................................................15

• Membership News

FRESNO-MADERA MEDICAL SOCIETY .......................................................................................16

• President’s Message

• Walk With A Doc Dates Released

• Financial Education Seminar Series for FMMS Members



CMA NEWSPhysicians should be aware that the terms of the various

contracts sent to physicians may vary and should be reviewedclosely. For example, physicians may be locked into the UMVScontract with no ability to terminate from one to five years,depending on the termination clause in their specific contract.

Additionally, the Network Providers section of some contractsstates that in the event a provider refers a beneficiary to an out-of-network provider without a referral or prior authorization, thereferring physician will be responsible for payment of the claimsincurred. CMA expressed concern with this provision and as aresult, UMVS later removed this language. However, CMA isseeking clarity from UMVS on how they are handling thosecontracts that went into effect before the language change.

CMA is also seeking clarification on language in theRecoupments section, which states UMVS may seek anoverpayment “at any time.” CMA is concerned that thislanguage may not be consistent with federal regulations, whichlimits TRICARE contractor’s ability to pursue overpayments to10 years, except in cases of fraud.

Physicians should also note that per the Prior Authorizationsection, in emergent situations physicians are required to notifyUMVS within 24 hours of providing services that would typicallyrequire a prior authorization. UMVS then has the “final bindingauthority” to decide whether a medical emergency existed and, ifnot, providers will not be reimbursed and cannot bill the patient.CMA continues to work with UMVS to obtain clarity on theseprovisions and will publish updates as they are available.Physicians with questions about the TRICARE network andcontract can call UMVS at 800-718-7572.

CMA PUBLISHES UPDATED ANALYSIS OFBLUE CROSS PRUDENT BUYER CONTRACTThe California Medical Association (CMA) has published anupdated analysis of the Blue Cross Prudent Buyer Contract. It isavailable free to members on our website at www.cmanet.org/ces.

CMA offers members free access to objective analyses ofseveral health plan participating provider contracts. While theseanalyses are not intended to be exhaustive, they are designed todraw a physician’s attention to issues that may warrant furtherinquiry or clarification.

As a reminder, CMA cannot make recommendations as towhether a physician should sign a particular contract, or whethera specific contract is good or bad. Our goal is to provide enoughinformation for physicians to make educated decisions beforesigning contracts.

CMA urges physicians to carefully review and understand thevast range of legal and practical implications associated with theexecution of any contract for the delivery of medical services, aswell as the associated management and administrativeimplications.

For additional information on evaluating and negotiatingcomplex managed care contracts, see CMA’s contracting toolkit,Taking Charge: A step by step guide to evaluate and prepare fornegotiations with managed care payors. The toolkit is availablefree to members at www.cmanet.

AMICUS BRIEFS FILED IN SUPPORTOF CMA’S SUIT TO PREVENT STATE CUTSTO MEDI-CAL REIMBURSEMENTA large number of national health care organizations have filedamicus curiae briefs in support of the California MedicalAssociation’s (CMA) request for an en banc review by the NinthCircuit Court of Appeals. The review is part of an effort to stopthe State of California from implementing a 10 percent cut toMedi-Cal provider reimbursement rates.

Last month, a three judge panel of the Ninth Circuit ruledthat the state could move forward with the rate cuts, passed bythe Legislature in the spring of 2011, despite an earlier districtcourt ruling that found that the cuts would irreparably harm themillions of patients who rely on Medi-Cal for health care.

CMA and the other plaintiffs in CMA et al. v. Douglas et al.– California Hospital Association, California Dental Associ -ation, California Pharmacists Association, National Associationof Chain Drug Stores, California Association of Medical ProductSuppliers, AIDS Healthcare Foundation and American MedicalResponse – argue that reducing payments in the Medi-Cal systemwill force providers out of the program at a time when millions ofnew patients will be diverted into the Medi-Cal system.

Those organizations signing the briefs include: NationalHealth Law Program, AARP, National Senior Citizens LawCenter, Public Interest Law Project, Asian Law Alliance.California Advocates for Nursing Home Reform, WesternCenter on Law and Poverty, Arizona Center for Law in thePublic Interest, Disability Rights Center, Disability Law Centerof Alaska, Disability Rights Idaho, Hawaii Disability RightsCenter, Disability Rights California, Alaska State Hospital andNursing Home Association, American Hospital Association,Arizona Hospital and Healthcare Association, HealthcareAssociation of Hawaii, Idaho Hospital Association, MontanaHospital Association, Nevada Hospital Association, OregonAssociation of Hospitals and Health Systems and theWashington State Hospital Association.

The lawsuit to prevent the cuts was originally filed by CMAin November 2011.

DID YOU RECEIVE A TRICARE CONTRACT FROM UMVS?As previously reported, UnitedHealth Military & VeteransServices (UMVS) began soliciting physician participation in itsnew provider network, which will serve TRICARE beneficiariesbeginning April 1, 2013. While some physicians may havereceived the contract notices as early as September 2012, othersreport they did not receive the contracts until January 2013.The California Medical Association (CMA) has learned UMVSsent three different notices to physicians. One notice went tophysicians whose United contracts do not permit unilateralamendments, inviting them to participate in the TRICAREproduct and asking them to sign and return the enclosedamendment. Another notice went to physicians whose Unitedcontracts do allow unilateral amendments, advising they wouldbe automatically opted into the UMVS TRICARE productunless they opted out in writing within 30 days of receipt of theletter. A third notice went to physicians who are not currentlycontracted with United, but are contracted through TriWest forthe TRICARE product, asking them to sign a UMVS contract. Please see CMA News on page 6


HHS MAKES SWEEPING CHANGESTO HIPAA PRIVACY ANDSECURITY RULES

The Department of Health and HumanServices (HHS) Office for Civil Rightshas released a final rule implementing awide range of changes to the HealthInformation Portability and Account -ability Act’s (HIPAA) privacy, security,enforcement and breach notificationrules. The long-awaited “omnibus” finalrule is based on statutory changesmandated by the 2009 Health InformationTechnology for Economic and ClinicalHealth (HITECH) Act and the GeneticInformation Nondiscrimination Act of2008. The rule provides patients withincreased protection and control of theirprotected health information, expands theHIPAA privacy and security requirementsto business associates and increasesenforcement authority and penalties.

“Much has changed in health caresince HIPAA was enacted over fifteenyears ago,” HHS Secretary KathleenSebelius said in a news release coordinated

CMA NEWSContinued from page 5

How Successful IsYour Practice?

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with the posting of the 563-page rule inthe Federal Register. “The new rule willhelp protect patient privacy and safeguardpatients’ health information in an ever-expanding digital age.”

The rule expands individuals’ rights toreceive electronic copies of their medicalrecords and provides patients the right toinstruct health care providers to restrictdisclosure of information to health plansin certain circumstances for treatmentthat is paid for out-of-pocket and in full. Italso sets new limits on the use of patientinformation for marketing and fundraisingpurposes and prohibits the sale of healthinformation without their permission.

Additionally, the final omnibus ruleclarifies when breaches of unsecuredhealth information must be reported toHHS, makes business associates directlyliable under HIPAA and increases pen -alties for noncompliance to a maximumpenalty of $1.5 million per violation.

“This final omnibus rule marks themost sweeping changes to the HIPAAPrivacy and Security Rules since they werefirst implemented,” said Leon Rodriguez,director of the Office for Civil Rights atHHS.

To comply with the new rule, physicianoffices will need to make significantchanges to their Notice of PrivacyPractices, business associate agreements, aswell as their privacy and security policies.The California Medical Associ ation(CMA) will be developing and updatingresources including model agree ments andpolicies in the coming months to helpphysicians comply with the new rule.

Official publication of the new rule inthe Federal Register is scheduled for Jan.25. The final HIPAA omnibus rule iseffective March 26, 2013. Coveredentities, including most physicians, andbusiness associates must comply withapplicable requirements by September 23,2013.

The new omnibus rule will also becovered in CMA’s February 6 webinar,“HIPAA Compliance: The FinalHITECH Rule.” The one-hour webinar isfree to CMA members. For infor mation, orto register, visit: www.cmanet.org/events.

Contact: Lisa Matsubara, 800-786-4262 [email protected].

Continued on next page


OBAMA SAYS PHYSICIANS CAN ASK PATIENTS ABOUTGUNS WITHOUT FEAR OF BREAKING THE LAWPresident Barack Obama last week clarified language in the2010 Affordable Care Act (ACA) that many health providers hadtaken to mean a ban on discussing gun ownership with patients.

Medical groups across the nation had expressed concernsabout whether they could discuss gun safety with patientsbecause of the little-noticed section of the ACA that prohibitsthe collection of gun ownership data by the Department ofHealth and Human Services (HHS). It also restricts wellness anddisease prevention programs run by insurers from requiring thecollection of data on individuals’ guns.

“Doctors and other health care providers also need to be ableto ask about firearms in their patients’ homes and safe storage ofthose firearms, especially if their patients show signs of certainmental illnesses or if they have a young child or mentally illfamily member at home,” Obama said during yesterday’s pressconference unveiling his new gun control plan.

“The Affordable Care Act does not prohibit or otherwiseregulate communication between doctors and patients, includingabout firearms,” the president’s gun-control plan notes.

Obama also ordered the HHS to “conduct or sponsor researchinto the causes of gun violence and the ways to prevent it.” Hedirected HHS to begin by identifying the most pressing researchquestions with the greatest potential public health impact andassessing existing public health interventions being implementedacross the nation to prevent gun violence.

AMA ANNOUNCES $10 MILLION INITIATIVETO REDESIGN MEDICAL EDUCATIONThe American Medical Association (AMA) has invited medicalschools to submit proposals for “bold, innovative projects” totransform medical education. Medical schools would receive partof a $10 million pot of money over the next five years to fundprojects that support a significant redesign of undergraduatemedical education.

“Rapid changes in health care require a transformation in theway we train future physicians,” said AMA President Jeremy A.Lazarus, MD, yesterday via a live streaming conference withmedical schools and medical students. “The AMA is deeply com -mitted to redesigning undergraduate medical education to preparethe medical students of today for the health care of tomorrow.”

He said funding would be awarded to medical schools fordeveloping new methods for teaching, training medical studentsfor patient safety, performance improvement and patient-centered team based care, improving students understanding ofthe health care system and finance; and enhancing thedevelopment of professionalism.

“In keeping with the AMA’s historic leadership in all levels ofphysician education, we are excited to continue our work toimprove medical education for patients and physicians,” said Dr.Lazarus. “We hope to find and support proposals to developinnovative new education models that can be duplicated inmedical schools across the country.”

From the initial pool of proposals, the AMA will invite a selectgroup of medical schools to submit a full proposal by May 15, 2013

CMA NEWSand will conduct a thorough review of all materials beforeannouncing the selected schools at its annual meeting in June2013.

For more information about the initiative and to view a shortvideo, visit www.changemeded.org.

NINE NEW CALIFORNIA MEDICARE ACOSAPPROVED BY CMSIn early January, the Centers for Medicare & Medicaid Services(CMS) announced the selection of 106 new Accountable CareOrganizations (ACOs) to participate in the Medicare Shared SavingProgram. This includes nine new ACOs with California serviceareas. The new California ACOs brings the state’s total to 24.

ACOs are organizations formed by groups of physicians andother health care providers who have agreed to work together tocoordinate care for Medicare patients. The Medicare SharedSavings Program, and other initiatives related to ACOs, wasmade possible by the Affordable Care Act.

The 106 ACOs announced last week bring the total numberof organizations participating in Medicare shared savingsinitiatives to 250.According to CMS, the new ACOs include a diverse cross-section of physician practices across the country. Roughly half ofall ACOs are physician-led organizations that serve fewer than10,000 beneficiaries. Approximately 20 percent of ACOs includecommunity health centers, rural health clinics and critical accesshospitals that serve low-income and rural communities.The nine newest California ACOs include Accountable CareClinical Services PC, San Diego Independent ACO, AffiliatedPhysicians IPA, Akira Health, Inc., APCN-ACO, Cedars-SinaiAccountable Care, Meritage ACO LLC, National ACO and theUCLA Faculty Practice Group.Fifteen of the new ACOs qualified to be “Advance PaymentACOs,” a model designed especially for solo and small groupphysician practices or hospitals and doctors that work in remoterural areas – entities who would benefit from greater access to upfront capital to invest in staff, electronic health record systems orother infrastructure required to improve care coordination.Medicare will recoup advance payments over time through futureshared savings. Golden Life, located in Sacramento, is the onlyCalifornia ACO participating in the Advanced Payment Model.

PROBLEMS GETTING PAID?The California Medical Association’s Center for EconomicServices provides direct reimbursement assistance to CMAphysician members and their office staff.

Reimbursement Help Line: 888-401-5911• One-on-one educational and reim burse ment assistance tophysician members and their staff

Practice Empowerment• Tools and resources to empower physician practices• Seminars and toolkits for physicians and their staffExperienced Staff• Staffed by practice management experts with a combinedexperience of over 125 years in medical practice operations

Need help? Contact CMA’s reimburse ment experts at 888-401-5911 or [email protected].

Continued from page 6


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CMA NEWS

Since 1856, the California Medical Association (CMA) has been a national leader inphysician advocacy. Here are some of the ways CMA was working for you in 2012.

Defending California physicians and their most vulnerable patients

• In February 2012, as a result of CMA’s lawsuit, a California judge issued an injunction preventing the statefrom imple menting a 10 percent cut to Medi-Cal reimbursement rates that was included in the previousyear’s budget. That ruling has since been overturned, but CMA will be requesting a rehearing before thefull Ninth Circuit Court of Appeals, preventing the cuts from impacting physicians and their patients.

• Due to CMA’s continued advocacy in Washington, DC, physicians providing care to Medicare patientsavoided, once again, a roughly 27 percent cut to reimbursement rates that would have come due to theprogram’s flawed Sustainable Growth Rate (SGR) formula.

• Through CMA’s Center for Economic Services, member physicians have been able to recoup nearly $7 million in contested claims from payors in the past three years.

A force in California’s capitol

• In 2012, CMA undertook an aggressive legislative package focusing primarily on immunization policyand public health. After months of work, the highlight of this package, Assembly Bill 2109, was signedinto law. The bill will require parents seeking to forgo mandatory childhood immunizations via a“personal belief exemption” to first meet with a physician and discuss the potential risks associated withthat decision.

• CMA was, again, called upon to halt an attempt by MICRA opponents to scuttle California’s longstanding malpractice protections. The bill, Senate Bill 1528, was introduced in the final hours of the 2012legislative session, and due to CMA’s aggressive grassroots advocacy, died on the floor with a remarkablyweak show of support.

A presence in the polling place

• In 2012, CMA’s political advocacy committee, CALPAC, enjoyed incredible success. During theNovember election, the vast majority of CALPAC backed candidates emerged from their contestsvictorious. Included in this group was Assemblymember Richard Pan, MD, a pediatrician and CMAmember who was elected to his second term in the state’s lower house and will also serve as chair of theAssembly Committee on Health.

• On the federal side, two CMA physician members, Raul Ruiz, MD, and Ami Bera, MD, will be headingto Washington, DC, to begin terms in House of Representatives. With the support of CALPAC, bothRuiz and Bera were successful in unseating powerful and well-financed incumbents.

A commitment to public health

• Throughout the year, CMA and its partner non-profit, the CMA Foundation, have lent support to severalpublic health campaigns, including those working to prevent ailments such as cervical cancer, obesity andchronic obstructive pulmonary disorder, helping ensure a healthier California.

For more information about CMA and its programs visit www.cmanet.org.

(Rev. 1-29-13)

2012: A year in review


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CMA NEWSCMS RELEASES FINAL RULEON PHYSICIAN PAYMENT DISCLOSURE

CMS has released a long-awaited final rule on the PhysicianPayments Sunshine Act, outlining a timeline for itsimplementation, Modern Healthcare reports (Lee, ModernHealthcare, 2/1).

Details of Final Rule Under the final

rule, manufacturersof pharma ceuticaland biological drugs,medical devices andmedical supplies –covered by Medicare,Medi caid and CHIP – starting Aug. 1 will be expected to reportall transfers of monetary value over $10 to physicians andteaching hospitals (Bunis, CQ HealthBeat, 2/1).

The types of transfers that must be reported includecharitable contributions, consulting fees, honoraria, and food,entertainment and travel reimbursements, The Hill’s“Healthwatch” reports (“Healthwatch,” The Hill, 2/1). Inaddition, the manufacturers and group purchasing organizationswill be responsible for reporting physician ownership andinvestment interests.

CMS set the Aug. 1 start-date for data collection to give theaffected entities time to prepare, officials said. All datacollected from August through December must be reported toCMS by March 31, 2014, according to the rule (CQ HealthBeat,2/1). The agency will publish the data on a public website bySept. 30, 2014, one year later than the date originally set in theACA (Modern Healthcare, 2/1). CMS is creating an electronicsystem to help facilitate the reporting process, according to CQHealthBeat (CQ HealthBeat, 2/1).

Physicians will be given a 45-day “review and correction”period to ensure the accuracy of any disclosures to CMS,according to the final rule. The rule also notes that theSunshine Act overrides similar state laws, creating thepossibility of “cost-savings, since a single reporting system forreporting this information is less burdensome than multipleprograms” (“Healthwatch,” The Hill, 2/1).

The final rule is scheduled for publication in the FederalRegister on February 8 (Frieden, MedPage Today, 2/1).

Jeremy Lazarus, president of the American MedicalAssociation, in a statement said the AMA will “carefullyreview” the rule, adding, “As the rule is implemented, we willwork to make sure physicians have up-to-date informationabout the new reporting process” (MedPage Today, 2/1).

DID YOU KNOW:Medicare receives over 1.2 billion claims per year? This

equates to:• 4.6 million claims per day• 575,000 claims per hour• 9,580 claims per minute• 160 claims per second

Source: AAOS Dec 2012

CMS NEWS

Education Series

Most webinars are FREE for CMA members, $99 for non-members.CMA members are eligible for special discounts on

ICD-10-CM Training from AAPCQuestions? CMA Member Help Center: 800-786-4262

Please note: this calendar is subject to change.Visit www.cmanet.org/events for updates.

Calendar updated 12/21/12

CMA Center for Economic ServicesWebinars At-A-Glance

March 6:Fraud and Abuse: Dangers and DefensesDHCS • 12:15-1:15pm

March 7:Essentials for ICD-10-CM: Part 1AAPC • 7:45-8:45am or 12:15-1:15pm

March 13:Utilizing the New State Disability Insurance (SDI) OnlineSystemEDD • 12:15-1:15pm


March 20:EHR Selection – Top 10 Tips for SuccessDavid Ginsberg • 12:15-1:15pm


March 27:Medi-Cal Affordable Care UpdateDHCS • 12:15-1:15pm

April 3:Strategic Planning From Vision to Action –A Self-Guided ProcessRachel Smith • 12:15-1:15pm

April 10:Preparing for EHR Implementation and ConversionDavid Ginsberg • 12:15-1:15pm

April 17:Valuing, Selling, Buying or Transitioning a PracticeDebra Phairas • 12:15-1:15pm

April 24:California’s Health Benefit Exchange: How it Will Impact Your Practice and Change Commercial InsuranceBrett Johnson • 12:15-1:15pm


IMPLEMENTATION OF SEVERAL AFFORDABLE CAREACT’S PROVISIONS DELAYEDThe Obama administration has missed the deadline forimplementing several Affordable Care Act provisions, as itfocuses on meeting the law’s requirements for the healthinsurance exchanges and the Medicaid expansion, Kaiser HealthNews/MedPage Today reports.

The four ACA provisions scheduled to take effect Jan. 1, 2013that are delayed are:

• Increased reimbursements for primary care physicians whotreat Medicaid beneficiaries;

• Changes in how hospitals and physicians are paid throughMedicare;

• Increased federal funding for states that eliminatecopayments for preventive care; and

• Guidance on how states are to implement a new coverageoption called the “basic health program,” which is aimed athelping low- and middle-income families who do notqualify for Medicaid gain coverage.

The administration has issued guidance on all but one of theprovisions, the basic health program. According toKHN/MedPage Today, that delay means that certain low- andmiddle-income families in states that already use federal fundingto offer applicable coverage – including Minnesota, New Yorkand Washington – might not have access to affordable coveragein 2014, because those states are scheduled to end their programsin anticipation of the basic health program’s implementation.HHS said that the rules for the basic health program would bereleased soon.

According to KHN/MedPage Today, guidance on theincreased Medicaid physician reimbursements was not releaseduntil November 2012, and a number of states have not yet hadtime to implement the change. CMS said that physicians will beable to collect increased reimbursements retroactive to Jan. 1once the states implement the provision (Galewitz, KaiserHealth News/Medpage Today, 2/2).

QUESTIONS LINGER ABOUT IMPLEMENTINGACA’S MEDICAID EXPANSION

With less than one year before the Affordable Care Act’sMedicaid expansion takes effect, questions continue to lingerabout expansion costs, whether states will cooperate with thefederal plan and a potential shortage of providers to meet theneeds of a larger pool of insured U.S. residents, the SacramentoBee reports.

An estimated eight million people are expected to obtainhealth insurance under the expansion in its first year, whichobservers say would be the largest one-year bump in enrollmentin Medicaid’s history (Pugh, Sacramento Bee, 2/13).

Matt Salo, executive director of the National Association ofMedicaid Directors, said every state that has implemented sometype of expansion in their Medicaid programs in the past has seenhigher-than-expected enrollment numbers, adding that “thepeople that show up are sicker” than the states expected.

Most of the eight million newly enrolled Medicaidbeneficiaries in 2014 are expected to be low-income adultswithout children, according to the Bee. The rest of the new

HE A LT HC AR E R E F ORM

beneficiaries are expected to include low-income parents whoseannual earnings exceed current eligibility requirements and low-income individuals with disabilities who do not qualify for theSupplemental Security Income program (Sacramento Bee, 2/13).

In related news, about $2 billion in Medicaid funding is spentannually on emergency care for patients who mostly areundocumented immigrants, Kaiser Health News reports. Thefunding, which has not been widely publicized, has beenavailable since the late 1980s and makes up less than one percentof the program’s total costs.

According to KHN, the funding “underscores the politicaland practical challenges” of declining to provide health benefitsto undocumented immigrants. During the health reform debatein 2010, Democrats pledged to block the group from obtaininghealth benefits under the ACA. President Obama renewed thatpledge when he released his immigration reform plan last month.

Federal law requires hospitals to treat all patients seekingemergency care, regardless of their citizenship or insurance status.While providers are prohibited from asking patients about theirinsurance or citizenship status, providers are able to determinetheir status if they are unable to provide a Social Security numberor birth certificate.

Hospital officials and researchers who have studied theEmergency Medicaid funding program have reported that most ofthe funding is allocated for reimbursements to hospitals thatdeliver babies for women who enter their emergencydepartments.

A KHN analysis of data from seven states that are believed tohave the highest undocumented immigrant populations foundthat the money goes toward emergency services for more than100,000 individuals annually. California hospitals are recipientsof nearly 50% of the funding.

LAWMAKERS PROPOSE BILL TO PERMANENTLYREPEAL MEDICARE SGR FORMULA

Reps. Joe Heck (R-Nev.) and Allyson Schwartz (D-Pa.)unveiled legislation (HR 574) that would permanently repeal thesustainable growth rate formula, which sets Medicare physicianreimbursement rates, The Hill’s “Healthwatch” reports.

Congress routinely has passed legislation to delay cuts calledfor by the SGR, but physicians face substantial reductions intheir Medicare reimbursements each time the “doc fix” expires(Baker, “Healthwatch,” The Hill, 2/6). The most recent doc fixdelayed the cuts until Jan. 1, 2014, at which time physicians facea 25 pecent reduction to the Medicare reimbursement rates.

HR 574 would maintain current physician reimbursementlevels through next year. It then would instruct CMS to developand test new payment models for the following five years. From2015 to 2018, reimbursement rates would increase by 2.5 percentannually for primary care physicians and 0.5 percent for all otherdoctors (Ethridge, CQ Roll Call, 2/6).

Physicians then would be called to adopt a replacement modelapproved by CMS (Daly, Modern Healthcare, 2/6). According to“Healthwatch,” the legislation aims to replace the SGR with asystem that rewards physicians for quality care, instead of thecurrent fee-for-service system (“Health watch,” The Hill, 2/6).

Please see Healthcare Reform on page 17

I’ve got to admit, on the surfaceit sounds pretty appealing. I’mspeaking about the healthsciences university proposed forthe hills overlooking beautifulMillerton Lake. In the samescenic area, the Tesoro Viejo andFriant Ranch proposals are alsobeing planned. But this is notsmart growth. And it is not sustainable growth.

Several questions cry out for answers: How dothese developments fit in with the SustainableCommunities Strategy now being fleshed out by theFresno Council of Governments and our state? Andhow do these plans fit in with Fresno City’s GeneralPlan, which calls for more in-fill, and less sprawl?

The proposed developments, located about 25miles from downtown Fresno, would clearly increasethe number of vehicle miles traveled. How would thedevelopers mitigate the significant increase in airpollutants caused by all that extra driving? Howwould these plans address the increased productionof greenhouse gases, as mandated by SB 375? Andfinally, how will these foothill projects protect ourwater resources, protect the core of our cities, helpour local economy, and preserve our beautifulfoothills?

Fresno city and other opponents of the develop -ment say such sprawl will bring additional problemsof traffic, air pollution and loss of farmland.

“It shouldn’t be lost on people that when new development leapfrogs, existingneighbor hoods suffer,” said Fresno City Manager Mark Scott, who fears projects such asthe university could siphon money and resources away from urban areas. “There is somuch opportunity to develop in the center of cities that already exists.”

The population of our Valley is expected to grow significantly over the next fewdecades, so there is a need for more schools to train healthcare workers, includingphysicians. The ideal place for such schools would be near where we already trainphysicians: Community Regional Medical Center.

The plans for major foothill development already have support from local officials,and developers hope to break ground in 2015. So time is of the essence. I encouragephysicians to let our public officials know about your concerns.

Author can be reached at [email protected].

Read more here:http://www.fresnobee.com/2013/01/12/3131408/fresno-developers-plan-medical.html#storylink=cpy


A I R Q U A L I T Y

Proposed Medical Universityat Millerton Lake:Good or Bad Idea?

Don H. Gaede, MDEdited by Michelle Garcia, Air Quality Director

THE FRESNO BEE

SAVE THE DATE:

April 12-14,2013

2013 YOSEMITEPOSTGRADUATE

INSTITUTEYosemite National Park

presented by

Information: [email protected] 559-224-4224x 118

Don H. Gaede, MD


Graduate Medical Education atKaweah Delta Medical Center:

What It Means to MeThomas L Gray, MD, TCMS Vice President

Actually this should read: what it means to you/us/the Medical Staff/theCommunity. More about that in a minute but first a brief review.

Six years ago representatives from the Medical Staff and Administration were exploring liaisons withtraining facilities as a means of increasing our referral base and improving physician recruitment to thearea. Efforts to reach out to regional GME providing institutions failed. Lindsay Mann, CEO of KDMC,then sent letters to every training program in the state soliciting interest. UC Irvine responded positivelyand over the next year visits were made. Meetings were held and a proposal was generated to developKaweah Delta residency programs affiliated with University of California, Irvine. This was affirmed andsupported by the medical staff and the hospital board. Funds for GME were allocated and ProgramDirectors were recruited. PlFs (Program Information Forms – applications for accreditation) werewritten, revised and approved. In July 2013 – that's just four months away – two residency programs willgo live! Candidates are currently interviewing for the Family Medicine and Emergency Medicineresidencies. These candidates are first rate! Meanwhile the program accreditation applications continuefor psychiatry and transitional year programs which hopefully will start in 2014 and 2015 respectively.The District is actively recruiting for a Program Director for a General Surgery Residency.

How will this affect me/you? First, when you come to the hospital next summer; you will see 12 newfaces. They will be eager to see patients, learn about your practice and, of course, do procedures. Andthey will be scattered throughout the hospital. The residents will be doing rotations on the major servicesduring their first year. For instance, Emergency Medicine residents will spend only 10 weeks in the EDduring their PGY-l year. The other thirty-eight weeks clinical rotations will be spent on other services:Pediatrics, Adult Medicine, Critical Care, Anesthesia, General Surgery and OB. So, unless you are apathologist, physiatrist or psychiatrist – anticipate interacting with our residents at the downtowncampus (BTW, Drs. Hewitt, Mills and Nasr have all told me privately that the really astute residents willall want to rotate through their services).

What will you have to do? If you belong to a contracted service you already have the advantage ofworking with residents on rotation. After a brief orientation, the residents will be seeing patients with

Tulare

3333 S. FairwayVisalia, CA 93277

559-627-2262Fax 559-734-0431

website: www.tcmsonline.org

TCMS OfficersSteve Cantrell, MD

President

Thomas Gray, MDPresident-elect

Monica Manga, MDSecretary/Treasurer

Gaurang Pandya, MDImmediate Past President

Board of DirectorsVirinder Bhardwaj, MDCarlos Dominguez, MDPradeep Kamboj, MD

Christopher Rodarte, MDAntonio Sanchez, MDRaman Verma, MD

CMA Delegates:Thomas Daglish, MDRoger Haley, MD

John Hipskind, MD

CMA Alternate Delegates:Robert Allen, MD

Ralph Kingsford, MD Mark Tetz, MD

Sixth District CMA TrusteeJames Foxe, MD

Staff:Steve M. BeargeonExecutive Director

Francine HipskindProvider Relations

Thelma YearyExecutive Assistant

Dana RamosAdministrative Assistant

Continued on page 18

American Red Cross Honors Community Hero ServiceThe Real Heroes Event will be celebrated on Friday, March 22 in Fresno. Sponsors and heroes arefrom all six counties represented in the Central Valley Chapter. The evening is set in the 1940s at thehistoric Chandler Airport in Fresno. It is a very patriotic and heart-warming evening with the soundsof a “big band” and period dress encouraged. For tickets or more information contact your local RedCross office at 559-732-6434 or via e-mail at Jane Fortune [email protected].

Hands-On Heroes Awards Call for NominationsOn April 18 at the Visalia Holiday Inn First 5 Tulare County will present Hands-On Heroes awardsto individuals in the community and a First 5 organization selected for their outstanding service to thepopulations they serve. The award honors selfless and passionate support, through recipients’ work orvolunteer activities, of Tulare County’s children ages 0 through 5. Nominations for these awards arecurrently being accepted in the following five categories: 1) Health and Wellness; 2) BehavioralHealth; 3) Early Care and Education; 4) Parent Education/Strong Families; and 5) ExceptionalVolunteer. For additional information contact First 5 Tulare County at 559-622-8650 or to downloada nomination form visit www.first5tc.org. Nominations are due by noon on March 11.

TCMS Annual Wine SocialFriday, May 3, 2013 • 6:30-8:30pmChinese Cultural Center, Visalia

SAVETHE

DATE!


2229 Q StreetBakersfield, CA 93301-2900

661-325-9025Fax 661-328-9372

website: www.kms.org

KCMS Officers

Wilbur Suesberry, MDPresident

Alpha J. Anders, MD President-elect

Eric J. Boren, MDSecretary

Ronald L. Morton, MDTreasurer

Joel R. Cohen, MDImmediate Past President

Board of DirectorsBradford A. Anderson, MDLawrence N. Cosner, MD

John L. Digges, MDJ. Michael Hewitt, MDSusan S. Hyun, MD

Melissa A. Larsen, MDMark L. Nystrom, MDSameer Gupta, MD

Edward W. Taylor, MD

CMA Delegates:Jennifer Abraham, MD

John Digges, MDRonald Morton, MD

CMA Alternate Delegates:Lawrence Cosner, Jr., MD

Staff:Sandi Palumbo, Executive Director

Kathy L. HughesAdministrative Assistant

FEBRUARY 2013Active.............................................................................................263Resident Active Members .................................................................2Active/65+/1-20hr .............................................................................4Active/Hship/1/2 Hship.....................................................................0Government Employed......................................................................6Multiple memberships........................................................................1Retired..............................................................................................60Total ..............................................................................................336New members, pending dues .............................................................1New members, pending application ..................................................0Total Members ..............................................................................337

Membership Recap

MEMBERSHIP NEWS

PO Box 1029Hanford, CA 93230

559-582-0310Fax 559-582-3581

KCMS Officers

Jeffrey W. Csiszar, MDPresident

VacantPresident-elect

Mario Deguchi, MDSecretary Treasurer

Theresa P. Poindexter, MDPast President

Board of DirectorsBradley Beard, MDJames E. Dean, MD

Thomas S. Enloe, Jr., MDYing-Chien Lee, MDUriel Limjoco, MD

Michael MacLein, MDKenny Mai, MD

CMA Delegates:Ying-Chien Lee, MD

StaffMarilyn Rush

Executive Secretary

Kern Kings

Julie Kasarjian, MD (Emergency Medicine) San Joaquin Community Hospital2615 Chester Avenue, 93301-2014661-395-3000/FAX: [email protected] Degree: Loma Linda U 2005Internship/Residency: Harbor UCLA Medical Center 2006-08

Kristopher Lyon, MD (Emergency Medicine) San Joaquin Community Hospital2615 Chester Avenue, 93301-2014661-395-3000/FAX: [email protected] Degree: Jefferson Medical Clg., PA 2006Residency: Loma Linda Medical Center 2006-009Board Certified: Emergency Medicine 2010

Jason P. Manuell, DO (Emergency Medicine) San Joaquin Community Hospital2615 Chester Avenue, 93301-2014661-395-3000/FAX: [email protected] Degree: Touro U, NV 2009Residency: U of NV School of Medicine 2010-12

The following physicians’ names, etc. are being published incompliance with the KCMS Constitution & Bylaws. BoardCertification will be listed only if the physician has been certified bya Specialty Board recognized by the American Board of MedicalSpecialists, as approved by the American Medical Association.

New Member


Post Office Box 28337Fresno, CA 93729-8337

1040 E. Herndon Ave #101Fresno, CA 93720

559-224-4224Fax 559-224-0276

website: www.fmms.org

FMMS OfficersRanjit Rajpal, MD

President

Prahalad Jajodia, MDPresident Elect

A.M. Aminian, MDVice President

Hemant Dhingra, MDSecretary/Treasurer

Sergio Ilic, MDPast President

Board of GovernorsS.P. Dhillon, MD

Ujagger-Singh Dhillon, MDWilliam Ebbeling, MDBabak Eghbalieh, MDAhmad Emami, MDDavid Hadden, MDS. Nam Kim, MD

Constantine Michas, MDTrilok Puniani, MDKhalid Rauf, MD

Rohit Sundrani, MDMohammad Sheikh, MD

CMA DelegatesFMMS President

A.M. Aminian, MDJohn Bonner, MDMichael Gen, MDBrent Kane, MDKevin Luu, MD

Andre Minuth, MDShazia Maghal, MDRoydon Steinke, MDToussaint Streat, MD

CMA Alternate DelegatesFMMS President-electPraveen Buddiga, MD

Surinder P. Dhillon, MDDon H. Gaede, MDPeter T. Nassar, MDTrilok Puniani, MDOscar Sablan, MD

Dalpinder Sandu, MDMickey Sachdeva, MD

CMA YPS DelegatePaul J. Grewall, MD

CMA YPS AlternateYuk-Yuen Leung, MD

CMA Trustee District VIVirgil Airola, MD

Staff:Sandi PalumboExecutive Director

President’s Message

RANJIT RAJPAL, MD

MOVING FORWARD THROUGH DIALOGUE AND CONVERSATION: ORGANIZEDMEDICINE AND THE NEW LANDSCAPE OF HEALTHCARE DELIVERY IN CALIFORNIA

As physicians and caregivers across the country scramble to adapt to the new dispensation ofhealthcare delivery under the mandates of the federal Affordable Care Act (ACA), many Valleyphysicians find themselves even more perplexed when it comes to traversing the new landscape ofhealthcare legislation, as it applies here in California.

To meet the educational and professional needs of Valley doctors and healthcare providers, FMMS,in partnership with CMA, is sponsoring a series of educational seminars which will cover a wide arrayof topics germane to public health, medical ethics, and jurisprudence as they relate to theimplementation of the ACA.

To commence the series, we held our opening seminar on the topicof Covered California- California’s health benefit exchange at ourFebruary Membership meeting. We were honored to have KristineMarck, an Associate Director in CMA’s Center for Economic Services,in Fresno to discuss the emerging changes arising in California’sinsurance marketplace. The seminar provided a broad and extensiveoverview of the multiple policy shifts underway within the juridicalarchitecture of California’s healthcare system and further highlightedhow these new policy and institutional changes will directly impact thetraditional medical practice and the future of patient-physicianrelationships.

As mandated by the ACA, each state is required to establish healthinsurance exchanges of their own, and those states that decline willinstead be required to enter into a federally arbitrated exchange. Thusfar, sixteen states (and D.C.) including California have opted for thestate-run exchange route, a move which has alarmed many within theCalifornia healthcare community.

Indeed, the present arrangement is rife with structural and procedural inadequacies, which havebeen thoroughly examined and interrogated by the CMA leadership working in collaboration withvarious stakeholders – including brokers, legislators and insurance companies.

Though the mechanisms within the exchange programs are designed, ostensibly, to providecompetitive marketplaces for patients to access affordable coverage, they effectively disempower bothpatients and physicians by entrusting the bulk of regulatory authority over insurance networks toexisting state regulators – the Department of Managed Health Care (DMHC) and the Department ofInsurance (DOI).

These agencies lack the ability to adequately assess the capacity of insurance networks. Tocompound matters, the current plan, which will be effective in January 2014, continues to favor “two-tier” networks which cloak adequacy criteria and rely primarily on self-attestations within insuranceprovider networks. As a consequence, patients will lose the autonomy to dictate the course of theirmedical treatment, and doctors will be coerced into misleading contracts which impose heavy burdenson their ability to deliver affordable healthcare of the highest quality.

FMMS, CMA and the greater family of organized medicine will continue our advocacy efforts onbehalf of patients and healthcare professionals to engage all concerned stakeholders, by movingforward through increased dialogue and conversation on these pressing issues. At a time of acceleratedchange and reorientation in California’s health landscape, it is vital for all Valley physicians andhealthcare providers to come together in unity and work with FMMS and CMA to advance ourmission of providing the highest standard of healthcare for our patients and the communities we serve.

Fresno-Madera

DOCTORS WILLBE COERCEDINTO MISLEADINGCONTRACTSWHICH IMPOSEHEAVY BURDENSON THEIR ABILITYTO DELIVERAFFORDABLEHEALTHCARE OFTHE HIGHESTQUALITY.


Fresno-Madera

Financial Education Seminar Series for FMMS MembersThe second in a series of Financial Education Seminars will be offered as a benefit toFMMS members and their guests, through a partnership with Central Valley PhysicianBenefits.

The March seminar will be hosted and presented by Eric Van Valkenburg, CLU,ChFC® and Amy Nuttall-Zwaan, CRPC®, CSNA, financial consultants with CentralValley Physician Benefits, and Robert Wright, attorney with Wright & WrightAttorneys at Law, Inc.

The presentation, “Your Most Complicated Asset: Life Insurance,” will include: • Why “modern” life insurance is so complicated and misunderstood by consumers; • Why so many insurance policies will fail, even when premiums are paid on time;• How to know when Insurance Company financial strength is below acceptablelimits;

• How to know when an existing policy is “broken” and how to fix it;• How to maximize return on the amounts contributed to a policy.

Wednesday, March 27, 2013 at 6 pm265 E. River Park Circle, #260, Fresno, CA 93720

(four-story building, corner of N. Friant Rd. and N. Fresno St.) (Note: Different location. The seminar will not be held at the FMMS office)

Space is limited! Reserve your spot as soon as possible by contacting: Central ValleyPhysician Benefits: 559-492-9592 or info@medicalsocietybenefits. com. A light mealwill be available.

Eric Van Valkenburg and Amy Nuttall-Zwaan are Registered Representatives with and securities offeredthrough LPL Financial. Member FINRA/SIPC.

'Walk with a Doc’ strives to encourage healthyphysical activity in people of all ages and reversethe consequences of a sedentary lifestyle in orderto improve their health and well-being.

ENCOURAGE YOUR PATIENTSTO PARTICIPATE!

2013 SATURDAY DATES:

• MAY 18

10:00-11:00am • Registration at 9:30amWoodward Regional Park • Sunset View Shelter

WHO CAN ATTEND:Participation is open to anyone interested in taking steps to improve their health.

EACH WALK IS LED BY LOCAL PHYSICIANSIn 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 WALKERSContact the Medical Society at 559-224-4224, ext. 114

Find us on Facebook: Fresno-Madera Medical Societyhttp://www.facebook.com/pages/Fresno-Madera-Medical-Society/107731015917068

Fresno-Madera Medical Society to Host Free Community Health Walks

WALK WITH A DOCCOMMUNITY OUTREACH PROGRAM

Seventeen physician groupssupport the bill, including theAmerican Academy of FamilyPhysicians, according to Schwartz.However, the bill has not receivedsupport from the RepublicanDoctors Caucus (Modern Health -care, 2/6).

It is unclear how the bill’s costswould be offset, according to CQRoll Call (CQ Roll Call, 2/6).Schwartz previously introducedsimilar legislation, but the high costof repealing the SGR blocked thebill’s passage (“Healthwatch,” TheHill, 2/6).

Meanwhile, House Ways andMeans Health Subcommittee ChairKevin Brady (R-Texas) is expectedto release a separate bill that wouldreplace the SGR with temporarypayment increases while thegovern ment worked with physiciansto develop a long-term alternative,Modern Healthcare reports.

The bill would use a modifiedfee-for-service model that offersextra payments to doctors whoimprove efficiency. It is expected torequire the approval of physiciangroups for Medicare quality andreporting activities used to deter -mine pay increases (Modern Health -care, 2/6).

Brady said the bill’s costs wouldbe offset by structural changes toMedicare (CQ Roll Call, 2/6).

The chances of Congress passinglegislation to repeal the SGRincreased after the CongressionalBudget Office released a report thatlowered the estimated cost ofrepealing the SGR from about $245billion over 10 years to $138 billion,National Journal reports (Sanger-Katz, National Journal, 2/6).

HealthcareReform


• MARCH 23 • APRIL 27


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

University Psychiatry Clinic: A slidingfee scale clinic operated by the UCSFFresno Dept. of Psychiatry at CRMC M-F8am-5pm. Call 559-320-0580.

Medical office spaces: 1,000sf up to2,500sf at NE. corner First/Herndon andNW corner First & Bullard starting at $1psf++ by owner. Call 559-449-7668 or 559-284-2625.

Camarena Health seeking FP/IM physicianfor Oakhurst facility. Requires CA physicianlicense. Contact Dir. of HR at 559-664-4158; [email protected] or faxresume to 559-675-5224.

ANNOUNCEMENT

FOR RENT / LEASE

PHYSICIAN WANTED

CLASSIFIEDS

you as you make rounds and see referrals.They are doctors, not students. They willdo H&Ps, progress, procedure notes, anddischarge summaries. But they do not knowyour craft. The residents will learn as youdispense pearls of wisdom and direct theirreading. You will learn how much you donot know from them, too.

The residents will receive a stipend fromthe hospital for their work. They cannotbill professional fees. You continue to dothat as you see your patients, direct theircare and supervise the residents. Every notethe resident enters must be verified andconfirmed by you in order for you to bill forthe service. The same applies to procedures.The residents can do them with yoursupervision. There will be a learning curvefor everyone. Initially the residents will beslow and require feeding of information.But as they learn, everything will becomeeasier and flow more smoothly. After twoyears, the more senior residents will be ableto supervise their juniors. You will havemore time to oversee their practice and

GME at KDMC


streamline yours. And you continue to billpro fees for patients on your service. Soundslike a win-win doesn't it?

There are a couple of other things tokeep in mind. In addition to teaching andsupervision; attending physicians have tocomplete evaluations of the residents ontheir service. This gives the resident theopportunity to address areas of weakness inknowledge and interactions with patientsand staff. The residents must do the same foryou I us, giving us the opportunity toimprove our skills as well. Additionally, ifthe residents feel mistreated, ignored, ordemeaned, they have a responsibility to re -port that to the Program Directors. Notonly would that reflect badly on theoffender, but it could jeopardize accredita -tion of the program. Negative evaluations ofthe trainees will be taken very seriously byProgram Directors, just as negative reportsfrom the residents regarding Attendingbehavior will be taken seriously. Since thatcould place the training programs at risk,the Program Directors will have to reportthese to the Medical Staff for action.

The training programs begin with 12residents in July. By 2020, when all yearsare full for the five programs, there will be76 residents at KDMC. The hospitalcontinues to expand, and the communitycontinues to grow; increasing in-and out-patient census. The start of GraduateMedical Education is timely and will beessential to recruiting physicians to meetthe increased demand for medical services.It offers a terrific opportunity for us toimprove the efficiency of the service weprovide. As we train new doctors, theybecome familiar with our practice style andknow what we will expect when seeingpatients they will be referring.

The doctors-in-training will become avital resource for your practice. Takeadvantage of the opportunity to becomeinvolved early and become familiar withthe Program Directors. They will be yourbest friends when it comes to GME, teach -ing techniques, knowing what to expectfrom residents and knowing what the resi -dents expect from you. The GME train hasleft the station and is barreling full steamahead. Upon arrival it will change the waywe practice medicine at KDMC. Thosechanges will be better for our patients andthe community... ALL ABOARD!

Author can be reached at:[email protected].

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VITAL SIGNSPost Office Box 28337Fresno, California 93729-8337

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

PRSRT STDU.S. Postage PAIDFresno, CAPermit No. 30

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.

Our passion protectsyour practice

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

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Vital Signs March 2013